FirstAid 2017 PDF

c Health Sciences
HIGH-YIELD PRINCIPLES IN
Public Health Sciences
[' ll is a mathematical fact that fifty percent of all doctors graduate in the
bottom half of their class."
Author Unknown
There are two kinds of statistics : the kind you look
Epidemiology/
Biostatistics
246
Ethics
253
The Well Patient
258
Social Sciences
259
up and the kind you
make up."
Rex Stout
On a long enough time line, the survival rate for everyone drops to zero.
Chuck Palahniuk
There are three kinds ol lies: lies, damned lies, and statistics ."
Mark Twain
I
A heterogenous mix of epidemiology, biostatistics, ethics, law, healthcare
delivery, patient safety , quality improvement, and more falls under the
heading of public health sciences. Biostatistics and epidemiology are the
foundations of evidence-based medicine and arc verv high-yield. Make
sure vou can apply biostatistical concepts such as sensitivity , specificity ,
and predictive values in a problem-solving format.
Medical ethics questions mav seem less concrete than questions from
other disciplines. For example, if a patient does or savs something.
what should you do or sav in response? Many medical students do not
diligently study these topics because the material is felt to be easy or a
matter of common sense. In our opinion, this is a missed opportunity.
In addition, the key aspects of the doctor-patient relationship ( eg,
communication skills ) are high-vield. Last, the exam has also recently
added an emphasis on patient safety and quality improvement topics.
which arc discussed in this chapter.
245
246
1
SECTION II
PUBLIC HEALTH SCIENCES
PUBLIC HEALTH SCIENCES EPIDEMIOLOGY / BIOSTATISTICS
Observational studies
STUDY TYPE
DESIGN
Cross- sectional study
Collects data from a group of people to assess

Disease prevalence.
frequency of disease (and related risk factors) at Can show risk factor association w ith disease, but
does not establish causality.
a particular point in time.
Asks, "What is happening?
Case-control study
Compares a group of people with disease to a

group without disease.
Looks for prior exposure or risk factor.

Asks, What happened? '
Cohort study
Compares a group with a given exposure or risk

factor to a group without such exposure.
Looks to see if exposure affects the likelihood of
disease.
Can be prospective (asks, Who will develop
disease?) or historical (asks, Who developed
the disease [exposed vs nonexposed] ?).
MEASURES /EXAMPLE
Odds ratio (OR ).

Patients w ith COPD had higher odds of a
history of smoking than those without COPD.
Relative risk ( RR).

had a higher risk of developing COPD
Smokers
than nonsmokers.
Twin concordance
study
Compares the frequency with which both

monozygotic twins or both dizygotic twins
develop the same disease.
Measures hcritability and influence of

environmental factors ( nature vs nurture ).
Adoption study
Compares siblings raised by biological vs

adoptive parents.
Measures heritability and influence of
Clinical trial
environmental factors.
Experimental study involving humans. Compares therapeutic benefits of 2 or more treatments,

or of treatment and placebo. Study quality improves when study is randomized, controlled, and
double-blinded ( ie, neither patient nor doctor knows whether the patient is in the treatment or
control group). Triple-blind refers to the additional blinding of the researchers analyzing the data.
Four phases ( Does the drug swim?!
DRUG TRIALS
TYPICAL STUDY SAMPLE
PURPOSE
Phase 1
Small number of healthy volunteers.
Is it safe? Assesses safety, toxicity,
Phase II
Small number of patients with disease of
Does it work? Assesses treatment efficacy,

optimal dosing, and adverse effects.
pharmacokinetics, and pharmacodynamics.

interest.
Phase III
Phase IV
large number of patients randomly assigned

either to the treatment under investigation or
to the best available treatment ( or placebo).
Is it as good or better?" Compares the new
Postmarketing surveillance of patients after

treatment is approved.
Can it stay? " Detects rare or long-term

adverse effects. Can result in treatment being
withdrawn from market.
treatment to the current standard of care tanv

improvement ?!
EPIDEMI 0 L06 Y / BI0 STATISTICS
Uses 2 x 2 table comparing test results with the

actual presence of disease. TP = true positive;
FP = false positive; TN = true negative; FN =
false negative.
Sensitivity and specificity are fixed properties
of a test. PPV and NPV vary depending on
disease prevalence.
Evaluation of
diagnostic tests
Sensitivity (true
positive rate )
Positive predictive
value
Negative predictive
value
Disease
TP
FP
FN
TN
PPV
= TP/ITP + FP)
Sensitivity Specificity
= TP/ fTP + FN) = TN/TTN + FPL
..
Prevalence
(T?
TP TN
FN * fP 4 TNl
= TN / (TN + FP)
= 1 - false-positive rate
SP-P-IN = highly SPecific test, when Positive,
rules IN disease
If specificity 100%. all positives must be Tl'4
Proportion of positive test results that are true

positive.
Probability that a person who has a positive test
result actually has the disease.
Proportion of negative test results that are true
negative.
Probability that a person with a negative test
result actually does not have the disease.
PPV = TP / (TP + FP )
PPV varies directly with pretest probability
( baseline risk, such as prevalence of disease):
high pretest probability high PPV'
Disease
lease
absent
present
TP
TN
FP
B
Test results
NPV = TN / ( TN + FN)
NPV7 varies inversely with prevalence or pretest
probability: high pretest probability low NPV'
POSSIBLE CUTOFF VALUES

A = 100% sensitivity cutoff value
B - practical compromise between specificity anti sensitivity
C = 100% specificity cutoff value
lowenna the cutoff point

B - A ( T FP 4 FN)
T Sensitivity t NPV
T Specificity X PPV
Raising the cutoff point

B
C ( tFNXFP)
T Specificity T PPV
i Sensitivity 1NPV
. T specificity. T PPV.
For example, in diabetes screening, raising the blood glucose level at which a patient is diagnosed will X sensitivity
and X NPV. The opposite changes occur with decreasing the blood glucose level at which a patient is diagnosed.
Ifssil
| Figure |
Proportion of all people without disease who

test negative, or the probability that when the
disease is absent, the test is negative.
Value approaching 100% is desirable for
ruling in disease and indicates a loss falsepositive rate. High specificity test used for
confirmation after a positive screening test.
I New I
iRevisedl
NPV
= TN/ON + FN)
= TP / ( TP + FN)
= 1 - false-negative rate
SN N-OUT = highly SeNsitive test, when
Negative, rules OUT disease
If sensitivity is 100%, all negatives must be TNj
.t
Likelihood ratio
247
Proportion of all people with disease who lest

positive, or the probability that when the
disease is present, the test is positive.
Value approaching 100% is desirable for ruling
out disease and indicates a low false negative
rate. High sensitivity test used for screening in
diseases with low prevalence.
Specificity (true
negative rate)
SECTION II
A measure indicating how likely a given test

result would occur in a patient with the
condition vs a patient without the condition.
I.Ri in
sensitivity
1 - specificity
_ I - sensitivity
specificity
13
248
SECTION II
Quantifying risk
EPIDEMIOLOGY / BIOSTATISTICS
Definitions and formulas are based on the classic

2 x 2 or contingency tabic.
Disease
si
II
II
Odds ratio
Typically used in case-control studies. OR

depicts the odds of an event ( eg. disease!
occurring giving a certain exposure ( a / b) vs
the odds of an event occurring in the absence
of that exposure ( c/d1
Relative risk
Typically used in cohort studies. Risk of

developing disease in the exposed group
OR
a /bj ad
RR =
be
a /( a + b )
c/(c + d )
divided by risk in the unexposed group ( eg. if

2\7c of smokers develop lung cancer vs 17c of
nonsmokers, RR = 21/1 = 21 ). If prevalence is
low, OR = RR .
RR = 1 no association between exposure and
disease.
RR > 1 e x p o s u r e associated with t disease
occurrence.
RR < 1
exposure associated
with t disease
occurrence.
Attributable risk
Relative risk reduction
Absolute risk
reduction
Number needed to
treat
Number needed to
harm
The difference in risk between exposed and

unexposed groups, or the proportion of
disease occurrences that are attributable to
the exposure (eg, if risk of lung cancer in
smokers is 21'/? and risk in nonsmokers is 1%,
then 20% of the lung cancer risk in smokers is
attributable to smoking).
T he proportion of risk reduction attributable to
the intervention as compared to a control (eg,
if 2% of patients who receiv e a flu shot develop
the flu, while 8% of unvaccinated patients
develop the flu , then RR = 2 /8 = 0.25, and
RRR = 0.75 ).
T he difference in risk (not the proportion )

attributable to the intervention as compared
to a control (eg, if 87c of people who receive
a placebo vaccine develop the flu vs 27c
of people who receive a flu vaccine, then
ARR = 8% - 17c = 6% = .06 ).
Number of patients who need to be treated for 1
patient to benefit .
Number of patients who need to be exposed to a
risk factor for 1 Datient to be harmed.
AR
a+b c+d
RRR = 1 - RR
ARR
c
c+d
NNT = 1 /ARR
NNH = 1/AR
a+b
Incidence vs
Incidence
prevalence
rate
Prevalence
Recurrence
Tril?fT
Mortality
Cure
H of new cases
# of people at risk
03
[ during a specified
time period )
SECTION II
249
Incidence looks at new cases ( incidents).

Prevalence looks at all current cases.
II of existing cases (at a point in

t otal It of people time)
ill a population
Prevalence
Incidence rate x average duration
1 - prevalence of disease
Prevalence - incidence for short duration diseaseleg, common cold ).
Prevalence > incidence for chronic diseases, due to
Prevalence - pretest probability.

t prevalence
t PPV and t NPV
large II of existing cases ( eg diabetes).
Precision vs accuracy
Precision (reliability )!
The consistency and reproducibility of a teslj

The absence of random variation in a test.
Random error 1 precision in a test,

t precision - i standard deviation
t precision t statistical power ( 1 pi.
,
Accuracy (validity)!
Tire trueness of test measurement

The absence of systematic error or bias in a test.
External validity
Applicability of obtained results bevond the

cohort that was studied.
X X
X
Accurate, not precise
Systematic error i accuracy in a test.
Precise, not accurate
Accurate and
precise
Not accurate,
not precise
250
SECTION II
Bias and study errors

TYPE
DEFINITION
EXAMPLES
STRATEGY TO REDUCE BIAS
Error in assigning subjects to

a study group resulting in
an unrepresentative sample.
Most commonly a sampling
bias.
Berkson bias study population Randomization

selected from hospital is
Ensure the choice of the right
less healthy than general
comparison/reference group
Recruiting participants
Selection bias
population
1 lealthy worker effect study
population is healthier than
the general population
Non-response biasparticipating subjects differ
from nonrespondents in
meaningful ways
Performing study
Recall bias
Patients with disease recall

Awareness of disorder alters
recall by subjects; common in exposure after learning of
similar cases
retrospective studies.
Measurement bias
Information is gathered in a
Association between HPV and Use objective, standardized,
and previously tested methods
systemic ally distorted manner. cervical carreer not observed
when using non-standardized
of data collection that arc
classifications
planned ahead of tinre
I lawthorne effect participants Use Dlacebo grouD
change their behavior in
response to their awareness of
Decrease time frottt exposure

to follow-up
being observed
Procedure bias
Observer- expectancy
bias
Subjects in different groups arc

not treated the same.
Patients in treatment group

spend more time in highly
specialized hospital units
If observ er expects treatment

Researchers belief in the
efficacy of a treatment changes group to show signs of
the outcome of that treatment
recovery, then he is more
(aka Pygmalion effect; selflikely to document positive
fulfilling prophecy).
outcomes
Blinding and use of placebo

reduce influence of
participants artd researchers

on procedures and
interpretation of outcomes
as neither are aware of group
allocation
Interpreting results
Confounding bias
When a factor is related to both Pulmonary disease is more

the exposure and outcome,
common itt coal workers
but not on the causal
than the general population;
however, people who w ork in
pathway - factor distorts or
confuses effect of exposure on coal mines also smoke more
outcome.
frequently than the gerteral
population
Lead-time bias
Early detection is confused

with t survival.
Early detection makes it

seem as though survival has
increased, but the natural
history of the disease has trot
changed
Multiple/repeated studies
Crossover studies (subjects act
as their own controls)
Matching ( patients with
similar characteristics in both
treatment atrd control groups)
Restriction
Randomization
Measure back-end survival
(adjust survival according to
the severity of disease at the
time of diagnosis)
252
SECTION I I
Outcomes of statistical hypothesis testing
Correct result
Stating that there is an effect or difference when

one exists (null hypothesis rejected in favor of
alternative hypothesis).
Stating that there is not an effect or difference
when none exists ( null hypothesis not
rejectedl.
Incorrect result
Type I error (a)
Type II error ((5)
Stating that there is an effect or difference

when none exists (null hypothesis incorrectly
rejected in favor of alternative hvpothcsis).
a is the probability of making a typeI error, p is
judged against a preset a level of significance
(usually 0.05 ). If p < 0.05, then there is less
than a 5% chance that the data will show
something that is not really there.
Also knorvn as false-positive error.

a = you accused an innocent maij
You can never prove" the alternate hypothesis,
but you can reject the null hypothesis as being
very unlikely
Also knorvn as false-negative error.

Stating that there is not an effect or difference
when one exists ( null lnpothesis is not rejected
when it is in fact false ).
P is the probability' of making a type II error. P P = y ou blindly let the guilty man go freet
is related to statistical power ( 1 - p), which is
If you t sample size, you t porver. T here is power
the probability' of rejecting the null hy pothesis
in numbers.
when it is false,
t poyver and l P by:
t sample size
t expected effect size
t precision of measurement
Confidence interval
For a given X% Cl rvc arc X% confident that

the true mean of the target population falls
within the calculated interval
Cl for population mean = x Z( SEM )
SI M = cr / yj( N ) |q = sample standard deviation.
N = sample size ]
Jl'he 95'/f Cl (corresponding to - .05 ) is often
used.
For the 95% CI Z = 1.96.
For the 99% Cl, Z = 2.58.
If the 95% Cl for a mean difference between 2

variables includes 0, then there is no significant
difference and H0 is not rejected.
If the 95% Cl for odds ratio or relative risk
includes 1, llu is not rejected.
If the Cls betyveen 2 groups do not overlap
statistically significant difference exists
If the Cls betyveen 2 groups overlap usually
no significant difference exists.
BEHAVIORAL SCIENCE ETHICS
SECTION I I
253
Common statistical tests
f-test
Checks differences between means of 2 groups.
Tea is meant for 2.
Example: comparing the mean blood pressure

between men and women.
ANOVA
Checks differences between means of > or more

groups
Chi-square (%2)
Checks differences between 2 or more

percentages or proportions of categorical
outcomes (not mean values).
Pearson correlation
|coefficientl
words: ANalysis Of YAriance.

Example: comparing the mean blood pressure
between members of different ethnic groups.
Pronounce Chi-tegorical.
Example: comparing the percentage of members
of s different ethnic groups who have essential
hypertension.
>
r is always between -1 and +1. The closer the absolute value of r is to 1, the stronger the linear
correlation between the 2 variables.

Positive r value positive correlation (as one variable t, the other variable t )
Negative r value negative correlation (as one variable t the other variable t ).
Coefficient of determination = r ~ lamount of variance in one variable that can be explained bv
variance in another variahltl).
re a 4
re 0 8
r!
r= 0
re 0.8
i
'V
FPQ aft td corfie "
i.
I
..
r* 0.4
m
Strong positive
Weak positive
correlation
correlation
No correlation
Weak negative
correlation
Strong negative
correlation

Core ethical principles
Autonomy
Beneficence
Obligation to respect patients as individuals ( truth-telling, confidentiality), to create conditions

necessary for autonomous choice (informed consent), and to honor their preference in accepting
or not accepting medical care.
Physicians have a special ethical ( fiduciary ) duty to act in the patient s best interest. May conflict
with autonomy (an informed patient has the right to decide) or what is best for society ( eg,
mandatory TB treatment). T raditionally, patient interest supersedes.
Nonmaleficence
"Do no harm. Must be balanced against beneficence; if the benefits outw eigh the risks, a patient
may make an informed decision to proceed (most surgeries and medications fall into this
category).
Justice
To treat nersons fnirlv and eonitahlv. T his does not nhvavs imnlv eouallv ( ep
triapel.
254
SECTION I I
Informed consent
A process (not just a document/signature) that
requires:
Disclosure: discussion of pertinent
information
Understanding: ability to comprehend
Capacity: ability to reason and make ones
own decisions ( distinct from competence, a
legal determination )
Voluntariness: freedom from coercion and
manipulation
Exceptions to informed consent:

Patient lacks decision-making capacity or is
legally incompetent
Implied consent in an emergency
Therapeutic privilege withholding
information when disclosure would severely
harm the patient or undermine informed
decision-making capacity
Waiver patient explicitly waives the right of
informed consent
Patients must have an intelligent understanding

of their diagnosis and the risks/benefits of
proposed treatment and alternative options,
including no treatment.
Patient must be informed that he or she can
revoke written consent at any time, even orally.
Consent for minors
A minor is generally am person < 18 s ears old.

Parental consent laws in relation to health
care vary b\ state. In general, parental consent
should be obtained, but exceptions exist for

emergency treatment ( eg, blood
transfusions )
or if minor is legally emancipated leg, married,

self supporting, or in the military1
Situations in which parental consent is usually

not required:
Sex (contraception, STIs, pregnancy)
Drugs (substance abuse)
Rock and roll (emergency/trauma)
Physicians should always encourage healthy
minor-guardian communication.
Physician
should seek
patient consent
Decision- making
capacity
is
patient assent even
il
not required.
Physician must determine w hether the patient is psychologically and legally capable of making
a particular health care decision. Note that decisions made with capacity cannot be revoked
simply if the patient later loses capacity
Components:
Patient is > 18 years old or otherwise legally emancipated
Patient makes and communicates a choice
Patient is informed (knows and understands)
Decision remains stable over time
Decision is consistent with patient s values and goals, not clouded by a mood disorder
Decision is not a result of altered mental status (eg, delirium, psychosis, intoxication )
r BCHAVIUKAL SuttfU
PUBLIC HEALTH SCIENIO
Advance directives
tifTTo
Instructions given by a patient in anticipation of the need for a medical decision. Details vary per
state law
Oral advance directive
Incapacitated patients prior oral statements commonly used as guide. Problems arise from variance
in interpretation. If patient was informed, directive was specific, patient made a choice, and
decision was repeated over time to multiple people, then the oral directive is more valid.
Living will ( written

advance directive)
Describes treatments the patient wishes to receive or not receive if he/she loses decision-making
capacity. Usually, patient directs physician to withhold or withdraw life-sustaining treatment if he/
she develops a terminal disease or enters a persistent vegetative state.
Medical power of
Patient designates an agent to make medical decisions in the event that he/she loses decision
making capacity. Patient may also specif)' decisions in clinical situations. Can be revoked by
patient if decision-making capacity is intact . More flexible than a living will.
attorney
Do not resuscitate
order
Surrogate decision-
maker
DNR order applies only to cardiopulmonary resuscitation.
If a patient loses decision-making capacity and has not prepared an advance directive, individuals
(surrogates) who know the patient must determine what the patient would have done. Priority of
Siblings
surrogates: The spouse ChiPS in spouse adult Children Parents
other
relative
Confidentiality
Confidentiality respects patient privacy and autonomy. If patient is not present or is incapacitated.
disclosing information to family and friends should be guided by professional judgment of
patient 's best interest. The patient may voluntarily waive the right to confidentiality (eg, insurance
company request ).
General principles for exceptions to confidentiality:
Potential physical harm to others is serious and imminent
Likelihood of harm to self is great
No alternative means exists to warn or to protect those at risk
Physicians can take steps to prevent harm
Examples of exceptions to patient confidentiality (many are state-specific ) include the following
( " The physician's good judgement SAVED the dav" f
Suieidal/homicidal patients
Abuse ( children, elderly, and /or prisoners)
Tarasoff decision California Supreme Court decision requiring physician to directly inform
and protect potential victim from harm.
Epileptic patients and other impaired automobile drivers.
Reportable diseases ( eg, STls, hepatitis, food poisoning ); physicians may have a duly to warn
public officials, who will then notify people at risk. Dangerous communicable diseases, such as
TB or Ebola, may require involuntary treatment ]
'
IFTBnitRH
256
SECTION II
BEHAVIORAL SCIENCE
ETHICS
Ethical situations
SITUATION
Patient is not adherent.
Attempt to identify the reason for nonadherence and determine his/her willingness to
change; do not coerce the patient into adhering or refer him / her to another physician.
Patient desires an unnecessary
Attempt to understand why the patient wants the procedure and address underlying
concerns. Do not refuse to see the patient or refer him / her to another physician . Avoid
performing unnecessary procedures.
procedure.
Patient has difficult)' taking

medications.
I:
i 1 J 'I
Provide written instructions; attempt to simplify treatment regimens; use teach-back

method (ask patient to repeat regimen back to physician ) to ensure comprehension .
Family members ask for information Avoid discussing issues with relatives without the patient s permission.
about patients prognosis.
A patient s family member asks you Attempt to identify why the family member believes such information would be
detrimental to the patients condition . Explain that as long as the patient has decision
not to disclose the results of a test
making capacity and does not indicate otherwise, communication of information
if the prognosis is poor because
concerning his/her care will not be withheld . 1 lowever, if vou believe the patient
the patient will be unable to
might harm himself or others if informed, then you may invoke therapeutic privilege
handle it.
and withhold the information!
A 17-year-old girl is pregnant and
Many states require parental notification or consent for minors for an abortion. Unless
there are specific medical risks associated with pregnancy, a physician should not
requests an abortion.
sway the patient s decision for an elective abortion ( regardless of maternal age or fetal
condition ).
The patient retains the right to make decisions regarding her child , even if her parents
A 15-vcar-old girl is pregnant and
wants to keep the child . I ler
disagree. Provide information to the teenager about the practical issues of caring for
a baby. Discuss the options, if requested . Encourage discussion between the teenager
parents want you to tell her to give
the child up for adoption.
and her parents to reach the best decision .
A terminally ill patient requests
In the overw helming majority of states, refuse involvement in any form of physicianassisted suicide. Physicians may, however, prescribe medically appropriate analgesics
physician assistance in ending
his/ her own life.
that coincidentally shorten the patient s life.
Assess the seriousness of the threat . If it is serious, suggest that the patient remain in the
Patient is suicidal.
hospital voluntarily; patient can be hospitalized involuntarily if hc/she refuses.
Patient states that he/she finds you
Ask direct , closed-ended questions and use a chaperone if necessary. Romantic
attractive.
relationships with patients are never appropriate.
A woman who had a mastectomy
Find out why the patient feels this way. Do not offer falsely reassuring statements (eg,
You still look good").
says she now feels ugly.
Patient is angry about the long time Acknowledge the patient 's anger, but do not take a patient s anger personally. Apologize
for any inconvenience. Stay away from efforts to explain the delay.
he /she spent in the waiting room .
Patient is upset with the way he /she Suggest that the patient speak directly to that physician regarding his/her concerns. If the
was treated by another doctor.
problem is with a member of the office staff, tell the patient you will speak to that person .
An invasive test is performed on the Regardless of the outcome, a physician is ethically obligated to inform a patient that a
mistake has been made.
wrong patient.
257
SECTION II
Ethical situations ( continued )

SITUATION
APPROPRIATE RESPONSE
A patient requires a treatment not

covered by his/her insurance.
Never limit or deny care because of the expense in time or money. Discuss all
treatment options with patients, even if some arc not covered by their insurance
Patient is victim of intimate partner

violence.
companies.
At ages 5 -7, children begin to understand that death is permanent, that all life
functions end completely at death, and that everything that is alive eventually
dies. Provide a direct, concrete description of his sisters death. Avoid cliches and
euphemisms. Reassure that the boy is not responsible. Identify and normalize fears
and feelings. Kncourage play and healthy coping behaviors (eg, remembering her in
his own way).
Ask if patient is safe and has an emergency plan. Do not pressure patient to leave his or
her partner, or disclose the incident to the authorities.
Patient wants to trv alternative or

holistic medicine.
Find out win and allow patient to do so as long as there arc no contraindications.
medication interactions, or adverse effects to the new treatment .
Phvsician colleague presents to

work impaired.
If impaired, incompetent, or unethical colleague threatens patient safety, report the

situation to local superv isory personnel. Should the organization fail to take action
alert the state licensing board.
Patient is officiallv determined to

suffer brain death. Patient s family
insists on maintaining life support
indefinitely because patient is still
moving when touched.
Gently explain to family that there is no chance of recovers , and that brain death is
A pharmaceutical company offers

vou a sponsorship in exchange for
advertising its new drug
Reject this offer. Generally, decline gifts and sponsorships to avoid any appearance of
conflict of interest. The AMA Code of Ethics does make exceptions for gifts directly
benefitting patients; gifts of minimal value; special funding for medical education
of students, residents, fellows: grants where recipients arc chosen bv independent
An adult refuses care because it is

against his/her religious beliefs.
Work with the patient bv cither explaining the treatment or pursuing alternative
treatments with the patient . However, a phvsician should never attempt to force adults
to receive care if it is contrary to their religious beliefs.
Mother and 15-vear-old daughter
Transfuse daughter, but do not transfuse mother. Emergent care can be refused bv the
healthcare proxy for an adult, particularly where patient preferences are known or
reasonably inferred, but not for a minod
A 7 year-old boy loses a sister to

cancer and now feels responsible.
eauivalent to death Movement is due to spinal arc reflex and is not voluntary. Patient
should be withdrawn from life support
institutional criteria; and where funds are distributed without attribution to sponsors.
arc unresponsive following a car

accident and are bleeding internally.
Father says do not transfuse because
they are Jehovah s Witnesses
SECTION II
PUBLIC HEALTH SCIENCES THE WELL PATIENT
PUBLIC HEALTH SCIENCES THE WELL PATIENT
Early developmental
milestones
Milestone dates are ranges that have been approximated and vary by source. Children not meeting
milestones may need assessment for potential developmental delay.
AGE
MOTOR
SOCIAL
Infant
Parents
Start
0-12 mo
Toddler
12- 36 mo
Preschool
3-5 yr
Observing,
Social smile (by 2 mo)

Primitive reflexes disappear
Moro ( by 3 mo ), rooting ( by
Stranger anxiety ( by 6 mo)
4 mo), palmar (by 6 mo),
Separation anxiety ( by 9 mo)
Babinski ( by 12 mo)
Posture lifts head up prone ( by
1 mo), rolls and sits (by 6 mo),
crawls (by 8 mo), stands ( by
10 mo), walks (by 12-18 mo)
Picks passes toys hand to
hand (by 6 mo), Pincer grasp
(by 10 mo)
Points to objects (by 12 mo)
Orients first to voice ( by

4 mo), then to name and
gestures (by 9 mo)
Object permanence ( by 9 mo)
Oratory says mama and
" dada" (by 10 mo)
Child
Rearing
Cruises, takes first steps ( by

12 mo)
Climbs stairs ( by 18 mo)
Cubes stacked number
= age (yr) x 3
Cutler \( feeds self with fork
and spoon (by 20 mo)
Kicks ball ( by 24 mo)
Recreation parallel play ( by

24-36 mo)
Rapprochement moves away
from and returns to mother
( by 24 mo)
Realization core gender
identity - formed (by 36 mo)
W ords 200 ssords by age 2

(2 zeros), 2-word sentences
Don't
Forget, they're still
Learning!
Drive tricvcle ( > wheels at

3 yr)
Drawings copies line or
circle, stick figure ( by 4 yr)
Dexterity hops on one foot
(by 4 yr), uses buttons or
zippers, grooms self ( by 5 yr )
Freedom comfortably spends

part of das ass ay from mother
Language 1000 ssords by age
Car seats for children
VERBAL /C0GNIT1VE
Working,
(by 3
vri
Friends cooperatise play, has

imaginary friends ( by 4 yr)
3 ( 3 zeros), uses complete

sentences and prepositions
(by 4 yr)
Legends can tell detailed
stories ( by 4 vr|
Children should ride in rear-facing car seats until thev are 2 sears old and in car seats with a
harness until thev are 4 sears. Older children should use a booster seat until thev are 8 sears
old or until the seat belt fits pi operlv. Children < 12 sears old should not ride in a seat ss ith an
airhaa
Changes in the
elderly
PUBLIC HEALTH SCIENCES SOCIAL SCIENCES
SECTION II
Sexual changes:
Men slower ereetion/ejaculation, longer refractor) period
Women vaginal shortening, thinning, and dryness.
Sleep patterns: I REM and slow-wave sleep; t sleep onset latency] t early awakenings
^
t suicide rate.
hearing
1 vision and
.
I immune response.
I renal, pulmonary, and Cl function .
=
1 muscle mass, t fat .

Intelligence docs not decrease!

Disease prevention
Primary
Prevent disease before it occurs (eg, HPV

vaccination)
Secondary
Screen early for and manage existing but

asymptomatic disease (eg Pap smear for
cervical cancer)
Tertiary
Treatment to reduce complications from

disease that is ongoing or has long-term effects
(eg, chemotherapy)
Quaternary identifying patients at risk of

unnecessary treatment, protecting from the
harm of new interventions ( eg, electronic
sharing of patient records to avoid duplicating
recent laboratory and imaging studies!
Types of insurance plans
Health Maintenance
Organization
Patients are restricted ( except in emergencies! to a limited panel of providers w ho arc in the
network.
Payment is denied for any service that does not meet established, es idencc-hascd guidelines.
Requires referral from primary care provider to see a specialist.
Point of Service
Patients arc allowed to sec providers outside of the netw ork, hut have higher out-of-pocket costs,
including higher copays and deductibles, for out-of-netw ork services.
Requires referral from primary care provider to see a specialist .
Preferred Provider
Patients are allowed to see physicians who are within or outside of the network. All serv ices have
higher enpavs and deductibles.
Do not need a referral from primary care provider to see a specialist.
Organization
Exclusive Provider
Organization
Patients arc limited (except in emergencies) to a network of doctors, specialists, and hospitals.
Does not require a referral from primary care provider to sec a specialist.
Patient payment models

Capitation!
Patient pays a fixed, predetermined fee in advance to cover all medical serv ices. Used in HMO
insurance plans!
Discounted fee- forservice
Patient pays for eaeli individual service at a predetermined, discounted rate,
Global payment
Patient pays for all expenses associated with a single incident of care with a single payment . Most
commonly used during elective surgeries, as it covers tile cost of surgery as w ell as the necessary
pre - and postoperative visits.
Medicare and
Medicaid
Medicare and Medicaid federal social

health care programd that originated from
amendments to the Social Security Act.
Medicare is available to patients > 65 years old.
< 65 with certain disabilities, and those with
end-stage renal disease.
Medicaid is joint federal and state health
assistance for people with very low income.
MedicarE is for Elderly

MedicaiD is for Destitute.
The 4 parts of Medicare:
Part A: Hospital insurance, home hospice
care
Part B: Basic medical bills ( eg, doctors fees,
diagnostic testing!
Part C: ( Parts A + B = Combrj) delivered by
approved private companies

Part D: Prescription drugs
Hospice care
Medical care focused oil providing comfort and palliation instead of definitive cure. Available to
patients on Medicare or Medicaid and in most private insurance plans whose life expectancy is
< 6 months.
During end - of-life care, priority is given to improving the patient 's comfort and relieving pain, and
care often includes opioid medications. Facilitating comfort is prioritized over potential side
effects leg, respiratory depression). This prioritization of positive effects over negative effects is
known as the principle of double effect.
Common causes of death (US) by age
#1
< 1 YR
1-14 YR
Congenital
malformations
Unintentional
injury
#2
Preterm birth
Cancer
#3
Maternal
Congenital
malformations
pregnancy
complication!
15-34 YR
Unintentional
injury
35-44 YR
45-64 YR
65+ YR
Unintentional
injury
Cancer
Heart disease
Suicide
Homicide
Cancer
1 leart disease
Unintentional
injury
Chronic
Heart disease
Cancer
respiratory
disease
262
SECTION II
Swiss cheese model
In complex organizations, flaws in multiple

processes and systems may align to cause
patient harm. Focuses on systems and
conditions rather than an individual's error.
FaAtrts m defense strategy

Hazard
N 'i i
|"
II M
Swapped
Figure
Types of medical
errors
May involve patient identification, diagnosis, monitoring, nosocomial infection, medications,

procedures, devices, documentation, handoffs. Errors causing harmful outcomes must be disclosed
to patients.
Active error
Occurs at level of frontline operator (eg, wrong

IV pump dose programmed).
Immediate impact.
Latent error
Occurs in processes indirect from operator hut

impacts patient care ( eg, different types of IV
pumps used within same hospital ).
Accident waiting to happen.
Root cause analysis
Uses records and participant interviews to

identify all the underlying problems that led to
an error. Categories of causes include process,
people (providers or patients), environment,
equipment, materials, management.
Retrospective approach applied after failure

event to prevent recurrence.
Plotted on fishbone ( Ishikawa, cause-and-effect )
diagram. Fix causes with corrective action
Failure mode and
Uses inductive reasoning to identify all the ways

a process might fail and prioritize these by
their probability of occurrence and impact on
patients.
forward-looking approach applied before process

implementation to prevent failure occurrence.
Medical error analysis
effects analysis
plan.
32
SECTION II
BIOCHEMISTRY MOLECULAR
BIOCHEMISTRY
Chromatin structure
DNA double- helix
HI histone
(linker)
DNA
Revised
Figure
Supercoiled
structure
ELK:h omatir
Nucleosome
(H2 A, H2B,
H3, H4) X 2
DNA exists in the condensed, chromatin form

in order to fit into the nucleus. Negatively
charged DNA loops tw ice around positively
charged histone octamer to form nucleosome
beads on a string. Histones are rich in the
amino acids lysine and arginine. HI binds to
the nucleosome and to linker DNA, thereby
stabilizing the chromatin fiber.
In mitosis, DNA condenses to form
chromosomes. DNA and histone synthesis
occur during S phase.
Heterochromatin
eta phase
chromosome
Heterochromatin_
Condensed, appears darker on EM (labeled H

in gj Transcriptionally inactive, stericallv
inaccessible t methvlation, 1 acetylation!
HeteroChromatin = Highly Condensed.

Barr bodies (inactive X chromosomes) are
heterochromatin.
Euchromatin
Less condensed, appears lighter on EM ( labeled

E in Hi Transcriptionally active, stericallv
Eu = true, truly transcribed.

Euchromatin is Expressed.
DNA methylation
Template strand cytosine and adenine are

methylated in DNA replication, which allows
mismatch repair enzymes to distinguish
between old and new strands in prokaryotes.
DNA methylation at CpG islands represses
accessible.
CpG Methylation Makes DNA Mute.
transcription.
Histone methylation
Usually reversibly represses DNA transcription,
Histone Methylation Mostly Makes DNA Mute.
but can activate it in some cases depending on
methylation location.
Histone acetylation
Relaxes DNA coiling, allowing for transcription.
Histone Acetylation makes DNA Active.
Transcriptionally active, sterically accessible.

Template strand cytosine and adenine are
methylated in DNA replication, which allows
mismatch repair enzymes to distinguish
between old and new strands in prokaryotes.
DNA methylation at CpG islands represses
transcription.
Usually reversibly represses DNA transcription,
but can activate it in some cases depending on
methylation location.
Relaxes DNA coiling, allowing for transcription.
DNA methylation
Histone methylation
Histone acetylation
CpG Methylation Makes DNA Mute.

Histone Methylation Mostly Makes DNA Mute.
Histone Acetylation makes DNA Active.
BIOCHEMISTRY
NucIcoSidc = base + ( dcoxylribose ( Sugar ).

NucleoTide = base + (deoxy )ribose + phosphaTe;
linked by V-V phosphodiester bond.
Nucleotides
PURines (A G) 2 rings.
PYrimidines (C,U,T)-1 ring.
Deamination of cytosine makes uracil.

Deamination of adenine makes guanine.
Uracil found m KNA ; thvminc in DNA .
Methylation of uracil makes tliviuinc ]
Purine (A C)
Pyrimidine (C U, T)
CO,
Aspartate
Glycine
\
c
N10
Euchromatin is Expressed.
-Formvt -
C ^N10 -Formyl tetrahydrofolate

N
..\
Carbamoyl
-A
phosphate
Aspartate
\N
[i
s' end of incoming nucleotide bears the
triphosphate ( energy source for the bond ).

Triphosphate bond is target of the V hydroxyl
attack ]
IT Rc As Gold.
CUT the PY (pie).

Thymine has a methyl.
G-C bond ( t H bonds) stronger than A-T bond
( 2 11 bonds; "G - C bonds arc like Graze Glue ),
t G-C content
t melting temperature of
DNA.
GAG Amino acids necessary for purine
synthesis:
Glvcine
Aspartate
Glutamine
Genetic code features
Unambiguous
Each codon specifies only 1 amino acid.
Degenerate/
redundant
Most amino acids are coded by multiple codons.
Commaless,
nonoverlapping
Read from a fixed starting point as a continuous

sequence of bases.
Genetic code is conserved throughout
evolution .
Accurate base pairing is usually required only in
first 2 nucleotide positions of mRNA codon .
Universal
Wobble
Exceptions: methionine and try ptophan encoded

by only 1 codon (AUG and UGG, respectively).
Exceptions: some viruses.
Exception in humans: mitochondria .
Codons that differ in srd , "wobble position may
code for same tRN.Vamino acid .
BIOCHEMISTRY
35
SECTION II
DNA replication
Eukaryotic DNA replication is more complex than the prokaryotic process but uses many
enzymes analogous to those listed below. In both prokaryotes and eukary otes, DNA replication is
semiconservative and involves both continuous and discontinuous ( Okazaki fragment ) synthesis,
V direction!
and occurs in the V
Prigin of
replication Q
Particular consensus sequence of base pairs

in genome where DNA replication begins.
May be single ( prokaryotes) or multiple
(eukaryotes).
Y-shaped region along DNA template where
leading and lagging strands are synthesized.
Peplication forkQ
pielicaseQ
pingle- stranded
binding proteinsjjj
pNA
topoisomerases
)
Al-rich sequences ( such as '1 VIA box regions!
are found in promoters and origins of
replication.
Unwinds DNA template at replication fork.

Prevent strands from reannealing.
Create a single- or double-stranded break in the
helix to add or remove supercoils.
Irinotecan /lopotecan inhibits eukaryotic

topoisomerase 1.
Etoposide/teniposidc inhibit eukaryotic
topoisomerase II.
Fluoroquinolones inhibit prokaryotic topoisomerase
11 ( DNAgvrase ) and topoisomerase IV|
Makes an RNA primer on which DNA
PrimaseJQ
pNAJpolymerase llljgj
polymerase III can initiate replication.

Prokary otic only. Elongates leading strand
by adding dcoxynuclcotidcs to the V end.
Elongates lagging strand until it reaches
primer of preceding fragment. V -* 5'
exonuclease activity proofreads" each added
nucleotide.
DNA polymerase 111 has 5' V synthesis and

proofreads with V 5' exonuclease.
Drugs blocking DNA replication otten base
modified V OH, pres enting addition of the next
nucleotide ("chain termination" ).
PNA polymerase IJJJ
Prokary otic only. Degrades RNA primer;

replaces it w ith DNA.
PNA ligasej]
Catalyzes the formation of a phosphodiestcr

loins Okazaki fragments.
bond within a strand of double-stranded DNAj
Often dysregulated in cancer cells, allowing
F.ukarvotes only An RNA -dependent DNA
unlimited replication.
polymerase that adds DNA to V ends of
chromosomes to avoid loss of genetic material
with every duplication.!
Telomerase
Sam functions as DNA polymerase lll;!ilso

excises RNA primer w ith 5' - V cxonucleasc.
,QTopoisomerase
DNA polymerase III
Ongmof replication
Helicase
Leading strand
Replication fork
Single - stranded
Origin of replication
binding protein
Lagging strand
Area o( interest
Leading strand
RNA primer
DNA tigase Revise
Primase
Fa
Lagging strand
Lagging strand
Okazaki fragment
Id
ovvnM
Leading strand
A polymerase III
III
DNA polymerase I
BIOCHEMISTRY
DNA repair
Single strand
Nucleotide excision
repair
Base excision repair
Defective in xeroderma pigmentosum, which

Specific endonucleases release the
oligonucleotides containing damaged bases;
prevents repair of pyrimidine dimers because
DNA polymerase and ligase fill and reseat the
of ultraviolet light exposure.
gap, respectively. Repairs bulky helix-distorting
lesions. Occurs in G( phase of cell cycle.
Base-specific Glvcosylasdremoves altered base
and creates AP site (apurinic/apyrirnidinic).
One or more nucleotides are removed bv
AP-Endonucleas which cleaves the 5' end.
Lyase cleaves the V end. DNAIj)lymerase-P
fills the gap and DNA jjjgasc seals it. Occurs
Important in repair of spontaneous/toxic

deamination.^
GEL PLease= (Glvcosvlase Endonuclease,
Lvase, Polymerase b. Ligase)
throughout cell cycle.

Mismatch repair
Newly synthesized strand is recognized,

mismatched nucleotides are removed,
and the gap is filled and rescaled. Occurs
predominantly in G-, phase of cell cycle.
Defective in Lynch syndrome (hereditary

nonpolyposis colorectal cancer [HNPCC]).
Double strand
Nonhomologous end
joining
DNA /RNA / protein

synthesis direction
Brings together 2 ends of DNA fragments to

repair double-stranded breaks. No requirement
for homologv. Some DNA mav be lost.
DNA and RNA arc both synthesized 5' V.

The 5' end of the incoming nucleotide bears
the triphosphate (energy source for bond ).
Protein synthesis is N-terminus to C-terminus.
Mutated in ataxia telangiectasia and breast /

ovarian cancers with BRC AI mutation;
Fanconi anemia]
mRNA is read 5' to V.

The triphosphate bond is the target of the
V hydroxyl attack . Drugs blocking DNA
replication often have modified V OH,
preventing addition of the next nucleotide
(chain termination").
Start and stop codons
mRNA start codons
Eukaryotes
AUG ( or rarely GUG).
At 1C inAUGurates protein synthesis.
Codes for methionine, which may be removed
before translation is completed.

Prokaryotes
mRNA stop codons
Codes for N-formylmethionine ( fMet).
fMet stimulates neutrophil chemotaxis.
UGA, UAA, UAG.
UGA = U Go Away.
UAA = lT Are Away
UAG = U Are Gone
UJ 8
SECTION II
BIOCHEMISTRY
Functional
organization of a
eukaryotic gene
Transcription start
(mRNA synthesized 5'
CAAT box
Coding strand 5'
CAAT
30
Polyadenylation
ATG = Start codon
TATA box
signal
"
TATAAT
Exonl
GT
5' UTR
Promoter
AG
Exon 2 GT
AG
Intron 1
Intron 2
Exon 3 AATAAA
}y
3' UTR
Regulation of gene expression
Promoter
Site where RNA polymerase II and multiple

other transcription factors bind to DNA
upstream from gene locus ( AT-rich upstream
sequence with TATA and CAAT boxes).
Promoter mutation commonly results in

dramatic 1 in level of gene transcription.
Enhancer
Stretch of DNA that alters gene expression by

binding transcription factors ( eg activator
Enhancers and silencers may be located close to,

far from, or even within (in an intron) the gene
whose expression it regulates.
Silencer
Site where negative regulators ( repressors) bind.
protcinsi
RNA polymerases
Eukaryotes
I, II, and III are numbered in the same order

RNA polymerase I makes rRNA imost
that their products are used in protein
numerous RNA, rampant).
sy nthesis: rRNA, mRNA, then tRN.U
RNA polymerase II makes mRNA ( largest RNA,
massive) mRNA is read 5' to V.
a-amanitin, found in Amanita phalloides (death
RNA polymerase III makes sS rRNA, tRNA
cap mushrooms ), inhibits RNA polymerase II.
Causes severe hepatotoxicity if ingested.
(smallest RNA, tiny).
No proofreading function, but can initiate
J\ctinomycin D inhibits RNA polymerase in
chains. RNA polymerase 11 opens DNA at
both prokary otes and eukaryotes.
promoter site.
Prokaryotes
1 RNA polymerase (multisubunit complex)

makes all s kinds of RNA.
Rifampin inhibits RNA polvmerase in

prokaryotes.
iRevised
Figure
40
SECTION II
BIOCHEMISTRY
tRNA
Structure
75-90 nucleotides, 2 structure, doverleaf form, anticodon end is opposite 5' aniinoacy! end. All
tRNAs, both eukaryotic and prokaryotic, have CCA at 5' end along with a high percentage of
chemically modified bases. The amino acid is covalently bound to the 5' end of the tRNA. CCA
Can Carry Amino acids.
T-arm: contains the TH'C (ribothymidine, pseudouridine, cytidine) sequence necessary for tRNAribosome binding. T-ann Tethers tRNA molecule to ribosointj
D-arm: contains diliydrouridine residues necessary for tRNA recognition by the correct aminoacyTtRNA synthetase. D-arm Detects the tRNA bv aminoacvl-tRNA svnthctascj
Acceptor stem: the 5 CCA-5' is the amino acid acceptor site.
Charging
Aminoacyl-tRNA synthetase ( 1 per amino acid; matchmaker; uses ATP) scrutinizes amino acid
before and after it binds to tRNA If incorrect, bond is hydrolyzed. The amino acid-tRNA bond
has energy for formation of peptide bond. A mischarged tRNA reads usual codon but inserts
wrong amino acid.
Aminoacyl-tRNA synthetase and binding of charged tRNA to the codon are responsible for
accuracy of amino acid selection.
Charging
Pairing
(aminoacylation)
( codon- anticodon)
Structure
OH
- 0
l:
Acceptor stem Ti -arm
Arruno acid
-*-
Aminoacyl-tRNA
synthetase
D-arm
V 0 C 0 > * * *c
* * *
Variable armS
Anticodon
loop
Amino acid
^0
Ir
t
îi.
. ..
position
.....,
a
ii
"
mRNA
: :
Anticodon 15 CAU 5 I-C*

'
^Wobble
IF2
*
" "
(Initiation factor )
ATP
, ..u
c cC cC a
S
1
'
r
Codon
(S AUG 5 )
Et
Protein synthesis
Initiation
Elongation
Initiated by CTP hydrolysis; initiation factors

( eukaryotic IP's ) help assemble the 40S
ribosomal subunit with the initiator tRNA
and are released when the mRNA and the
ribosomal 60S subunit assemble with the
complex.
1. Aminoacyl-tRNA binds to A site (except for
Kukaryotes: 40S + 60S -* 80S ( Even ).

PrOkaryotcs: 10S + 50S 70S lOdd ).
Suithesis occurs troin N - lermimis to
C-terminns
ATP tRNA Activation ( charging).

GTP tRNA Gripping and Going places
(translocation ).
initiator methionine)
2. rRNA ( ribozyme") catalyzes peptide bond

formation, transfers growing polypeptide to
amino acid in A site
A Ribosome advances 5 nucleotides toward 5'
end of mRNA, moving peptidvl tRNA to 1'
site (translocation)
Termination
Stop codon is recognized by release factor,

and completed polypeptide is released from
ribosome.
Think of going APE":

A site = incoming Aminoacyl-tRNA .
P site = accommodates growing Peptide.
E site = holds Empty tRNA as it Exits.
f < sl
ssr \
rO fc U
S'
sV
i
'
- -
*
Revised
Figure
40S
B
\42
SECTION II
BIOCHEMISTRY
BIOCHEMISTRY CELLULAR
Cell cycle phases
Checkpoints control transitions between phases of cell cycle. This process is regulated by cyclins,
cyclin-dependent kinases (CDKs), and tumor suppressors. M phase (shortest phase of cell cycle)
includes mitosis ( prophase, prometaphase, metaphase, anaphase, telophase) and cytokinesis
( cytoplasm splits in two). C| and G( arc of variable duration.
REGULATION OF CEIL CYCLE
Cydin- dependent
Constitutive and inactive.
kinasej
'
Regulator) proteins that control cell cycle

events; phase specific; activate CDKs.
Cydin- CDK complexes Phosphorylate other proteins to coordinate
cell cycle progression; must be actu ated and
inactivated at appropriate times for cell cycle
to progress.
Tumor suppressors
pot induces p2l, which inhibits CDKs
hypophosphorylation (activation) of Rb
H inhibition of G,-S progression. Mutations in
Cyclins
XX
X
XX
/i
tumor suppressor genes resuli in unrestrained

cell division (eg. Li-Fraumeni syndrome).
vs
*'. , .
Rb p53 modulate
G restriction point
10
CEUTYPES
Remain in G0, regenerate from stem cells.
Neurons, skeletal and cardiac muscle RBCs.
Stable (quiescent)
Enter G| from Gn when stimulated.
Hepatocytes, lymphocytes.
Labile
Never go to G(), divide rapidly w ith a short G( .

Most affected b\ chemotherapv.
Bone marrow, gut epithelium, skin, hair follicles,

germ cells.
Rough endoplasmic
reticulum
Site of synthesis of secretory (exported) proteins

and of N-linked oligosaccharide addition to
many proteins.
Nissl bodies ( RER in neurons) synthesize
peptide neurotransmitters for secretion.
Free ribosomes unattached to any membrane;
site of synthesis of cytosolic and organellar
proteins.
Mucus-secreting goblet cells of the small

intestine and antibody-secreting plasma cells
are rich in RER.
Smooth endoplasmic
reticulum
Site of steroid synthesis and detoxification of

drugs and poisons. Lacks surface ribosomes.
Laver hepatocytes and steroid hormoneproducing cells of the adrenal cortex and
gonads are rich in SER.
Permanent
BIOCHEMISTRY
43
SECTION II
Golgi is the distribution center for proteins and lipids from the ER to the vesicles and plasma
membrane. Modifies N-oligosaccharidcs on asparagine. Adds O-oligosaccharides on serine and
threonine. Adds mannose-6-phosphate to proteins for trafficking to lysosomes.
Endosomes are sorting centers for material from outside the cell or from the Golgi, sending it to
lysosomes for destruction or back to the membrane/Golgi for further use.
Cell trafficking
l-cell disease (inclusion cell disease/mucolipidosis type II) inherited lysosomal storage disorder;
defect in N-acetylglucosaminyl-l-phosphotransferase failure of the Golgi to phosphors late
mannose residues ( ic, i mannosc-6-phosphatc) on glycoproteins
proteins arc secreted
extraeellularly rather than delivered to lysosomes. Results in coarse facial features, clouded
corneas, restricted joint movement, and high plasma levels of lysosomal enzymes Often fatal in
childhood.
K>
10
Signal recognition particle (SRP)

Abundant, cytosolic ribonucleoprotein that
*****
Clathrin
y
Early
endo
COM
Late
traffics proteins from the ribosome to

the RER. Absent or dysfunctional SRP
-* proteins accumulate in the cytosol.
Vesicular trafficking proteins

COPI: Golgi Golgi ( retrograde); cis Golgi
endosome
COMI
Golgi
apparatus
'
reticu inn
cis-Golgi (anterograde).
c:*
Endoplasmic
1 vo (COP11 ) steps forward ( anterograde); one

(GOPI ) step back ( retrograde ).
Clathrin: trans-Golgi lysosomes; plasma
membrane endosomes (receptormediated endoeytosis [eg, LDL receptor
CIS
activity]).
Nuclear envelope
Peroxisome
FR.
COPI1: ER
aiK
Membrane-enclosed organelle involved in catabolism of vcry-long-chain fattv acids ( through

( - oxidation), branchcd-chain fatty acids, amino acids, and ethanol.
i
Diseases o| the iicroxisoine coiiiiimiiK K - nl to neurologic diseases due I deficits in ssnthesis
"
il plasmalogens, imporlant phospholipids in irnelin. PeroxiMiin il diseases include Zellweger
syndrome i hypotonia, seziures. hepatomegaly, earlv deathi and Refsum disease iscalv skin, ataxia.
cataracts/night blindness, shortening of 4th toe, cpiphvseal dvsplasia ).
BIOCHEMISTRY
Cytoskeletal elements
A netw ork of protein fibers within the cytopl:asm that supports cell structure, cell and organelle
movement, and cell division.
TYPE OF FILAMENT
PREDOMINANT FUNCTION
EXAMPLES
Microfilaments
Muscle contraction, cytokinesis
Actin, microvilli.
Intermediate
filaments
Maintain cell structure
Vimentin, desmin, cytokeratin, larnins, glial

fibrillary acid proteins (GFAP), neurofilaments.
Microtubules
Movement, cell division
Cilia, flagella, mitotic spindle, axonal trafficking,

centrioles.
Immunohistochemical stains for intermediate filaments

STAIN
CELL TYPE
IDENTIFIES
ViMEntinj
MEsenchvmal tissue leg. fibroblasts.

endothelial cells, macrophages!
MEsenchvmal tumors leg. sarcoma), but

also manv other tumors (eg. cndoMEtrial
carcinoma, renal cell carcinoma.
MEningiomai
DesMin
Muscle
Cytokeratin
Epithelial cells
GFAP
NeuroGlia
Muscle tumors (eg, rhabdomyosarcoma)
Epithelial tumors (eg, squamous cell carcinoma )
( eg, astrocytes, Schw ann cells,
Astrocytoma, glioblastoma
oligodendroglia)
Neurofilaments
Microtubule
Positive
end (+)
Heterodimer
Neuronal tumors (eg, neuroblastoma)
Neurons
Drugs that act on microtubules ( Microtubules

Cylindrical outer structure composed of a
helical array of polymerized heterodimers
Get Constructed Yerv Poorly ):
Mebendazole (antihclminthic)
of a- and [J- tubulin. Each dimer has 2 GTP
bound. Incorporated into flagella, cilia, mitotic
Griscofulvin (antifungal)
Colchicine (antigout)
spindles. Grows slowly, collapses quickly .
Also involved in slow axoplasmic transport in
VincristineA'inblastine (anticancer )
neurons.
Protofilament
Negative
end H
Paclitaxel (anticancer )
Molecular motor proteins transport cellular

cargo toward opposite ends of microtubule
Negative end Near Nucleus

Positive end Points to Periphery
tracks.
Dynein retrograde to microtubule (+ -* ).
Kinesin anterograde to microtubule ( +).
BIOCHEMISTRY
Cilia structure
Sodium-potassium
pump
9 doublet + 2 singlet arrangement ol
microtubules farrows in Q).

Basal bods ( base of cilium below cell
membrane) consists of 9 microtubule triplets
( arrow in Ehvitli no central niieroliihulei
Axonemal dynein ATPase that links peripheral
9 doublets and causes bending of cilium by
differential sliding of doublets.
SECTION II
45
Kartagener syndrome (1 ciliary dyskinesia)

immotile cilia due to a dynein arm defect.
Results in 1 male and female fertility due tet
immotile sperm and dysfunctional fallopian

lube cilia, respectively; t risk of ectopic
pregnancy. Can cause bronchiectasis,
recurrent sinusitis, chronic ear infections,
conductive hearing loss, and situs inversus ( eg,
dextrocardia on CXRll
Pl MPKIM - PI IMP K2 IN
Xa+-K+ ATPase is located in the plasma
membrane with ATP site on cytosolic side.
Ouabain inhibits by binding to K+ site.
Cardiac glycosides ( digoxin and digitoxin )
For each ATP consumed, sNV go out of the
cell ( pump phosphorylatcd ) and 2K* come into directly inhibit the Na -K+ ATPase, which
leads to indirect inhibition of Na+/Ca+
the cell (pump dephosphorylated ).
Plasma membrane is an asymmetric linid
exchange t [Ca*]j -* t cardiac contractility.
'
bilaver containing cholesterol, phospholipids.

sphingolipids, glvcolipids, and proteins.
Extracellular
space
3Na+ /*
V*nf
Membrane
Cytosol
j. i
* e)
V1
A
A
I I ) {Vjtf '- fs
cr ,
i
5Na+
'
P
ATP
ADP
2K*
*\
2K
BIOCHEMISTRY
Osteogenesis
imperfecta
Genetic bone disorder ( brittle bone

disease) caused by a variety of gene defects
(most commonly COLlAl and COL1 A2 ).
Most common form is autosomal dominant
with t production of otherwise normal type I
collagen. Manifestations can include:
Multiple fractures with minimal

trauma Q Q; may occur during the birth
SECTION II
May be confused with child abuse.
Patients can t BITI

B ( BONES = multiple fractures )
I ( LVL - blue sclerae)
I ( TFhTH = dental imperfections!
I ( PAR - hearing loss)
process
Blue sclerae Q due to the translucent
connective tissue over choroidal veins
(Some forms have tooth abnormalities,
including opalescent teeth that wear easily
due to lack of dentin ( dentinogenesis
imperfecta)
Hearing loss ( abnormal ossicles|
Upper
extremity
Ehiers-Danlos
syndrome
Menkes disease
Fault) collagen synthesis causing

hyperextensiblc skin, tendency to bleed ( easy
bruising), and hvpermobile joints Q.
Multiple tvpes. Inheritance and severity vary.
Can be autosomal dominant or recessive. May
be associated with joint dislocation, berry and
aortic aneurysms, organ rupture.
Hypermobility tvpc ( joint instability): most

common type.
Classical type ( joint and skin symptoms): caused

by a mutation (eg, COL5AI , COLSAZjin type
V collagen.
Vascular type (vascular and organ rupture l:
deficient type III collagen.
X-linked recessive connective tissue disease caused by impaired copper absorption and transport
due to defective Menkes protein (ATP7A). Leads to i activity oflysyl oxidase ( copper is a
necessary cofactor). Results in brittle, kinky" hair, growth retardation, and hypotonia.
47
50
SECTION II
Flow cytometry
BIOCHEMISTRY
BIOCHEMISTRY
LABORATORY TECHNIQUES
Laboratory technique to assess size, granularity,

and protein expression ( immunophenotype ) of
individual cells in a sample.
Cells arc tagged with antibodies specific to

surface or intracellular proteins. Antibodies
are then tagged with a unique fluorescent
dye. Sample is analyzed one cell at a time by
focusing a laser on the cell and measuring
light scatter and intensity of fluorescence.
Commonly used in workup of hematologic

abnormalities (eg, paroxysmal nocturnal
hemoglobinuria , fetal RBCs in mothers blood )
and immunodeficiencies ( eg, CD4 cell count
in HIV ).
Fluorescent
label
Antibody
y w>*
Anb -CD3 Ab 'J
Anti -CD8 Ab
Cell
/1
LT :CI
Huorescence
is detected .
labeled cells
re
z1
are counted
Data are plotted either as histogram (one

measure) or scatter plot (any two measures, as
shown ). In illustration:
Cells in left lower quadrant for both CDS
and CD3.
Cells in right lower quadrant for CDS and
for CDllt Right lower quadrant is empty
because all CDS-expressing cells also express
Cells in left upper quadrant for CDs and
0 for CPtt
Cells in right upper quadrant for CD8
and CDs ( red + blue purple).
Microarrays
10*
10 s
8 102
to1
life
10
10
CDx i
Laser makes
label fluoresce
10!
10
CM
10!
10*
63
Thousands of nucleic acid sequences are arranged in grids on glass or silicon . DNA or RNA probes
are hybridized to the chip, and a scanner detects the relative amounts of complementary binding.
Used to profile gene expression levels of thousands of genes simultaneously to study certain diseases
and treatments. Able to detect single nucleotide polymorphisms (SNPs) and copy number
variations (CNVs) for a variety of applications including genotyping, clinical genetic testing,
forensic analysis, cancer mutations, and genetic linkage analysis.
BIOCHEMISTRY
BIOCHEMISTRY
LABORATORY TECHNIQUES
51
SECTION II
Note that line art for Enzyme linked immunosorbent assay was deleted and text
rewritten in 8th pass pages for 2016 edition. Please clarify needed changes.
Enzyme -linked
immunosorbent assay
Immunologic test used to detect the presence of either a specific antigen (eg. HBsAg ) or antibody
(eg, anti- HBs) in a patient s blood sample. Detection involves the use of an antibody linked to an
enzyme. Added substrate reacts with cnzvtnc, producing a detectable signal ( eg, color change ).
Major ELISA variations include direct , sandwich , and competitive. Can have high sensitivity and
specificity.
Karyotyping
A process in which metaphase chromosomes arc stained , ordered, and numbcrcdJQ according to
morphology, size, arm-length ratio, and banding pattern. Can be performed on a sample of blood ,
bone marrow, amniotic fluid , or placental tissue. Used to diagnose chromosomal imbalances (eg,
autosomal tTisomies, sex chromosome disorders).
Al
19
Fluorescence in situ
hybridization
..
IQ
Fluorescent DNA or RNA probe binds to specific gene site of interest on chromosomes (arrows in
point to abnormalities!
)
Used for specific localization of genes and direct visualization of chromosomal anomalies at the
molecular level.
..
\ lu lodclctiiin l i e i : n
a hi
i t I to
n
al the same 1 ir
on the second copy of that chromosome
Translocation fluorescence outside the original chromosome
Duplication extra site of fluorescence on one hromosomc relative I " its lionn ilogous
i
chromosome
Cloning methods
Cloning is the production of a recombinant DNA molecule that is self- perpetuating.

Steps:
1. Isolate eukaryotic mRNA ( post-RNA processing stepsi of interest.
2. Expose mRNA to reverse transcriptase to produce cDNA ( lacks introns).
v Insert cDNA fragments into bacterial plasmids containing antibiotic resistance genes.
4. Transform recombinant plasmid into bacteria.
5. Survis ing bacteria on antibiotic medium produce cloned DNA (copies of cDNA).
BIOCHEMISTRY
BIOCHEMISTRY GENETICS
'i ,
Genetic terms (continued )

TERM
DEFINITION
EXAMPLE
Mosaicism
Presence of genetically distinct cell lines in the
McCune- Albright syndrome due to mutation

affecting G-protcin signaling. Presents with
unilateral cafc-au-lait spots with ragged
edges, polyostotic fibrous dysplasia, at least
one endocrinopathv (eg. precocious pubertvi
same individual.
Somatic mosaicism mutation arises from

mitotic errors after fertilization and propagates
through multiple tissues or organs.
Gonadal mosaicism mutation onlv in egg or
sperm cells. If parents and relatives do not
have the disease, suspect gonadal (or germline )
Lethal if mutation occurs before fertilization

(affecting all cells), but survivablc in patients
with mosaicism.
mosaicisni
Locus heterogeneity
Mutations at different loci can produce a similar
Albinism.
Allelic heterogeneity
phenotype.
Different mutations in the same locus
produce the same phenotype.
ff-thalassemia.
Heteroplasmy
Presence of both normal and mutated

mlDNA, resulting in variable expression in
mitochondrially inherited disease.
Uniparental disomy
Offspring receives 2 copies of a chromosome from Uniparental is el ploid ( correct number of

chromosomes ), not aneuploid. Most occurrences
1 parent and no copies from the other parent.
of UPD normal phenotype. Consider UPD
1 Ictcrodlsomv (heterozygous) indicates a meiosis
1 error. Isodlsomv (homozygous) indicates a
in an individual manifesting a recessive disorder
meiosis II errodor postzygotic chromosomal
when only one parent is a carrier.
duplication of one of a pair of chromosomes,
and loss of the other of the original pair.
Hardy-Weinberg
population genetics
pA
qa
pA
qa
AA
Aa
'
P * P =P
pxq
Aa
aa
pxq
qxq = q>
If a population is in Hardy-Weinberg
equilibrium and if p and q arc the frequencies
of separate alleles, then: p" + 2pq + q
= 1 and
p + q = 1, which implies that:
p- = frequency of homozygosity for allele
q- = frequency of homozygosity for allele j
2pq = frequency of heterozygosity (carrier
frequency, if an autosomal recessive disease ).
Tlw * frpnupnrv of an YJSnl'prl wrfsivp rlunacp
Hardy-Weinberg law
assumptions include:
No mutation occurring at the locus

Natural selection is not occurring
Completely random mating

No net migration
Variable expressivity
Patients with the same genotype have varying

phenotypei
2 patients with neurofibromatosis type 1 ( NF1)

may have varying disease severity.
Incomplete
penetrance
Not all individuals with a mutant genotype

show the mutant phenotype.
BRCAl gene mutations do not always result in

breast or ovarian cancer.
Pleiotropy
One gene contributes to multiple phenotypic

effects.
Untreated phenylketonuria ( PKU ) manifests with

light skin, intellectual disability, and musty hods
odor.
Anticipation
Increased severity or earlier onset of disease in

succeeding generations.
Trinucleotide repeat diseases ( eg, Huntington

disease).
Loss of heterozygosity
If a patient inherits or develops a mutation in

a tumor suppressor gene, the complementary
Retinoblastoma and the two-hit hypothesis,

Lynch syndrome ( HNPCC), Li-Fraumeni
syndrome.
allele must be delctcd /mutated before cancer

develops. This is not true of oncogenes.
Dominant negative
mutation
Linkage
disequilibrium
Exerts a dominant effect. A heterozvgote

produces a nonfunctional altered protein that
also prevents the normal gene product from
functioning.
Tendency for certain alleles at 2 linked
loci to occur together more or less often
than expected by chance . Measured in a
population, not in a family, and often varies in
different populations.
Mutation of a transcription factor in its allosteric

site. Nonfunctioning mutant can still bind
DNA, preventing wild-type transcription factor

from binding.
BIOCHEMISTRY
'i ,
Genetic terms (continued )

TERM
DEFINITION
EXAMPLE
Mosaicism
Presence of genetically distinct cell lines in the
McCune- Albright syndrome due to mutation

affecting G-protcin signaling. Presents with
unilateral cafc-au-lait spots with ragged
edges, polyostotic fibrous dysplasia, at least
one endocrinopathv (eg. precocious pubertvi
same individual.
Somatic mosaicism mutation arises from

mitotic errors after fertilization and propagates
through multiple tissues or organs.
Gonadal mosaicism mutation onlv in egg or
sperm cells. If parents and relatives do not
have the disease, suspect gonadal (or germline )
Lethal if mutation occurs before fertilization

(affecting all cells), but survivablc in patients
with mosaicism.
mosaicisni
Locus heterogeneity
Mutations at different loci can produce a similar
Albinism.
Allelic heterogeneity
phenotype.
Different mutations in the same locus
produce the same phenotype.
ff-thalassemia.
Heteroplasmy
Presence of both normal and mutated

mlDNA, resulting in variable expression in
mitochondrially inherited disease.
Uniparental disomy
Offspring receives 2 copies of a chromosome from Uniparental is el ploid ( correct number of

chromosomes ), not aneuploid. Most occurrences
1 parent and no copies from the other parent.
of UPD normal phenotype. Consider UPD
1 Ictcrodlsomv (heterozygous) indicates a meiosis
1 error. Isodlsomv (homozygous) indicates a
in an individual manifesting a recessive disorder
meiosis II errodor postzygotic chromosomal
when only one parent is a carrier.
duplication of one of a pair of chromosomes,
and loss of the other of the original pair.
Hardy-Weinberg
population genetics
pA
qa
pA
qa
AA
Aa
'
P * P =P
pxq
Aa
aa
pxq
qxq = q>
If a population is in Hardy-Weinberg
equilibrium and if p and q arc the frequencies
of separate alleles, then: p" + 2pq + q
= 1 and
p + q = 1, which implies that:
p- = frequency of homozygosity for allele
q- = frequency of homozygosity for allele j
2pq = frequency of heterozygosity (carrier
frequency, if an autosomal recessive disease ).
Tlw * frpnupnrv of an YJSnl'prl wrfsivp rlunacp
Hardy-Weinberg law
assumptions include:
No mutation occurring at the locus

Natural selection is not occurring
Completely random mating

No net migration
56
SECTION II
Autosomal dominant
diseases
BIOCHEMISTRY
Achondroplasia, autosomal dominant polycystic kidney disease, familial adenomatous polyposis,

familial hypercholesterolemia, hereditary hemorrhagic telangiectasia, hcrcditjrv spherocytosis,
Huntington disease, Li-Fraumeni syndrome, Marfan syndrome, multiple endocrine neoplasias,
neurofibromatosis type 1 (von Recklinghausen disease), neurofibromatosis type 2, luberous
sclerosis, von I lippel-Lindan disease.
Hereditary
hemorrhagic
telangiectasia
Inherited disorder ofblood vessels. Findings: blanchingskin lesions ( telangiectasias), recurrent

epistaxis, skin discolorations, arteriovenous malformations (AVMs), GI bleeding, hematuria. Also
known as Osler-VVeber-Rendu syndrome.
Li- Fraumeni
syndrome
Abnormalities in f P53 ichromosome 17 ) multiple malignancies at an early age. Also known as

SBLA cancer syndrome (sarcoma, breast, leukemia, adrenal gland).
Marfan syndrome
FBN1 gene mutation on chromosome 15 defective fibrillin (scaffold for elastin) connective
tissue disorder affecting skeleton, heart, and eyes. Findings: tall with long extremities, pectus
carinatum I more specific ) or pectus excavatunj hvpermobile joints, and long, tapering fingers and
toes (arachnodactyly); cystic medial necrosis of aorta aortic incompetence and dissecting aortic
aneurysms; floppy mitral valve. Subluxation of lenses, typically upward and temporally.
Neurocutaneous disorder characterized by cafe-au-lait spots, cutaneous neurofibromas, optic

gliomas, pheochromocytomas, Lisch nodules ( pigmented iris hamartomas). 100% penetrance,
variable expression. Caused by mutations in the NFI gene on chromosome 17; 17 letters in "von
Recklinghausen.
Neurofibromatosis
type 1 (von
Recklinghausen
disease)
Findings: bilateral acoustic schwannomas, juvenile cataracts, meningiomas, and ependymomas.

NF2 gene on chromosome 22; type 2 = 22.
Neurofibromatosis
type 2
Albinism, autosomal recessive polycystic kidney disease ( ARPKD), cvstic fibrosis, glycogen
storage diseases, hemochromatosis, Kartagcncr syndrome, mucopolysaccharidoses (except
Hunter syndrome), phenylketonuria, sickle cell anemia, sphingolipidoscs (except Fabry disease!,
thalassemias, Wilson disease.
Autosomal recessive
diseases
offspring of affected females may show signs of
inheritance
1-0
Or#
disease.
LTO
i# (Soh
= unaffected male;H = affected male; O = unaffected female; #
within a family due to heteroplasmy.

Mitochondrial myopathies rare disorders;
often present with myopathy, lactic acidosis,
and CNS disease, eg, MELAS syndrome
(mitochondrial encephalopathy, lactic
acidosis, and stroke-like episodes ). 2 to

failure in oxidative phosphorylation. Muscle
bio [) s \ otten shows "ragged red fiheis" ( due to
)
accumulations of diseased mitochondria!
- affected female.
66
SECTION II
Autosomal dominant
diseases
BIOCHEMISTRY
Achondroplasia, autosomal dominant polycystic kidney disease, familial adenomatous polyposis,

familial hypercholesterolemia, hereditary hemorrhagic telangiectasia, hcrcditjrv spherocytosis,
Huntington disease, Li-Fraumcni syndrome, Marfan syndrome, multiple endocrine neoplasias,
neurofibromatosis type 1 (von Recklinghausen disease ), neurofibromatosis type 2, luberous
sclerosis, von Hippel-Lindau disease.
Hereditary
hemorrhagic
telangiectasia
Inherited disorder of blood vessels. Findings: blanehin skin lesions ( telangieetasias), recurrent
epistaxis, skin discolorations, arteriovenous malformations (AVMs), GI bleeding, hematuria. Also
known as Osler-VVeber-Rendu syndrome.
Li- Fraumeni
syndrome
Abnormalities in TP53 ichromosome 17 ) multiple malignancies at an early age. Also known as

SBLA cancer syndrome (sarcoma, breast, leukemia, adrenal gland).
Marfan syndrome
FBN1 gene mutation on chromosome 15 defective fibrillin (scaffold for elastin) connective
tissue disorder affecting skeleton, heart, and eyes. Findings: tall with long extremities, pectus
carinatum imore specific ) or pectus exeavatunj hvpermobile joints, and long, tapering fingers and
toes (arachnodactvly); cystic medial necrosis of aorta aortic incompetence and dissecting aortic
aneurysms; floppy mitral valve. Subluxation of lenses, typically upward and temporally.
Neurofibromatosis
type 1 (von
Recklinghausen
disease)
Neurofibromatosis
type 2
Autosomal recessive
diseases
Neurocutaneous disorder characterized by cafe-au-lait spots, cutaneous neurofibromas, optic

gliomas, pheochromocytomas, Lisch nodules ( pigmented iris hamartomas). 100% penetrance,
variable expression. Caused by mutations in the IVF1 gene on chromosome 17; 17 letters in "von
Recklinghausen.
Findings: bilateral acoustic schwannomas, juvenile cataracts, meningiomas, and ependymomas.

NF2 gene on chromosome 22; type 2 = 22.
Albinism, autosomal recessive polycystic kidnev disease (ARPKD), cvstic fibrosis, glycogen
storage diseases, hemochromatosis, Kartagcncr syndrome, mucopolysaccharidoses ( except
Hunter syndrome), phenylketonuria, sickle cell anemia, sphingolipidoscs ( except Fabry disease),
thalassemias, Wilson disease.
$8
SECTION II
BIOCHEMISTRY
BIOCHEMISTRY
Muscular dystrophies
,
T
M HWI
V4Wk
X linkcd disorder typically due to framcshift
Duchenne
S' #?
.*
GENETICS
Becker
Myotonic type 1
Fragile X syndrome
or nonsense mutations truncated or

absent dystrophin proteirt progressive
mvofiber damagrj Weakness begins in pelvic
girdle muscles and progresses superiorly.
Pscudohypertrophy of calf muscles due to
fibrofattv replacement of muscle Q. Gower
maneuver patients use upper extremities
to help them stand up. Waddling gait. Onset
before 5 years of age. Dilated cardiomyopathy
is common cause of death.
Duchenne = deleted dystrophin .

Dystrophin gene ( DJWD) is the largest
protein-coding human gene t chance of
spontaneous mutation. Dystrophin helps
anchor muscle fibers, primarily in skeletal and
cardiac muscle. It connects the intracellular
cvtoskeleton (actin) to the transmembranc
proteins a- and P dystroglycan, which are
connected to the extracellular matrix ( ECM ).
Loss of dystrophin results in myonecrosis
t CK and aldolase are seen ; Western blot and
muscle biopsy confirm diagnosis.

Deletions can cause both Duchenne and
X-linked disorder typically due to non
frameshift insertions in dystrophin gene
Becker.
( partially functional instead of truncated ). Less
severe than Duchenne. Onset in adolescence
or early adulthood.
Autosomal dominant. CTG trinucleotide repeat My Tonia, My Testicles (testicular atrophy ),
My Toupee (frontal balding), My Ticker
expansion in the DMPK gene - abnormal
(arrhythmia).
expression of myotonin protein kinase
myotonia, muscle wasting, cataracts,
testicular atrophy, frontal balding, arrhythmia.
X-linked dominant inheritance. Trinucleotide

repeat in FAIR 1 gene mcthylation
1 expression. Most common cause of
inherited intellectual disability and autism
and 2 nd most common cause of genetically
associated mental deficiency ( after Down
syndrome!Findings:
post pubertal
Trinucleotide repeat disorder (CGG) n.

Fragile X = eXtra large testes, jaw, ears.
COMPLICATIONS
TREATMENT
X-linked recessive
disorders
aureus [ early infancy), t' aeruginosa i adolescence] ), chronic

bronchitis and bronchiectasis reticulonodular pattern on CXR, opacification of sinusei
Pancreatic insufficiency, malabsorption with steatorrhea, fat-soluble vitamin deficiencies (A, D E,
K ), biliary cirrhosis, liver disease. Meconium ileus in newborns.
Infertility in men (absence of vas deferens, spermatogenesis may be unaffected ) and subfertility in
women (amenorrhea, abnormally thick cervical mucus ).
Nasal polyps, clubbing of nails.
Recurrent pulmonary infections ( eg, i
Multifactorial: chest physiotherapy, albuterol , aerosolized dornase alfa ( DNAse), and hypertonic
saline facilitate mucus clearance. Azithromycin used as anti-inflammaton agent . Ibnprofen slow s
disease progressing Pancreatic enzymes for insufficiency.
Ornithine transcarbamyla.se deficiency, Fabry
disease, Wiskott-Aldrich syndrome, Ocular
albinism, G6PD deficiency, Hunter syndrome,
Bruton agammaglobulinemia Hemophilia
A and B, Lcsch - Nyhan syndrome, Duchcnnc
(and Becker) muscular dystrophy.
Lyonization female carriers variabK affected
depending on the percentage inactivation of
the X chromosome earn ing the mutant vs
normal gentj
Oblivious Female \\ ill Often Give I ler Boys

1 ler x-Linked Disorders
$8
SECTION II
BIOCHEMISTRY
BIOCHEMISTRY
Muscular dystrophies
,
T
M HWI
V4Wk
X linkcd disorder typically due to framcshift
Duchenne
S' #?
.*
GENETICS
Becker
Myotonic type 1
Fragile X syndrome
or nonsense mutations truncated or

absent dystrophin proteirt progressive
mvofiber damagrj Weakness begins in pelvic
Pscudohypertrophy of calf muscles due to
to help them stand up. Waddling gait. Onset
before 5 years of age. Dilated cardiomyopathy
is common cause of death.

Dystrophin gene ( DJWD) is the largest
protein-coding human gene t chance of
spontaneous mutation. Dystrophin helps
cvtoskeleton (actin) to the transmembranc
proteins a- and P dystroglycan, which are
connected to the extracellular matrix ( ECM ).
Loss of dystrophin results in myonecrosis
t CK and aldolase are seen ; Western blot and

X-linked disorder typically due to non
frameshift insertions in dystrophin gene
Becker.
( partially functional instead of truncated ). Less
severe than Duchenne. Onset in adolescence
or early adulthood.
Autosomal dominant. CTG trinucleotide repeat My Tonia, My Testicles (testicular atrophy ),
My Toupee (frontal balding), My Ticker
expansion in the DMPK gene - abnormal
(arrhythmia).
expression of myotonin protein kinase
myotonia, muscle wasting, cataracts,
testicular atrophy, frontal balding, arrhythmia.

repeat in FAIR 1 gene mcthylation
1 expression. Most common cause of
inherited intellectual disability and autism
and 2 nd most common cause of genetically
syndrome!Findings:
post pubertal
Trinucleotide repeat disorder (CGG) n.

Fragile X = eXtra large testes, jaw, ears.
. M ifrcte fiber
.
X-linkcd disorder typically due to frameshift
Duchenne
or nonsense mutations truncated nr

absent dystrophin protend progressise
invofiber damagtj Weakness begins in pelvic
Pseudohypertrophy of calf muscles due to
to help them stand up. W addling gait. Onset
before S years of age. Dilated cardiomyopathy
is common cause of death .
Becker

Dystrophin gene ( DMD) is the largest
protein-coding human gene -* t chance of
spontaneous mutation . Dystrophin helps
cytoskeleton (actin ) to the transmembrane
proteins a- and JJ-dystroglycan , which are
connected to the extracellular matrix (ECM ).
Loss ofdvstrophin results in nrvonecrosis.
t CK and aldolase are seen; W'estcrn blot and

X-litrked disorder typically due to non frameshift insertions in dystrophin gene
Becker.
( partialh functional instead of truncated ). Less
scs'crc than Duchenne. Onset in adolescence
or early adulthood .
Autosomal dominant. CTG trinucleotide repeat My Ponia. My Testicles ( testicular atrophy),
My Toupee ( frontal balding ), My Ticker
expansion in the DMPK gene abnormal
(arrhythmia ).
expression ofmyotonin protein kinase
- myotonia, muscle wasting, cataracts,
testicular atrophy, frontal balding, arrhythmia .
'
Myotonic type 1
Fragile X syndrome

repeat in FAJR1 gene methvlation
1 expression . Most common cause of
inherited intellectual disability' and autism
aird 2 nd most common cause of genetically
svndromcl
Trinucleotide repeat disorder (CGG ) n.

Fragile \ = cXtra large testes, jasv, cars.
Findings; post pubcrtal
macroorchidism icnlarged testes ), long face

rvith a large jaw, large everted ears, autism ,
mitral valve prolapse.
Trinucleotide repeat
expansion diseases
Huntington disease, mvotonic dystrophy .

fragile \ syndrome, and Friedreich ataxia.
Mav shorv genetic anticipation ( disease severity
t and age of onset t in successive generations ).
Huntington disease (CAG ) n
Mvotonic dy strophy = ( CTG )
Fragile X syndrome = ( CGC )n

Friedreich ataxia ( GAA ) j
Trv ( trinucleotide) hunting for mv fragile cagefree eggs ( X ).
Caudate has i ACh and GABA

Cataracts, loupe ( carls balding in men ).
Gonadal atrophy
Chin ( protruding ) Giant Gonads
GAit Ataxi 4
BIOCHEMISTRY
Autosomal trisomies
Down syndrome
(trisomy 21)
Edwards syndrome
(trisomy 18)
Findings: inlellcctuil disability Hat facies,

prominent epicanthal folds, single palmar
crease, gap between 1st 2 toes, duodenal
atresia, Hirschsprung disease, congenital heart
disease (eg, atrioventricular septal defect|,
Brushfield spots. Associated with earlv-onset
Alzheimer disease (chromosome 21 codes for
amyloid precursor protein) and t risk of ALL
and AML.
95% of cases due to meiotic nondisjunction
( t with advanced maternal age; from 1:1500 in
women < 20 to 1:25 in women > 45 years old).
4% of cases due to unbalanced Robertsonian
translocation, most typically between
chromosomes 14 and 21. \% of cases due
to mosaicism ( no association with maternal
nondisjunction; postfertilization mitotic errorj
Incidence 1:700.
Drinking age ( 21).
Most common viable chromosomal disorder and
most common cause of genetic intellectual
disability.
First-trimester ultrasound commonly shows
t nuchal translucency and hypoplastic nasal
bone; 1 serum PAPP-A, t free (3-hCG
Second-trimester quad screen shows
1 a-fctoprotcin, t (J-hCG i estriol,
t inhibit! A.
Findings: PR1XCF, Edward: Prominent

occiput Rockcr-bottom feet Intellectual
disability Nondisjunction Clenched fists
( with overlapping fingers ), low-set Lars
micrognathia ( small jaw ), congenital heart
disease. Death usually occurs within 1 year of
Incidence 1:8000.
Flection age ( 18).
2nd most common autosomal trisoimlresulting
in live birth (most common is Down syndrome).
PAPP-A and free P-hCG are i in first trimester.
Quad screen shows i a-fetoprotein, 1 P-hCG,
1 estriol, i or normal inhihin A.
birth1
Patau syndrome
(trisomy 13 )
59
SECTION II
Findings: severe intellectual disability, rockerbottom feet, microphthalmia, microcephaly,

deft liP/Palate, holoProsencephaly,
Polydactyly, congenital heart disease, cutis
aplasia. Death usually occurs within 1 year of
birth.
Incidence 1:15,000.
Puberty (13).
First-trimester pregnancy screen shows J free
P-hCG, i PAPP-A.
Nondisjunction in meiosis II
Nondisjunction in meiosis I
n
t
Nondisjunction
<
C 3
C 3
Meiosis I
C 3
n +1
lllXDCIn +1
Trisomy
C 3
C 3
A A
III
Meiosis II
n -1
n 1
Monosomy
Gametes
Nondisjunction
ll ll l III
,
_ -, ,
'n
Normal
n 1
n +1
.
J l
II
Monosomy Trisomy
60
SECTION II
BIOCHEMISTRY
Genetic disorders by
CHROMOSOME
SELECTED EXAMPLES
chromosome
von Hippel-Lindau disease, renal cell carcinoma
ADPKD (PKD2), achondroplasia, Huntington disease
Cri-du-chat syndrome, familial adenomatous polyposis
Hemochromatosis ( HFE )
Williams syndrome, cystic fibrosis
Friedreich ataxia
11
1?
Patau syndrome, Wilson disease, retinoblastoma ( RBI ), BRCA2
Wilms tumor, Pglobin gene defects ( eg, sickle cell disease, P-thalassemia)
15
Prader-Willi syndrome, Angelman syndrome, Marfan syndrome
16
ADPKD iPKDl ), a-globin gene defects (eg, a-thalassemia)
17
Neurofibromatosis type 1 BRCA 1, p53l
18
Edwards syndrome
20
Maturitv-onset diabetes of the voung
21
Down syndrome
22
Neurofibromatosis type 2, DiC eorge syndrome ( 22ql 1)

Fragile X syndrome, X-linked agammaglobulinemia, Klinefelter syndrome (XXY)
Robertsonian
translocation
Chromosomal translocation that commonly involves chromosome pairs 13, 14, 15, 21, and 22.
One of the most common types of translocation. Occurs when the long arms of 2 acrocentric
chromosomes (chromosomes with centromeres near their ends ) fuse at the centromere and the
2 short arms are lost. Balanced translocations normally do not cause any abnormal phenotype.
Unbalanced translocations can result in miscarriage, stillbirth, and chromosomal imbalance ( eg.
Down syndrome, Patau syndrome).
Cri- du- chat syndrome
Congenital microdeletion of short arm of

chromosome 5 (46 XX or XT', 5p ).
Findings: microcephaly, moderate to
severe intellectual disability, high-pitched
crying/mewing, epicanthal folds, cardiac
abnormalities (VSD),
Williams syndrome
Congenital microdclction of long arm of chromosome 7 (deleted region includes clastin gene).
Findings: distinctive elfin facies, intellectual disability, hypercalcemia ( t sensitivity to vitamin D),
well-developed verbal skills, extreme friendliness with strangers, cardiovascular problems.
Cri da chat = cry of the cat.
Ul HRHlVH
BIOCHEMISTRY
BIOCHEMISTRY
NUTRITION
Vitamin A ( retinol )
FUNCTION
Antioxidant; constituent of visual pigments

( retinal ); essential for normal differentiation
of epithelial cells into specialized tissue
( pancreatic cells, mucus secreting cells);
prevents squamous metaplasia. Used to treat
measles and APLj
DEFICIENCY
EXCESS
Night blindness ( nyctalopia ); dry, scaly

skin (xerosis cutis ); corneal degeneration
( keratomalacia ); Bitot spots on conjunctiva;
immunosuppression.
Acute toxicity nausea , vomiting, vertigo, and
blurred vision .
Chronic toxicity alopecia, dry skin (eg,
scaliness), hepatic toxicity and enlargement ,
arthralgias, and pseudotumor cerebri .
Teratogenic ( cleft palate, cardiac abnormalities),
therefore a 0 pregnancy test and two forms of
contraception are required before isotretinoin
( vitamin A derivative ) is prescribed .
Retinol is vitamin A, so think retin A ( used

topically for wrinkles and Acne ).
Found in liver and leaf) vegetables.
Use oral isotretinoin to treat severe cystic acne.
Use all-trails retinoic acid to treat acute
promyelocvtic leukemia .
Isotretinoin is teratogenic.
Vitamin B1 ( thiamine )
FUNCTION
Think ATP: a ketoglutarate dehydrogenase,

Transketolase, and Pyruvate dehydrogenase.
Spell beriberi as BerlBerl to remember
vitamin Bj .
Wernicke- Korsakoff syndrome confusion ,
ophthalmoplegia , ataxia (classic triad ) +
confabulation , personality change, memory
Impaired glucose breakdown ATP depletion

worsened by glucose infusion ; highly aerobic
tissues (eg, brain , heart ) are affected first.
In alcoholic or malnourished patients, give
thiamine before dextrose to avoid precipitating
Wernicke encephalopathy Diagnosis made
by t in RBC transketolase activity following
vitamin B| administration .
loss ( permanent ). Damage to medial dorsal

nucleus of thalamus, mammillary bodies.
Dry beriberi polyneuritis, symmetrical muscle
wasting.
Wet beriberi high -output cardiac failure
(dilated cardiomyopathy), edema.
DEFICIENCY
In thiamine pyrophosphate (TPP), a cofactor for

several dehydrogenase enzyme reactions:
Pyruvate dehydrogenase ( links glycolysis to
TCA cycle )
a-ketoglutarate dehydrogenase (TCA cycle )
Transketolase ( HMP shunt )
Branchcd chain ketoacid dehydrogenase
64
SECTION I I
BIOCHEMISTRY
BIOCHEMISTRY NUTRITION
Vitamin B7 (biotin)
FUNCTION
Cofactor for carboxylation enzymes (which add

a 1-carbon group):
Pyruvate carboxylase: pyruvate (3C)
-* oxaloacetate (4C )
Acetyl-CoA carboxylase: acetyl-CoA (2C i
malonyl-CoA ( 3C)
Propionyl-CoA carboxylase: propionvl-CoA
( 3C ) methylmalonyl-CoA (4C )
Avidin in egg whites avidly binds biotin.
DEFICIENCY
Relatively rare. Dermatitis, alopecia, enteritis.

Caused by antibiotic use or excessive ingestion
of raw egg whites.
Vitamin B9 (folate)
FUNCTION
Converted to tctrahydrofolic acid ( THF), a

coenzyme for 1-carbon transfcr/mcthylation
reactions.
Important for the synthesis of nitrogenous bases
in DNA and RNA.
Found in leaf) green vegetables. Absorbed in

jejunum. Folate from foliage.
Small reserve pool stored primarily in the liver.
DEFICIENCY
Macrocytic, megaloblastic anemia;

hypersegmented polymorphonuclear cells
( PMNs); glossitis; no neurologic symptoms
( as opposed to vitamin Bp deficiency). Labs:
t homocysteine, normal methylmalonic acid
levels. Most common vitamin deficiency in
the United States. Seen in alcoholism and
Deficiency can be caused by several drugs (eg,

phenytoin sulfonamides, methotrexate).
Supplemental maternal folic acid at least 1 month
prior to conception and during earlv pregnanevi
1 risk of neural tube defects.
pregnancy.
BIOCHEMISTRY
65
SECTION II
Vitamin B12 (cobalamin )

FUNCTION
Cofactor for methionine synthase (transfers

ClI, groups as methylcobalamin) and
methvhnalonvl-CoA mutase. Important for
DNA synthesis
DEFICIENCY
Macrocytic, megaloblastic anemia;

hypersegmented PMNs; paresthesias
and subacute combined degeneration
( degeneration of dorsal columns, lateral
corticospinal tracts, and spinocerebellar tracts)
due to abnormal myelin. Associated with
t serum homocysteine and methylmalonic
acid levels, along with 2 folate deficiency
Prolonged deficiency - irreversible nerve
damage.
Found in animal products.

Synthesized only by microorganisms. Very large
reserve pool (several sears) stored primarily in
the liver. Deficiency caused by malabsorption
(eg, sprue, enteritis. Diphyllobotlirium latum ),
lack of intrinsic factor (pernicious anemia,
gastric bypass surgery), absence of terminal
ileum ( surgical resection, eg, for Crohn
disease), or insufficient intake (eg, veganism).
Anti-intrinsic factor antibodies diagnostic for
pernicious anemia.
Fatty acids with odd number of

carbons, branched-chain ammo acids
Protein
I
Methionine
SAM
CH to anabolic
D III IN MS
B,,
Methylmalonyl- CoA
Methylmalonyl-CoA
5- adenosyl
Methionine synthase
mutase
Succinyt- CoA
Homocysteine
Heme
Adenosine
TCA
Cysteine
Vitamin C (ascorbic acid)

FUNCTION
Antioxidant; also facilitates iron absorption

by reducing it to Fc "+ state. Necessary
for hydroxylation of proline and lysine in
collagen synthesis. Necessary for dopamine
P-hvdroxylase, which converts dopamine to
Found in fruits and vegetables.

Pronounce absorbic acid.
Ancillary treatment for methemoglobinemia by
reducing Fe + to Fe- \
NE
DEFICIENCY
Scurvy swollen gums, bruising, petcchiae,

hemarthrosis, anemia, poor wound healing,
perifollicular and subperiosteal hemorrhages,

corkscrew" hair.
Weakened immune response.
EXCESS
Nausea, vomiting, diarrhea, fatigue, calcium

oxalate nephrolithiasis. Can t risk of
iron toxicity in predisposed individuals
(eg, those with transfusions, hereditary
hemochromatosis).
Vitamin C deficiency causes sCurvy due to a

Collagen synthesis defect.
DO
Vitamin D
SECTION II
BIOCHEMISTRY
D = ergocalciferol ingested from plants.

D, = cholecalciferol consumed in milk, formed in sun-exposed skin (stratum basale ).
25 - OH D, = storage form.
l,25 (OH),D (calcitriol) = active form,
FUNCTION
DEFICIENCY
EXCESS
t intestinal absorption of calcium and phosphate, t bone mineralization at low levels, t bone
resorption at higher levels.

Rickets in children (bone pain and deformity), osteomalacia in adults (bone pain and muscle
weakness), hypocalcemic tetany. Breastfed infants should receive oral vitamin D. Deficiency is
exacerbated by low sun exposure, pigmented skin, prematurity.
Hypercalcemia, hypcrcalciuria, loss of appetite, stupor. Seen in granulomatous disease (t activation

of vitamin D by epithelioid macrophages ).
Vitamin E ( tocopherol / tocotrienol )

FUNCTION
Antioxidant ( protects RBCs and membranes

from free radical damage).
Can lead to impaired absorption of vitamin K

enhanced anticoagulant effects of warfarin!
DEFICIENCY
Hemolytic anemia, acanthocytosis,

muscle weakness, posterior column and
spinocerebellar tract demyelination.
Neurologic presentation may appear similar

to vitamin Bp deficiency, but without
megaloblastic anemia, hypersegmenled
neutrophils, or t serum methylmalonic acid
levels.
Vitamin K ( phytomenadione, phylloquinone, phytonadione)

FUNCTION
Activated bv epoxide reductase to the

reduced form, which is a cofactor for the
y-carboxvl ition of glutamic acid residues on
various proteins required for blood clotting.
DEFICIENCY
K is for Koagulation. Necessary for the

maturation of clotting factors II, VII, IX, X,
and proteins C and S. Warfarin inhibits
vitamin K-dcpcndcnt synthesis of these factors
Synthesized bv intestinal floral

and protein
Neonatal hemorrhage with t PT and t aPTT
Not in breast milk; neonates are given vitamin
but normal bleeding time (neonates have
K injection at birth to prevent hemorrhagic
sterile intestines and are unable to synthesize
disease of the newborn.
vitamin K |. Can also occur after prolonged use
of broad-spectrum antibiotics.
BIOCHEMISTRY
SECTION I I
67
Zinc
FUNCTION
DEFICIENCY
Mineral essential for the activity of 100+ enzymes. Important in the formation of zinc fingers
( transcription factor motif ).
Delayed wound healing, hypogonadism, 1 adult hair (axillary; facial, pubic ), dysgeusia. anosmia,
acrodermatitis enteropathica Q. May predispose to alcoholic cirrhosis.
Malnutrition
Kwashiorkor
Marasmus
New I
maael
Protein malnutrition resulting in skin lesions,

edema due to 1 plasma oncotic pressure,
liver malfunction (fatty change due to
i apolipoprotein synthesis). Clinical picture is
small child with swollen abdomen Q.
Kwashiorkor results from a proteindeficient MEAL:

Malnutrition
Total calorie malnutrition resulting in

emaciation (tissue and muscle wasting, loss of
subcutaneous fat; note wrinkled skin in dj
+/- edema.
Marasmus results in Muscle wasting,
Edema
Anemia
Liver (fatty )
BIOCHEMISTRY
Enzyme terminology
BIOCHEMISTRY METABOLISM
69
SECTION II
An enzymes name often describes its function. For example, glucokinase is an enzyme that
catalyzes the phosphorylation of glucose using a molecule of ATP The following are commonly
used enzyme descriptors.
Phosphorylase
Catalyzes transfer of a phosphate group from a high-energy molecule (usually ATP) to a substrate
( eg phosphofructokinase).
Adds inorganic phosphate onto substrate w ithout using ATP (eg, glycogen phosphorylase).
Phosphatase
Removes phosphate group from substrate (eg, fructosc -l,6-bisphosphatasc).
Dehydrogenase
Catalyzes oxidation-reduction reactions (eg, pyruvate dehydrogenase).

Adds hydroxyl group i-OH) onto substrate (eg tyrosine hydroxylase).
Kinase
Hydroxylase
Carboxylase
Mutase
Transfers CO,groups with the help of biotin (eg, pyruvate carboxylase ).

Relocates a functional group w ithin a molecule ( eg, vitamin Bp-dependent methylmalonyT-CoA
mutase)
Synthase /synthetase
Combines 2 molecules into 1 { condensation reaction ) either using an energy source

not ( synthetase ) ( eg, glvcogen synthase ).
( synthase)
or
Rate - determining enzymes of metabolic processes

PROCESS
ENZYME
REGULATORS
Glycolysis
Phosphofructokinase-I (PFK-1)
AMP , fructose-2,6-bisphosphate
ATP , citrate
Gluconeogenesis
Fructose-1,6-bisphosphatase
Citrate
AMP , fructose-2,6-bisphosphate
TCA cycle
Isocitrate dehydrogenase
ADP
ATP , NADH
Glycogenesis
Glycogen synthase
Glucosc-6-phosphatc , insulin , cortisol

Epinephrine , glucagon
Glycogenolysis
Glycogen phosphorylase
Epinephrine , glucagon , AMP

Glucose-6-phosphate , insulin , ATP
HMP shunt
Glucose-6-phosphatc dehydrogenase ( G6PD)
NADP
NADPH
De novo pyrimidine
synthesis
Carbamoyl phosphate synthetase II
ATP , PRPP
UTP
De novo purine
synthesis
Glutamine-phosphoribosvlpvrophosphate
(PRPP) amidotransferase
AMP , inosinc monophosphate ( IMP) ,

GMP
Urea cycle
Carbamoyl phosphate synthetase I
X-acetylglutamate
Fatty acid synthesis
Acetyl-CoA carboxylase (ACC )
Insulin , citrate
Glucagon , palmitoyl-CoA
Fatty acid oxidation
Carnitine acyltransfcrasc 1
Malonyl-CoA
Ketogenesis
IIMG-CoA synthase
Cholesterol synthesis
HMG-CoA reductase
Insulin , thyroxine
Glucagon , cholesterol 0
BIOCHEMISTRY
ATP production
Activated carriers
Universal electron
acceptors
SECTION I I
Aerobic metabolism of glucose produces 52 net

ATP via malate-aspartate shuttle (heart and
liver), 50 net ATP via glyccrol- 5 -phosphate
shuttle (muscle).
Anaerobic glycolysis produces only 2 net ATP
per glucose molecule.
ATP hydrolysis can be coupled to energetically
unfavorable reactions.
Arsenic causes glycolysis to produce zero net

ATP.
CARRIER MOLECULE
CARRIED IN ACTIVATED FORM
ATP
NADII, NADPH, FADH2
CoA, lipoamide
Phosphors ! groups
Electrons
Biotin
co2
Tetrahydrofolates
S-adenosvbnethionine (SAM )
CH groups
TPP
Aldehydes
Acyl groups
1-carbon units
Nicotinamides (NAD* from vitamin B;,

NADPI 1 is a product of the 1 IMP shunt.
NADPII is used in:
NADP* ) and flavin nucleotides (FAD* from
Anabolic processes
vitamin IT ).
NAD* is gcncrallv used in catabolic processes
Respiratory burst
to carry reducing equivalents away as NADH.
Cytochrome P-450 system
NADPI 1 is used in anabolic processes ( steroid
* Glutathione reductase
and fatty acid synthesis) as a supple of reducing
equivalents.
Hexokinase vs
glucokinase
Phosphorylation of glucose to yield glucosc-6-phosphatc serves as the 1st committed step of

glycolysis (also serves as the 1st step of glycogen synthesis in the liver). Reaction is catalyzed
he either hexokinase or glucokinase, depending on the tissue. At low glucose concentrations,
hexokinase sequesters glucose in the tissue. At high glucose concentrations, excess glucose is
stored in the liver.
Hexokinase
Glucokinase
Location
Most tissues, except liver

and pancreatic P cells
Liver, P cells of pancreas
K,
Lower ( t affinity)
Higher ( 1 affinity)
Lower (1 capacity)
Higher ( t capacity)
Induced by insulin
No
Yes
Feedback-inhibited by
Yes
No
No
Yes
glucose- 6-phosphatc
Gene mutation on chromosome
20 associated with maturityonset diabetes of the vouna
71
72
SECTION II
Glycolysis regulation,
key enzymes
BIOCHEMISTRY
BIOCHEMISTRY
Net glycolysis (cytoplasm):

Glucose + 2 P, + 2 ADP + 2 NAD+
METABOLISM
2 pyruvate + 2 ATP + 2 NADH + 2 H + + 2 H,0.
Equation not balanced chemically, and exact balanced equation depends on ionization state of
reactants and products.
Glucose
REQUIRE ATP
Hexokinase / glucokinase3
Fructose-6-P
Glucose-6-P hexokinase.
Fructose-6-P glucokinase.
Glucose-6- P
Fructose-l,6-BP
Phosphofructokinase -1
( rate limiting step)
AMP , fructose-2,6 -bisphosphate .

ATP , citrate .
G!ucokirvase in liver and {J cells of pancreas, hexokinase

in all other tissues.
1, 5-BPG
PRODUCE ATP
<
5-PG
Phosphoglycerate kinase
Fructose-1 ,6-bisphosphate .
ATP , alanine .
Pyruvate
Phosphoenolpyruvate
Pyruvate kinase
Regulation by
fructose -2,6
bisphosphate
FBPase-1
Fmctose-6-P *
Gluconeogenesis <
FBPase -2
PFK -1
> Fructose-1, 6-BP
Glycolysis
PFK - 2
(active in
(active in
fasting state)
fed state)
Fructose-26-BP
FBPase - 2 (fructose bisphospliatase- 2 ' and PFK 2 ( phosphofructokinase-2 are the same bifunctional
enzyme whose function is reversed by phosphorylation by protein kinase A.
Fasting state: t glucagon t cAMP t protein kinase A * T FBPase 2, 1 PFK-2 , less glycolysis,
more gluconeogenesis.
Fed state: t insulin 1 cAMP l protein kinase A i FBPase-2, t PFK-2 , more glycolysis, less
gluconeogenesis.
Pyruvate
dehydrogenase
complex
Mitochondrial enzyme complex linking

glycolysis and TGA cycle. Differentially
regulated in fed/fasting states (active in fed
state).
Reaction: pyruvate + NAD* + CoA aectylCOA + C02 + NADH.
Tlie complex contains s enzymes that require 5
cofactors:
1 . Thiamine pvrophosphate ( Bj )
2. Lipoic acid
s. CoA ( B-, pantothenic acid )
4. FAD ( B7, riboflavin )
5. NAD; ( B , niacin)
Activated by:
T NAD*/ NADH ratio
t ADP
The complex is similar to the a-kctoglutarate

dehydrogenase complex (same cofactors
similar substrate and action ), which converts
a-kctoglutarate succinyl-CoA ( TGA cycle).
The Lovelv Co- enzymes For Ncrdi

Arsenic inhibits lipoic acid . Findings:
vomiting, rice-water stools, garlic breatlijOT
prolongation.
;I
HUNJIM I
Electron transport
:hain and oxidative
ihosphorylation
inIt
NADH electrons from glycolysis enter mitochondria via the malatc-aspartatc or glyccrol-5 phosphate shuttle. FAD11, electrons are transferred to complex II (at a lower energy level than
NADII). The passage of electrons results in the formation of a proton gradient that, coupled to
oxidative phosphorylation, drives the production of ATP.
NADH NAD-
FADH?
ADP + P,
7,0;+ 2H'
FAD
ATP
H;0
Mitochondrial
matrix
V VI
Complex I
2,4-Dinitrophenol
Aspirin overdose
H*
ATP PRODUCED VIA ATP SYNTHASE
1 NADll
OXIDATIVE PHOSPHORYLATION POISONS
Electron transport
inhibitors
Complex II
(succinate
dehydrogenase)
Rotenone
Inner mitochondrial
membrane
Complex III
(
H'
Cyanide
rn
co
Complex V
JJ
AntimycinA
2.5 ATP; 1 FADH,
Complex IV
H*
Oligomycin
Intermembrane
space
[Revi
H
1.5 ATP.
Directly inhibit electron transport, causing a

i proton gradient and block of ATP synthesis.
RotcnONE: complex ONE inhibitor.

An-5 -mycin (antimycin) A : complex 5
inhibitor.
CO/CN: complex -t inhibitors ( 4 letters).
ATP synthase
inhibitors
Directly inhibit mitochondrial ATP synthase,

causing an t proton gradient. No ATP is
produced because electron transport stops.
Oligomycin.
Uncoupling agents
t permeability of membrane, causing a i proton

gradient and t O-, consumption. ATP synthesis
stops, but electron transport continues.
2,4-Dinitrophenol (used illicitly for weight

loss), aspirin ( fevers often occur after aspirin
overdose), thernrogenin in brown fat .
Produces heat.
jluconeogenesis,
rreversible enzymes
Pyruvate carboxylase
In mitochondria. Pvruvatc
Phosphoenolpyruvate
carboxykinase
In cytosol. Oxaloacctatc
Fructose-1,6bisphosphatase
Glucose- 6-
Pathway Produces Fresh
oxaloacctatc.
Requires GTP
phosphoenolpyruvate.
In cytosol. Fructose- 1,6-bisphosphate
fructose-6-phosphate.
In ER. Glucose-6-phosphate glucose.
Glucose.
Requires biotin, ATP. Activated bv acetyl-CoA.
Citrate AMP fructose 2.6-bisDhosphate .
phosphatase
Occurs primarilv in liver; serves to maintain eugiveemia during fasting. Enzymes also found in
kidney, intestinal epithelium. Deficiency of the key gluconeogenic enzymes causes hypoglycemia.
( Muscle cannot participate in gluconeogenesis because it lacks glucose- 6-phosphatase).
Odd chain fatty acids yield I propionyl-CoA during metabolism, which can enter the TCA cycle
( as succinvl-CoA ), undergo gluconeogenesis, and serve as a glucose source. Even-chain fatty acids
cannot produce new glucose, since they yield only acctyl-CoA equivalents.
76
SECTION II
BIOCHEMISTRY
Disorders of fructose metabolism

Essential fructosuria
Fructose intolerance
Involves a defect in fructokinase. Autosomal recessive. A benign, asymptomatic condition, since

fructose is not trapped in cells.
Symptoms: fructose appears in blood and urine.
Disorders of fructose metabolism cause milder symptoms than analogous disorders of galactose
metabolism.
Hereditary deficiency of aldolase B. Autosomal recessive. Fructose-l-phospbate accumulates,
causing a i in available phosphate, which results in inhibition of glycogenolysis and
gluconeogenesis. Symptoms present following consumption of fruit, juice, or hones . Urine dipstick
will be (tests for glucose only); reducing sugar can be detected in the urine (nonspecific test for
inborn errors of carbohydrate metabolism).
Symptoms: hypoglycemia, jaundice, cirrhosis, vomiting.
Treatment: i intake of both fructose and sucrose ( glucose + fructose).
Fructose metabolism lliver)
Dihydroxyacetone
Fructose
Fructokinase
T^T
ATP
Fructose-1-P
Those phosphate
isomerase
Aldolase B
Glyceraldehyde- 3-P
Glyceraldehyde
ADP
NADH
Glycolysis
Revised
ATP
ADP
NAD*
Glycerol
Disorders of galactose metabolism
Galactokinase
deficiency
Classic galactosemia
Hereditary deficiency of galactokinase. Galactitol accumulates if galactose is present in diet.

Relatively mild condition , Autosomal recessive.
{symptoms: galactose appears in blood ( galactosemia) and urine ( galactosuria); infantile cataracts.
May present as failure to track objects or to develop a social smile.
Absence of galactose-1-phosphate uridyltransferase. Autosomal recessive Damage is caused b\
accumulation of toxic substances ( including galactitol, which accumulates in the lens of the eye).
Sy mptoms develop when infant begins feeding ( lactose present in breast milk and routine formula ).
Symptoms: failure to thrive, jaundice, hepatomegaly, infantile cataracts, intellectual disability. Can
lead to F coli sepsis in neonates.
Treatment: exclude galactose and lactose ( galactose + glucose: from diet.
Galactose metabolism
Galactokinase
Galactose
ATP
ADP
Aldose
reductase
Galactose -l-P
Uridyltransferase
TV
v_y
UDP-Glu UDP-Gal
4 - epimerase
Cialartitol
Glucose -l-P
Glycolysis/glycogenesis
Fructose is to Aldolase B as Galactose is to

UridylTransferase ( FAB CUT).
The more serious defects lead to PO+ depletion.
:igure
BIOCHEMISTRY
Sorbitol
77
SECTION I I
An alternative method of trapping glucose in the cell is to convert it to its alcohol counterpart
called sorbitol, via aldose reductase. Some tissues then convert sorbitol to fructose using
sorbitol dehydrogenase; tissues with an insufficient amount /activity of this enzyme are at risk
for intracellular sorbitol accumulation, causing osmotic damage (eg cataracts, retinopathy, and
peripheral neuropathy seen with chronic hyperglycemia in diabetes)
High blood levels of galactose also result in conversion to the osmotically active galactitol via aldose
reductase.
.
.
Liver, ovanes. and seminal vesicles have both enzymes

Sorbitol dehydrogenase
Aldose reductase
Glucose
Fructose
Sorbitol
NADPH
NAD *
Lens has primarily aldose reductase Retina, Kidneys and Schwann cells have only aldose reductase ILuRKS),
Aldose reductase
Glucose
NADPH
Sorbitol
FINDINGS
Insufficient lactase enzyme dietary lactose intolerance. Lactase functions on the brush border to
digest lactose (in human and cow milk ) into glucose and galactose.
Primary: age-dependent decline after childhood ( absence of lactase-persistent allele ), common in
people of Asian, African, or Native American descent.
Secondary : loss of brush border due to gastroenteritis ( eg, rotavirus), autoimmune disease, etc .
Congenital lactase deficiency: rare, due to defective gene.
Stool demonstrates i pll and breath shows t hydrogen content with lactose hydrogen breath test
Intestinal biopsy reveals normal mucosa in patients with hereditary lactose intolerance.
Bloating, cramps, flatulence, osmotic diarrhea.
TREATMENT
Avoid dairy products or add lactase pills to diet; lactose-free milk .
Lactase deficiency
'
Amino acids
Essential
Acidic
Basic
Only l,-amino acids are found in proteins.
Glucogenic: methionine ( Met ) histidiui

< (Hi.4)
valine ( Vail.
Glucogeme/ketogcnic: isoleucinc i lie),
phenylalanine (Phc), threonine (Thr),
tryptophan ( Trp).
Ketogenic: leucine (Leu), lysine ( Lys).
Aspartic acid (Asp ) and glutamic acid (Glu).
Negatively charged at body pH.
Histidine ( His), lvsinc ( Lvs ). arginine lArg).
Arg is most basic.
PIis has no charge at body piI.
I met his valentine, she is so sweet ( glucogenic ).

All essential amino acids need to be supplied in
the die!
His lvs ( lies) arc basic. Arg and His are reauired
during periods of groyvth. Arg and Lys are t in
histones, which bind negatively charged DNA.
Transport of ammonia by alanine and glutamine!

Muscle
Amino acids
(NH5)
u- Ketoacids
Liver
Alanine
u- Ketoglutarate
Glutamate INH3)
Alanine
(NHj)
Cahill cycle
Glucose
A^ i
Pyruvate
Cori cycle
Lactate
u-Ketoglutarate
. Glucose
Pyruvate
Lactate
Glutamate (NH3)
Urea (NH 3)
S3
Hyperammonemia
fikN
Asterixis
Can be acquired (eg. liver disease) or hereditary

( eg. urea cycle enzyme deficiencies).
Results in excess NI1 , which depletes

a-ketoglutarate, leading to inhibition of TCA
cycle.
Treatment: limit protein in diet.
May be given to l ammonia levels:
Lactulose to acidify the C[ tract and trap
NH+ * for excretion.

Antibiotics (eg, rifaxinrim tqj l colonic
ammoniagcnic bacteria.
Benzoate, phcnylacetatc, or phcnvlhutvrate
hind glycine to form hippurate and lead to
excretion of NILi
- ion
Ammonia accumulation tremor ( asterixis),
slurring of speech, somnolence, vomiting

cerebral edema, blurring of vision,
Catecholamine synthesis/tyrosine catabolism

Phenylalanine
BH<
PKU
Tyrosine
BH, Tyrosine
Homogentisic acid <
Alkaptonuria Homoq
Phenylalanine
hydroxylase
isate
oxidase
'
hydroxylase
Albinism
DOPA
Maleylacetoacetic acid (Dihydroxyphenylalanine)
B6
Fumarate
DOPA
1
decarboxylase "
Dopamine
(TCA cycle )
Tyrosinase
Carbidopa
'
Epinephrine
SECTION II
Phenylketonuria
Vitamin C Dopamine
I |J-hydroxylase
Catechol O- methyl transferase
Norepinephrine
Phenylethanolamine W
SAM mclhyltransferase
80
Melanin
BIOCHEMISTRY
- Cortisol
- -
Metanephrlne
Revise
Figure
Normetanephrine
Vanillytmandelic acid
Homovamllic acid 0
Due to I phenylalanine hydroxylase or

I lelralivdrohiopterin I hi Hcohiclor
(malignant PKU ). Tyrosine becomes essential
t phenylalanine excess phenylkctones in
urine.
Findings: intellectual disability, growth
retardation, seizures, fair skin, eczema, musty
body odor.
Treatment: t phenylalanine and f tyrosine in
diet, tetrahydrobiopterin supplementation.
Maternal PKU lack of proper dietary therapy
during pregnancy. Findings in infant:

microcephaly, intellectual disability, growth
retardation, congenital heart defects.
Autosomal recessive. Incidence = 1:10,000.

Screening occurs 2-5 days after birth (normal at
birth because of maternal enzyme during fetal
life).
Phenylkctones phcnylacetate, phenyllactatc,
and phenylpyruvatc
Disorder of aromatic amino acid metabolism
musty body odor.
PKU patients must avoid the artificial sweetener
aspartame, which contains phenylalanine.
Congenital deficiency ofhomogentisate oxidase in the degradative pathway of tyrosine to futnarate

pigment-forming homogentisic acid accumulates in tissue Q. Autosomal recessive. Usually
Alkaptonuria
benign.
Findings: bluish - black connective tissue, ear cartilage, and sclcrac ( ochronosis ); urincj turns black on
prolonged exposure to air. May have debilitating arthralgias ( homogentisic acid toxic to cartilage).
!
i
Homocystinuria
Types (all autosomal recessive ):

Cystathionine synthase deficiency
( treatment : t methionine , t cysteine, t B( ,
BJTJ and folate in diet)
i affinity of cystathionine synthase for
pyridoxal phosphate ( treatment: tt B6 and
t cysteine in diet )
Methionine synthase ( homocysteine
methyltransferase) deficiency ( treatment:
t methionine in dictl
)
Methionine <
Methionine
synthase
Homocysteine
All forms result in excess homocysteine.

11( ) \ l ( K Astinuiia tt I lomocvstcinc in
Cystathionine
synthase
/ B,
Serine
mine Osteoporosis. M ntannid habitus .

Ocular changes ( downward and inward
lens subluxation ) Cardiovascular effects
thrombosis and atherosclerosis stroke and
Ml ), kYphosis, intellectual disability
> Cystathionine
Cysteine
BIOCHEMISTRY
Glycogen storage
diseases
12 types, all resulting in abnormal glycogen

metabolism and an accumulation of glycogen
within cells Periodic acid Schiff stain
identifies glycogen and is useful in identifying
these diseases.
SECTION II
Very Poor Carbohydrate Metabolism

. and V arc autosomal recessive,
,
'lypes 1, 11, 111
DISEASE
FINDINGS
DEFICIENT ENZYME
COMMENTS
Von Gierke disease
Severe fasting hypoglycemia,

11 Glycogen in liver, t blood
lactate, t triglycerides,
t uric acid (Gout), and
Glucose-6-phosphatase
Treatment: frequent oral

glucose /cornstarch; avoidance
(type 1)
Pompe disease
(type II)
hepatomegaly.
Cardiomegaly, hypertrophic-
Lysosomal acid a-1,4glucosidase with a-1,6glucosidase activity (acid

cxcrcisrf intolerance, and
systemic findings lead to early
maltase)
cardlomvopaths, hypotonia
of fructose and galactose

Impaired gluconeogenesis and
glycogenolysis
Pomfje trashes the PumP(l,4 j
( heart, liver, and muscle)
death.
Cori disease
(type III)
Milder form of von Gierke

( type 11 with normal blood
lactate levels. Accumulation
of limit dextrin like
structures in cytosol.
Debranching enzyme
( a-1,6-glucosidase)
Gluconeogenesis is intact
McArdle disease
( type V )
t glycogen in muscle, but

muscle cannot break it down
painful Muscle cramps,
Skeletal muscle glycogen

phosphorvlase
(Myophosphorylase)
Bl< x >d glucose levels typically

unaffected
Myoglobinuria (red urine)

with strenuous exercise, and
arrhythmia from electrolyte
abnormalities. Second-wind
phenomenon noted during
exercise due to t muscular
blood flow.
McArdle = Muscle
BIOCHEMISTRY
Lysosomal storage
diseases
DISEASE
Each is caused by a deficiency in one of the many lysosomal enzymes. Results in an accumulation
of abnormal metabolic products.

FINDINGS
DEFICIENT ENZYME
ACCUMULATED SUBSTRATE
INHERITANCE
Early: Triad of episodic peripheral

neuropathy, angiokeratomas Q,
a-galactosidase A
Ceramide
trihexoside
XR
0 Glucocerebrosidase
(P-glucosidase); treat
Glueocerebroside
AR
AR
Sphingolipidoses
Fabry disease
hypohidrosis. Late: progressive renal

failure, cardiov ascular disease.
Gaucher disease
m,
A
Most common.
Hepatosplenomegaly, pancytopenia,
osteoporosis, avascular necrosis of
femuj bone crises, Gaucher cells fl
( lipid-laden macrophages resembling
crumpled tissue paper ).
with recombinant
glucocerebrosidase
Progressive neurodegencration,
hepatosplenomegaly, foam cells
i lipid-laden macrophages) H,
cherry-red spot on macula Q.
Sphingomyelinase
Sphingomyelin
Tay-Sachs disease
Progressiv e neurodegencration,
developmental delay, cherry-red
spot on macula 0, lysosomes with
onion skin, no hepatosplenomegaly
( vs Niemann-Pick).
O HeXosaminidase
( "TAv-SaX "!
GM ganglioside
Krabbe disease
Peripheral neuropathy, destruction of

oligodendrogliai, developmental delay,
0 Gaiactocerebrosi-
Galactocerebroside, AR
psychosine
Arylsulfatase A
Cerebroside sulfate
AR
1Icparan sulfate,
dermatan sulfate
AR
1 Icparan sulfate,
dermatan sulfate
XR
Niemann-Pick disease
-*
rX% * t:l
&
'C
.
Metachromatic
leukodystrophy
optic atrophy, globoid cells .

Central and peripheral demyelination
dasc
AR
with ataxia, dementia.
Mucopolysaccharidoses
Hurler syndrome
Hunter syndrome
a-L-iduronidase
Developmental delay, gargoylism,
airway obstruction, corneal clouding,
hepatosplenomegaly.
Mild Hurler + aggressive behavior, no Iduronate sulfatase
corneal clouding.
GM; Ceramide trihexoside
o,
GM,
Sulfatides
Gatactocerebroside
Glueocerebroside
Ceramide
No man picks ( Niemann-Pick) his nose with

his sphinger ( sphingomyelinase).
Tay SaX lacks heXosaminidase.
Ilunters sec clearly ( no corneal clouding) and
aggressively aim for the X ( X-linked recessive),
t incidence ofTay-Sachs, Niemann-Pick and
some forms of Gaucher disease in Ashkenazi
Sphingomyelin 119
Jews.
BIOCHEMISTRY
BIOCHEMISTRY
Degradation
Fatty acid synthesis

FA )
( palmitate, a 16C
Malonyl-CoA
f--
Acetyl CoA
Cell cytoplasm
Mitochondrial
membranes
Fatty acid * CoA

Fatty acid CoA
synthase
CO2 ( biotin )
JK
Citrate
)"" Malonyl- CoA
Systemic 1 carnitine deficiency inherited

defect in transport of LCFAs into the
mitochondria toxic accumulation. Causes
weakness, hypotonia, and hvpoketotic
Carnitine
shuttle
shuttle
II
SYtrate SYnthesis.
=
CARnitine = CARnage of fatty acids.
Fatty Acyl-CoA
ATP citrate
lyase
METABOLISM
Fatty ac id synthesis requires transport of citrate

from mitochondria to cytosol. Predominantly
occurs in liver, laetating mammary glands, and
adipose tissue.
Long-chain fatty acid I LCFAl degradation
requires carnitine-dependent transport into the
mitochondrial matrix.
Fatty acid metabolism

Synthesis
Mitochondrial
matrix
hypoglycemia.
Citrate
Fatty Acyl-CoA
[i oxidation
(Acyl CoA
dehydrogenases)
Acetyl-CoA
/\ TCA
Ketone
bodies
Medium -chain acyl -CoA dehydrogenase

deficiency 1 ability to break down fatty
acids into acetvl-CoA accumulation of lath
acyl carnitines in the blood with hvpoketotic
hvpoglvcemica. Causes vomiting, lethargy,
seizures, coma, liver dysfunction. Can lead to
sudden death in infants or children . Treat bv
avoiding fasting.
cycle
87
SECTION II
BIOCHEMISTRY
Metabolic fuel use
4 kcal = lg GARB
7 kcal = lg ALCOHOL
9 kcal = lg FATTY ACID!
100% -
-z
\ //
\f
j\ .
V
2 sec
10 sec
.\
-\
-4-
Stored ATP
Creatme phosphate
Anaerobic metabolism
Aerobic metabolism
Overall performance
1min
Duration of exercise
Fasting and starvation
2 hr
\a
Priorities are to supply sufficient glucose to the brain and RBGs and to preserve protein.
Fed state (after a

meal)
Glycolysis and aerobic respiration,
Fasting (between
meals)
Ilepatic glycogenolysis (major); hepatic

gluconeogenesis, adipose release of FFA
Starvation days 1- 3
Blood glucose levels maintained by:

Hepatic glycogenolysis
Adipose release of FFA
Muscle and liver, which shift fuel use from
glucose to FFA
Hepatic gluconeogenesis from peripheral
tissue lactate and alanine, and from
adipose tissue glycerol and propionylCoA ( from odd-chain FFA the only
triacylglvcerol components that contribute
to gluconeogenesis)
Insulin stimulates storage of lipids, proteins, and

glycogen.
Glucagon and epinephrine stimulate use of fuel
reserves.
(minor ).
Starvation after
day 3
Adipose stores ( ketone bodies become the main

source of energy for the brain). After these arc
depleted, vital protein degradation accelerates,
leading to organ failure and death.
Amount of excess stores determines surviv al
time.
Glycogen reserves depleted after day 1.

RBGs lack mitochondria and therefore cannot
use ketones.
Protein
10-
S'
F-
Fat
6L
5 <Carbohydrate
1
4
3
5
Weeks of starvation
8
ta
BIOCHEMISTRY
89
SECTION II
Major apolipoproteins
Chylomicron
Apolipoproteln
Function
E.
Mediates remnant uptake
Activates LCAT
Lipoprotein lipase cofactor
Chylomicron
VLDL
remnant
IDL
LDL
HDL
Mediates remnant
uptake (Everythinq
Except LDU
AT
Activates LCAT
C-ll.
Lipoprotein lipase
Cofactor that
Catalyzes Cleavaqe
B- 48
Mediates chylomicron
secretion into lymphatic
B-100
Binds LDL receptor
Lipoprotein functions
Lipoproteins are composed of varying

proportions of cholesterol, TGs, and
phospholipids. LDL and 1 IDL cart)' the
most cholesterol.
LDL transports cholesterol from liver to tissues.

HDL transports cholesterol from periphery to
LDL is Lousy.
1 IDL is Healths
liver.
Cholesterol
Needed to maintain cell membrane integrity and to synthesize bile acid, steroids, and vitamin Dj
Chylomicron
VLDL
Delivers dietarv TGs to peripheral tissue. Delivers cholesterol to liver in the form of chylomicron
remnants, which are mostly depleted of their TGs. Secreted bv intestinal epithelial cells
Delivers hepatic TGs to peripheral tissue. Secreted by liver.
IDL
Formed in the degradation of VLDL. Delivers TGs and cholesterol to liver.
LDL
Delivers hepatic cholesterol to peripheral tissues. Formed by hepatic lipase modification of IDL in
the liver and peripheral tissue. Taken up by target cells via receptor-mediated endocytosis.
HDL
Mediates reverse cholesterol transport from periphery to liver. Acts as a repository for
apolipoproteins C and E (which arc needed for chylomicron and VLDL metabolism). Secreted
from both liver and intestine. Alcohol t synthesis.
Abetalipoproteinemla
Autosomal recessive. Chylomicrons. VLDL, LDL absent. Deficiency in ApoB48, ApoBlOO.

Affected infants present with severe fat malabsorption, steatorrhea, failure to thrive. Retinitis
pigmentosa and spinocerebellar degeneration due to vitamin F, deficiency. Progressive ataxia .
Acanthocvtosis.
Treatment: Restriction of long-chain fattv acids, large doses of oral vitamin E.
1 76
SECTION II
IMMUNOLOGY
Immune system
organs
Follicle
Medulla
Paracortex
LYMPHOID STRUCTURES
LYMPHOID STRUCTURES
1 organs:
Bone marrow immune cell production B cell maturation!

T cell maturation!
2 organs:
Spleen, lymph nodes, tonsils, Peyer patches
Allow immune cells to interact with antigen
Thymus
Lymph node
IMMUNOLOGY
IMMUNOLOGY
A 2 lymphoid organ that has many afferents, 1 or more efferents. Encapsulated , with trabeculae.
Functions are nonspecific filtration by macrophages, storage of B and T cells, and immune
response activation .
Site of B cell localization and

proliferation . In outer cortex. 1 follicles
are dense and dormant . 2 follicles have
pale central germinal centers and are
active.
Consists of medullary cords (closely

packed lymphocytes and plasma cells)
and medullar)- sinuses. Medullary
sinuses communicate with efferent
lymphatics and contain reticular cells
and macrophages.
Houses T cells. Region of cortex between

follicles and medulla. Contains high
endothelial venules through which T
and B cells enter from blood . Not well
developed in patients with DiGeorge
syndrome.
Paracortex enlarges in an extreme cellular
immune response (eg, viral infection ).
Afferent
lymphatic
Follicles IB celts)
1 follicle
Paracortex
(T cells)
Germinal cente
Mantle zone
Medullary cord
( lymphocytes,
plasma cells)
Vein
Postcapillary
venule
Artery
Capillary
supply
SS0
Trabecula
Capsule
efferent
lymphatic
Medullary sinus
( reticular cells,
macrophages)
IMMUNOLOGY
IMMUNOLOGY
LYMPHOID STRUCTURES
Located in LUQ of abdomen, anterior to left

kidney, protected bv th - llth ribs.
{sinuosoids are long, vascular channels in red
pulp ired arrow in Q ) with fenestrated "barrel
is
Revised
Fact
Capsule
Red pulp IRBCs)

Sinusoid
Mantle zone
Marginal zone
White pulp ( WBCs)
Reticular fibrous
framework
Follicle ( B cells)
Penartenolar
lymphoid sheath
laeoi a
Germinal center
( PALS) (T cells )
Splenic dysfunction ( eg, postsplcnectoiny, sickle

cell disease): 1 IgM 1 complement activation
^
t C3b opsonization t susceptibility
to encapsulated organisms.
Postsplenectomy:
hoop basement membrane.
Howell-Jolly bodies ( nuclear remnants )
T cells are found in the periarteriolar
lymphatic sheath ( PALS ) within the white
Target cells
pulp (white arrow in Q ).
Thrombocytosis ( loss of sequestration and
B cells are found in follicles within the
removal )
Ly mphocytosis ( loss of sequestration )
white pulp.
The marginal zone, in between the red pulp Vaccinate patients undergoing splenectomy
and white pulp, contains macrophages and
against encapsulated organisms
( pneumococcal , Hib. meningococcal ) .
specialized B cells, and is where antigenpresenting cells ( APCs) capture blood-borne
antigens for recognition by lymphocytes.
Macrophages found nearby in spleen remove
encapsulated bacteria.
Spleen
-s
Open
cifcu at on
osed
Pulp vein
Vein
am
m
Thymus
Artery
'
I' I
i'
ILS
Located in the anterosuperior mediastinum .

Site of T-cell differentiation and maturation .
Encapsulated - Thymus is derived from the
Third pharyngeal pouch. Lymphocytes of
mesenchymal origin . Cortex is dense with
immature T cells; medulla is pale with mature
T cells and Hassall corpuscles Q containing
epithelial reticular cells.
T cells = Thymus
B cells = Bone marrow
Hypoplastic in DiGeorge syndrome and severe
combined immunodeficiency ( SC1D ).
Thymoma lienign neoplasm
mild association with
of thymus,
myasthenia gravis and
superior vena cava syndrome)
IMMUNOLOGY
IMMUNOLOGY LYMPHOCYTES
SECTION II
IMMUNOLOGY -- LYMPHOCYTES
innate vs adaptive immunity
COMPONENTS
MECHANISM
Innate immunity
Adaptive immunity
Neutrophils, macrophages, monocytes,

dendritic cells, natural killer (NK | cells
(lymphoid origin), complement
Germline encoded
T cells, B cells, circulating antibodies
RESISTANCE
Resistance persists through generations; does

not change within an organisms lifetime
RESPONSE TO PATHOGENS
Nonspecific
Occurs rapidly (minutes to hours ]
No memory response!
PHYSICAL BARRIERS
SECRETED PROTEINS
KEY FEATURES IN PATHOGEN

RECOGNITION
Epithelial tight junctions, mucus

Lysozyme, complement, C-reactive protein
(CRP), defensins
Toll-like receptors (TLRs): pattern recognition
receptors that recognize pathogen-associated
molecular patterns (PAMPs). Examples of
PAMPs include LPS ( gram bacteria),
flagcllin ( bacteria), nucleic acids (viruses).
Variation through V( DiJ recombination during
lymphocyte development
Microbial resistance not heritable
Highly specific, refined over time
Develops over long periods; memory response is
faster and more robust
Immunoglobulins
Memory cells: activated B and T cells;
subsequent exposure to a previously
encountered antigen stronger, quicker
immune response
180
SECTION II
Major
histocompatibility
IMMUNOLOGY
IMMUNOLOGY
LYMPHOCYTES
MI IC encoded by HLA genes. Present antigen fragments to T cells and bind T-cell receptors
( TCRs ).
complwjl and II
MHC II (2 letters)
MHC I (1 letter )
STRUCTURE
TCR and CD8

I long chain 1 short chain
HLA DP, HLA-DQ. HLA-DR

TCR and CD4
2 equal-length chains
EXPRESSION
All nucleated cells, APCs, platelets
J \ PCs
LOCI
BINDING
HLA-A, HLA- B. HLA C
Not on RBC 4
FUNCTION
Present endogenously synthesized antigens leg

viral or cytosolic proteins) to CD8+ cytotoxic
ANTIGEN LOADING
Antigen peptides loaded onto MHC I
Present exogenously synthesized antigens ( eg,

bacterial proteins) to CD4+ helper T cells
T cells
ASSOCIATED PROTEINS
in RPR
after delivery via TAP ( transporter associated
with antigen processing )
(5,- microglobulin
Antigen loaded following release of invariant

chain in an acidified endosome
Invariant chain
Peptide- binding
groove
Peptide binding
<
I '1 '
p, rracroglobutm
! membrane
Cel
iQOQOQQOOOOboOOOOQl
CeL membrane
HLA subtypes associated with diseases
A3
Hemochromatosis
B8
Addison disease, myasthenia gravi
B27
Psoriatic arthritis, Ankylosing spondylitis,

IBD-associatcd arthritis, Reactive arthritis
( formerly Reiter syndrome!
PAIR . Also known as seronegative arthropathies.
DQ2 / DQ8
Celiac disease!
Multiple sclerosis, hav fever, SLE ,
I ate (8) too ( 2) much gluten at Dairy Queen.
DR 2
Multiple has pastures have dirty
Goodpasture syndrome!
DR 3
Diabetes mcllitus type I , SI , I ',, Graves disease,

Hashimoto thyroiditis, Addison diseasej
2-3, S- l .- K
DR 4
Rheumatoid arthritis, diabetes mcllitus ri pe 1,
There are 4 walls in a "rheum ( room ).
DR 5
Pernicious anemia vitamin Bp deficiency,

Hashimoto thvroiditii
Addison disease!
IMMUNOLOGY
Natural killer cells
SECTION II
181
Use perforin and granzymes to induce apoptosis of vitally infected cells and tumor cells.
Lymphocyte member of innate immune system.
Activity enhanced by IL-2, IL-12, IFN-a, and IFN-P.
Induced to kill when exposed to a nonspecific activation signal on target cell and/or to an absence
of class 1 Ml IC on target cell surface.
Also kills via antibody-dependent cell-mediated cytotoxicity (CD16 binds Fe region of bound Ig,
activating the NK cell).
Major functions of B and T cells
Recognize antigen undergo somatic hypermutation to optimize antigen specificity .

Produce antibody differentiate into plasma cells to secrete specific immunoglobulins.
Maintain immunologic memory memory B cells persist and accelerate future response to antigen.
B cells (humoral
immunity!
]
T cells (cell-mediated
immunity)!
CD4+ 1 cells help B cells make antibodies and produce cytokines to recruit phagocytes and
activate other leukocytes.
CD8+ T cells directly kill virus-infected cells.
Delayed cell-mcdiatcd hypersensitivity ( type IV ).
Acute and chronic cellular organ rejection.
Rule of 8: MHC II x CD-I = 8; MHC I x CDS = 8.
Differentiation of T cells
Bone marrow
Lymph node
Thymus
CD8+ T cell
Cytotoxic T celt (kills virus-infected,

neoplastic, and donor graft cells!
Th cell
( D t ( Dar
.
'
.
Teel
T cell precursor
Th, cell
CD4 tT cell
Helper T celt
ll - 4
-cell receptor
Y (Tbinds
MHCI
rCf.
Cortex
or MHC III
Medul
Th , cell
CD8
k
| CD4
Positive selection
Thymic cortex. T cells expressing TCRs capable of binding self-MHC on cortical epithelial cells
survive.
Negative selection
Thymic medulla. T cells expressing TCRs with high affinity for self antigens undergo apoptosis.
Tissue-restricted self-antigens are expressed in the thymus due to the action of autoimmune
regulator (AIRE); deficiency leads to autoimmune polycndocrinc syndromc-1.
1U <['] !
Helper T cells
I l lII MLliMaiMMWIillflSMBHMaaiailM
Thl cell
Th 2 cell
Secretes IFX -yand 1L-2
Secretes IL-4. ILo, IL-fj IL-10, IL- B
Activates macrophages and cytotoxic I cells
Recruits eosinophils for parasite defense and

promotes IgF production by B cells
Differentiation induced by IFN-yand IL-12

Differentiation induced by IL-4
Inhibited bv IL-4 and IL-10 ( from Th2 cell )
Inhibited bv IFN - y ( from 1 hl cell )
Macrophage-lymphocyte interaction dendritic cells, macrophages, and other Al'Cs release IL-12 ,
whichjstimulates T cells to differentiate into Thl cells. Till cells release IFN-y to stimulate
'
macrophages.
I Iclpcr T cells have CD4, which binds to Ml 1C II on AlCs
Cytotoxic T cells
Kill virus-infcctcd. neoplastic, and donor graft cells by inducing apoptosis.

Release cytotoxic granules containing preformed proteins ( eg, perforin , granzyme B).
Cytotoxic T cells have CD8, which binds to MHC 1 on virus-infected cells.
Regulatory T cells
Help maintain specific immune tolerance bv suppressing CD4 and CD8 T-cell effector functions.
Identified by expression of CD?, CD4, CD2S. and FOXlL
Activated regulatory T cells ( Trees j produce anti-inflammatory cytokines (eg, IL-10, TGF-fJ).
IPEX syndrome Dysfunction of FOXP? - autoimmunity. Characterized bv enteropathy ,

endocrinopatln , nail dystrophy, dermatitis, and /or other autoimmune dermatologic conditions.
IMMUNOLOGY
T- and B- cell activation
SECTION II
183
APCs: B cells, dendritic cells. Langerhans cells, macrophages T helper cell 4

Two signals are required for T-cell activation, B-cell activation, and class switching.
Naive T-cell activation
1. Dendritic cell (specialized APC) samples and processes antigen.

2. Dendritic cell migrates to the draining lymph node.
3. T-cell activation (signal 1): antigen is presented on MHC II and recognized by TCR on Th
|antigen is presented on MHC I to Tc (CD8+) cell.
(CD4+) cell. Kndogcnous or cross-prcsentec
4. Proliferation and survival ( signal 2): costimulatory signal via interaction of B7 protein on
dendritic cell ( CDSO/86 ) and CD28 on naive T cell
5. Th cell activates and produces cytokines. Tc cell activates and is able to recognize and kill virusinfected cell.
B -cell activation and

class switching
1. Th-cell activation as above.

2. B -cell receptor-mediated cndocytosis; foreign antigen is presented on Ml 1C !i and recognized
by TCR on Th cell.
3. CD40 receptor on B cell binds CD40 ligand ( CD40L) on Th cell.
4. I'll cell secretes cytokines that determine lg class switching of B cell. B cell activates and
undergoes class switching, affinity maturation, and antibody production.
g
Dendritic cell
m
1
Thcetl
ICD4+)
B7 (CD80/86)
Revised!
Figure [
Naive T cell
Bcell
IMMUNOLOGY IMMUNE RESPONSES
IMMUNOLOGY
SECTION II
187
System of hepatieallv synthesized plasma proteins that play a role in innate immunity and
inflammation. Membrane attack complex (MAC) defends against gram bacteria.
Complement
Classic pathway IgG or IgM mediated.

Alternative pathway microbe surface
molecules.
Lectin pathway mannose or other sugars on
ACTIVATION
GM makes classic cars.
microbe surface.
FUNCTIONS
C3b opsonization.
CTa, C4a, C5 a anaphylaxis.
C 5a neutrophil chemotaxis.
C5b 9 cytolysis by MAC.
C3b binds bacteria.
Opsonins Csb and IgG are Ihe two 1

opsonins in bacterial defense; enhance
phagocytosis. Clb also helps clear immune
Opsonin (Greek) = to prepare for eating,
complexes.
Inhibitors decay-accelerating factor ( DAF,
aka CD55 ) and Cl esterase inhibitor help
prevent complement activation on self cells
(eg, RBCs|.
HP1*
Alternative
C3 -
Spontaneous and
>
C3b
Bb
C3
C3bBb
C3bBb3b
IC5 convertasel
(C3 conwrtase)
microbial surfaces
Lectin
C5a
Cl-like
C5 .
C3b
complex
Microbial surfaces
leg. mannose)
C6-C9
fMACl (CSb- 9)
C4a
C4
Classic
Antigen antibody
complexes
Cl
C5a
C 46
clb
C2
*
Complement disorders
C 4b2b
lysis
cytotoxicity
C 4b2b3b
(C5 convertase)
(C3 convertase)
C3
'Historically, the larger fragment of C2 was

caked C2a but is now referred to as C2b.
C1 esterase inhibitor
deficiency
Causes hereditary angioedema due to unregulated activation of kallikrein t bradykinin. ACE

inhibitors are contraindicated. Causes hereditary angioedema due to unregulated activation of
kallikrein t bradykinin. Characterized bv 1 C 4 levels. ACE inhibitors are contraindicated.
C3 deficiency
Increases risk of severe, recurrent pyogenic sinus and respiratory tract infections; t susceptibility to
type 111 hypersensitivity reactions.
Terminal complement deficiency increases susceptibility to recurrent Neisseria bacteremia.
C 5-C9 deficiencies
CD55 deficiency!
Also called decav-accelerating factor ( DAF) deficiency. Causes complement-mediated lysis of RBCs
and paroxysmal nocturnal hemoglobinuria
188
SECTION II
IMMUNOLOGY
Important cytokines
SECRETED BY MACROPHAGES
IL-1
pauses fever, acute inflammation. Activates

endothelium to express adhesion molecules.
Induces chemokiue secretion to recruit VVBCs.
Hot T-bone stF.AK"
IL-1: fever ( hot).

IL-2: stimulates T cells.
IL- s: stimulates bone marrow.
IL-4: stimulates IgE production.
IL 5: stimulates IgA production.
IL-6: stimulates aKute-phase protein
production.
IL- 6
IL-8
Causes fever and stimulates production of acutephase proteins.

Major chcmotactic factor for neutrophils.
Clean up on aisle 8. Neutrophils are recruited
by IL-8 to clear infections.
IL-12
Induces differentiation ofT cells into Till cells.

Activates NK cells.
TNF- ot
Activates endothelium. Causes VY'BC

recruitment, vascular leak.
Causes cachexia in malignancy

^
Maintains granuloma iin TR .
SECRETED BY ALLTCELLS
IL-2
Stimulates growth of helper, cytotoxic, and

regulatory Tcells, and NK cells.
IL-3
Supports growth and differentiation of bone

marrow stem cells. Functions like CM-CSF.
FROM Thl CELLS
Interferon-y
Secreted by NK cells and T cells in response to

antigen or IL-12|from macrophages; stimulates
macrophages to kill phagocytoscd pathogens.
Inhibits differentiation ofThl cells.
Also activates NK cells to kill virus-infected

cells. Increases MHC expression and antigen
presentation by all cells.
FROM Th2 CELLS
IL- 4
Induces differentiation of T cells into Th 2 cells.

Promotes growth of B cells. Enhances class
switching to IgE and IgG.
IL-5
Promotes growth and differentiation of B cells.
IL-10
Enhances class switching to IgA. Stimulates

growth and differentiation of eosinophils.
Attenuates inflammatory response. Decreases
TGF-P and IL-10 both attenuate the immune
response.
expression of MHC class II and Thl cytokines.
Inhibits activated macrophages and dendritic
cells. Also secreted bv regulators T cells.
Cell surface proteins
T cells
Helper T cells
Cytotoxic T cells
Regulatory T cells
B cells
Macrophages
MHC I present on all nucleated cells ( ie, not mature RBCs).
TCR (binds antigen MHC complex)

CD? (associated with TCR for signal
transduction)
CD28 ( binds B7 on APC )
CXCR4/CCR 5 (co-receptors for HIV)
CD4, CD40L
CD8
CXCR4/CCR 5
CD4, CD25
Ig ( binds antigen)
CD19, CD20, CD21 (receptor for EBV), CD40
MHC II, B7
You can drink Beer at the Bar when youre 21:

B cells, Epstein-Barr virus, CD21.
CD14 ( receptor for PAMPs, eg, LPS ), CD40

CCR5
MHC II B7 (CD80/86)
Fc and C?b receptors (enhanced phagocytosis)
ICD56 ( suggcstivdmarker for NK )
NK cells
Hematopoietic stem
cells
CD34
Anergy
State during which a cell cannot become activated by exposure to its antigen. T and B cells
become anergic when exposed to their antigen without costimulatory signal (signal 2). Another
mechanism of self-tolerance.
Effects of bacterial
toxins
Superantigens (S pyogenes and S aureus ) cross link the p region of the T-cell receptor to the MHC
class II on APCs. Can activate any CD4+ T cell massive release of cytokines.
Endotoxins/lipopolysaccharide (gram @ bacteria ) directly stimulate macrophages by binding to
endotoxin receptor TLR4/CD14; Th cells are not involved.
Antigenic variation
Classic examples:
Bacteria Salmonella ( 2 flagellar variants),
Borrelia recurrentis (relapsing fever).
N sionorrhoeae ( pilus protein )
Viruses-influenza , HIV, HCV
Parasites trypanosomes
Some mechanisms for variation include DNA

rearrangement and RNA segment rcassortmer
(eg. influenza maior shift ) or protein mutation
(eg. influenza minor drift).
IMMUNOLOGY
SECTION II
Passive vs active immunity
Passive
Active
MEANS OF ACQUISITION
Receiving preformed antibodies
Exposure to foreign antigens
ONSET
Rapid
Slow
DURATION
Short span of antibodies (half-life = s weeks)
EXAMPLES
IgA in breast milk, maternal IgG crossing

placenta, antitoxin, humanized monoclonal
Long-lasting protection (memory)

Natural infection, vaccines, toxoid
NOTES
Vaccination
antibody
After exposure to Tetanus toxin. Botulinum
toxin, HBV, Varicella,fiabies virus, or
diphtheria antitoxin, unvaccinated patients are
given preformed antibodies (passive) To Be
Mealed Very Rapidly"
Combined passive and active immunizations

can be given for hepatitis B or rabies exposure
Induces an active immune response ( humoral and/or cellular ) to specific pathogens.
VACCINE TYPE
DESCRIPTION
Live attenuated
vaccine
Pro: induces strong,

Microorganism loses its pathogenicity but
retains capacity for transient growth within
often lifelong
inoculated host. Induces cellular and humoral immunity.
responses. MMR and varicella are live
Con: mav revert to
virulent form. Often
vaccines that can be given to patients with 111V
who have a CD4 cell count > 200/mmi
contraindicated
in pregnancy and
immunodeficiency.
BCC, influenza
Pathogen is inactivated by heal or chemicals.

Maintaining epitope structure on surface
antigens is important for immune response.
Mainly induces a humoral response.
Rabies, Influenza
(injection) Polio
(Salk ), hepatitis A
( R.l.P. Always ).
Inactivated or killed
vaccine
PROS /CONS
Pro: safer than live

vaccines.
Con: weaker immune
response; booster
shots usually
required.
EXAMPLES
( intranasal ), measles,
mumps, polio (Sabin),

rotavirus, rubella!
varicella, yellow fever.
IMMUNOLOGY
Hypersensitivity types ( continued )
Type III
l\
-it
A
IMMUNOLOGY
Immune complex antigen-antibody ( IgG)

complexes activate complement , which attracts
neutrophils; neutrophils release lysosomal
enzymes.
Can be associated with vasculitis and systemic
manifestations.
Serum sickness an immune complex disease

in which antibodies to foreign proteins are
produced ( takes 5 days ). Immune complexes
form and are deposited in membranes, where
they fix complement ( leads to tissue damage ) .
IMMUNE RESPONSES
193
SECTION II
In tv pc 111 reaction , imagine an immune

complex as 3 things stuck together: antigen
antibodv complement.
Examples:
Arthus reaction
SLE
Polyarteritis nodosa
Poststreptococcal glomerulonephritis
Serum sickness
Most serum sickness is now caused by drugs
( not serum ) acting as haptens. Fever, urticaria,
arthralgia, proteinuria, Ivmphadenopathy
occur 5-10 days after antigen exposure.
More common than Arthus reaction .
Arthus reaction a local subacute antibodymediated hypersensitivity reaction .

Intradermal injection of antigen into a
Antigen-antibody complexes cause the Arthus

reaction .
Test: immunofluorescent staining.
presensitized ( has circulating IgG ) individual

leads to immune complex formation in the
skin . Characterized by edema , necrosis, and
activ ation of complement.
Delayed (T-cell-mediated ) type sensitized

T cells encounter antigen and then release
cytokines ( leads to macrophage activation ).
Type IV
Response does not involve antibodies (vs types I ,

II. and III ).
Tl> cells
Fourth ( type) and last ( delayed ).

Pell mediated; therefore, it is not transferable by
serum .
4 T's = T cells Transplant rejections, TB skin
tests Touching (contact dermatitis).
Test: patch test , PPD.
Examples:
Contact dermatitis (eg, poison ivy, nickel
allergy )
a
Graft-versus-host disease
Multiple sclerosis
Pernicious anemia
Granulomatous inflammation
JA
IMMUNOLOGY
Blood transfusion reactions

TYPE
PATHOGENESIS
CLINICAL PRESENTATION
TIMING
Allergic reaction
Type 1 hypersensitivity' reaction

against plasma proteins in
transfused blood.
Severe allergic reaction.
IgA-deficient individuals
must receive blood products
without IgA.
Urticaria, pruritus,
wheezing, fever. Treat with
antihistamines.
(Within 2- hours
Dyspnea, bronehospasm,
hypotension, respiratory
[Within minutes
Anaphylactic reaction
Febrile nonhemolytic
transfusion reaction
arrest, shock. Treat with
epinephrine.
Type II hypersensitivitv
reaction. Host antibodies
against donor HLA antigens
and WBCs
Fever, headaches, chills,

flushing.
Tvpc II hvpcrsensitivitv
Fever, hvpotcnsion, tachypnea, [V\ ithin 1 hour

tachycardia, flank pain,
hemoglobinuria ( intravascular
[Within 1-6 hours
Acute hemolytic
transfusion reaction
reaction. Intravascular
hcmolvsis ( ABO blood

group
incompatibility) or
cxtravascular hcmolvsis i host
hemolysis), jaundice
(
cxtravascular ).
antibodv reaction against

foreign antigen on donor
RBCs).
Transfusion-related
acute lung injury!
Donor anti-leukocvte
antibodies against recipient
neutrophils and pulmonary
endothelial cells!]
Respiratory distress and

noneardiogenic pulmonary
edema]
[Within 6 hours
IMMUNOLOGY
Autoantibodies
SECTION II
AUTOANTIBODY
ASSOCIATED DISORDER
Anti-ACh reeeptoij
Myasthenia gravii
Anti-glomerular basement mcmbrane|
Goodpasture syndrome!
Anti-3 glycoproteiii
Anticardiolipin, lupus anticoagulant
Antiphospholipid syndrome!
Anticentromerel
Limited scleroderma ( CRPiST syndrome!

Pemphigus vulgaril
Anti-desmoglcin (anti-dcsniosomcil
Anti-glutamic acid decarboxvlase islet cell
SLE, antiphospholipid syndromtj
Type
1 diabetes mellituij
cvtoplasmic
antibodies
Antihemidesmosomej
Antisvnthetase (eg. anti-lo-1). anti-SRP. anti-
Bullous pemphigoid!
Poly myositis, dermatomyositii
'
lielicase (anti-Mi-2l
Antimicrosomal. antithy roglobulin. anti-thvroid
Uashimoto thvroiditi'j
peroxidase!
Antimitochrondrialj
1 biliars cirrhosi
Antioarietal cell, anti-intrinsic factoil

Antiphospholipasc A, receptoij
Pernicious anemia|
Anti-Scl-70 (anti-DNA topoisomerase l!
Scleroderma (diffuse!
Anti-smooth muscle|
Autoimmune hepatitis type lj
Anti-SSA , anti-SSB ( anti-Ro, anti-Lai
Sjiigren syndromej
Anti-TSH receptoij
Grases disease
Anti-press naptic voltage-gated calcium channel
Lambert-Eaton myasthenic syndrome!
1 ' membranous nephropathsj
IgA anti endomvsial IgA anti-tissue
transglutaminase!
MPO-ANCA/p-ANC.Ai
Celiac disease!
Microscopic polyangiitis eosinophilic
granulomatosis with pohangiitis ( Churg-Straus >

syndrome), ulccrathc
colitis!
PRVA \CA /c-ANC.\i
Granulomatosis with pohangiitis ( Wegener!
Rheumatoid factor ( IgM antibody against IgG

Fc region) anti-CCP ( more specific )!
Rheumatoid arthritii
Antinuclear (ANA!
Nonspecific screening antibody, often associated
Anti-dsDNA. anti- Smith!
SLPl
Anti-histone
Drug-induced lupus
Anti-Ul RNP ( ribonucleoprotein||
Mixed connectirc tissue disease!
with Sl Fi
196
SECTION I I
IMMUNOLOGY
Immunodeficiencies
DISEASE
DEFECT
PRESENTATION
FINDINGS
B- cell disorders
Defect in BTK . a tyrosine

Recurrent bacterial and
X- linked (Bruton)
enteroviral infections after 6
agammaglobulinemia kinase gene no B-cell
months ( 1 maternal IgG).
maturation. X-linkcd recessive
(t in Boys)
Selective IgA
deficiency
Unknown. Most common 1
immunodcficiencv.
i IgA with normal IgG, IgM

Majority Asymptomatic.
Can see Airway and GI
levels, t suscentibilitv to
giardiasis. Common in
infections Autoimmune
patients with celiac diseasii
disease Atopy. Anaphylaxis to
IgA-containing products.
Common variable
immunodeficiency
Absent B cells in peripheral

blood, 1 Ig of all classes,
Absent /scanty lymph nodes
and tonsils. Live vaccines
contraindicate
Defect in B-cell differentiation. Can be acquired in 20s Alls;

t risk of autoimmune disease,
Many causes.
bronchiectasis, lymphoma,
sinopulmonary infections.
1 plasma cells
1 immunoglobulins.
T- cell disorders
Thymic aplasia
(DiGeorge syndrome)
22qll deletion; failure

to develop srd and 4th
pharyngeal pouches absent
thymus and parathyroids.
Tetany (hypocalcemia),
recurrent viral/fungal
infections (T-cell deficiency),
conotruncal abnormalities
(eg. tetralogy' of Fallot,
i T cells, 1 PTH, 1 Ca -*.
Absent thymic shadow on
CXRJ
truncus arteriosus).
IL-12 receptor
deficiency
1 Thl response. Autosomal
recessive.
Disseminated mycobacterial
l IFN-y.
and fungal infections; may
present after administration of
BCG vaccine
Autosomal dominant
hyper- lgE syndrome
( Job syndrome)
Chronic
mucocutaneous
candidiasis
t IgF, i IFN-y
Deficiency of Thl7 cells due to FATED: coarse Facies, cold
(noninflamed) staphylococcal
STAT5 mutation impaired
t eosinophils,
Abscesses, retained primary
recruitment of neutrophils to
sites of infection.
Teeth, t IgE, Dermatologic
problems (eczema).
Noninvasive Candida albicans Absent in vitro T-cell
T-cell dysfunction. Many
infections of skin and mucous
causes.
proliferation in response to
Candida antigens.
membranes.
Absent cutaneous reaction to
Candida antigens.
IMMUNOLOGY
IMMUNOLOGY
SECTION II
IMMUNE RESPONSES
Immunodeficiencies ( continued )
"
DISEASE
DEFECT
PRESENTATION
FINDINGS
B - and T-cell disorders

Severe combined
immunodeficiency
Ataxia -telangiectasia
Several types including

defective II.-2 R gamma chain
( most common , X-linkcd ),
adenosine deaminase
deficiency ( autosomal
recessive).
Failure to thrive, chronic

diarrhea , thrush . Recurrent
viral, bacterial , fungal, and
protozoal infections.
Treatment: bone marrowtransplant ( no concern for
rejection ).
Defects in ATM gene failure Triad : cerebellar defects
( Ataxia ), spider Angiomas
to repair DNA double strand
( telangiectasia y ), IgA
breaks cell cycle arrest .
deficiency.
Hyper- IgM syndrome
Wiskott-Aldrich
syndrome
Most commonly due to

defective CD40L on Th cells
class sw itching defect;
X-l inked recessive.
Mutation in WAS gene;
leukocytes and plateletj
unable to reorganize actin
cvtoskeleton defective
antigcn-presentatioiA X-linked
recessive.
Severe pyogenic infections

early in life; opportunistic
infection with Pneumocystis,

Cryptosporidium, CMV.
WATER: W iskott-Aldrich :
Thrombocytopenia, Eczema,
Recurrent ( pyogenic )
infection
t risk of autoimmune disease
and malignancy.
1 T cell receptor excision
circles ( TRFCs).
Absence of thymic shadow
(CXR), germinal centers
( lymph node biopsy), and
T cells ( flow cytometry ).
t AFP.
t IgA , IgG, and IgF.
Lymphopenia, cerebellar
atrophy.
t risk of Ivnrphoma and
leukemia .
Normal or t IgM.
it IgG, IgA, IgF,.
Failure to make germinal
centers.
1 to normal IgG , IgM.
t IgE, IgA.
Fewer and smaller platelets.
Phagocyte dysfunction
Leukocyte adhesion
deficiency (type 1 )
Chediak- Higashi
syndrome
Chronic
granulomatous
disease
Defect in LFA-1 integrin

(GDIS) protein on
phagocytes; impaired
migration and chemotaxis;
autosomal recessive.
Recurrent bacterial skin and

mucosal infections, absent
pus formation, impaired
wound healing, delayed
separation of umbilical cord
(> 40 days).
t neutrophils
Absence of neutrophils at
infection sites
Defect in lysosomal trafficking

regulator gene ( LY'ST ).
Microtubule dysfunction in
phagosotne-lysosome fusion;
autosomal recessive.
Recurrent pyogenic
infections by staphylococci
and streptococci, partial
albinism, peripheral
neuropathy, progressive
neurodegeneration , infiltrat
lymphohistioevtosis.
Giant granules [ Q, arrows) in

granulocytes and platelets.
Pancytopenia .
Mild coagulation defects.
t susceptibility to catalase
Abnormal dihydrorhodamine
(flow cytometry) test ( l green
fluorescence ).
Nitroblue tetrazolium dye
reduction test fails to turn
blue ( note, this test!is
obsolete!
Defect ofNADPIl oxidase

I reactive oxygen
species (eg, superoxide )

and i respiratory burst
in neutrophils; X-liuked
recessive most common .
organisms
198
SECTION II
IMMUNOLOGY
IMMUNOLOGY
IMMUNE RESPONSES
Infections in immunodeficiency
PATHOGEN
J!CELLS
JBCaLS
i GRANULOCYTES
l COMPLEMENT
Bacteria
Sepsis
F.neapsulated ( Please
SHINE mvSKiSi
Pseudomonas
aeruginosa,
Staphylococcus,
Burkholderia cepacia
Encapsulated species
with early component
Streptococcus
pneumoniae ,
Haemophilus
Influenzae type B,
Neisseria
Pseudomonas
aeruginosa , Serratia,
Nocardia
deficiencies
Neisseria with late
component { MAC )
deficiencies
meningitidis ,
Escherichia coli ,
Salmonella ,
Klebsiella
pneumoniae, group B
Group B
Viruses
CMV, EBV, JC
viru.' j VZV, chronic
infection with
respiratory/Gl viruses
Streptococcus
Entcroviral
encephalitis,
poliovirus
( live vaccine
contraindicated )
G1 giardiasis (no IgA)
N /A
N /A
Candida ( local ). PCP.

Candida (systemic),
N/A
Crvbtococcui
Asberzillus. Mucoii
Note: B-cell deficiencies tend to produce recurrent bacterial infections, whereas T-ccll deficiencies produce more fungal and
viral infections.
Fungi / parasites
Grafts
Autograft
Syngeneic graft
( isograft )
From self.
From identical twin or clone.
Allograft
From nonidentical individual of same species.
Xenograft
From different species.
200
SECTION II
IMMUNOLOGY IMMUNOSUPPRESSANTS
IMMUNOLOGY
Immunosuppressants
Agents that block lymphocyte activation and proliferation. Reduce acute transplant rejection by
suppressing cellular immunity Frequently combined to achieve greater efficacy with i toxicity.
Chronic suppression t risk of infection and malignancy.
DRUG
MECHANISM
USE
TOXICITY
Cyclosporine
Calcincurin inhibitor;
hinds cvclophilin.
Blocks T-cell
activation by
preventing IL-2
transcription.
Psoriasii rheumatoid
Nephrotoxicity
hypertension,
Tacrolimus (FK 506)
arthritis.
neurotoxicity;
gingival hyperplasia,
hirsutism.
Calcineurin inhibitor; Transplant rejection

binds FKS06 binding
prophylaxis.
protein (FKBP).
Blocks T-cell activation
mTORjmhibitor; binds
Blocks T-cell
activation and B-cell
differentiation by
preventing response
to IL-2
Kidney transplant
rejection prophy laxis
Kidney sir -vives.

Synergistic with
cyclosporine.
Also used in drugeluting stents.
insulin resistance,
hyperlipidemia;
not nephrotoxic.
specifically!
Azathioprine
Antimetabolite
precursor of
6-mercaptopurine.
Inhibits Ivmphocvte
proliferation by
blocking nucleotide
synthesis.
Rheumatoidarthritis
Reversibly inhibits
Lupu nephritis.
.
glomerulonephritis.
.
Edema, hy pertension
tremor.
Pancytopenia
6-MP degraded by
Crohn disease
xanthine oxidase;
toxicity t by
allopurinol.
other autoimmune
conditions.
IMP dehy drogenase

preventing purine
synthesis of B and T
Pronounce azathiopurine.
GJ upset,
Associated with
invasive CMV
pancytopenia
hypertension,
infection.
hyperglycemia.
cells.
Less nephrotoxic and

ncurotoxic.
Inhibit NF KB.
Suppress both B- and
T-cell function by
i transcription of
many cytokines.
Induce apoptosis ofT
celU
and neurotoxicity;
Monoclonal antibodies;
block 1L-2R.
nephrotoxic.
nojgingival
PanSirtopcnia
(pancytopenia )
Daclizumab,
basiliximab
Corticosteroid
t risk of diabetes
hy perplasia or
FKBP.
mofetil
Similar to cyclosporine,
Both calcineurin
inhibitors are highly
hirsutism.
transcription.
Mycophenolate
hyperlipidemia
b\ preventing IL-2
Sirolimus (RapamycinU
NOTES
,
\ lanv Autoimmune
and inflammatory
disorders, adrenal
insufficiency, asthma.
('LL. non-!lodgkin
lvmphonni
Mav experience
Cushing syndrome
osteoporosis.
hyperglycemia
diabetes, amenorrhea,
adrenocortical
atrophy , peptic ulcers

psychosis, cataracts.
avascular necrosis
( femoral head ) ]
adrenal insufficiency
if stopped abruptly
after chronic usdi
IMMUNOLOGY
SECTION II
Immunosuppression targets
Basiiiximab.
dadizumab
FKBP +
FKBP +
Tacrolimus
CD3
/
Cydophilln +
Cyclosporine
6- MP
"
mTOR
NFAT
PRPP
IMP
dehydrogenase
rogenase
Corticosteroids
i
i
t
THELPER
caL
Mycophenolate
1 Calcineurin N
NFAT-P
Azathioprine
IL- 2R
Srolimus
(rapamycinl
Proliferation
genes
Denovo
Inflammatory
cytokine genes
Purine
nucleotides
>
W - KB
amidotransferase
purine
DNA replication
synthesis
Recombinant
cytokines and clinical
uses
AGENT
CLINICAL USES
Aldesleukin (IL-2)
Renal cell carcinoma, metastatic melanoma
Epoetin alfa (erythropoietin)
FilGRAstim iG CSFi GRAnulocvte
stimulating
Anemias (especially in renal failure)

Recovery of bone marrow
SarGRAMOSTIMl(GM-CSF)1
GRAnulocvte and MOnocvte STIMkilation

Recovery of bone marrow
IFN-a
Chronic hepatitis B and C, Kaposi sarcoma,

malignant melanoma, hairvcell leukemia,
condvloma acuminatum, renal cell eareinomal
IFN-P
IFN Y
Multiple sclerosis
Chronic granulomatous disease
' 1 h romhocy topenia

Romiplostim ( thrombopoictin analog),
eltrombopag ithrombopoietin receptor agonist!
Oprelvekin ( IL-ll )
Thrombocy topenia
Revised
Figure
202
SECTION II
IMMUNOLOGY
Therapeutic antibodies
AGENT
TARGET
CLINICAL USE
NOTES
CD52
CLL, MS
"Alvmtuzumab chronic
Cancer therapy
Alemtuzumab
lymphocytic leukemia
Bevacizumab
VEGF
Colorectal cancer, renal cell

carcinoma, non-small cell
lung canceij
Cetuximab
ECFR
Stage IVr colorectal cancer,

head and neck cancer
Rituximab
CD20
B-cell non-Hodgkin
lymphoma, CLL, rheumatoid
arthritis, ITP
Trastuzumab
HFR 2 /neu
Breast cancer, gastric cancel
HER: Iras2zumab
IBD, rheumatoid arthritis,
F tanercept is a decoy
TNF- a receptor and not a
monoclonal antibody
Autoimmune disease therapy

Adalimumab,
certolizumab,
Soluble TNF-a
ankylosing spondylitis,
psoriasis
qolimumab,
infliximab!
Eculizumab
Complement protein C5
Natalizumab
a4-integrin
Paroxysmal nocturnal
hemoglobinuria
Multiple sclerosis, Crohn
disease
Ustekinumab
IL-12 /IL-2?
Psoriasis, psoriatic arthritis
Platelet glycoproteins llb/llla
Antiplatelet agent for

prevention of ischemic
complications in patients
a4-integrin; YVBC adhesion

Risk of PML in patients with
JC virus
Other applications
Abciximab
lib times Ilia equals

absiximab"
undergoing percutaneous
coronary intervention
Digoxin immune Fab
Digoxin
Osteoporosis; inhibits osteoclast Denosumab affects osteoclast:

maturation (mimics
osteoprotegerin)
Antidote for digoxin toxicity
Omalizumab
IgE
Refractory allergic asthma!
Denosumab
RANKL
prevents IgE binding to FceRI

Palivizumab
RSV F protein
RSV prophylaxis for high-risk
infants
Ranibizumab,
bevacizumab
VEGF
Neovascular age-related
macular degeneration;
proliferative diabetic
retinopathy and macular
edema!
PaliVIzumab Virus
Abetalipoproteinemia
Autosomal recessive. Chylomicrons, VLDL, LDL absent. Deficiency in ,\poB48, ApoBlOO.

Affected infants present with severe fat malabsorption, steatorrhea, failure to tliriu. Retinitis
1
pigmentosa and spinocerebellar degeneration due to vitamin F deficiency. Progressive ataxia.
Acanthocvtosis.
Treatment: Restriction of long- chain fattv ac ids, large doses of oral vitamin E
90
SECTION I I
BIOCHEMISTRY
Familial dyslipidemias
TYPE
INHERITANCE
PATHOGENESIS
T BLOOD LEVEL
CLINICAL
AR
Lipoprotein lipase or
apoUpoprotein C-ll
deficiency
Chylomicrons, TC,
cholesterol
Pancreatitis,
Absent or defective
LDL receptors
1 la: LDL. cholesterol

lib: 1.D1 cholesterol.
Hyper-
chylomicronemia
l| Familial hyper
cholesterolemia
AD
VLDLJ
hepatosplenoinegaly, and
eruptive/pruritie xanthomas
( no t risk for atherosclerosis).
Creamy layer in supernatant.
Ileterozygotes (1:500) have
cholesterol = TOOmg/dL;
homozygotes (sen rare| have
cholesterol 700+ mg/dL.
Accelerated atherosclerosis (may
have Ml before age 20), tendon
(Achilles) xanthomas, and
cornea] arcus
III Dvsbetalipoproteinemia
AR
Defective ApoE
Chvlomicrons. VLDL
IV Hyper
AD
Hepatic
overproduction of
VLDL
VLDL TC
triglyceridemia
Premature atherosclerosis.
tuberoeruptive xanthomas,
xanthoma striatum palmare
Hypertriglyceridemia (> 1000

mg/dL) can cause acute
pancreatitis
:f;i :f.Tn:inuntVi
Mu
r.f
Bacterial structures
CHEMICAL COMPOSITION
FUNCTION
Flagellum
Proteins.
Pilus/fimbria
Glycoprotein.
Motility.
Mediate adherence of bacteria to cell surface;
sex pilus forms during conjugation.
STRUCTURE
Appendages
Specialized structures
Gram only.
Survival: resist dehydration, heat, chemicals.
Keratin-like coat; dipicolinic acid;
Spore
peptidoglycan DNA.
Cell envelope
Capsule
Organized, discrete polysaccharide layer ( except

poly-D glutamate on B anthracis ).
Protects against phagocytosis.
Glycocalyx
Loose network of polysaccharides.
Mediates adherence to surfaces, especially

foreign surfaces (eg, indwelling catheters).
Outer membrane
Outer leaflet: contains endotoxin ( LPS/LOS).

Embedded proteins: porins and other outer
membrane proteins (OMPs)
Gram only.
Endotoxin: lipid A induces TMF and IL-I;
Inner leaflet: phospholipids.
Most OMPs are antigenic.

Porins: transport across outer membrane.
Periplasm
Space between cytoplasmic membrane

and outer membrane in gram bacteria.
(Peptidoglycan in middle.)
Cell wall
Peptidoglycan is a sugar backbone with peptide

side chains cross-linked by transpeptidase.
Phospholipid bilayer sac with embedded
proteins (eg penicillin-binding proteins
[ PBPs) ) and other enzymes.
Lipoteichoic acids ( gram only ) extend from
(Accumulates components exiting gram

cells, including hydrolytic enzymes
(eg. (3-lactamases).
Net-like structure gives rigtd support, protects
against osmotic pressure damage.
Site of oxidative and transport enzymes; PBPs
involved in cell wall synthesis.
Lipoteichoic acids induce I NF and 1L- 1.
Cytoplasmic
membrane
antigenic O polysaccharide component
membrane to exterior.
Cell walls
Unique to
gram
Unique to
gram 0
Common to both
Flagellum
Lipoteichoic acid
Pilus
jmsud
''WWV
Gfi i MNH
V-iPeptidoglycan
Gram (?)
outer
membrane
iRevis
Figu
Periplasmic space
((5- lactamase location)
Cytoplasmic
membrane "
Endotoxin /LPS
Ponn
Gram 0
>11 walls
Common to both
Unique to
gram
Lipoteichoic acfd
Flagellum
Unique to
gram 0
PH IS
IS
T
*
>
Ceil wall
Cytoplasmic
Gram
outer
membrane
Revised!
Figure |
P e n p l a s m i c space
- Penplasmic
((5-lactamase location)
i
Peptidoglycan
64kv. .
I - '-.
Endotoxin' /LPS
^
"
membrane "
Gram
<3
94
SECTION II
MICROBIOLOGY
MICROBIOLOGY
BASIC BACTERIOLOGY
Stains
Gram stain
First-line lab test in bacterial identification . Bacteria with thick peptidoglycan layer retain crystal
v iolet dye ( gram ); bacteria with thin peptidoglycan layer turn red or pink ( gram ) with
counterstain .
The bugs below do not Gram stain well.
These Microbes May Lack Real Color
Too thin to be visualized.

Cell wall has high lipid content.
Treponema Leptospira
Mycobacteria
Mycoplasma, Ureaplasma
Legionella, Rickettsia , Chlamydia , Bartonella ,
Ehrlichia , Anaplasma
Giemsa stain
Periodic acid -Schiff

stain
Ziehl - Neelsen stain
(carbol fuchsin )
India ink stain
Silver stain
Fluorescent antibody
stain
No cell wall.
Primarily intracellular; also, Chlamydia lack
classic peptidoglycan because of i muranuc
acid.
Certain Bugs Really Try my Patience.
Chlamydia , Borrelia. Rickettsia.

Trypanosomes Q, Plasmodium
Stains glvcogcn , mucopolysaccharides; used
to diagnose Whipple disease ( Tropheryma
whipplei )
Acid-fast bacteriajpg, Mycobacteria 0 .
*
blocardia: stains mvcolic acid in cell wall ) ;
protozoa ( eg, Cry0tos0oridium oocvstsj
Cr) ptococcus neofomwns 0; mucicarmine
can also be used to stain thick polysaccharide
capsule red
Fungi |cg, Coccidioides Q, Pneumocystis
jirovecii ), Legionella , Helicobacter pylori
Used to identify many bacteria and viruses.
PaSs the sugar.
Alternative is auramine-rhodamiue stain for

screening ( inexpensive, more sensitive but less
specific ).
Example is FTA-ABS for confirming syphilis.
aU
irv
Pf
Properties of growth
media
Selective media
Indicator (differential )
media
s.*
,
V
'
iD
The same type of media can possess both (or neither) of these properties.
Favors the growth of particular organism while preventing growth of other organisms, eg, ThaycrMartin agar contains antibiotics that allow the selective growth of Neisseria bv inhibiting the
growth of other sensitive organisms.
Yields a color change in response to the metabolism of certain organisms, eg, MaeConkey agar
contains a pi I indicator; a lactose fermenter like E coli will convert lactose to acidic metabolites
- color change.
SECTION II
MICROBIOLOGY
MICROBIOLOGY BASIC BACTERIOLOGY
Intracellular bugs
Obligate intracellular
Rickettsia , CHlamydia, COxiella. Rely on host

ATP.
Salmonella , \eisseria , Brucella. Mycobacterium, Some Nasty Bugs May Five FacultativcLY.
Listeria, Francisella , Legionella, Yersinia pestis .
Facultative
intracellular
Encapsulated bacteria
Stay inside (cells ) when it is Really Cl Lilly and

COld.
'
Examples are Pseudomonas aeruginosa

Streptococcus pneumoniae Q Haemophilus
Influenzae type B, Neisseria meningitidis ,
Escherichia coli , Salmonella. Klebsiella
pneumoniae, and group B Strep. Their
capsules serve as an antiphagocytic virulence
factor.
Capsular polysaccharide + protein conjugate
serves as an antigen in vaccines.
vaccines
Some vaccines containing polysaccharide

capsule antigens are conjugated to a carrier
protein, enhancing immunogenicity by
promoting T-cell activation and subsequent
class switching. A polysaccharide antigen
alone cannot be presented to T cells.
Urease-positive
organisms
Proteus , Cryptococcus , II pylori , l reaplasma

Socardia , Klebsiella, S epidermidis,
S saprophyticus Urease hydrolyzes urea to
release ammonia and CO t pH. Potentiate
struvite ( ammonium magnesium phosphate)
stones. Proteus most likely to cause struvite
Please SHINE my SKiS.

Are opsonized, and then cleared by spleen.
Asplenics have l opsonizing ability and thus
t risk for severe infections. Give S pneumoniae
11 influenzae , N meningitidis vaccines.
Pneumococcal vaccine: PCVls ( pneumococcal
conjugate vaccine ) PPSV ? s i pneumococcal

polysaccharide vaccine with no coniugatcd
protein)
|f I influenzae type B ( conjugate vaccine)
Meningococcal vaccine ( conjugate vaccine)
Pee Cl I LIN KSS.
renal calculi]
Catalase- positive
organisms
Catalase degrades I ECU into H,0 and

bubbles of O,Q before it can be converted
to microbicidal products by the enzyme
myeloperoxidase. People with chronic
granulomatous disease (NADPH oxidase
deficiency) have recurrent infections with
certain catalase organisms.
Examples: Socardia, Pseudomonas , Listeria ,
Aspergillus, Candida, E coli , Staphylococci,
Serratia. B cepacia, H pylori.
Cats Need PLACESS to Belch their Hairballs.
vaccines
Urease positive
organisms
Some vaccines containing polysaccharide

capsule antigens are conjugated to a carrier
protein , enhancing inununogcnicity by
promoting T-cell activation and subsequent
class switching. A polysaccharide antigen
alone cannot be presented to T cells.
Pneumococcal vaccine: PCVls ( pneumococcal

conjugate vaccine ). PPSV 2 s ( pneumococcal
polysaccharide vaccine with no conjugated
protein )
|f/ influenzae type B (conjugate vaccine)

Meningococcal vaccine ( conjugate vaccine)
Proteus , Cryptococcus, H pylori , Ureaplasma ,

iSocardia , Klebsiella , S epidermidis,
S saprophyticus I ' l e a s e hvdrolv /.e.s urea to
t pH . Potentiate
release ammonia and CO
PeeCHUNKSS.
struvite (ammonium magnesium phosphate )

stones. Proteus most likely to cause struvite
renal calculi!
Catalase- positive
organisms
V
A.
V
Catalase degrades 11 O, into H ?0 and

bubbles of O, Q before it can be converted
to microbicidal products by the enzyme
myeloperoxidase. People with chronic
granulomatous disease ( NADPH oxidase
deficiency) have recurrent infections with
certain catalase organisms.
Examples: Kocardia , Pseudomonas , Listeria ,
Aspergillus , Candida , E coli , Staphylococci,
Serratia , B cepacia , H pylori.
MICROBIOLOGY
Pigment producing
bacteria
MICROBIOLOGY
Cats Need PLACESS to Belch their Hairballs.
BASIC BACTERIOLOGY
Actinomyces israelii yellow "sulfur" granules,

w hich are composed of filaments of bacteria ,
S aureus yellow pigment.
1 aeruginosa blue-green pigment ( pvoevanin
and
Aureus ( Latin) = gold.
Acrugula is green .
S epidermidis
Viridans streptococci ( S mutans, S sanguinis)
nmmnte evadnn of IHKI
Catheter and prosthetic device infections

Dental plaques, infective endocarditis
Respirators tree colonization in patients
with evstic fibrosis, ventilator associated
pneumonia , contact lens-associated kcratitU
Otitis media
Nontypeable ( unencapsulated ) H influenza

Tlipse
Serratia marcescens think red maraschino

cherries.
Paeruginosa
Bacterial virulence
Israel has yellow sand .
p\ overdin )
Serratia marcescens red pigment .
In vivo biofilmproducing bacteria
SECTION II
inimiinp resnnnsp
Spore forming
bacteria
jr
MV
j
Some bacteria can form spores Q at tire end

of the stationary phase when nutrients are
limited.
Spores are highly resistant to heat and
chemicals. Have dipicolinic acid in their core.
1 lave no metabolic activity. Must autoclave to
potentially kill spores (as is done to surgical
equipment ) by steaming at 121C for 15
minutes.
MICROBIOLOGY
> MICROBIOLOGY
Bacillus anthracis
Bacillus cereus
Clostridium botulinum
Clostridium difficile
Anthrax
Food poisoning
Botulism
Pseudomembranous
colitis
Clostridium perfringens Gas gangrene

Clostridium tetani
Tetanus
Be Cerious About ALL Clostridia .
BASIC BACTERIOLOGY
[l
Main features of exotoxins and endotoxins
Exotoxin
Endotoxin
SOURCE
Certain species of gram and gram bacteria
Outer cell membrane of most gram bacteria
SECRETED FROM CELL
Yes
Polypeptide
No
PROPERTY
CHEMISTRY
Lipid A component of LPS (structural part of

bacteria; released when lysed )
ADVERSE EFFECTS
Plasmid or bacteriophage
High ( fatal dose on the order of 1 pg )
CLINICAL EFFECTS
Various effects (see following pages )
Low (fatal dose on the order of hundreds of

micrograms )
Fever, shock ( hypotension ), DIC
MODE OF ACTION
Various modes (see follow ing pages)
Induces TNF, IL-1, and IL-6
ANTIGENICITY
Induces high-titer antibodies called antitoxins
Poorly antigenic
VACCINES
Toxoids used as vaccines

Destroyed rapidly at 60 <>C (except
staphvlococc il enterotoxin and E coli heatstable toxin!
Tetanus, botulism, diphtheria
No toxoids formed and no vaccine available

Stable at 1 ()0C for 1 hr
LOCATION OF GENES
HEAT STABILITY
TYPICAL DISEASES
Bacterial chromosome
Mcningococcemia; sepsis by gram rods
MICROBIOLOGY
MICROBIOLOGY BASIC BACTERIOLOGY
101
SECTION II
Bugs with exotoxins (continued )

BACTERIA
TOXIN
MECHANISM
MANIFESTATION
Clostridium
perfringens
Alpha toxin
Phospholipase (Iccilhinase)
Degradation of phospholipids myonecrosis

( "gas gangrene") and hemolysis ( double zone
of hemolysis on blood agar)
Streptococcus
pyogenes
Streptolysin O
Lyse cell membranes
that degrades tissue and

cell membranes
Protein that degrades cell
membrane
Lyses RBCs; contributes to fj-hemolysis;

host antibodies against toxin (ASO) used to
diagnose rheumatic fever ( do not confuse
with immune complexes of poststreptococcal
glomerulonephritis)
Superantigens causing shock
Staphylococcus
aureus
Toxic shock
Streptococcus
Exotoxin A
syndrome toxin
( TSST-1)
pyogenes
Endotoxin
Toxic shock syndrome: fever, rash, shock; other

Binds to MHC II and ICR
outside of antigen binding
toxins cause scalded skin syndrome (exfoliative
site to cause overwhelming
toxin) and food poisoning ( cntcrotoxin)
release of IL-1, IL-2,
Toxic shock-like svndromd fever, rash, shock
IFN-v, and TNF-a
shock
LPS found in outer membrane of gram

bacteria ( both cocci and rods). Composed of
O antigen + core polysaccharide + lipid A itlie
toxic component).
Released upon cell lysis or by living cells by
blebs detaching from outer surface membrane

(vs exotoxin, which is actively secreted ).
Three main effects: macrophage activation
( TLR4), complement
activation, and tissue
factor activation.
FNDOTOXINS:
Edema
N itric oxide
DIC/Death
Outer membrane
TNF-a
O-antigen + core polysaccharide + lipid A
eXtrcmcly heat stable
IL-1 and IL-6
Neutrophil chcmotaxis
Shock
Macrophage activation
(TLR4)
Endotoxin
(lipid A component)
Complement activation
Tissue factor activation
rL
IL L IL-6
Fever
TNF-a
Fever and hypotension
Nitric oxide
Hypotension
Cfc
C5a
j
8
Coagulation
cascade
Histamine release
Hypotension and edema
Neutrophil chemotaxis
DIC
104
SECTION II
Staphylococcus
saprophyticus
MICROBIOLOGY
MICROBIOLOGY
CLINICAL BACTERIOLOGY
Gram , catalase , coagulase , urease cocci in clusters. Novobiocin resistant.

Normal flora of female genital tract and perineum .
Second most common cause of uncomplicated UTI in young women ( most common cause is
E coli ).
Streptococcus
pneumoniae
4
T
t
'
Gram . lancet-shaped diplococci Q
Encapsulated. IgA protease. Optochin

sensitive. Most common cause of:
*
Meningitis
Otitis media ( in children )
Pneumonia
Sinusitis
Viridans group
streptococci
Gram . a-hemolytic cocci. They arc normal

flora of the oropharynx that cause dental
caries ( Streptococcus mutam and S mitis)
and subacute bacterial endocarditis at
damaged heart valves (S sanguinis ) Resistant
to optochin. differentiating them from
Sjpneumoniae, which is a hemolytic hut is
optochin sensitise.
Sanguinis = blood. Think, "there is lots of

blood in the heart (endocarditis). S sanguinis
makes dextrans, which bind to fibrin -platelet
aggregates on damaged heart salves
Viridans group strep lise in the mouth because
they are not afraid of the chin (op to chin
resistant).
Gram cocci. Group A strep Q cause:
JvNF.S ( major criteria for acute rheumatic
Streptococcus
pyogenes ( group A
streptococci )
Pyogenic pharyngitis, cellulitis, impetigo

( " hones -crusted " lesions ) , ers sipelas
Toxigenic scarlet fever , toxic shock-like
syndrome, necrotizing fasciitis
Immunologic rheumatic feser,
Pneumococcus is associated with "rusts

sputum , sepsis in patients with sickle cell
disease and splenectomy.
No sarulencc without capsule.
glomerulonephritis
Bacitracin sensitise, P-hemolytic, pvrrolidonyl
arylamidase I PVRi . Hsaluronie acid capsule
inhibits phagocytosis. Antibodies to M protein
enhance host defenses against S pyogenes but
can give rise to rheumatic feser.
ASO titer or anti - PNasc B antibodies indicate
recent S pyogenes infectioij
- -
fever):
Joints polyarthritis
--
v carditis
Nodules (subcutaneous)
Erythema marginatum
Sydenham chorea
Pharyngitis can result in rheumatic phever"
and glomerulonephritis.
Impetigo usually precedes glomerulonephritis.
Scarlet fever blanching, sandpaper-like body
rash , strawberry tongue, and circumoral
pallor in the setting of group A streptococcal
pharyngitis (erythrogenic toxin ).
Bacillus anthracis
Cutaneous anthrax
Gram . spore-forming rod that produces anthrax toxin . The only bacterium with a polypeptide
capsule (contains D-glutamate ). Microscopy show ' s long chains resembling "medusa heads."
Painless papule surrounded hy vesicles ulcer with black eschar ( Q) ( painless, necrotic !
uncommonly progresses to bacteremia and death.
jp
Pulmonary anthrax
Inhalation of spores flu -like symptoms that rapidly progress to fever, pulmonary hemorrhage,
mediastinitis, and shock . Also known as woolsorter 's disease
106
SECTION II
Bacillus cereus
MICROBIOLOGY
Gram rod. Causes food poisoning.

Spores survive cooking rice. Keeping rice
warm results in germination of spores and
enterotoxin formation.
Emetic type usually seen with rice and pasta.
Nausea and vomiting within 1-5 hr. Caused
by cereulide, a preformed toxin.
Diarrheal type causes watery, nonbloody
diarrhea and C1 pain within 8 18 hr.
Clostridia ( with
MICROBIOLOGY CLINICAL BACTERIOLOGY
Reheated rice syndrome.
Gram , spore-forming, obligate anaerobic rods.
exotoxins)
C tetani
Produces tetanospasmin, an exotoxin causing

tetanus. Tetanus toxin (and botulinum toxin i
are proteases that cleave SNARE proteins for
neurotransmitters. Blocks release of inhibitory
neurotransmitters, GABA and glycine, from
Rcnshaw cells in spinal cord.
Causes spastic paralysis, trismus (lockjaw), risus
sardonicus (raised eyebrows and open grin ),
opisthotonos ( spasms of spinal extensorj).
Prevent with tetanus vaccine. Treat with
antitoxin +/- vaccine booster, diazepam ( for
muscle spasms), and wound debridement.
Tetanus is tetanic paralysis.
C botulinum
Produces a heat-labile toxin that inhibits

ACh release at the neuromuscular junction,
causing botulism. In adults, disease is caused
by ingestion of preformed toxin. In babies,
ingestion of spores (eg, in honey) leads to
disease ( floppy baby syndrome ). Treat with
antitoxin.
Symptoms of botulism ( the 4 D 'si: Diplopia

Dysarthria, Dvpshagia, Dyspnea
C perfringens
Produces a toxin ( lecithinase, a phospholipase)

that can cause myonecrosis ( gas gangrene Q)
and hemolysis.
Spores can survive in undercooked food:
when ingested, bacteria release heat-labile
enterotoxin food poisoning.
Botulinum is from bad bottles of food, juice, and

honey (causes a descending flaccid paralysis).
Local botox injections used to treat focal
dystonia, achalasia, and muscle spasms. Also
used for cosmetic reduction of facial wrinkles.
Perfringens perforates a gangrenous leg.
C difficile
Produces 2 toxins. Toxin A, enterotoxin, binds to

brush border of gut and alters fluid secretion.
Toxin B. evtotoxin, causes cvtoskcletal
disruption via actin depolvmerization. Both
Difficile causes diarrhea. Treatment:
metronidazole or oral vancomycin. For

recurrent cases, consider repeating prior
regimen, fidaxomicin, or fecal microbiota
Produces 2 toxins. Toxin A. cntcrotoxin, binds to

brush border of gut and alters fluid secretion.
Ihxin It cvlotoxin. (.Muses cvtoskclct il
disruption via actin depolv merization. Both
toxins lead to diarrhea pseudomembranous
colitis Q
|Often 2 to antibiotic use, especially
clindamycin or ampicilliu; associated with PP1
use. Diagnosed bv detecting one or both toxins
in stool by PCR ,
C difficile
Difficile causes diarrhea. Treatment:
metronidazole or oral vancomycin. For

recurrent cases, consider repeating prior
regimen, fidaxomicin, or fecal microbiota
transplant.
I
MICROBIOLOGY
Corynebacterium
diphtheriae
Gram rod; transmitted via respirators

droplets. Causes diphtheria via exotoxin
encoded by Pprophage. Potent exotoxin
inhibits protein synthesis via ADP-ribosvIation
ofEF-2.
Symptoms include pseudomembranous
phary ngitis ( grayish-white membrane Q)
with lymphadenopathy, myocarditis, and
arrhythmias.
Lab diagnosis based on gram rods with
metaehromatic ( blue and red) granules and
Elek test for toxin
SECTION II
Coryne = club shaped.

Black colonies on cystine-tellurite agar.
ABCDEFG:
ADP-ribosylation
P-prophage
Corynebacterium
Diphtheriae
Elongation Factor 2
Granules
Toxoid vaccine prevents diphtheria.
Gram , facultativ e intracellular rod; acquired by ingestion of unpasteurized dairy products and
cold deli meats, via transplacental transmission, or by vaginal transmission during birth. Grows
well at refrigeration temperatures (4C-10C; cold enrichment "!
Forms rocket tails" (red in Q) via actin polymerization that allow intracellular movement and cellto-cell spread across cell membranes, thereby avoiding antibody. Characteristic tumbling motility'
in broth.
Can cause amnionitis, septicemia, and spontaneous abortion in pregnant women; granulomatosis
infantiseptica; neonatal meningitis; meningitis in immunocompromised patients; mild, selflimited gastroenteritis in healthy individuals.
Treatment: ampicillii)
Listeria
monocytogenes
V
Nocardia vs
Both are gram 0 and form long, brandling filaments resembling fungi.
Actinomyces
Nocardia
Actinomyces
Aerobe
Anaerobe
Acid fast ( weak) Q
Not acid fast Q
Found in soil
Normal oral, reproductive, and Gl flora
Causes pulmonary infections in

immunocompromised (can mimic TB but
with PPD ); cutaneous infections after
trauma ill immunocompetent
Causes oral/facial abscesses that drain through

sinus tracts, often associated with dental caries/
extraction; form jvcllovv sulfur granules;" can
Treat with sulfonamides (TMP-SMX )
Treat with penicillin
fV
w
T
also cause P1D with IUDs
Treatment is a SNAP: Sulfonamides Vocrmfia; Actinomyces Penicillin
Primary and secondary tuberculosis
PPD if current infection or past exposure.

PPD if no infection and in sarcoidosis or
HIV infection ( especially with low CD4+ cell
Mycobacterium
'*' * * tuberculosa
i
i
Ghon
com pie*
Ghon locus -v
(usually mid /
lower lobes!
Primary tuberculosis
1
__
> 90X
}< m
Progressive primary tuberculosis
(AIDS malnutrition)
Healing by fibrosis
Calcification
(tuberculin )
Reactivation
2*
tuberculosis
Fibrocaseous
count!
Interferon-y release assay ( IGRA) has fewer false
positives from BCG vaccination .
Caseating granulomas with central necrosis
( upper left) and Langhan jgiant cells (arrow)
are characteristic of 2 tuberculosis.
Progressive
lung disease
Bacteremia
1/
cavitary lesion
'
( usually upper
V Milia
lobes)
M'
.vv
rcrabne
!
Localized destructive disease
Cavity
Caseation
Scar
-4
Lymph nodes
i rt 1 . . v
'
amm &
rJ
tubercu
Lungs
V , '
Liver
--1
'
1 rin .l
V" Joints and

long bones
Mycobacteria
m>A
tuberculosis ( TB, often resistant TB symptoms include fever, night sweats,

to multiple drugs).
weight loss, cough ( nonproductive or
M avium intmcellulare ( causes disseminated ,
productive ), hemoptysis.
Cord factor creates a "serpentine cord
non- I B disease in AIDS; often resistant to
multiple drugs). Prophylaxis with azithromycin appearance in virulent M tuberculosis
when CDT + count < 50 cclls/mm '.
strains; inhibits macrophage maturation and
induces release ofT\ F-a. Sulfatides (surface
M scrofulaceum (cervical lymphadenitis in
glycolipids ) inhibit phagolysosomal fusion.
children ).
M marinum ( hand infection in aquarium
handlers).
All mycobacteria are acid-fast organisms ( pink
rods; arrows in Q),
Mycobacterium
MICROBIOLOGY
MICROBIOLOGY
Leprosy ( Hansen
disease)
SECTION II
Caused by Mycobacterium leprae , an acid-fast bacillus that likes cool temperatures ( infects skin
and superficial nerves "glove and stocking loss of sensation Q) and cannot be grown in vitro .
Diagnosed via skin biopsy or tissue FCHj Reservoir in United States: armadillos.
Hansen disease has 2 forms:
Lepromatous presents diffusely over the skin, with leonine ( lion-like) facies 0, and is
communicable; characterized by low cell-medialcd immunity with a humoral Th 2 response.
Lepromatous form can be lethal .
Tuberculoid limited to a few hypocsthetic, hairless skin plaques; characterized by high cellmediated immunity with a largely Th 1-type immune response.
Treatment: dapsone and rifampin for tuberculoid form ; clofazimine is added for lepromatous form .
Neisseria
Gram diplococci. Metabolize glucose

and produce IgA proteases. Contain
lipooligosacclraridcs ( LOS ) with endotoxin like cytotoxic capabilities. N gonorrhoeae is
often intracellular (within neutrophils ) Q.
Gonococci
Meningococci
No polysaccharide capsule
No maltose metabolized
No vaccine due to antigenic variation of pilus
proteins
Sexually or perinatally transmitted
Causes gonorrhea, septic arthritis, neonatal
conjunctivitis ( 2 5 days after birth!pelvic
inflammatory disease ( PID), and Fitz- HughCurtis syndrome
Polysaccharide capsule
Maltose fermentation
Vaccine ( type B vaccine not widely available)
Condoms i sexual transmission , erythromycin

eye ointment prevents neonatal blindness
Treatment: ceftriaxone + ( azithromycin

or doxycycline ) for possible chlamydial
coinfection
Haemophilus
influenzae
MemnGococci ferment Maltose and Glucose.

Gonococci ferment Glucose.
Transmitted via respiratory and oral secretions

Causes mcningococcemia w ith petechial
hemorrhages and gangrene of toes ,
meningitis, Waterhouse Friderichsen
syndrome (adrenal insufficiency, fever, DIC,
shock1
Rifampin , ciprofloxacin, or ceftriaxone

prophylaxis in close contacts
Treatment: ceftriaxone or penicillin G
Vaccine contains tvpc b capsular polysaccharide

Small gram (coccobacillary ) rod . Aerosol
( pol \ ribosvlrihitol phosphatei conjugated
transmission . Nontypeable ( uncncapsulated )
ttjdiphthcria toxoid or other protein . Given
strains are the most common cause of mucosal
between 2 and 18 months of age.
infections iotitis media , conjunctivitis,
Does not cause the flu (influenza virus docsl.
bronchitis ) as well as invasive infections since
w
the vaccine for capsular type b as introduced.
Produces IgA protease. Culture on chocolate
agar, which contains factors V ( NAD*) and X
( hematin ) for growth ; can also be grown with
S aureus , which provides factor V through the
hemolysis of RBCs. HaEMOPhilus causes
Fpiglottitis ( endoscopic appearance in JJ
can be cherry red" in children; thumb sigrf
on x ray Q ) , Meningitis, Otitis media , and
Pneumonia.
Treatment: amoxicillin +/- clavulanate for
mucosal infections; ceftriaxone for meningitis;

rifampin prophylaxis for close contacts.
MICROBIOLOGY
Bordetella pertussis
MICROBIOLOGY
SECTION II
Gram , aerobic coccobacillus. Virulence factors include pertussis toxin (disables Gj and tracheal
cytotoxin. Three clinical stages:
Catarrhal low -grade fevers, corvza .
Paroxysmal paroxysms of intense cough followed In inspirator! "w hoop" ( ''whooping cough " ) ,
posttussive vomiting.
Convalescent gradual recovery of chronic eouglj
Prevented by Tdap. DTaP vaccines. May be mistaken as viral infection due to lymphocytic
fr/ tni iinmnnn rpcnrtnco
Ecthyma gangrenosum
UTIs
Diabetes, drug use
Osteomyelitis (eg. puncture wounds)

Mucoid polysaccharide capsule
Otitis externa (swimmers car )
Nosocomial infections (catheters,
equipment)
exotoxin A
Skin infections ( hot tub folliculitis)
piperacillin , ticarcillin )
Aeruginosa aerobic.
Mucoid polysaccharide capsule max contribute

to chronic pneumonia in cystic fibrosis patients
due to biofilm formation.
Can cause wound infection in burn victims.
Corneal ulcers /keralitis in contact lens wearers/
minor cxc trauma .
Frequently found in water -* hot tub folliculitis.
Ecthyma gangrenosum rapidly progressive,
necrotic cutaneous lesion Q caused by
Pseudomonas bacteremia , ' typically seen in
immunocompromised patients.
SECTION II
Escherichitjcoli
MICROBIOLOGY
Cram rod. coli virulence factors: fimbriae cystitis and pyelonephritis ( P-pili ); K capsulepneumonia neonatal meningitis; LPS endotoxin septic shock.
STRAIN
TOXIN ANO MECHANISM
PRESENTATION
EIEC
Microbe invades intestinal mucosa and causes

necrosis and inflammation.
Invasive; dysentery. Clinical manifestations

similar to Shigella.
ETEC
Produces heat-labile and heat-stable

enteroToxins. No inflammation or invasion.
Travelers' diarrhea ( watery).
EPEC
No toxin produced. Adheres to apical surface,

flattens villi, prevents absorption.
Diarrhea, usually in children ( Pediatrics).
EHEC
0157:H7 is most common serotype in US. Often Dysentery ( toxin alone causes necrosis and
transmitted via undercooked meat, raw leafs
inflammation).
Does not ferment sorbitol or produce
vegetables.
glucuronidase ( vs othciit' coli ).
Shiga-like toxin causes hemolytic- uremic
syndrome: triad of anemia, thrombocytopenia, Hemorrhagic, Hamburgers, Hemolytic-uremic
and acute renal failure due to microthrombi
syndrome.
forming on damaged endothelium
mechanical hemolysis (with schistocytes on
peripheral blood smear), platelet consumption,
and l renal blood flow.
Klebsiella
Gram rod; intestinal flora that causes lobar

pneumonia in alcoholics and diabetics when
aspirated. Very mucoid colonics [J caused by

abundant polysaccharide capsules. Dark red
"currant jelly" sputum ( blood/mucus).
Also cause of nosocomial UTIs.
|As of KlebsiellA:
Aspiration pneumonia
Abscess in lungs and liver
Alcoholics
di-A-betics
Curr-A -nt jelly sputum

1
liusc spms
UII d i i u o i i i c u ,
constipation, abdominal
pain , fever ); treat
with ceftriaxone or
sources
Antibiotics not
indicated
S flexneri , S boydii, S sannei

Invasion of M cells is kev to
Carrier state with
Gastroenteritis is
usually caused by non -
gallbladder colonization
typhoidal Salmonella
pathogenicity; organisms that

produce little toxin can cause disease
due to invasioij
fluoroquinolone
Vibrio choierae
Gram , flagellated , comma shaped 0, oxidase , grows in alkaline media. Endemic to

developing countries. Produces profuse rice-water diarrhea via enterotoxin that permanently
activates Gs, t cAMP. Sensitive to stomach acid ( acid labile ); requires large inoculum ( high ID- ( I )
unless host has l gastric acidity Associated with contaminated water and sealood . Prompt oral
rehydration is necessary.
Yersinia enterocolitica
Gram rod . Usually transmitted from pet feces (eg, puppies), contaminated milk , or pork . Causes
acute diarrhea or pseudoappendicitis ( right lower abdominal pain due to mesenteric adenitis and /
or terminal ileitis).
11
MICROBIOLOGY
MICROBIOLOGY
Helicobacter pylori
Curved , terminally flagellated ( motile ), gram ) ) rod [|that is triple : catalase , oxidase , and
urease ( can use urea breath test or fecal antigen test for diagnosis). Urease produces ammonia ,
creating an alkaline environment, which helps H pylori survive in acidic mucosa. Colonizes
mainly antrum of stomach ; causes gastritis and peptic ulcers (especially duodenal i . Risk factor for
peptic ulcer disease, gastric adenocarcinoma , and M ALI ' lymphoma .
Most common initial treatment is triple therapy: Amoxicillin ( metronidazole if penicillin allergy )
+ Clarithromycin + Proton pump inhibitor; Antibiotics Cure Pylori .
Spirochetes
Spiral-shaped bacteria Q with axial filaments.

Includes Horrelia ( bigsize), Leptospira, and
Treponema. Only Horrelia can be visualized
using aniline dyes ( Wright or Gicmsa stain )
in light microscopy due to size. Treponema is
visualized by dark-field microscopy or direct
fluorescent antibods ( DFA ) microscopy.
Leptospira interrogans
Spirochete with hook-shaped ends found in water contaminated with animal urinejCausc 4
leptospirosis flu-like symptoms, myalgias (classically of calves), jaundice, photophobia with
conjunctival suffusion (erythema without exudate). Prevalent among surfers and in tropics ( eg,
BLT.
llorrelia is Big.
Hawaii ).
Weil disease ( ictcrohemorrhagic leptospirosis) severe form with jaundice and azotemia from liver
and kidney dysfunction, fever, hemorrhage, and anemia .
Lyme disease
Caused by Horrelia burgdorferi , which is

transmitted by the Ixodes deer tick ^3 (also
vector for Anaplasma spp. and protozoa
Habesia ). Natural reservoir is the mouse.
Mice are important to tick life cycle.
Common in northeastern United States.
Stage 1 early localized: erythema migrans Q,
flu -like symptoms.
Stage 2 early disseminated: secondary lesions,
carditis, AV block , facial nerve ( Bell ) palsy,
migratory myalgias/transient arthritis.
Stage s late disseminated: encephalopathies,
chronic arthritis.
A Key Lyme pie to the PACK:

Facial nerve palsy ( ty pically bilateral )
Arthritis
Cardiac block
Erythema migrans.
Treatment: doxvcvline ( 1st line ); amoxicillin and
cefuroxime in pregnant women and children .
MICROBIOLOGY
MTUUJDTUTUGT
UJNIIAL DALI tKiULUUY
1HIL 1i
Treatment for all: doxvcvclinc [ except during pregnancvil
Rickettsial diseases
and vector-borne
illnesses
RASH COMMON
Rickettsia rickettsii. vector is tick. Despite its

Classic triad headache, fever, rash (vasculitis).
Palms and soles rash is seen in Coxsackievirus
name, disease occurs primarily in the South
A infection ( hand, foot, and mouth disease),
Atlantic states, especially North Carolina.
Rash ty pically starts at wrists and ankles and
Roekv Mountain spotted fever, and 2 Syphilis
( you drive CARS using your palms and soles).
then spreads to trunk, palms, and soles.
Rickettsii on the wRists, Typhus on the Trunk.
Endemic ( fleas) R txplii.
Epidemic ( human body louse) R prowazekii .
Rash starts centrally and spreads out, sparing
palms and soles.
Rocky Mountain
spotted fever
Typhus
RASH RARE
Ehrlichia, vector is tick. Monocytes with

morulae J (mulberry-like inclusions ! in
cytoplasm.
Anaplasma, vector is tick. Granulocytes with
morulae Q in cytoplasm.
Coxiella burnetii , no arthropod vector. Spores
inhaled as aerosols from cattle/sheep amniotic
fluid. Presents as pneumonia. Common cause
of culture Endocarditis.
Ehrlichiosis
Anaplasmosis
Q fever
MEGA berry
Monocytes = Ehrlichiosis
Granulocytes = Anaplasmosis
y fever is Queer because it has no rash or vector

and its causative organism can survive outside
in its endospore form. Not in the Rickettsia

genus, but closely related.
B,
*'
4
118
SECTION II
Chlamydiae
MICROBIOLOGY
rul
1#
Chlamydiae cannot make their own ATP. They

are obligate intracellular organisms that cause
mucosal infections. 2 fomis:
Elementary body (small, dense)
is "Knfectious" and Enters cell via
Endocytosis; transforms into reticulate body.
Reticulate body Replicates in cell by fission;
Reorganizes into elementary bodies.
Chlamydia trachomatis causes reactive arthritis
(Reiter syndrome ), follicular conjunctivitis Q,
nongonococcal urethritis, and Ill )
Chlamydophila pneumoniae and Chlamxdophila
psittaci cause atypical pneumonia; transmitted
by aerosol.
Treatment ' azithromycin ( favored because one
time treatment ) or doxvcvclinc; (+ ceftriaxone
C
;i- _i
Chlamys = cloak (intracellular).

C psittaci has an avian reservoir (parrots),
causes atypical pneumonia.
Lab diagnosis: PCR, nucleic acid amplification
test. Cvtoplasmiclinclusions seen on Giemsa or
fluorescent antibody stained smear.
The chlamydial cell wall lacks classic

peptidoglvcan ( due to reduced muramic acid ),
rendering (5-lactam antibiotics less effective.
118
SECTION II
MICROBIOLOGY
Chlamydiac cannot make their own ATP. They

are obligate intracellular organisms that cause
mucosal infections. 2 forms:
Elementary body (small, dense)
is "Knfectious" and Enters cell via
Endocvtosis; transforms into reticulate body.
Reticulate body Replicates in cell by fission;
Reorganizes into elementary bodies.
Chlamydia trachomatis causes reactive arthritis
( Reiter syndrome ), follicular conjunctivitis ,
nongonococcal urethritis, and Ill)
Chlamydophila pneumoniae and Chlamxdopliila
psittaei cause atypical pneumonia; transmitted
by aerosol.
Treatment : azithromycin ( favored because one
Chlamydiae
Chlamys = cloak ( intracellular).

C psittaei has an avian reservoir ( parrots),
causes atypical pneumonia.
Lab diagnosis: PCR, nucleic acid amplification
test . Cytoplasmic!inclusions seen on Giemsa or
fluorescent antibody-stained smear.
The chlamydial cell wall lacks classic

peptidoglycan (due to reduced muramic acid),
rendering P-lactam antibiotics less effective.
time treatment ) or doxvcyclinc; ( + ceftriaxone

for possible concomitant gonorrheal
Chlamydia trachomatis serotypes

ABC = Africa, Blindness, Chronic infection.
Types A, B, and C
Chronic infection, cause blindness due to

follicular conjunctivitis in Africa.
Types D- K
Urethritis/PID, ectopic pregnancy, neonatal

D-K = everything else.
pneumonia (staccato cough) with eosinophilia, Neonatal disease can be acquired during
neonatal conjunctivitis ( 1 2 weeks after birthj
passage through infected birth canal.
Types LI, L2, and L3
Lymphogranuloma venereum small, painless
ulcers on genitals -* swollen, painful inguinal

lymph nodes that ulcerate ( buboes). Treat with
doxycycline.
Mycoplasma
pneumoniae
s'
Classic cause of atypical walking pneumonia

( insidious onset, headache, nonproductive
cough, patchy or diffuse interstitial infiltrate ).
X-ray looks worse than patient. High titer of
cold agglutinins (IgM), which can agglutinate
or lyse RBCs. Crown on Eaton agar.
Treatment: macrolides, doxycycline, or
fluoroquinolone (penicillin ineffective since
Mycoplasma have no cell wall).
No cell wall. Not seen on Gram stain.
Pleomorphic Q.
Bacterial membrane contains sterols for stability.
Mycoplasmal pneumonia is more common in
patients < 30 years old.
Erequcnt outbreaks in military recruits and
prisons.
Mycoplasma gets cold w ithout a coat (cell wall).
MICROBIOLOGY
MICROBIOLOGY MYCOLOGY
ystemic mycoses
All of the following can cause pneumonia and can disseminate.

All are caused bv dimorphic fungi: cold (20C ) = mold; heat ( 37 ) = veast. The only exception is
Qiccidioidoe which is a spherule (not yeast) in tissue.
Svstemic mycoses can form granulomas i like TB ); cannot be transmitted person-to-person (unlike
TB ).
Treatment: fluconazole or itraconazole for local infection; amphotericin B for systemic infection !
DISEASE
Histoplasmosis
ENDEMIC lOCATIOIi|
PATHOtOGIC FEATURES
Mississippi and Ohio

River \Jillev4
Macrophage filled
with Histoplasnia
( smaller than
RBC ) Q
UNIQUE SIGNS/S VMPTOM
^
Palatal /tonguc ulcers.
splenomegaly]
Coccidioidomycosis
determination of
urme /scruni antigen.
Kastern and
Central US
Broad-base budding
of Blastomyces ( same
size as RBC) fj.
nodules]
Southwestern US!
Spherule ( much larger

than RBC ) filled
with endospores of
Coccidioides H.
*w
jiW
lung disease, can

disseminate to skin /
bone. Verrucous skin
lesions can simulate
Blasto Inids hroadlv.
Inflammatory
SCC. Forms
granulomatous
California
Para
coccidioidomycosis
Ilisto hides ( w ithin

macrophages ) Bird
(eg, starlings ) or bat
droppings.
Diagnosis made via
Blastomycosis
NOTES
Disseminates
to skin/bone.
Frslhema nodosum
( desert bumpsl
or multifonne.
Arthralgias (desert
rheumatism ). Can
Coccidio crowds
endospores.
cause meningitis!
Latin America!
Budding veast of
Iartjcoccidiodtrs with
captain's wheel
formation (much
larger than RBC j [ A .
Similar to
coccidiomvcosis
males > females]
Paracoccidio parasails
w ith the captain 's
wheel all the was to
Latin America.
'
120
SECTION II
MICROBIOLOGY
MICROBIOLOGY
MYCOLOGY
Cutaneous mycoses
Tinea is the clinical name given to dermatophyte ( cutaneous fungal ) infections. Dermatophytes
include Mictmporum, Trichophyton , and Epidermophyton. Branching septate hvphae visible on
KOH preparation with blue fungal stain . Associated with pruritu ' j
Tinea
(dermatophytes)
Tinea capitis
Occurs on head , scalp. Associated with lymphadenopathy, alopecia, scaling 0.
Tinea corporis
Occurs on torso. Characterized by erythematous scaling rings ( ringworm ) and central

clearing Q. Can be acquired from contact with an infected cat or dog.
Tinea cruris
Occurs in inguinal area | ]. Often does not show the central clearing seen in tinea corporis.
Tinea pedis
Three varieties:
Interdigital Q; most common
Moccasin distribution Q
Vesicular type
Onychomycosis; occurs on nails.
Tinea unguium
Caused by Alalassesia spp. ( Pityrosporum spp.), a yeast-like fungus ( not a dermatophyte despite
being called tinea ). Degradation of lipids produces acids Ibat damage melanocytes and cause
hvpopigmcntcd 3. hvperpigmcnted , and /or pink patches. Weaker association with pruritu 4
Can occur any time of year, but more common in summer ( hot , humid weather). Spaghetti and
meatballs" appearance on microscopy Q.
Treatment: selenium sulfide, topical and/or oral antifungal medications.
Tinea ( pityriasis)
versicolor
jft.
Jit *
'
Jk
M
MICROBIOLOGY
SECTION I I
Opportunistic fungal infections

Candida albicans
Aspergillus
fumigatus
alba = white. Dimorphic; forms pseudohyphae and budding yeasts at 20C , germ tubes at
T7C O
Systemic or superficial fungal infection. Causes oral 0 and esophageal thrush in
immunocompromised (neonates, steroids, diabetes, AIDS), vulvovaginitis (diabetes, use of
antibiotics), diaper rash, endocarditis ( IV drug userst. disseminated candidiasis ( to any organ),
chronic mucocutaneous candidiasis.
Treatment; oral fluconazole/topical azole for vaginal nystatin, fluconazole, or caspofungin for oral /
esophageal; fluconazole, caspofungin, or amphotericin B for systemic,
Septate hvphae that branch at 45 Acute Angle [3- Produces conidia in radiating chains at end of
conidiophore 0.
Causes invasive aspergillosis in immunocompromised, patients with chronic granulomatous discascj
Can cause aspergillomas in pre-existing lung cavities, especially after TB infection.
Some species of Aspergillus produce Aflatoxin
Allergic bronchopulmonary aspergillosis ( ABPA): hypersensitivity response associated with
asthma and cystic fibrosis; may cause bronchiectasis and cosinophilia.
5-10 pm with narrow budding. Heavily encapsulated yeast. Not dimorphic.
Found in soil, pigeon droppings. Acquired through inhalation with hematogenous dissemination
to meninges. Culture on Sabouraud agar Highlighted with India ink ( clear halo Q) and
mucicarmine ( red inner capsule 0). Latex agglutination test detects polysaccharide capsular
antigen and is more specific.
Causes cryptococcosis, cryptococcal meningitis, cryptococcal encephalitis ( soap bubble" lesions
in brain), primarily in immunocompromised.
Treatment : amphotericin B + flucytosine followed bv fluconazole for cryptococcal meningitis.
Irregular, broad, nonseptate hvphae branching at w ide angles Q.
Mucormycosis. Causes disease mostly in ketoacidotic diabetic and/or neutropenic patients (eg
leukemia). Fungi proliferate in blood vessel walls, penetrate cribriform plate, and enter brain.
Rhinocerebral, frontal lobe abscess; cavernous sinus thrombosis Headache, facial pain, black
necrotic eschar on face; may have cranial nerve involvement.
Treatment: surgical debridement, amphotericin B.
Cryptococcus
neoformans
Mucor and Rhizopus

spp.
.
*
IV?
,<s
I O
7/o
fjMt
'
P
<
F
n
H
*%
.- v
MICROBIOLOGY
MICROBIOLOGY PARASITOLOGY
MICROBIOLOGY -PARASITOLOGY
rotozoa gastrointestinal infections
ORGANISM
DISEASE
Giardia lamblia
Giardiasis bloating, flatulence,

foul-smelling, fatty diarrhea
(often seen in campers/hikers)
think fat-rich Ghirardelli
TRANSMISSION
DIAGNOSIS
TREATMENT
Cysts in water
Multinucleated
trophozoites Q or
cysts Q in stool
Metronidazole
Cysts in water
Serology and /or
Metronidazole;
chocolates for fatty stools of

Giardia
Entamoeba
histolytica
Amebiasis bloody diarrhea

(dysentery), liver abscess
(anchovy paste exudate ),
RUQ pain; histology shows

flask-shaped ulcer
trophozoites (with
paromomycin or
engulfed RBCs
in the cytoplasm)
iodoquino! for
asymptomatic cyst
or cysts with up to
passerj
T nuclei in stool 1
Entamoeba Eats
Erythrocyte
Cryptosporidium
Severe diarrhea in AIDS

Mild disease (watery diarrhea) in
immunocompetent hosts
Oocysts on acid-fast
Oocysts in water
stain Q
Prevention i by
filtering city
water supplies);
nitazoxanide in
immunocompetent
hosts
>
124
SECTION II
MICROBIOLOGY
Protozoa CNS infections

ORGANISM
DISEASE
TRANSMISSION
DIAGNOSIS
TREATMENT
Toxoplasma
gondii
Congenital toxoplasmosis =
Cysts in meat (most

common); oocysts
in cat feces; crosses
Serology, biopsy
( tachyzoite) Q
Sulfadiazine +
pyrimethamine
Amoebas in spinal
fluid Q
Amphotericin B has
been effective for a
few survivors
Trypomastigotc in
Suramin for bloodborne disease or

mi larsoprol for
CNS penetration
classic triad of chorioretinitis,

hydrocephalus, and intracranial
calcifications; reactivation in
AIDS -* brain abscesses usually
seen as multiple ring- enhancing
Naegleria fowleri
placenta ( pregnant
women should
avoid cats)
lesions on MRtfl
Rapidly fatal meningoencephalitis Swimming in
freshwater lakes
( think Nalgene
bottle filled
with fresh water
containing
Naegleria ); enters
via cribriform plate
Trypanosoma
brucei
Tsetse flv a painful

African sleeping sicknessenlarged lymph nodes, recurring bite
fever (due to antigenic variation),
somnolence, coma
Two subspecies: Trypanosoma
brucei rhodesiense Trypanosoma
brucei gambiense
blood smear El
( "I sure am
mellow when
I'm sleeping;
remember
melatonin helps
with sleep!
cr
C>
. I*
k
>1
V.
r
MICROBIOLOGY
SECTION II
1 27
Nematodes (roundworms)
ORGANISM
DISEASE
TREATMENT
TRANSMISSION
Intestinal
Enterobius vermicularis
(pinworml|
Caused anal pruritus ( diagnosed bv seeing Fecal- oral

egg Q ia the tape test)
Ascaris lumbricoides
(giant roundworm)
May cause!obstruction at
Strongyloides
Caused vomiting, diarrhea, epigastric
'
ileocecal valve
Fecal-oral; knobbv -coated,

oval eggs seen in feces
Pvrantcl pamoate or
bendazoles ( because
worms are bendy)
Bendazoles
under microscope!
stercoralis
(threadworm)
Ancylostoma
duodenale, Necator
americanus
( hookworms)
pain (may mimic peptic ulcer)
Causedanemia bv sucking blood from
Larvae in soil penetrate skin;

rhabditiform larvae seen in
feces under microscope!
Ivermectin or
Larvae penetrate skin
Bendazoles or pvrantel
intestinal \val|
bendazoles
pamoate
Cutaneous larva migrans pruritic,
serpiginous rash from walking barefoot
on contaminated beach
Trichinella spiralis
Larvae enter bloodstream and enevst in

striated muscle cells inflammation of
muscle
Undercooked meat ( cspeciallv Bendazoles

pork ); fecal-oral ( less likely )
Trichinosis fever, vomiting, nausea.

periorbital edema, myalgia
Trichuris trichiura
( whipworm!
Often asymptomatic; can cause loose

stool and anemia, rectal prolapse in
children with heavy infection!
Fecal-ora!
Bendazole!
Visceral larva migrans nematodes
Fecal-oral
Bendazoles
Tissue
Toxocara canis
migrate to blood through intestinal wall

causing inflammation and damage.
Freuuentlv affects heart ( myocarditis)
liver, eves (visual impairment,
blindness), and CNS (seizures, coma |]
Onchocerca volvulus
Skin changes, loss of clastic fibers, and

Female blackfly
river blindness ( black flies, black skin
nodules, black sight ); allergic reaction
Loa loa
Swelling in skin, worm in conjunctiva
Deer fly. horse fly mango fly
Dicthylcarbamazinc
Wuchereria bancrofti
Lymphatic filariasis (elephantiasis!
Female mosquito
Diethylcarbamazine
Ivermectin ( ivermectin
for river blindness)
to microfilaria possible
worms invade lymph nodes and

cause inflammation, which can block
lymphatic vessels H, takes 9 nro-1 yr
after bite to become symptomatic!
Long page please

edit to fit
''m
128
SECTION II
MICROBIOLOGY
MICROBIOLOGY
PARASITOLOGY
Cestodes ( tapeworms )
ORGANISM
DISEASE
TRANSMISSION
TREATMENT
Taenia solium El
Intestinal tapeworm
Ingestion ol larvae encysted in

undercooked pork
Ingestion of eggs in food
contaminated with human
fece j
Ingestion of larvae from rawfreshwater fish
Praziquantel
Ingestion of eggs from dog
Albendazole
Cvsticercosis,
neurocysticcrcosis Q
Diphyllobothrium
latum
Vitamin Bp deficiency
(tapeworm competes for Bp
in intestine) megaloblastic
anemia
Echinococcus
granulosus Q
Hvdatid evsts |"eggshell

calcification" ) in liver H,
causing anaphylaxis
Praziquantel; albendazole for

neurocysticcrcosis
Praziquantel
feces
Sheep arc an intermediate host
mm
.
Trematodes (flukes )
ORGANISM
DISEASE
TRANSMISSION
TREATMENT
Schistosoma
User and spleen enlargement

( S mansoni , egg with lateral
spine El), fibrosis, and
Snails arc host; cercariac

penetrate skin of humans
Praziquantel
Undercooked fish
Praziquantel
Jt
f!
c
;o
Clonorchis sinensis
inflammation
Chronic infection with
S haematobium ( egg with
terminal spine O ) can lead
to squamous cell carcinoma
of the bladder ( painless
hematuria ) and pulmonary
hypertension
Biliary tract inflammation

pigmented gallstones
Associated with
cholangiocarcinoma
MICROBIOLOGY
MICROBIOLOGY
PARASITOLOGY
SECTION II
Ectoparasites
jSarcoptes scabie (
Mite burrow into stratum comcrum and

cause scabies: pruritus ( worse at night ) and
serpiginous burrows ilincsl in webspacc of
hands and feetO
Common in children , crowded populations

( jails, nursing homes); transmission through
skin -lo-skin contact ( most common ) or via
foniite4
Treatment: permethrin cream , washing/drying
all clothing / bedding, treat close contacts.
Blood-sucking insects that cause intense

pruritus with associated excoriations,
commonly on scalp and neck ( head lice ) or
)
waistband and axilla ( body lice!
Can transmit Rickettsia prowazekii ( epidemic

t \ plinj). Barrelia recurrentis ( relapsing fever),
Bartonella quintana ( trench fever ).
//
fediculus humanus/
Phthirus pubis(
Parasite hints
ASSOCIATIONS
Biliary
ORGANISM
tract disease , chol.iugiocarcinoma
Brain cysts, seizures
I leniaturia , squamous cell bladder cancer

Liver ( hydatid ) evsts
Microcytic
anemia
Mvalgias, periorbital edema
Perianal pruritus
Portal hypertension
Vitamin
Treatment includes pyrethroids, malathion , or

ivermectin lotion , and nit Q combing. Children
with head lice can be treated at home w ithout
interrupting school .
Bn deficiency
Clonorchis sinensis
Taenia solium ( neurocvsticercosis )
Schistosoma haematobium
Echinococcus granulosus
.\nc\lostoma ,\ecator
Tnchinella spiralis
Enterohius
Schistosoma mansoni Schistosoma japonicum
I 'iiplixllobothrium latum
130
SECTION II
MICROBIOLOGY
MICROBIOLOGY VIROLOGY
Viral structure
general features
Naked virus with

icosahedra! capsid
Enveloped virus with

icosahedra! capsid
Enveloped virus with

helical capsid
Surface
- protein
Capsid
Nucleic acid
tjgS /TV*
- Lipid
<:::
XK
V ,
V /
iZ bilayer
CapS d
Capsid
, ' s^ Nucleic'
\
acid
bilayer
Upid
Lipid blU
- Helical mnucleocapsid
integrated RNA ia
with into
Viral genetics
Recombination
Reassortment
Complementation
Phenotypic mixing
Exchange of genes between 2 chromosomes by crossing over within regions of significant base
sequence homology.
When viruses with segmented genomes ( eg, influenza virus) exchange genetic material. For
example, the 2009 novel H1N1 influenza A pandemic emerged via complex viral reassortment of
genes from human, swine, and avian viruses. lias potential to cause antigenic shift.
When I of 2 viruses that infect the cell has a mutation that results in a nonfunctional protein, the
nonnrutated virus complements the mutated one bv making a functional protein that serves
both v iruses. For example, hepatitis D virus requires the presence of replicating hepatitis B virus
to supply IIBsAg, the envelope protein for HDV.
Occurs with simultaneous infection of a cell with 2 v iruses. Genome of virus A can be partially or
completely coated (forming pseudovirion) with the surface proteins of virus B. Type B protein coat
determines the tropism (infectivity) of the hybrid virus. However, the progeny from this infection
have a type A coat that is encoded by its type A genetic material
Viral vaccines
Live attenuated
vaccines
MMR. Yellow fever. Rotavirus, Influenza

( intranasal i. Chickcnpox VCV ). Smallpox.
Sabin polio virus.
I
Killed
Rabies, Influenza ( injected), Salk Folio, and

HAV vaccines. Killed/inactivated vaccines
Subunit
HBV ( antigen = HBsAg), HPV ( types 6, 11, 16,

and 18).
induce only humoral immunity but arc stable.
Music andI.YRICSS are best enioved Live.

|MMR = measles, mumps, rubella; live
attenuated vaccine that can he given to
11IV patients who do not show' signs of
immunodeficiency.
SalK = Killed.
RIP Always.
MICROBIOLOGY
RNA viral genomes
All RNA viruses except Rcoviridae are ssRNA.

stranded RNA viruses: 1 went to a retro
SECTION I I
All are ssRNA ( like our mRNA), except

repeato-virus (reovirus) is dsRNA.
( retrovirus) toga ( togas irus| parts;svhcrc

I drank flavored (flavivirus) Corona
( coronavirus ) and ate hippie ( hepevirus)
California (calicivirus) pickles (picornavirus).
Naked viral genome

infectivity
Purified nucleic acids of most dsDNA (except poxviruses and HBV) and strand ssRNA
( = mRNA) viruses are infectious. Naked nucleic acids of strand ssRNA and dsRNA viruses are
not infectious. They require polymerases contained in the complete virion.
Viral replication
DNA viruses
All replicate in the nucleus ( except poxvirus ). "Pox is out of the box (nucleus).
RNA viruses
All replicate in the cytoplasm (except influenza virus and retroviruses ).
Viral envelopes
DNA virus
characteristics
Naked (nonenveloped ) viruses include

Papillomavirus, Adenovirus, Parvovirus,
Polyomavirus, Calicivirus, Picornavirus,
Reovirus, and 1 lepevirus.
Generally, enveloped viruses acquire their
envelopes from plasma membrane when
they exit from cell. Exceptions include
herpesviruses, which acquire envelopes from
nuclear membrane.
Give PAPP smears and CPR to a naked hippie
( hepevirus)
DNA = PAPP; RNA = CPR and hepevirus
Some general rules all DNA viruses:

GENERAL RULE
COMMENTS
Are HHAPPPPy viruses
Are icosahedral
Hepadna, Herpes, Adeno, Pox, Parvo,

Papilloma, Polyoma.
Except parvo (single stranded).
Except papilloma and polyoma (circular,
supercoiled ) and hepadna (circular,
incomplete).
Except pox (complex).
Replicate in the nucleus
Except pox (carries own DNA-dependent RNA
Are double stranded

Have linear genomes
polymerase).
MICROBIOLOGY
SECTION II
133
Long page please

edit to fit
Herpesviruses
Enveloped, DS, and linear viruses
VIRUS
ROUTE OF TRANSMISSION
CUNICAL SIGNIFICANCE
NOTES
Herpes
simplex
virus-1
Respirators
secretions, saliva
Gingivostomatitis, keratoconjunctivitis Q,
herpes labialis HI herpetic whitlow on finger
temporal lobe encephalitis, esophagitis,
Most common cause of sporadic

encephalitis, can present as altered
mental status, seizures, and/or
'
aphasia.
erythema multiform
Herpes
simplex
virus-2
Sexual contact,
Varicella Zoster virus

(HHV-3)
Respiratory
Latent in sacral ganglia. Viral

meningitis more common with
HSV 2 than with IISV-1.
Varicella-zoster (chickenpox 0, shingles Q ),

encephalitis, pneumonia.
Most common complication of shingles is post
Latent in dorsal root or trigeminal

ganglia; CN V, branch
perinatal
Epstein- Barr
virus (HHV- 4)
secretions
Respiratory
teens, young
adults )
virus (HHV-5 )
herpetic neuralgia.
Mononucleosis fever, hcpatosplenomegaly,
pharyngitis, and lvmphadenopathv

l especially posterior cervical nodes bi. Often
misdiagnosed as strep throat: can differentiate
secretions,
saliva; aka
"kissing disease,"
(common in
Cytomegalo
Herpes genitalis Q, neonatal herpes.
Congenital
transfusion,
sexual contact,
because amoxicillin in HHV-4 infection causes

maeulopapular rasli Avoid contact sports until
resolution due to risk of splenic rupture.
Associated with lymphomas (eg, endemic
Burkitt lymphoma), nasopharyngeal
carcinoma (especially Asian adults!
Mononucleosis ( Monospot ) in
immunocompetent patients; infection in
immunocompromised! especially pneumonia
in transplant patients; esophagitis; AIDS
Retinitis ( sightomcgalovirus"): hemorrhage,
saliva, urine,
transplant
Human
herpes
viruses 6
and 7
Saliva
Human
herpesvirus
8
Sexual contact
cotton-wool exudates, vision loss.

Congenital CMV
Roseola infantum (exanthem subitum); high
fevers for several days that can cause seizures,
followed by diffuse macular rash Q.
involvement can cause herpes

zoster ophthalmic mi
Infects B cells through CD21.
Atypical lymphocytes on peripheral

blood smear 0 not infected B
cells but reactive cytotoxic T cells.
Monospot test heterophile
antibodies detected by agglutination
of sheep or horse RBCs.
Infected cells have characteristic

"owl eve" inclusions Q.
Latent in mononuclear cells.
Roseola; fever first, Rosie (cheeks)
later.
IIIIV-7 less common cause of
roseola.
1
Kaposi sarcoma (neoplasm of endothelial cells).
Seen in HIV/AIDS and transplant patients.
Dark /violaceous plaques or nodules Q
representing vascular proliferations.
Can also affect Gl tract and lungs.
SLtfl
Sri
-L
S [
\
-
kl
te co
f
SECTION II
HSV identification
h\
*
rID
MICROBIOLOGY
Viral culture for skin/genitalia.

CSF PCR for herpes encephalitis.
Tzanck test a smear of an opened skin vesicle to detect multinuclcatcd giant cells Q commonly
seen in HSV-1, HSV-2, and YZV infection.
Intranuclear eosinophilic Cowdrv A inclusions also seen with IISV-I. IISV-2, WAj
Tzanck heavens I do not have herpes.
MICROBIOLOGY
SECTION I I
RNA viruses
VIRALFAMILY
ENVELOP
RNA STRUCTURE
CAPSIOSYMMETRV
MEDICAL IMPORTANCE
Reoviruses
No
DS linear
10-12 segments
leosahedral
(double)
Picornaviruses
No
SS linear
leosahedral
Coltivirus3 Colorado tick fever

Rotavirus cause of fatal diarrhea in childrcnl
Poliovirus polio-Salk /Sabin vaccines IPV/OPV
Echovirus aseptic meningitis
Rhinovirus "common cold

Coxsackievirus aseptic meningitis; herpangina
( mouth blisters, fever); hand, foot, and mouth
disease; myocarditis; pericarditis
11AY acute viral hepatitis
PERCH
Hepevirus
No
SS linear
leosahedral
HEV
Caliciviruses
No
SS linear
leosahedral
Norovirus viral gastroenteritis
Flaviviruses
Yes
SS linear
leosahedral
HCV
Yellow fever1
Dengue3
St. Louis encephalitis3
West Nile virus'1 ( meningoencephalitis)
Zika virus
Togaviruses
Yes
SS linear
leosahedral
Rubella
Western and Eastern euuine encephalitis^
Chikungunva viru4
Retroviruses
Yes
SS linear
2 copies
leosahedral
(HTLV),
complex
and conical
1 lave reverse transcriptase

HTLV T-cell leukemia
HIV AIDS
(HIV )
Coronaviruses
Yes
SS linear
Helical
"Common cold," SARS, MERS
Orthomyxoviruses
Yes
SS linear
Helical
Influenza virus
Helical
PaRaMyxovirus:
8 segments
Paramyxoviruses
Yes
SS linear
Nonsegmented
Parainfluenza croup
RSV bronchiolitis in babies; Rx ribavirin
Measles, Mumps
Rhabdoviruses
Yes
SS linear
Helical
Rabies
Filoviruses
Yes
SS linear
Helical
Ebola /Marburg hemorrhagic fever often fatal!
Arenaviruses
Yes
SS or
1 lelical
LCMV lymphocytic choriomeningitis virus

Lassa fever encephalitis spread by rodents
circular
2 segments
Bunyaviruses
Yes
SS circular
s segments
Helical
California encephalitis3
Sandfly/Rift Valley fevers'1
Crimean-Congo hemorrhagic fever 3
Hantavirus hemorrhagic fever, pneumonia
Delta virus
Yes
SS circular
Uncertain
11DV is a "defective" virus that requires the

presence of HBV to replicate
'll
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MICROBIOLOGY
MICROBIOLOGY
Orthomyxoviruses. Enveloped, ssRNA

viruses with 8-segment genome. Contain
hemagglutinin ( binds sialic acid and promotes
viral cntrvt) and neuraminidase promotes
progeny virion release) antigens. Patients at
risk for fatal bacterial supcrinfection , most
commonly S aureus , S pneumoniae , and
11 jjn /luenzae.
Causes pandemics. Reassortment of viral
genome segments, such as when segments of
human flu A virus rcassort with swine flu A
Influenza viruses
Genetic shift/
antigenic shift
VIROLOGY
SECTION II
Reformulated vaccine ( the flu shot ) contains

viral strains most likely to appear during the flu
season , due to the virus' rapid genetic change.
Killed viral vaccine is most frequently used.
Live attenuated vaccine contains temperaturesensitive mutant that replicates in the nose but
not in the lung; administered ilitranasally.
Sudden shift is more deadlv than gradual drift
virus.
Reassortment
Causes epidemics. Minor (antigenic drift )

changes based on random mutation in
hemagglutinin or neuraminidase genes.
Genetic drift/
antigenic drift
Random
mutations '
v:
va
A togasirus. Causes rubella, once known as German ( s-dav i measles. Fever, postauricular and
other lymphadcnopathy. arthralgias, and fine, confluent rash that starts on face and spreads
centrifugally to involve trunk and extremities Q. Causes mild disease in children but serious
congenital disease (a ToRCHeS infection). Congenital rubella findings include blueberry
muffin" appearance due to dermal extramedullary hematopoiesis.
Rubella virus
Cl
Paramyxoviruses
Paramyxov iruses cause disease in children. They include those that cause parainfluenza (croup;
seal-like barking cough ), mumps, and measles as well as RSV, which causes respiratory tract
infection ( bronchiolitis, pneumonia ) in infants. All contain surface F ( fusion ) protein , which
causes respiratory epithelial cells to fuse and form multinuclcatcd cells. Palivizumab ( monoclonal
antibody against F protein ) prevents pneumonia caused by RSV infection in premature infants.
Palivizumab for Parainvxovirus ( RSV ) Prophvlaxis in Premies.
h 38
SECTION II
MICROBIOLOGY
Croup ( acute laryngotracheobronchitis)
Caused In parainfluenza viruses i paramyxovirus ), Virus mcmhranc contains hemagglutinin

( binds sialic acid and promotes viral entry ) and neuraminidase ( promotes progeny virion release )
antigens. Results in a "seal-like barking cough and inspiratory stridoj Narrowing of upper trachea
and subglottis leads to characteristic steeple sign on x-ray
Severe croup can result in pulsus
paradoxus 2 to upper airway obstruction.
Measles (rubeola )
virus
A paramyxovirus that causes measles. Usual

presentation involves prodromal fever with
cough, coryza, and conjunctivitis, then
eventually Koplik spots ( bright red spots with
blue-white center on buccal mucosa ),
followed 1-2 days later by a tnaculopapular

that starts at the head/neck and spreads
downward. Lymphadenitis with WarthinFinkeldey giant cells ( fused lymphocytes ) in
a background of paracortical hyperplasia.
SSPE (subacute sclerosing pancnccphalitis,
occurring years later ), encephalitis ( 1:2000),
and giant cell pneumonia (rarely, in
immunosuppressed ) are possible sequelae.
rash
Mumps virus
A paramyxovirus that causes mumps,

uncommon due to effectiveness of MMR
vaccine.
Symptoms: Parotitis d, Orchitis (inflammation
of testes), aseptic Meningitis, and Pancreatitis.
Can cause sterilitv (especially after pubertv).
T Cs of measles:
Cough
Coryza
Conjunctivitis
Vitamin A supplementation can reduce
morbidity and mortality from measles,
particularly in malnourished children.
Mumps makes your parotid glands and testes as

big as POM-Poms
MICROBIOLOGY
Bullet-shaped virus Q. Negri bodies

( cytoplasmic inclusions Qi commonly
found in Purkinje cells of cerebellum and
in hippocampal neurons. Rabies has long
incubation period (weeks to months) before
symptom onset. Postexposurc prophylaxis
is wound cleaning plus immunization with
Rabies virus
*
r:
SECTION II
Infection more commonly from bat, raccoon, and

skunk bites than from dog bites in the United
Stales; aerosol transmission leg, bat caves) also
possible.
killed vaccine and rabies immunoglobulin.

Example of passive-active immunity.
Travels to the CNS by migrating in a retrograde
fashion ( via dvnein motorsjiup nerve axons
after binding to ACh receptors.
Progression of disease: fever, malaise
- agitation, photophobia, hydrophobia,
*
hypersalivation -* paralysis, coma death.
Ebola virus
Zika virus
tor Zika virus
to come .
A filovirus Q that targets endothelial cells,

phagocytes, hepatocytes. Following an
incubation period of up to 21 days, presents
with abrupt onset of flu-like symptoms,
diarrhea/vomitiug, high fever, myalgia. Can
progress to DIG, diffuse hemorrhage, shock .
Diagnosed w itli RT-PCR within 48 hr ol
symptom onset. High mortality rate.
Transmission requires direct contact with bodily

fluids, fonntes (including dead bodies), infected
bats or primates (apes/monkeys); high incidence
of nosocomial infection.
Supportive care, no definitive treatment . Strict
isolation of infected individuals and barrier
practices for health care workers are kev to
preventing transmission.
MICROBIOLOGY
SECTION II
141
Hepatitis serologic markers

Anti-HAV (IgM)
IgM antibody to HAV; best test to detect acute hepatitis A.
Anti-HAV (IgG)
IgG antibody indicates prior HAV infection and/or prior vaccination; protects against reinfection.
HBsAg
Antigen found on surface of HBV; indicates hepatitis B infection.
Anti-HBs
Antibody to IIBsAg; indicates immunity to hepatitis B due to vaccination or recovery from

infection.
HBcAg
Antigen associated with core of HBV.
Anti- HBc
Antibody to HBcAg; IgM = acute/rcccnt infection; IgG = prior exposure or chronic infection. IgM
anti-HBc may be the sole marker of infection during window period.
HBeAg
Secreted by infected hepatocyte into circulation. Not part of mature HBV virion. Indicates active
viral replication and therefore high transmissibility.
Anti- HBe
Antibody to HBcAg; indicates low transmissibility.
Important
diagnostic
Incubation
Prodrome,
period
acute disease
Early
HBsAg
-HBc)
Anti-
Anti-HBs
HBc
land-HBc )
tests
HBsAg
Relative
concentration
of reactants
Convalescence
Late
(anti
Coat protein
IHBsAg)
Anti- HBc
DNA
polymerase
^ HBV particles^
Core (HBcAg)
3
i-
HBsAg
Anti - HBs
Window period
DNA genome
DNA polymerase
Anti-HBe
HBeAg
Virus particle
Level of
detection
V "7
Symptoms
exposure
tALT
HBsAg
Anti-HBs
a
HBeAg
/
Acute HBV
Window
Chronic HBV (high infectivity)
Months after
Anti- HBe
Anti-HBc
IgM
IgM
IgG
Chronic HBV (low infectivity)
IgC
Recovery
IgG
Immunized
142
SECTION I I
MICROBIOLOGY
HIV
Diploid genome ( 2 molecules of RNA).

The 5 structural genes ( protein coded for):
" env (gpl 20 and gp 41):
Formed from cleavage of gpl60 to form
Envelope proteins
acquired through budding from
host cell plasma membrane
p!7: Matrix protein
gpl20
Docking
glycoprotein
Lipid envelope
gp 41
Transmembrane
: reopt m
wts
apsid protein
transcriptase
envelope glycoproteins.
gpl20 attachment to host CD4+ T cell.
gp4l fusion and entry.
gag (p24 and pl7] capsid and matrix
proteins, respectively.
po/ reverse transcriptase, aspartate protease,
integrase.
Reverse transcriptase synthesizes dsDNA from
genomic RNA; dsDNA integrates into host
genome.
Virus binds CD4 as well as a coreceptor, either

CCR 5 on macrophages (carls' infection ) or
CXCR4 on T cells (late infection ).
Homozygous CCR 5 mutation = immunity.
Heterozygous CCR 5 mutation = slower course.
HIV diagnosis
Presumptive diagnosis made w ith ELISA

(sensitive, high false rate and low threshold,
rule out test ); results jeonfirmed with
Western blot assay ( specific, low false rate
and high threshold, rule in test).
Viral load tests determine the amount of viral
RNA in the plasma. High viral load associated
with poor prognosis. Also use viral load to
monitor effect of drug therapy.
AIDS diagnosis 200 CD4+ cells/innV
(normal: 500-1500 cclls/mml. HIV with
AlDS-defining condition (eg, Pneumocystis
pneumonial orCD4+ percentage < 14%.
ELISAAVestern blot tests look for antibodies to

viral proteins; these tests often are falsely
in the first 1-2 months of HIV infection and
falsely initially in babies bom to infected
mothers (anti-gpl 20 crosses placenta ). Use
I'CK m neon lies to detect viral load.
MICROBIOLOGY
Prions
MICROBIOLOGY
SYSTEMS
SECTION II
145
Prion diseases are caused by the conversion of a normal ( predominantly a-helical) protein termed
prion protein ( PrI*) to a (i-pleated form ( PrPsc ), which is transmissible via CNS- rclated tissue
( iatrogenic CJD ) or food contaminated bv BSE -infected animal products ( variant CJD). PrP'1
resists protease degradation and facilitates the conversion of still more PrP1 to PrP*c, Resistant to
standard sterilizing procedures, including standard autoclaving. Accumulation of PrP* results in
spongiform encephalopatlnjand dementia , ataxia , and death.
Creutzfeldt-Jakob disease rapidlv progressive dementia , typically sporadic (some familial forms).
Bovine spongiform encephalopathy ( BSE) also known as mad cow disease."
Kuru acquired prion disease noted in tribal populations practicing human cannibalism .
MICROBIOLOGY- SYSTEMS
Normal flora:
dominant
LOCATION
MICROORGANISM
Skin
S epidermidis
Nose
S epidermidis; colonized by S aureus
Oropharynx
Viridans group streptococci
S mutans
B fragilis > E coli
Lactobacillus , colonized by E coli and group
Vagina
B strep
Neonates delivered by C-section have no flora but are rapidly colonized after birth.
Dental plaque
Colon
Bugs causing food

poisoning
S aureus and B cereus food poisoning starts quickly and ends quickly.
MICROORGANISM
SOURC OF INFECTION
B cereus
Reheated rice. " Food poisoning from reheated

rice? Be serious! ( B cereus )
C botulinum
Improperly canned foods ( toxins ), raw honey

(spores)
C perfringens
Reheated meat
Undercooked meat
Ecoli 0157:117
Deli meats, soft cheeses
L monocytogenes
Salmonella
Poultry, meat , and eggs
Meats, mayonnaise, custard; preformed toxin
S aureus
V parahaemolyticus and V vulnificus?
Contaminated seafood
vulnificus
w
V
from
also
infections
contact with contaminated water or shellfish.
ound
can
cause
MICROBIOLOGY
Prions
MICROBIOLOGY SYSTEMS
SECTION II
145
Prion diseases are caused by the conversion of a normal (predominantly a-helical ) protein termed
prion protein ( Prlx ) to a 3-pleated form ( PrP51), which is transmissible via CNS-related tissue
( iatrogenic CJD) or food contaminated bv BSE -infected animal products ( variant CJD ) . PrP't
resists protease degradation and facilitates the conversion of still more PrP to PrPc. Resistant to
standard sterilizing procedures, including standard autoclaving. Accumulation of PrPc results in
spongiform enccphalopathsjand dementia, ataxia, and death.
Creutzfeldt-Jakob disease rapidly progressive dementia, typically sporadic isome familial forms).
Bovine spongiform encephalopathy ( BSE) also known as "mad cow disease."
Kuru acquired prion disease noted in tribal populations practicing human cannibalism.
Normal flora:
dominant
lOCAtlON
MICROORGANISM
Skin
S epidermidis
Nose
S epidermidis; colonized by S aureus
Oropharynx
Viridans group streptococci
Dental plaque
S mutant
Colon
B fragilis > E coli
Vagina
Lactobacillus, colonized by E coli and group

B strep
Neonates delivered by C-section have no flora but are rapidly colonized after birth
Bugs causing food

poisoning
S aureus and B ccreus food poisoning starts quicklv and ends quickly.
MICROORGANISM
SOURCE OF INFECTION
B cereus
Reheated rice. "Food poisoning from reheated

rice? Be serious!" (B cereus)
C botulinum
Improperly canned foods ( toxins ), raw hones

(spores)
C perfringens
Reheated meat
Eco/i 0157:117
Undercooked meat
L monocytogenes
Deli meats, soft cheeses
Salmonella
Poultry, meat, and eggs
S aureus
Meats, mayonnaise, custard; preformed toxin
V parahaemolyticus and V vulnificusa
aVvulnificus
Contaminated seafood
can also cause wound infections from contact with contaminated water or
shellfish.
148
SECTION I I
Urinary tract
infections
MICROBIOLOGY
Cystitis presents with dysuria, frequency, urgency, suprapubic pain, and WBCs ( but not WBC
casts) in urine. Primarily caused by ascension of microbes from urethra to bladder. Males
infants with congenital defects, vesicoureteral reflux. Elderlv enlarged prostate. Ascension to
kidney results in pyelonephritis, which presents with fever, chills, flank pain, costovertebral angle
tenderness, hematuria, and WBC casts.
Ten times more common in women (shorter urethras colonized by fecal flora). Other predisposing
factors: obstruction, kidney surgery, catheterization, GU malformation, diabetes, pregnancy.
UTI bugs
SPECIES
FEATURES
Escherichia coli
Leading cause of UTI. Colonies show green

Diagnostic markers:
metallic sheen on EMB agar.
Leukocyte esterase = evidence of WBC
activity.
2nd leading cause of UTI in sexually active
Nitrite test = reduction of urinary nitrates
women.
by bacterial species (eg, E coli ),
srd leading cause of UTI.Iairge mucoid capsule
Urease test = urease-producing bugs ( eg.
and v iscous colonies.
S saproplivticus. Proleus, Klebsiellct ).
Some strains produce a red pigment; often
nosocomial and drug resistant.
Staphylococcus
saprophyticus
Klebsiella pneumoniae
Serratia marcescens
COMMENTS
Proteus mirabilis
Often nosocomial and drug resistant.

Motility causes swarming" on agar; produces
urease; associated with struvite stones.
Pseudomonas
aeruginosa
Blue-green pigment and fruity odor; usually

nosocomial and drug resistant.
Enterococcus
Common vaginal infections
SIONS AND SYMPTOMS
Bacterial vaginosis
Trichomonas vaginitis
Candida vulvovaginitis
No inflammation
Inflammation ( strawberry
cervix)
Frothy, yellow-green, foul
smelling discharge
Inflammation
Thick, white, cottage cheese"
discharge Q
Motile trichomonads Q
pH > 4.5
Metronidazole
Treat sexual partner(s)
Pscudohyphae
pH normal (4.0-4.5)
Thin, white discharge Q with

fishy odor
LAB FINDINGS
TREATMENT
Clue cells
pH > 4.5
Metronidazole
I
-
'
\
-azoles
fv
SECTION II I MICROBIOLOGY
Red rashes of childhood

AGENT
ASSOCIATED SYNDROME / DISEASE
Coxsackievirus type A
Hand-foot-mouth disease
Oval-shaped vesicles on palms and soles Q;

vesicles and ulcers in oral mucosa
Human herpesvirus 6
Roseola (exanthem subitum )
Asymptomatic rose-colored macules appear

on body after several days of high fever; can
present with febrile seizures; usually affects
Measles virus
Measles (rubeola)
Confluent rash beeinning at head and moving

down; rash precededlbv cough, con / a,
conjunctivitis, and blue-white ( Koplik ) spots
infants
on buccal mucosa
Parvovirus B19
Erythema infectiosum ( fifth disease)
Slapped cheek" rash on face (can cause

hydrops fetalis in pregnant women)
Rubella virus
Rubella (German measles)
Pink macules and papules begin at head

and move down, remain discrete -* fine
desquamating truncal rash; postauricular
lymphadenopathx
Streptococcus pyogenes
Scarlet fever
Erythematous, sandpaper-like rash Q with fever

and sore throat
Varicella - Zoster virus
Chickenpox
Vesicular rash begins on trunk; spreads to face

and extremities with lesions of different stages
150
SECTION I I
MICROBIOLOGY
Red rashes of childhood

AGENT
ASSOCIATED SYNDROME/DISUSE
Coxsackievirus type A
Hand-foot-nioutli disease
Oval-shaped vesicles on palms and soles

vesicles and ulcers in oral mucosa
Human herpesvirus 6
Roseola (exanthem subitum )
Asymptomatic rose-colored macules appear

on body after several days of high fever; can
present with febrile seizures; usually affects
infants
Measles virus
Measles Irubeola i
Confluent rash beginning at head and moving

down; rash precedec|hy cough, coryza,
conjunctivitis, and blue-w hite i KLoplik ) spots
on buccal mucosa
Parvovirus B19
Erythema infectiosum ( fifth disease )
Slapped cheek" rash on face Q] ( can cause

hydrops fetalis in pregnant women)
Rubella virus
Rubella (German measles )
Fink macules and papules begin at head

fine
and move down, remain discrete
desquamating truncal rash; postauricular
Streptococcus pyogenes
Scarlet fever
lymphadenopathy
Erythematous, sandpaper-like rash Q with few
and sore throat
Varicella-Zoster virus
Chickcnpox
Y'esicular rash begins on trunk; spreads to face

and extremities with lesions of different stage
MICROBIOLOGY
SECTION II
151
Sexually transmitted infections

DISEASE
CLINICAL FEATURES
ORGANISM
AIDS
Opportunistic infections, Kaposi sarcoma,
HIV
lymphoma
Chancroid
Painful genital ulcer with exudate, inguinal
adenopathy
Haemophilus ducreyi (its so painful, vou "do

cry )
Chlamydia
Urethritis, cervicitis, epididymitis,

conjunctivitis, reactive arthritis, PID
Chlamydia trachomatis ( D-K )
Condylomata
acuminata
Genital warts, koilocytes
HPV-6 and - 11
Genital herpes
Painful penile, vulvar, or cervical vesicles and

ulcers; can cause systemic symptoms such as
fever, headache, myalgia
HSV-2, less commonly HSV-1
Gonorrhea
Urethritis, cervicitis, PID. prostatitis,

epididymitis, arthritis, creamy purulent
discharge
Painless, beefv red ulcer that bleeds rcadilv on
Neisseria gonorrhoeae
Granuloma inguinale
(donovanosis)
contact
Not common in US
Hepatitis B
Jaundice
Lymphogranuloma
venereum
Infection of lymphatics; painless genital ulcers,

painful lymphadenopathy ( ie, buboes)
Primary syphilis
Painless chancre
Secondary syphilis
Fever, lymphadenopathy, skin rashes,

condylomata lata
Tertiary syphilis
Gummas, tabes dorsalis, general paresis, aortitis,

Argyll Robertson pupil
Trichomoniasis
Vaginitis, strawberry cervix, motile in wet prep
Klebsiella (Calvmmatobacterium ) granulomatis:

cytoplasmic donovan bodies ( bipolar staining)
seen on microscopy
HBV
C trachomatis ( LI LA )
Treponema pallidum
Trichomonas vaginalis
MICROBIOLOGY
SECTION II
153
Bugs affecting unvaccinated children

FINDINGS/LABS
PATHOGEN
Beginning at head and moving down with
Rubella yirus
Dermatologic
Rash
postauricular lymphadenopathy
Beginning at head and moving down; rash
preceded by cough, conza. conjunctivitis, and
blue-white ( Koplik) spots on buccal mucosa
Measles virus
Neurologic
Microbe colonizes nasopharynx
11 influenzae type B
Can also lead to myalgia and paralysis
Poliovirus
Epiglottitis
Fever with dysphagia, drooling, and difficulty

breathing due to edematous cherry red"
epiglottis; " thumbprint sign" on x-ray
Pharyngitis
Grayish oropharyngeal exudate

( pseudomembranes" may obstruct airway);
Corynebaclerium diplitheriae (elaborates toxin
Meningitis
Respiratory
painful throat
Bug hints (if all else

fails)
influenzae type B (also capable of causing

epiglottitis in fully immunized children)
that causes necrosis in pharynx, cardiac, and

CNS tissue)
CHARACTERISTIC
ORGANISM
Asplcnic patient ( due to surgical splenectomy

or autosplenectomy, eg, chronic sickle cell
Encapsulated microbes, especially SHiN
disease )
(S pneumoniae H
N meningitidis )
influenzae type B >
Branching rods in oral infection, sulfur granules
Actinomyces israelii
Catalase microbes, especially S aureus

Klebsiella
Currant
jelly" sputum
Dog or cat hite

Facial nerve palsv (typically bilateral 1
Vasteurella multocida
Fungal infection in diabetic or

immunocompromised patient
1 lealth care provider
Neutropenic patients
Organ transplant recipient
A lucor or Rbizopus spp.
Borrelia burgdorferi ( Lyme disease)
HBV (from needlestick )
Candida albicans ( systemic), Aspergillus

CMV
Pediatric infection
Trophenma whipplei ( Whipple disease)

Haemophilus influenzae ( including epiglottitis)
Pneumonia in cystic fibrosis, burn infection
Pseudomonas aeruginosa
Pus, empyema, abscess
S aureus
Rash on hands and feet
Coxsackie A virus, Treponema pallidum,
Sepsis/mcnmgitis in newborn
Group B strep
Surgical wound
S aureus
Traumatic open wound
Clostridium perfringens
PAS
Rickettsia rickettsii
MICROBIOLOGY
MICROBIOLOGY
Penicillinase-sensitive
penicillins
MECHANISM
CLINICAL USE
ANTIMICROBIALS
SECTION II
Amoxicillin , ampicillin ; aminopenicillms.

Same as penicillin . Wider spectrum;
penicillinase sensitive. Also combine with
clavulanic acid to protect against destruction
by P -lactamase.
Kxtended-spectrum penicillin II influenzae,
H pylori , E coli Listeria monocytogenes ,
Proteus mirabilis , Salmonella , Shigella ,
Wlinolenicillins are AMPed-up penicillin .

AmOxicillin has greater Oral bioavailability
than ampicillin .
Coverage: ampicillin /amoxicillin 1 IIIEEPSS

kill enterococci.
enterococci.
ADVERSE EFFECTS
MECHANISM OF RESISTANCE
Penicillinase- resistant
penicillins
MECHANISM
CLINICAL USE
ADVERSE EFFECTS
Antipseudomonal
penicillins
1 Is persensitivily reactions; rash ;

pseudomembranous colitis.
Penicillinase in bacteria (a type of p-lactamase )

cleaves p-lactam ring.
Dieloxacillin , nafcillin , oxacillin.

Same as penicillin . Narrow spectrum;
penicillinase resistant because bulky R group
blocks access of p-lactamase to P-lactam ring.
S aureus (except MRSA; resistant because of
altered penicillin-binding protein target site ).
Use
naf ( nafcillin ) for staph ."
Hypersensitivity reactions, interstitial nephritis.
Piperacillin, ticarcillin.
MECHANISM
Same as penicillin . Extended spectrum .
CLINICAL USE
Pseudomonas spp. and gram rods; susceptible to penicillinase; use with P-lactamase inhibitors.
ADVERSE EFFECTS
Hypersensitivity reactions.
^-
lactamase inhibitors
Include Clavulanic acid , Avibactanr ,

Sulbactam. Tazobactani Often added
to penicillin antibiotics to protect the
antibiotic from destruction by P-lactamase
CAST.
155
56
SECTION II
MICROBIOLOGY
MICROBIOLOGY
ANTIMICROBIALS
Cephalosporins (generations i-V )

MECHANISM
P-lactam drugs that inhibit cell wall synthesis

but are less susceptible to penicillinases.
Bactericidal.
CLINICAL USE
1st generation (cefazolin, cephalexin) gram

cocci, Proteus mirabilis, E coli , Klebsiella
pneumoniae. Cefazolin used prior to surgery to
prevent S aureus wound infections.
2nd generation (cefaclor, cefoxitin,
cefuroximc) gram cocci, H influenzae,
Enterobacter aerogenes, Seisseria spp., Serratia
marcescens , Proteus mirabilis , E coli , Klebsiella
pneumoniae.
3rd generation (ceftriaxone, cefotaxime,
cefDodoxime. ceftazidimdl serious gram
infections resistant to other JJ-lactams.
4th generation (cefepime) gram organisms,

with t activity against Pseudomonas and gram
organisms.
5th generation (ceftaroline) broad gram and
grant organism coverage, including MRSA;
does not cover Pseudomonas.
Hypersensitivity reactions, autoimmune
hemolytic anemia, disulfiram-likc reaction,
vitamin K deficiency. Exhibit cross-reactivity
with penicillins, t nephrotoxicity of
aminoglycosides.
Structural change in penicillin -binding proteins
( transpeptidases ).
ADVERSE EFFECTS
MECHANISM Of RESISTANCE
Organisms typically not covered by 1st 4th

generation cephalosporins are LAME:
Listeria , Atypicals (Chlamydia, Mycoplasma ),
MRSA, and Enterococci. Exception:
ceftaroline ( 5th generation cephalosporin )
covers MRSA.
1st generation PEcK.
Fake fox fur.

2nd generation HENS PEcK.
Can cross blood-brain barrier.

Ceftriaxone meningitis. gonorrhea.
disseminated Lvme disease.
Ceftazidime Pseudomonas
MICROBIOLOGY
Tetracyclines
MECHANISM
MICROBIOLOGY
ANTIMICROBIALS
SECTION II
1 59
Tetracycline, doxycycline, minocycline.

Bacteriostatic; bind to sOS and prevent attachment of aminoacyl - tRNA; limited CNS penetration .
Doxycycline is fecally eliminated and can be used in patients with renal failure. Do not take
tetracyclines with milk ( Ca ~ ), antacids ( Ca -~ or Mg * ), or iron -containing preparations because
divalent cations inhibit drugs' absorption in the gut.
CLINICAL USE
Bonelia burgdorferi , M pneumoniae. Drugs' ability to accumulate intraccllularly makes them very
effective against Rickettsia and Chlamydia. Also used to treat acne. Doxvcveline effective against
ADVERSE EFFECTS
GI distress, discoloration of teeth and inhibition of bone growth in children , photosensitivity.

Contraindicated in pregnancy.
1 uptake or t efflux out of bacterial
MRSAt
cells by plasmid -encoded transport pumps.
Chloramphenicol
MECHANISM
CLINICAL USE
Blocks peptidyltransferase at 50S ribosomal subunit. Bacteriostatic.
Meningitis ( Haemophilus influenzae , Neisseria meningitidis Streptococcus pneumoniae ) and Rocky

Mountain spotted fever ( Rickettsia rickettsii ).
1 imiled use owing to toxicities but often still used in developing countries because of low cost.
Anemia ( dose dependent ), aplastic anemia (dose independent ), gray baby syndrome ( in premature
infants because they lack liver UDP-glucuronyl transferase).
Plasmid-encoded acetyltransferase inactivates the drug.
ADVERSE EFFECTS
Clindamycin
MECHANISM
CLINICAL USE
Blocks peptide transfer (translocation ) at 50S

ribosomal subunit . Bacteriostatic.
Anaerobic infections (eg, Bacteroides spp..
Clostridium perfringens ) in aspiration
ADVERSE EFFECTS
pneumonia, lung abscesses, and oral

infections. Also effective against invasive
group A streptococcal infection .
Pseudomembranous colitis (C difficile
overgrow th ), fever, diarrhea .
Treats anaerobic infections above the diaphragm

vs metronidazole (anaerobic infections below
diaphragm ),
162
SECTION II
Fluoroquinolones
MECHANISM
MICROBIOLOGY
MICROBIOLOGY
ANTIMICROBIALS
Ciprofloxacin, norfloxacin, levofloxacin. ofloxacin , moxifloxacin , gemifloxacin, enoxacin .

Inhibit prokaryotic enzymes topoisomerasc
II ( DNAgyrase) and topoisomerase IV.
Bactericidal. Must not be taken with antacids.
CLINICAL USE
Gram rods of urinary and Gl tracts ( including

Pseudomonas ), Neisseria , some gram
organisms, otitis externa.
ADVERSE EFFECTS
GI upset , superinfections, skin rashes, headache,

dizziness. Less commonly, can cause leg
cramps and myalgias. Contraindicated in
pregnant women , nursing mothers, and
children < 18 years old due to possible damage
to cartilage. Some may prolong QT interval.
May cause tendonitis or tendon rupture in
people > 60 years old and in patients taking
prednisone.
Fluoroquinolones hurl attachments to vour

bones.
Chromosome-encoded mutation in DNA

gyrase, plasmid-mediated resistance, efflux
pumps.
Daptomycin
MECHANISM
l .ipopeptide that disrupts cell membrane of

gram cocci.
CLINICAL USE
S aureus skin infections (especial!) MRSA ),

bacteremia, endocarditis, VRE.
ADVERSE EFFECTS
Myopathy, rhabdomvolysis.
Not used for pneumonia (avidly binds to and is

inactivated by surfactant ).
Metronidazole
MECHANISM
Forms toxic free radical metabolites in the

bacterial cell that damage DNA. Bactericidal ,
antiprotozoal.
CLINICAL USE
Treats Uiardia , Entamoeba , trichomonas

Gardnerella vaginalis Anaerobes ( Baeleroides ,
C difficile ). Used with a proton pump inhibitor
and clarithromycin for " triple therapy" against
H Pylori.
Disulfiram-like reaction (severe flushing,
tachycardia , hypotension ) with alcohol;
headache, metallic taste .
ADVERSE EFFECTS
GET GAP on the Metro with metronidazole!

Treats anaerobic infection below the diaphragm
vs clindamycin ( anaerobic infections above
diaphragm ).
164
SECTION I I
MICROBIOLOGY
MICROBIOLOGY ANTIMICROBIALS
Isoniazid
MECHANISM
CLINICAL USE
ADVERSE EFFECTS
. Bacterial catalaseperoxidase (encoded by KatG) needed to

convert INI 1 to active metabolite.
Mycobacterium tuberculosis . The only agent
used as solo prophylaxis against TB. Also used
as monotherapy for latent TB.
1 synthesis of mycolic acids
Hepatotoxicitv, P-450 inhibition, drug-induced
Different 1NH half-lives in fast vs slow

acetylators.
INH Injures Neurons and Hepatocvtes.
SLE. anion gap metabolic acidosis, vitamin

Bdeficiencvi ( peripheral neuropaths ,
sideroblastic anemia). Administer svith
pyridoxine ( Bh ).
Mutations leading to undcrcxpression of KatC.
Pyrazinamide
MECHANISM
Mechanism uncertain. Pyrazinamide is a prodrug that is converted to the active compounc

pyrazinoic acid. Works best at acidic pH ( eg, in host phagolysosomes).
CLINICAL USE
lycobacterium tuberculosis.
Hyperuricemia, hepatotoxicitv.
ADVERSE EFFECTS
i\
Ethambutol
MECHANISM
i carbohydrate polymerization of mycobacterium cell wall by blocking arabinosyltransferas
CLINICAL USE
A lycobacterium tuberculosis.
ADVERSE EFFECTS
Optic neuropathy (red-green color blindness). Pronounce evethambutol.
Streptomycin
MECHANISM
Interferes with 50S component of ribosome.
CLINICAL USE
Mycobacterium tuberculosis ( 2nd line).
ADVERSE EFFECTS
Tinnitus, vertigo, ataxia, nephrotoxicity.
MICROBIOLOGY
Echinocandins
MECHANISM
SECTION II
167
Anidulafungin, caspofungin, micafungin.

Inhibit cell wall synthesis by inhibiting synthesis of P-gluean.
CLINICAL USE
Invasive aspergillosis, Candida.
ADVERSE EFFECTS
GI upset, flushing (by histamine release).
Griseofulvin
MECHANISM
Interferes with microtubule function; disrupts mitosis. Deposits in keratin-containing tissues (eg,
nails).
CLINICAL USE
Oral treatment of superficial infections; inhibits growth of dermatophytes ( tinea, ringworm).
ADVERSE EFFECTS
Teratogenic, carcinogenic, confusion, headaches, disulfiram-like reaction! t cytochrome P-450 and
warfarin metabolism.
Antiprotozoan therapy
Pyrimethamine (toxoplasmosis), suramin atrd melarsoprol (Trypanosoma brucei ), nifurtimox

( Tcruzi ). sodium stibogluconate ( leishmaniasis).
Anti-mite/louse
therapy
Pcrmethrin ( blocks Na* channels

-* neurotoxicity), malathion
(acetylcholinesterase inhibitor), lindane
( blocks GABA channels
neurotoxicity).
Used to treat scabies ( Sarcoptes scabiei ) and
lice lPediculus and Pthirus ).
Treat PML ( Pests Mites and I ice) with PML

( Permethrin, Malathion Lindane), because
they N \G you ( Na, AChE, GABA blockade ) ,
Chloroquine
MECHANISM
Blocks detoxification of heme into hemozoin. Heme accumulates and is toxic to plasmodia.
CLINICAL USE
Treatment of plasmodial species other than P falciparum (frequency of resistance in P falciparum

is too high ). Resistance due to membrane pump that l intracellular concentration of drug. Treat
P falciparum with artemether/lumefantrine or atovaquone/proguanil. For life-threatening malaria,
use quinidine in US ( quinine elsewhere) or artcsunatc.
ADVERSE EFFECTS
Retinopathy; pruritus (especially in dark-skinned individuals ).
Antihelminthic
therapy
Mebendazole (microtubule inhibitor), pyrantel pamoate, ivermectin, diethylcarbamazine,

praziquantel.
168
SECTION II
MICROBIOLOGY
Antiviral therapy
HIV ANTIVIRAL
THERAPY
FUSION
ATTA< HMENI
Ml IV ' K
OTHER ANTIVIRAL
THERAPY
.- w a s
PRO
REVERSE
TRANSCRIPTASE
Receptor
binding
SYNTHESIS
PENETRATION
UMMM
transcription
^ V/x
DNA
integration
INTEGRASE
Transcription
Dolutegravif
Elviiegravir
Interferon -a
IHBV. HCV)
NRTIs
Abacavir IABCI
Didanosine (ddl)
Emtncrtabine IFTC]
Lamivudme (3TQ
Stavudine (d4T)
Tenofovir (TDF)
Zidovudine (ZDV,
formerly AZT )
Atazanavir
AS
Indnavir
Loplnavir
Ritonavir
Saquinavir
Packaging
and assombly
'
SYNTHESIS
^ ^1
Amarudlne 1LtorlBItefWdM
!l 0 yefuse !
J
n
. ..
Rimantadine
/
LL
vr.
tfavirenz
Ncv m me
Virion
assembly
PROTEASE
Darunavir
Fosamprenavir
y
NUCLEIC ACID
ftMMWII
Proteolytic
UNCOATING
NNR1 Detavirdme
v /x
Endo
cytosis
3
MAMMALIAN
CELL
CD 4 + T CELL
Guanosine analogs
Acyclovir, etc IHSV VZV)
Ganciclovir (CMV)
Viral DNA polymerase

inhibitors
Cidolovir 1 HSV*
Foscarnet / CMV
Guanmcl
e nucleotide
synthesis
Ribavirin IRSv, HCVI
Acyclovir resistant
RELEASE OF PROGENY VIRUS
Neuraminidase inhibitors
Budding
Oseltarmvirl Inllucn
. ..
/ aA B
Zanamivit
.
Release
Oseltamivir, zanamivir
I release of progeny virus.
MECHANISM
Inhibit influenza neuraminidase
CLINICAL USE
Treatment and prevention of both influenza A and B . Start within 4S hours of influenza symptom
onset.
Acyclovir, famciclovir, valacydovir

MECHANISM
Guanosinc analogs. Monophospliorylated by HSV/VZV thymidine kinase and not phosphorylatcd

in uninfected cells - few adverse effects. Triphosphate formed by cellular enzymes. Preferentially
inhibit viral DNA polymerase by chain termination.
CLINICAL USE
HSV and VZV. Weak activity against EBV No activity against CMV. Used for HSVmduced mucocutaneous and genital lesions as well as for encephalitis. Prophylaxis in
immunocompromised patients. No effect on latent forms of HSV and VZV. Valacyclovir, a
prodrug of acyclovir, has better oral bioavailability .

For herpes zoster, use famciclovir.
ADVERSE EFFECTS
Obstructive crystalline nephropathy and acute renal failure if not adequately hydrated.
Mutated viral thymidine kinase.
170
SECTION II
HIV therapy
MICROBIOLOGY
Highly active antiretroviral therapy (HAART): often initiated at the time of HIV diagnosis.
Strongest indication for patients presenting with AIDS defining illness, low CD4+ cell counts
(< 50( 1 cclls/nnn?), or high viral load. Regimen consists of 5 drugs to prevent resistance:
2 NRTIs and preferrablv an integrase inhibitor.
DRUG
MECHANISM
TOXICITY
Competitively inhibit nucleotide binding to
Bone marrow suppression lean be reversed

with granulocyte colons -stimulating factor
[G-CSF] and erythropoietin ), peripheral
neuropaths, lactic acidosis ( nucleosides ),
anemia ( ZDV ), pancreatitis (didanosine).
Abacavir contraindicated if patient has
1ILV-B 5701 mutation due to t risk of
NRTIs
Abacavir ( ABC)
Didanosine (ddl)
Emtricitabine (FTC)
Lamivudine ( 3TC)
Stavudine (d4T)
Tenofovir (TDF)
Zidovudine (ZDV,
formerly AZT)
transcriptase and terminate the DNA

chain (lack a V Ol 1 group). Tenofovir is a
nucleoTide; the others arc nucleosides and
need to be phosphorylated to be active.
ZDV' can be used for general prophslaxis
and during pregnane) to t risk of fetal
transmission.
1 lave vou dined ( vudinei w ith my nuclear
(nucleosides ) family?
reverse
'
hvperscnsitivitsl
NNRTIs
Delavirdine
Efavirenz
Nevirapine
Bind to reverse transcriptase at site different

from NRTIs. Do not require phosphorylation
to be active or compete w ith nucleotides.
Rash and hcpatotoxicity are common to all

NNRTIs. Vivid dreams and CNS symptoms
are common with efavirenz. Delavirdine and
efavirenz are contraindicated in pregnancy.
Protease inhibitors
Atazanavir
Darunavir
Fosamprenavir
Indinavir
Lopinavir
Ritonavir
Saquinavir
Assembly of virions depends on HIV-1 protease Hyperglycemia, GI intolerance (nausea,

{ pot gene ), which cleaves the polypeptide
diarrhea), lipodystrophy (Cushing-like
syndrome).
products of HIV mRNA into their functional
Nephropathv. hematuria! thrombocytopenia
parts. Thus, protease inhibitors prevent
(indinavm
maturation of new viruses.
Ritonavir can boost other drug concentrations Rifampin (potent CYI/UCT inducer )
contraindicated with protease inhibitors
by inhibiting cytochrome P-450.
All 111V protease inhibitors end iii-navir.
because it can decrease prolease inhibitor
Navir (never ) tease a protease.
concentration; instead use rifabutii
Integrase inhibitors
Raltegravir
Elvitegravir
Dolutegravir
Inhibits HIV genome integration into host cell
'
T creatine kinase.
chromosome by reversibly inhibiting HTV

integrase.
Fusion inhibitors
Enfuvirtide
Binds gp41 inhibiting viral entry.
Maraviroc
Binds CCR-5 on surface of T cells/monocytes,

inhibiting interaction w ith gpl 20.
Skin reaction at injection sites.
MICROBIOLOGY
MICROBIOLOGY ANTIMICROBIALS I SECTION I I
T7T
Interferons
MECHANISM
CLINICAL USt
ADVERSE EFFECTS
Glycoproteins normally synthesized by virus-infected cells, exhibiting a w ide range of antiviral and
antitumoral properties.
IFN-ot; chronic hepatitis B and C, Kaposi sarcoma, hairy cell leukemia, condyloma acuminatum,
renal cell carcinoma, malignant melanoma.
IK \ P: multiple sclerosis.
IFN-y: chronic granulomatous disease.
Flu-like symptoms, depression, neutropenia, myopathy.
Hepatitis C therapy
DRUG
MECHANISM
CUNICAL USE
Ribavirin
Inhibits synthesis of guanine nucleotides

by competitively inhibiting inosine
monophosphate dehydrogenase.
Chronic IICV; also used in RSV (palivizumab

preferred in children)
Adverse effects: hemolytic anemia; severe
teratogen.
Sofosbuvir
Inhibits IICV RNA-dependent RNA polymerase Chronic IICV' in combination with ribavirin.
simeprevir. ledipasvir (NS5A inhibitor ).
acting as a chain terminator.
+/ peginterferon alfi
Do not use as monotherapy.
Adverse effects; fatigue, headache, nausea.
Simeprevir
HCY' protease inhibitor; prevents viral
replication.
Infection control
techniques
Chronic HCY' in combination with ledipasvir

(NS5A inhibitor).
Do not use as monotherapy.
Adverse effects: photosensitivity reactions, rash.
Goals include the reduction of pathogenic organism counts to safe levels (disinfection ) and the
inactiv ation of self-propagating biological entities ( sterilization)
Autoclave
Pressurized steam at > 120C. May be sporicidal.
Alcohols
Denature proteins and disrupt cell membranes. Not sporicidal.
Chlorhexidine
Denatures proteins and disrupts cell membranes. Not sporicidal.
Hydrogen peroxide
Free radical oxidation. Sporicidal.
Iodine and iodophors
Halogcnation of DNA, RNA. and proteins. May be sporicidal.
Antimicrobials to
avoid in pregnancy
ANTIMICROBIAL
AOVERSE EFFECT
Sulfonamides
Kernicterus
Aminoglycosides
Fluoroquinolones
Clarithromycin
Ototoxicity
Cartilage damage
Tetracyclines
Discolored teeth, inhibition of bone grow th
Einbryotoxic
Ribavirin
Teratogenic
Griseofulvin
Teratogenic
Chloramphenicol
Gray baby syndrome
SAFe Children Take Really Good Care.
I Pathology
HIGH- YIELD PRINCIPLES IN
Pathology
Digressions , objections, delight in mockery, carefree mistrust are signs of

health; everything unconditional belongs in pathology."
Friedrich Nietzsche
You cannot separate passion from pathology any more than

separate a person's stririt from his body."
you
can
Richard Sclzer
The fundamental principles of pathology are key to understanding

diseases in all organ systems. Major topics such as inflammation and
neoplasia appear frequently in questions across different organ systems,
and such topics are definitely high yield. For example, the concepts of
cell injury and inflammation are key to understanding the inflammatory
response that follows myocardial infarction, a very' common subject of
board questions. Similarly, a familiarity with the early cellular changes
that culminate in the development of neoplasias for example,
esophageal or colon cancer is critical. Finally, make sure you
recognize the major tumor-associated genes and are comfortable with
key cancer concepts such as tumor staging and metastasis.
Inflammation
204
Neoplasia
214
204
SECTION II
PATHOLOGY INFLAMMATION
PATHOLOGY
ATP-dependent programmed cell death intrinsic andicxtrinsic pathway both pathways activate caspascs (cytosolic proteases) cellular
breakdown including cell shrinkage, chromatin condensation, membrane blebbing, and
formation of apoptotic bodies, w hich arc then ph igocvtoscd
Characterized by deeply eosinophilic cytoplasm and basophilic nucleus, pvknosis muelear
shrinkage ), and karvorrbexis ( fragmentation caused hv cndonuclease-mcdi,itct
|cleavagc).
Cell membrane typically remains intact without significant inflammation ( unlike necrosis ).
ONA laddering ( fragments in multiples of 180 bp) is a sensitive indicator of apoptosis ]
Apoptosis
Involved in tissue remodeling in embryogenesis. Occurs when a regulating factor is withdrawn

from a proliferating cell population (eg. 1 IL 2 after a completed immunologic reaction
apoptosis of proliferating effector cells ). Also occurs after exposure to injurious stimuli (eg,
radiation, toxins, hypoxia)
Regulated by Bc]-2 family of proteins such as BAX and BAK (proapoptotic ) and Bcl-2
(antiapoptotic).
Bcl-2 prevents cytochrome c release by binding to and inhibiting APAF 1. APAF-1 normally
binds cytochrome c and induces activation of caspase 9, initiating caspase cascade. If Bcl-2 is
overexpressed (eg, follicular lymphoma t[ 14;18] ), then APAF-1 is overly inhibited, t caspase
activation and tumorigenesis.
Intrinsic
(mitochondrial )
pathway
2 pathways:
Ligand receptor interactions ( FasL binding to Fas [CD95 ] or TNF-ot binding to its receptoj)
Immune cell (cytotoxic T-cell release of perforin and granzyme B)
Fas-FasL interaction is necessary in thymic medullary negative selection. Mutations in Fas
t numbers of circulating self-reacting lymphocytes due to failure of clonal deletion.
Defective Fas-FasL interactions cause autoimmune lymphoproliferative syndrome.
Extrinsic (death
receptor) pathway
Intrinsic
Extrinsic
(mitochondrial) pathway
(death receptor ) pathway
Fa$L /}
DNA damage
Radiation, ROS, toxins
Misfolded proteins
Hypoxia
r t
^ TNFu
J
Cytotoxic T cell
Granzyme
efforin
ospasa
pS 5 activation
ytoctirome C
BAXTBAK
be
KM
Execu m
caspases
.r
APAF-1
Macrophage
Initiator
caspases
ft
Wj/tefetal dispersion
rsion
Cytoplasmic
b eb
/ 2
,/
Ligands for
macrophage cell
receptors
_
Apoptotic
body
IA
H
i[
11 > 1
Figure
PATHOLOGY
PATHOLOGY
Necrosis
INFLAMMATION
Enzymatic degradation and protein denaturation of cell due to exogenous injury

components leak. Inflammatory process ( unlike apoptosis ).
TYPE
SEEN IN
DUE TO
Coagulative
Ischemia/infarcts in
most tissues (except
brain)
Ischemia or infarction ;
Liquefactive
Bacterial abscesses,
brain infarcti
Neutrophils release
lysosomal enzymes
that digest the
HISTOLOGY
205
SECTION II
intracellular
Cell outlines preserved but nuclei disappear

t cytoplasmic binding of eosinjdyes Q
proteins denature, then
enzymatic degradation
Early: cellular debris and macrophages

Late: cystic spaces and cavitation ( brain )
Neutrophils and cell dehris seen with
bacterial infection
tissue H: enzymatic
Caseous
TB, systemic fungi

( eg. Histoplasma
capsulation ), Nocardia
Fat
Enzymatic: acute
pancreatitis
(saponification of
peripancreatic fat )
Nonenzymatic:
traumatic (eg, breast
degradation first , then

proteins denature
Macrophages wall
off the infecting
microorganism
granular debris Q
Damaged
Fragmented cells and debris surrounded by

lymphocytes and macrophages
Outlines of dead fat cells without peripheral

nuclei ; saponification of fat ( combined with
C;r ' i appears dark blue on I I & E stain 0
cells release
lipase to break
down triglycerides.
liberating fatty acids
'
to bind calcium
-* saponification
injury )
Fibrinoid
Vessel walls are thick and pink 0
Immune complexes
Immune reactions in
vessels ( eg. polvartcritis combine with
nodosa ) , preedampsia .
fibrin - vessel wall
malignant
damage ( type III
hypertension!
hypersensitivity
reaction!
Gangrenous
Distal extremity and

Cl tractL after chronic
ischemia
48 - .
'
w*
Coagulative
Liquefactive superimposed on coagulative
Dry: ischemia Q
Wet: superinfection
v
w
.**
>
-- -
'
\
*
K
Uv
: SW
r,
YVI
*
Cell injury
PATHOLOGY
REVERSIBLE WITH 02
IRREVERSIBLE
Cellular /mitoehondrial swelling (1 ATP

-* 1 activity of VC/ICL ami Ca niinml
Mitochondrial permeability /v acuolization;

phospholipid-containing amorphous densities
within mitochondria (swelling alone is
reversible)
Nuclear chromatin clumping
Nuclear pvknosis ( condensation), karvorrhexis

( fragmentation ), karyolysis ( fading)
Plasma membrane damage (degradation of
membrane phospholipid)
Membrane blebbing
1 glycogen
Fatty change
Kibosomal/polysomal detachment Ii protein
synthesis)
Ischemia
llmaael
Inadequate blood supply to meet demand.

Regions most vulnerable to hypoxia /ischemia and subsequent infarction:
ORGAN
REGION
Brain
ACA/MCA /PCA boundary areasjb
Heart
Subendocardium ( LV )
Kidney
Straight segment of proximal tubule (medulla )

Thick ascending limb (medulla)
Area around central vein (zone III)
Liver
I New I
Lysosomal rupture
Cali influx easpase activation - apoptosis
Splenic flexure,3 rectum'1

Watershed areas ( border zones) receive blood supply from most distal branches of 2 arteries with
limited collateral vascularity. These areas are susceptible to ischemia from hypoperfusion ( blue
Colon
area in Ql
^Neurons most vulnerable to hypoxic-ischemic insults include Purkinje cells of the cerebellum and
pyramidal cells of the hippocampus and neocortex ( zones 3, 5 , 6|
PATHOLOGY
SECTION II
207
Types of Infarct j
Red Infarct!
Pale (anemic) infarcts Q occur in solid organs with a single (end-arterial ) blood supply, such as
heart, kidney, and spleen.
Pale Infarcti
L-
Red ( hemorrhagic ) infarcts Q occur in venous occlusion and tissues with multiple blood supplies,
such as liver, lung, intestine, testes; reperfusion ( eg, after angioplasty ). Reperfusion injury is due to
damage by free radicals.
Red = reperfusion.
m
'
Inflammation
Characterized by rubor (redness), dolor (pain ), color ( heat), tumor ( swelling), and
functio luesa ( loss of function).

Vascular component
t vascular permeability, vasodilation, endothelial injury.
Cellular component
Neutrophils extravasate from circulation to injured tissue to participate in inflammation through

phagocytosis, degranulation, and inflammatory mediator release.
Neutrophil, eosinophil, and antibody ( pre-existing), mast cell, and basophil mediatecj
Acute inflammation is rapid onset ( seconds to minutesl and of short duration (minutes to
days). Outcomes include complete resolution, abscess formation, or progression to chronic
inflammation.
Mononuclear cell (monocytes/macrophages, lymphocytes, plasma cells) and fibroblast mediated.
Characterized by persistent destruction and repair. Associated with blood vessel proliferation,
fibrosis. Granuloma: nodular collections of epithelioid macrophages and giant cells. Outcomes
include scarring and amyloidosis.
Acute
Chronic
208
SECTION II
PATHOLOGY
PATHOLOGY
INFLAMMATION
Types of calcification
Dystrophic
calcification
m
i
Ca -+ deposition in abnormal tissues 2 to injury or necrosis.

lends to be localized (eg, calcific aortic stenosis ). 3 shows dystrophic calcification ( yellow star),
small bony tissue ( yellow arrow's), and thick fibrotic wall (red arrows).
Seen in I B ( lung and pericardium ) and other granulomatous infectionj liquefactive necrosis
of chronic abscesses, fat necrosis, infarcts, thrombi, schistosomiasis, congenital CMV
+ toxoplasmosis + rubellij psammoma bodies. CREST svndronnj
Is not directly associated with scrum Ca + levels ( patients arc usually nomiocalccmic ).
&
Metastatic
calcification
1u.
Widespread ( ie, diffuse, metastatic) deposition of Ca-4 in normal tissue 2 to hypercalcemia (eg,
1 hyperparathyroidism, sarcoidosis, hvpervitaminosis D) or high calcium -phosphate product
levels (eg, chronic renal failure with 2 hyperparathyroidism, long-temi dialysis, calciphvlaxis,
multiple mvclom 4) .
shows metastatic calcifications of alveolar walls in acute pneumonitis rrows).

Ca + deposits predominantly in interstitial tissues of kidney, lung, and gastric mucosa (these tissues
lose acid quickly; t pH favors deposition ). Nephrocalcinosis of collecting ducts may lead to
nephrogenic diabetes insipidujand renal failurcj
Patients are usually not normocalcemic.
Inhalationlinjury and
sequelae
PATHOLOGY
Pulmonary complication associated with smoke

and fire. Caused by heat , particulates (< 1 |im
diameter), or irritants (eg. NIK ) -* chemical
tracheobronchitis, edema , pneumonia,
ARDS. Many patients present 2 to burns,
COjjnhalation, or arsenic poisoning.
Bronchoscopy shows severe edema, congestion

of bronchus, and soot deposition (Q, 18 hours
after inhalation injury; Q, resolution at 11 days
after injury).
Scar formation
70-807c of tensile strength regained at T months iwhcn type I collagen is replaced with type III
collagent little additional tensile strength will be regained afterward.
SCAR TYPE
Hypertrophic Q
Keloid
COLLAGEN SYNTHESIS
t ftvne I collagen!
ttt ( type III collagen )
COLLAGEN ORGANIZATION
Parallel
Disorganized
EXTENT OF SCAR
Confined to borders of original wound
SCAR EVOLUTION OVER YEARS
RECURRENCE
Possible spontaneous regression

Infrequent
Extends beyond borders of original wound with

clawlike projections typically on earlobes,
face, upper extremities
Possible progressive grow'th
Frequent
PREDISPOSITION
None
t incidence in ethnic groups with darker skin
\"
\
*YS
PATHOLOGY
Wound healing
Tissue mediators
PATHOLOGY
INFLAMMATION
SECTION II
MEDIATOR
ROLE
PDGF
Secreted by activ ated platelets and macrophages

Induces vascular remodeling and smooth muscle
TC F-P
cell migration
Stimulates fibroblast growth for collagen synthesis
Stimulates angiogenesis
Stimulates cell growth via tyrosine kinases (eg,
EGFR /ErbBi )
Angiogenesis, fibrosi .
Metalloproteinases
Tissue remodeling
FCF
EGF
VEGF
Stimulates angiogenesis
PHASE OF WOUND HEAUNG
EFFECTOR CELLS
CHARACTERISTICS
Inflammatory (up to
3 days after wound)
Platelets, neutrophils, macrophages
Proliferative
(day 3-weeks after
wound )
Fibroblasts, myofibroblasts, endothelial cells,

keratinocytes, macrophages
Clot formation, t vessel permeability and

neutrophil migration into tissue; macrophages
clear debris 2 days later
Deposition of granulation tissue and type
III collagen, angiogenesis, epithelial cell
proliferation, dissolution of clot , and wound
contraction ( mediated by myofibroblasts)^
Delayed wound healing in vitamin C deficiency
and copper deficiency
Remodeling
( 1 week -6+ months
after wound )
Granulomatous
diseases
mmma
Fibroblasts
Type III collagen replaced by ty pe 1 collagen ,

t tensile strength of tissue
Delayed wound healing in zinc deficiency
Bacterial :
1
Mycobacteria (tuberculosis, leprosy)

Bartonella henselae (cat scratch disease)
Listeria monocytogenes ( granulomatosis
infantiseptica )
Treponema pallidum ( 3 syphilis)
Fungal: endemic mycoses ( eg, histoplasmosis)
Parasitic: schistosomiasis
Autoinflammatory:
Sarcoidosis Q
Crohn disease
* Primary biliary cirrhosis
Subacute (de Quervain/granulomatous )
thyroiditis
Granulomatosis with polyangiitis ( Wegener)
Eosinophilic granulomatosis with
polyangiitis ( Churg-Strauss)
Giant cell ( temporal ) arteritis
Takayasu arteritis
Foreign material : berylliosis, talcosis,
hypersensitivity pneumonitis
Granulomas arc composed of epitheloid cells

{ macrophages w ith abundant pink cytoplasm I
with surrounding multinucleated giant
cells and lymphocytes. ITiJcclls secrete
IFN-y, activating macrophages. TNF-a
from macrophages induces and maintains
granuloma formation . Anti-TNF drugs can , as
a side effect , cause sequestering granulomas to
break down , leading to disseminated disease.
Always test for latent TB before starting antiTNF therapy.
Associated with hypercalcemia due to caleitriol
( ],25-[OH], vitamin D?) production .
Caseating necrosis more common with
infectious causes (eg, TB). Diagnosing
sarcoidosis requires noncaseating granulomas
on biopsy.
Exudate vs transudate
Exudate
Transudatgl
Cellular (cloudy)
t protein ( > 2.9 e/dl .i
f LDH ( vs scrum )
Due to:
Lymphatic obstruction (chylous)
Inflammation /infection
- Malignancy
Hypocellular (clear)
i protein (< 2.5 g/dl
t LDH (vs serum )
Due to:
t
*
hydrostatic
pressure (eg, IIF, Na +
retention )
i oncotic pressure ( eg, cirrhosis, nephrotic
syndrome )
Lights criteria
Diagnostic analysis comparing serum and pleural fluid protein and LDII levels.
If > 1 criterion is met * effusion is likelv exudative.
IfO criteria are met by definition , effusion is transudative.
1 . Pleural protein /seruin protein ratio > 0.5
2. Pleural LDH /scrum LDH ratio > 0.6
r Pleural LDH > of Hie upper limit of normal for serum LDH
Erythrocyte
sedimentation rate
Products of inflammation ( eg, fibrinogen ) coat RBCs and cause aggregation . The denser RBC
aggregates fall at a faster rale within a pipette tube. Often co-tested with CRP levels.
t ESR
i ESR
Most anemias
Infections
Inflammation (eg, giant cell [temporal] arteritis,
polymyalgia rheumatica )
Cancer (eg, metastases, multiple myeloma )
Renal disease (end-stage or nephrotic syndrome )
Pregnancy
Sickle cell anemia (altered shape )

Polycythemia ( t RBCs "dilute aggregation
factors)
I IF
Microcytosis
Hvpofibrinogenemia
PATHOLOGY
kocyte
avasation
SECTION II
209
Extravasation predominantlv occurs at postcapillary venules.

WBCs exit from blood vessels at sites of tissue injur) and inflammation in 4 steps:
VASCULATURE/STROMA
O Margination and rolling
K-sclectin ( from
defective in
WeibcT -
Palade bodies!
leukocyte adhesion deficiency type 2

( J Sialyl-Lewisx)
Tight binding (adhesion)
LEUKOCYTE
P-selectin
GlyCAM-1, CD54
ICAM-1 (CD54)
defectivjin
leukocyte adhesion deficiency type 1

(I CD18 integrin subunit)
Diapedesis WBC travels between
Sialyl-Lewisx
Sialyl-Lewisx
L-selectin
VCAM-1 (CD106)
COll /18 integrins

(LFA 1, Mac-1)
VLA-4 integrin
PECAM-1 (CD31)
PECAM-1 (CD31)
Chemotactic products
released in response
to bacteria: C5a, IL-8,
LTB4, kallikrein,
platelet-activating factor
Various
endothelial cells and exits blood vessel
Migration WBC travels through

interstitium to site of injury or infection
guided by chemotactic signals
I MN
O Margination 6 rolling
Diapedesis Migration
Tight binding
Sialyl-Lewis'
Vesse
umet
PMN
PMN
E- - ei 1
LFA -1
JJ
Ijg
Endothelium
Interstitium
ICAM-1
PMN
^^
Ml
PMN
>
radical injury
Free radicals damage cells via membrane lipid peroxidation, protein modification, and DNA
breakage.
Initiated via radiation exposure (eg, cancer therapy), metabolism of drugs ( phaseI), redox reactions,
nitric oxide (eg inflammation)!transition metals, WBC (eg, neutrophils, macrophages) oxidative
burst.
Free radicals can be eliminated by scavenging enzymes (eg, catalase, superoxide dismutase,
glutathione peroxidase), spontaneous decay, antioxidants (eg, vitamins A, C,E), and certain metal
carrier proteins (eg, transferrin, ceruloplasmin)
Examples:
Oxygen toxicity: retinopathy of prematurity ( abnormal vascularization), bronchopulmonary
dysplasia, reperfusion injury after thrombolytic thcrapsl
* Drug/chemical toxicity: carbon tetrachloride and acetaminophen overdose (hepatotoxicitv)
Metal storage diseases: hemochromatosis (iron) and Wilson disease (copper)
PATHOLOGY
PATHOLOGY
INFLAMMATION
213
SECTION II
Abnormal aggregation of protcins (or their fragments ) into (3-plcatcd linear sheets damage
and apoptosis. Amyloid deposits visualized by Congo red stain Q, polarized light ( apple green
birefringence) Q, and I l&E stain (Q shows deposits in glomerular mesangial areas [white arrows],
tubular basement membranes [ black arrows] ).
Amyloidosis
COMMON TYPES
DESCRIPTION
AL ( primary )
Due to deposition of proteins from Ig Light chains. Can occur as a plasma cell disorder or
associated with multiple myeloma. Often affects multiple organ systems, including renal
( nephrotic syndrome), cardiac ( restrictive cardiomyopathy, arrhythmia), hematologic (easy
bruising, splenomegaly). G1 ( hepatomegaly), and neurologic ( neuropathy).
Seen with chronic inflammatory conditions such as rheumatoid arthritis, IBD,
spondyloarthropathy, familial Mediterranean fever, protracted infection . Fibrils composed of
serum Amyloid A. Often multisystem like AL amyloidosis.
Fibrils composed of [A -inicroglobulni in patients with FSRD and /or on long-term dialysis. May
present as carpal tunnel syndrome.
Heterogeneous group of disorders, including familial amyloid polyneuropathies due to transthyretin
gene mutation.
Due to deposition of normal ( wild- type) transthyretin (TTR ) predominantly in cardiac ventricles.
Slower progression of cardiac dysfunction relative to AL amyloidosis.
Amyloid deposition localized to a single organ . Most important form is amyloidosis in Alzheimer
disease due to deposition of fT-amyloid protein cleaved from amyloid precursor protein ( APP).
Islet amyloid polypeptide ( IAPP ) is commonly seen in diabetes mcllitus type 2 and is caused by
deposition of amylin in pancreatic islets.
Isolated atrial amyloidosis due to atrial natriuretic peptide is common in normal aging, which can
predispose to t risk of atrial fibrillatiorj
Amyloid deposition lo ventricular eiidinmocardiinii in restrictive cardiomyopathy
Calcitonin deposition in tumor cells in medullary carcinoma of the thvroid.
AA (secondary)
Dialysis- related
Heritable
Age - related (senile)
systemic
Organ - specific
mm
n
a
'
'
rf s
'-
i.
Lipofuscin
im
/.
mm
fa
i
tv
\w
"
-V\ .
-6
.
.
'
rN
* 1
j
A yellow -brown "wear and tear * pigment associated w ith normal aging.
Formed by oxidation and polymerization of autophagoevtosed organellar membranes.
Autopsy of elderly person will reveal deposits in heart , colon Cl, liv er, kidney, eye, and other organs.
214
SECTION II
PATHOLOGY
PATHOLOGY NEOPLASIA
PATHOLOGY NEOPLASIA
Cjellular changes
Hyperplasia!
t in number of cells. May be a risk factor for future malignancy (eg, endometrial hyperplasia | but
not considered premalignanl!
Hypertrophy
f in size of cells.
Atrophy
iin tissue mass due to l in size and/or number of cells. Causes inc lude disuse, denervation, loss of
blood supply, loss of hormonal stimulation, poor nutrition.
Dysplasia
Disordered, non-neoplastic cell growth Term used only with epithelial cells. Mild dysplasia is
usually reversible: severe dysplasia usually progresses to carcinoma in situ.
Metaplasial
Replacement of one cell type by another. Usually due to exposure to an irritant, such as gastric
acid or cigarette smoke. Reversible if the irritant is removed but may undergo malignant
transformation with persistent insult leg, Barrett esophagus esophageal adenocarcinoma )!
Neoplasial
Uncontrolled, clonal proliferation of cells. Can be benign or malignant!

Complete lack of differentiation of cells in a malignant neoplasm.
The degree to which a malignant tumor resembles its tissue of origin;
Anaplasia
Differentiation!
Well-differentiated tumors ( often less aggressive) closely resemble t heir tissue of origin
Poorly differentiated tumors ( often more aggrcssivel look almost nothing like their tissue of
origiij
f * r>*\i
Hyperplasia
Change in cell size

and number
Reversible
Hypertrophy

Normal cells
Change in cell type

and structure
Dysplasia
Reversible
Atrophy
Irreversible
Metaplasia
Change in
cell type
and structure
ntfffy i '
Neoplasia
Anaplasia
I New I
[Figure ]
PATHOLOGY NEOPLASIA
PATHOLOGY
SECTION II
215
Hallmarks of cancer: evasion of apoptosis, growth signal self-sufficiency, anti-growth signal

insensitivity, sustained angiogenesis, limitless replicative potential, tissue invasion, and metastasis.
Neoplastic
progression
Normal cells w ith hasal apical pol rritvi See cervical example Q, which shows normal cells and
spectrum of dysplasia, as discussed below
Normal cells
OMOIOM o;
MM
Abnormal proliferation of cells with loss of si/c, shape, and orientation (eg, koilocvtic change, arrow
in ijComparc vs hyperplasia l cells t in number ).
Dysplasia
'
Neoplastic cells have not invaded the intact basement membrane,

t Ikiuclearcvtoplasmid ratio and clumped chromatin.
Neoplastic cells encompass entire thickness.
Carcinoma in situ/
preinvasive
m
sst
Cells have invaded basement membrane using collagenases and hydrolases (metalloproteinases).
Cell-cell contacts lost by inactivation of f -cadhcrin.
Invasive carcinoma
Spread to distant organ via lymphatics or bloodt
Metastasis
"Seed and soil
theory of metastasis:
* Seed = tumor embolus.

Soil = target organ is often the first-encountered capillary bed ( eg, liver, lungs, bone, brain, etc ).
J
Blood Of
tympfutic
Normal
Mild dysplasia
Moderate dysplasia
Severe dysplasia/
carcinoma in situ
216
SECTION II
PATHOLOGY
PATHOLOGY NEOPLASIA
Tumor grade vs stage
Grade
Degree of cellular differentiation and mitotic

activity on histology. Range from low grade
(well differentiated ) to high grade ( poorly
differentiated, undifferentiated or anaplastic).
Stage almost always has more prognostic value

than grade.
TNM staging system is used with mam
cancers ; exceptions include brain tumors and
leukemia jj
Stage
Degree of localization/spread based on site and

size of 1 lesion, spread to regional lymph
nodes, presence of metastases. Based on
clinical (c) or pathology (p) findings. Example:
cTsNlMO
TNM staging system ( Stage = Spread ):

T = Tumor size/local invasion!
N = Node involvement
M = Metastases
Each TNM factor has independent prognosticvalue; M factor often most important.
Tumor nomenclature
Carcinoma implies epithelial origin, whereas sarcoma denotes mesenchymal origin. Both terms
imply malignancy.
Terms for non-neoplastic malformations include hamartoma (disorganized overgrowth of tissues in
their native location, eg, Peutz -Jeghers polyps) and choristoma (normal tissue in a foreign location,
eg, gastric tissue located in distal ileum in Meckel diverticulum).
Benign tumor is usually well differentiated, well demarcated, low mitotic activity, no metastasis, no
necrosis.
Malignant tumor may show poor differentiation, erratic growth, local invasion, metastasis, and
1 apoptosis. Upregulation of telomerase prevents chromosome shortening and cell death.
CELL TYPE
BENIGN
MALIGNANT
Epithelium
Adenoma, papilloma
Adenocarcinoma, papillary carcinoma
Blood vessels
Hemangioma
Angiosarcoma
Smooth muscle
Leiomyoma
Leiomyosarcoma
Mesenchyme
Leukemia, lymphoma
Blood cells
Striated muscle
Rhabdomyoma
Rhabdomyosarcoma
Connective tissue
Fibroma
Fibrosarcoma
Bone
Osteoma
Osteosarcoma
Fat
Lipoma
Melanocyte
Nevus/mole
Liposarcoma
Melanoma
Cancer epidemiology
Skin cancer ( basal > squamous melanoma) is the most common cancer ( not included in list).
MEM
Cancer incidencel
NOTES
1. Pros!
Coll Copied to clipboard.
: i .iitil
r
Cancer mortality
WQME'A
1. Lung
2. Prostate
v Colon /rectum
l. Lung
2. Breast
3. Colon /rectum
1. Leukemia
2. Brain and CNS
3,
Neuroblastoma
|Lung cancer incidence has

dropped in men, but has
not changed significantly in
women
Cancer is the 2nd leading cause

of death in the United States
(heart disease is 1st).
PATHOLOGY
PATHOLOGY NEOPLASIA
Tumor grade vs stage
Grade
Stage almost alw ays has more prognostic v alue

than grade.
TNM staging system is used with many
cancers; exceptions include brain tumors and
Degree of cellular differentiation and mitotic

activity on histology. Range from low grade
(well differentiated) to high grade (poorly
differentiated, undifferentiated or anaplastic).
leukemias!!
Stage
Tumor nomenclature
Degree of localization/spread based on site and

size of 1 lesion, spread to regional lymph
nodes, presence of metastases. Based on
clinical (c ) or pathology ip ) findings. Example:
CT3N1M0
TNM staging system ( Stage = Spread):

1 = Tumor sizc /local invasion!
N = Node involvement
M = Metastases
Each TNM factor has independent prognostic
value; M factor often most important.
Carcinoma implies epithelial origin, whereas sarcoma denotes mesenchymal origin. Both terms
imply malignancy.
Terms for non-neoplastic malformations include hamartoma ( disorganized overgrow th of tissues in
their native location, eg, Peutz-Jeghers polyps) and choristoma (normal tissue in a foreign location,
eg, gastric tissue located in distal ileum in Meckel diverticulum ).
Benign tumor is usually well differentiated, well demarcated, low mitotic activity, no metastasis, no
necrosis.
Malignant tumor may show poor differentiation erratic grow th, local invasion, metastasis, and
t apoptosis. Uprcgulation of telomcrasc prevents chromosome shortening and cell death.
CELL TYPE
BENIGN
MALIGNANT
Epithelium
Adenoma, papilloma
Adenocarcinoma, papillary carcinoma
Mesenchyme
Leukemia, lymphoma
Blood cells
Blood vessels
Hemangioma
Angiosarcoma
Smooth muscle
Leiomyoma
Leiomyosarcoma
Striated muscle
Rhabdomyoma
Rhabdomyosarcoma
Connective tissue
Fibroma
Fibrosarcoma
Bone
Osteoma
Osteosarcoma
Fat
Lipoma
Nevus/mole
Liposarcoma
Melanoma
Melanocyte
Cancer epidemiology
Cancer incidence!
Skin cancer ( basal > squamous melanoma) is the most common cancer (not included in list ).
NOTES
CHILDREN (AGE 0-14)
WOMEU
MEty
I. Prostate
1. Breast
1. Leukemia
Lung cancer incidence has
2. Brain and CNS
2. Lung
2. Lung
dropped in men, but has
'
5. Colon/rectum
3. Colon /rcctum
not changed significantly ii
. Neuroblastoma
women
Cancer mortality
1. Lung
2. Prostate
3. Colon /rcctum
1. Lung
2. Breast
3. Colon /rcctum
1. Leukemia
2. Brain and CNS
v
Neuroblastoma
Cancer is the 2nd leading cause

of death in the United States
( heart disease is 1st ).
PATHOLOGY
PATHOLOGY NEOPLASIA
SECTION II
217
Paraneoplastic syndromes
DESCRIPTION /MECHANISM
MOST COMMONLY ASSOCIATED CANCER (S)
Acanthosis nigricans
1lyperpigmented velvety plagues in axilla and

neck
Gastric adenocarcinoma and other visceral

malignancies |but more commonly associated
with obesity and insulin resistance)
Sign of Leser-Trelat
Sudden onset of multiple seborrheic keratoses
GI adenocarcinomas and other visceral
MANIFESTATION
Cutaneous
malignancies
Endocrine
Hypercalcemia
Squamous cell carcinomas of lung, head, and

neck; renal, bladder, breast, and ovarian
PTHrP
carcinomas
t 1,25 -( OHN vitamin D (calcitriol )
Cushing syndrome
t ACTH
Lymphoma
Small cell lung cancer
Hyponatremia (SIADH)
t ADH
Polycythemia
T Krythropoietin
Renal cell carcinoma, hepatocellular

carcinoma, hemangioblastoma,
pheochroinocytoina, leiomyoma
Hematologic
Pure red cell aplasia
Anemia with low reticulocytes
Thymoma
Good syndrome
1 lypogammaglobulinemia
Thymoma
Trousseau syndrome
Migrators superficial thrombophlebitis
Adenocarcinomas, especially pancreatic
Nonbacterial
thrombotic (marantic)
endocarditis
Deposition of sterile platelet thrombi on heart

valves
Adenocarcinomas, especially pancreatic
Anti-NMDA receptor
encephalitis
Psychiatric disturbance, memory deficits,

seizures, dyskinesias, autonomic instability,
language dysfunction
Ovarian teratoma
Opsoclonusmyoclonus ataxia
syndrome
Dancing eyes, dancing feet
Neuroblastoma (children), small cell lung

cancer (adults)
Paraneoplastic
cerebellar
degeneration
Antibodies against antigens in Purkinjtlcells
Small cell lung cancer (anti-1lu ), gvnecologic
Paraneoplastic
encephalomyelitis
Antibodies against Hu antigens in neurons
Lambert-Eaton
myasthenic syndrome
Antibodies against prcsynaptic (P/Q type) Ca+

channels at NMJ
Myasthenia gravis
Antibodies against postsvnaptic ACh receptor
Neuromuscular
and breast cancers (anti-Yo) and Hodgkin

lymphoma ianti-Tri
at NMJ
Thymoma
218
SECTION II
Oncogenes
PATHOLOGY NEOPLASIA
PATHOLOGY
Gain of function - t cancer risk. Need damage to only one allele of an oncogens
GENE
GENE PRODUCT
ASSOCIATED NEOPLASM
ALK
Receptor tyrosine kinase
Lung adenocarcinoma
BCR- ABL
Tyrosine kinase
CML, ALL
BCL-2
Anliapoptotic molecule (inhibits apoptosis!
BRAF
Serinc /threonine kinase
Follicular and diffuse large B cell lymphomas

Melanoma. non-Hodgkin lvmphoma, papillary
c- KIT
Cytokine receptor
Gastrointestinal stromal tumor (GIST )
thy roid carcinoma!
c-MYC
Transcription factor
Burkitt lymphoma
HER2 / neu (c- erbB2 )
Receptor ty rosine kinasel
Breast and gastric carcinomas
JAK2
Tyrosine kinase
Chronic myeloproliferative disorders
KRAS
GTPase
Colon cancer, lung cancer, pancreatic cancer
mat
MYCN
Neuroblastoma
RET
Receptor tyrosine kinasa
MEN 2 A and 2B, medullary thyroid cancer
Tumor suppressor
genes
Loss of function
Lung tumor
t cancer risk; both ( trvni alleles of a tumor suppressor gene must be lost for
expression of disease
GENE
GENE PRODUCT
ASSOCIATED CONDITION
APC
Negative regulator of B-catenin/WNT pathway
Colorectal cancer (associated rvith FAP)
BRCA1/BRCA2
DNA repair protein
Breast, ovarian, and pancreatic canceil
CDKN2 A
Melanoma, pancreatic cancer
DCC
. blocks G, -* S phase
DCC Deleted in Colon Cancer
DPC4/SMAD4
DPC Deleted in Pancreatic Cancer
Pancreatic cancer
MEN!
Menin
MEN 1
NF1
Ras C 1 Pa sc activating protein (neurofibromin )
Neurofibromatosis type 1
Columns
NF2
Merlin ischwannomin) protein
Neurofibromatosis type 2
2 & 3 were
PTEN
pi 6
- .
Tyrosine phosphatase of PIP (eg protein kinase
B lAKTl activation)
Rb
Inhibits E2F; blocks G]
TPS3
p53 activates p21
-* S phase
. blocks Gi
S phase
Colon cancer
Breast cancer, prostate cancer, endometrial

cancer
Retinoblastoma, osteosarcoma
Most human cancers, Li Fraumeni syndrome

(multiple malignancies at early age aka, SBI ,A
cancer sy ndrome: Sarcoma, Breast, Leukemia,
)
Adrenal gland!
TSC1
Hamartin protein
Tuberous sclerosis
TSC2
Tuberin protein
Tuberous sclerosis
VHL
Inhibits hypoxia inducible factor la
von Hippel-Lindau discasej
WT 1{
Transcription factor that regulates urogenital

development
Wilms Tumor (nephroblastoma)
220
SECTION II
Psammoma bodies
PATHOLOGY
PATHOLOGY NEOPLASIA
Laminated, concentric spherules with dystrophic calcification Q, PSaMMoma bodies arc seen in:
Papillary carcinoma of thyroid
Serous papillary cystadenocarcinoma of ovary
Meningioma
Malignant mesothelioma
T
Serum tumor markers
Tumor markers should not be used as the 1 tool for cancer diagnosis or screening. T hey may be
used to monitor tumor recurrence and response to therapy, but definitive diagnosis is usually made
via biopsy.
MARKER
ASSOCIATED CANCER
Alkaline phosphatase
Mctastascs to bone or liver Paget disease of

bone, seminoma ( placental ALP).
a- fetoprotein
Hepatocellular carcinoma, hepatoblastoma, yolk Normally made by fetus. Transiently elevated in

sac (endodermal sinus) tumor, mixed germ
pregnancy. High levels associated with neural
cell tumor.
tube and abdominal wall defects, low levels
associated with Down syndrome.
Produced by syncyTiotrophoblasts of the
I lydatidiform moles and Choriocarcinomas
(Gestational trophoblastic disease), testicular
placenta.
cancer, mixed germ cell tumor.
Breast cancer.
PhCG
CA 15-3/CA 27-29
NOTES
CA 19- 9
Pancreatic adenocarcinoma.
CA 125
Ovarian cancer.
Calcitonin
Medullary thvroid carcinoma
Must exclude hepatic origin bv checking LKTs

and CCT levels.
..
lalone and in
MEN2 A MEN2B ) ]
CEA
Carcinoembrvonic antigen. Very nonspecific.
Major associations: colorectal and pancreatic

cancers.
Minor associations: gastric, breast, and

medullary thvroid carcinomas]
Chromoaranin
Neuroendocrine tumors.
PSA
Prostate cancer.
Prostate-specific antigen
Can also be elevated in BPH and prostatitis.

Questionable risk /benefit for screening.
Surveillance marker for recurrent disease after
prostatectonn]
P-glycoprotein
Also known as multidrug resistance protein 1 MDR 1). Classically seen in adrenocortical
carcinom hut also expressed bv other cancer cells ( eg colon, liver). Used to pump out toxins
including chemotherapeutic agents ( one mechanism of l responsiveness or resistance to
chemotherapy over time).
i
PATHOLOGY
PATHOLOGY NEOPLASIA
SECTION II
Cachexia
Weight loss, muscle atrophy, and fatigue that occur in chronic disease (eg, cancer, AIDS, heart
failure, COPD). Mediated by TNF, IFN-y, IL-1, and IL-6.
Common metastases
Most sarcomas spread hematogenously; most carcinomas spread via lymphatics. However, four
carcinomas route hcmatogcnouslv: follicular thyroid carcinoma, choriocarcinoma, renal cell
carcinoma, and hepatocellular carcinoma!
SITE OF METASTASIS
1 TUMOR
Brain
Lung > breas||> melanoma, colon, kidneii
221
NOTES
50% of brain tumors are from metastases Q 0.

Commonly seen as multiple wellcircumscribed
tumors at gray/white matter junction
Liver
Colon stomach > pancreas.
Livcr Q 0 and lung are the most common sites

of metastasis after the regional lymph nodes.
Bone
Prostate, breast > lung, thyroid, kidney.
Bone metastasis Q Q 1 bone tumors (eg,

multiple myeloma, lytic). Common mets to
bone: breast (mixed),lung (mixed), thyroid
( lytic), kidney ( lytic), prostate ( blastic).
Predilection for axial skeleton 0
m
b.
m<
'
'
226
SECTION II
PHARMACOLOGY PHARMACOKINETICS & PHARMACODYNAMICS
PHARMACOLOGY
Elimination of drugs
Zero- order
elimination
Rate of elimination is constant regardless of Cp

( ie, constant amount of drug eliminated per
unit time ). C i linearly with time. Examples
of drugs Phcnytoin, Ethanol, and Aspirin ( at
high or toxic concentrations)
Capacity-limited elimination.
PEA . (A pea is round, shaped like the 0 in
Rate of elimination is directly proportional

to the drug concentration (ie, constant
fraction of drug eliminated per unit time).
Cp i exponentially with time. Applies to most
drugs.
Flow -dependent elimination.
zero-order.)
First- order elimination
Zero order elimination
First order elimination
Elimination rate
2 U/h
Elimination rate
4 U/ h
.
!
Time of tj/ j is constant
Time of tw J,as
concentration J.
:ui
Firjl lUj >
as concentration l
First ty2
2 U /h
lU/h
\ 2 U/ h
Second tl/2 >
devisee
Figure
Second
^ = TYlirdti
Q 5 U/h
/j
Time (h)
Time (h)
Urine pH and drug

elimination
Weak acids
Ionized species are trapped in urine and cleared quickly. Neutral forms can be reabsorbed.
Examples: phenobarbital, methotrexate, aspirin. Trapped in basic environments. Treat overdose

with bicarbonate to alkalinizc urincj
RCOOI 1
(lipid soluble )
Weak bases
S3
RCOO- + IP
(trapped )
Example: amphetamines, TCAs. Trapped in acidic environments. Treat overdose with ammonium
chloride to acidify urincj
RNH *
RNH:+ H+
( trapped )
(lipid soluble )
Drug metabolism
Geriatric patients lose phase I first.
Phase 1
Reduction, oxidation, hydrolysis with

cytochrome P-450 usually yield slightly polar,
water- soluble metabolites (often still active).
Phase II
Ccriatric patients have More GAS ( phase II ) .

Conjugation ( Mcthvlation, Glucuronidation,
Xcetylation, Sulfation) usually yields very polar, Patients who are slow acetylators have t side
effects from certain drugs because of l rate of
inactive metabolites (renally excreted ).
metabolism.
228
SECTION I I
PHARMACOLOGY PHARMACOKINETICS & PHARMACODYNAMICS
PHARMACOLOGY
Receptor binding
Agonist plus
competitive
antagonist
Agonist
alone
Agonist
al< ne
Effect of
antagonist
I 50
Lower
efficacy
Agonist
alone
Partial agonist
alone
"
Effect of
competitive
Agonist plus
noncompetitive
antagonist
antagonist
01
10
to
Agonist dose
100
1000
Ot
10
10
00
0.1
1000
Agonist dose
1.0
10
Agonist dose
100
1000
,1
AGONIST WITH
EFFECT
EXAMPLE
Competitive
Sliifts curve right (1 potency), no change

in efficacy. Can be overcome by t the
concentration of agonist substrate.
Shifts curve down (i efficacy). Cannot be
overcome by t agonist substrate concentration.
Diazepam (agonistl + flumazcnil (competitive

antagonist) on GABA receptor.
Norepinephrine ( agonist ) + phenoxvbenzamine
(noncompetitive antagonist) on a-receptors.
Acts at same site as full agonist, but with lower

maximal effect (i efficacy). Potency is an
Morphine ( full agonist) vs buprenorphine

(partial agonist) at opioid p-receptors.
antagonist
Noncompetitive
antagonist
Partial agonist
(alone)
Therapeutic index
independent variable.
Measurement of drug safety.
TITE: Therapeutic Index = TD-(i / ED50.

Safer drugs have higher IT values. Drugs with
lower TI v alues frequently require monitoring
( eg. Warfarin. Theophylline, Digoxin.
Lithium; Warning! T hese Drugs arc Lethal!).
ID;o ( lethal median dose) often replaces TD;o
in animal studies.
TDJO _ median toxic dose

EDJQ median effective dose
Therapeutic window dosage range that can
safely and effectively treat disease.
Efficacy
100
Therapeutic index
ED
Toxicity
ED = Effective dose
TD = Toxic dose
iu
0
Log (drug concentration)
E9
PHARMACOLOGY AUTONOMIC DRUGS
PHARMACOLOGY
SECTION I I

Central and peripheral nervous system
Medul a
* e r f
Parasympathetic
Pre (long)
V *-T
A
U
T
0
Spinal cord
Prc (short]
[ACh
Post (long)
| ACh
M Sweat glands
M
I
C
[ACh
Sympathetic
Cardiac and smooth

muscle, gland cells,
nerve terminals
fACh
Renal vasculature
smooth muscle
/*
-[ACh W,
r
Adrenal medulla
S..
Blood
Catecholamine
//
transmission
SOMATIC
Voluntary motor nerve
[ACh
5
a, Cardiac
u.
l1:
muscle, vessels
Skeletal muscle
Neuromuscular
junction
Adrenal medulla is directly innervated hv preganglionic sympathetic fibers.

Sweat glands are part of the sympathetic pathway but arc innervated bv cholinergic fibers.!
Acetylcholine
Receptors
Nicotinic ACh receptors are ligand-gated Na*/K4 channels. Two subtypes: \N ( found in autonomic
ganglia, adrenal medulla) and NM (found in neuromuscular junction of skeletal muscle).
Muscarinic ACh receptors are G-protein-coupled receptors that usually act through 2nd
messengers. 5 subty pes: M| f o u n d in heart, smooth muscle, brain, exocrine glands, and on sweat
glands (cholinergic sympathetic).
PHARMACOLOGY
G-protein-linked second messengers

G- PROTEIN CLASS
MAJOR FUNCTIONS
t vascular smooth muscle contraction, t pupillary dilator muscle

contraction ( mydriasis), t intestinal and bladder sphincter muscle
contraction
i sympathetic (adrenergic ) outflow, 1 insulin release, i lipolysis, t platelet

aggregation, l aqueous humor production
A
A
t heart rate, t contractility ( one heart!t renin release, t lipolvsis
Vasodilation, bronchodilation (two lungs)] t lipolysis, t insulin release,

t uterine toire ( tocolysis), ciliary muscle relaxation, t aqueous humor
production
t lipolysis, t thermogenesis in skeletal muscle
Mediates higher cognitive functions, stimulates enteric nervous system]
M2
i heart rate and contractility of atria
M3
t exocrine gland secretions (eg, lacrimal, sweat, salivary, gastric acid ),

t gut peristalsis, t bladder contraction, bronchoconstriction, t pupillary
sphincter muscle contraction ( miosis), ciliary muscle contraction
(accommodation), t insulin releast]
RECEPTOR
Sympathetic
Parasympathetic
Dopamine
Relaxes renal vascular smooth inuseki activates direct pathway of striatum
Modulates transmitter release, especially in brain, inhibits indirect

pathway of striatum
Histamine
t nasal and bronchial mucus production, t vascular permeability,

contraction of bronchioles, pruritus, pain
H2
t gastric acid secretion
v,
t vascular smooth muscle contraction
v2
t IRC) permeability and reabsorption in collecting tubules of kidney]
Vasopressin
After qisses ( kisses), you get a qii| 1 kick) out of siq (sick ) sqs (super qinky sex ).
,..
Hj
Uj, Vj,
M Mj
Receptor
DAG
Phospholipase C
Lipids
Pi. foPi 0,.
H2 V2
Receptor
MJ. < / j. Dj
Receptor
IP
HAVe 1 M&M.
Protein
kinase C
I i<*V
Smooth muscle contraction
ATP
Gs
G,
Adenylyl cyclase
f ia>x
i
cAMP
(heart)
Protein kinase A
Myosin light -chain
kinase (smooth
muscle)
MAD 2s.
Revised
Figure
PHARMACOLOGY
231
SECTION II
Release of norepinephrine from a sympathetic nerve ending is modulated bv NE itself, acting on

presMiaptic ou-autoreceptors negative feedback.
~
\ mphetamines use the NE transporter ( NET ) to enter the presvnaptic terminal, where they utilize
the vesicular monoamine transporter ( VMAT ) to enter neurosecretory vesicles. This displaces NK
from the vesicles. Once NE reaches a concentration threshold within the presvnaptic terminal
the action of NKT is reversed, and NE is expelled into the synaptic cleft, contributing to the
characteristics and effects of t NR observed in patients taking amphetamines.
Autonomic drugs
CHOLINERGIC
NORADRENERGIC
AXON
AXON
Tyrosine
Choline
Tyrosine
Metyrosme
i N im
Choline *
Acetyl- CoA
Hemicholinium
Dopamine
LhAT
\o
Reserpine
&
Release -modulating
receptors
Vesamicol
Ca2+
NE
Ca 2+
AO
,
Amphetamine
impnc
ephedrine
Botulinum
orl
Reuptake
Cocaine, TCAs,
Choline +
&
AT II
-OO
amphetamine
cetate
Revised
NEQ
Figure
Diffusion,
metabolism
00 '
receptor
AChE inhibitors
Adrenoreceptors or p
AChE
POSTSYNAPTIC MEMBRANE
Grcie will) routing arrow repreient tramporlrrv Drug n ifaWcs are of historical iignificance.
POSTSYNAPTIC MEMBRANE
232
SECTION II
PHARMACOLOGY
Cholinomimetic agents
DRUG
ACTION
APPLICATIONS
Activates bond and bladder smooth

muscle; resistant to ACliE. "Bethany, call
( bethanechol ) me to activate sour bonds and
Postoperative ileus, neurogenic ileus, urinary

retention
Direct agonists
Bethanechol
bladder.
Carbachol
Carbon copy of acetylcholine.
Constricts pupil and relieves intraocular

pressure in open-angle glaucoma
Methacholine
Stimulates muscarinic receptors in airway when
Challenge test for diagnosis of asthma
inhaled.
Pilocarpine
Contracts ciliary muscle of eye ( open-angle

glaucoma ), pupillary sphincter (closed-angle
glaucoma); resistant to AChE. You cry, drool,
and sweat on your
pilow.
Potent stimulator of sweat, tears, and saliva

Open-angle and closed-angle glaucoma,
xerostomia (Sjogren syndrome)
Indirect agonists (anticholinesterases)

Galantamine,
donepezil,
t ACh.
Alzheimer disease ( Alzheimer patients gallantly

swim down the riveri
rivastiqminel
Edrophonium
t ACh
Historically used to diagnose myasthenia gravis;

anti-AChRAb ( anti-acetvleholine receptor
Neostigmine
t ACh.
Nco CNS - No CNS penetration (quaternary
Postoperative and neurogenic ileus and

urinary retention, myasthenia gravis,
reversal of neuromuscular junction blockade
( postoperative).
antibody) test currently useqj
amine)
Physostigmine
t ACh Physostigmine plivxes atropine
overdose.
Anticholinergic toxicitv; phrccly (freely ) crosses

blood-brain barrier CNS ( tertiary amine).
t ACh; t muscle strength. Pyridostigmine gets
Myasthenia gravis ( long acting); does not

penetrate CNS (quaternary amine).
Note: With all cholinomimetic agents, watch for exacerbation of COPD, asthma, and peptic ulcers when giving to susceptible
patients.
Pyridostigmine
rid of myasthenia gravis.
Cholinesterase
inhibitor poisoning
Often due to organophosphates, such as

parathion, that irreversibly inhibit AChE.
Causes Diarrhea, Urination, Miosis,
Bronchospasm, Bradycardia, Excitation
of skeletal muscle and CNS, Lacrimation,
Sweating, and Salivation. May lead to
respiratory failure if untreated.
DUMBBELSS.
Organophosphates are often components of
insecticides; poisoning usually seen in farmers.
Antidote atropine (competitive inhibitor ) +
pralidoxime ( regenerates AChE if given early).
PHARMACOLOGY
PHARMACOLOGY
AUTONOMIC DRUGS
SECTION II
23
Muscarinic antagonists
DRUGS
ORGAN SYSTEMS
APPLICATIONS
Atropine,
homatropine,
tropicamide
Eye
Produce mydriasis and cycioplegia.
Benztropine
CNS
Parkinson disease ( park my Benz").

Acute dystonia.
Cl, respiratory
Parenteral: preoperative use to reduce airway
Hyoscyamine,
dicyclomine
GI
Oral: drooling, peptic ulcer .

Antispasmodics for irritable bowel syndrome.
Ipratropium,
tiotropium
Respiratory
COPD, asthma ( 1 pray 1 can breathe soonf ).
Oxybutynin,
solifenacin,
tolterodine
Genitourinary
Reduce bladder spasms and urge urinary

incontinence (overactive bladder).
Scopolamine
CNS
Motion sickness.
trihexyphenidyl
Glycopyrrolate
secretions.
Atropine
Muscarinic antagonist. Used to treat bradycardia and for ophthalmic applications.

ACTION
NOTES
Eye
t pupil dilation , cycioplegia
Airway
1 secretions
Blocks DUMBBeLSS in cholinesterase

inhibitor poisoning. Docs not block excitation
of skeletal muscle and CNS (mediated by
nicotinic receptors ) .
ORGAN SYSTEM
Stomach
J acid secretion
Gut
1 motility
Bladder
1 urgency in cystitis
t body temperature (due to t sweating);
rapid pulse; dry mouth ; dry, flushed skin ;
cycioplegia; constipation; disorientation
Can cause acute angle-closure glaucoma in
elderly ( due to mydriasis), urinary retention
in men with prostatic hyperplasia , and
hyperthermia in infants
ADVERSE EFFECTS
Side effects:
Hot as a hare
Drv as a bone
Red as a beet
Blind as a bat
Mad as a hatter
Jimson weed ( Datura) -* gardener's pupil
( mydriasis due to plant alkaloids)
PHARMACOLOGY
Rnd
ls
'
1$
Muscarinic antagonists
DRUGS
ORGAN SYSTEMS
APPLICATIONS
Atropine,
homatropine,
tropicamide
Eye
Produce mydriasis and cycloplegia.
Benztropine
CNS
Parkinson disease (park my Benz ).

Acute dystonia.
GI, respiratory
Parenteral: preoperative use to reduce airway
trihexyphenidyl
Glycopyrrolate
secretions.
Oral: drooling, peptic ulcer.
Hyoscyamine,
dicyclomine
C1
Antispasmodics for irritable bowel syndrome.
Ipratropium,
tiotropium
Respiratory
GOPD, asthma (I pray 1 can breathe soon!").
Oxybutynin,
solifenacin,
Genitourinary
Reduce bladder spasms and urge urinary

incontinence (overactive bladder).
CNS
Motion sickness.
tolterodine
Scopolamine
Atropine
ORGAN SYSTEM
Muscarinic antagonist. Used to treat bradycardia and for ophthalmic applications.

ACTION
NOTES
Eye
t pupil dilation, cycloplegia
Airway
i secretions
Blocks DUMBBeLSS in cholinesterase

inhibitor poisoning. Docs not block excitation
of skeletal muscle and CNS (mediated by
nicotinic receptors ).
Stomach
i acid secretion
Gut
1 motility
Bladder
1 urgency in cystitis
ADVERSE EFFECTS
t body temperature (due to t sweating);

rapid pulse; dry mouth; dry flushed skin;
cycloplegia; constipation; disorientation
Can cause acute angle-closure glaucoma in
elderly ( due to mydriasis), urinary retention
in men with prostatic hyperplasia, and
hyperthermia in infants
Side effects:
Hot as a hare
Dry as a bone
Red as a beet
Blind as a bat
Mad as a hatter
|imson weed ( Datura )
gardeners pupil
234
SECTION II
PHARMACOLOGY
PHARMACOLOGY
AUTONOMIC DRUGS
Sympathomimetic;
ACTION
APPLICATIONS
Albuterol, salmeterol
Pz > P,
Dobutamine
Pi > P;.
Dopamine
D| = D, > p > a
Epinephrine
P>a
Albuterol for acute asthma or COPD. Salmeterol

for long-term asthma or COPD control.
Heart failure ( HK| ( inotropic > chronotropic ),
cardiac stress testing.
Unstable bradycardia , HF, shock; inotropic and
chronotropic effects at lower doses due to (5
effects; vasoconstriction at high doses due to a
effects.
Anaphylaxis, asthma, open-angle glaucoma;
a effects predominate at high doses.
Significantly stronger effect at P receptor than
norepinephrine.
Postoperative hypertension , hypertensive crisis.
Vasodilator (coronary, peripheral, renal, and
splanchnic). Promotes natriuresis. Can cause
hypotension and tachycardia.
Flectrophvsiologic evaluation of
tachyarrhythmias. Can worsen ischemia.
Autonomic insufficiency and postural
hypotension. May exacerbate supine
hypertension.
Urinarv urge incontinence or overactive bladder.
Hypotension, septic shock.
DRUG
Direct sympathomimetics
Fenoldopam
Isoproterenol
P, = Pz
Midodrine
Mirabeqron
&
Norepinephrine
oi| >
Phenylephrine
ai > a:
a2 > P|
Hypotension ( vasoconstrictor), ocular procedures

( mydriatic ), rhinitis (decongestant ).
Indirect sympathomimetics
Amphetamine
Indirect general agonist , reuptake inhibitor, also

releases stored catecholamines
Narcolepsy, obesity, ADI ID.
Cocaine
Indirect general agonist , reuptake inhibitor
Causes vasoconstriction and local anesthesia.

Never give P- blockcrs if cocaine intoxication is
suspected (can lead to unopposed ot| activation
and extreme hypertension ).
Ephedrine
Indirect general agonist, releases stored
Nasal decongestion, urinary incontinence,

hypotension .
catecholamines
PHARMACOLOGY
Norepinephrine vs
isoproterenol
235
SECTION II
Nfcjt systolic and diastolic pressures as a result of aj-mediated vasoconstriction f mean arterial
pressure reflex bradycardia. I lowever, isoproterenol (no longer commonly used) has little a
effect but causes |J -mediated vasodilation, resulting in 1 mean arterial pressure and t heart rate
through P| and reflex activity.
Norepinephrine (a > p)
Widened
pulse
ptnswe
Epinephrine la p)
*\
\V~ Systole
Pi > ai
MAP
\ OMStohc
Isoproterenol ip > a)
/ ' \
ft
^
A
V* V
Reflex bxadycardu
p, >
CO < >
HR
MAP
PP
i
TT
T
CO
HR
MAP
PP
U n o p p o s e d P7
TT
TT
MAP i
PP TT
T
T
T
T
CO
HR
Sympatholytics (a2- agonists )

DRUG
APPLICATIONS
ADVERSE EFFECTS
Clonidine, guanfacine
Hypertensive urgency ( limited situations),

ADHD, Tourctte syndrome
CNS depression, bradycardia, hypotension,

respirators depression, miosis, rebound
a- methyldopa
Hypertension in pregnancy
hvpertension with abrupt cessation
Direct Coombs hemolysis, SLE like syndrome
236
SECTION I I
PHARMACOLOGY
a-blockers
DRUG
APPLICATIONS
ADVERSE EFFECTS
Irreversible. Plieochromocytomal ( used

preoperatively) to prevent catecholamine
(hypertensive) crisis
Reversible. Give!lo patients on MAO inhibitors
who eat tyramine-containing foods
Orthostatic hypotension, reflex tachycardia
Nonselective
Phenoxybenzaminel
Phentolamine|
a selective (-osin ending)

Prazosin, terazosin,
doxazosin,
tamsulosin
Urinary symptoms of BPH; PTSD ( prazosin);

hypertension (except tamsulosin)
lst-dose orthostatic hypotension, dizziness,

headache
Depression
Sedation, t serum cholesterol, t appetite
a2 selective
Mirtazapine
Effects of ot-blocker (eg, phentolamine) on BP responses to epinephrine and phenvlephrimj

Epinephrine
a.
1
55
Systolic
>a
_y
1
Net depressor
effect
Unopposed fl2
MAP
Jj
Before a-blockade
\\
Net prr
eifKt
Phenylephrine
Alter u-blockade
Before u- blockade
ft
Pj Reftei tachycardia
\_
1
i
a.
Time
Kpinephrine response exhibits reversal of mean arterial

pressure from net increase ( the q response) to a net
decrease (the 0-, response).
Suppression of
pressor effect
Net pressor
After a- blockade
Reflex bradycardia
Time
Pheny lephrine response is suppressed but not reversed

because it is a "pure" q- agonist I lacks fl-agonist
properties!
)
PHARMACOLOGY
PHARMACOLOGY
p- blockers
AUTONOMIC DRUGS
237
SECTION II
Accbutolol, atenolol, bctaxolol , bisoprolol , carvedilol, csmolol , labctalol , metoprolol, nadolol .

nebivolol , pindolol , propranolol , timolol .
APPLICATION
ACTIONS
NOTES/EXAMPLES
Angina pectoris
i heart rate and contractility, resulting in 1 O2
Myocardial infarction!
consumption
1 mortality
Supraventricular
i AV conduction velocity (class 11
tachycardial
Hypertension
Heart failure
Glaucoma!
Variceal bleeding
Metoprolol , esmolol
antiarrhythmic)
1 cardiac output , 1 renin secretion (due to
Pj-receptor blockade on JGA cells)
i mortality ( bisoprolol , carvedilol , metoprolol )
l production of aqueous humoii
Timolol
i hepatic venous pressure gradient and portal

hypertension
Nadolol , propranolol
ADVERSE EFFECTS
Erectile dysfunction, cardiovascular adverse

effects ( bradycardia , AV' block , HF), CNS
adverse effects (seizures , sedation , sleep
alterations ), dyslipidemia ( metoprolol ), and
astluna /COPD exacerbations
Use with caution in cocaine users due to risk

of unopposed a-adrenergic receptor agonist
activity
Despite theoretical concern of masking
hypoglycemia in diabetics, benefits likely
outweigh risks; not contraindicated
SELECTIVITY
selective antagonists ( P
Pi -partial
agonist), atenolol ,
> (5, ) acehutolol

bctaxolol , bisoprolol
Selective antagonists mostly go from A to M

with 1st half of alphabet )
P(
esinolol metoprolol
Nonselective antagonists (P| = P-, ) nadolol ,
pindolol ( partial agonist ), propranolol timolol
Nonselective a- and (3-antagonists carvedilol .
labetalol
Nebivolol combines cardiac-selective
Pi -adrenergic blockade with stimulation
of P -receptors, which activate nitric oxide
synthase in the vasculature
,
Nonselective antagonists mostly go from N to 7.

( P with 2nd half of alphabet )
Nonselective a- and P-antagonists have modified
suffixes ( instead of -olol")
238
SECTION I I
PHARMACOLOGY
Ingested seafood toxins

TOXIN
SOURCE
ACTION
SYMPTOMS
TREATMENT
Tetrodotoxin
Pufferfish.
Highly potent toxin;

binds fast voltagegated Na* channels
Nausea, diarrhea,
paresthesias,
weakness, dizziness,
loss of reflexes.
tjapportive.
Nausea, vomiting,
ijrpportive.
in cardiac /nerve
tissue, preventing
Ciguatoxin
Histamine
(scombroid
poisoning)
Reef fish such as

barracuda, snapper,
and moray eel .
depolarization.
Opens Na+
channels, causing
depolarization.
Spoiled dark-meat fish
Bacterial histidine
such as tuna, mahimahi, mackerel, and

bonito.
decarboxylase converts
histidine to histamine.
Frequently
misdiagnosed as fish
allergy .
diarrheal perioral
numbness;
reversal of hot and
cold sensations;
bradycardia, heart
block, hypotension!
Mimics anaphylaxis:
acute burning
sensation of mouth,
flushing of face,
erythema, urticaria,
itching. May progress
to bronchospasm,
angioedema
hypotension.
Antihistamines.
Albuterol and
epinephrine if needed.
Beers criteria
New
lEasil
Widely used criteria developed to reduce inappropriate prescribing and harmful polypharmacy in
the geriatric population. Includes > SO medications that should be avoided in elderly patients due
to 1 efficacy and/or t risk of adverse events. Examples include:
Anticholinergics, antihistamines, antidepressants, benzodiazepines, opioids ( t risk of delirium,

sedation, falls, constipation, urinary retention|
a-blockers It risk of hypotension)
PPIs ft risk of C difficile infection)
NSAlDs ( t risk of Cd bleeding, especially with concomitant anticoagulation )
PHARMACOLOGY
PHARMACOLOGY TOXICITIES AND SIDE EFFECTS
SECTION II
239
PHARMACOLOGY - TOXICITIES AND SIDE EFFECTS
Specific toxicity
TOXIN
TREATMENT
treatments
Acetaminophen
N-acetvlcystcine ( replenishes glutathione!
ACHE inhibitors, organophosphates
Atropine > pralidoxime
Antimuscarinic, anticholinergic agents
Physostigmine, control hyperthermia
Arsenic
Digitalis (digoxin)
Dimercaprol, succimer
Fluinazenil
ropine, glucagon
100% O,, hyperbaric O,
Penicillamine, trientine ( Copper pennv)
Nitrite + thiosulfate, hydroxocobalamin
Anti- dig Fab fragments
Heparin
Protamine sulfate
Benzodiazepines
(J-blockers
Carbon monoxide
Copper
Cyanide
Iron
Deferoxamine, deferasirox, deferiprone
Lead
EDTA, dimercaprol, succimer, penicillamine
Mercury
Dimercaprol, succimer
Fomcpizole > ethanol, dialysis
Methylene blue, vitamin C
Methanol, ethylene glycol (antifreeze)
Methemoglobin
Opioids
NalOjtCjie
Salicylates
NaHCO (alkalinize urine), dialysis
TCAs
NaHCO
Warfarin
Vitamin K (delayed effect), fresh frozen plasma

( immediate)
Drug reactions cardiovascular

DRUG REACTION
CAUSAL AGENTS
Coronary vasospasm
Amphetamines, cocaine, ergot alkaloids sumatriptanl
Cutaneous flushing
Vancomycin, Adenosine, Niacin, Nitrates, Ca= channel blockers, Kchinocandins ( VANNCKt
Dilated
cardiomyopathy
Anthracyclines (eg, doxorubicin, daunorubicin); prevent with dexrazoxane
Torsades de pointes
AntiArrhythmics (class L\, III), antiBiotics (eg, macrolides), antiCychotics ( eg, haloperidol ),
antiDepressants (eg, TCAs), antiEmetics (eg, ondansetron) (ABODE).
240
SECTION II
Drug reactions
DRUG REACTION
PHARMACOLOGY
PHARMACOLOGY
TOXICITIES AND SIDE EFFECTS
endocrine/ reproductive
Adrenocortical
insufficiency
Diabetes insipidus
Hot flashes
Hyperglycemia
CAUSAL AGENTS
NOTES
HPA suppression 2 to glucocorticoid
withdrawal
Lithium, demedocyclinc
Tamoxifen, clomiphene
Tacrolimus, Protease inhibitors Niacin, HCTZ, Taking Pills Necessitates Having blood
Corticosteroids
Hypothyroidism
Lithium, amiodarone, sulfonamides
SIADH
Carbamazcpine, Cyclophosphamide, SSRIs
Drug
reactions
DRUG REACTION
gastrointestinal
CAUSAL AGENTS
Erythromycin
Diarrhea
Acamprosatc, acarbosc, cholinesterase

inhibitors, colchicine, erythromycin,
czctimibc, metformin , misoprostol, orlistat,
pramlintide, quinidine, SSRIs
Ualothane, Amanita phalloides ( death cap
mushroom ) Valproic acid Acetaminophen
Hepatitis
Pancreatitis
Pill -induced
esophagitis
Pseudomembranous
colitis
Can t Concentrate Serum Sodium
NOTES
Acute cholestatic
hepatitis, jaundice
Focal to massive
hepatic necrosis
Checked
Rifampin, isoniazid , pyrazinamidc, statins,

fibrates
Didanosine, Corticosteroids, Alcohol , Valproic acid .
-Vzathioprinc, Diuretics (furosemide, HCTZ )
Bisphosphonates, ferrous sulfate, NSAIDs,
potassium chloride. tetracvcline4
Ampicillin. cephalosporins, clindamvcin.
fluoroquinolone
Liver HAVAc
Drugs Causing A Violent Abdominal Distress

Caustic effect minimized with upright posture
and adequate water ingestion .
Antibiotics predispose to superinfection by

resistant C difficile
PHARMACOLOGY
SECTION I I
241
Drug reactions hematologic

DRUG REACTION
CAUSALAGENT 5
NOTES
Agranulocytosis
Clozapine, Carbamazcpine, Propylthiouracil,

Methimazole, Colchicine, Ganciclovir
Carbamazepine, Methimazole, NSAIDs,
Benzene, Chloramphenicol, Propylthiouracil
Methyldopa, penicillin
Can Cause Pretty .Major Collapse of
Aplastic anemia
Direct Coombs
positive hemolytic
anemia
Druq reaction with
eosinophilia and
systemic symptoms
( DRESS
Allopurinol, anticonvulsants, antibiotics,

sulfonamides
Granulocytes
Cant Make New Blood Cells Properly
Potentially fatal delayed hypersensitivity
reaction. Latency period { 2-8 weeks)

followed bv fever, morbilliform!skin rash, and
frequent multiorgan involvement. Treatment:
withdrawal of offending drug, corticosteroids.
Gray baby syndrome
Chloramphenicol
Hemolysis in G6PD
deficiency
Isoniazid, Sulfonamides, Dapsone, Primaquine,

Aspirin, Ibuprofen, Nitrofurantoin
Hemolysis IS D PAIN
Megaloblastic anemia
Hvdroxvurea, Phcnvtoin, Methotrexate, Sulfa
Youre having a mega blast with PMSl
drug!
Thrombocytopenia
Heparin
Thrombotic
OCPs, hormone replacement therapy
complications
Drug reactions musculoskeletal / skin /connective tissue

DRUG REACTION
CAUSAL AGENTS
Fat redistribution
Protease inhibitors Glucocorticoids
Gingival hyperplasia
Phcnv toin, Ca+ channel blockers, cyclosporine
Hyperuricemia (gout)
Pyrazinamidc, Thiazides, Furosemidc, Niacin,

Cyclosporine
Statins, fibrates. niacin, colchicine, dantomvein.
hvdroxvehloroquinc, interferon-a,
Myopathy
NOTES
Fat PiG
Painful Tophi and Feet Need Care
penicillamine, glucocorticoid!
Osteoporosis
Corticosteroids, progesterone-only birth control,

aromatase inhibitors, anticonvulsants, heparin!
Photosensitivity
Sulfonamides, Amiodarone, Tetracyclines,
SAT For Photo
5-FU
Rash ( StevensJohnson syndrome)
Anti-epileptic drugs (especially lamotrigine),

allopurinol, sulfa drugs, penicillin
Steven Johnson has epileptic allergy to sulfa

drugs and penicillin
SLE- like syndrome
Sulfa drugs, Hydralazine, Isoniazid,

Procainamide, Phenytoin, Etanercept
Having lupus is "SHIPP-E
Teeth discoloration
Tetracyclines
Fluoroquinolones
Tendonitis, tendon
rupture, and
cartilage damage
242
SECTION I I
PHARMACOLOGY
Drug reactions neurologic

DRUG REACTION
CAUSAL AGENTS
NOTES
Cinchonismi
Quinidine, quinine!
Can present with tinnitus, psy chosis, hearing,
visual and cognitive impairment
*.
Antipsychotic Reserpine, Metodopramide
Cogwheel rigidity of ARM
Seizures
Isoniazid (vitamin B6 deficiency), Bupropion,

Imipenem/cilastatin, Tramadol, Enflurane
With seizures,IBITE my tongue
Tardive dyskinesia
Antipsychotics, metodopramide
Parkinson-like
syndrome
Drug reactions renal/genitourinary

DRUG REACTION
CAUSAL AGENTS
Fanconi syndrome
Cisplatin, ifosfamide expired tetracyclines
Hemorrhagic cystitis
Interstitial nephritis
NOTES
tenofovid
Cyclophosphamide, ifosfamide
Penicillins, furosemide. NSA 1IX proton pump
inhibitors
Prevent by coadministering with mesna
Drug reactions respiratory

DRUG REACTION
CAUSAL AGENTS
Dry cough
ACE inhibitors
Pulmonary fibrosis
Methotrexate, Nitrofurantoin, Carmustine,

Bleomycin, Busulfan, Amiodarone
NOTES
My Nose Cannot Breathe Bad Air
Drug reactions multiorgan

DRUG REACTION
CAUSAL AGENTS
Antimuscarinic
Atropine, TCAs, H|-blockers, antipsychotics
Disulfiram-like
reaction
lst-generation Sulfonvlurcas Procarbazine,

certain Cephalosporins Griseofulvin
Nephrotoxicity/
ototoxicity
Metronidazole!
Aminoglycosides, vancomycin, loop diuretics,
cisplatin. amphotericin Bil
NOTES
Sorrv Pals. Cant Go MingleJ
Cisplatin toxicity may respond to amifostinc.
PHARMACOLOGY
Cytochrome P- 450
interactions ( selected )
SECTION II
Inducers (+)
Substrates
Inhibitors (-)
Chronic alcohol use

St. John's wort
Anti-epilcptic!
Acute alcohol abuse

Macrolides
Isoniazid ( 1NH )
Phenytoin
Phcnobarbital
Nevirapine
Rifampin
Griseofulvin
Carbamazepine
Theophylline
Warfarin
243
Grapefruit
Omeprazole
OCPs
Sulfonamides
Ouiiiidine
Cimetidine
Ritonavir
Amiodarone
Ciprofloxacin
Ketoconazole
Chronic alcoholics Steal
Phen-Phcn and Never
Refuse Greasy Garbs
Sulfa drugs
Always Think When Outdoors
Sulfonamide antibiotics, Sulfasalazine,

Probenecid, Furoscmidc, Acetazolamidc,
Celecoxib, Thiazides, Sulfonylureas.
Patients with sulfa allergies may develop
fever, urinary tract infection, StevensJohnson syndrome, hemolytic anemia,
thrombocytopenia, agranulocytosis, acute
interstitial nephritis, and urticaria (hives)
Sy mptoms range from mild to life threatening.
Mv AMIGOS give me Quality

CRAC hi
Scary Sulfa Pharm FACTS
244
1
SECTION I I
PHARMACOLOGY
PHARMACOLOGY MISCELLANEOUS
PHARMACOLOGY MISCELLANEOUS
Drug names
ENDING
CATEGORY
EXAMPLE
Antimicrobial
- azole
- bendazole
-cillin
Ergosterol synthesis inhibitor

Antiparasitic/antihelminthic
Ketoconazole
Mebendazole
Ampicillin
Tetracycline
Oseltamivir
-cycline
-ivir
Peptidoglvcan cross-linking inhibit
Protein synthesis inhibitor

Neuraminidase inhibitor
Protease inhibitor
DNA polymerase inhibitor
Macrolide antibiotic
Ritonavir
Inhalational general anesthetic

Typical antipsychotic
Ilalothanc
Thioridazine
Barbiturate
Local anesthetic
Phenobarbital
Lidocaine
- etine
SSRI
-ipramine, -triptyline
TCA
5-HTIB/ID agonist
Benzodiazepine
Fluoxetine
Imipramine, amitriptyline
-navir
-ovir
-thromycin
Acyclovir
Azithromycin
CNS
- ane
-azine
-barbital
- caine
-triptan
-zepam, -zolam
Sumatriptan
Diazepam, alprazolam
Autonomic
-olol
Cholinergic agonist
Nondepolarizing paralytic
P-blocker
- stigmine
AChE inhibitor
- chol
-curium, -curonium
Bethanechol, carbachol
Atracurium, vecuronium
-terol
P;-agonist
Propranolol
Neostigmine
Albuterol
-zosin
aj-antagonist
Prazosin
Cardiovascular
- afil
- dipine
-pril
- sartan
- statin
- xaban
Other
- dronate
- glitazone
-prazole
-prost
PDE 5 inhibitor
Sildenafil
Dihydropvridine Ca2+ channel blocker

ACE inhibitor
Angiotensin-II receptor blocker
HMG-CoA reductase inhibitor
Direct factor Xa inhibitor!
Amlodipine
Captopril
Bisphosphonatc
PPAR-y activator
Proton pump inhibitor
Prostaglandin analog
-antagonist
Losartan
Atorvastatin
Apixaban, edoxaban rivaroxaban
Alendronate
Rosiglitazone
Omeprazole
Latanoprost
-tidine
Cimetidinc
-tinib
Tvrosine kinase inhibitoil
Imatinib
-tropin
Pituitary hormone
Somatotropin
-ximab
Chimeric monoclonal Ab
1Iumanized monoclonal Ab
Basiliximab
Daclizumab
-zumab
268
SECTION I I I
CARDIOVASCULAR EMBRYOLOGY
CARDIOVASCULAR
Blood in umbilical vein has a Po-, of = TO nun Hg

Umbilical
and is = 80% saturated with
arteries have low O, saturation.
T important shunts:
O Blood entering fetus through the
umbilical vein is conducted via the ductus
venosus into the IVC, bypassing hepatic
circulation.
0 Most of the highly Oxygenated blood
reaching the heart via the IVC is directed
through the foramen ( Jjvalc and pumped
into the aorta to supplv the head and bodv.
I)eoxygenated blood from the SVC passes
through the RA RV main pulmonary
artery |l Rictus arteriosus descending
aorta; shunt is due to high fetal pulmonary
artery resistance (due partly to low O,
tension).
At birth, infant lakes a breath; i resistance
in pulmonary vasculature t left atrial
pressure vs right atrial pressure; foramen ovale
closes (now called fossa ovalis); t in O, ( from
respiration) and 1 in prostaglandins (from
placental separation) - closure of ductus
arteriosus.
indomcthacin helps close PDA ligamentum
arteriosum (remnant of ductus arteriosus).
Prostaglandins K and 1 ki ll p PDA open.
Fetal circulation
To brain (high
02)
Ductus
arteriosus
To lungs
(high resistance)
\
Superior vena cava
Foramen ovale
To lungs
(high resistance)
Pulmonary
V
l
artery
'.
O Ductus
venosus
Aorta
Inferior vena cava
Portal vein
Umbilical vein
Internal iliac artery
To placenta
Umbilical
ft
arteries
From placenta
Fetal-postnatal derivatives
AllaNtois -* urachus
MediaN umbilical ligament
Ductus arteriosus
Ligamentum arteriosum
Ductus venosus
Ligamentum venosum
Foramen ovale
Fossa ovalis
Notochord
Nucleus pulposus
UmbiLical arteries
McdiaL umbilical ligaments
Umbilical vein
Ligamentum teres hepalis ( round ligament of
the livcrll
Urachus is part of allantoic duct between

bladder and umbilicus.
Contained in falciform ligament .
CARDIOVASCULAR
CARDIOVASCULAR ANATOMY
269
SECTION I I I
CARDIOVASCULAR ANATOMY
Coronary artery anatomy
Right coronary artery ( RCA)
Left main coronary artery (LCA)
left circumflex coronary

artery (LCX] supplies lateral
and posterior walls of left
ventricle, anterolateral papillary
muscle
Left anterior descending
artery ILADI supplies anterior !h
of interventricular septum,
anterolateral papillary muscle,
and antenor surface of left ventricle
Revised
Figure
Right (acute)
marginal artery
supplies right
left (obtuse) marginal artery
ventncle
Posterior descending/ interventricular artery ( PDA)

supplies AV node posterior Vrof interventricular septum,
posterior lh walls of ventndes, and posteromedial papillary muscle
SA undo is usually supplied hv RCA , AV node

is supplied by PDA lie, doiiiinanl circulationL
Infarct may cause nodal dysfunction
(brady cardia or heart block)
Right-dominant circulation ( 85%) = PDA arises
from RCA.
Left-dominant circulation (8%) = PDA arises
from LCX.
Codominant circulation ( 7%) = PDA arises
from both LCX and RCA.
Coronary artery occlusion most commonly
occurs in the LAD.
Coronary blood flow peaks in early diastole.
The most posterior part of the heart is the left
atrium; enlargement can cause dysphagia (due
to compression of the esophagus) or hoarseness
(due to compression of the left recurrent
laryngeal nerve, a branch of the vagus)
Pericardium consists of 5 layers ( from outer to
inner);
Fibrous pericardium
Parietal layer of serous pericardium
Visceral layer of serous pericardium
Pericardial cavity lies behveen parietal and
visceral layers.
CARDIOVASCULAR
CARDIOVASCULAR
PHYSIOLOGY
SECTION III
271
Cardiac output variables
Stroke volume
Stroke Volume affected by Contractility,

Aftcrload, and Preload
t SV with:
f Contractility (eg, anxiety, exercise )
t Preload (eg, early pregnancy)
i Aftcrload
SV CAP.
A failing heart has l SV (systolic and /or diastolic
dysfunction )
Contractility (and SV') t with:

Catecholamine stimulation via 0 i receptor
( inhibition of phospholambaii
t Cir '
entry into sarcoplasmic reticulum t Ca*induced Ca + release )
t intracellular Ca +
1 extracellular Na + ( 1 activity of Na + /Ca - ~
exchanger)
Digitalis ( blocks Na+/K+ pump
-* t intracellular Na* - i Na + /Ca'+
exchanger activity t intracellular Ca + )
fVlvoCARDial O, demand is t bv:
t Contractility
t Afterload ( proportional to arterial pressure )
t heart Rate
t Diameter of ventricle ( I wall tension )
Preload approximated by ventricular EDV;
depends on venous tone and circulating blood
Contractility (and SV' ) i with:

Ppblockade ( 1 cAMP)
HF with systolic dysfunction
Acidosis
Hvpoxia/hypercapnia ( 1 Po7 / f PcOj)
Non-dihydropyridine Ca 2+ channel blockers
Contractility
Myocardial oxygen
demand
Preload
volume.
Afterload
Afterload approximated by MAP.

t afterload t pressure t wall tension per
Laplaces law.
LV compensates for t aftcrload by thickening

(hypertrophy) itr order to 1 wall tension .
Ejection fraction
EDV ESV
EDV
Left ventricular EF is an index of ventricular
contractility; normal EF is > 55%.
hr
SV
= EDV =
Wall tension follows Laplaces law:

Wall tension
P urc x radms
2 x wall thickness
VEnodilators (eg, nitroglycerin ) t prEload
VAsodilators (eg, hydrAlAzine) 1 Aftcrload

( Arterial ).
ACE inhibitors and ARBs i both preload and
afterload .
Chronic hypertension ( t MAP ) LV
hypertrophy.
EF 1 in systolic HF.
EF normal in heart failure with preserved
ejection fraction 11 IFpEFA
272
SECTION I I I
CARDIOVASCULAR
Starling curve
CARDIOVASCULAR PHYSIOLOGY
Force of contraction is proportional to enddiastolie length of cardiac muscle fiber
Eercise
(preload).
t contractility with catecholamines, positive
inotropcs (eg, digoxin).
I contractility with loss of myocardium ( eg, MI ),
P-blockcrs (acutely),non-dihvdropyridine Ca*+
Ml t DM
I
E
'-' V '
-.
ll
. f.
=igure |
HF + digoxin
>
<
v
channel blockers, dilated cardiomyopathy.

HF
Ventricular EDV (preload)
Resistance, pressure,
flow
AP = Q x R
Capillaries have highest total cross-sectional
Similar to Ohms law: AV = IR
area and low est flow velocity.
Volumetric flow rate ( Q ) = flow velocity (v ) x
JPressure gradient drives flow from high pressure
to low pressure.
cross-scctional area ( A)
Arterioles account for most of TPR. Veins
Resistance
_ driving pressure (AP) _ 8r|(viscosity ) x length provide most of blood storage capacity.
Viscosity depends mostly on hematocrit
flow ( Q )
rtf
Viscosity t in hvpcrprotcinemic states (eg,
Total resistance of vessels in scries:
multiple myeloma ), polycy themia
R| Rj + R, + R . . .
V iscosity I in anemia
Total resistance of vessels in parallel:
1
1
1 I
T ~ Rj + R2 + R 1
276
SECTION III
CARDIOVASCULAR
CARDIOVASCULAR
PHYSIOLOGY
Auscultation of the heart

Where to listen: APT
Aortic area:
Pulmonic area :
Systolic murmur
Aortic stenosis
Flow murmur
(eg. physiologic murmur )
Aortic valve sclerosis
Left sternal border

Diastolic murmur
Aortic regurgitation
Pulmonic regurgitation
Systolic murmur
Hypertrophic
cardiomyopathy
Aortic
Pulmonic
Tricuspid
Mitral
Systolic ejection murmur

Pulmonic stenosis
Flow murmur
Tricuspid area:
Holosystolic murmur
Tricuspid regurgitat on
Ventncular septal defect
Diastolic murmur
Tricuspid stenosis
Atnal septal defect (T flow
across tricuspid valve)
T
M
Mitral area (apex ):

Holosystolic murmur
Mitral regurgitation
Diastolic murmur
Mitral stenosis
ia
BEDSIDE MANEUVER
EFFECT
Inspiration ( t venous return to right atrium )

Hand grip ( t afterload )
t intensity of right heart sounds

t intensity of MR, AR, VSD murmurs
1 hvpertroplhc cardiomyopathy murmurs, AS!
MVP: later onset of click /murmur
1 intensity of most murmurs ( including AS)

t intensity of hypertrophic cardiomyopathy murmur
MVP: earlier onset of click /murmur
t intensity of hypertrophic cardiomyopathy murmur
Rapid squatting ( t venous return, t preload , t aftcrload )
t intensity of AS, MR, and VSD
MVP: later onset of click /murmur
Svstolic heart sounds include aortic/pulmonic stenosis, mitral /tricuspid regurgitation, VSD M \ T, hypertrophic
Valsalva ( phase II ), standing up ( 1 preload )
murinuri
cardiomyopathy
Diastolic heart sounds include aortic/pulmonic regurgitation, mitral /tricuspid stenosis.
CARDIOVASCULAR
CARDIOVASCULAR
PHYSIOLOGY
SECTION III
277
Heart murmurs
Systolic
Cresccndo-decresccndo systolic ejection murmur (ejection click may he present ).

LV aortic pressure during systole . Loudest at heart base; radiates to carotids.
Pulsus parvus et tardus pulses are weak with a delayed peak. Can lead to
Syncope , Angina, and Dyspnea on exertion ( SAD ). Most commonly due to agerelated calcification in older patients (> 60 years old ) or in younger patients with
early-onset calcification of bicuspid aortic valve.
I lolosystolic, high-pitched blowing murmur.
Mitral loudest at apex and radiates toward axilla . MR is often due to ischemic heart
disease ( post-MI ), MVP, LV dilatation.
Tricuspid loudest at tricuspid a re4 TR commonly caused by RV dilatation .
Rheumatic fever and infective endocarditis can cause either MR or TR .
Aortic stenosis
S2
SI
LAAAAAAAAAMAMMM I
.
Mitral /tricuspid regurgitation
S2
St
LAAMAAAAAAAAAAAAAJ
late systolic crescendo murmur with midsystolic click ( MC; due to sudden tensing
of chordae tendineae). Most frequent valvular lesion . Best heard over apex. Loudest
just before S2. Usually benign . Can predispose to infective endocarditis. Can be
caused by myxomatous degeneration ( 1 or 2 to connective tissue disease such as
Marfan or Ehlers-Danlos syndrome), rheumatic fever , chordae rupture.
Mitral valve prolapse

St
MC
S2
L/rtl
Holosystolie, harsh-sounding murmur. Loudest at tricuspid area .
Ventricular septal defect

S2
SI
LVWMAAAAAAAAAAI
Diastolic
Aortic regurgitation
S2
SI
Lv /
' /M w y u
Mitral stenosis
SI
..
Follows opening snap ( OS; due to abrupt halt in leaflet motion in diastole, after
rapid opening due to fusion at leaflet tips) . Delayed rumbling mid-to-latc diastolic
niurimnjff interval between S2 and OS correlates with t severity ). LA L.V
S2 OS
I LMIW
High-pitched blowing early diastolic decrescendo murmur. Long diastolic

murmur, hyperdynamic pulse, and head bobbing when severe and chronic. Wide
pulse pressure. Often due to aortic root dilation, bicuspid aortic valve, endocarditis,
rheumatic fever. Progresses to left I IF.
aim
*.*
pressure during diastole. Often occurs 2 to rheumatic fever. Chronic MS can

result in LA dilatation.
Continuous
Patent ductus arteriosus
S2
LAAAAMAAAAAAAAIAAAA
Continuous machine like murmur . Loudest at S2. Often due to congenital rubella
or prematurity. Best heard at left infraclavicular area .
CARDIOVASCULAR
Electrocardiogram
Conduction pathway SA node
P wave atrial depolarization. Atrial

atria
repolarization is masked by QRS complex.
bundle
node
lis
and
of
I
AV
right
-*
PR interval time from start of atrial
left bundle branches -* Purkinje fibers
depolarization to start of ventricular
-* ventricles; left bundle branch divides into
depolarization ( normally < 200 msec).
left anterior and posterior fascicles.
SA node pacemaker" inherent dominance with QRS complex ventricular depolarization
(normally < 120 msec).
slow phase of upstroke.
AV node located in posteroinferior part of
QT interval ventricular depolarization,
mechanical contraction of the ventricles,
interatrial septum. Blood supply usually
ventricular repolarization.
from RCA. 100-msec delay allows time for
T wave ventricular repolarization. T-wave
ventricular filling.
inversion may indicate ischemia or recent \H
Pacemaker rates SA > AV > bundle of His/
|point junction betw een end of QRS complex
Purkinje/ventricles.
and start of ST segment.
Speed of conduction Purkinje > atria
ST segment isoelectric, ventricles depolarized.
> ventricles > AV node.
U wave prominent in hypokalemia,
bradycardia.
5 mm
0 2 seconds
Aorta
Superior
vena cava
SA node
N.
Bachmann
bundle
AV node
S-T
PR
segment
+05
segment
/ po re
Left bundle
branch
+1.0
u
0 m\
Bundle of His
--
interval
Right bundle
branch
Purkinje fibers
an
interval
Left anterior
fascicle
|_
Atm!
- Left postenor
fascicle
O T interval
VcntncuUr
depoUnzattor depounzaccm
-0.5
J
VCTtncuU
repoianrauon
fi
282
SECTION I I I
CARDIOVASCULAR
ECG tracings
RHYTHM
DESCRIPTION
Atrial fibrillation
Chaotic and erratic baseline with no discrete P waves in between
EXAMPLE
RR ,
irregularly spaced QRS complexes. Irregularly irregular
heartbeat . Most common risk factors include hypertension and

coronary artery disease (CADl. Can lead to thromboembolic
events, particularly stroke.
Treatment includes anticoagulation, rate control, rhythm control,
and/or cardioversion.
Atrial flutter
Ventricular
fibrillation
RR,
x RR ,
Irregular baseline (absent P wavesl
A rapid succession of identical, back-to-back atrial depolarization

waves. The identical appearance accounts for the saw tooth
appearance of the flutter waves.
Treat like atrial fibrillation. Definitive treatment is catheter
ablation.
A completely erratic rhythm with no identifiable w aves. Fatal

arrhythmia without immediate CPR and defibrillation.
RR ,
RR.
RR.
RR,
41 sawtooth pattern
AWVA/V
No discernible rhythm
AV block
Firstjdeqree
The PR interval is prolonged (> 200 msec). Benign and

asymptomatic. No treatment required.
Seconcjdegree
Mobitz type I
( Wenckebach)
Progressive lengthening of PR interval until a beat is dropped

(a P wave not followed by a QRS complex ). Usually
asymptomatic. Variable RR interval with a pattern (regularly
irregular).
Mobitz type II
Thirdjdegree
(complete )
Dropped beats tlrat are not preceded by a change in the length of

the PR interval (as in type I).
May progress to srd-degree block. Often treated with pacemaker.
pg
jr'
^
^PR
* PR(J =
'
"
PR
^PR
<
<
' PR
i4PR,
p ware, absent QRS u
^
P wave absent QRS
The atria and ventricles beat independently of each other. P waves and QRS complexes not rhythmically
associated. Atrial rate > ventricular rate. Usually treated with pacemaker. Can be caused by Lyme
disease.
RR,
RR,
I P wave on ORS compter
PP = PP, = PP, = PP
Pwave
CARDIOVASCULAR
Baroreceptors and chemoreceptors

EFFERENT
AFFERENT
Solitary nucleus
Mi au a
Vagus
nerve
- chain
y Sympathetic
'
Parasympathetic
vagus nerve
COfd
Receptors:
Aortic arch transmits via vagus nerve to solitary nucleus of
medulla (responds to i and t in BP).
Carotid sinus ( dilated region at carotid bifurcation) transmits via
glossopharyngeal nerve to solitary nucleus of medulla ( responds
to i and t in BP).
Baroreceptors:
- P n:t
Carotid body
chemoreceptor
Sympathetic
nerves
Hypotension 1 arterial pressure i stretch i afferent

baroreceptor firing t efferent sympathetic firing and
A efferent parasympathetic stimulation vasoconstriction,
t HR, T contractility, t BP. Important in the response to severe
hemorrhage.
Aortic
baroreceptor
SAnode
Blood
vessels
Avnode
Carotid massage t pressure on carotid sinus t stretch

-* t afferent baroreceptor firing -* t AV node refractory period
i HR.
Component ot Cushing reflex ( triad of hvpertensioij
bradycardia, and respirators depression) t intracranial
pressure constricts arterioles -* cerebral ischemia - t pCQ,
and 1 pH central reflex sympathetic t in perfusion pressure
t stretch peripheral reflex baroreceptor(hypertension )
Aortic
chemoreceptor
283
Released from ventricular myocytes in response to t tension. Similar physiologic action to ANP,
with longer half-life. B \ P blood test used for diagnosing HF ( very good negative predictive value).
Available in recombinant form (nesiritidc) for treatment of HK
B- type (brain )
natriuretic peptide
Carotid sinus
baroreceptor
SECTION I I I
Released from atrial myocytes in response to t blood volume and atrial pressure. Acts via cGMP.
Causes vasodilation and i Na* reabsorption at the renal collecting tubule. Dilates afferent renal
arterioles and constricts efferent arterioles, promoting diuresis and contributing to "aldosterone
escape mechanism.
Atrial natriuretic
peptide
IX:
Glossopharyngeal
nerve
induccd bradycardia.
Chemoreceptors:
Peripheral carotid and aortic bodies arc stimulated hv A Pa,

(< 60 mm Hg), t Pco7, and 1 pH of blood.
Central are stimulated by changes in pH and Pco, of brain
interstitial fluid, which in turn are influenced by arterial CO-,.
Do not directly respond to Po7.
CARDIOVASCULAR
Capillary fluid
exchange
Interstitial fluid
l
SECTION I I I
Starling forces determine fluid movement through capillary membranes:

Pc = capillary pressure pushes fluid out of capillary
Pl = interstitial fluid pressure pushes fluid into capillary

itc = plasma colloid osmotic (oncotic) pressure pulls fluid into capillary
It1 = interstitial fluid colloid osmotic pressure pulls fluid out of capillars
Jv = net fluid flow = Kf f(Pc - Pj) - g(ltc - ft,)]
Kf = permeability of capillary to fluid
C, = reflection coefficient ( measure of permeability of capillary to protein!
Edema excess fluid outflow into interstitium commonly caused by:
'
P n
Capillary
t capillary pressure ( t ; eg, HF)

* l plasma proteins ( t rtc; eg, nephrotic syndrome, liver failure, protein malnutrition)
t capillary permeability ( t ; eg, toxins, infections, burns)
t interstitial fluid colloid osmotic pressure ( t TTj; eg, lymphatic blockagel
Pc
Kf
285
CARDIOVASCULAR PATHOLOGY
CARDIOVASCULAR
SECTION III
287
Congenital heart diseases ( continued )
Right-to-L,eft shunts: caRLy cyanosis.

Left-to-Right shunts: I ateR cyanosis.
LEFTTO -RIGHT SHUNTS
Late cyanosis ( 2 to Eiscnmcngcr syndrome)

blue kids.
Frequency: V'SD > ASD > PDA.
Ventricular septal
defect
Most common congenital cardiac defect.

Asymptomatic at birth, may manifest weeks
later or remain asymptomatic throughout life.
Most self resolve; larger lesions may lead to L.V
overload and HF.
O saturation t in RV and pulmonary artery .
Atrial septal defect
Defect in interatrial septum Q; loud SI; wide,

fixed split S2. Ostium secundum defects
most common and usually occur as isolated
findings; ostium primum defects rarer yet
usually occur with other cardiac anomalies.
Symptoms range from none to HF. Distinct
from patent foramen ovale in that septa are
missing tissue rather than unfused.
CL saturation t in RA RV, and pulmonary

arterv. Mav lead to paradoxical cmbolj
In fetal period, shunt is right to left (normal).

In neonatal period, f pulmonary vascular
resistance -* shunt becomes left to right
progressive RVII and/or LVH and HF.
Associated with a continuous, "machine -like"
murmur. Patency is maintained by PGF
synthesis and low O tension. Uncorrcctcd
PDA Q can eventually result in late cyanosis
in the lower extremities (differential cyanosis).
Endomethacin (indomcthacin) ends patency

of PDA; PCF keeps ductus Going (may be
necessary to sustain life in conditions such as
transposition of the great vessels).
PDA is normal in utcro and normally closes only
after birth.
O'
rJ
Patent ductus
arteriosus
LF
PA
Eisenmenger
syndrome
LV
Uncorrcctcd Icft-to-right shunt ( VSD, ASD,

PDA ) t pulmonary blood flow
pathologic
remodeling of vasculature - pulmonary'
arterial hypertension. RVH occurs to
compensate -* shunt becomes right to
left. Causes late cy anosis, clubbing Q, and
polycythemia Age of onset varies.
VSD
RVII
OTHER ANOMALIES
Coarctation of the
aorta
Aortic narrowing near insertion of ductus arteriosus ( juxtaductal) Associated with bicuspid aorticvalve, other heart defects, and Turner syndrome. Hypertension in upper extremities and weak,
delayed pulse in lower extremities (brachial-femoral delay). With age, intercostal arteries enlarge
due to collateral circulation; arteries erode ribs notched appearance on CXR. Complications
include HF, t risk of cerebral hemorrhage ( berry aneurysms), aortic rupture, and possible
endocarditis.
288
SECTION III
Congenital cardiac
defect associations
CARDIOVASCULAR
DISORDER
DEFECT
Alcohol exposure in utero ( fetal alcohol

syndrome)
Congenital rubella
VSD, PDA, ASD, tetralogy of Fallot
Down syndrome
AV septal defect (endocardial cushion defect ),

VSD, ASD
Infant of diabetic mother
t ransposition of great vessels
Marfan syndrome
MVP, thoracic aortic aneurysm and dissection,

aortic regurgitation
Prenatal lithium exposure
Ebstein anomaly
Turner syndrome
Bicuspid aortic valve, coarctation of aorta
PDA, pulmonary artery stenosis, septal defects
Williams syndrome
Supravalvular aortic stenosis
22qll syndromes
Truneus arteriosus, tetralogy of Fallot
Defined as persistent systolic BP > 140 mm Hg and/or diastolic BP > 90 nun Hg
Hypertension
RISK FACTORS
t age, obesity, diabetes, physical inactivity, excess salt intake, excess alcohol intake, family history;
African American > Caucasian > Asian.
FEATURES
90% of hypertension is 1 (essential ) and related to t CTO or t TPR; remaining 10% mostly 2
to renal/renovascular disease (eg, atherosclerosis, fibromuscular dvsplasiaj [ string of beads"
appearance Q], usually found in younger women) and 1 hyperaldosteronism
Hypertensive urgency severe (> 180/> 120 mm Hg) hypertension without acute end-organ
damage.
Hypertensive emergency severe hypertension with evidence of acute end- organ damage (eg,
encephalopathy, stroke, retinal hemorrhages and exudates, papilledema, MI, HF, aortic dissection,
kidney injury, microangiopathic hemolytic anemia, eclampsia).
CAD, LVH, HF, AF; aortic dissection, aortic aneurysm; stroke; chronic kidney disease
( hypertensive nephropathy) Q; retinopathy.
PREDISPOSES TO
9}
tv^
* '
CARDIOVASCULAR
Aortic dissection
SECTION III
291
Longitudinal intimal tear forming a false lumen EJ. Associated with hypertension, bicuspid aortic
valve, inherited connective tissue disorders ( eg, Marfan syndrome). Can present with tearing
chest pain, of sudden onset, radiating to the back +/- markedly unequal BP in arms. CXR shows
mediastinal widening. Can result in organ ischemia, aortic rupture, death. Two types:
Stanford type A (proximal): involves Ascending aorta. May extend to aortic arch or descending
aorta. May result in acute aortic regurgitation or cardiac tamponade. Treatment: surgery.
Stanford type B ( distal ): only involves descending aorta ( Below liganrcntum arteriosum). No
ascending aorta involvement. Treat medically with {{-blockers, then vasodilators.
Ischemic heart disease manifestations

Angina
Chest pain due to ischemic myocardium 2 to coronary artery narrowing or spasm; no myocyte
necrosis.
Stable usually 2 to atherosclerosis; exertional chest pain in classic distribution (usually with
ST depression on KCG), resolving with rest or nitroglycerin.
Variant (Prinzmetal) occurs at rest 2 to coronary artery spasm; transient ST elevation on
ECC. Known triggers include tobacco, cocaine, and triptans, but trigger is often unknown.
Treat with Ca 2* channel blockers, nitrates, and smoking cessation (if applicable).
Unstable thrombosis with incomplete coronary artery occlusion; +/- ST depression and/or
T-wave inversion on ECG but no cardiac biomarker elevation ( unlike NSTEMI); t in frequency
or intensity of chest pain or any chest pain at rest.
:
Coronary steal
syndrome
Sudden cardiac death
Chronic ischemic
heart disease
Myocardial infarction
Distal to coronary stenosis, vessels are maximally dilated at baseline. Administration of vasodilators
(eg, dipyridamole, regadenoson) dilates normal vessels and shunts blood toward well-perfused
areas i flow and leads to ischemia in poststenotic regions Principle behind!pharmacologic
stress tests.
Death from cardiac causes within 1 hour of onset of symptoms, most commonly due to a lethal
arrhythmia (eg. VF). Associated with GAD (up to 70% of cases), cardiomyopathy ( hypertrophic,
dilated), and hereditary ion channelopathies ( eg, long QT syndrome, Brugada syndrome). Prevent
with implantable cardioverter-defibrillator (ICD).
Progressive onset of HF over many years due to chronic ischemic myocardial damage.
Most often acute thrombosis due to rupture of coronary artery atherosclerotic plaque, t cardiac
biomarkers (CK-MB, troponins) are diagnostic.
ST- segment elevation Ml ( STEMI)
Non- ST- segment elevation Ml (NSTEMI)
Transmural infarcts
Full thickness of myocardial wall involved
ST elevation on EGG, Q waves
Subendocardium (inner At especially
Subendocardial infarcts
vulnerable to ischemia
'
ST depression on ECG
V5
CARDIOVASCULAR
SECTION III
Cardiomyopathies
Dilated
cardiomyopathy
Most common cardiomyopathy (90% of cases).

Often idiopathic or familial. Other etiologies
include chronic Alcohol abuse, wet Beriberi,
Coxsackic B viral myocarditis, chronic
Cocaine use, Chagas disease Doxorubicin
toxicity, hemochromatosis, sarcoidosis,
peripartum cardiomyopathy,
bindings: HF, S 3, systolic regurgitant murmur,
dilated heart on echocardiogram, balloon
appearance of heart on CXR.
Treatment: Na+ restriction, ACE inhibitors,
p-blockers, diuretics, digoxin, ICD, heart
*>
Hypertrophic
cardiomyopathy
transplant.
60-70% of cases are familial, autosomal
Systolic dysfunction ensues.

Eccentric hypertrophy Q (sarcomeres added in
series).
\BCCCD.
Takotsubo cardiomyopathy: "broken heart
syndrome " ventricular apical ballooning
likely due to increased sympathetic stimulation
( stressful situations).
Diastolic dysfunction ensues.
dominant imost commonly due to mutations

in genes encoding sarcomeric proteins, such as
myosin binding protein C and 0-mvosin heavy
clnmt Can be associated with Friedreich
ataxia. Causes syncope during exercise and
may lead to sudden death in young athletes
due to ventricular arrhythmia.
Findings: S4, systolic murmur. May see mitral
regurgitation due to impaired mitral valve
Marked ventricular concentric hypertrophy

(sarcomeres added in parallel!H, often septal
predominance. Myofibrillar disarray and
fibrosis.
Obstructive hypertrophic cardiomyopathy
(subset ) asymmetric septal hypertrophy
and systolic anterior motion of mitral valve
outflow obstruction dyspnea, possible
syncope.
closure.
Treatment: cessation of high-intensity athletics,
use of 0 -blocker or non-dihydropyridine Ca-+
channel blockers (eg, verapamil). ICD if
patient is high risk.
Restrictive/infiltrative
cardiomyopathy
Puppy I.I ASII: Iostradiation fibrosis, loftier

syndrome, Endocardial fibroelastosis
( thick fihroelaslic tissue in endocardium of
voung children ! Amyloidosis, Sarcoidosis
Hemochromatosis ( although dilated

cardiomyopathy is more common )!
Diastolic dysfunction ensues. Can have loss voltage ECG despite thick myocardium
(especially amyloid).
SECTION III
Heart failure
HI
CARDIOVASCULAR
Clinical syndrome of cardiac pump dysfunction -* congestion and low perfusion. Symptoms
include dyspnea, orthopnea, fatigue; signs include Ss heart sound, ralej jugular venous distention
(J\'D), pitting edema Q.
Systolic dysfunction reduced EF, t EDY; J contractility often 2 to isehemia/MI or dilated
cardiomyopathy.
Diastolic dysfunction preserved EF, normal EDY; 1 compliance often 2 to myocardial
hypertrophy.
Right HF most often results from left HF. Cor pulmonale refers to isolated right HF due to
pulmonary cause.
ACE inhibitors or angiotensin 11 receptor blockers. [Yblockers ( except in acute decompensated HF ),
and spironolactone 1 mortality. Thiazide or loop diuretics are used mainly for symptomatic relief.
Hydralazine with nitrate therapy improves both symptoms and mortality in select patients.
Left heart failure
Orthopnea
Shortness of breath when supine: t venous

return from redistribution of blood (immediate
gravity effect ) exacerbates pulmonary vascular

congestion.
Paroxysmal
nocturnal dyspnea
Breathless awakening from sleep: t venous

return from redistribution of blood,
reabsorption of peripheral edema, etc.
Pulmonary edema
t pulmonary venous pressure pulmonary

venous distention and transudation of fluid.
1IV contract nty
Pulmonary
Jtrra
Pulmonary venous
lRv output
Presence of hemosiderin-laden macrophages

T System venous
tmm
ettema
Right heart failure
Hepatomegaly
(nutmeg liver)
t central venous pressure -* t resistance to

portal flow. Rarely, leads to "cardiac cirrhosis
Jugular venous
distention
t venous pressure.
Peripheral edema
t venous pressure
Shock
T PretoMl * cardoc
output 'compensation;
Hemorrhage, dehydration
burns
teauorpdon
f IV
.i-'i-i;of
* Sytnptfnetc
id fly
SVR
SKIN
(PRELOAD)
CO
(AFTERLOAD)
TREATMENT
Cold.
11
IV fluids
clammy
Acute MI, HF, valvular
dysfunction, arrhythmia
Obstructive
T Renal Na*
wdHO
Inadequate organ perfusion and delivery of nutrients necessary for normal tissue and cellular
function. Initially may be reversible but life-threatening if not treated promptly.
PCWP
Cardiogenic
fluid transudation.
CAUSED BY
Hypovolemic
Reno
..
It (t( XM
( HF" cells) in lungs.
1 Carctac
congestion
Cardiac tamponade
pulmonary embolism,
tension pncumothora 4
Inotropes, diuresis
Cold
clammy
11
Relieve obstruction
Warm
Dry
l
l
11
11
IV fluids, pressors
Distributive
Sepsis, anaphylaxis
CNS injury
CARDIOVASCULAR
Fever (most common symptom), new murmur,
Bacterial endocarditis
Roth spots (round white spots on retina

surrounded by hemorrhageJQ), Osier nodes
(tender raised lesions on finger or toe pads
due to immune complex depositing. Janeway
lesions (small, painless, erythematous lesions

on palm or sole) Q, glomerulonephritis,
septic arterial or pulmonary emboli, splinter
hemorrhages Q on nail bed. Multiple blood
cultures necessary for diagnosis.
Acute S aureus ( high virulence).
Large vegetations on previously normal
valves Q Rapid onset .
Subacute viridans streptococci I low
virulence ). Smaller vegetations on
congenitally abnormal or diseased valves.
Sequela of dental procedures. Gradual
onset.
S bovis ( gallolyticus ) is present in colon cancer,
S epidermidis on prosthetic valves.
Endocarditis may also be nonbacterial
(marantic /thrombotic) 2 to malignancy,
hypercoagulablc state, or lupus.
SECTION III
Mitral valve is most frequently involved.

Tricuspid valve endocarditis is associated with
IV drug abuse (don' t tri" drugs). Associated
with S aureus. Pseudomonas, and Candida .
Culture most likely Coxiella burnetii .
Bartonella spp., HACEK ( Haemophilus ,
Aggregatibacter ( formerly Actinobacillus ),

Cardiobacterium , Eikenella, Kingella )
V Bacteria FROM JANE V
Fever
Roth spots
Osier nodes
Murmur
Janeway lesions
Anemia
Nail-bed hemorrhage
Emboli
.
/i
c
a
297
7m
298
SECTION III
Rheumatic fever
if *J
term
'
.;
CARDIOVASCULAR
A consequence of pharyngeal infection with

group A P-hemolytic streptococci. Late
sequelae include rheumatic heart disease,
which affects heart valves mitral > aortic
tricuspid ( high-pressure valves affected most).
Early lesion is mitral valve regurgitation;
late lesion is mitral stenosis. Associated
with Aschoff bodies ( granuloma with giant
cells [blue arrows in 0)), Anitschkow cells
(enlarged macrophages with ovoid, wavy,
rod-like nucleus [red arrow in Q[ ), t anti
streptolysin O (ASO) titers.
Immune mediated (type II hypersensitivity);
not a direct effect of bacteria. Antibodies
to M protein cross-react with self antigens
(molecular mimicry).
JVNT.S (major criteria):

Joint (migratory polyarthritis)
V (carditis)
Nodules in skin (subcutaneous)
Erythema marginatum
Sydenham chorea
Treatment /prophylaxis: penicillin.
Acute pericarditis
Inflammation of the pericardium [ O, red arrows!. Commonly presents with sharp pain, aggravated
by inspiration, and relieved by sitting up and leaning forward. Often complicated by pericardia]
effusion [white arrow in O]. Presents with friction rub. ECG changes include widespread STsegment elevation and/or PR depression.
Causes include idiopathic (most common; presumed viral), confirmed infection (eg,
Coxsackievirus), neoplasia, autoimmune (eg, SLE, rheumatoid arthritis), uremia, cardiovascular
(acute STEMI or Dressier syndrome), radiation therapy.
Cardiac tamponade
Compression of the heart by fluid (eg, blood, effusions [arrows in 0] in pericardial space) I CO.
E q u i l i b r a t i o n of diastolic pressures in all 4 chambers.
Findings: Heck tri nl ( Inpotension. distended in i k wins, distant heuit sounds ;, I IK pulsus
p.uudoMJs ECO slums low voltage (JRS and eleetiR .ll ultcm.uis due
heart in large effusion).
Pulsus paradoxus 1 in amplitude of systolic BP by > 10 mm Hg during inspiration Seen in

cardiac tamponade, asthma, obstructive sleep apnea, pericarditis, croup.
Syphilitic heart
disease
3 syphilis disrupts the vasa vasorum of the

aorta with consequent atrophy of vessel wall
and dilatation of aorta and valve ring.
May see calcification of aortic root, ascending
aortic arch, and thoracic aortai Leads to tree
bark appearance of aorta.
Can result in aneurysm of ascending aorta or

aortic arch, aortic insufficiency,
CARDIOVASCULAR
Cardiac tumors
Myxomas
SECTION III
299
Most common heart tumor is a metastasis ( eg mclanomaj

Most common 1 cardiac tumor in adults Q. 907c occur in the atria (mostly left atrium). Myxomas
are usually described as a "hall valve obstruction in the left atrium ( associated with multiple
syncopal episodes ). Mas hear early diastolic " tumor plop sound. Histology: Gelatinous material,
myxoma cells immersed in glycosaminoglycans.
Rhabdomyomas
Kussmaul sign
Most frequent 1 cardiac tumor in children (associated with tuberous sclerosis ). I listology:
hamartomous growths.
t in ) \ T on inspiration instead of a normal L

Inspiration negative intTathoraeie pressure not transmitted to heart impaired filling of right
ventricle -* blood backs up into venae cavae -* JVD. May be seen with constrictive pericarditis,
restrictive cardiomyopathies, right atrial or ventricular tumors.
300
SECTION III
CARDIOVASCULAR
Vasculitides
EPIDEMI010GY/PRESENTATI0N
PATHOLOGY/LABS
Usually elderly females.

Unilateral headache ( temporal artery), jaw
claudication.
May lead to irreversible blindness due to
ophthalmic artery occlusion.
Associated with polymyalgia rheumatica.
Usually Asian females < 40 years old.
Pulseless disease" ( weak upper extremity
pulses), fever, night sweats, arthritis, myalgias,
skin nodules, ocular disturbances.
Most commonly affects branches of carotid

artery
Large vessel vasculitis

-
Giant cell (temporal)

arteritis
Takayasu arteritis
Focal granulomatous inflammation Q.

t ESR.
Treat with high-dose corticosteroids prior to
temporal artery biopsy to prevent blindness.
Granulomatous thickening and narrowing of

aortic arch Q and proximal great vessels,
t KSR.
Treat with corticosteroids.
Medium- vessel vasculitis

Polyarteritis nodosa
Kawasaki disease
(mucocutaneous
lymph node
syndrome )
Buerger disease
(thromboangiitis
obliterans)
middle-aged males]
1 lepatitis It seropositivity in W/ of patients.
Fever, weight loss, malaise, headache.
GI: abdominal pain, melena.
Hypertension, neurologic dysfunction,
cutaneous eruptions, renal damage.
Usually
Asian children < 4 vears old

Conjunctival injection Rash ( polymorphous
desquamating), Adenopathy (cervical),
Strawberry tongue (oral mucositis) 0, Handfoot changes ( edema, erythema), fever.
Heavy smokers, males < 40 years old.

Intermittent claudication may lead to
gangrene Q, autoamputation of digits,
superficial nodular phlebitis.
Raynaud phenomenon is often present.
Typically involves renal and visceral vessels, not

pulmonary arteries.
JTransmural inflammation of the arterial wall
with fibrinoid necrosis.

Different stages of inflammation may coexist in
different vessels.
Innumerable renal microaneurysms H and spasms
on arteriogram.
Treat with corticosteroids, cyclophosphamide.
CRASH and burn.
May develop coronary- artery- aneurysms 14

thrombosis or rupture can cause death.
Treat with IV immunoglobulin and aspirin.
Segmental thrombosing vasculitis.

Treat with smoking cessation.
Small-vessel vasculitis
Granulomatosis
with polyangiitis
( Wegener )
Upper respiratory tract : perforation of nasal

septum, chronic sinusitis, otitis media,
mastoiditis.
Lower respiratory tract: hemoptysis, cough,
dyspnea.
Renal: hematuria, red cell casts.
Triad:
Focal necrotizing vasculitis
* Necrotizing granulomas in the lung and
upper airway
Necrotizing glomerulonephritis
PR > -ANCA/c-ANCA Q (anti-proteinase 3).
CXR: large nodular densities.
Treat with cyclophosphamide, corticosteroids.
Microscopic
polyangiitis
Necrotizing vasculitis commonly involving

lung, kidneys, and skin with pauci-immunc
glomerulonephritis and palpable purpura.
Presentation similar to granulomatosis with
polyangiitis but without nasopharyngeal
involvement.
No granulomas.
MPO-ANCA /p-ANCAd (anti
myeloperoxidase).
Treat with cyclophosphamide, corticosteroids.
Vasculitides (continued )
PATHOLOGV/ WBS
EPIDEMIOLOGY/ PRESENTATION
Small- vessel vasculitis (continued)
Eosinophilic
granulomatosis with
polyangiitis (ChurgStrauss)
Asthma, sinusitis, skin nodules or purpura,

peripheral neuropath) (eg, wrist/foot drop).
Can also involve heart Cl, kidneys ( pauciimmune glomerulonephritis).
Granulomatous, necrotizing vasculitis with

eosinophilia Q.
MPO-ANCA/p-ANCA, t IgE level.
Henoch-Schonlein
purpura
Most common childhood systemic vasculitis.

Often follows URI.
Classic triad:
Skin: palpable purpura on buttocks/legs Q
Vasculitis 2 to IgA immune complex

deposition.
Associated with IgA nephropathy ( Berger
disease).
Arthralgias
GI: abdominal pain

L
3
i t
Y 4
ni
o)
'A
C
c
3?
is
02
SECTION III
CARDIOVASCULAR PHARMACOLOGY
CARDIOVASCULAR
Hypertension treatment
Hypertension with
heart failure
Thiazide diuretics, ACE inhibitors, angiotensin

II receptor blockers ( ARBs ), dihydrops ridine
Ca -+ channel blockers.
Diuretics, ACE inhibitors/ARBs, p-blockers
(compensated HE), aldosterone antagonists.
Hypertension with
diabetes mellitus
ACE inhibitors/ARBs, Ca -+ channel blockers,

thiazide diuretics, P-blockers.
Hypertension in
pregnancy
Hydralazine, labetalol, methyldopa, nifedipine.
Primary ( essential)
hypertension
Calcium channel
blockers
MECHANISM
CLINICAL USE
P-blockers must be used cautiously in

decompensated HE and are contraindicated in
cardiogenic shock.
ACE inhibitors/,\ RBs are protective against
diabetic nephropathy.
Amlodipine, clevidipine, nicardipine, nifedipine, niniodipine (dihydropyridines, act on vascular

smooth muscle); diltiazem, verapamil (non-dihydropyridines, act on heart).
Block vollage-dependeni 1 -type calcium channels of cardiac and smooth muscle 1 muscle
contractility.
Vascular smooth muscle amlodipine = nifedipine > diltiazem > verapamil.
Heart verapamil > diltiazem > amlodipine = nifedipine ( verapamil = ventricle).
Dihydropyridines (except niniodipine): hypertension, angina (including Prinzmetal), Raynaud
phenomenon.
Niniodipine: subarachnoid hemorrhage ( presents cerebral vasospasm).
Nicardipine, clevidipinci hypertensive urgenev or emergency

Non-dihydropyridines: hypertension, angina, atrial fibrillation/flutter.
ADVERSE EFFECTS
Non-dihvdropyridine: cardiac depression, AV block, hyperprolactinemia, constipation.

Dihvdropyridine: peripheral edema, flushing, dizziness, gingival hyperplasia.
Hydralazine
smooth muscle relaxation. Vasodilates arterioles > veins; afterload reduction.
MECHANISM
t cGMP
CLINICAL USE
Severe hypertension (particularly acute), III' ( with organic nitrate). Safe to use during pregnancy.
Frequently coadministered with a P-blocker to prevent reflex tachycardia.
ADVERSE EFFECTS
Compensatory tachycardia (contraindicated in angina /CAD), fluid retention, headache, angina.

Lupus-like syndrome.
Hypertensive
Drugs include clevidipine, fenoldopam, labetalol, nicardipine, nitroprusside.
emergency
Nitroprusside
Short acting; t cGMP via direct release of NO. Can cause cyanide toxicity (releases cyanide)
Fenoldopam
Dopamine D| receptor agonist coronary, peripheral, renal, and splanchnic vasodilation, t BP,
t natriuresis. Also used postoperatively as an antihypertensive. Can cause hypotension and
tachycardia.
CARDIOVASCULAR
CARDIOVASCULAR
Nitrates
MECHANISM
CLINICAL USE
ADVERSE EFFECTS
PHARMACOLOGY
Nitroglycerin, isosorbide dinitrate, isosorbide mononitrate.
Vasodilate by t NO in vascular smooth muscle t in cGMP and smooth muscle relaxation.

Dilate veins arteries, 4 preload.
Angina, acute coronary' syndrome, pulmonary edema.
Reflex tachycardia (treat with (3-blockers), hypotension, flushing, headache, Monday disease in
industrial exposure: development of tolerance for the vasodilating action during the work week
and loss of tolerance over the weekend tachycardia, dizziness, headache upon reexposure.
Contraindicated in right ventricular infarction.
Antianginal therapy
303
SECTION III
Goal is reduction of myocardial O-* consumption (MVOg) by i 1 or more of the determinants of

MV02: end-diastolic volume BP, MR, contractility.
COMPONENT
NITRATES
End- diastolic volume
p- BLOCKERS
No effect or t
Blood pressure
Contractility
No effect
Little/no effect
NITRATES p- BLOCKERS
No effect or 4
Heart rate
T (reflex response)
No effect or 4
Ejection time
L ittle/no effect
MVO2
Verapamil is similar to (3-blockers in effect.

Pindolol and accbutolol partial 3-agonists that should be used with caution in angintj
Ranolazine
MECHANISM
Inhibits the late phase of sodium current thereby reducing diastolic wall tension and oxygen
consumption. Does not affect heart rate or contractility.
CLINICAL USE
Angina refractory to other medical therapies.
ADVERSE EFFECTS
Constipation, dizziness, headache, nausea, QT prolongation.
Selective PDE- 3
inhibitor
MECHANISM
Milrinone
Selective PDK -3 inhibitor; 1 cAMP breakdown t Qu entry into cardiac mvocvtes and vascular
smooth muscle cells t inotropv, t peripheral arterial/venous vasodilation .
CLINICAL USE
Short term use in acute decompensated heart failure.
ADVERSE EFFECTS
Arrhy thmias, hypotension
CARDIOVASCULAR
CARDIOVASCULAR
PHARMACOLOGY
Lipid-lowering agents
DRUG
LDl
HDl
TRIGLYCERIDES
MECHANISMS OF ACTION
ADVERSE EFFECTS/PROBLEMS
HMG -CoA reductase

inhibitors
Hi
Hepatotoxicity (T LFTs),
myopathy (esp. when used
with fibrates or niacin )
Bile acid resins

Cholestyramine,
colestipol,
colesevelam
Slightly t
Slightly t
Inhibit conversion of HMGCoA to mevalonate, a

cholesterol precursor;
1 mortality in CAD patients
Prevent intestinal rcabsorption
of bile acids; liver must use
cholesterol to make more
Ezetimibe
Fibrates
Gemfibrozil,
bezafibrate,
fenofibrate
Niacin ( vitamin B3)
tt
(eg, lovastatin,
pravastatin )
Gl upset, 1 absorption of
other drugs and fat-soluble
vitamins
Prevent cholesterol absorption

at small intestine brush
border
Rare t LFTs, diarrhea
111
Upregulate LPL t TG
clearance
Activates PPAR-a to induce
HDL synthesis
Myopathy (t risk with

statins ), cholesterol
gallstones
Inhibits lipolysis ( hormonesensitive lipase ) in adipose

tissue; reduces hepatic VLDL
synthesis
Red , flushed face, which is

l by NSAIDs or long-term
use
Hyperglycemia
Hyperuricemia
PCSK9 inhibitors
alirocumab,
evolocumab
111
Myalgias, delirium.
Inactivation of LDL reccptor
degradation , increasing
dementia , other
neurocognitive effects
amount of LDL removed

from bloodstream
Liver
Enterocyte
Blood
Intestinal lumen
Acetyl CoA
HMG -CoA
ApoE
receptc i
HMG - CoA
CHOLESTEROL
Lymphatics
LHl
ABSORPTION
Ht
CHY
IC. dUC
rem
Mevalonate
/ Triacylglyceride
1 / /n
to esterol
MEVALONATE
SYNTHESIS
t L
/'
Niacin
Statins
Lovastatin
Pravastatin
Simvastatin
Atorvastatin
>
c+>-i
FFA
FFA
Lipolysis
Adipose tissue
LDL
receptor
LDL
LPL UPREGULATION
--
Cholesterol
FA
Bile acids
BILE ACID
REABSORPTION
Bile acid resins
HDL
Rosuvastatin
Cholesterol
FFA
Bile acids
receptor
HOL )
VLDL
LPt *
HDL
E20 - i be
*
FFA
'
pool
Fibrates
gemfibrozil
bezafibrate
fenofibrate
*
V. ADIPOSE LIPOLYSIS
cholestyramine
colestipol
colesevelam
B 06
SECTION I I I
Antiarrhythmics
sodium channel
blockers ( class I)
CARDIOVASCULAR
Slow or block ( t ) conduction (especially in depolarized cells). I slope of phase 0 depolarization. Are
state dependent ( selectively depress tissue that is frequently depolarized [eg, tachycardia] ).
Class IA
Quinidine, Procainamide, Disopyram idc.

The Queen Proclaims Diso's pyramid.
MECHANISM
t AP duration, t effective refractors period

( ERP ) in ventricular action potential, t QT
interval, some potassium channel blocking
CLINICAL USE
Both atrial and ventricular arrhythmias,

especially re-entrant and ectopic SVT and VT.
ADVERSE EFFECTS
Cinchonism ( headache, tinnitus with

quinidinc ), reversible SI.E-likc syndrome
(procainamide), heart failure (disopyramide),
thrombocytopenia, torsades dc pointes due to
t QT interval.
Class IB
Lidocaine, McxilcTinc. I'd Buy Liddy's
Class IA
/X
Slope of
phase 0
effects
Class IB
Mexican Tacos."
MECHANISM
1 AP duration. Preferentially affect ischemic or

depolarized Purkinje and ventricular tissue.
Phenytoin can also fall into the IB category.
CLINICAL USE
Acute ventricular arrhythmias (especially postM11, digitalis-induced arrhythmias. IB is Best

post-MI.
ADVERSE EFFECTS
CNS stimulation /depression, cardiovascular
Class 1C
I lecainide, Propafenone. Can 1 have Iries,
Slope of
phase 0
ADVERSE EFFECTS
Proarrhylhmic, especially post-MI

(contraindicated ). 1C is Contraindicated in
structural and ischemic heart disease.
r\
Class 1C
Please.
Significantly prolongs ERP in AV node and

accessors bypass tracts. No effect on ERP in
Purkinje and ventricular tissue
Minimal effect on AP duration.
SVIs, including atrial fibrillation. Only as a last
resort in refractory VT.
r\
Vv
depression.
MECHANISM
Slope of
phase 0
308
SECTION III
CARDIOVASCULAR
Verapamil, diltiazem .
Antiarrhythmics
CARDIOVASCULAR
PHARMACOLOGY
calcium channel
blockers ( class IV )
MECHANISM
I conduction velocity, f F.RP, t PR interval.
CLINICAL USE
Prevention of nodal arrhythmias (eg, SVT), rate control in atrial fibrillation .
ADVERSE EFFECTS
Constipation , flushing, edema, cardiovascular effects ( HF, AV block, sinus node depression ).
Class IV
60 i
1:
i
Slow rise of
action potential
- 30
Threshold
-60 |
- 90
Prolonged
repolarization
latAV node )
100
200
potential
500 400
Time ( ms)
500
600
r
700
Other antiarrhythmics
Adenosine
Mg 2 +
t K+ out of cells -* hvpcrpolarizing the cell and 1 1, decrease AV node conduction . Drug of
choice in diagnosing/terminating certain forms of SVT. Very short acting (~ 15 sec). F,ffects
blunted by theophylline and caffeine ( both arc adenosine receptor antagonists). Adverse effects
include flushing, hypotension, chest pain , sense of impending doom , bronchospasm .
Effective in torsades de pointes and digoxin toxicity .
Ivabradlne
MECHANISM
CLINICAL USE
ADVERSE EFFECTS
Selective inhibition of funny sodium channels Ilf I. prolonging slow depolarization phase I phase f ).
1 SA node firing; negative chronotropic effect without inotropv. Reduces cardiac O, requirement .
Chronic stable angina who cannot take [5-blockcrs. Chronic heart failure with reduced ejection
fraction.
Luminous phenomcna /visual brightness, hypertension , bradycardia .
HIGH- YIELD SYSTEMS
Endocrine
If you skew the endocrine system, you lose the

endocrine patterns change , it alters the way
in the battem tends to trib another.
pathways to self . When

think and feel. One shift
Embryology
310
Anatomy
310
Physiology
312
Pathology
321
Pharmacology
338
you
Hilary
Mantel
We have learned that there is an endocrinology of elation and despair, a

chemistry of mystical insight, and , in relation to the autonomic nervous
system, a meteorology and even . . . an astro- physics of changing moods.
Aldous (Leonard ) Huxley
Chocolate causes certain endocrine glands to secrete hormones that affect

your feelings and behavior by making you happy.
Elaine Sherman, Book of Divine Indulgences
309
310
SECTION I I I
ENDOCRINE EMBRYOLOGY
ENDOCRINE
ENDOCRINE EMBRYOLOGY
Thyroid development
Thyroid diverticulum arises from floor of

primitive pharvnx and descends into neck.
Connected to tongue by thyroglossal
duct, which normally disappears but may
persist as cysts or the pyramidal lobe of
thyroid. Foramen cecum is normal remnant
of thyroglossal duct. Most common
ectopic thyroid tissue site is the tongue
( lingual thyroid ). Removal may result in
hypothyroidism if it is the only thyroid tissue
Foramen cecum
Persistent
thyroglossal
duct
Thyroid
gland
Trachea
present.
Thyroglossal duct cyst Q presents as an anterior
midline neck mass that moves with swallowing
Thymus
or protrusion of the tongue (vs persistent

cervical sinus leading to branchial cleft cyst in
lateral neck ).
Thyroid tissue and parafollicular cells ( aka,
C cells, produce Calcitoniil) of the thyroid are
derived from endoderni
ENDOCRINE ANATOMY
Adrenal cortex and
medulla
Adrenal cortex (derived from mesoderm) and medulla (derived from neural crest ).
ANATOMY
iff ,
Zona Glomerulosa
PRIMARY REGULATORY CONTROL
SECRETORY PRODUCTS
Renin -angiotensin
Mineralocorticoids (aldosterone)
ACTH. CRH
Glucocorticoids (cortisol)
ACTH. CRH
Sex hormones tendrooens)
'itVvSi
CORTEX
Zona Fasciculate
Revised
)
Reticularis
3V
'
imaffin cells
Preganglionic sympathetic fibe
ids with Salt (mineralocorticoids Sugar ( glucocorticoi

vou go, the sweeter it gets.
Figure
SECTION III
ENDOCRINE PHYSIOLOGY
ENDOCRINE
Insulin
SYNTHESIS
SOURCE
FUNCTION
Ircproinsulin ( synthesized in RFR ) cleavage

of presignal proinsulin (stored in secretory
granules ) cleavage of proinsulin exocytosis
of insulin and C-pcptidc equally. Insulin and
C'-peptide are t in insulinoma and sulfonylurea
use, whereas exogenous insulin lacks C-peptide.
C peptide
Promsulm
ii
'
p-chan
Released from pancreatic |3 cells.

Binds insulin receptors ( tyrosine kinase
activity ), inducing glucose uptake (carriermediated transport) into insulin-dependent
tissue 0 and gene transcription.
Anabolic effects of insulin:
t glucose transport in skeletal muscle and
adipose tissue
t glycogen synthesis and storage
t triglyceride synthesis
t Na* retention ( kidneys)
t protein synthesis ( muscles)
t cellular uptake of K and amino acids
i glucagon release
t lipolysis in adipose tissue
Unlike glucose, insulin does not cross placenta.
Insulin-dependent glucose transporters:

GLUTdt adipose tissue, striated muscle
( exercise can also increase GLUT-lt
expression)
Insulin-independent transporters:
GL.UT1L RBCs, brain, cornea, placenta
GLL 12jlbidirectional): P islet cells, liver,
kidney, small intestine
Gl.l"1 brain, placenta
"
GLUTEI ( fructose ): spermatocytes, GI tract

Brain utilizes glucose for metabolism normally
and ketone bodies during starvation. RBCs
require much glucose because tiles lack
mitochondria for aerobic metabolisirj
REGULATION
n-
BRICK L, (insulin-independent glucose uptake):

Brain, RBCs, Intestine, Cornea, Kidney,Liver.
Glucose is the major regulator of insulin release, t insulin response w ith oral vs IN glucose because of
incrctins such as elucagon-like peptide 1 ( GLIM ) and glucose-dependent insulinotropic polypeptide
( GIPi which are released after meals and t P cell sensitivity to glucose.
Glucose enters P cells t ATP generated from glucose metabolism closes K+ channels (target
of sulfonylureas 0 and depolarizes P cell membrane O. Voltage-gated Ca-+ channels open
Ca-+ influx Q and stimulation of insulin exocytosis
Insulin
ATP-sensitive
K* channels close
prasphonWnii
voltage -gited
Ca; chan: i -i
i
ATP
|/
'. v
-#
Depolarization
larization
-V
PtKxpborosilide- 3
knase pathway
GLUI 4
Glucose
:
an way
i
t ATP/ADP ratio f Intracellular

Ca
A MV
GLUT -2
Glucose
/Glycolysis
, \
C3 Glucose
Glycogen
protein
lipid, proie
thesis
bo
of insulin
e
vesicles
containing
GLUT 4
Cell growth
DNA
synthesis
Insulin-dependent glucose uptake
Irsu n
Bii i I
vessel
Insulin secretion by pancreatic (J cells
314
SECTION III
ENDOCRINE
ENDOCRINE
PHYSIOLOGY
Prolactin
Structurally homologous to growth hormone.

Excessive amounts of prolactin associated with
1 libido.
SOURCE
Secreted mainly by anterior pituitary.
FUNCTION
Stimulates milk production in breast; inhibits

ovulation in females and spermatogenesis
in males by inhibiting GnRH synthesis and
release.
REGULATION
Prolactin secretion from anterior pituitary

is topically inhibited bv dopamine from
tuberoinfundibular pathway of hypothalamu
Prolactin in turn inhibits its own secretion
by t dopamine synthesis and secretion from
hypothalamus. TRH t prolactin secretion (eg,
in 1 or 2 hypothyroidism).
Dopamine agonists (eg, bromocriptine) inhibit

prolactin secretion and can be used in
treatment of prolactinoma.
Dopamine antagonists (eg, most antipsychoties;
and estrogens (eg, OCPs, pregnancy) stimulat
prolactin secretion.
--
Sight/cry of baby
Higher cortical centers
Hypothalamus
~~
S
Medications
Chest wall injury (via ANSI
Nipple stimulation
T Plasma T3FT4
TRH
Dopamine
Posterior
pituitary
Anterior
pituitary
-0
Estrogen
SV FSH
--
Prolactin
Renal failure
Via reduced
prolactin elimination
iGnRH
S LH
'
<
Milk production
- Pregnancy
Ovulation
Spermatogenesis
ENDOCRINE
SECTION III
315
Growth hormone ( somatotropin )

SOURCE
FUNCTION
REGULATION
Secreted by anterior pituitary.

Stimulates linear growth and muscle mass
through IGF-1 ( somatomedin C) secretion by
liver, t insulin resistance ( diabetogenic).
Released in pulses in response to growth

hormone-releasing hormone (GHRH ).
Secretion t during exercise, deep sleep,
puberty, hypoglycemia. Secretion inhibited by
glucose and somatostatin release via negative
Excess secretion ofGH (eg, pituitary adenoma )

may cause acromegaly ( adults ) or gigantism
(children). Treat with somatostatin analogs (eg,
octreotide) or surgery.
Stimulates hunger (orcxigcnic effect ) and GH

release (via GH seeretagog receptor ). Produced
by stomach. Sleep deprivation or Prader-Willi
syndrome t ghrelin production.
Satiety hormone. Produced by adipose tissue.
Mutation of leptin gene congenital obesity.
Sleep deprivation or starvation i leptin
production.
Act at cannabinoid receptors in hypothalamus
and nucleus accumbens, two key brain areas
for the homeostatic and hedonic control of
food intake t appetite.
Ghrelin makes you hunghre.
feedback by somatomedin.
Appetite regulation
Ghrelin
Leptin
Endocannabinoids
Leptin keeps you thin.
Exogenous cannabinoids cause " the munchics T
Antidiuretic hormone
SOURCE
FUNCTION
REGULATION
Synthesized in hypothalamus ( supraoptic

nuclei i. stored and secreted by posterior
pituitary.
Regulates serum osmolarity ( V 7-receptors)
and blood pressure ( V|-reccptorsl. Primary
function is serum osmolarity regulation (ADH
t serum osmolarity, t urine osmolarity) via
regulation of aquaporin channel insertion in
principal cells of renal collecting duct.
Osmoreceptors in hvpothalamus ( primarvj;
hvpovolemiaj
ADI 1 level is i in central diabetes insipidus ( Dl ),

normal or t in nephrogenic DI.
Nephrogenic Dl can be caused by mutation in
V, receptor.
Desmopressin acetate (ADH analog) is a

treatment for central DI and nocturnal
enuresis.
ENDOCRINE
SECTION III
313
Glucagon
SOURCE
Made by a cells of pancreas.
REGULATION
Secreted in response to hypoglycemia. Inhibited by insulin, hyperglycemia, and somatostatin.
Hypothalamic- pituitary hormones

HORMONE
FUNCTION
CUNICAL NOTES
CRH
t AC'I'H, MSH, P-cndorphin
1 in chronic exogenous steroid use
Dopamine
1 prolactin, TSH
GHRH
t GH
Dopamine antagonists (eg, antipsychotics) can

cause galactorrhea due to hyperprolactinemia
Analog (tesamorelin) used to treat
HIV-associated lipodystrophy
GnRH
t FSH LH
Suppressed by hyperprolactinemia
Tonic GnRH suppresses 1liG axis
Pulsatile GnRH leads to puberty, fertility
Prolactin
l GnRH
Pituitary prolactinoma amenorrhea,

osteoporosis, hy pogonadism, galactorrhea
Somatostatin
t GH, TSH
Analogs used to treat acromegaly
TRH
t TSH, prolactin
t TRH ( eg, in 172: hvDothvroidisml mav

increase prolactin secretion - galactorrhea
ENDOCRINE
SECTION III
315
Growth hormone ( somatotropin )

SOURCE
Secreted by anterior pituitary.
FUNCTION
Stimulates linear growth and muscle mass

through IGF-I (somatomedin C) secretion by
liver, f insulin resistance ( diabetogenic ).
REGULATION
Released in pulses in response to growth

hormone-releasing hormone ( GHRH).
Secretion t during exercise, deep sleep,
puberty, hypoglycemia. Secretion inhibited bv
glucose and somatostatin release via negative
feedback by somatomedin.
Excess secretion of GH (eg, pituitary adenoma 1

may cause acromegaly ( adults) or gigantism
(children). Treat with somatostatin analogs ( eg,
octreotide) or surgery.
Ghrelin
Stimulates hunger (orcxigcnic effect) and GH

release (via GH secretagog receptor ). Produced
by stomach. Sleep deprivation or Prader-Willi
syndrome t ghrelin production.
Ghrelin makes you hunghre.
Leptin
Satiety hormone. Produced by adipose tissue.

Mutation of leptin gene congenital obesity.
Sleep deprivation or starvation -* t leptin
Leptin keeps you thin.
Appetite regulation
Endocannabinoids
production.
Act at cannabinoid receptors in hypothalamus
and nucleus aceumbens, two key brain areas
for the homeostatic and hedonic control of
food intake - t appetite.
Exogenous cannabinoids cause the munchics.l
Antidiuretic hormone
SOURCE
Synthesized in hypothalamus ( supraoptic

nuclei), stored and secreted by posterior
pituitary.
FUNCTION
Regulates serum osmolarity ( VVreceptors)

and blood pressure ( V|-receptors). Primary
function is serum osmolarity regulation ( ADII
1 serum osmolarity, t urine osmolarity) via
regulation ofaquaporin channel insertion in
principal cells of renal collecting duct.
REGULATION
Osmoreceptors in hvpothalamus iprimarvi;
hvpovolemiai
ADI 1 level is 1 in central diabetes insipidus ( Dl ),

normal or t in nephrogenic DI.
Nephrogenic DI can be caused by mutation in
V -receptor.
Desmopressin acetate (ADH analog) is a
treatment for central DI and nocturnal
enuresis
Adrenal steroids and congenital adrenal hyperplasias

ACTH
Ke'oeofwole { blocks several steps in steroidogenesisI
i 1
Cholesterol
Anastrorole. exemeslsne
Cholesterol desmoUtse
Pregnenolone
l n i/ li
17 - hydroxypregnenolone
SJJ- hydroxysteroid
dehydrogenase
Progesterone
17u-hydroxylase
17-hydroxyprogesterone
21-hydroxylase
11-deoxycorticosterone
Aromatasc
Aromatase
Androstenedione
Testosterone
5-reductase
Cortisol
Corticosterone
11
Aldosterone synthase
ll-deoxycortiso(
Dehydroepiandrosterone (DHEA)
Estrone
Estradiol
Dihydrotestosterone
IDHT1
Glycyrrhetic acid
Aldosterone
Cortisone
ZONAGLOMERUIOSA
ZONA FASCICULATA
Glucocorticoids
Finasteride
Angiotensin II
Mineralocorticoids
ZONA RETICULARIS
Androgens
Estrogens DHT
Adrenal cortex
ENZYME DEFICIENCY
8
Q 17u-hydroxylase
MINERALOCORTICOIDS
CORTISOL
SEX
HORMONES
BP
[K+]
LABS
PRESENTATION
i androstenedione
XV: ambiguous
genitalia,
undescended testes
XX: lacks 2 sexual
development
21-hydroxylase
t renin activity
t 17 hvdroxy
progeslerone
0 lip-hydroxylase8
i aldosterone
t 11 deoxycorti
1 renin activity
Most common
Presents in infancy Is;
wasting) or childhoc
i precocious puberty
XX: virilization
XX: virilization
costerone
(results in
t BP)
by an enlargement of both adrenal glands due to t ACTH

All congenital adrenal enzyme deficiencies are characterized
hvpcrpigmentationi
stimulation ( in response to i cortisol i, and skin
ENDOCRINE
SECTION III
317
Cortisol
SOURCE
Adrenal zona fasciculata.
Bound to corticosteroid-binding globulin.
FUNCTION
t Blood pressure:
Cortisol is a BIG FIB.

Exogenous corticosteroids can cause
reactivation of T B and candidiasis ( blocks IL-2
production).
Upregulates ot|-receptors on arterioles

t sensitivity to norepinephrine and
epinephrine |permissive action!

)
At high concentrations, can bind to

mineralocorticoid (aldosterone) receptors
t Insulin resistance (diabetogenic )
t Gluconeogenesis, lipolysis, and proteolysis
I Fibroblast activity ( causes striae)
i Inflammatory and Immune responses:
Inhibits production of leukotrienes and
prostaglandins
Inhibits WBC adhesion - neutrophilia
Blocks histamine release from mast cells
F osinopenia, lvinphopeiiial
Blocks IL-2 production

1 Bone formation (i osteoblast activity)
REGULATION
Calcium homeostasis
CRH ( hypothalamus ) stimulates ACTH release

(pituitary) cortisol production in adrenal
zona fasciculata. Excess cortisol 1 CRH,
ACTH, and cortisol secretion.
Chronic stress induces prolonged secretion.
Plasma Ca-+ exists in three forms:

lonized/free (~ 45%, active formj
Bound to albumin (- 40%)
Bound to anions (- 15%)
t in piI
Vitamin D|
SOURCE
D from exposure of skin to sun, ingestion of

fish and plants. D7 from ingestion of plants,
fungi, yeasts. Both converted to 25-011 in liver
and to l,25-( OH ) vitamin D ( active form) in
i
kidnevj
FUNCTION
,_.
t absorption of dietary Ca~* and P04
Enhances bone mineralization.

REGULATION
t l,25-(OH),
production.
l,25-(OH) j feedback inhibits its own
production.
'>-
t PTH, 1 Ca*,i P04
t affinity of albumin (t negative

charge ) to bind Ca+ hypocalcemia ( cramps,
pain, paresthesias, carpopedal spasm ) . Ionized /
free Cali is 1 regulator of PTH; changes in
pH alter PTII secretion, whereas changes in
albumin do not
Deficiency rickets in kids, osteomalacia in

adults. Caused by malabsorption, i sunlight,
poor diet, chronic kidney failure.
24,25-(OH), D is an inactive form of vitamin D
PPH leads to t Ca -+ rcabsorption and
i PO_ j reabsorption in the kidney, whereas
l,25-(OHl;D leads
_ to t absorption of both
,,
Ca+ and PO+ in the gut.
ENDOCRINE
Calcitonin
SOURCE
Parafollicular cells ( C cells) of thyroid,
FUNCTION
i bone resorption of Ca-*.
REGULATION
t serum Ca-+ -* calcitonin secretion.
Calcitonin opposes actions of PTU. Not

important in normal Ca-+ homeostasis.
Calcitonin tones down Ca-' Calcitonin times
down Ca^ levels and keeps it in boncj
Iodine-containing hormones that control the bodys metabolic rate.
Thyroid hormones
( T3 /T4 )
Follicles of thyroid. Most T formed in target

tissues.
SOURCE
T functions
Bone growth (synergism with GH)

CNS maturation
t P| receptors in heart = t CO, HR, SV,
FUNCTION
contractility
t basal metabolic rate via t Na+/K+-ATPase

activity - t O-, consumption RR, body
temperature
t glycogenols sis, gluconeogenesis, lipolysis
production.
lBs:
TRH ( hypothalamus) stimulatesTSH

( pituitary), which stimulates follicular cells.
May also be stimulated by thyroid-stimulating
immunoglobulin ( TSI ) in Graves disease.
Negative feedback by free T?, Tj to anterior
pituitary i sensitivity to TRIP
Wolff-Chaikoff effect excess iodine
temporarily inhibits thyroid peroxidase
-* t iodine organification I T5/T4
REGULATION
Brain maturation
Bone growth
(l-adrcncrgic effects
Basal metabolic rate t
Thyroxine-binding globulin (TBG) hinds most
T;/Tj in blood; only free hormone is active,
i TBG in hepatic failure, steroids; t TBG in
pregnancy or OCP use (estrogen t TBG ).
Tj is major thyroid product; converted to T in
peripheral tissue by >'-deiodinasc.
T binds nuclear receptor w ith greater affinity
than T4
Thyroid peroxidase is the enzyme responsible
for oxidation and organification of iodide as
well as coupling of monoiodots rosine (MIT)
and di-iodotvrosinc ( Dl l ). 1111' + 1111 = Tg.
DIT + MIT = TV
Propylthiouracil inhibits both thyroid peroxidase
and 5'-dciodinasc. Methimazolc inhibits
thyroid peroxidase only. Glucocorticoids
inhibit peripheral conversion of 1 to IT
'
Hypothalamus
--
Thyroid follicular epithelial cell
Blood
Peripheral tissue
Follicular lumen
TRH
TG
TG
Thyroglobuiin
l V.-
Anterior pituitary \
Q
"
S
Somatostatin
TSH
Downstream thyroid
function
Thyroid
Deiodinase
l
Thyroid follicular ceils
iv
TJ,
J
;+
Effector organs
- Oxidation
on,
Na*
peroxidase
,*
T
T
5 -dciodinasc
TyTj
( to circulation)
Thyroid
peroxidase
MIT. DiT
TSI
Organification
of I
-orr
Tr
TG
Coupling reaction
Thyroid peroxidase
DIT
"
MIT
- DIT
,
.
tndocytosis
Tr
TG
DIT
MIT
MIT
320
SECTION I I I
ENDOCRINE
Signaling pathways of endocrine hormones
cAMP
FSH,UI ACTH, TSH, GRII, I CG, ADI 1

FLAT ChAMP
( Vj receptor), MSH, PTH, calcitonin, GHRH,
glucagon, histamine ( H-,-receptorl
cGMP
BNP, ANP, EDRF (NO)
GnRH, Oxytocin, ADH ( Vprcccptor), TRH,

Histamine ( Hpreceptor) Angiotensin II,
P3
BAD GraMPa
Tliink vasodilators
GOAT HAG
Gastrin
Intracellular receptor
Progesterone, F,strogen, Testosterone, Cortisol,

Vldosterone, IVIp V'itamin D
Receptor tyrosine
kinase
Insulin, ICF-1, FGF, PDGF, EGF
Nonreceptor tyrosine
kinase
Signaling pathway of
steroid hormones
PET CAT on TV
MAP kinase pathway

Think Growth factors
Prolactin, Immunomodulators (eg, cytokines
JAK/STAT pathway
IL-2, IL-6, IKN) GH, G-GSF, Erythropoietin, Think acidophils and cytokine:
PIGGLET
Thrombopoietin
Steroid hormones are lipophilic and therefore

must circulate bound to specific binding
globulins, which t their solubility.
In men, f sex hormone-binding globulin
( SIIBG) lowers free testosterone
- gynecomastia.
In women, 1 SI 1BG raises free testosterone
- hirsutism.
t SI IBG.
OCPs, pregnancy
Cytoplasm
Nucleus
Binding to enhancer l e element In DNA
(WW
H
Transformation of
receptor to expose DNA
binding domain
Bmding to receptor
located in nucleus or
in cytoplasm
H) Hormone
I
^Pre-mRNA
mRNA
mRNA
I
I
I
1
BWBE
ENDOCRINE
ENDOCRINE PATHOLOGY
SECTION III
321
ENDOCRINE PATHOLOGY
Cushing syndrome
ETIOLOGY
FINDINGS
DIAGNOSIS
t cortisol due to a variety of causes:
Exogenous corticosteroids result in i ACTH, bilateral adrenal atrophy. Most common cause.
Primary adrenal adenoma, hyperplasia, or carcinoma result in t ACTH, atrophy of
uninvolved adrenal gland. Can also present with pseudohyperaldosteronism.
ACTH-sccrcting pituitary adenoma (Cushing disease); paraneoplastic ACTH secretion (eg,
small cell lung cancer, bronchial carcinoids) result in t ACTH, bilateral adrenal hyperplasia.
Cushing disease is responsible for the majority of endogenous cases of Cushing syndrome.
Hypertension, weight gain, moon facies Q, abdominal striae Q and truncal obesity, buffalo hump,
skin changes icg. thinning, striadl. osteoporosis, hyperglycemia (insulin resistance), amenorrhea,
immunosuppression.
Screening tests include: t free cortisol on 24-hr urinalysis, t midnight salivary cortisol, and no
suppression with overnight low - dose dexamethasone test. Measure serum ACTH. If I, suspect
adrenal tumor or exogenous glucocorticoids. If t, distinguish between Cushing disease and
ectopic ACTH secretion with a high-dose|dexamethasone suppression test and CRH stimulation
test. Ectopic secretion w ill not decrease with dexamethasone because the source is resistant to
negative feedback: ectopic secretion will not increase with CRH because pituitary ACTH is
suppressed.
Measure ACTH
v
Elevated
Suppressed
1
ACTH - independent
Cushing syndrome
ACTH-dependent
Cushing syndrome
r
or adrenal tumor (consider
MRI to confirm)
High-dose dexamethasone suppression test
CRH stimulation test
L
Adequate
suppression =
Cushing disease
No suppression =
ectopic ACTH
secretion
t ACTH. cortisol =
Cushing disease
1
.
No f ACTH cortisol =
ectopic
ACTH secretion
22
ENDOCRINE
Adrenal insufficiency
ENDOCRINE PATHOLOGY
Inability of adrenal glands to generate enough

glucocorticoids +/ mineralocorticoids for the
body's needs. Symptoms include weakness,
fatigue, orthostatic hypotension, muscle
aches, weight loss, GI disturbances, sugar and/
or salt cravings. Treatment: glucocorticoid/
mineralocorticoid replacement.
Primary adrenal
insufficiency
A
i
V7
s- l
/3
Diagnosis involves measurement of scrum

electrolytes, morning/random serum cortisol
and ACTH ( low cortisol, high ACTI1 in 1
adrenal insufficiency; low cortisol, low ACTH
in 27? adrenal insufficiency due to pituitary/
hypothalamic disease ), and response to ACTH
stimulation test .
Alternatively, can use metyrapone stimulation
test: metyrapone blocks last step of cortisol
synthesis ( ll-deoxycortisol -* cortisol). Normal
response is 1 cortisol and compensatory
t ACTH and 11-deoxycortisol. In 1 adrenal
insufficiency, ACTH is t but ll-deoxycortisol
remains 1 after test. In 273 adrenal
insufficiency, both ACTH and ll-deoxycortisol
remain l after test.
Deficiency of aldosterone and cortisol

Primary Pigments the skin/mucosa.
Associated with autoimmune polyglandular
production due to loss of gland function
- hypotension ( hvponatremie volume
syndromes.
contraction), hyperkalemia, metabolic acidosis, Waterhouse-Friderichsen syndrome acute
lc adrenal insufficiency due to adrenal
skin and mucosal hyperpigmentation Q ( due
to t MSII, a byproduct of ACTH production
hemorrhage associated with septicemia
from proopiomelanocortin [POMC ]).
(usually Neisseria meningitidis ), DIC,
Acute sudden onset (eg, due to massive
endotoxic shock.
hemorrhage). May present with shock in
acute adrenal crisis.
Chronic aka Addison disease. Due to
adrenal atrophy or destruction by disease
(autoimmune destruction most common in
the Western world; TB most common in the
developing world).
Secondary adrenal
insufficiency
Seen with 1 pituitary ACTH production.

No skin/mucosal hyperpigmentation, no
Secondary Spares the skin/mucosa.
hyperkalemia laldosterone synthesis preserved

due to intact RAA axi 4).
Tertiary adrenal
insufficiency
Hyperaldosteronism
Seen in patients with chronic exogenous
Tertiary from Treatment.
steroid use, precipitated by abrupt withdrawal.

Aldosterone synthesis unaffected.
Increased secretion of aldosterone from adrenal gland. Clinical features include hypertension, 1 or
normal K+, metabolic alkalosis. No edema due to aldosterone escape mechanism.
Primary
hyperaldosteronism
Seen with adrenal adenoma (Conn syndrome) or bilateral adrenal hyperplasia! t aldosterone,
1 renin.
Secondary
hyperaldosteronism
Seen in patients w ith renovascular hypertension, juxtaglomerular cell tumor (due to independent
activation of rcnin-angiotensin-aldostcrone system), t aldosterone, t renin. Kdeina mav be seen 2
to causes such as heart failure or cirrhosis.
324
SECTION III
ENDOCRINE
ENDOCRINE PATHOLOGY
Pheochromocytoma
ETIOLOGY
7
SYMPTOMS
Most common tumor of the adrenal medulla in

adults Q. Derived from chromaffin cells (arise
from neural crest).
Up to 25% of cases associated with germline
mutations ( eg, NF I , VHL , RET [MEN 2A
Rule of 10's:
10% malignant
10% bilateral
10% extra-adrenal ( eg bladder wall, organ of
Zuckcrkandl1
10% calcify
10% kids
Most tumors secrete epinephrine,

norepinephrine, and dopamine, which can
cause episodic hypertension.
Symptoms occur in "spells relapse and remit.
Episodic hyperadrenergic symptoms ( 5 Ps):
my
Pressure ( t BP)
Pain ( headache)
Perspiration
Palpitations ( tachycardia)
Pallor
FINDINGS
TREATMENT
t catecholamines and metanephrines in urine
and plasma.
Irreversible a-antagonists (eg,
phenoxybenzamine) followed by (1-blockers
prior to tumor resection, a-blockade must be
achieved before giving [5-blockcrs to avoid a
hypertensive crisis.
Phenoxybenzamine (16 letters) is given for

phcochromocs Ionia (also 16 letters).
ENDOCRINE
ENDOCRINE PATHOLOGY
SECTION III
325
Hypothyroidism vs hyperthyroidism
SKiNS / SYMPTOMS
Hypothyroidism
Hyperthyroidism
Cold intolerance ( t heat production)
Heat intolerance ( t heal production!
Weight gain, t appetite
Weight loss, t appetite
Hvpoactivitv lethargy, fatigue, weakness,
Hyperactivity, anxiety, insomnia, hand tremor
depressed rnooq
Constipation
t reflexes (delayed/slow relaxing)
Hypothyroid myopathy ( proximal muscle
weakness, t CK )
Myxedema ( facial/periorbital )
Iivperdefecationl
t reflexes ( brisk )
Thyrotoxic myopathy ( proximal muscle

weakness, normal CK )
Pretibial myxedema ( Graves disease), periorbital

edema
Dry, cool skin; coarse, brittle hair

Bradycardia, dyspnea on exertion
LAB FINDINGS
Warm, moist skin; fine hair

Chest pain, palpitations, arrhythmias,
t number and sensitivity of |3-adrenergic
arrhvthmias (eg. atrial fibrillation!, receptors
(permissive effect )
t TSH (if 1)
A TSH (if 1)
t free T, and T+
t free or total T, and T
Hypercholesterolemia (due to 1 LDL receptor
Hypocholesterolcmia (due to t LDL receptor

expression)
expression)
Causes of goiter
Smooth/diffuse
Nodular
Graves disease
Hashimoto tliyroiditis
Iodine deficiency
TSH-sccreting pituitary adenoma
'loxic
multinodular goiter
Thyroid adenoma
Thyroid cancer
Thyroid cyst
326
SECTION III
ENDOCRINE PATHOLOGY
ENDOCRINE
Hypothyroidism
Hashimoto thyroiditis
Most common cause of hypothyroidism in iodine-sufficient regions; an autoimmune disorder with

antithyroid peroxidase (antiinicrosomal) and antithyroglobulin antibodies. Associated with HLADR3 and -DR t risk of non-Hodgkin lymphoma (typically of B-cell origin).
May be hvperthyroid early in course due to thyrotoxicosis during follicular rupture.
Histologic findings: Hurthle cells, lymphoid aggregates with germinal centers Q.
Findings: moderately enlarged, nontender thyroid.
Congenital
hypothyroidism
(cretinism)
Severe fetal hypothyroidism due to maternal hypothyroidism, thyroid agenesis, thyroid dysgenesis
(most common cause in US), iodine deficiency, dyshormonogenetic goiter.
Findings: Pot-bellied, Pale, Puffy-faced child with Protruding umbilicus Protuberant tongue, and
Poor brain development: the 6 Ps Q Q.
Subacute
granulomatous
thyroiditis (de
Quervain)
Self-limited disease often following a flu-like illness (eg, viral infection).

May be hyperthyroid early in course, followed by hypothyroidism.
Histology: granulomatous inflammation.
Findings: t ESR, jaw pain, very tender thyroid, (de Quervain is associated with pain.)
Riedel thyroiditis
Thyroid replaced by fibrous tissue with inflammatory infiltrate 0. Fibrosis may extend to local
structures (eg, trachea, esophagus), mimicking anaplastic carcinoma. A are hypothyroid.
Considered a manifestation of IgG -related systemic disease (eg, autoimmune pancreatitis,
^ aortitis).
retroperitoneal fibrosis, noninfectious
(
Findings: fixed, hard rock-like), painless goiter.
Iodine deficiency Q, goitrogens (eg, amiodarone, lithium), Wolff-Chaikoff effect (thyroid gland
downregulation in response to t iodide).
Other causes
m
m mm
&
BC
Before treatment
f t. j
Mm i\
After treatment
mmMX .
- r-V
."
ENDOCRINE PATHOLOGY
ENDOCRINE
SECTION III
329
Diagnosis of
parathyroid disease
l hy perparathyroidism
Ihypi rplasia, adenoma,
carcinoma ) :
2 hyperparathyroidism
( vitamin D deficiency,
chronic re lal failure)
jL. ,
,
Normal
1 hypoparathyroidism
(surgica resection,
autoi nmune)
PT H- independent
ypercalcemi
(excesi Ca2+ intake :ancer )
10
12
14
16
18
Ca2+ (mg /dL)
Hypoparathyroidism
20
0
Due to accidental surgical excision of parathyroid glands, autoimmune destruction, or DiGeorge

syndrome. Findings: tetany, hypocalcemia, hyperphosphatemia.
Chvostek sign tapping of facial nerve (tap the Cheek) contraction of facial muscles.
Trousseau sign occlusion of brachial artery with BP cuff (cuff the Triceps) carpal spasm.
Pseudohypoparathyroidism type 1A (Albright hereditary osteodystrophy) unresponsiveness of
kidney to PTH hypocalcemia despite t PTH levels. Characterized by shortened 4th/ 5th digits,
short stature. Autosomal dominant. Due to defective Gs protein a-subunit causing end-organ
resistance to PTH. Defect must be inherited from mother due to imprinting.
Pseudopseudohypoparathyroidism physical exam features of Albright hereditary
osteodystrophy but without end-organ PTH resistance (PTH level normal j Occurs when
defective G& protein a-subunit is inherited from father.
330
SECTION III
ENDOCRINE
ENDOCRINE
PATHOLOGY
Hyperparathyroidism
Primary
hyperparathyroidism
mI
Secondary
hyperparathyroidism
Usually due to parathyroid adenoma or

hyperplasia . Hypercalcemia , hypercalciuria
(renal stones), hypophosphatemia , t PTH,
t ALP, t cAMP in urine . Most often
asymptomatic. May present with weakness and
constipation ( groans"), abdominal /flank pain
( kidney stones, acute pancreatitis), depression
( psychiatric overtones ).
2 hyperplasia due to i Ca + absorption

and /or t PO 5-, most often in chronic
renal disease^ (causes hvpovitaminosis
D and hyperphosphatemia - I Calzj).
Hypocalcemia , hyperphosphatemia in
chronic renal failure (vs hypophosphatemia
with most other causes), t ALP, t PTH .
Osteitis fibrosa cystica cystic bone spaces

filled with brown fibrous tissue Q ( brown
tumor" consisting of osteoclasts and deposited

hemosiderin from hemorrhages; causes bone
pain ).
Stones, bones, groans, and psychiatric
overtones."
Tertiary
hyperparathyroidism
Familial hypocalciuric
He
hypercalcemia
located
Fact
Renal osteodystrophy renal disease 2 and

3 hyperparathyroidism bone lesions.
Refractory (autonomous) hyperparathyroidism

resulting from chronic renal disease tt PTH ,
t Ca 2+.
,
Defective G-coupled Ca = sensing receptors in multiple tissues (eg, parathyroids, kidneys). Higher
than normal Ca levels required to suppress PTIT . Excessive renal Ca reuptake -* mild
hypercalcemia and hvpocalciuria with normal to t PTH levels.
Pituitary adenoma
Benign tumor, most commonly prolactinoma (arises from lactotrophs). Adenoma Q may be
functional ( hormone producing) or nonfunctional (silent). Nonfunctional tumors present with
mass effect ( bitemporal hemianopia , hypopituitarism , headache). Functional tumor presentation
is based on the hormone produced .
Prolactinoma symptoms: females present with galactorrhea , amenorrhea , and 1 bone density due
to suppression of estrogen . Males present with low libido and infertility. Treatment includes
dopamine agonists (eg, bromocriptine, cabergoline), transsphenoidal resectioij
Nelson syndrome
Enlargement of existing ACTH-secreting pituitary adenoma after bilateral adrenalectomy for

refractory Cushing disease (due to removal of cortisol feedback mechanism ). Presents with
hyperpigmentation, headaches and bitemporal hemianopia . Treatment: pituitary irradiation or
surgical resection .
332
SECTION III
Diabetes insipidus
ETIOLOGY
FINDINGS
WATER DEPRIVATION TEST3
ENDOCRINE
ENDOCRINE
PATHOLOGY
Characterized by intense thirst and polyuria with inability to concentrate urine due to lack of ADH
(central ) or failure of response to circulating ADH (nephrogenic).
Central Dl
Nephrogenic Dl
Pituitary tumor, autoimmune, trauma , surgery,

ischemic encephalopathy, idiopathic
Hereditary (ADH receptor mutation ), 2

to hypercalcemia , hypokalemia , lithium ,
demeclocycline (ADH antagonist)
iADH
Urine specific gravity < 1.006
Serum osmolality > 290 mOsm/kg
Hyperosmotic volume contraction
Normal or t ADH levels

Urine specific gravity < 1.006
Serum osmolality > 290 mOsm /kg
Hyperosmotic volume contraction
> 50% t in urine osmolality only after

administration of ADH analog
Minimal change in urine osmolality, even after

administration of ADH analog
HCTZ, indomethacin , amiloride

Desmopressin acetate
Hydration
Hydration , avoidance of offending agent
aNo water intake for 2-3 hr followed by hourly measurements of urine volume and osmolarity and plasma Na + concentration
and osmolarity. ADH analog (desmopressin acetate) is administered if serum osmolality > 295-300 mOsm /kg, plasma
Na+ > 145, or urine osmolality does not rise despite a rising plasma osmolality.
TREATMENT
Syndrome of
inappropriate
antidiuretic
fiormone secretion
Characterized by:
Excessive free water retention
Euvolemic hyponatremia with continued
urinary Na + excretion
Urine osmolality > serum osmolality
Body responds to water retention with
1 aldosterone and t ANP and BNP
t urinary Na+ secretion -* normalization
of extracellular fluid volume euvolemic
hyponatremia. Very low serum Na+ levels
can lead to cerebral edema , seizures. Correct
slowly to prevent osmotic demyelination
syndrome (formerly known as central pontine
myelinolysis).
J
Causes include:
* Ectopic ADH (eg, small cell lung cancer)
CNS disorders/head trauma
Pulmonary disease
Drugs (eg, cyclophosphamide)
Treatment: fluid restriction, salt tablets, IV
hypertonic saline, diuretics, conivaptan,
5
tolvaptan, demeclocycline.
Increased urine osmolarity during water

deprivation test indicates psychogenic
polydipsia .
336
SECTION III
ENDOCRINE
ENDOCRINE
PATHOLOGY
Hyperosmolar
hyperqlycemid
nonketotic syndrome
State of profound hyperglycemia induced dehydration and t serum osmolalihl classically seen
in elderly type 2 diabetics with limited ability to drink . Hyperglycemia excessive osmotic
diuresis dehydration -* eventual onset of HHNS. Symptoms: thirst , polyuria , lethargy, focal
neurological deficits ( eg, seizures), can progress to coma and death if left untreated . Labs:
hyperglycemia (often > 600 mg /dL ), T serum osmolalihi (> 320 mOsm/kg), no acidosis ( pH >
7.3, ketone production inhibited by presence of insulin ). Treatment: aggressive IV fluids, insulin
therapy.
Glucagonoma
Tumor of pancreatic a cells -* overproduction of glucagon . Presents with dermatitis ( necrolvtic

migratory erythema), diabetes ( hyperglycemia), DVT, declining weight, depression. Treatment:
octreotide, surgery.
Insulinoma
Tumor of pancreatic P cells
Somatostatinoma
Tumor of pancreatic 6 cells
Carcinoid syndrome
mm
Rare syndrome caused by carcinoid tumors

( neuroendocrine cells Q; n le prominent
rosettes [arrow] ), especially metastatic small

bowel tumors, which secrete high levels
of serotonin ( 5-HT). Not seen if tumor is
limited to GI tract ( 5-HT undergoes first-pass
metabolism in liver). Results in recurrent
diarrhea , cutaneous flushing, asthmatic
wheezing, right-sided valvular heart disease
( tricuspid regurgitation , pulmonic stenosis) .
t 5-hydroxyindoleacetic acid ( 5-HIAA) in
urine, niacin deficiency ( pellagra ).
Treatment: surgical resection, somatostatin
analog (eg, octreotide).
Zollinger- Ellison
syndrome
Gastrin-secreting tumor ( gastrinoma ) of pancreas or duodenum . Acid hypersecretion causes

recurrent ulcers in duodenum and jejunum . Presents with abdominal pain ( peptic ulcer disease,
distal ulcers), diarrhea (malabsorption ). Positive secretin stimulation test: gastrin levels remain
elevated after administration of secretin , which normally inhibits gastrin release. May be
associated with MEN 1 .
overproduction of insulin hypoglycemia. May see Whipple triad:

low blood glucose, symptoms of hypoglycemia (eg, lethargy, syncope, diplopia ), and resolution of
symptoms after normalization of glucose levels. Symptomatic patients have i blood glucose and
t C -peptide levels (vs exogenous insulin use). ~ 10% of cases associated with MEN 1 syndrome .
Treatment: surgical resection.
overproduction of somatostatin 1 secretion of secretin ,

cholecvstokinin , glucagon , insulin, gastrin , gastric inhibitory peptide ( GIPl May present with
diabetes/glucose intolerance, steatorrhea , gallstones, achlorhvdrial Treatment: surgical resection;
somatostatin analogs (eg, octreotide) for symptom control .
Rule of l /3s:
1/ 3 metastasize
1/ 3 present with 2 nd malignancy
1 / 3 are multiple
Most common malignancy in the small
intestine.
338
SECTION III
ENDOCRINE
ENDOCRINE PHARMACOLOGY
Diabetes mellitus
drugs
Treatment strategies:
Type 1 DM low-carbohydrate diet, insulin replacement
Type 2 DM dietary modification and exercise for weight loss; oral agents, non-insulin injectables,
insulin replacement
Gestational DM (GDM) dietary modifications, exercise, insulin replacement if lifestyle
modification fails
CLINICAL USE
ACTION
RISKS/CONCERNS
Insulin, rapid acting

Lispro,
Aspart,
Glulisine
Type 1 DM, type 2 DM,

GDM (postprandial glucose
control).
Binds insulin receptor (tyrosine

kinase activity) rapidly, no
LAG.
Liver: t glucose stored as
glycogen.
Muscle: t glycogen, protein
synthesis; t Ki uptake.
Fat: t TG storage.
Hypoglycemia, lipodystrophy,
rare hypersensitivity reactions.
Insulin, short acting

Regular

GDM, DKA (IV),
hyperkalemia (+ glucose),
Inhibits hepatic
gluconeogenesis and
the action of glucagon.
1 gluconeogenesis,
t glycolysis, t peripheral
glucose uptake ( t insulin
GI upset; most serious adverse

effect is lactic acidosis (thus
contraindicated in renal
insufficiency).
DRUG CLASSES
Insulin preparations
stress hyperglycemia.
Insulin, intermediate
acting

GDM.
NPH
Insulin, long acting
Detemir,
glargine
Type 1 DM, type 2 DM, GDM

( basal glucose control).
Oral hypoglycemic drugs

Biguanides
Metformin
Oral. First-line therapy in type

2 DM, causes modest weight
loss.
Can be used in patients
without islet function.
Sulfonylureas
First generation:
Stimulate release of
endogenous insulin in
type 2 DM. Require some
islet function, so useless in
chlorpropamide,
tolbutamide
Second generation:
glimepiride,
glipizide,
glyburide
Glitazones/
thiazolidinediones
Pioglitazone,
rosiglitazone
typeJi JDM.
Used as monotherapy in
typeJ2JDM or combined with
above agents. Safe to use in
renal impairment.
sensitivity).
Close IC channel in 3-cell
Risk of hypoglycemia t in renal
membrane cell depolarizes
failure, weight gain.
-* insulin release via t Ca
First generation: disulfiram-like
influx.
effects.
Second generation:
hypoglycemia.
insulin sensitivity in
peripheral tissue. Binds to
PPAR-Y nuclear transcription
regulator.-
Weight gain, edema.

Weight gain, edema, HH t risk
of fractures.
ENDOCRINE
SECTION III
339
Diabetes mellitus drugs (continued )

DRUG CLASSES
CLINICAL USE
ACTION
RISKS /CONCERNS
Stimulate postprandial
insulin release by binding
to Kt channels on (3 -cell
membranes (site differs from
sulfonvlureas).
Hypoglycemia ( t risk with

renal failure), weight gain.
t glucose- dependent insulin
Nausea, vomiting, pancreatitis;

modest weight loss.
Oral hypoglycemic drugs (continued)

Meglitinides
Nateglinide,
repaglinide
Used as monotherapy in
type 2 DM or combined with
GLP- 1 analogs
Type 2 DM.
metformin.
release, 1 glucagon release.
Exenatide,
liraglutide (sc injection)
DPP- 4 inhibitors
1 gastric emptying, t satiety.
Type 2 DM.
Linagliptin,
saxagliptin,
sitagliptin
Inhibits DPP-4 enzyme that

deactivates GLP-1, thereby
Mild urinary or respiratory

infections; weight neutral.
t glucose-dependent insulin
release, 1 glucagon release,
1 gastric emptying, t satiety.
Amylin analogs
Pramlintide
(sc injection)
Type 1 DM, type 2 DM.
1 gastric emptying, 1 glucagon.
Hypoglycemia (in setting of

mistimed prandial insulin),
Sodium- glucose
co -transporter 2
( SGLT 3D inhibitors
Canagliflozin,
dapagliflozin,
empagliflozin
Type 2 DM.
Block reabsorption of glucose

in PCT.
Glucosuria, UTIs, vaginal yeast

infections, hyperkalemia,
dehydration (orthostatic
a- glucosidase
inhibitors
Acarbose,
miglitol
Type 2 DM.
nausea.
hypotension ), weight los 4
Inhibit intestinal brush-border
GI disturbances.
a-glucosidases.
Delayed carbohydrate
hydrolysis and glucose
absorption -* 1 postprandial
hyperglycemia.
aGenes activated by PPAR-y regulate fatty acid storage and glucose metabolism. Activation of PPAR-y t insulin sensitivity and
levels of adiponectin.
Thionamides
MECHANISM
CLINICAL USE
Propylthiouracil (PTU), methimazole.

Block thyroid peroxidase, inhibiting the oxidation of iodide and the organification and coupling
of iodine inhibition of thyroid hormone synthesis. Propylthiouracil also blocks 5'-deiodinase
-* i peripheral conversion of
to T$.
Hyperthyroidism. PTU blocks Peripheral conversion PTU used in first trimester of pregnancy ( due
to methimazole teratogenicity); methimazole used in second and third trimesters of pregnancy
( due to risk of PTU-induced hepatotoxicityt

ADVERSE EFFECTS
Skin rash, agranulocytosis (rare), aplastic anemia, hepatotoxicity.

Methimazole is a possible teratogen (can cause aplasia cutis).
340
SECTION III
ENDOCRINE
Levothyroxine (T4), triiodothyronine (T3 )

MECHANISM
Thyroid hormone replacement.
CLINICAL USE
Hypothyroidism, myxedema. Used off-label as weight loss supplements.
ADVERSE EFFECTS
Tachycardia, heat intolerance, tremors, arrhythmias.
Hypothalamic / pituitary drugs

DRUG
CLINICAL USE
ADH antagonists
(conivaptan,
tolvaptan)
SIADH, block action of ADH at V 7-receptor.
Desmopressin acetate
Central (not nephrogenic) DI, von Willebrand diseaseT sleep enuresi4
GH
GH deficiency, Turner syndrome.
Oxytocin
Stimulates labor, uterine contractions, milk let-down; controls uterine hemorrhage.
Somatostatin
Acromegaly, carcinoid syndrome, gastrinoma, glucagonoma, esophageal varices.
(octreotide)
Demeclocycline
MECHANISM
ADH antagonist (member of tetracycline family).
CLINICAL USE
SIADH.
ADVERSE EFFECTS
Nephrogenic DI, photosensitivity, abnormalities of bone and teeth.
Fludrocortisone
MECHANISM
Synthetic analog of aldosterone with little glucocorticoid effects.
CLINICAL USE
Mineralocorticoid replacement in 1 adrenal insufficiency.
ADVERSE EFFECTS
Similar to glucocorticoids; also edema, exacerbation of heart failure, hyperpigmentation.
Cinacalcet
MECHANISM
Sensitizes Ca-+-sensing receptor (CaSR) in parathyroid gland to circulating Ca 2+
CLINICAL USE
1 or 2 hyperparathyroidism.
ADVERSE EFFECTS
Hypocalcemia.
1 PTH.
HIGH- YI E LD SYSTEMS
Gastrointestinal
good set of bowels is worth more to a man than any quantity of brains
Man
Embryology
342
Anatomy
343
Physiology
354
Pathology
357
Pharmacology
379
josh Billings
should strive to have his intestines relaxed all the days of his life
Moses Maimonides
Is life worth living? It all depends on the liver
William James
341
342
SECTION III
GASTROINTESTINAL
GASTROINTESTINAL EMBRYOLOGY
GASTROINTESTINAL EMBRYOLOGY
Normal
gastrointestinal
embryology
Foregut esophagus to upper duodenum

Midgut lower duodenum!to proximal 1h of transverse colon.
Hindgut distal /? of transverse colon to anal canal above pectinate line.
'
Midgut development:
" 6th week physiologic midgut herniates through umbilical ring
10 th week returns to abdominal cavity + rotates around superior mesenteric artery (SMA),
total 270 counterclockw ise
1
Ventral wall defects
Developmental defects due to failure of:

Rostral fold closure sternal defects
Lateral fold closure omphalocele,
Gastroschisis extrusion of abdominal

contents through abdominal folds (typically
right of umbilicus); not covered by peritoneum
gastroschisis
Caudal fold closure bladder exstrophy
or amnioij
Omphalocele |ierniation of abdominal

contents into umbilical cord, sealed by
peritoneum Q.
Congenital umbilical hernia
form of
incomplete closure of umbilical ring. Manyclose spontaneously.
Tracheoesophageal
anomalies
Esophageal atresia (EA) with distal tracheoesophageal fistula (TEF) is the most common (85%).
Polyhydramnios in utero. Neonates drool, choke, and vomit with first feeding. TEF allows air to
enter stomach (visible on CXR). Cyanosis is 2 to laryngospasm (to avoid reflux-related aspiration).
Clinical test: failure to pass nasogastric tube into stomach.
In Il-type, the fistula resembles the letter H. In pure EA the CXR shows gasless abdomen .
Esophagus
Tracheoesophageal
fistula
Trachea
1
S
V Esophageal
&
1
Normal anatomy
Pure EA
( atresia or stenosis)
Intestinal atresia
Pure TEF
(H- type)
atresia
EA with distal TEF

(most common)
E)
Presents w ith bilious vomiting and abdominal distension within first 1-2 days of life.
Duodenal atresia failure to recanalize dilation of stomach and proximal duodenum ( double
bubble on x-ray O). Associated with Down syndrome.
Jejunal and ileal atresia disruption of mesenteric vessels ischemic necrosis segmental
resorption (bowel discontinuity or apple peel ). lejunal atresia commonly associated with triple
bubble" sign on x-rav.
GASTROINTESTINAL ANATOMY
GASTROINTESTINAL
SECTION III
343
Hypertrophic pyloric
stenosis
Most common cause of gastric outlet obstruction in infants ( 1:600). Palpable olive mass in
epigastric region, visible peristaltic waves!and nonbilious projectile vomiting at ~ 2-6 weeks old.
More common in firstborn males; associated with exposure to macrolides. Results in hypokalemic
hypochloremic metabolic alkalosis ( 2 to vomiting of gastric acid and subsequent volume
contraction). Treatment is surgical incision ( pyloromyotomy).
Pancreas and spleen
Pancreas derived from foregut. Ventral pancreatic buds contribute to uncinate process and main
pancreatic duct. The dorsal pancreatic bud alone becomes the body, tail, isthmus, and accessory
pancreatic duct. Both the ventral and dorsal buds contribute to pancreatic head.
Annular pancreas ventral pancreatic bud abnormally encircles 2nd part of duodenum; forms a
ring of pancreatic tissue that may cause duodenal narrowing Q and Vomiting.
Pancreas divisum ventral and dorsal parts fail to fuse at 8 weeks. Common anomaly; mostly
asymptomatic, but may cause chronic abdominal pain and/or pancreatitis.
Spleen arises in mesentery of stomach (hence is mesodermal) but has foregut supply (celiac trunk
splenic artery).
embryology
Gallbladder
Accessory
pancreatic duct
Pancreat c
duct
Minoi
oapilla
Dorsal
pancreatic
bud
Major papilla
Ventral
pancreatic bud
Uncinate
Main
pancreatic
duct
process
Retroperitoneal structures include GI structures

that lack a mesentery and non-GI structures.
Injuries to retroperitoneal structures can cause
blood or gas accumulation in retroperitoneal
Retroperitoneal
structures
space.
Right
'
Ascending
colon
Av\
Duodenum
Kidneys
Esophagus (thoracic portion) [not shown]
Rectum ( partially) [not shown]
Peritoneum
Pancreas
^ MML .
Transversalis fascia
Left
Descending
renal
space
Kidney
Aorta
SAD PUCKER:
Suprarenal (adrenal) glands [not shown]
Aorta and IVC
Duodenum (2nd through 4th parts)
Pancreas (except tail)
Ureters [not shown]
Colon (descending and ascending)
GASTROINTESTINAL
Digestive tract
anatomy
SECTION III
345
Layers of gut wall (inside to outside MSMS):

Mucosa epithelium, lamina propria, muscularis mucosa
Submucosa includes Submucosal nerve plexus (Meissner), Secretes fluid
Muscularis externa includes Myenteric nerve plexus ( Auerbach), Motility
Serosa ( when intraperitoneal), adventitia (when retroperitoneal)
Ulcers can extend into submucosa, inner or outer muscular layer. Erosions are in the mucosa only.
Frequencies of basal electric rhythm ( slow waves):
Stomach 3 waves /min
* Duodenum 12 waves/min
11eum 8-9 waves/min
ri
Tunica muscularis
Mucosa
- pithelium
Lamina propria
Muscularis mucosa
externa
Tunica submucosa
Mesentery
Intestinal villi
m
-
submucosal
Vein
Artery
Submucosa
Lymph vessel
Epithelium
Lumen
Muscularis mucosa
>v Yv
' >
Myenteric nerve plexus

(Auerbach)
Iperitoneuml
Submucosal nerve
plexus (Meissner)
Muscularis
Inner circular layer
Myenteric nerve plexus
(Auerbach)
- Tunica serosa
Enlarged view
cross-section
Submucosal gland
Outer longitudinal layer

Serosa
Digestive tract histology
Esophagus
Nonkeratinized stratified squamous epithelium.
Stomach
Gastric glands.
Duodenum
Villi and microvilli t absorptive surface.

Brunner glands (HC02--secreting cells of submucosa) and crvpts of Lieberkuhn (contain stem cells
that replace enterocytes/goblet cells and Paneth cells that secrete defensins, lysozyme, and TNFl
Jejunum
Plicae circulares and crypts of Lieberkuhn.
Ileum
patches (lymphoid aggregates in lamina propria, submucosa), plicae circulares (proximal

ileum), and crypts of Lieberkuhn.
Largest number of goblet cells in the small intestine.
Crypts of Lieberkuhn but no villi; abundant goblet cells.
Colon
Peyer
GASTROINTESTINAL
Celiac trunk
Left gastric artery
Esophageal branch of
left gastric artery .
Short gastric arteries
Celiac artery
Proper hepatic
artery
Right gastric artery Common

hepatic artery
Gastroduodenal
Spleen
artery
Left gastroepiploic
artery
Splenic artery
Right gastroepiploic artery
-Posterior superior
Anterior superior
pancreaticoduodenal
arteries
pancreaticoduodenal artery
SECTION III
Branches of celiac trunk: common hepatic,

splenic, and left gastric. These constitute the
main blood supply of the stomach.
Strong anastomoses exist between:
Left and right gastroepiploics
Left and right gastrics
Posterior duodenal ulcers penetrate
gastroduodenal artery causing hemorrhage .
347
GASTROINTESTINAL
Pectinate ( dentate )
line
lemormoKK
J
r
S II
if
5
.
==
as
'amj$
External
Pect irate
lemorrhoid
line
ANATOMY
SECTION III
349
Formed where endoderm ( hindgut) meets ectoderm .
internal hemorrhoids,
adenocarcinoma .
Arterial supply from superior rectal artery
( branch of IMA) .
Venous drainage: superior rectal vein inferior
Above pectinate line
Internal
GASTROINTESTINAL
mesenteric vein
system!

splenic vein
Internal hemorrhoids receive visceral

innervation and are therefore not painful .
Lymphatic drainage to internal iliac lymph
nodes.
portal
External hemorrhoids receive somatic

Below pectinate line external hemorrhoids,
innervation (inferior rectal branch of pudendal
anal fissures, squamous cell carcinoma .
Arterial supply from inferior rectal artery ( branch nerve) and are therefore painful if thrombosed .
Lymphatic drainage to superficial inguinal nodes.
of internal pudendal artery).
Venous drainage: inferior rectal vein internal

Anal fissure tear in the anal mucosa below the
pudendal vein internal iliac vein -* common Pectinate line. Pain while Pooping; blood on
iliac vein * IVC.
toilet Paper. Located Posteriorly because this
area is Poorly Perfused . Associated with lowfiber diets and constipation .
GASTROINTESTINAL
Biliary structures
SECTION III
351
Gallstones ( filling defects, red arrows in Q) that reach the confluence of the common bile and
pancreatic ducts at the ampulla of Vater can block both the common bile and pancreatic ducts
(double duct sign), causing both cholangitis and pancreatitis, respectively.
Tumors that arise in head of pancreas (usually ductal adenocarcinoma) can cause obstruction of
enlarged gallbladder with painless jaundice (Courvoisier sign!
common bile duct
Cystic duct
Liver
Gallbladder
^
1
Common hepatic duct
Common bile duct
0
Accessory
Ned
Ron
pancreatic duct
Pancreas
Head
Sphincter of Oddi
Ampulla of Vater Main pancreatic duct

Duodenum
Femoral region
Lateral to medial: Nerve-Artery-VeinLymphatics.
You go from lateral to medial to find your

N AVeL.
Femoral triangle
Contains femoral nerve, artery, vein.
Venous near the penis.
Femoral sheath
Fascial tube 3-4 cm below inguinal ligament.

Contains femoral vein, artery, and canal (deep
inguinal lymph nodes) but not femoral nerve.
ORGANIZATION
'
Femoral Nerve
Inguinal
ligament
Femoral Artery
Sartorius
.ymphatics
Femoral Vein
muscle
Femoral ring-site of
femoral hernia
Revised
Figure
Femoral
sheath
Adductor longus
muscle
GASTROINTESTINAL
SECTION III
353
A protrusion of peritoneum through an opening, usually at a site of weakness. Contents may be at

risk for incarceration (not reducible back into abdomen/pelvis) and strangulation (ischemia and
necrosis). Complicated hernias can present with tenderness, erythema, fever.
Hernias
Diaphragmatic hernia
Indirect inguinal
hernia
Abdominal structures enter the thorax;

may occur due to congenital defect of
pleuroperitoneal membrane Q, or as a result
of trauma. Commonly occurs on left side due
to relative protection of right hemidiaphragm
by liver.
Most commonly a hiatal hernia, in which
stomach herniates upward through the
esophageal hiatus of the diaphragm.
Goes through the internal (deep) inguinal ring,
external (superficial) inguinal ring, and into
the scrotum. Enters internal inguinal ring
lateral to inferior epigastric vessels. Occurs in
infants owing to failure of processus vaginalis
to close (can form hydrocele). Much more
common in males Q.
Sliding hiatal hernia is most common.

Gastroesophageal junction is displaced
upward; hourglass stomach.
Paraesophageal hernia gastroesophageal
junction is usually normal. Fundus protrudes
into the thorax.
An indirect inguinal hernia follows the path of

descent of the testes. Covered by all 3 layers of
spermatic fascia.
Direct inguinal hernia
Protrudes through the inguinal ( Hesselbach)

MDs dont Lie:
Medial to inferior epigastric vessels = Direct
triangle. Bulges directly through abdominal
wall medial to inferior epigastric vessels. Goes
hernia.
Lateral to inferior epigastric vessels = Indirect
through the external (superficial) inguinal ring
hernia.
only. Covered by external spermatic fascia.
Usually in older men.
Femoral hernia
Protrudes below inguinal ligament through

femoral canal below and lateral to pubic
tubercle. More common in females, but
overall inguinal hernias are the most common.
Inguinal
(Poupart)
ligament.
Indirect
inguinal hernia
Femoral artery
.m
Rectus abdominis muscle
Inferior
epigastric vessels
Direct inguinal hernia
Inguinal ( Hesselbach) triangle

X
More likely to present with incarceration or

strangulation than inguinal hernias.
Femoral hernia
Femoral vein
Inguinal ( Hesselbach) triangle:

* Inferior epigastric vessels
Lateral border of rectus abdominis
Inguinal ligament
356
SECTION III
Pancreatic secretions
GASTROINTESTINAL
Isotonic fluid; low flow

ROLE
ENZYME
GASTROINTESTINAL PHYSIOLOGY
high Cl , high flow
high HCO -.
NOTES
Secreted in active form
a- amylase
Starch digestion
Lipases
Fat digestion
Proteases
Protein digestion
Trypsinogen
Converted to active enzyme trypsin

Converted to trypsin by enterokinase/
-* activation of other proenzymes and cleaving enteropeptidase, a brush-border enzyme on
duodenal and jejunal mucosa
of additional trypsinogen molecules into active
trypsin ( positive feedback loop)
Includes trypsin, chymotrvpsin, elastase,

carboxypeptidases
Secreted as proenzymes also known as
zymogens
Only monosaccharides ( glucose, galactose, fructose) are absorbed by enterocytes. Glucose and
galactose are taken up by SGLT1 (Na+ dependent). Fructose is taken up by facilitated diffusion by
GLUT-5. All are transported to blood by GLUT-2.
D-xylose absorption test: distinguishes GI mucosal damage from other causes of malabsorption.
Carbohydrate
absorption
Vitamin/mineral absorption
Iron
Absorbed as Fe-+ in duodenum.
Folate
Absorbed in small bowel.
b2
Absorbed in terminal ileum along with bile

salts, requires intrinsic factor.
Unencapsulated lymphoid tissue Q found in
Peyer patches
Wm
m
A&lMf
Bile
lamina propria and submucosa of ileum.

Contain specialized M cells that sample and
present antigens to immune cells.
B cells stimulated in germinal centers of Peyer
patches differentiate into IgA-secreting plasma
cells, which ultimately reside in lamina
propria. IgA receives protective secretory
component and is then transported across the
epithelium to the gut to deal with intraluminal
antigen.
Iron Fist, Bro

Clinically relevant in patients with small bowel
disease or after resection.
Think of IgA, the Intra-gut Antibody. And

always say secretory IgA.
Composed of bile salts (bile acids conjugated to glycine or taurine, making them water soluble),
phospholipids, cholesterol, bilirubin, water, and ions. Cholesterol 7a-hydroxylase catalyzes
rate-limiting step of bile acid synthesis.
Functions:
Digestion and absorption of lipids and fat-soluble vitamins

Cholesterol excretion ( bodvs primary means of eliminating cholesterol)
Antimicrobial activity (via membrane disruption)
GASTROINTESTINAL
GASTROINTESTINAL PATHOLOGY
SECTION III
357
Heme is metabolized by heme oxygenase to biliverdin, which is subsequently reduced to bilirubin.

Unconjugated bilirubin is removed from blood by liver, conjugated with glucuronate, and excreted
in bile.
Direct bilirubin conjugated with glucuronic acid; water soluble.
Indirect bilirubin unconjugated; water insoluble.
Bilirubin
Excreted in urine as
urobilin ( yellow color)
Kidney
90
mterohepatic
20%
Macrophages
Bloodstream
Gut
Liver
Albumin
RBCs
Heme
Unconjugated
bilirubin
Unconjugated bilirubinalbumin complex
JDP -
Conjugated
bilirubin
glucuronosyltransferase
Indirect bilirubin
( water insoluble)
Urobilinogen
'
Direct bilirubin
[ water soluble )
i'
bat ana
80 %
Excreted in feces as
stercobilin ( brown
color of stool)
Salivary gland tumors
wmm
mm g
-
Most commonly benign and in parotid gland. Tumors in smaller glands more likely malignant.
Typically present as painless mass/swelling. Facial pain or paralysis suggests malignant
involvement of CN VII.
Pleomorphic adenoma ( benign mixed tumor) most common salivary gland tumor Q.
Composed of chondromyxoid stroma and epithelium and recurs if incompletely excised or
ruptured intraoperativelv.
Mucoepidermoid carcinoma most common malignant tumor, has mucinous and squamous
components.
Warthin tumor (papillary cystadenoma lymphomatosum) benign cystic tumor with germinal
centers . Typically found in white smokers . Bilateral in 10%; malignant in 107c .
360
SECTION III
Gastritis
Acute gastritis
GASTROINTESTINAL
GASTROINTESTINAL
Erosions can be caused by:

NSAIDs i PGE -, i gastric mucosa
protection
Burns (Curling ulcer ) hypovolemia
-* mucosal ischemia
Brain injury (Cushing ulcer) t vagal
stimulation t ACh t H + production
Chronic gastritis
H pylori
Mucosal inflammation, often leading to atrophy

( hypochlorhydria hvpergastrinemia ) and
intestinal G -cell metaplasia ( t risk of gastric
cancers).
Most common t risk of peptic ulcer disease,
MALT lymphoma.
Autoantibodies to parietal cells and intrinsic
factor, t risk of pernicious anemia .
,
Autoimmune
Menetrier disease
PATHOLOGY
Especially common among alcoholics and

patients taking daily NSAIDs (eg, patients with
rheumatoid arthritis).
Burned by the Curling iron .
Always Cushion the brain .
Affects antrum first and spreads to body of

stomach .
Affects body/fundus of stomach.
Gastric hyperplasia of mucosa hypertrophied rugae ( looking like brain gyri Cl), excess
mucus production with resultant protein loss and parietal cell atrophy with I acid production .
Precancerous.
A
Gastric cancer
L <$
wr
i t f.
Virchow node involvement of left

Most commonly gastric adenocarcinoma ;
lymphoma , GI stromal tumor, carcinoid ( rare).
supraclavicular node by metastasis from
stomach .
Early aggressive local spread with node/liver
Krukenberg tumor bilateral metastases to
metastases. Often presents late, with weight
loss, early satiety, and in some cases acanthosis
ovaries. Abundant mucin-secreting, signet ring
cells.
nigricans or Leser-Trelat sign .
Intestinal associated with H pylori, dietary Sister Mary Joseph nodule subcutaneous
nitrosamines (smoked foods ), tobacco
periumbilical metastasis.
smoking, achlorhydria , chronic gastritis.
Commonly on lesser curvature; looks like
ulcer with raised margins.
Diffuse not associated with H pylori ; signet
ring cells ( mucin-filled cells with peripheral
nuclei) Q; stomach wall grossly thickened
and leathery ( linitis plastica ).
GASTROINTESTINAL
SECTION III
363
Inflammatory bowel diseases
Crohn disease
Ulcerative colitis
LOCATION
Any portion of the GI tract, usually the terminal

ileum and colon. Skip lesions, rectal sparing.
GROSS MORPHOLOGY
Transmural inflammation -* fistulas.

Cobblestone mucosa, creeping fat, bowel wall
thickening ( string sign on barium swallow
x-ray Q), linear ulcers, fissures.
MICROSCOPIC MORPHOLOGY
Noncaseating granulomas and lymphoid
Colitis = colon inflammation. Continuous

colonic lesions, always with rectal involvement.
Mucosal and submucosal inflammation only.
Friable mucosal pseudopolyps (compare
normal Q with diseased Q) w ith freely
hanging mesentery. Loss of haustra lead
pipe appearance on imaging.
Crypt abscesses and ulcers, bleeding, no
granulomas.
Malabsorption /malnutrition , colorectal cancer
( t risk with pancolitis).
Fulminant colitis, toxic megacolon , perforation .
COMPLICATIONS
INTESTINAL MANIFESTATION
EXTRAINTESTINAL MANIFESTATIONS
aggregates.
Malabsorption /malnutrition, colorectal cancer
( t risk with pancolitis).
Fistulas (eg, enterovesical fistulae, which can
cause recurrent UTI and pneumaturia ),
phlegmon /abscess, strictures (causing
obstruction ), perianal disease.
Diarrhea that may or may not be bloody.
Bloody diarrhea.
Rash ( pyoderma gangrenosum , erythema nodosum ), eye inflammation (episcleritis, uveitis), oral
ulcerations (aphthous stomatitis), arthritis ( peripheral, spondylitis).
1 sclerosing cholangitis. Associated with

p-ANCA.
Kidney stones (usually calcium oxalate),

gallstones. Mav be <> for anti-Saccharomyces
cervisiae antibodies (ASCA ) .
TREATMENT
5-aminosalicylic preparations (eg, mesalamine),

6-mercaptopurine, infliximab, colectomy.
Corticosteroids, azathioprine, antibiotics (eg,

ciprofloxacin , metronidazole), infliximab,
adalimumab.
For Crohn , think of a fat granny and an old
crone skipping down a cobblestone road away
from the wreck ( rectal sparing ).
Ulcerative colitis causes ULCCCERS:

Ulcers
Large intestine
Continuous, Colorectal carcinoma, Crypt
abscesses
Extends proximally
Red diarrhea
Sclerosing cholangitis
<
2,-
GASTROINTESTINAL
Pharyngoesophageal false diverticulum Q.

Esophageal dysmotility causes herniation of
mucosal tissue at Killian triangle between the
thyropharvngeal and cricopharyngeal parts of
the inferior pharyngeal constrictor. Presenting
symptoms: dysphagia , obstruction , gurgling,
Zenker diverticulum
aspiration, foul breath, neck mass. Most

common in elderly males.
SECTION III
365
Elder MIKE has bad breath .
Elderly
Males
Inferior pharyngeal constrictor
Killian triangle
Esophageal dysmotility
Halitosis
True diverticulum. Persistence of the vitelline

The rule oil 2 s:
2 times as likely in males.
duct . May contain ectopic acid-secreting
2 inches long.
gastric mucosa and/or pancreatic tissue. Most
common congenital anomaly of GI tract . Can
2 feet from the ileocecal valve.
cause hematochezia/melena ( less commonly!
2% of population .
Commonly presents in first 2 years of life.
RLQ pain, intussusception , volvulus, or
obstruction near terminal ileum . Contrast with
May have 2 types of epithelia ( gastric/
omphalomesenteric cyst = cystic dilation of
pancreatic).
vitelline duct .
Diagnosis: pertechnetate study for uptake by
ectopic gastric mucosa.
Meckel diverticulum
Umbilicus
t?
Meckel diverticulum
p.isk t with Down syndrome.

Congenital megacolon characterized by lack
Diagnosed hv rectal suction biopsy, which shows
of ganglion cells/enteric nervous plexuses
( Auerbach and Meissner plexuses) in distal
absence of ganglionic cell4
segment of colon. Due to failure of neural crest Treatment: resection .
Hirschsprung disease
cell migration . Associated with mutations in

RET.
Presents with bilious emesis, abdominal
distention , and failure to pass meconium
within 48 hours -* chronic constipation .
Normal portion of the colon proximal to the
aganglionic segment is dilated, resulting in a
transition zone.
Anomaly of midgut rotation during fetal development improper positioning of bowel , formation
of fibrous bands ( Ladd bands). Can lead to volvulus, duodenal obstruction.
Malrotation
L v ei
Ladd
rands
Small
Large
intestine
366
SECTION III
Volvulus
GASTROINTESTINAL
GASTROINTESTINAL
PATHOLOGY
Twisting of portion of bowel around its

mesentery; can lead to obstruction and
infarction Q 0. Can occur throughout the
GI tract. Midgut volvulus more common in
infants and children . Sigmoid volvulus more
common in elderly.
I New 1
llmagel
Intussusception
fl
Telescoping Q of proximal bowel segment into

distal segment, commonly at ileocecal junction .
Compromised blood supply intermittent
abdominal pain often with currant jelly stools.
Unusual in adults (associated with intraluminal
mass or tumor that acts as lead point that
is pulled into the lumen). Majority of cases
occur in children ( usually idiopathic; may be
associated with recent viral infection , such as
adenovirus -* Pever patch hypertrophy -* lead
point also associated with rotavirus vaccin ;
most common pathologic lead point is Meckel
diverticulum ). Abdominal emergency in early
childhood, with bulls-eye appearance on
ultrasound.
::
>
cfflMfiSl
GASTROINTESTINAL
SECTION III
367
Other intestinal disorders
Acute mesenteric
ischemia
Critical blockage of intestinal blood flow (often embolic occlusion of SMA) -* small bowel necrosis
-* abdominal pain out of proportion to physical findings. May see red currant jelly stools.
Chronic mesenteric
Intestinal angina: atherosclerosis of celiac artery, SMA, or IMA -* intestinal hypoperfusion

postprandial epigastric pain food aversion and weight loss.
ischemia
Colonic ischemia
Reduction in intestinal blood flow causes ischemia. Crampv abdominal pain followed by
hematochezia. Commonly occurs at watershed areas (splenic flexure, distal colon). Typically
Angiodysplasia
Tortuous dilation of vessels -* hematochezia. Most often found in the right- sided colori More
common in older patients. Confirmed by angiography.
Adhesion
Fibrous band of scar tissue; commonly forms after surgery; most common cause of small bowel
obstruction. Can have well-demarcated necrotic zones.
Ileus
Intestinal hypomotilitv without obstruction -* constipation and 1 flatus; distended/tympanic

abdomen with 1 bowel sounds. Associated with abdominal surgeries, opiates, hypokalemia, sepsis.
Treatment: bowel rest, electrolyte correction, cholinergic drugs (stimulate intestinal motility).
In cystic fibrosis, meconium plug obstructs intestine, preventing stool passage at birth.
affects elderly.
Meconium ileus
Necrotizing
enterocolitis
Seen in premature, formula-fed infants with immature immune system. Necrosis of intestinal
mucosa ( primarily colonic) with possible perforation, which can lead to pneumatosis intestinalis,
free air in abdomen, portal venous gas.
368
SECTION III
Colonic polyps
HISTOLOGIC TYPE
GASTROINTESTINAL
Growths of tissue within the colon Q. May be neoplastic or non-neoplastic. Grossly characterized
as flat, sessile, or pedunculated (on a stalk) on the basis of protrusion into colonic lumen.
Generally classified by histologic type.
CHARACTERISTICS
Generally non-neoplastic
Hamartomatous
Solitary lesions do not have significant risk of transformation. Growths of normal colonic tissue
with distorted architecture. Associated with Peutz- Jeghers syndrome and juvenile polyposis.
Mucosa)
Small, usually < 5 mm. Look similar to normal mucosa. Clinically insignificant
Result of mucosal erosion in inflammatory bowel disease. When in clusters may be associated with
dysplasia]
Inflammatory
pseudopolypst
Submucosal
May include lesions such as lipomas, leiomyomas, fibromas, and others.
Hyperplastic
Generally smaller and predominantly located in the rectosigmoid region. May occasionally evolve
into serrated polyps and more advanced lesions.
Malignant potential
Adenomatous
Neoplastic, via chromosomal instability pathway with mutations in APC and KRAS . Tubular |
histology has less malignant potential than villous H; tubulovillous has intermediate malignant
potential. Usually asymptomatic; may present with occult bleeding.
Serratedl
Premalignant, via CpG hypermethylation phenoty pe pathway with microsatellite instability and
mutations in BRAF. Saw-tooth pattern of crypts on biopsy. Up to 20% of cases of sporadic CRC J
"
Polyp
*
-
nm.
Essa
a
Polyposis syndromes
Familial adenomatous
polyposis
Autosomal dominant mutation of APC tumor suppressor gene on chromosome 5q. 2-hit hypothesis.
Thousands of polyps arise starting after puberty; pancolonic; always involves rectum. Prophylactic
colectomy or else 100% progress to CRC.
Gardner syndrome
FAP + osseous and soft tissue tumors, congenital hypertrophy of retinal pigment epithelium,
impacted/supernumerary teeth.
Turcot syndrome
Peutz-Jeghers
syndrome
FAP + malignant CNS tumor (eg, medulloblastoma, gliomaj Turcot = Turban .

Autosomal dominant syndrome featuring numerous hamartomas throughout GI tract, along with
hyperpigmented mouth, lips, hands, genitalia. Associated with t risk of breast and GI cancers (eg,
colorectal, stomach, small bowel, pancreatic).
Juvenile polyposis
syndrome
Autosomal dominant syndrome in children (typically < 5 years old) featuring numerous
hamartomatous polyps in the colon, stomach, small bowel. Associated with t risk of CRC.
GASTROINTESTINAL
Lynch syndrome
SECTION III
369
Previously known as hereditary nonpolyposis colorectal cancer (HNPCC). Autosomal dominant

mutation of DNA mismatch repair genes with subsequent microsatellite instability. ~ 80%
progress to CRC. Proximal colon is always involved. Associated with endometrial, ovarian, and
skin cancers.
Colorectal cancer
EPIDEMIOLOGY
Most patients are > 50 years old. ~ 25% have a
RISK FACTORS
Adenomatous and serrated polyps, familial

cancer syndromes, 1BD, tobacco use, diet of
processed meat with low fiber.
PRESENTATION
Rectosigmoid > ascending > descending.

Ascending exophytic mass, iron deficiency
anemia, weight loss.
Descending infiltrating mass, partial
obstruction, colicky pain, hematochezia.
Rarely, presents with S( bovis ( gallolvticus )
family history.
Right side bleeds; left side obstructs.
bacteremia.
Iron deficiency anemia in males (especially > 50
years old) and postmenopausal females raises
suspicion.
Screen patients > 50 years old with
colonoscopy Q, flexible sigmoidoscopy, fecal
occult blood test, or fecal DNA test.
Apple core lesion seen on barium enema
x-ray Q.
CEA tumor marker: good for monitoring
recurrence, should not be used for screening.
DIAGNOSIS
Molecular
pathogenesis of
colorectal cancer
Chromosomal instability pathway: mutations in APC cause FAP and most sporadic CRC (via
adenoma-carcinoma sequence; (firing) order of events is AK-53).
Microsatellite instability pathway: mutations or methylation of mismatch repair genes (eg, MLH 1 )
cause Lynch syndrome and some sporadic CRC (via serrated polyp pathway). Overexpression of
CQX-2 has been linked to colorectal cancer, NSAIDs may be chemopreventive.
Chromosomal instability pathway
Loss of tumor suppressor

Loss of APC gene
Normal colon
Colon at risk
-J. intercellular adhesion

t proliferation
gene( s) (p53, DCC)
KRAS mutation
Adenoma
Unregulated
intracellular
signaling
fffi
'
Carcinoma
T tumorigenesis
!
41
&
370
SECTION III
GASTROINTESTINAL
Cirrhosis and portal hypertension
Cirrhosis diffuse bridging fibrosis (via stellate cells) and regenerative nodules (red arrows in EJ;
whitqarrow shows splenomegaly) disrupt normal architecture of liver; t risk for hepatocellular
carcinoma (HCC ). Etiologies include alcohol (60-70% of cases in the US), nonalcoholic
steatohepatitis, chronic viral hepatitis, autoimmune hepatitis, biliary disease, genetic/metabolic
disorders.
Portal hypertension t pressure in portal venous system. Etiologies include cirrhosis (most
common cause in Western countries), vascular obstruction (eg, portal vein thrombosis, BuddChiari syndrome), schistosomiasis.
Es
(- hematemesis)
Gastric varices
(-* melena)
Hematologic
Thrombocytopenia
Anemia
Coagulation disorders
Metabolic
Hyperbilirubinemia
Hyponatremia
Gynecomastia
Amenorrhea
Cardiovascular
Cardiomyopathy
- Peripheral edema
Primary / spontaneous
bacterial peritonitis
Idiopathic infection of ascites fluid. Often asymptomatic, but can cause fevers, chills, abdominal
pain, ileus, or worsening encephalopathy. Most common pathogens are gram negatives, especially
E coli .
Diagnosis: Paracentesis with absolute neutrophil count ( ANC ) > 250 cells/mm
GASTROINTESTINAL
SECTION III
371
Serum markers of liver pathology

ENZYMES RELEASED IN LIVER DAMAGE
Aspartate
aminotransferase
and alanine
aminotransferase
t in most liver disease: ALT > AST

t in alcoholic liver disease: AST > ALT
AST > ALT in nonalcoholic liver disease suggests progression to advanced fibrosis or cirrhosis
Alkaline phosphatase
t in cholestasis (eg, biliary obstruction), infiltrative disorders, bone disease
y- glutamyl
t in various liver and biliary diseases ( just as ALP can), but not in bone disease; associated with
transpeptidase
alcohol use
FUNCTIONAL LIVER MARKERS
Bilirubin
t in various liver diseases (eg, biliary obstruction, alcoholic or viral hepatitis, cirrhosis), hemolysis
Albumin
1 in advanced liver disease, marker of livers synthetic function
Prothrombin
t in advanced liver disease (i production of clotting factors, thereby measuring the livers synthetic
Platelets
1 in advanced liver disease (1 thrombopoietin, liver sequestration) and portal hypertension

(splenomegaly/splenic sequestration)
function)
Reye syndrome
Rare, often fatal childhood hepatic encephalopathy. Findings: mitochondrial abnormalities, fattyliver (microvesicular fatty change), hypoglycemia, vomiting, hepatomegaly, coma. Associated with
viral infection (especially VZV and influenza B) that has been treated with aspirin. Mechanism:
aspirin metabolites 1 P-oxidation by reversible inhibition of mitochondrial enzymes. Avoid aspirin
in children, except in those with Kawasaki disease.
372
SECTION III
GASTROINTESTINAL
Alcoholic liver disease
Hepatic steatosis
Macrovesicular fatty change that may be

reversible with alcohol cessation.
Alcoholic hepatitis
Requires sustained, long-term consumption.

Swollen and necrotic hepatocytes with
neutrophilic infiltration. Mallory bodies Q
(intracytoplasmic eosinophilic inclusions of
damaged keratin filaments).
Alcoholic cirrhosis
Final and irreversible form. Micronodular,

irregularly shrunken liver with hobnail
appearance. Sclerosis (arrows in Q) around
central vein (zone III). Manifestations
of chronic liver disease (eg, jaundice,
hypoalbuminemia).
gg-
Nonalcoholic fatty
liver disease
.V.
-I
aim
.w
si
gP &ai|
i
Make a toAST with alcohol:

AST > ALT (ratio usually > 2:1).
SB
m m1
i
i
m .
Metabolic syndrome (insulin resistance);

ALT > AST (Lipids)
obesity fatty infiltration of hepatocytes
-* cellular ballooning and eventual necrosis.
May cause cirrhosis and HCC. Independent of
alcohol use.
7 -:
Hepatic
encephalopathy
portosystemic shunts I Nfty metabolism neuropsychiatric dysfunction,

Reversible neuropsychiatric dysfunction ranging from disorientation /asterixis (mild ) to difficult
arousal or coma (severe!Triggers:
t Nfty production and absorption (due to dietary protein, GI bleed, constipation, infection).
i NH removal (due to renal failure, diuretics, bypassed hepatic blood flow post-TIPS).
Treatment: lactulose ( t NPty+ generation) and rifaximin or neomycin (1 NH producing gut
Cirrhosis
bacteria).
X ..
372
SECTION III
GASTROINTESTINAL
Alcoholic liver disease
Hepatic steatosis
Macrovesicular fatty change that may be

reversible with alcohol cessation.
Alcoholic hepatitis
Requires sustained, long-term consumption.

Swollen and necrotic hepatocytes with
neutrophilic infiltration. Mallory bodies Q
(intracytoplasmic eosinophilic inclusions of
damaged keratin filaments).
Alcoholic cirrhosis
Final and irreversible form. Micronodular,

irregularly shrunken liver with hobnail
appearance. Sclerosis (arrows in Q) around
central vein (zone III). Manifestations
of chronic liver disease (eg, jaundice,
hypoalbuminemia).
gg-
Nonalcoholic fatty
liver disease
.V.
-I
aim
.w
si
gP &ai|
i
Make a toAST with alcohol:

AST > ALT (ratio usually > 2:1).
SB
m m1
i
i
m .
Metabolic syndrome (insulin resistance);

ALT > AST (Lipids)
obesity fatty infiltration of hepatocytes
-* cellular ballooning and eventual necrosis.
May cause cirrhosis and HCC. Independent of
alcohol use.
7 -:
Hepatic
encephalopathy
portosystemic shunts I Nfty metabolism neuropsychiatric dysfunction,

Reversible neuropsychiatric dysfunction ranging from disorientation /asterixis (mild ) to difficult
arousal or coma (severe!Triggers:
t Nfty production and absorption (due to dietary protein, GI bleed, constipation, infection).
i NH removal (due to renal failure, diuretics, bypassed hepatic blood flow post-TIPS).
Treatment: lactulose ( t NPty+ generation) and rifaximin or neomycin (1 NH producing gut
Cirrhosis
bacteria).
X ..
GASTROINTESTINAL
Hepatocellular
carcinoma / hepatoma
Most common 1 malignant tumor of liver

in adults Q. Associated with HBV (+/
cirrhosis) and all other causes of cirrhosis
(including HCV, alcoholic and nonalcoholic
fatty liver disease, autoimmune disease,
hemochromatosis, (Xj-antitrypsin deficiency)
and specific carcinogens (eg, aflatoxin
from Aspergillus ). May lead to Budd-Chiari
373
syndrome.
SECTION III
Ev * :I'#'
v
Findings: jaundice, tender hepatomegaly,

ascites, polycythemia, anorexia . Spreads
hematogenously.
Diagnosis: t a-fetoprotein ; ultrasound or
contrast CT/MRI Q, biopsy.
Other liver tumors
Common , benign liver tumor Q; typically occurs at age 30-50 years. Biopsy contraindicated
because of risk of hemorrhage.
Cavernous
hemangioma
7.
-y:
A
mi
Hepatic adenoma
Rare, benign liver tumor, often related to oral contraceptive or anabolic steroid use; may regress
spontaneously or rupture (abdominal pain and shock).
Angiosarcoma
Malignant tumor of endothelial origin; associated with exposure to arsenic, vinyl chloride.
GI malignancies, breast and lung cancer. Most common overall ; metastases rarely solitanj
Metastases
Budd -Chiari syndrome
Thrombosis or compression of hepatic veins with centrilobular congestion and necrosis

-* congestive liver disease ( hepatomegaly, ascites, varices, abdominal pain , liver failure). Absence
of JVD. Associated with hypercoagulable states, polycythemia vera , postpartum state, HCC. May
cause nutmeg liver ( mottled appearance).
-antitrypsin
^deficiency
Misfolded gene product protein aggregates in

hepatocellular ER cirrhosis with
PAS globules in liver. Codominant trait .
!m v
In lungs, 1 (X|-antitrypsin -* uninhibited elastase

I elastic tissue panacinar
in alveoli
emphysema .
374
SECTION III
Jaundice
GASTROINTESTINAL
Abnormal yellowing of the skin and/

or sclera Q due to bilirubin deposition.
Hyperbilirubinemia 2 to t production or
1 disposition ( impaired hepatic uptake,
HOT Liver Common causes of increased

levels of bilirubin.
Hemolysis
Obstruction
Tumor
Liver disease
conjugation, excretion).
Unconjugated
(indirect )
hyperbilirubinemia
Hemolytic, physiologic (newborns), Crigler-Najjar, Gilbert syndrome.
Conjugated (direct)
hyperbilirubinemia
Biliary tract obstruction: gallstones, cholangiocarcinoma, pancreatic or liver cancer, liver fluke.
Biliary tract disease:
1 sclerosing cholangitis
1 biliary cholangitij
Excretion defect: Dubin-Johnson syndrome Rotor syndrome .
Hepatitis, cirrhosis.
Mixed (direct
and indirect)
hyperbilirubinemia
Physiologic
neonatal jaundice
At birth, immature UDP-glucuronosyltransferase -* unconjugated hyperbilirubinemia

jaundice/
kernicterus ( deposition of unconjugated, lipid-soluble bilirubin in the brairj particularly basal
ganglia).
Occurs after first 24 hours of life and usually resolves without treatment in 1-2 weeks.
Treatment: phototherapy (non-UV) isomerizes unconjugated bilirubin to water-soluble form.
GASTROINTESTINAL
Hereditary
hyperbilirubinemias
O Gilbert syndrome
Crigler- Najjar
syndrome, type I
Dubin-Johnson
syndrome
SECTION III
375
All autosomal recessive.

Relatively common, benign condition!
Mildly 1 UDP-glucuronosyltransferase
conjugation and impaired bilirubin uptake.
Asymptomatic or mild jaundice usually with
stress, illness, or fasting t unconjugated
bilirubin without overt hemolysis. Bilirubin
t jLv ith fasting and stress.
Absent UDP-glucuronosyltransferase. Presents
Type II is less severe and responds to
early in life; patients die within a few years.
phenobarbital, which t liver enzyme synthesis.
Findings: jaundice, kernicterus (bilirubin
deposition in brain), t unconjugated bilirubin.
Treatment: plasmapheresis and phototherapy.
Conjugated hyperbilirubinemia due to defective Q Rotor syndrome is similar, but milder in
liver excretion. Grossly black liver. Benign.
presentation without black liver. Due to
impaired hepatic uptake and excretion.
HEPATIC SINUSOID
Hemoglobin
Circulating bilirubin
( albumin bound, unconjugated, water insoluble)
Kupffer cell
(macrophage)
Endothelial celt
Space of Disse
Hepatocyte
.
BILIRUBIN
UPTAKE
Unconjugated bilirubin
f
I2
o CONJUGATION
0
Conjugated bilirubin
(bilirubin diglucuronide water soluble)
INTRACELLULAR
TRANSPORT
-\
Bile
canaliculus
lumen
Sfas/ s
Bite low
Hepatocyte
Obstructive jaundice
( downstream)
0
376
SECTION III
Wilson disease
( hepatolenticular
degeneration )
GASTROINTESTINAL
Autosomal recessive!mutations in hepatocyte copper-transporting ATPase ( ATP7 B gene;

chromosome 13) 1 copper excretion into bile and incorporation into apoceruloplasmin
(I serum ceruloplasmin). Copper accumulates, especially in liver, brain, cornea, kidneys; t urine
copped
Presents before age 40 with liver disease (eg, hepatitis, acute liver failure, cirrhosis), neurologic
disease (eg, dysarthria, dystonia, tremor, parkinsonism), psychiatric disease, Kayser-Fleischer rings
(deposits in Descemet membrane of cornea) Q, hemolytic anemia, renal disease (eg, Fanconi
syndrome).
Treatment: chelation with penicillamine or trientine, oral zinc.
Hemochromatosis
Recessive mutations in HFE gene (C282Y > H63P, chromosome 6, associated with HLA-A j)
-* abnormal iron sensing and t intestinal absorption ( t ferritin, t iron, 1 TIBC -* t transferrin
saturation). Iron overload can also be 2 to chronic transfusion therapy (eg, (3-thalassemia major).
Iron accumulates, especially in liver, pancreas, skin, heart, pituitary, joints. Hemosiderin (iron)
can be identified on liver MRI or biopsy with Prussian blue stain Q.
Presents after age 40 when total bod}' iron > 20 g; iron loss through menstruation slows progression
in women. Classic triad of cirrhosis, diabetes mellitus, skin pigmentation ( bronze diabetes ). Also
causes restrictive cardiomyopathy ( classic ) or dilated cardiomyopathy ( reversibid), hypogonadism,
arthropathy (calcium pyrophosphate deposition; especially metacarpophalangeal joints). HCC is
common cause of death.
Treatment: repeated phlebotomy, chelation with deferasirox, deferoxamine, oral deferiprone.
Biliary tract disease
May present with pruritus, jaundice, dark urine, light-colored stool, hepatosplenomegaly. Typically
with cholestatic pattern of LFTs ( t conjugated bilirubin, t cholesterol, t ALP).
Primary sclerosing
cholangitis
ADDITIONAL FEATURES
PATHOLOGY
EPIDEMIOLOGY
Unknown cause of concentric

onion skin bile duct
Classically in middle-aged men Associated with ulcerative

colitis. p-ANCA . t IgM.
with IBD.
Can lead to 2 biliary
cholangitii t risk of
cholangiocarcinoma and
gallbladder cancer.
fibrosis - alternating
strictures and dilation with
beading of intra- and
extrahepatic bile ducts on
ERCP, magnetic resonance
cholangiopancreatography
(MRCP).
Primary biliary
cholanqitisi
Secondary biliary
cholanaitisi
Autoimmune reaction
-* lymphocytic infiltrate
+ granulomas -* destruction
of intralobular bile ducts.
Classically in middle-aged
women.
Anti-mitochondrial antibody ,
t IgM. Associated with other
autoimmune conditions
(eg, Sjogren syndrome,
Hashimoto thyroiditis,
CREST, rheumatoid arthritis,
celiac disease).
May be complicated by
Extrahepatic biliary obstruction Patients with known
-* t pressure in intrahepatic
obstructive lesions ( gallstones,
ascending cholangitis.
ducts -* injury/ fibrosis and
biliary strictures, pancreatic
bile stasis.
carcinoma).
GASTROINTESTINAL
SECTION III
377
Risk factors (4 F s):

t cholesterol and/or bilirubin, 1 bile salts, and
1. Female
gallbladder stasis all cause stone%
2. Fat
2 types of stones:
3. Fertile ( pregnant)
Cholesterol stones (radiolucent with 10-20%
4. Forty
opaque due to calcifications) 80% of stones.
Diagnose with ultrasound . Treat with elective
Associated with obesity, Crohn disease,
cholecystectomy if symptomatic!
advanced age, estrogen therapy, multiparity,
pan cause fistula between gallbladder and
rapid weight loss, Native American origin.
2
Gjtract air in biliary tree (pneumobilia)
Pigment stonesJQ (black = radiopaque, Ca +
bilirubinate, hemolysis; brown = radiolucent,
passage of gallstones into intestinal tract
obstruction of ileocecal valve (gallstone
infection). Associated!with Crohn disease,
ileus).
chronic hemolysis, alcoholic cirrhosis,
advanced age, biliary infections, total
parenteral nutrition ( TPN).
Most common complication is cholecystitis;
also, acute pancreatitis, ascending cholangitis]
Gallstones
( cholelithiasis)
RELATED PATHOLOGIES
CHARACTERISTICS
Biliary colic
Uncomplicated disease associated with nausea /vomiting and dull right upper quadrant ( RUQ) pain.
Neurohormonal activation (eg, by CCK after a fatty meal ) triggers contraction of gallbladder,
forcing stone into cystic duct. Labs are normal, ultrasound shows cholelithiasis.
Choledocholithiasis
Presence of gallstone(s) in common bile duct, often leading to elevated ALP, GGT, direct bilirubin,
and/or AST/ALT.
Cholecystitis
Acute or chronic inflammation of gallbladder usually from cholelithiasis (stone at neck of

gallbladder [red arrow in HI with gallbladder wall thickening [ yellow arrows!). Gallstones most
commonly blocking the cystic duct 2 infection; less commonly from acalculous due to
ischemia and stasis, or infection (eg, CMV ). Murphv sign: inspiratory arrest on RUQ palpation
due to pain. ALP if bile duct becomes involved (eg, ascending cholangitis).
Diagnose with ultrasound or cholescintigraphv ( HIDA scan ).
'
Porcelain gallbladder
tJ
Ascending cholangitis
Calcified gallbladder due to chronic cholecystitis; usually found incidentally on imaging [].
Treatment: prophylactic cholecystectomy due to high rates of gallbladder cancer (mostly
adenocarcinoma).
Infection of biliary tree usually due to obstruction that leads to stasis/bacterial overgrowth.
Charcot triad of cholangitis:
Jaundice
Fever
RUQ pain
Reynolds pentad adds:
Altered mental status
a
Shock
378
SECTION III
Autodigestion of pancreas by pancreatic enzymes (Q shows pancreas [ yellow arrows] surrounded by

edema [red arrows]).
Causes: Idiopathic, Gallstones, Ethanol, Trauma, Steroids, Mumps, Autoimmune disease,
Scorpion sting, Hypercalcemia /Hypertriglyceridemia (> 1000 mg/dL), ERCP, Drugs (eg, sulfa
drugs, NRTIs, protease inhibitors).I GET SMASHED.
Diagnosis by 2 of > criteria: acute epigastric pain often radiating to the back, t serum amylase or
lipase (more specific) to 3x upper limit of normal, or characteristic imaging findings.
Complications: pseudocyst Q (lined by granulation tissue, not epithelium), necrosis, hemorrhage,
infection, organ failure (ARDS, shock, renal failure), hypocalcemia (precipitation of Ca 2+ soaps).
Acute pancreatitis
GASTROINTESTINAL
'Art
*
Chronic pancreatitis
Chronic inflammation, atrophy, calcification of the pancreas Q. Major causes are alcohol abuse
and idiopathic. Complications include pancreatic insufficiency ( also a problem in cystic fibrosis)
and pseudocystfr
Pancreatic insufficiency may manifest with steatorrheaL fat-soluble vitamin deficiency, diabetes
mellitus.
Amylase and lipase may or may not be elevated (almost always elevated in acute pancreatitis).
rr,
Pancreatic
adenocarcinoma
>
'
...fW.
V V;/
.' r r V'
Very aggressive tumor arising from pancreatic ducts (disorganized glandular structure with cellular
infiltration Q); often metastatic at presentation, with average survival ~ 1 year after diagnosis.
Tumors more common in pancreatic head Q (-* obstructive jaundice). Associated with CA 19-9
tumor marker (also CEA, less specific).
Risk factors:
Tobacco use
Chronic pancreatitis (especially > 20 years)
Diabetes
Age > 50 years
Jewish and African-American males
Often presents with:
Abdominal pain radiating to back
Weight loss (due to malabsorption and anorexia)
Migratory thrombophlebitis redness and tenderness on palpation of extremities (Trousseau
syndrome)
* Obstructive jaundice with palpable, nontender gallbladder (Courvoisier sign)
Treatment: Whipple procedure, chemotherapy, radiation therapy.
a
GASTROINTESTINAL PHARMACOLOGY
GASTROINTESTINAL
GASTROINTESTINAL
SECTION III
379
PHARMACOLOGY
Acid suppression therapy

jRP
Vagus nerve
G cells
rQy+ ECL cells
H stam ne
A h
Atropine
-0
TT
HCOj (
alkaline tide"- T blood pH
after gastric acid secretion
(eg , after meals, vomiting )
"
NpY
l1
V
, receptor
LCK
ptor
HCO, t H*
"
_
_AT
H 2 blockers
s,
Ct
cAMP :
Proton pump inhibitors

Antacids
ADVERSE EFFECTS
-- &
Gastric
parietal
Cq+ H,
CLINICAL USE
|Carbonic anhydrase
MECHANISM
H , receptor
'
H2 blockers
Prostaglandins
Somatostatin
cell
ATPase
j [ ]*
Cimetidine, ranitidine, famotidine, nizatidine.
e
^
|*
Misoprostol
Sucralfate,
Lumen
bismuth
Take H ? blockers before you dine. Think table

for 2 to remember H7.
Reversible block of histamine H 7-receptors i H+ secretion by parietal cells.

Peptic ulcer, gastritis, mild esophageal reflux.
Cimetidine is a potent inhibitor of cytochrome P-450 ( multiple drug interactions); it also has
antiandrogenic effects ( prolactin release, gynecomastia , impotence, 1 libido in males); can
cross blood-brain barrier (confusion , dizziness, headaches) and placenta . Both cimetidine and
ranitidine 1 renal excretion of creatinine . Other H7 blockers are relatively free of these effects.
Proton pump inhibitors Omeprazole, lansoprazole, esomeprazole, pantoprazole, dexlansoprazole .

MECHANISM
CLINICAL USE
ADVERSE EFFECTS
Irreversibly inhibit H+/K+ ATPase in stomach parietal cells.

Peptic ulcer, gastritis, esophageal reflux, Zollinger-Ellison syndrome, component of triple therapy
for H pylori, stress ulcer prophylaxis
t risk of C difficile infection, pneumonia i serum Mg + with long-term use.
,
GASTROINTESTINAL PHARMACOLOGY
GASTROINTESTINAL
SECTION III
381
Loperamide
MECHANISM
Agonist at p- opioid receptors; slows gut motility. Poor CNS penetration ( low addictive potential).
CLINICAL USE
Diarrhea.
ADVERSE EFFECTS
Constipation, nausea.
Ondansetron
MECHANISM
5-HT antagonist; 1 vagal stimulation. Powerful central-acting antiemetic.
CLINICAL USE
Control vomiting postoperatively and in patients

undergoing cancer chemotherapy.
Headache, constipation, QT interval prolongation, serotonin syndrome
ADVERSE EFFECTS
Metoclopramide
MECHANISM
D,- receptor antagonist, t resting tone, contractility. LES tone, motility, promotes gastric emptying
Does not influence colon transport time.
CLINICAL USE
Diabetic and postsurgerv gastroparesis, antiemetic, persistent GERDi
ADVERSE EFFECTS
t parkinsonian effects, tardive dyskinesia. Restlessness, drowsiness, fatigue, depression, diarrhea.

Drug interaction with digoxin and diabetic agents. Contraindicated in patients with small bowel
obstruction or Parkinson disease (due to D? -receptor blockade).
Orlistat
MECHANISM
Inhibits gastric and pancreatic lipase
CLINICAL USE
Weight loss.
ADVERSE EFFECTS
Steatorrhea, 1 absorption of fat-soluble vitamins.
Laxatives
1 breakdown and absorption of dietary fats.
Indicated for constipation or patients on opiates requiring a bowel regimen.
TYPE
MECHANISM
ADVERSE EFFECTS
Bulk-forminq
Draws water into gut lumen, bulk forming
Bloating
(eq, psyllium,
methylcellulose)
Stimulant (eq, senna)
Enteric nerve stimulation
Emollients (eq,
Osmotic draw into lumen
colonic contraction Diarrhea, melanosis coli

Diarrhea
docusate)
Aprepitant
I Fact
i
MECHAN ) SM
Substance P antagonist. Blocks NKi receptors in brain.
CLINICAL USE
Antiemetic for chemotherapy-induced nausea and vomiting.
HIGH- YIELD SYSTEMS
Hematology
and Oncology
Of all that is written , I love only what a person has written with his own
Anatomy
384
Physiology
387
Pathology
392
Pharmacology
411
blood .
Friedrich Nietzsche
I used to get stressed out , but my cancer has put everything into
perspective."
Delta
The best blood will at some time get into a fool or a mosquito.
Goodrem
Austin OMalley
Carcinoma works cunningly from the inside out. Detection and

treatment often work more slowly and gropingly , from the outside in.
Christopher
Hitchens
Study tip: When reviewing oncologic drugs, focus on mechanisms and

side effects rather than details of clinical uses, which may be lower yield.
383
384
SECTION III
HEMATOLOGY AND ONCOLOGY ANATOMY
HEMATOLOGY AND ONCOLOGY

Erythrocyte
Carries 0? to tissues and C02 to lungs.
Anucleate and lacks organelles; biconcave Q,

with large surface area-to-volume ratio for
rapid gas exchange. Life span of 120 days.
Source of energy is glucose (90% used
in glycolysis, 10% used in HMP shunt).
Membrane contains Cl-/HC(X - antiporter,
which allows RBCs to export HC05 and
transport CO? from the periphery to the lungs
for elimination.
"
Thrombocyte
( platelet )
Leukocyte
Eryth = red; cyte = cell.

Erythrocytosis = polycythemia = t hematocrit.
Anisocytosis = varying sizes.
Poikilocytosis = varying shapes.
Reticulocyte = immature RBC; reflects

erythroid proliferation.
Bluish color on Wright-Giemsa stain of
reticulocytes represents residual ribosomal
RNA.
Involved in 1 hemostasis. Small cytoplasmic

fragment Q derived from megakaryocytes.
Life span of 8-10 days. When activated by
endothelial injury, aggregates with other
platelets and interacts with fibrinogen to
form platelet plug. Contains dense granules
(ADP, Ca~+) and a granules (vWF, fibrinogen,
fibronectin). Approximately XA of platelet pool
is stored in the spleen .
Thrombocytopenia or i platelet function results

in petechiae.
vWF receptor: Gplb.
Fibrinogen receptor: GpIIb/IIIa.
Divided into granulocytes (neutrophil,

eosinophil, basophil, mast celt) and
mononuclear cells (monocytes, lymphocytes).
WBC differential count froirjl highest to lowest
(normal ranges per USMLE):
Neutrophils (~ 60% j
Lymphocytes (~ 30% j
Monocytes (~ 6%fe
Leuk = white; cyte = cell,
Neutrophils Like Making Everything Better.
Eosinophils (~
Basophils (~ YXj)
Neutrophil
L5
Acute inflammatory response cell. Increased in
Hypersegmented neutrophils (nucleus has 6+

bacterial infections. Phagocytic. Multilobed
lobes) are seen in vitamin BJ2/ folate deficiency,
nucleus Q. Specific granules contain leukocyte t band cells (immature neutrophils) reflect states
alkaline phosphatase (LAP), collagenase,
of t myeloid proliferation ( bacterial infections,
CML)
lysozyme, and lactoferrin. Azurophilic
granules (lysosomes) contain proteinases,
Important neutrophil chemotactic agents: C 5 a,
acid phosphatase, myeloperoxidase, and
IL- 8, LTB , kallikrein, platelet-activating
^
factor.
P-glucuronidase.
385
Phagocytoses bacteria , cellular debris, and

senescent RBCs. Long life in tissues.
Macrophages differentiate from circulating
blood monocytes Q. Activated by y-interferon.
Can function as antigen-presenting cell via
MHC II.
Macro = large; phage = eater.

Macrophage: in the tissue. Name differs in
each tissue tvpe ( eg, Kupffer cell in the liver,
histiocytes in connective tissue).
Important component of granuloma formation
( eg, TB, sarcoidosis).
Lipid A from bacterial LPS binds CD14 on
macrophages to initiate septic shock .
Eosin = pink dye; philic = loving.

Causes of eosinophilia = NAACP:
Defends against helminthic infections (major

basic protein ). Bilobate nucleus. Packed
with large eosinophilic granules of uniform
size Q. Highly phagocytic for antigen-
V# %/
A
* w
Produces histaminase, major basic protein

( MBP, a helminthotoxin ), eosinophil
peroxidase, eosinophil cationic protein , and
eosinophil -derived neurotoxiri
Macrophage
Hi
ISwappedl
Eosinophil
Q
r
SECTION III
Mono = one (nucleus); cyte = cell .

Monocyte: in the blood .
WJocFb
Image
ANATOMY
Differentiates into macrophage in tissues.

Large, kidney-shaped nucleus Q. Extensive
frosted glass cytoplasm.
Monocyte
antibody complexes.
Neoplasia
Asthma
Allergic processes
Chronic adrenal insufficiency
Parasites ( invasive)
Basophil
Mediates allergic reaction . Densely basophilic

granules Q contain heparin (anticoagulant )
and histamine (vasodilator). Leukotrienes
synthesized and released on demand .
Basophilic staining readily with basic stains.

Basophilia is uncommon, but can be a sign of
myeloproliferative disease, particularly CML .
Mast cell
Mediates allergic reaction in local tissues.

Mast cells contain basophilic granules Q and
originate from the same precursor as basophils
but are not the same cell type. Can bind the
Fc portion of IgE to membrane . IgE cross
links upon antigen binding degranulation
-* release of histamine , heparin , trvptase, and
eosinophil chemotactic factors.
Involved in type I hypersensitivity reactions.

Cromolyn sodium prevents mast cell
degranulation (used for asthma prophylaxis),
>
386
SECTION III
Highly phagocytic APC Q. Functions as link between innate and adaptive immune systems.
Expresses MHC class II and Fc receptors on surface. Called Langerhans cell in the skin.
Dendritic cell
&
Lymphocyte
90 'p
Om
Refers to B cells, T cells, and NK cells. B cells and T cells mediate adaptive immunity. NK cells are
part of the innate immune response. Round, densely staining nucleus with small amount of pale
cytoplasm Q.
OaA
Bcell
CD20
CD19
CD21
...
'- '
LI
T cell
4 4
Part of humoral immune response. Originates

from stem cells in bone marrow and matures in
marrow. Migrates to peripheral lymphoid tissue
(follicles of lymph nodes, white pulp of spleen,
unencapsulated lymphoid tissue). When antigen
is encountered, B cells differentiate into plasma
cells (which produce antibodies) and memory
cells. Can function as an APC via MHC II.
B = Bone marrow,
Mediates cellular immune response. Originates

from stem cells in the bone marrow, but
matures in the thymus. T cells differentiate
into cytotoxic T cells (express CD8, recognize
MHC I), helper T cells (express CD4,
recognize MHC II), and regulatory T cells.
CD28 (costimulatory signal) necessary for
T-cell activation. The majority of circulating
lymphocytes are T cells (80%).
T is for Thymus.
CD4+ helper T cells are the primary target of
HIV.
MHC x CD = 8 (eg, MHC 2 x CD4 = 8, and
MHC 1 x CD8 = 8).
388
SECTION III
HEMATOLOGY AND ONCOLOGY PHYSIOLOGY
Blood groups
Rh classification
ABO classification
RBC type
Group antigens on
RBC surface
Antibodies in plasma
Clinical relevance
lift
&
Anti- B
Anti- A
JOCC
YV
AX*
IgM
IgM
Receive B or AB
- hemolytic
Receive A or AB
- hemolytic
reaction
reaction
-fv
AB
A&B
()
NONE
Rh (D)
Anti- A
NOBE
Rh
0
Anti-B
yXc
Receive any non-0
- hemolytic
reaction
Universal donor
of RBCs; universal
recipient of plasma
NONE
Anti- D
NONE
IgM
Universal recipient
of RBCs; universal
donor of plasma
Rh
Y
IgG
Universal recipient
of RBCs
Treat mother with

anti-D Ig (RhoGAM)
during and after each
pregnancy to prevent
anti-D IgG formation
Rh hemolytic disease
of the newborn
IgM does not cross placenta; IgG does cross placenta.

Rh mothers exposed to fetal Rh blood (often during delivery) may make anti-D IgG. In
subsequent pregnancies, anti-D IgG crosses the placenta -* hemolytic disease of the newborn
(erythroblastosis fetalis) in the next fetus that is Rh. Administration of anti-D IgG ( RhoGAM)
to Rh pregnant women during third trimester and early postpartum period!prevents maternal
anti-D IgG production.
Rh mothers have anti-D IgG only if previously exposed to Rh blood.
ABO hemolytic disease

of the newborn
Most common form. Usually occurs in a type O mother with a type A, B, or AB fetus. Can occur in
a first pregnancy as maternal anti-A and/or anti-B IgG antibodies are formed early in life. Does not
worsen with future pregnancies. Presents as mild jaundice in the neonate within 24 hours of birth;
treatment is phototherapy or exchange transfusion.
389
SECTION III
Hemoglobin electrophoresis
On a gel, hemoglobin migrates from the

negatively charged cathode to the positively
charged anode. HbA migrates the farthest,
followed by HbF, HbS, and IIbfl This is
because the missense mutations in HbS and
HbC replace glutamic acid with valine
(neutral) and lysine , respectively, impacting
the net protein charge.
Origin
AA -^ Normal adult
1 T
^Normal newborn
AS Sickle cell trait
AF
SS - Sickle cell disease
i
AC
>Hb C trait
>Hb SC disease
CC Hb C disease
xx
Cathode
SC
F
Anode
A: normal hemoglobin (5 chain (HbA, adult)

F: normal hemoglobin y chain (HbF, fetal)
S: sickle cell hemoglobin p chain (HbS)
C hemoglobin C p chain (HbC)
A Fat Santa Claus

B
Coagulation and kinin pathways

Collagen,
basement membrane,
y'
Kallikrein
activated platelets
Contact
activation
(intrinsic)
pathway
(extrinsic)
V|
Tissue factor
li
XIla
XI
t Permeability
- *-
jVHIa
VIII
with vWF)
ANTICOAGULANTS: lla ( thrombin)

- heparin (greatest efficacy)
- LMWH (dalteparin, enoxaparin)
- direct thrombin inhibitors (argatroban,
bivalirudin, dabigatran)
pathway
ANTICOAGULANTS: factor Xa
- LMWH (greatest efficacy)
- heparin
- direct Xa inhibitors (apixaban, rivaroxaban)
- fondaparinux
Pain
Kinin cascade
Xla
Vila
Prothrombin Thrombin
Plasminogen
is
Fibrinogen Fibrin monomers
Hemophilia A: deficiency of factor VIII (XR)

Hemophilia B: deficiency of factor IX ( XR)
Hemophilia C: deficiency of factor XI (AR )
T Vasodilation
Bradykinin $;
XII
IX
Ticcu firtnr
Tissue
factor
HMWK
--
tPA
Plasmin
Combined
pathway
Note: Kallikrein activates bradykinin; ACE inactivates bradykinin

* = require Ca2*, phospholipid
= inhibited by vitamin K antagonist warfarin
= cofactor
activates but not part of coagulation cascade
>
,THROMBOLYTICS:
alteplase, reteplase,
streptokinase, tenecteplase
Aminocaproic acid
Fibrinolytic system
Xllla
Fibrin degradation
products
Fibrin mesh stabilizes
platelet plug
390
SECTION III
PHYSIOLOGY
Coagulation cascade components
Procoagulation
Oxidized
vitamin K
Epoxide
reductase
reduced
vitamin K
(acts as
cofactor )
inactive precursors of II, VII, IX, X, C, S

y-glutamyl transferase
mature (active) II, VII, IX, X, C, S
Anticoagulation
Thrombin-thrombomodulin complex
Protein
{endothelial cells)
S
Protein C
cleaves and inactivates Va, Villa
activated protein C
tPA
Plasminogen
plasmin
Fibrinolysis:
1. cleavage of fibrin mesh
2. destruction of coagulation factors
Warfarin inhibits the enzyme vitamin K

epoxide reductase.
Neonates lack enteric bacteria , which produce
vitamin K .
Vitamin K deficiency: 1 synthesis of factors II,
VII , IX, X, protein C, protein S.
vWF carries/ protects VIII ( volksWagen
Factories make grS ( great ) car ? j
Antithrombin inhibits activated forms of factors
II , VII , IX, X, XI , XII.
Heparin enhances the activity of antithrombin .
Principal targets of antithrombin : thrombin and
factor Xa.
Factor V Leiden mutation produces a factor V
resistant to inhibition by activated protein C.
tPA is used clinically as a thrombolytic.
SECTION I I I
391
Platelet plug formation ( primary hemostasis)
o
INJURY
Endothelial damage
-* transient
vasoconstriction via
neural stimulation reflex
and endothelm (released
from damaged cell)
.!
St
EXPOSURE
vWF binds to exposed
collagen
vWF is from Weibel-Palade
bodies of endothelial
cells and a-granules of
platelets
(J)
ADHESION
Platelets bind vWF via Gplb
receptor at the site of injury
only (specific ) platelets
undergo conformational
change
AGGREGATION
Fibnnogen binds Gpllb /llla receptors and links platelets
ACTIVATION
ADP binding to receptor

induces Gpllb/ llla
expression at platelet
surface
Balance between
Pro-aggregation factors:
Anti- aggregation factors:
TXA2 (released PGI2 and NO (released
by platelets) by endothelial cells)
i blood flow T blood flow
T platelet aggregation i platelet aggregation
Platelets release ADP and

Ca 2+ (necessary
ary for
coagulation cascade), TXA2
Temporary plug stops bleeding; unstable, easily dislodged
atelets adhere
ADP helps platelets
to endothelium
urn
2* hemostasis
Coagulation cascade
Formation of insoluble fibrin mesh.

Aspirin irreversibly inhibits cyclooxygenase,
thereby inhibiting TXA 2 synthesis
Clopidogrel, prasugrel, and ticlopidine inhibit
ADP-induced expression of GpIIb/IIIa.
Abciximab, eptifibatide, and tirofiban inhibit
GpIIb/IIIa directly.
Ristocetin activates vWF to bind Gplb. Failure
of aggregation!with ristocetin assay occurs in
von Willebrand disease and Bernard-Soulier
Thrombogenesis
Clopidogrel, prasugrel,
ticlopidine
Platelet
(vWR
Aspirin
platelets
(fibrinogen)
Fibrinogen
Arachidonic
ADP receptor
COX
TXA
Platelet phospholipid
Kir:
syndrome.
Deficiency: Glanzmann thrombasthenia

Gpllb / llla
Deficiency: Bernard Soulier syndrome
)Gpllb/ llla
Abciximab,
n s e i on
0
Subendothel al
:ollagen
Thrombomodulin
Willebrand
lisease
Activated
protein C
Protein C
~ Vascular endothelial cells
Inside
endothelial
cells
|
|(vWF + factor VIII)
thromboplastin
tPA, PGI,
392
SECTION III
HEMATOLOGY AND ONCOLOGY PATHOLOGY

Pathologic RBC forms
TYPE
EXAMPLE
ASSOCIATED PATHOLOGY
NOTES
Acanthocyte
("spur cell")JO
Vj
Liver disease,
Acantho = spiny.
Basophilic stippling Q
Dacrocyte
("teardrop cell") jg
Degmacyte
("bite cell")J0
yo
Mi
w1
abetalipoproteinemia (states of
cholesterol dysregulation).
Lead poisoning, sideroblastic

anemias, mvelodysplastic
syndromes.
Seen primarily in peripheral smear,

as opposed to ringed sideroblasts
seen in bone marrow.
Aggregation of residual ribosomes.
Bone marrow infiltration (eg,

myelofibrosis).
RBC sheds a tear because its

mechanically squeezed out of its
home in the bone marrow.
G6PD deficiency.
Echinocyte
("burrceinjg
Elliptocyte
W* SS*
*00
deficiency.
Hereditary elliptocytosis, usually

asymptomatic; caused by
mutation in genes encoding RBC
membrane proteins (eg, spectrin).
Macro- ovalocyteJO
End-stage renal disease, liver

disease, pyruvate kinase
? So!
Megaloblastic anemia (also

hvpersegmented PMNs), marrow
failure.
Different from acanthocyte; its

projections are more uniform and
smaller.
PATHOLOGY
SECTION III
393
Pathologic RBC forms ( continued )

TYPE
EXAMPLE
Ringed siderobiast (JJ
QV
"
'
NOTES
Sideroblastic anemia. Excess iron

in mitochondria .
Seen in bone marrow, as opposed

to basophilic stippling in
peripheral smear.
DIC , TTP/ HUS,

HELLP syndrome, mechanical
hemolysis (eg, heart valve
prosthesis).
Examples include helmet cell.
iW
DO
Schistocyte jj
Sickle cellJJJ
Spherocyte SJJ
Si
f%
Sickling occurs with dehydration ,

deoxvgenation , and at high
altitude.
Hereditary spherocytosis, drug- and

infection-induced hemolytic
anemia .
HbC disease, Asplenia , Liver

disease, Thalassemia.
Target celljQ
HALT, said the hunter to his
target.
Other RBC abnormalities

TYPE
EXAMPLE
Heinz bodies Q
NOTES
Seen in G 6PD deficiency.
Oxidation of Hb -SH groups

to -S S- -* Hb precipitation
( Heinz bodies), with subsequent
phagocytic damage to RBC
membrane -* bite cells.
Seen in patients with functional

hvposplenia or asplenia.
Basophilic nuclear remnants found

in RBCs.
Howell-Jolly bodies are normally
removed from RBCs by splenic
macrophages.
Howell -Jolly bodiesJQJ

Swapped
Image
v .
_
(V
t
w . qi
PATHOLOGY
SECTION III
393
Pathologic RBC forms ( continued )

TYPE
EXAMPLE
Ringed siderobiast (JJ
QV
"
'
NOTES
Sideroblastic anemia. Excess iron

in mitochondria .
Seen in bone marrow, as opposed

to basophilic stippling in
peripheral smear.
DIC , TTP/ HUS,

HELLP syndrome, mechanical
hemolysis (eg, heart valve
prosthesis).
Examples include helmet cell.
iW
DO
Schistocyte jj
Sickle cellJJJ
Spherocyte SJJ
Si
f%
Sickling occurs with dehydration ,

deoxvgenation , and at high
altitude.
Hereditary spherocytosis, drug- and

infection-induced hemolytic
anemia .
HbC disease, Asplenia , Liver

disease, Thalassemia.
Target celljQ
HALT, said the hunter to his
target.
Other RBC abnormalities

TYPE
EXAMPLE
Heinz bodies Q
NOTES
Seen in G 6PD deficiency.
Oxidation of Hb -SH groups

to -S S- -* Hb precipitation
( Heinz bodies), with subsequent
phagocytic damage to RBC
membrane -* bite cells.
Seen in patients with functional

hvposplenia or asplenia.
Basophilic nuclear remnants found

in RBCs.
Howell-Jolly bodies are normally
removed from RBCs by splenic
macrophages.
Howell -Jolly bodiesJQJ

Swapped
Image
v .
_
(V
t
w . qi
394
SECTION III
Anemias
ANEMIAS
1
MCV 80-100 fL
(Normocytic )
MCV < 80 fL
(Microcytic)
MCV > 100 fL

(Macrocytic )
NONHEMOLYTIC
HEMOLYTIC
(Reticulocyte count
(Reticulocyte count t )
NON MEGALOBLASTIC
MEGALOBLASTIC
normal or i)
INTRINSIC
[ Sideroblastic anemia3
C
(
ACD (late)
X
I
Lead poisoning
Thalassemias
Iron deficiency (late)
J (
I r o n deficiency (early)
D C
ACD (early)
] (
Aplastic anemia
) (
Chronic kidney disease
EXTRINSIC
RBC membrane defect:

hereditary spherocytosis
RBC enzyme deficiency:
G6PD pyruvate kinase
Autoimmune
F o l a t e deficiency
I
B deficiency
' '
J (
L i v e r disease
) (
Alcoholism
Orotic aciduria
] (
Diamond-Blackfan anemia
( Macroangiopathic ) f
Keetons
HbC disease
J(
'
( Microangiopathic ) (
""
hemoglobinuria
( SALTI)
Sickle cell anemia
On a peripheral blood smear, a lymphocyte nucleus is approximately the same size as a normocytic RBC. If RBC is larger than lymphocyte nucleus, consider macrocytosis; if RBC is smaller,
consider microcytosis.
aCopper deficiency can cause a microcytic sideroblastic anemia .
Microcytic ( MCV < 80 fL ), hypochromic anemia

Iron deficiency
I iron due to chronic bleeding (eg, GI loss, menorrhagia), malnutrition, absorption disorders, GI
surgery (eg, gastrectomy! or t demand (eg, pregnancy) t final step in heme synthesis.
Labs: i iron, t TIBC, i ferritin, l transferrin saturation . Microcytosis and hypochromasia (central
pallor) ElSymptoms: fatigue, conjunctival pallor Q, pica (consumption of nonfood substances), spoon nails
(koilonychia).
May manifest as glossitis, cheilosis] Plummer-Vinson syndrome (triad of iron deficiency anemia,
esophageal webs, and dysphagia).
a- thalassemia
Defect: a-globin gene deletions
i a-globin synthesis, cis deletion ( both deletions occur on

deletion (deletions occur on separate
chromosomes) prevalent in African populations.
4 allele deletion: r o a-globin. Excess y-globin forms ( Hb Barts). Incompatible with life (causes
hydrops fetalis).
3 allele deletion: inheritance of chromosome with cis deletion + a chromosome with 1 allele
deleted HbH disease. Very little a-globin. Excess p-globin forms ( HbH)
2 allele deletion: less clinically severe anemia.
1 allele deletion: no anemia (clinically silent).
same chromosome) prevalent in Asian populations; trans
'
Microcytic ( MCV < 80 fL ), hypochromic anemia ( continued )
P-thalassemia
SECTION III
395
Point mutations in splice sites and promoter sequences i p-globin synthesis. Prevalent in
Mediterranean populations.
P-thalassemia minor ( heterozygote): p chain is underproduced. Usually asymptomatic. Diagnosis
confirmed by t HbA2 (> 3.5%) on electrophoresis.
P-thalassemia major ( homozygote): P chain is absent severe microcytic, hypochromic
anemia with target cells and increased anisopoikilocytosis Q requiring blood transfusion
( 2 hemochromatosis). Marrow expansion ( crew cut on skull x-ray) skeletal deformities.
Chipmunk facies . Extramedullary hematopoiesis hepatosplenomegaly. t risk of parvovirus
B19-induced aplastic crisis t HbF (a2y2). bF is protective in the infant and disease becomes
symptomatic only after 6 months, when fetal hemoglobin declines.
HbS/ p-thalassemia heterozygote: mild to moderate sickle cell disease depending on amount of
P-globin production.
Lead poisoning
PATHOLOGY
Lead inhibits ferrochelatase and ALA dehydratase -* i heme synthesis and t RBC protoporphyrin .
Also inhibits rRNA degradation RBCs retain aggregates of rRNA ( basophilic stippling ).
Symptoms of LEAD poisoning:
Lead Lines on gingivae ( Burton lines) and on metaphyses of long bones Q] on x-ray.
Encephalopathy and Erythrocyte basophilic stippling.
* Abdominal colic and sideroblastic Anemia .
* Drops
wrist and foot drop. Dimercaprol and EDTA are 1st line of treatment .
Succimer used for chelation for kids ( It sucks to be a kid who eats lead ).
Exposure risk t in old houses with chipped paint .
1
>
Sideroblastic anemia
y.:
0O% O n
> Oft tt
[Causes: genetic (eg, X-linked defect in A-ALA synthase gene), acquired!( myelodvsplastic
syndromes), and reversible (alcohol is most common ; also lead , vitamin B6 deficiency, copper
deficiency, isoniazid ).
Lab findings: t iron , normal / i TIBC , t ferritin . Ringed sideroblasts ( with iron-laden, Prussian
blue-stained mitochondria ) seen in bone marrow Q. Peripheral blood smear: basophilic stippling
of RBCs.
Treatment: pyridoxine ( B6, cofactor for 5-ALA synthase).
2P 0rS5
m
q
396
SECTION III
Macrocytic ( MCV > 100 fL ) anemia

DESCRIPTION
PATHOLOGY
FINDINGS
Impaired DNA synthesis maturation of

nucleus of precursor cells in bone marrow
delayed relative to maturation of cytoplasm .
RBC macrocvtosis, hypersegmented

neutrophils Q, glossitis.
Folate deficiency
Causes: malnutrition (eg, alcoholics),

malabsorption , drugs (eg, methotrexate,
trimethoprim , phenytoin ), t requirement (eg,
hemolytic anemia , pregnancy).
t homocysteine, normal methylmalonic acid.

No neurologic symptoms (vs Bp deficiency).
Vitamin B12
(cobalamin )
deficiency
Causes: insufficient intake (eg, veganism ),

malabsorption (eg, Crohn disease), pernicious
anemia , Diphyllobothrium latum (fish
tapeworm), gastrectomy.
t homocysteine, t methylmalonic acid.

Neurologic symptoms: dementia , subacutcl
combined degeneration (due to involvement of
Megaloblastic anemia
4Q
o^
0
Bp in fatty acid pathways and myelin synthesis):

spinocerebellar tract, lateral corticospinal tract,
dorsal column dysfunction .
Historically diagnosed with the Schilling test,
a 4-stage test that determines if the cause is
dietary insufficiency vs malabsorption .
Anemia secondary to insufficient intake may take
several years to develop due to livers ability to
store Bp (as opposed to folate deficiency).
Orotic aciduria
Inability to convert orotic acid to UMP

(de novo pyrimidine synthesis pathway)
because of defect in UMP synthase.
Autosomal recessive. Presents in children as
failure to thrive, developmental delay, and
megaloblastic anemia refractor}' to folate
and Bp. No hyperammonemia (vs ornithine
transcarbamylase deficiency t orotic acid
with hyperammonemia ).
Orotic acid in urine.

Treatment: uridine monophosphate to bypass
mutated enzyme.
Nonmegaloblastic
anemia
Diamond - Blackfan
anemia
Macrocytic anemia in which DNA synthesis is

unimpaired.
Causes: alcoholism , liver disease .
RBC macrocvtosis without hypersegmented
Rapid-onset anemia within 1st year of life due to

intrinsic defect in ervthroid progenitor cells.
t 7c HbF ( but i total Hb).

Short stature, craniofacial abnormalities, and
upper extremity malformations ( triphalangeal
thumbs) in up to 50% of cases.
neutrophils.
Normocytic,
normochromic anemia
SECTION III
397
Normocytic, normochromic anemias are classified as nonhemolytic or hemolytic. The hemolytic

anemias are further classified according to the cause of the hemolysis (intrinsic vs extrinsic to the
RBC ) and by the location of the hemolysis (intravascular vs extravascular).
Intravascular
hemolysis
Findings: 1 haptoglobin, t LDH, schistocytes and t reticulocytes on blood smear. Characteristic

hemoglobinuria, hemosiderinuria, and urobilinogen in urine. May also see t unconjugated
bilirubin. Notable causes are mechanical hemolysis (eg, prosthetic valve), paroxysmal nocturnal
hemoglobinuria, microangiopathic hemolytic anemias.
Extravascular
hemolysis
Findings: macrophages in spleen clear RBCs. Spherocytes in peripheral smear, t LDH, no

hemoglobinuria/hemosiderinuria, t unconjugated bilirubin, which can cause jaundice. Can
present with urobilinogen in urine.
Nonhemolytic, normocytic anemia

DESCRIPTION
Anemia of chronic
disease
Inflammation t hepcidin (released by liver,

binds ferroportin on intestinal mucosal
cells and macrophages, thus inhibiting
iron transport) -* I release of iron from
macrophages and i iron absorption from gut.
FINDINGS
1 iron, 1 TIBC, t ferritin.

Normocytic, but can become microcytic.
Treatment: EPO (chronic kidney disease only).
Associated with conditions such as rheumatoid

arthritis, SLE, neoplastic disorders, and
chronic kidney disease.
Aplastic anemia
>
m
?
X
t.
Caused by failure or destruction of myeloid

stem cells due to:
a Radiation and
drugs (benzene,
chloramphenicol, alkylating agents,
antimetabolites)
Viral agents (parvovirus B19, EBV, HIV,
hepatitis viruses)
Fanconi anemia (DNA repair defect
causing bone marrow failure; macrocytosis
may be seen on CBC ); also short staturej
t incidence of tumors/leukemia, cafe-au-lait
spots, thumb/radial defects
Idiopathic (immune mediated, 1 stem cell
defect); may follow acute hepatitis
5
1 reticulocyte count, t EPO.

Pancytopenia characterized by severe anemia,
leukopenia, and thrombocytopenia. Normal
cell morphology, but hvpocellular bone
marrow with fatty infiltration Q (dry bone
marrow tap).
Symptoms: fatigue, malaise, pallor, purpura,
mucosal bleeding, petechiae, infection.
Treatment: withdrawal of offending
agent, immunosuppressive regimens (eg,
antithvmocyte globulin, cyclosporine), bone
marrow allograft, RBC/platelet transfusion,
bone marrow stimulation (eg, GM-CSF).
398
SECTION III
LONG PAGE - Edit to lose lines?
Intrinsic hemolytic anemia

DESCRIPTION
FINDINGS
Hereditary
spherocytosis
Extravascular hemolysis due to defect in

proteins interacting with RBC membrane
skeleton and plasma membrane (eg, ankyrin,
band 3, protein 4.2, spectrin). Mostly
autosomal dominant inheritance .
Results in small, round RBCs with less surface
area and no central pallor (t MCHC)
-* premature removal by spleen.
Splenomegaly, aplastic crisis ( parvovirus B19

infection).
Labs: osmotic fragility test . Normal to
l MCV with abundance of cells.
Treatment: splenectomy.
G6PD deficiency
Most common enzymatic disorder of RBCs.

Causes extravascular and intravascular
Back pain, hemoglobinuria a few days after

oxidant stress.
Labs: blood smear shows RBCs with Heinz
bodies and bite cells.
Stress makes me eat bites of fava beans with
Heinz ketchup.
hemolysis.
X-linked recessive.
Defect in G6PD 1 glutathione t RBC
susceptibility to oxidant stress. Hemolytic
anemia following oxidant stress (eg, sulfa
drugs, antimalarials, infections, fava beans).
Autosomal recessive. Defect in pyruvate kinase

1 ATP rigid RBCs extravascular
hemolysis.
Glutamic acid-to-lysine mutation in P-globin.
Causes extravascular hemolysis.
Pyruvate kinase
deficiency
HbC disease
Hemolytic anemia in a newborn.
Patients with HbSC ( 1 of each mutant gene)

have milder disease than HbSS patients.
Labs ( homozygotes): blood smear shows
hemoglobin crystals inside RBCs and target
cells.
hemoglobinuria
t complement-mediated intravascular RBC

lysis (impaired synthesis of CPI anchor for
decay-accelerating factor that protects RBC
membrane from complement). Acquired
mutation in a hematopoietic stem cell,
t incidence of acute leukemias. Patients
may complain of red or pink urine ( from the
Sickle cell anemia
HbS point mutation causes a single amino

acid replacement in P chain (substitution
of glutamic acid with valine). Causes
extravascular and intravascular hemolysis.
Triad: Coombs hemolytic anemia,

pancytopenia, and venous thrombosis.
Labs: CD 55 /59 RBCs on flow cytometry.
Treatment: eculizumab (terminal complement
inhibitor).
hemoglobinuriaj
v
*
^
Pathogenesis: low 02, high altitude, or acidosis

precipitates sickling (deoxvgenated HbS
polymerizes) -* anemia and vaso-occlusive
disease.
Newborns are initially asymptomatic because of
t HbF and I HbS.
Heterozygotes (sickle cell trait) also have
resistance to malaria.
8% of African Americans carry an HbS allele.
Sickle cells are crescent-shaped RBCs EJ.
Crew cut on skull x-ray due to marrow
expansion from t erythropoiesis (also seen in
thalassemias).
Complications in sickle cell disease:

Aplastic crisis (due to parvovirus B19).
Autosplenectomv (Howell-Jolly bodies)
-* t risk of infection by encapsulated
organisms ( eg, S pneumoniae ).
Splenic infarct /sequestration crisis.
Salmonella osteomyelitis.
Painful crises (vaso-occlusive): dactylitis Q
(painful swelling of hands/feet), priapism,
acute chest syndrome, avascular necrosis,
0
stroke.
Renal papillary necrosis (1 Po2 in papilla) and

microhematuria (medullary infarcts).
Diagnosis: hemoglobin electrophoresis.
Treatment: hydroxyurea ( t HbF), hydration.
PATHOLOGY
SECTION III
399
Extrinsic hemolytic anemia

DESCRIPTION
Autoimmune
hemolytic anemia
FINDINGS
Warm ( IgG) chronic anemia seen in SLE

and CLL and with certain drugs (eg,
a-methyldopa) ( warm weather is Great ).
Cold ( IgM and complement ) acute
anemia triggered by cold; seen in CLL,
infections, and
Mycoplasma
infectious Mononucleosis ( cold weather is
MMMiserable ). RBC agglutinates Q may
cause painful, blue fingers and toes with cold
exposure.
Many warm and cold AIHAs are idiopathic in
Autoimmune hemolytic anemias are usually

Coombs .
Direct Coombs test anti- Ig antibody ( Coombs
reagent ) added to patients RBC ? j RBCs
agglutinate if RBCs are coated with Ig.
Indirect Coombs test normal RBCs added to
patients serum . If serum has anti-RBC surface
Ig, RBCs agglutinate when Coombs reagent
added .
etiology.
Patient component
Reagent( s)
Result
( agglutination )
!
I
X/
RBCs +/- anti-RBC Ab
-<
A x
Patient serum +/anti-donor RBC Ab
0 Result
(no agglutination )
-C A
Anti- human globulin

(Coombs reagent )
j*
Y
0Result
Anti-RBC Ab present
Result
Anti-RBC Ab absent
K
Donor blood
.Sx
Anti-human globulin
(Coombs reagent)
Result
Anti-donor RBC Ab present
Y
Result
Anti-donor RBC Ab absent
Microangiopathic
anemia
Pathogenesis: RBCs are damaged when passing

through obstructed or narrowed vessel lumina.
Seen in PIC, TTP/ HUS, SLE, HELLP
syndrome, and malignant hypertensioij
Schistocytes (eg, helmet cells ) are seen on

peripheral blood smear due to mechanical
destruction ( schisto = to split) of RBCs.
Macroangiopathic
anemia
Prosthetic heart valves and aortic stenosis may

also cause hemolytic anemia 2 to mechanical
destruction of RBCs.
Schistocytes on peripheral blood smear.
Infections
t destruction of RBCs (eg, malaria , Babesia ).
Heme synthesis
porphyrias, and lead
poisoning
SECTION III
401
The porphyrias are hereditary or acquired conditions of defective heme synthesis that lead to the
accumulation of heme precursors. Lead inhibits specific enzymes needed in heme synthesis,
leading to a similar condition.
CONDITION
AFFECTED ENZYME
ACCUMULATED SUBSTRATE
Lead poisoning
Ferrochelatase and
ALA dehydratase
Protoporphyrin, 5-ALA Microcytic anemia ( basophilic stippling in

peripheral smear , ringed sideroblasts in
(blood)
bone marro\ , GI and kidney disease.
Children exposure to lead paint mental
deterioration.
Adults environmental exposure (eg, batteries,
ammunition) -* headache, memory loss,
demyelination.
PRESENTING SYMPTOMS
Acute intermittent
porphyria
Porphobilinogen
deaminase
Porphobilinogen,
5-ALA,
coporphobilinogen
Symptoms ( 5 Ps):
Painful abdomen
Port wine-colored urine
0
Polyneuropathy
Psychological disturbances
Precipitated by drugs (eg, cytochrome P-450
inducers), alcohol, starvation
Treatment: glucose and heme, which inhibit
ALA synthase. Exacerbated with alcohol
consumption.
(urine)
Porphyria cutanea
tarda
Uroporphyrinogen
decarboxylase
Uroporphyrin (teacolored urine)
Blistering cutaneous photosensitivitv and

hvperpigmentatioi Q. Most common
porphyria.
Most common porphyria. Exacerbated with
alcohol consumption.
V
Location
Enzymes
Intermediates
Diseases
Glucose, heme
Mitochondria
Glycine + succinyl-CoA
B
u
I'
6- aminolevulinic acid synthase:

rate-limiting step
Sideroblastic anemia (X linked)
Lead poisoning
( Acute intermittent porphyria
^
^
Uroporphyrinogen decarboxylase
Porphyria cutanea tarda
Ferrochelatase
Lead poisoning
5-aminolevulinic acid
5-aminolevulinic acid dehydratase
^
(
Porphobilinogen
Porphobilinogen deaminase
Hydroxymethylbilane
Cytoplasm
Uroporphyrinogen III
Coproporphyrinogen III
Mitochondria
-A
Protoporphyrin
f
Heme
iheme - T ALA synthase activity

T heme - l ALA synthase activity
402
SECTION III
Iron poisoning
High mortality rate with accidental ingestion by children (adult iron tablets may look like candy).
MECHANISM
Cell death due to peroxidation of membrane lipids.
SYMPTOMS/SIGNS
Nausea, vomiting, gastric bleeding, lethargy, scarring leading to GI obstruction.
TREATMENT
Chelation (eg, IV deferoxamine, oral deferasirox) and dialysis.
Coagulation disorders
PT tests function of common and extrinsic pathway (factors I, II, V, VII, and X ). Defect t PT.
INR (international normalized ratio) calculated from PT. 1 = normal, > 1 = prolonged. Most
common test used to follow patients on warfarin.
PIT tests function of common and intrinsic pathway (all factors except VII and XIII). Defect
t PTT.
Coagulation disorders can be due to clotting factor deficiencies or acquired inhibitors. Diagnose
with a mixing study, where normal plasma is added to patient s plasma. Clotting factor
deficiencies are corrected, whereas factor inhibitors are not corrected.
PTT
MECHANISM AND COMMENTS
Hemophilia A , B, or C
Intrinsic pathway coagulation defect.

A: deficiency of factor VIII t PTT; X-linked recessive.
B: deficiency of factor IX t PTT; X-linked recessive.
* C: deficiency of factor XI t PTT; autosomal recessive.
Macrohemorrhage in hemophilia hemarthroses (bleeding into joints, such
as knee Q), easy bruising, bleeding after trauma or surgery (eg, dental
procedures).
Treatment: desmopressin + factor VIII concentrate (A); factor IX concentrate
(B); factor XI concentrate (C).
Vitamin K deficiency
General coagulation defect. Bleeding time normal.

I activity of factors II, VII, IX, X, protein C, protein S.
DISORDER
_PT
Platelet disorders
PATHOLOGY
SECTION III
403
Defects in platelet plug formation t bleeding time ( BT ).

Platelet abnormalities -* microhemorrhage: mucous membrane bleeding, epistaxis, petechiae ,
purpura , t bleeding time, possibly decreased platelet count ( PC).
DISORDER
PC
BT
MECHANISM AND COMMENTS
Bernard -Soulier
-H
Defect in platelet plug formation . Large platelets.

1 Gplb -* defect in platelet-to-vWF adhesion.
Defect in platelet integrin (XmJT (GpIIb/ IIIa ) defect in platelet-to-platelet

aggregation , and therefore platelet plug formation!
flâbs: blood smear shows no platelet clumping.
syndrome
Glanzmann
thrombasthenia
"
Hemolytic- uremic
syndrome
Characterized by thrombocytopenia , microangiopathic hemolytic anemia , and

acute renal failure.
Typical HUS is seen in children, accompanied by diarrhea and commonly
) (eg, 0157: H 7 ). HLJS in adults
caused by Enterohemorrhagic E coli ( EHEC|
does not present with diarrhea; EHECj infection not required .
Same spectrum as TIP, with a similar clinical presentation and same initial
treatment of plasmapheresis.
Immune
thrombocytopenia
Anti-GpIIb/ IIIa antibodies splenic macrophage consumption of

platelet-antibodv complex. May be primary disorder or secondary to
autoimmune disorder, viral illness, malignancy, or drug reaction!
Labs: t megakaryocytes on bone marrow biopsy.
Treatment: steroids, IVIG , splenectomy (for refractory ITP).
Thrombotic
thrombocytopenic
Inhibition or deficiency of ADAMTS 13 (vWF metalloprotease)

-* 1 degradation of vWF multimers.
Pathogenesis: t large vWF multimers t platelet adhesion t platelet
aggregation and thrombosis.
Labs: schistocytes, t LDII .
Symptoms: pentad of neurologic and renal symptoms, fever, thrombocytopenia,
and microangiopathic hemolytic anemia .
Treatment: plasmapheresis, steroids.
purpura
PATHOLOGY
SECTION III
405
Blood transfusion therapy

COMPONENT
DOSAGE EFFECT
CLINICAL USE
Packed RBCs
Acute blood loss, severe anemia
Platelets
t Hb and 07 carrying capacity

t platelet count ( t ~ 5000/mmVunit)
Fresh frozen plasma /
t coagulation factor levels
DIC, cirrhosis, immediate warfarin reversal
Stop significant bleeding (thrombocytopenia ,

qualitative platelet defects)
prothrombin complex
concentrate)
Coagulation factor deficiencies involving

fibrinogen and factor VIII
Blood transfusion risks include infection transmission ( low ), transfusion reactions, iron overload ( may lead to 2
hemochromatosis), hypocalcemia ( citrate is a Ca -+ chelator), and hyperkalemia ( RBCs may lyse in old blood units).
Cryoprecipitate
Contains fibrinogen , factor VIII , factor XIII,

vWF, and fibronectin
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. Presentations often blur definitions.
Hodgkin vs
non - Hodgkin
lymphoma
Hodgkin
Non - Hodgkin
Localized, single group of nodes; contiguous
Multiple lymph nodes involved ; extranodal
spread (stage is strongest predictor of

prognosis ). Many patients have a relatively
good prognosis.
involvement common; noncontiguous spread.
Characterized by Reed-Sternberg cells.
Majority involve B cells; a few are of T-cell
Bimodal distribution-young adulthood and

> 55 years; more common in men except for
nodular sclerosing type.
Can occur in children and adults.
Associated with EBV.
May be associated with HIV and autoimmune
Constitutional ( B ) signs/symptoms: low-grade

fever, night sweats, w eight loss]
May present with constitutional ( B ) signs/

symptoms]
lineage.
diseases.
Hodqkin lymphomal
if
I riC A
. -4
Contains Reed-Sternberg cells: distinctive tumor giant cells; binucleate or bilobec with the 2 halves
as mirror images ( owl eyes Q). 2 owl eyes x 15 = 30. RS cells are CD15+ and CD30+ B -cell
origin. Necessary but not sufficient for a diagnosis of Hodgkin lymphoma.
SUBTYPE
NOTES
Nodular sclerosis
Lymphocyte-rich
Most common
Mixed cellularity
Eosinophilia , seen in immunocompromised
Lymphocyte depleted
Seen in immunocompromised patients
Best prognosis
patients
406
SECTION III

LONG PAGE
- Edit to fit?
Non-Hodgkin lymphoma
TYPE
OCCURS IN
GENETICS
COMMENTS
t(8;14) translocation
Starry sky appearance, sheets of lymphocytes

with interspersed tingible body macrophages
Neoplasms of mature B cells

Burkitt lymphoma
Adolescents or young
adults
Diffuse large B- cell

lymphoma
Usually older adults,
Follicular lymphoma
Adults
Mantle cell lymphoma
Adult males
but 20% in children
of c-myc (8) and

heavy-chain Ig ( 14)
(arrows in Q).
Associated with EBV.
Jaw lesion [j] in endemic form in Africa; pelvis
or abdomen in sporadic form.
Alterations in Bcl-2,
Most common type of non-Hodgkin lymphoma
in adults.
Bcl-6
t(14;18) translocation Indolent course; Bcl-2 inhibits apoptosis.
of heavy-chain Ig ( 14)
Presents with painless waxing and waning
and BCL-2 (18)
lymphadenopathv. Follicular architecture:
small cleaved cells ( grade 1), large cells ( grade
3), or mixture ( grade 2).
translocation
t ( 11;14)
Very aggressive, patients typically present with
late-stage disease.
of cyclin D1 ( 11) and
heavy-chain Ig ( 14),
CD 5+
Associated with chronic inflammatorv diseases
tf 11,18)
( Sjogren syndrome, chronic gastritis [ MALT
lymphoma]).
Considered an AIDS-defining illness. Variable
Most commonly
associated with HIV/
presentation: confusion, memory loss,
AIDS; pathogenesis
seizures. Mass lesion(s) on MRI, needs to be
involves EBV
distinguished from toxoplasmosis via CSF
infection
analysis or other lab tests.
Marqinal cell
lymphoma
Adults
Primary central
nervous system
lymphoma
Adults
Neoplasms of mature T cells

Adult T- cell lymphoma
Adults
Mycosis fungoides/
Sezary syndrome
Adults
Caused by HTLV
(associated with IV
drug abuse)
Adults present with cutaneous lesions; especially

affects populations in Japan, West Africa, and
the Caribbean.
Lytic bone lesions, hypercalcemia.
Mycosis fungoides presents with skin patches 0/
plaques (cutaneous T-cell lymphoma),
characterized by atypical CD4+ cells with
cerebriform nuclei and intraepidermal
aggregates of neoplastic cells ( Pautrier
microabscess). May progress to Sezary
syndrome (T-cell leukemia).
fc
Multiple myeloma
M spike ;
Albumin
q 02
Monoclonal plasma cell ( fried egg"

appearance) cancer that arises in the marrow
and produces large amounts of IgG ( 55%) or
IgA ( 25%). Bone marrow > 10% monoclonal
plasma cells. Most common 1 tumor arising
within bone in people > 40-50 years old.
Associated with:
t susceptibility to infection
Primary amyloidosis (AL)
Punched-out lytic bone lesions on x-ray Q
M spike on serum protein electrophoresis
Ig light chains in urine ( Bence Jones
protein)
Rouleaux formation Q ( RBCs stacked like
poker chips in blood smear)
Numerous plasma cells Q with clock-face
chromatin and intracytoplasmic inclusions
0
SECTION III
Think CRAB:
HyperCalcemia
Renal involvement
Anemia
Bone lytic lesions/Back pain
Multiple Myeloma: Monoclonal M protein

spike
Distinguish from Waldenstrom
macroglobulinemia M spike = IgM
-* hyperviscosity syndrome (eg, blurred vision,
Raynaud phenomenon); no CRAB findings.
containing immunoglobulin.
Monoclonal gammopathy of undetermined
significance (MGUS) monoclonal expansion
of plasma cells (bone marrow < 10%
monoclonal plasma cells), asymptomatic,
may lead to multiple myeloma. No CRAB
findings. Patients with MGUS develop
multiple myeloma at a rate of 1-2% per year.
&
. Ar/\
<
Myelodysplastic
syndromes
Stem-cell disorders involving ineffective

hematopoiesis -* defects in cell maturation of
all nonlymphoid lineages. Caused by de novo
mutations or environmental exposure (eg,
radiation, benzene, chemotherapy). Risk of
transformation to AML .
407
Pseudo-Pelger-Huet anomaly neutrophils

with bilobed nuclei. Typically seen after
chemotherapy,
408
SECTION III
PATHOLOGY
Unregulated growth and differentiation of WBCs in bone marrow -* marrow failure -* anemia
( A RBCs), infections ( 1 mature WBCs), and hemorrhage ( 1 platelets). Usually presents with
t circulating WBCs ( malignant leukocytes in blood ); rare cases present with normal /1 WBCs.
Leukemic cell infiltration of liver, spleen, lymph nodes, and skin ( leukemia cutis) possible.
Leukemias
TYPE
NOTES
Lymphoid neoplasms
Acute lymphoblastic
leukemia / lymphoma
Chronic lymphocytic
leukemia /small
lymphocytic
lymphoma
Hairy cell leukemia
Most frequently occurs in children; less common in adults (worse prognosis). T-cell ALL can
present as mediastinal mass ( presenting as SVC-like syndrome). Associated with Down syndrome.
Peripheral blood and bone marrow have 111 lymphoblasts Q.
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.
Age: > 60 years. Most common adult leukemia. CCD20 +, CD2 > 4 j CD 5+ B-cell neoplasm .
Often asymptomatic, progresses slowly; smudge cells Q in peripheral blood smear; autoimmune
hemolytic anemia. CLL = Crushed Little Lymphocytes (smudge cells).
Richter transformation SLL /CLL transformation into an aggressive lymphoma , most commonly
diffuse large B-cell lymphoma ( DLBCL).
Age: Adult males. Mature B-cell tumor. Cells have filamentous, hair-like projections
(fuzzy appearing on LM H ).
Causes marrow fibrosis -* dry tap on aspiration . Patients usually present with massive splenomegaly
and pancytopenia!
Stains TRAP (tartrate-resistant acid phosphatase) . TRAP stain largely replaced with flow
cytometry.
Treatment: cladribine, pentostatin.
Myeloid neoplasms
Acute myelogenous
leukemia
Median onset 65 years. Auer rods 0; myeloperoxidase cytoplasmic inclusions seen mostly in
APL ( formerly M 3 AML); 111 circulating myeloblasts on peripheral smear; adults.
Risk factors: prior exposure to alkylating chemotherapy, radiation , myeloproliferative disorders,
Down syndrome. APL: t ( 15;17 ), responds to all-trans retinoic acid ( vitamin A ), inducing
differentiation of promyelocytes; D1C is a common presentation!
Chronic myelogenous
leukemia
Occurs across the age spectrum with peak incidence 45-85 years, median age at diagnosis 64 years
Defined by the Philadelphia chromosome (t[9;22], BCR-ABL ) and myeloid stem cell proliferation .
Presents with dysregulated production of mature and maturing granulocytes (eg, neutrophils,
metamyelocytes, myelocytes, basophils Q) and splenomegaly. May accelerate and transform to
AML or ALL ( blast crisis ).
Very low LAP as a result of low activity in malignant neutrophils (vs benign neutrophilia
[ leukemoid reaction], in which LAP is t ).
Responds to bcr-abl tyrosine kinase inhibitors (eg, imatinib).
<
m
^
:
9
La?0
Chronic
myeloproliferative
disorders
409
SECTION III
The myeloproliferative disorders (polycythemia vera, essential thrombocythemia, myelofibrosis, and

CML) are malignant hematopoietic neoplasms with varying impacts on WBCs and myeloid cell
lines. Associated with V617F JAK 2 mutation.
Polycythemia vera
A form of 1 polycythemia. Disorder of t hematocrit. May present as intense itching after

hot shower. Rare but classic symptom is erythromelalgia (severe, burning pain and red-blue
coloration) due to episodic blood clots in vessels of the extremities Q. J
1 EPO (vs 2 polycythemia, which presents with endogenous or artificially t EPO). Treatment is
phlebotomy, hydroxyurea, ruxolitinib ( JAK 1/ 2 inhibitor).
Essential
thrombocythemia
Characterized by massive proliferation of megakaryocytes and platelets. Symptoms include

bleeding and thrombosis. Blood smear shows markedly increased number of platelets, which may
be large or otherwise abnormally formed Q. Erythromelalgia may occur.
Myelofibrosis
Obliteration of bone marrow with fibrosis H due to t fibroblast activity. Often associated with
massive splenomegaly and teardrop RBCs Q. Bone marrow is crying because its fibrosed and
is a dry tap.
RBCs
WBCs
PLATELETS
PHILADELPHIA CHROMOSOME
M2 MUTATIONS
Polycythemia vera
Essential
thrombocythemia
e
e
( 30-50%)
Myelofibrosis
Variable
Variable
( 30-50%)
CML
ro
^
^
9G
Polycythemia
PLASMA VOLUME
Relative
EPO LEVELS
ASSOCIATIONS
02 SATURATION
-
Dehydration, burns.
Lung disease, congenital heart

disease, high altitude.
Malignancy (eg, renal cell

carcinoma, hepatocellular
RBCMASS
Appropriate absolute
Inappropriate absolute
carcinoma), hydronephrosis.
Due to ectopic EPO
secretion.
Polycythemia vera
tt
EPO i in PCV due to negative
feedback suppressing renal

EPO production.
410
SECTION III
PATHOLOGY
Chromosomal translocations
TRANSLOCATION
t(8;14)
t (9;22) (Philadelphia
chromosome)
ASSOCIATED DISORDER
Burkitt lymphoma (c-tnyc activation )
CML ( BCR-ABL hybrid ), ALL ( less common ,

poor prognostic factor!
Philadelphia CreaML cheese.

The Ig heavy chain genes on chromosome 14
are constitutivelv expressed. When other
genes (eg, c-myc and BCL-2 ) are translocated
next to this heavy chain gene region , they are
overexpressed .
Mantle cell lymphoma (cyclin D1 activation )

Follicular lymphoma ( BCL-2 activation )
APL ( M 3 type of AML)
Responds to all-frans retinoic acid .
Maliqnant cell surface
DISEASE
SURFACE MARKERS
markers
ALL
CD 10
CLL
CD 5, 19, 20, 23
AML
CD 13. 15, 64
t( ll;14)
t(14;18)
t(15;17 )
CML
Langerhans cell
histiocytosis
Hodgkin Lymphoma
CD 15. 30
Non - Hodgkin Lymphoma
CD 5 (Mantlet CD 20
Collective group of proliferative disorders of

dendritic ( Langerhans) cells. Presents in a
child as lytic bone lesions Q and skin rash or
as recurrent otitis media with a mass involving
the mastoid bone. Cells are functionally
immature and do not effectively stimulate
primary T cells via antigen presentation .
Cells express S-100 (mesodermal origin ) and
CDla. Birbeck granules ( tennis rackets or
rod shaped on EM ) are characteristic Q.
g&at
am
' MS
fcfsjfi
i3
V i
'
PHARMACOLOGY
411
SECTION III
PHARMACOLOGY
Heparin
MECHANISM
Lowers the activity of thrombin and factor Xa . Short half-life.
CLINICAL USE
Immediate anticoagulation for pulmonary embolism ( PE ), acute coronary syndrome, MI, deep
venous thrombosis ( DVT ). Used during pregnancy (does not cross placenta ). Follow FIT.
ADVERSE EFFECTS
Bleeding, thrombocytopenia ( HIT ), osteoporosis, drug-drug interactions. For rapid reversal

(antidote), use protamine sulfate ( positively charged molecule that binds negatively charged
heparin ).
Low-molecular-weight heparins (eg, enoxaparin , dalteparin ) act predominantly on factor Xa .
Fondaparinux acts only on factor Xa . Both have better bioavailabilitv, and 2-4 times longer half
life; car!be administered subcutaneously and without laboratory monitoring. Not easily reversible .
NOTES
Heparin - induced thrombocytopenia ( HIT ) development of IgG antibodies against heparin

bound platelet factor 4 ( PF4). Antibody-heparin -PF4 complex activates platelets thrombosis and
thrombocytopenia .
Direct thrombin
inhibitors
MECHANISM
CLINICAL USE
Bivalirudin ( related to hirudin , the anticoagulant used by leeches), dabigatran , argatrobanj
Directly inhibits activity of free and clot-associated thrombin .

Venous thromboembolism, atrial fibrillation. Can be used in HIT. Does not require lab
monitoring.
ADVERSE EFFECTS
Bleeding; reverse dabigatran with idaruci /. umab. Can attempt to use activated prothrombin
complex concentrates ( PCC ) and/or antifibrinolytics (eg, tranexamic acid ) if no reversal agent
available!
412
SECTION III
HEMATOLOGY AND ONCOLOGY PHARMACOLOGY
Warfarin
MECHANISM
Interferes with y-carboxylation of vitamin In

dependent clotting factors II, VII, IX, and X,
and proteins C and S. Metabolism affected
by polymorphisms in the gene for vitamin
K epoxide reductase complex (VKORC1).
In laboratory assay, has effect on EXtrinsic
pathway and t PT. Long half-life.
CLINICAL USE
Chronic anticoagulation (eg, venous

thromboembolism prophylaxis, and prevention
of stroke in atrial fibrillation). Not used in
pregnant women ( because warfarin, unlike
heparin, crosses placenta). Follow PT/INR.
ADVERSE EFFECTS
Bleeding, teratogenic, skin/tissue necrosis Q,
drug-drug interactions. Proteins C and S have

shorter half-lives than clotting factors II,
VII, IX, and X, resulting in early transient
hypercoagulability with warfarin use. Skin /
tissue necrosis within first few days of large
doses believed to be due to small vessel
microthromboses.
The EX-PresidenT went to war(farin).
For reversal of warfarin, give vitamin K.

For rapid reversal, give fresh frozen plasma or
prothrombin complex concentrate
Heparin bridging: heparin frequently used
when starting warfarin. Ileparin 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.
Heparin vs warfarin
ROUTE OF ADMINISTRATION
Heparin
Warfarin
Parenteral (IV, SC)
Oral
SITE OF ACTION
Blood
Liver
ONSET OF ACTION
Rapid (seconds)
Slow, limited by half-lives of normal clotting

factors
MECHANISM OF ACTION
Activates antithrombin, which 1 the action of

Ila (thrombin) and factor Xa
Impairs synthesis of vitamin K-dependent

clotting factors II, VII, IX, and X, and anti
clotting proteins C and S
Dayj
DURATION OF ACTION
Hoursj
AGENTS FOR REVERSAL
Protamine sulfate
MONITORING
PTT (intrinsic pathway)
PT/INR (extrinsic pathway)
CROSSES PLACENTA
No
Yes (teratogenic)
Vitamin K, fresh frozen plasma, prothrombin

complex concentrate
Direct factor Xa
inhibitors
SECTION III
413
ApiXaban, rivaroXaban.
MECHANISM
Bind to and directly inhibit factor Xa.
CLINICAL USE
Treatment and prophylaxis for DVT and PEj stroke prophylaxis in patients with atrial fibrillation.
Oral agents do not usually require coagulation monitoring.
ADVERSE EFFECTS
Bleeding. Not easily reversible. Experimental reversal agents (eg, andexanet alfa) in development
MECHANISM
Alteplase (tPA), reteplase (rPA), streptokinase, tenecteplase (TNK-tPA).

Directly or indirectly aid conversion of plasminogen to plasmin, which cleaves thrombin and fibrin
clots t PT, t PIT,' no change in platelet count .
CLINICAL USE
Early MI, early ischemic stroke, direct thrombolysis of severe PE.
ADVERSE EFFECTS
Bleeding. Contraindicated in patients with active bleeding, history of intracranial bleeding,

recent surgery, known bleeding diatheses, or severe hypertension. Reverse with antifibrinolvtics
( eg, aminocaproic acid, tranexamic acid ), platelet transfusions, and factor corrections ( eg,
crvopreeipitate, fresh frozen plasma, prothrombin complex concentrate). No specific reversal
agent
Thrombolytics
ADP receptor inhibitors

MECHANISM
Clopidogrel, prasugrel, ticagrelor (reversible), ticlopidine.

Inhibit platelet aggregation bv irreversibly blocking ADP ( P2Yn) receptot Prevent expression of
glycoproteins Ilb/IIIa on platelet surface.
CLINICAL USE
Acute coronary syndrome; coronary stenting. 1 incidence or recurrence of thrombotic stroke.
ADVERSE EFFECTS
Neutropenia (ticlopidine). TTP may be seen.
Cilostazol, dipyridamole
MECHANISM
Phosphodiesterase inhibitor ; t cAMP in platelets, resulting in inhibition of platelet aggregation;
vasodilators.
CLINICAL USE
Intermittent claudication, coronary vasodilation, prevention of stroke or TIAs (combined with
ADVERSE EFFECTS
Nausea, headache, facial flushing, hypotension, abdominal pain.
aspiring
Glycoprotein Ilb/ IIIa

inhibitors
Abciximab, eptifibatide, tirofiban.
MECHANISM
Bind to the glycoprotein receptor Ilb/IIIa on activated platelets, preventing aggregation. Abciximab
is made from monoclonal antibody Fab fragments.
CLINICAL USE
Unstable angina, percutaneous transluminal coronary angioplasty.
ADVERSE EFFECTS
Bleeding, thrombocytopenia.
NEUROLOGY AND SPECIAL SENSES
NEUROLOGY PATHOLOGY
487
SECTION III
Movement disorders
DISORDER
PRESENTATION
CHARACTERISTIC LESION
NOTES
Restlessness and intense urge

to movq
Extension of wrists causes
flapping motion
Can be seen with neuroleptic
Athetosis
Slow, writhing movements;
Basal ganglia (eg, Huntington)
Writhing, snake-like
movement.
Chorea
Sudden, jerky, purposeless
Basal ganglia (eg, Huntington)
Chorea = dancing.
Akathisial
Asterixis
use or in Parkinson disease
Associated with hepatic

encephalopathy, Wilsons
disease, and other metabolic
derangements.
especially seen in fingers
Svndenham chorea seen in

acute rheumatic fever.
movements
Dystonia
Sustained, involuntary muscle

contractions
Writers cramp; blepharospasm;

torticollis
Essential tremor
High-frequency tremor
with sustained posture
(eg, outstretched arms),
worsened with movement or
when anxious
Often familial. Patients often

self-medicate with alcohol,
which 1 tremor amplitude.
Treatment: nonselective
P-blockers (eg, propranolol ),
primidone.
Hemiballismus
Sudden, wild flailing of 1 arm

+/ ipsilateral leg
Contralateral subthalamic
nucleus (eg, lacunar stroke)
Intention tremor
Slow, zigzag motion when

pointing/extending toward a
Cerebellar dysfunction
Myoclonus
Sudden, brief, uncontrolled

muscle contraction
Jerks; hiccups; common in
Uncontrolled movement of distal Parkinson disease

appendages (most noticeable
in hands); tremor alleviated by
intentional movement
Occurs at rest; pill-rolling

tremor of Parkinson disease.
When vou park your car, it is
at rest.
Pronounce Half-of-body
ballistic."
Contralateral lesion.
target
Resting tremor
metabolic abnormalities such

as renal and liver failure.
SECTION III
415
Antimetabolites
DRUG
MECHANISM3
CLINICAL USE
ADVERSE EFFECTS
Azathioprine,
6- mercaptopurine
Purine (thiol) analogs

-* 1 de novo purine synthesis.
Activated by HGPRT.
Azathioprine is metabolized
into 6-MP.
Preventing organ rejection,

rheumatoid arthritis, IBD,
SLE; used to wean patients
off steroids in chronic disease
and to treat steroid-refractor}'
chronic disease.
Mvelosuppression, GI, liver.

Azathioprine and 6-MP are
metabolized by xanthine
Purine analog -* multiple

mechanisms (eg, inhibition
of DNA polymerase, DNA
strand breaks).
Hairy cell leukemia.
Mvelosuppression,
nephrotoxicity, and
Cladribine
Cytarabine
(arabinofuranosyl
cytidine)
oxidase; thus both have

t toxicity with allopurinol or
febuxostat.
neurotoxicity.
Pyrimidine analog inhibition Leukemias (AML), lymphomas. Mvelosuppression with

of DNA polymerase.
megaloblastic anemia.
CYTarabine causes
panCYTopenia.
5 - fluorouracil
Pyrimidine analog bioactivated

to 5-FdUMP, which
covalently complexes folic
Colon cancer, pancreatic

cancer, basal cell carcinoma
acid. Capecitabine is a
prodrug with similar activity
This complex inhibits
Effects enhanced with the

addition of leucovorin.
Mvelosuppression, palmarplantar ervthrodvsesthesial
( topical).
thymidylate synthase
- .i dTMP
Methotrexate
1 dTMP
synthesis.
aAll arc S-phase specific.
1 DNA
synthesis
Folic acid analog that
competitively inhibits
dihydrofolate reductase
1 DNA
Cancers: leukemias
(ALL), lymphomas,
choriocarcinoma, sarcomas.
Non-neoplastic: ectopic
pregnancy, medical
abortion (with misoprostol),
rheumatoid arthritis, psoriasis,
IBD, vasculitis.
Mvelosuppression, which is
reversible with leucovorin
rescue.
Hepatotoxicity.
Mucositis (eg, mouth ulcers).
Pulmonary fibrosis.
416
SECTION III
PHARMACOLOGY
Antitumor antibiotics
DRUG
MECHANISM
CLINICAL USE
ADVERSE EFFECTS
Bleomycin
Induces free radical formation

-* breaks in DNA strands.
Testicular cancer, Hodgkin

lymphoma.
Pulmonary fibrosis, skin

hyperpigmentation . Minimal
mvelosuppression.
Dactinomycin
(actinomycin D)
Intercalates in DNA.
Doxorubicin ,
daunorubicin
Wilms tumor, Ewing sarcoma ,

rhabdomyosarcoma . Used for
childhood tumors ( children
act out ).
Solid tumors, leukemias,
Generate free radicals.
Intercalate in DNA -* breaks in lymphomas.
DNA -* 1 replication .
Myelosuppression .
Cardiotoxicity (dilated
cardiomyopathy),
myelosuppression, alopecia.
Dexrazoxane ( iron chelating
agent), used to prevent
cardiotoxicity.
Alkylating agents
DRUG
MECHANISM
CLINICAL USE
ADVERSE EFFECTS
Busulfan
Cross-links DNA.
CML . Also used to ablate

patients bone marrow before
bone marrow transplantation .
Severe myelosuppression ( in
almost all cases), pulmonary
fibrosis, hyperpigmentation .
Cyclophosphamide,
ifosfamide
Nitrogen mustard; cross-link

DNA at guanine N-7. Require
Solid tumors, leukemia ,

lymphomas.
Myelosuppression; hemorrhagic
Brain tumors ( including
CNS toxicity (convulsions,

dizziness, ataxia).
bioactivation bv livei
cystitis, prevented with

mesna (thiol group of mesna
binds toxic metabolites) or
N-acetylcvsteine .
Nitrosoureas
(Carmustine,
lomustine,
semustine,
streptozotocini
Require bioactivation .
Cross blood-brain barrier
CNS. Cross link DNA.
glioblastoma multiforme).
PHARMACOLOGY
SECTION III
417
Microtubule inhibitors
DRUG
MECHANISM
CLINICAL USE
ADVERSE EFFECTS
Paclitaxel, other taxols
Hyperstabilize polymerized
microtubules in M phase so
that mitotic spindle cannot
break down (anaphase cannot
Ovarian and breast carcinomas.
Mvelosuppression , neuropathy,
hypersensitivity.
Solid tumors, leukemias,

Hodgkin (vinblastine) and
non-Hodgkin ( vincristine)
lymphomas.
Vincristine: neurotoxicity
(areflexia , peripheral neuritis),
occur).
Vincristine, vinblastine Vinca alkaloids that bind
p-tubulin and inhibit
its polymerization into
microtubules -* prevent
mitotic spindle formation
( M-phase arrest).
constipation ( including
paralytic ileus).
Cisplatin, carboplatin
MECHANISM
Cross-link DNA.
CLINICAL USE
Testicular, bladder, ovary, and lung carcinomas.

Nephrotoxicity, peripheral neuropathy, ototoxicity. Prevent nephrotoxicity with amifostine (free
radical scavenger) and chloride (saline) diuresis.
ADVERSE EFFECTS
Etoposide, teniposide
MECHANISM
CLINICAL USE
ADVERSE EFFECTS
Etoposide inhibits topoisomerase II t DNA degradation .

Solid tumors ( particularly testicular and small cell lung cancer ), leukemias, lymphomas.
Mvelosuppression , alopecia .
Irinotecan, topotecan
CLINICAL USE
Inhibit topoisomerase I and prevent DNA unwinding and replication .

Colon cancer (irinotecan ); ovarian and small cell lung cancers (topotecan ).
ADVERSE EFFECTS
Severe mvelosuppression , diarrhea.
MECHANISM
Hydroxyurea
MECHANISM
Inhibits ribonucleotide reductase
CLINICAL USE
Melanoma , myeloproliferative syndromes (eg, CML, polvcvthemia vera ), sickle cell ( T HbF ) j
ADVERSE EFFECTS
Severe mvelosuppression .
1 DNA Synthesis (S phase specific).
418
SECTION III
PHARMACOLOGY
Prednisone, prednisolone
MECHANISM
Various; bind intracvtoplasmic steroid receptor; alter gene transcription .
CLINICAL USE
Most commonly used glucocorticoids in cancer chemotherapy. Used in CLL, non-Hodgkin

lymphoma ( part of combination chemotherapy regimen ). Also used as immunosuppressants (eg,
in autoimmune diseases).
Cushing-like symptoms; weight gain , central obesity, muscle breakdown , cataracts, acne,
osteoporosis, hypertension , peptic ulcers, hyperglycemia , psychosis.
ADVERSE EFFECTS
Bevacizumab
MECHANISM
Monoclonal antibody against VEGF. Inhibits angiogenesis.
CLINICAL USE
Solid tumors (colorectal cancer, renal cell carcinoma ).
ADVERSE EFFECTS
Hemorrhage, blood clots, and impaired wound healing.
Erlotinib
MECHANISM
EGFR tyrosine kinase inhibitor.
CLINICAL USE
Non-small cell lung carcinoma .
ADVERSE EFFECTS
Rash .
Cetuximab
MECHANISM
CLINICAL USE
ADVERSE EFFECTS
Monoclonal antibody against EGFR .

Stage IV colorectal cancer ( wild-type KRAS ) , head and neck cancer.
Rash , elevated LFTs, diarrhea.
Imatinib
MECHANISM
Tyrosine kinase inhibitor of BCR ABL ( Philadelphia chromosome fusion gene in CML) and c-kit
(common in GI stromal tumors).
CLINICAL USE
CML, GI stromal tumors (GIST j
ADVERSE EFFECTS
Fluid retention .
Rituximab
CLINICAL USE
Monoclonal antibody against CD20, which is found on most B -cell neoplasms.

Non- Hodgkin lymphoma , CLL , ITP, rheumatoid arthritis,
ADVERSE EFFECTS
t risk of progressive multifocal leukoencephalopathy.
MECHANISM
PHARMACOLOGY
SECTION III
419
Tamoxifen, raloxifene
MECHANISM
CLINICAL USE
ADVERSE EFFECTS
Selective estrogen receptor modulators (SERMs) receptor antagonists in breast and agonists in
bone. Block the binding of estrogen to ER cells.
Breast cancer treatment ( tamoxifen only) and prevention. Raloxifene also useful to prevent
osteoporosis.
Tamoxifen partial agonist in endometrium, which t the risk of endometrial cancer; hot flashes.
Raloxifene no t in endometrial carcinoma because it is an estrogen receptor antagonist in
endometrial tissue.
Both t risk of thromboembolic events (eg, DVT, PE ).
Trastuzumab ( Herceptin )
MECHANISM
Monoclonal antibody against HER-2 (c-erbB2 ), a tyrosine kinase receptor. Helps kill cancer cells
that overexpress HER-2 , through inhibition of HER 2-initiated cellular signaling and antibodydependent cytotoxicity.
CLINICAL USE
HER-2 breast cancer and gastric cancer (trasZzumab).
ADVERSE EFFECTS
Cardiotoxicity. Heartceptin damages the heart.
Vemurafenib
MECHANISM
Small molecule inhibitor of BRAF oncogene melanoma. VEmuRAF-enib is for V600Emutated BRAF inhibition .
CLINICAL USE
Metastatic melanoma.
Common
chemotoxicities
Cisplatin /Carboplatin
nephrotoxicity)
ototoxicity (and
peripheral neuropathy
Bleomycin , Busulfan pulmonary fibrosis
Vincristine
Doxorubicin -* cardiotoxicity
Trastuzumab ( Herceptin ) cardiotoxicity
Cisplatin /Carboplatin nephrotoxic (and
ototoxicity
CYclophosphamide
hemorrhagic cystitis
5 FU -* myelosuppression
6-MP -* myelosuppression
Hydroxyurea - myelosuppression
Methotrexate myelosuppression
Musculoskeletal, Skin,
and Connective Tissue
Rigid , the skeleton of habit alone upholds the human frame.
Beauty may be skin deep , but ugly goes clear to the bone."
Virginia Woolf
Leonardo da Vinci
thrive in life
you
422
Pathology
433
Dermatology
443
Pharmacology
453
Redd Foxx
The function of muscle is to pull and not to push, except in the case of
the genitals and the tongue .
To
Anatomy and
Physiology
need three bones. A wishbone. A backbone. And a
tunny bone.
Reba McEntire
421
422
SECTION III
MUSCULOSKELETAL, SKIN, AND CONNECTIVE TISSUE
ANATOMY AND PHYSIOLOGY
MUSCULOSKELETAL, SKIN, AND CONNECTIVE TISSUE- ANATOMY AND PHYSIOLOGY

Knee exam
ACL: extends from lateral femoral condyle to

anterior tibia.
PCL: extends from medial femoral condyle to
posterior tibia.
Perform knee exam with patient supine.

TEST
PROCEDURE
Anterior drawer sign
Bending knee at 90 angle, t anterior gliding

of tibia due to ACL injury. Lachman test is
similar, but at 30 angle.
Posterior drawer sign
Femur
Lateral
condyle
-^-
ACL
LCL
Lateral
meniscus
Fibula
Medial
condyle
PCL
V-MCL
Medial
meniscus
Tibia gg
ACL tear
Antenor drawer sign
Bending knee at 90 angle, t posterior gliding of

tibia due to PCL injury.
PCL tear
Posterior drawer sign
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.
McMurray test
During flexion and extension of knee with

rotation of tibia /foot:
Pain, popping on external rotation
-* medial meniscal tear
Pain, popping on internal rotation
lateral meniscal tear
Abduction
(valgus)
force
MCL tear
Adduction
LCL tear
(varus)
force
External
Medial tear
rotation
Internal
rotation
' P'
Lateral tear
0
Common fractures
Boxer 's fracture
Striking hard object with a closed fist
-* metacarpal neck fracture of 3th digit

Greenstick fracture
Bending force
radius
Torus fracture
compression fracture of distal
Axial force applied to immature bone -* simple

buckle fracture of cortex
ART GOES HERE FPO
424
SECTION III
Overuse injuries of the elbow
pain near medial epicondyle.
Medial epicondylitis
(golfer 's elbow )
Repetitive flexion (forehand shots) or idiopathic
Lateral epicondylitis
(tennis elbow )
Repetitive extension ( backhand shots) or idiopathic
Wrist bones
pain near lateral epicondyle.
Scaphoid, Lunate, Triquetrum,

Pisiform, Hamate, Capitate, Trapezoid,
Trapezium Q. (So Long To Pinky, Here
Comes The Thumb).
Scaphoid ( palpated in anatomic snuffbox ) is
the most commonly fractured carpal bone,
typically due to a fall on an outstretched hand.

Complications of proximal scaphoid fractures
include avascular necrosis and nonunion
owing to retrograde blood supply
Dislocation of lunate may cause acute carpal
tunnel syndrome
Carpal tunnel
syndrome
Entrapment of median nerve in carpal tunnel; nerve compression paresthesia, pain, and
numbness in distribution of median nerve ( thenar eminence atrophies but sensation spared,
because palmar cutaneous branch enters the hand external to carpal tunnel). Associated with
pregnancy ( due to edema!rheumatoid arthritis, hypothyroidism, diabetes, acromegaly dialysisrelated amyloidosis; may be associated with repetitive use. Tinel sign ( on percussion) and Phalen
maneuver (on 90 flexion) of wrist produces tingling.
Guyon canal
syndrome
Compression of ulnar nerve at wrist or hand. Classically seen in cyclists due to pressure from
handlebars.
MUSCULOSKELETAL , SKIN , AND CONNECTIVE TISSUE
SECTION III
425
Upper extremity nerves

NERVE
CAUSES OF INJURY
PRESENTATION
Axillary ( C5-C6)
Fractured surgical neck of humerus; anterior

dislocation of humerus
Flattened deltoid
Loss of arm abduction at shoulder (> 15 j)
Loss of sensation over deltoid muscle and lateral
Musculocutaneous
Upper trunk compression
Loss of forearm flexion and supination

Loss of sensation over lateral forearm
Radial (C 5-T1)
Midshaft fracture of humerus; compression of

axilla , eg, due to crutches or sleeping with arm
over chair ( Saturday night palsy )
Wrist drop: loss of elbow, wrist, and finger

extension
i grip strength (wrist extension necessary for
maximal action of flexors)
Loss of sensation over posterior arm /forearm and
dorsal hand
Median (C5-T1)
Supracondylar fracture of humerus ( proximal

lesion ); carpal tunnel syndrome and wrist
laceration (distal lesion )
Ape
Ulnar (C8-T1)
Fracture of medial epicondyle of humerus

funny bone ( proximal lesion ); fractured
hook of hamate (distal lesion ) from fall on
outstretched hancfl
Ulnar claw on digit extension

Radial deviation of w rist upon flexion ( proximal
Superficial laceration of palm
Ape
arm
(C5-C7 )
Recurrent branch of
median nerve (C5-T1)
Axillary nerve
^4
lesion )
Loss of w rist flexion , flexion of medial fingers,
abduction and adduction of fingers ( interossei),
actions of medial 2 lumbrical muscles
Loss of sensation over medial IV2 fingers
including hypothenar eminence
hand
Loss of thenar muscle group: opposition ,
abduction , and flexion of thumb
No loss of sensation
CB
Median nerve
Axillary nerve
Musculocutaneous nerve
Radial nerve
Ulnar nerve
Intercostobrachial
nerve
Medial antebrachial
Musculocutaneous nerve
"
cutaneous nerve
I
Radial nerve
Radial nerve
Medial brachial
Radial nerve
Recurrent branch
of median nerve
Ulnar nerve
^ cutaneous nerve
Radial nerve
,
Median nerve
hand and Popes blessing

Loss of wrist flexion, flexion of lateral fingers,
thumb opposition , lumbricals of 2nd and 3rd
digits
Loss of sensation over thenar eminence and
dorsal and palmar aspects of lateral 3 /2 fingers
with proximal lesionf
J
%
Palm of hand
Median nerve
Radial nerve
Ulnar nerve
Dorsum of hand
426
SECTION III
Brachial plexus lesions
O Erb palsy ('waiter's tip")

0 Klumpke palsy (claw hand)
0 Wrist drop
O Winged scapula
Deltoid paralysis
Saturday night palsy(wrist drop)
0 Difficulty flexing elbow, variable
sensory loss
Decreased thumb function,
'Pope's blessing'
C5
Randy
Lateral
Upper
Musculocutaneous
Travis
Drinks
Median (flexors)
Beer
Ulnar
C6
Axillary
Middle
Posterior 0
C7
(Extensors)
Cold
Radial
C8
Lower
Medial
Intrinsic muscles of hand,

claw hand
Trunks
T1
1 1
1 1 i
Divisions Cords
Branches
Long thoracic
J
L
Roots
CONDITION
INJURY
CAUSES
MUSCLE DEFICIT
FUNCTIONAL DEFICIT
Erb palsy ( waiter 's

tip")
Traction or
tear of upper
( Erb-er ) trunk:
C 5 -C6 roots
Infants lateral
traction on neck
during delivery
Deltoid,
supraspinatus
Abduction (arm
hangs by side)
Infraspinatus
Lateral rotation (arm

medially rotated)
Flexion, supination
Adults trauma
Biceps brachii
(arm extended and
pronated)
Klumpke palsy
Traction or tear
of lower trunk:
C8-T1 root
Infants upward
force on arm
during delivery
Adults trauma
(eg, grabbing a
tree branch to
break a fall)
Thoracic outlet
syndrome
Compression
of lower trunk
and subclavian
vessels
Cervical rib
(arrows in
Hi
Pancoast tumor
Intrinsic hand
muscles:
lumbricals,
interossei,
thenar,
hypothenar
Total claw hand:

lumbricals normally
flex MCP joints and
extend DIP and PIP
joints
Same as Klumpke Atrophy of intrinsic

hand muscles;
palsy
ischemia, pain,
and edema
due to vascular
compression
Winged scapula
Lesion of long
thoracic nerve
Axillary node
dissection after
mastectomy,
stab wounds
Serratus anterior
Inability to anchor
scapula to thoracic
cage cannot
abduct arm above
horizontal position
PRESENTATION
428
SECTION III
Lower extremity nerves

NERVE
INNERVATION
lliohypoqastric
(T12-L1)
Sensory
suprapubic region
CAUSE OF INJURY
PRESENTATION/COMMENTS
Abdominal surgery
Burning or tingling pain in

surgical incision site radiating
Motor transversus abdominis

and internal oblique
to inguinal and suprapubic
region
Genitofemoral nerve
(L1-L2)
Sensory
scrotum /labia
i anterior thigh sensation

beneath inguinal ligament;
absent cremasteric reflex
Laparoscopic surgery
majora, medial thigh
Motor cremaster
Lateral femoral
cutaneous (L2-L3 )
Obturator (L 2- L4)
Sensory: anterior and lateral
thigh
Sensory
medial thigh
Tight clothing, obesity

pregnancy
i thigh sensation (anterior and

lateral)
Pelvic surgery
i thigh sensation (medial) and
Motor obturator externus.

adductor longus, adductor
brevis, gracilis, pectineus.
adductor magnus
Femoral (L 2- L4)
Sensory
anterior thigh.
adduction
Pelvic fracture
Motor quadriceps, iliopsoas.

pectineus, sartorius
Sciatic ( L4-S3 )
Sensory posterior thigh
Herniated disc
Motor semitendinosus.
semimembranosus, biceps
femoris, adductor magnus
Common peroneal
(L4- S2)
Sensory dorsum of foot

Motor biceps femoris, tibialis
anterior, extensor muscles
1 thigh flexion and leg
extension.
medial leg
Splits into common peroneal
and tibial nerves
Trauma or compression of
lateral aspect of leg, fibular
neck fracture
PED = Peroneal Everts and

Dorsiflexes; if injured, foot
dropPED
Foot drop inverted and

plantarflexed at rest, loss of
eversion and dorsiflexion;
steppage gait ; loss of
sensation on dorsum of foot
Tibial (L4-S3)
Sensory sole of foot

Motor triceps surae, plantaris,
popliteus, flexor muscles
Knee trauma, Baker cyst

( proximal lesion); tarsal
tunnel syndrome (distal

lesion)
TIP = Tibial Inverts and

Plantarflexes; if injured, cant
stand on TIPtoes
Inability to curl toes and loss of
sensation on sole; in proximal
lesions, foot everted at rest
with loss of inversion and
plantar flexion
SECTION III
429
Lower extremity nerves ( continued )

CAUSE OF INJURY
NERVE
INNERVATION
Superior qluteal ( L4-
Motor gluteus medius, gluteus Iatrogenic injury during

intramuscular injection to
minimus, tensor fascia latae
upper medial gluteal region
11
Normal
Trendelenburg sign
1f.
Inferior qluteal ( L 5 - S2)
Pudendal (S 2- S 4)
PRESENTATION/COMMENTS
Trendelenburg sign /gait

pelvis tilts because weightbearing leg cannot maintain
alignment of pelvis through
hip abduction
Lesion is contralateral to the
side of the hip that drops,
ipsilateral to extremity' on
which the patient stands
Choose superolateral gluteal
quadrant as intramuscular
injection site to avoid nerve
injury
Motor gluteus maximus
Posterior hip dislocation
Difficulty climbing stairs, rising
from seated position; loss of

hip extension
Sensory
perineum
Stretch injury during childbirth
Motor urethral and anal

sphincters
1 sensation in perineum and

genital area; can cause fecal
or urinary incontinence
Can be blocked with local
anesthetic during childbirth
using ischial spine as a
landmark for injection
Hip muscles
ACTION
MUSCLES
Abductors
Gluteus medius, gluteus minimus
Adductors
Adductor magnus, adductor longus, adductor brevis
Extensors
Gluteus maximus semitendinosi, semimembranosus
Flexors
Iliopsoas, rectus femoris, tensor fascia lata, pectineus
Internal rotation
Gluteus medius, gluteus minimus, tensor fascia latae
External rotation
Iliopsoas, gluteus maximus, piriformis, obturator
430
SECTION III
Signs of lumbosacral
radiculopathy
Paresthesia and weakness related to specific

lumbosacral spinal nerves. Usually, the
intervertebral disc herniates into the central
canal , affecting the inferior nerves (eg,
herniation of L 3/4 disc affects L4 spinal nerve,
but not L3) j
Intervertebral discs generally herniate

posterolaterally, due to the thin posterior
longitudinal ligament and thicker anterior
longitudinal ligament along the midline of the
vertebral bodies.
DISC LEVEL
FINDINGS
L3-L4
Weakness of knee extension , 1 patellar reflex
L4-L 5
Weakness of dorsiflexion , difficulty in heel-
L 5-S1
Weakness of plantar flexion, difficult} in toe

walking, i Achilles reflex
walking
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
Axilla /lateral thorax
Long thoracic
Lateral thoracic
Surgical neck of
humerus
Axillary
Posterior circumflex
Midshaft of humerus
Radial
Median
Deep brachial
Brachial
Popliteal fossa
Tibial
Popliteal
Posterior to medial
malleolus
Tibial
Posterior tibial
Distal humerus/
cubital fossa
ARTERY
Muscle conduction to
contraction
Revised Exterior
| Figure | Cvtosol
Dihydropyridine receptor
T-tubule membrane
8$
Ryanodine
receptor
Sarcoplasmic
3
reticulum
SECTION III
431
T-tubules are extensions of plasma membrane juxtaposed with terminal cisternae of the
sarcoplasmic reticulum, allowing for coordinated contraction of musclej
In skeletal muscle, 1 T-tubule + 2 terminal cisternae = triad.
In cardiac muscle, 1 T-tubule + 1 terminal cisterna = dyad.
1. Action potential depolarization opens presynaptic voltage-gated Ca2+ channels, inducing
neurotransmitter release.
2. Postsvnaptic ligand binding leads to muscle cell depolarization in the motor end plate.
3. Depolarization travels along muscle cell and down the T-tubule.
4. Depolarization of the voltage-sensitive dihydropyridine receptor, mechanically coupled to the
ryanodine receptor on the sarcoplasmic reticulum, induces a conformational change in both
receptors, causing Ca-+ release from sarcoplasmic reticulum.
5. Released Ca-+ binds to troponin C, causing a conformational change that moves tropomyosin
out of the myosin-binding groove on actin filaments.
6. Myosin releases bound ADP and P| displacement of myosin on the actin filament (power
stroke). Contraction results in shortening of H and I bands and between Z lines (IlIZ
shrinkage), but the A band remains the same length (A band is Always the same length) .
7. Binding of a new ATP molecule causes detachment of myosin head from actin filament.
Hydrolysis of bound ATP ADP, myosin head adopts high-energy position (cocked") for the
next contraction cycle.
T- tubule
Actin Myosin
li
Mitochondrion
M line
|
A band
|| I band |
U
H band
Types of muscle fibers
Type 1 muscle
Slow twitch; red fibers resulting from

t mitochondria and myoglobin concentration
( t oxidative phosphorylation) -* sustained
contraction. Proportion t after endurance
training.
Type 2 muscle
Fast twitch; white fibers resulting from

i mitochondria and myoglobin concentration
(t anaerobic glycolysis). Proportion t after
weight /resistance training, sprinting
Think 1 slow red ox.
432
SECTION III

Agonist
Endothelial cells
o|_
L-arginine
L-type voltage
gated Ca2
channel
v ^
Action
potential +
Receptor
i
*
NO synthase
TCa - calmodulin
complex
CONTRACTION
CONTRACTION
NO
Smooth muscle cell
Myosin-light -chain
kinase
(MLCK )
T Ca2 -
Ca 2
NO diffusion
.
I
NO
TCa;*
+*
Acetylcholine
bradykinin, etc
GTP
Myosin
+ actin
cGMP
I
4
Myosin-light-chain
phosphatase
Myosin-P
+ actin
( MLCP)
RELAXATION
Nitric oXide
RELAXATION
Bone formation
Endochondral
ossification
Membranous
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
remodel to lamellar bone. In adults, woven bone occurs after fractures and in Paget disease.
Defective in achondroplasia.
Bones of calvarium and facial bones. Woven bone formed directly without cartilage. Later
remodeled to lamellar bone.
Cell biology of bone

Osteoblast
Builds bone by secreting collagen and catalyzing mineralization in alkaline environment via ALP.
Differentiates from mesenchymal stem cells in periosteum. Osteoblastic activity measured by
bone ALP, osteocalcin, propeptides of type I procollagen.
Osteoclast
Dissolves bone by secreting H+ and collagenases. Differentiates from a fusion of monocyte /

macrophage lineage precursors.
Parathyroid hormone
At low, intermittent levels, exerts anabolic effects ( building bone) on osteoblasts and osteoclasts
(indirect). Chronically t PTH levels (1 hyperparathyroidism) cause catabolic effects (osteitis
Estrogen
Inhibits apoptosis in bone-forming osteoblasts and induces apoptosis in bone-resorbing osteoclasts.

Causes closure of the epiphyseal plate during puberty. Estrogen deficiency (surgical or
postmenopausal), excess cycles of remodeling, and bone resorption lead to osteoporosis.
fibrosa cystica).
432
SECTION III

Agonist
Endothelial cells
o|_
L-arginine
L-type voltage
gated Ca2
channel
v ^
Action
potential +
Receptor
i
*
NO synthase
TCa - calmodulin
complex
CONTRACTION
CONTRACTION
NO
Smooth muscle cell
Myosin-light -chain
kinase
(MLCK )
T Ca2 -
Ca 2
NO diffusion
.
I
NO
TCa;*
+*
Acetylcholine
bradykinin, etc
GTP
Myosin
+ actin
cGMP
I
4
Myosin-light-chain
phosphatase
Myosin-P
+ actin
( MLCP)
RELAXATION
Nitric oXide
RELAXATION
Bone formation
Endochondral
ossification
Membranous
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
remodel to lamellar bone. In adults, woven bone occurs after fractures and in Paget disease.
Defective in achondroplasia.
Bones of calvarium and facial bones. Woven bone formed directly without cartilage. Later
remodeled to lamellar bone.
Cell biology of bone

Osteoblast
Builds bone by secreting collagen and catalyzing mineralization in alkaline environment via ALP.
Differentiates from mesenchymal stem cells in periosteum. Osteoblastic activity measured by
bone ALP, osteocalcin, propeptides of type I procollagen.
Osteoclast
Dissolves bone by secreting H+ and collagenases. Differentiates from a fusion of monocyte /

macrophage lineage precursors.
Parathyroid hormone
At low, intermittent levels, exerts anabolic effects ( building bone) on osteoblasts and osteoclasts
(indirect). Chronically t PTH levels (1 hyperparathyroidism) cause catabolic effects (osteitis
Estrogen
Inhibits apoptosis in bone-forming osteoblasts and induces apoptosis in bone-resorbing osteoclasts.

Causes closure of the epiphyseal plate during puberty. Estrogen deficiency (surgical or
postmenopausal), excess cycles of remodeling, and bone resorption lead to osteoporosis.
fibrosa cystica).
PATHOLOGY
SECTION III
433
MUSCULOSKELETAL, SKIN, AND CONNECTIVE TISSUE- PATHOLOGY

Achondroplasia
Failure of longitudinal bone growth (endochondral ossification) short limbs. Membranous

ossification is not affected -* large head relative to limbs. Constitutive activation of fibroblast
growth factor receptor (FGFR 3 ) actually inhibits chondrocyte proliferation. > 85% of mutations
occur sporadically; autosomal dominant with full penetrance (homozygosity is lethal). Most
common cause of dwarfism.
Osteoporosis
Trabecular (spongy) and cortical bone lose mass Can lead to vertebral compression fractures ( ,
small arrows; large arrows show normal-for-age
and interconnections despite normal bone
mineralization and lab values (serum Ca + and vertebral body height for comparison) acute
back pain, loss of height, kyphosis. Also can
P04'-).
Most commonly due to t bone resorption
present with fractures of femoral neck, distal
related to i estrogen levels and old age.
radius (Colles fracture).
Can be secondary to drugs (eg, steroids,
alcohol, anticonvulsants, anticoagulants,
thyroid replacement therapy) or other
medical conditions (eg, hyperparathyroidism,
hyperthyroidism, multiple myeloma,
malabsorption syndromes).
Diagnosed by a bone mineral density scan
(dual-energy x-ray absorptiome [DEXAp with
a|T-score of < 2.5 or by a fragility fracture of
hip or vertebra. Screening recommended in
women > 65 years olcjj
Prophylaxis: regular weight-bearing exercise
and adequate Ca~+ and vitamin D intake
throughout adulthood.
Treatment: bisphosphonates, teriparatide,
SERMs, rarely calcitonin; denosumab
(monoclonal antibody against RANKL).
Normal vertebrae
Mild compression fracture
Osteopetrosis ( marble
bone disease, AlbersSchonberq disease )!
A
Failure of normal bone resorption due to defective osteoclasts thickened, dense bones that are
prone to fracture. Defective osteoclasts cause overgrowth and sclerosis of cortical bone. Bone fillj
marrow space -* pancytopenia, extramedullary hematopoiesis. Mutations (eg, carbonic anhydrase
II) impair ability of osteoclast to generate acidic environment necessary for bone resorption.
X-rays show bone-in-bone ('stone bone) appearance Q. Can result in cranial nerve impingement
and palsies as a result of narrowed foramina. Bone marrow transplant is potentially curative as
osteoclasts are derived from monocytes.
434
SECTION III
Osteomalacia / rickets
Defective mineralization of osteoid

(osteomalacia) or cartilaginous growth plates
(rickets, only in children). Most commonly due
to vitamin D deficiency.
X-rays show osteopenia and Looser zones
(pseudofractures) in osteomalacia, epiphyseal
widening and metaphyseal cupping/fraying in
rickets. Children with rickets have pathological
boujlegs , bead-like costochondral junctions
(rachitic rosary), craniotabes (soft skull).
1 vitamin D 1 serum Ca2+
t PTH
secretion
i serum
Hyperactivity of osteoblasts
Paget disease of bone

( osteitis deformans)
Osteonecrosis
( avascular necrosis)
,j
t ALP.
Common, localized disorder of bone

remodeling caused by t osteoclastic activity
followed by t osteoblastic activity that forms
poor-quality bone. Serum Ca ~+, phosphorus,
and PTH levels are normal, t ALP. Mosaic
pattern of woven and lamellar bone (osteocytes
within!lacunae in chaotic juxtapositions); long
bone chalk-stick fractures, t blood flow from
t arteriovenous shunts may cause high-output
heart failure, t risk of osteogenic sarcoma.
Infarction of bone and marrow, usually very

painful. Most common site is femoral
head Q (due to insufficiency of medial
circumflex femoral artery). Causes include
Corticosteroids, Alcoholism, Sickle cell
disease, Trauma, the Bends (caisson /
decompression disease), LEgg-Calve-Perthes
disease (idiopathic), Gaucher disease, Slipped
capital femoral epiphysis CAST Bent LEGS.
PATHOLOGY
m'
A1
f
Hat size can be increased due to skull

thickening ; hearing loss is common due to
auditory foramen narrowing.
Stages of Paget disease:
Lytic osteoclasts
Mixed osteoclasts + osteoblasts
Sclerotic osteoblasts
Quiescent minimal osteoclast /osteoblast
activity.
Treatment: bisphosphonates, calcitonin.
a
D :
-v : \-
0'
obturator artery
Media femoral
circumflex artery
Lateral femoral
circumflex artery
cerstKM
zone infarcted
436
SECTION III
PATHOLOGY
Primary bone tumors

TUMOR TYPE
EPIDEMIOLOGY/LOCATION
CHARACTERISTICS
Osteochondroma
Most common benign bone tumor.

Males < 25 years old.
Bony exostosis with cartilaginous (chondroid)

capQ.
Rarely transforms to chondrosarcoma.
Giant cell tumor
20-40 years old.

Epiphyseal end of long bones. Arises most
Locally aggressive benign tumor.

Soap bubble appearance on x-ray Q.
Multinucleated giant cells that express RANKLj
Benign tumors
commonly at distal femur and proximal tibia!

Osteoclastoma.
Malignant tumors
Osteosarcoma
(osteogenic sarcoma)
Most common 1 malignant bone tumoj

Bimodal distribution: 10-20 years old (1), > 65
(2).
Predisposing factors: Paget disease of bone, bone

infarcts, radiation, familial retinoblastoma,
Li-Frauineni syndrome (germline pS 3
Codman triangle (from elevation of periosteum)

or sunburst pattern on x-ray.
Aggressive. Treat with surgical en bloc resection
(with limb salvage) and chemotherapy.
mutation).
Ewing sarcoma
Metaphysis of long bones, often around knee Q.

Anaplastic small blue cell malignant tumor QJ.
Boys < 15 years old.
Commonly appears in diaphysis of long bones,
Extremely aggressive with early metastases, but
pelvis, scapula, ribs.
responsive to chemotherapy.
Onion skin periosteal reaction in bone.
Associated with t(l1;22) translocation causing
fusion protein EWS-FLI 1.
11 + 22 = 33 (Patrick Ewings jersey number).
r
.
Round cell lesions

Ewing sarcoma
Myeloma
f<
Fibrous dysplasia
C5
Osteoid osteoma
( nighttime pan central nidusl
Osteosarcoma
I{
Simple bone cyst
Osteochondroma
Physis
Giant cell tumor
&4 \
7,
\
-
tti
hi
rn
1
>-
PATHOLOGY
SECTION III
437
Osteoarthritis and rheumatoid arthritis
PATHOGENESIS
Osteoarthritis
Rheumatoid arthritis
Mechanical wear and tear destroys articular
Autoimmune inflammatory cytokines and

cells induce pannus (proliferative granulation
tissue) formation, which erodes articular
cartilage and bone.
cartilage ( DID ) and causes inflammation with

inadequate repair. Chondrocytes mediate
degradation and inadequate repaid
PREDISPOSING FACTORS
Age, female, obesity, joint trauma.
Female, HLA-DR4, smoking, silica exposure.

rheumatoid factor ( IgM antibody that
targets IgC Fc rcgioij in 80%), anti-cyclic
citrullinated peptide antibody (more specific).
Pain, swelling, and morning stiffness lasting
> 1 hour, improving with use. Symmetric
joint involvement. Systemic symptoms
(fever, fatigue, weight loss). Extraarticular
manifestations common.*
PRESENTATION
Pain in weight-bearing joints after use (eg,

at the end of the day), improving with rest.
Asymmetric joint involvement. Knee cartilage
loss begins medially ( bowlegged ). No
systemic symptoms.
JOINT FINDINGS
Osteophytes (bone spurs), joint space narrowing, Erosions, juxtaarticular osteopenia, soft tissue
swelling, subchondral cysts, joint space
subchondral sclerosis and cysts. Synovial
narrowing ( more prominent as disease
fluid non-inflammatory ( WBC < 2000/mm5).
progresses Deformities include cervical
Involves DIP (Heberden nodes Q) and PIP
subluxatiorj fingers with ulnar deviation,
( Bouchard nodes), and 1st CMC; not MCP.
sw an neck Q, and boutonniere. Synovial fluid
inflammatory ( WBC > 2000/mm5). Involves
MCP, PIP, wrist; not DIP or 1st CMC.
TREATMENT
Acetaminophen, NSAIDs, intra-articular

glucocorticoids.
NSAIDs, glucocorticoids, disease-modifying

agents (methotrexate, sulfasalazine,
hydroxychloroquine, leflunomide), biologic
agents (eg, TNF-a inhibitors).
^ Extraarticular manifestations
include 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), AA amyloidosis, Sjogren syndrome, scleritis, carpal tunnel syndrome.
Normal
Normal
Osteoarthritis
Thickened
Joint capsule
and synovial
lining
Synovial
cavity
Cartilage
/I*0
-
capsule
slight synovial
nypertrophy
Osteophyte
U cerated
3^::-
sclerotic bone
Joint space
narrowing
sulxhondiai
bone cyst
Joint capsule
and synovial
lining
Synovial
cavity
Cartilage
\
v
Rheumatoid
arthritis
Bone and
cartilage
erosion
i creased
synovial fluid
Pannus
formation
Revised
Figure
438
SECTION III
PATHOLOGY
Gout
Acute inflammatory monoarthritis caused by precipitation of monosodium urate crystals in

joints Q. More common in males. Associated with hyperuricemia, which can be caused by:
Underexcretion of uric acid (90% of patients) largely idiopathic, potentiated by renal failure!;
can be exacerbated by certain medications (eg, thiazide diuretics).
Overproduction of uric acid ( 10% of patients) Lesch-Nyhan syndrome, PRPP excess, t cell
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 Q).
FINDINGS
31
SYMPTOMS
Asymmetric joint distribution. Joint is swollen, red, and painful. Classic manifestation is painful
MTP joint of big toe (podagra). Tophus formation Q (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) or alcohol consumption!(alcohol metabolites compete for same excretion sites in
kidney as uric acid 1 uric acid secretion and subsequent buildup in blood).
TREATMENT
Acute: NSAIDs (eg, indomethacin), glucocorticoids, colchicine.

Chronic ( preventive): xanthine oxidase inhibitors (eg, allopurinol, febuxostat).
u
-J
'
*
Q
Calcium
pyrophosphate
deposition disease
Deposition of calcium pyrophosphate crystals within the joint space. Occurs in patients > 50 years
old; both sexes affected equally. Usually idiopathic, sometimes associated with hemochromatosis,
hyperparathyroidism, joint trauma.
Pain and swelling with acute inflammation ( pseudogout) and/or chronic degeneration ( pseudo
osteoarthritis). Knee most commonly affected joint.
Chondrocalcinosis (cartilage calcification) on x-ray.
Crystals are rhomboid and weakly birefringent under polarized light (blue when parallel to
r to-
light) .
Acute treatment: NSAIDs, colchicine, glucocorticoids.
Prophylaxis: colchicine.
Sjogren syndrome
a- #
szaerir
rA
Autoimmune disorder characterized by

destruction of exocrine glands (especially
lacrimal and salivary) by lymphocytic
infiltrates Q. Predominantly affects females

40-60 years old.
Findings:
Inflammatory joint pain
Keratoconjunctivitis sicca (1 tear production

and subsequent corneal damage)
Xerostomia (1 saliva production)
Presence of antinuclear antibodies,
rheumatoid factor (can be in the absence of
rheumatoid arthritis), antiribonucleoprotein
antibodies: SS-A ( anti-Ro) and/or SS-B ( anti-
PATHOLOGY
SECTION III
439
A common 1 disorder or a 2 syndrome

associated with other autoimmune disorders
(eg, rheumatoid arthritis, SLE, systemic
sclerosis).
Complications: dental caries; mucosa-associated
lymphoid tissue (MALT) lymphoma (may
present as parotid enlargement)
^
Salivary
gland biopsy can be used to confirm
diagnosis.
Laj
Bilateral parotid enlargement
Septic arthritis
S aureus, Streptococcus, and Neisseria gonorrhoeae are common causes. Affected joint is swollen
red, and painful. Synovial fluid purulent ( WBC > 50,000/mm ).
Gonococcal arthritis STI that presents as either purulent arthritis (eg, knee) or triad of
polyarthralgias, tenosynovitis (eg, hand), dermatitis (eg, pustules).
440
SECTION III
PATHOLOGY
Arthritis without rheumatoid factor ( no anti-IgG antibody). Strong association with HLA-B27
( MHC class I serotype). Subtypes ( PAIR) share variable occurrence of inflammatory back
pain (associated with morning stiffness, improves with exercise), peripheral arthritis, enthesitis
( inflamed insertion sites of tendons, eg, Achilles), dactylitis ( sausage fingers ), uveitis.
Seronegative
spondyloarthritis
Psoriatic arthritis
Associated with skin psoriasis and nail lesions.

Asymmetric and patch}' involvement Q.
Dactylitis and pencil-in-cup deformity of
DIP on x-ray Q.
Seen in fewer than lA of patients with psoriasis.
Ankylosing
spondylitis
Symmetric involvement of spine and sacroiliac

joints ankylosis ( joint fusion ), uveitis, aortic
regurgitation .
Bamboo spine (vertebral fusion ) H Can cause

restrictive lung disease due to limited chest wall
expansion .
More common in males.
Crohn disease and ulcerative colitis are often

associated with spondyloarthritis.
Inflammatory bowel
disease
Formerly known as Reiter syndrome.

Classic triad :
Reactive arthritis
Conjunctivitis
Urethritis
Arthritis
Can t see, can t pee, can t bend my knee.

Post-GI ( Shigella , Salmonella, Yersinia ,
Campylobacter ) or Chlamydia infections.
f
r
Wt
(r
PATHOLOGY
441
SECTION III
Systemic lupus erythematosus

SYMPTOMS
m
RU
Classic presentation: rash, joint pain, and fever,

most commonly in a female of reproductive
age and African-American descent.
Libman-Sacks Endocarditis nonbacterial,
verrucous thrombi usually on mitral or aortic
valve and can be present on either surface of
the valvdfLSE in SLE).
Lupus nephritis ( glomerular deposition of antiDNA immune complexes) can be nephritic
or nephrotic ( hematuria or proteinuria).
Most common and severe type is diffuse
proliferative.
RASH OR PAIN:
Rash (malar Q or discoid )
Arthritis (nonerosive)
Serositis
Hematologic disorders (eg, cvtopenias)
Oral/nasopharyngeal ulcers
Renal disease
Photosensitivity
Antinuclear antibodies
Immunologic disorder (anti-dsDNA, anti-Sm,

antiphospholipid)
Neurologic disorders (eg, seizures, psychosis)
Common causes of death in SLE:

*
FINDINGS
Cardiovascular disease
Infections
Renal disease
Antinuclear antibodies (ANA)
Sensitive, not specific
Anti-dsDNA antibodies
Specific, poor prognosis (renal disease)

Specific, not prognostic (directed against
Anti-Smith antibodies
snRNPs)
Antihistone antibodies
Sensitive for drug-induced lupus (eg,

hydralazine, procainamide)
i C3, C4, and CH50 due to immune complex
formation.
TREATMENT
Antiphospholipid
syndrome
NSAIDs, steroids, immunosuppressants,

hydroxychloroquine.
1 or 2 autoimmune disorder (most commonly

in SLE).
Diagnose based on clinical criteria including
history of thrombosis (arterial or venous)
or spontaneous abortion along with
Anticardiolipin antibodies can cause false

positive VDRL/RPR, and lupus anticoagulant
can cause prolonged PTT, which is not
corrected by the addition of normal platelet
free plasmaj
laboratory findings of lupus anticoagulant,

anticardiolipin, anti-Pi glycoprotein antibodies.
Treat with systemic anticoagulation.
Mixed connective
tissue disease
Features of SLE, systemic sclerosis, and/or polymyositis. Associated with anti-Ul RNP antibodies
(speckled ANA).
442
SECTION III
Sarcoidosis
PATHOLOGY
Characterized by immune mediated, widespread noncaseating granulomas Q, elevated serum

ACE levels, and elevated CD4+ /CD8+ ratio in bronchoalveolar lavage fluid . More common in
African-American females. Often asymptomatic except for enlarged lymph nodes. Findings on
CXR of bilateral adenopathy and coarse reticular opacities Q; CT of the chest better demonstrates
the extensive hilar and mediastinal adenopathy Q.
Associated with restrictive lung disease (interstitial fibrosis), erythema nodosum , lupus pernio (skin
lesions on face resembling lupus), Bell palsy, epithelioid granulomas containing microscopic
Schaumann and asteroid bodies, uveitis, hypercalcemia ( due to t la-hydroxylase-mediated
vitamin D activation in macrophages).
Treatment: steroids (if symptomatic).
'
r N
Polymyalgia rheumatica
SYMPTOMS
Pain and stiffness in shoulders and hips, often with fever, malaise, weight loss. Does not cause
muscular weakness. More common in women > 50 years old ; associated with giant cell (temporal )
arteritis.
FINDINGS
t ESR, t CRP, normal CK.

Rapid response to low-dose corticosteroids.
TREATMENT
Fibromyalqia
( central sensitization
svndromeL
Most commonly seen in females 20-50 years old. Chronic, widespread musculoskeletal pain
associated with stiffness , paresthesias, poor sleep, fatigue, cognitive disturbance ( fibro fog ).
Treatment: regular exercise, antidepressants (TCAs, SNRIs), anticonvulsants.
Polymyositis /
dermatomyositis
DERMATOLOGY
SECTION III
443
t CK, ANA, anti-Jo-1, anti-SRP, anti-Mi-2 antibodies. Treatment: steroids followed by

long-term immunosuppressant therapy (eg, methotrexate).
Polymyositis
Progressive symmetric proximal muscle weakness, characterized by endomvsial inflammation with

CD8+ T cells. Most often involves shoulders.
Dermatomyositis
Similar to polymyositis, but also involves malar rash (similar to SLE), Gottron papules Q,
heliotrope (erythematous periorbital) rash Q, shawl and face rash Q, mechanics hands. t risk
of occult malignancy. Perimysial inflammation and atrophy with CD4+ T cells.
k.
Neuromuscular junction diseases

Myasthenia gravis
Lambert-Eaton myasthenic syndrome
FREQUENCY
Most common NMJ disorder
Uncommon
PATHOPHYSIOLOGY
Autoantibodies to postsynaptic ACh receptor
Autoantibodies to presynaptic Ca~^ channel

-* 1 ACh release
CLINICAL
Ptosis, diplopia, weakness

Worsens with muscle use_
Proximal muscle weakness, autonomic

symptoms (dry mouth, impotence)
Improves with muscle use
Improvement after edrophonium ( tensilon) test

ASSOCIATED WITH
Thymoma, thymic hyperplasia
AChE INHIBITOR ADMINISTRATION
Reverses symptoms (edrophonium to diagnose,

pyridostigmine to treat)
Minimal effect
444
SECTION III
Scleroderma ( systemic
sclerosis)
MUSCULOSKELETAL, SKIN , AND CONNECTIVE TISSUE
DERMATOLOGY
Triad of autoimmunity, noninflammatory vasculopathy, and collagen deposition with fibrosis,

Commonly sclerosis of skin, manifesting as puffy, taut skin Q without wrinkles, fingertip pitting
Q- Also sclerosis of renal, pulmonary (most common cause of death), cardiovascular, GI systems.
75% female. 2 major types:
Diffuse scleroderma w idespread skin involvement, rapid progression, early visceral
involvement. Associated with anti-Scl-70 antibody (anti-DNA topoisomerase I antibody).
Limited scleroderma limited skin involvement confined to fingers and face. Also with
CREST syndrome: Calcinosis/anti-Centromere antibody 0, Raynaud phenomenon,
Esophageal dysmotility, Sclerodactyly, and Telangiectasia. More benign clinical cours
M
'
Raynaud phenomenon
1 blood flow to the skin due to arteriolar (small vessel) vasospasm in response to cold or stress:
color change from white (ischemia) to blue (hypoxia) to red (reperfusion). Most often in the
fingers Q and toes. Called Raynaud disease when 1 (idiopathic), Raynaud syndrome when 2
to a disease process such as mixed connective tissue disease, SLE, or CREST (limited form of
systemic sclerosis) syndrome. Digital ulceration (critical ischemia) seen in 2 Raynaud syndrome.
Treat with Ca-+ channel blockers.
MUSCULOSKELETAL, SKIN , ARP CONNECTIVE TISSUE- DERMATOLOGY

Skin has 3 layers: epidermis, dermis,
subcutaneous fat (hypodermis, subcutis).
Skin layers
Epidermis layers from surface to base Q:

0
'
p0
.. * <
sSPermis
';
[3
Stratum Corneum (keratin)

Stratum Lucidum
Stratum Granulosum
Stratum Spinosum (desmosomes)
Stratum Basale (stem cell site)
Californians Like Girls in String Bikinis.
446
SECTION III
DERMATOLOGY
Dermatologic microscopic terms

LESION
CHARACTERISTICS
EXAMPLES
Hyperkeratosis
t thickness of stratum corneum

Hyperkeratosis with retention of nuclei in
Psoriasis, calluses
Parakeratosis
Psoriasis
stratum corneum
Hypergranulosis
Spongiosis
Acantholysis
Acanthosis
t thickness of stratum granulosum

Epidermal accumulation of edematous fluid in
intercellular spaces
Separation of epidermal cells
Epidermal hyperplasia ( t spinosum)
Lichen planus
Eczematous dermatitis
Pemphigus vulgaris
Acanthosis nigricans, psoriasis
Pigmented skin disorders
Albinism
Melasma (chloasma )
Vitiligo
Normal melanocyte number with 4 melanin production Q due to 4 tyrosinase activity or defective
tyrosine transport , t risk of skin cancer.
Hyperpigmentation associated with pregnancy ( mask of pregnancy Q) or OCP use.
Irregular areas of complete depigmentation H- Caused by autoimmune destruction of melanocytes.
'
-r
DERMATOLOGY
SECTION III
447
Common skin disorders
Acne
Multifactorial etiology t sebum ( T androgens) production, abnormal keratinocvte desquamation,

Propionibacterium acnes colonization of the pilosebaceous unit, ( comedones), and inflammation
( papules /pustules , nodules, cysts). Treatment includes retinoids, benzoyl peroxide, and antibiotics!
Atopic dermatitis
Pruritic eruption, commonly on skin flexures. Often associated with other atopic diseases (asthma,
allergic rhinitis, food allergies); t serum IgE. Usually appears on face in infancy Q and then
antecubital fossalH when older.
(eczema)
Allergic contact
dermatitis
Type IV hypersensitivity reaction that follows exposure to allergen. Lesions occur at site of contact
(eg, nickel 0, poison ivy, neomycin Q).
Melanocytic nevus
Common mole. Benign, but melanoma can arise in congenital or atypical moles. Intradermal nevi
are papular Q. Junctional nevi are flat macules 0.
Pseudofolliculitis
barbae
Foreign body inflammatory facial skin disorder characterized by firm, hyperpigmented papules and
pustules that are painful and pruritic . Located on cheeks, jawline, and neck. Commonly occurs as
a result of shaving ( razor bumps), primarily affects African American males.
Psoriasis
Papules and plaques w ith silvery scaling Q, especially on knees and elbow s. Acanthosis with
parakeratotic scaling (nuclei still in stratum corneum), Munro microabscesses, t stratum
spinosum, \ stratum granulosum. Auspitz sign (arrow in Q) pinpoint bleeding spots from
exposure of dermal papillae w hen scales are scraped off. Can be associated w ith nail pitting and
psoriatic arthritis.
Rosacea
Seborrheic keratosis
Inflammatory facial skin disorder characterized by erythematous papules and pustules Q, but no
comedones. May be associated with facial flushing in response to external stimuli (eg, alcohol,
heat). Phymatous rosacea can cause rhinophvma ( bulbous deformation of nose).
Flat, greasy, pigmented squamous epithelial proliferation with keratin-filled cysts ( horn cysts) Q.
Looks stuck on. Lesions occur on head, trunk, and extremities. Common benign neoplasm of
older persons.
Leser-Trelat sign D sudden appearance of multiple seborrheic keratoses, indicating an underlying
malignancy (eg, GI, lymphoid).
Verrucae
Warts; caused by HPV. Soft, tan-colored, cauliflower-like papules G3. Epidermal hyperplasia,
hyperkeratosis, koilocvtosis. Condyloma acuminatum on genitals 0.
Urticaria
Hives. Pruritic wheals that form after mast cell degranulation 0. Characterized by superficial
dermal edema and lymphatic channel dilation.
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449
SECTION III
DERMATOLOGY
Skin infections
Bacterial infections
Impetigo
Erysipelas
Cellulitis
Abscess
Necrotizing fasciitis
Staphylococcal scalded
skin syndrome
Very superficial skin infection . Usually from S aureus or S pyogenes. Highly contagious. Honeycolored crusting Q.
Bullous impetigo Q has bullae and is usually caused by S aureus .
Infection involving upper dermis and superficial lymphatics, usually from S pyogenes. Presents with
well-defined demarcation between infected and normal skin QAcute, painful , spreading infection of deeper dermis and subcutaneous tissues. Usually from
S pyogenes or S aureus . Often starts with a break in skin from trauma or another infection 0.
Collection of pus from a walled-off infection within deeper layers of skin Q. Offending organism is
almost always S aureus.
Deeper tissue injury, usually from anaerobic bacteria or S pyogenes. Pain may be out of proportion
to exam . Results in crepitus from methane and CO, production . Flesh-eating bacteria . Causes
bullae and a purple color to the skin QExotoxin destroys keratinocvte attachments in stratum granulosum only (vs toxic epidermal
necrolysis, which destroys epidermal-dermal junction ). Characterized by fever and generalized
erythematous rash with sloughing of the upper layers of the epidermis 0 that heals completely.
Nikolsky sign. Seen in newborns and children, adults with renal insufficiency.
Viral infections
Herpes
Herpes virus infections ( HSV1 and HSV2 ) of skin can occur anywhere from mucosal surfaces to
normal skin . These include herpes labialis, herpes genitalis, herpetic whitlow Q (finger ).
Molluscum
Umbilicated papules Q caused by a poxvirus. While frequently seen in children, it may be sexually
transmitted in adults.
Causes varicella (chickenpox) and zoster (shingles). Varicella presents with multiple crops of
lesions in various stages from vesicles to crusts. Zoster is a reactivation of the virus in dermatomal
distribution (unless it is disseminated ).
Irregular, white, painless plaques on lateral tongue that cannot be scraped off Q. EBV mediated .
Occurs in HIV-positive patients, organ transplant recipients. Contrast with thrush (scrapable) and
leukoplakia ( precancerous).
contagiosum
Varicella zoster virus
Hairy leukoplakia
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450
SECTION III
DERMATOLOGY
Blistering skin disorders
Pemphigus vulgaris
Potentially fatal autoimmune skin disorder with IgG antibody against desmoglein (component of
desmosomes).
Flaccid intraepidermal bullae Q caused by acantholvsis ( keratinocytes in stratum spinosum are
connected bv desmosomes, resembling a row of tombstones ); oral mucosa is also involved . Type
II hypersensitivity reaction
Immunofluorescence reveals antibodies around epidermal cells in a reticular ( net-like ) pattern Q.
Nikolsky sign (separation of epidermis upon manual stroking of skin ).
Less severe than pemphigus vulgaris. Involves IgG antibod} against hemidesmosomes (epidermal
basement membrane; antibodies are bullow the epidermis).
Tense blisters H containing eosinophils affect skin but spare oral mucosa.
Immunofluorescence reveals linear pattern at epidermal-dermal junction 0.
Nikolsky sign .
Pruritic papules, vesicles, and bullae (often found on elbows) Q- Deposits of IgA at tips of dermal
papillae. Associated with celiac disease. Treatment: dapsone, gluten-free diet .
Associated with infections (eg, Mycoplasma pneumoniae. IISV ), drugs (eg, sulfa drugs, P-lactams,
phenytoin), cancers, autoimmune disease . Presents with multiple types of lesions macules,
papules, vesicles, target lesions ( look like targets with multiple rings and dusky center showing
epithelial disruption ) QCharacterized by fever, bullae formation and necrosis, sloughing of skin at dermal -epidermal
junction , high mortality rate. Typically 2 mucous membranes are involved 0 Q, and targetoid
skin lesions may appear, as seen in erythema multiforme. Usually associated with adverse drug
reaction . A more severe form of Stevens-Johnson syndrome (SJS) with > 30 % of the body surface
area involved is toxic epidermal necrolysis Q Q (TEN ). 10-30 % involvement denotes SJS-TEN .
Bullous pemphigoid
Dermatitis
herpetiformis
Erythema multiforme
Stevens-Johnson
syndrome
<?
-%
SECTION III
DERMATOLOGY
451
Miscellaneous skin disorders
Acanthosis nigricans
Actinic keratosis
Erythema nodosum
Lichen Planus
Pityriasis rosea
Sunburn
Epidermal hyperplasia causing symmetric, hyperpigmented thickening of skin, especially in axilla

or on neck Q El- Associated with insulin resistance (eg, diabetes, obesity, Cushing syndrome),
visceral malignancy (eg, gastric adenocarcinoma).
Premalignant lesions caused by sun exposure. Small, rough, erythematous or brownish papules or
plaques Q 0. Risk of squamous cell carcinoma is proportional to degree of epithelial dysplasia.
Painful raised inflammatory lesions of subcutaneous fat ( panniculitis), usualhjon anterior shins.
Often idiopathic, but can be associated with sarcoidosis, coccidioidomycosis, histoplasmosis, TB,
streptococcal infections Q, leprosy Q, inflammatory bowel disease.
Pruritic, Purple, Polygonal Planar Papules and Plaques are the 6 Ps of lichen Planus 0 Q.
Mucosal involvement manifests as Wickham striae (reticular white lines) and hvpergranulosis.
Sawtooth infiltrate of lymphocytes at dermal-epidermal junction. Associated with hepatitis C.
Herald patch Q followed days later by other scaly erythematous plaques, often in a Christmas
tree distribution on trunk Q. Multiple plaques with collarette scale. Self-resolving in 6-8 weeks.
Acute cutaneous inflammatory reaction due to excessive UV irradiation. Causes DNA mutations,
inducing apoptosis of keratinocytes. UVB is dominant in sunBurn, UVA in tAnning and
photoAging. Exposure to UVA and UVB increase the risk of skin cancer. Can lead to impetigo,
skin cancers (basal cell carcinoma, squamous cell carcinoma, melanoma).
25
452
SECTION III
DERMATOLOGY
Skin cancer
Basal cell carcinoma
Most common skin cancer. Found in sun-exposed areas of body (eg, face). Locally invasive, but
rarely metastasizes. Waxv, pink, pearly nodules, commonhjwith telangiectasias, rolled borders,
central crusting or ulceration Q. BCCs also appear as nonhealing ulcers with infiltrating growth
Q or as a scaling plaque (superficial BCC ) Q. Basal cell tumors have palisading nuclei 0-
4
Squamous cell
carcinoma
Second most common skin cancer. Associated with excessive exposure to sunlight,
immunosuppression, chronically draining sinuses, and occasionalhiarsenic exposure. Commonly
appears on face Q, lower lip Q, ears, hands. Locally invasive, may spread to lymph nodes,
and will rarely metastasize. Ulcerative red lesions with frequent scale. ( listopathology: keratin
pearls 0.
Actinic keratosis, a scaly plaque, is a precursor to squamous cell carcinoma.

Keratoacanthoma is a variant that grows rapidly (4-6 weeks) and may regress spontaneously over
months 0.
%
Melanoma
Common tumor with significant risk of metastasis. S-100 tumor marker. Associated with sunlight
exposure and dysplastic nevi; fair-skinned persons are at t risk. Depth of tumor correlates with risk
of metastasis. Look for the ABCDEs: Asymmetry, Border irregularity, Color variation, Diameter
> 6 mm, and Evolution over time. At least 4 different types of melanoma, including superficial
spreading Q, nodular Q, lentigo maligna Q, and acral lentiginous Q Often driven by activating
mutation in BRAF kinase. Primary treatment is excision with appropriately wide margins.
Metastatic or unresectable melanoma in patients with BRAF V600E mutation may benefit from
vemurafenib, a BRAF kinase inhibitor.
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454
SECTION III
PHARMACOLOGY
Aspirin
MECHANISM
NSAID that irreversibly inhibits cyclooxygenase ( both COX-1 and COX-2) by covalent acetylation
1 synthesis of TXA 7 and prostaglandins, t bleeding time. No effect on PT, PTT. Effect lasts
until new platelets are produced.
CLINICAL USE
Low dose (< 300 mg/day): 1 platelet aggregation. Intermediate dose ( 300-2400 mg/day): antipyretic
and analgesic. High dose ( 2400-4000 mg/day): anti-inflammatory.
ADVERSE EFFECTS
Gastric ulceration, tinnitus (CN VIII). Chronic use can lead to acute renal failure, interstitial
nephritis, GI bleeding. Risk of Reve syndrome in children treated with aspirin for viral infection.
Causes respiratory alkalosis early, but transitions to mixed metabolic acidosis-respiratory alkalosis.
Celecoxib
the cyclooxygenase (COX ) isoform 2 ( Selecoxib ), which!is found

in inflammatory cells and vascular endothelium and mediates inflammation and pain; spares
COX-1, which helps maintain gastric mucosa. Thus, does not have the corrosive effects of other
NSAIDs on the GI lining. Spares platelet function as TXA -, production is dependent on COX-1.
MECHANISM
Reversibly inhibits selectively
CLINICAL USE
Rheumatoid arthritis, osteoarthritis.
ADVERSE EFFECTS
t risk of thrombosis. Sulfa allergy.
Nonsteroidal
anti-inflammatory
Ibuprofen, naproxen, indomethacin, ketorolac, diclofenac, meloxicam, piroxicam.
druqs ( NSAIDsL
MECHANISM
CLINICAL USE
ADVERSE EFFECTS
Reversibly inhibit cyclooxygenase (both COX-1 and COX-2). Block prostaglandin synthesis.
Antipyretic, analgesic, anti-inflammatory. Indomethacin is used to close a PDA.
Interstitial nephritis, gastric ulcer (prostaglandins protect gastric mucosa), renal ischemia
( prostaglandins vasodilate afferent arteriole), aplastic anemia.
Leflunomide
CLINICAL USE
Reversibly inhibits dihydroorotate dehydrogenase, preventing pyrimidine synthesis. Suppresses

T-cell proliferation.
Rheumatoid arthritis, psoriatic arthritis.
ADVERSE EFFECTS
Diarrhea, hypertension, hepatotoxicity, teratogenicity.
MECHANISM
Bisphosphonates
Alendronate, ibandronate, risedronate, zoledronate.
MECHANISM
Pyrophosphate analogs; bind hydroxyapatite in bone, inhibiting osteoclast activity.
CLINICAL USE
Osteoporosis, hypercalcemia, Paget disease of bone, metastatic bone disease, osteogenesis
ADVERSE EFFECTS
Esophagitis (if taken orally, patients are advised to take with water and remain upright for 30
minutes), osteonecro sis of jaw, atypical stress fractures.
imperfecta.
455
SECTION III
PHARMACOLOGY
Teriparatide
MECHANISM
Recombinant PTH analog given subcutaneously daily, t osteoblastic activity.
CLINICAL USE
Osteoporosis. Causes t bone growth compared to antiresorptive therapies (eg, bisphosphonates).
ADVERSE EFFECTS
t risk of osteosarcoma ( avoid use in patients with Paget disease of the bone or unexplained
elevation of alkaline phosphatase).
Transient hypercalcemia.
Gout drugs
Chronic gout drugs (preventive)
Allopurinol
Competitive inhibitor of xanthine oxidase

i conversion of hypoxanthine and xanthine to
urate. Also used in lymphoma and leukemia
to prevent tumor lvsis-associated urate
nephropathy, t concentrations of azathioprine
and 6-MP ( both normally metabolized by
xanthine oxidase).
,
Febuxostat
Inhibits xanthine oxidase.
Pegloticase
Recombinant uricase that catalyzes metabolism

of uric acid to allantoin (a more water-soluble
product).
Probenecid
Inhibits reabsorption of uric acid in proximal

convoluted tubule (also inhibits secretion of
penicillin). Can precipitate uric acid calculi.
Diet
Purines
Hypoxanthine
I Xanthine
1 oxidase
Xanthine
I Xanthine
I oxidase
Plasma
uric acid
Allopurinol,
febuxostat
Urate crystals deposited

in joints
$
Probenecid and
high -dose salicylates
Acute gout drugs

NSAIDs
Nucleic acids
Naproxen, indomethacin.
Avoid salicylates; all but the highest doses
depress uric acid clearance. Other NSAIDs are
better tolerated]
Glucocorticoids
Oral, intra-articular, or parenteral.
Colchicine
Binds and stabilizes tubulin to inhibit
Urine
Gout
Tubular
reabsorption
Tubular
secretion
Diuretics and
low -dose salicylates
microtubule polymerization, impairing

neutrophil chemotaxis and degranulation.
Acute and prophylactic value. GI side effects.
TNF-a inhibitors
All TNF-a inhibitors predispose to infection, including reactivation of latent TB, since TNF is
important in granuloma formation and stabilization.
DRUG
MECHANISM
CLINICAL USE
Etanercept
Fusion protein (receptor for TNF-a + IgGj Fc),

produced by recombinant DNA.
Etanercept is a TNF decoy receptor.
Rheumatoid arthritis, psoriasis, ankylosing
Anti-TNF-a monoclonal antibody.
Inflammatory bowel disease, rheumatoid arthritis,

ankylosing spondylitis, psoriasis
Infliximab,
adalimumab,
certolizumabj
spondylitis
HIGH - YI E LD SYSTEMS
Neurology and
Special Senses
Estimated amount of glucose used by an adult human brain each day,
expressed in M & Ms: 250.
Harpers Index
Embryology
458
Anatomy and
Physiology
461
Pathology
479
Otology
500
Ophthalmology
502
Pharmacology
512
Anythings possible if youve got enough nerve.
J.K. Rowling Harry Potter and the Order of the Phoenix

,
I like nonsense ; it wakes up the brain cells.
Dr. Seuss
I
believe in an open mind , but not so olren that
your
brains fall out.
Arthur Hays Sulzberger

The chief junction of
the body is to earn the brain around ."
Thomas Edison
457
458
SECTION III
NEUROLOGY EMBRYOLOGY
Neural development
Neural plate
Day 18
'-Notochord
Neural fold
Notochord induces overlying ectoderm to differentiate into neuroectoderm and form neural plate.
Neural plate gives rise to neural tube and neural crest cells.
Notochord becomes nucleus pulposus of intervertebral disc in adults.
Alar plate (dorsal): sensory

Basal plate (ventral): motor
Same orientation as spinal cord.
Neural tube
Neural
Day 21
Regional specification of developing brain

Three primary
Five secondary
vesicles
vesicles
Telencephalon
Wall
Cavity
Forebrain
(prosencephalon)
Diencephalon
Midbrain
(mesencephalon)
Mesencephalon
Hindbrain
(rhombencephalon)
Metencephalon
Adult derivatives of:

Cavities
Walls
Cerebral
Lateral
hemispheres
ventricles
Thalamus,
Third
Hypothalamus
ventricle
Midbrain
Aqueduct
Rons
Upper part of
fourth ventricle
Cerebellum
Myelencephalon
Medulla
Spinal cord
CNS /PNS origins
Lower part of
fourth ventricle
113
Neuroepithelia in neural tubcj CNS neurons, ependymal cells ( inner lining of ventricles, make
CSF), oligodendroglia, astrocytes.
Neural crest PNS neurons, Schwann cells.
Mesoderm Microglia ( like Macrophages).
SECTION III
423
Common knee conditions
"Unhappy triad"
Common injury in contact sports due to lateral force applied to a planted leg. Classically, consists
of damage to the ACL Q, MCL, and medial meniscus (attached to MCL); however, lateral
meniscus injury is more common. Presents with acute knee pain and signs of joint injury/
instability.
Prepatellar bursitis
Inflammation of the prepatellar bursa over the kneecaptp. Can be caused by repeated trauma or
("housemaid's knee" )j
pressure from excessive kneeling.
Baker cyst
Popliteal fluid collection in gastrocnemius-semimembranous bursa Q commonly communicating

with synovial space and related to chronic joint disease.
Rotator cuff muscles
'A
Shoulder muscles that form the rotator cuff:

SItS (small t is for teres minor).
Supraspinatus (suprascapular nerve)
Acromion
Supraspinatus
abducts arm initially ( before the action
Coracoid
of the deltoid); most common rotator cuff
Biceps tendon
injury Q (trauma or degeneration and
Infraspinatus
- Subscapularis
impingement tendinopathy or tear),
Teres minor
assessed by empty/full can test.
Infraspinatus (suprascapular nerve) laterally
Posterior
Anterior
rotates arm; pitching injury.
teres minor (axillary nerve) adducts and
a
laterally rotates arm.

Subscapularis (upper and lower subscapular
nerves) medially rotates and adducts arm.
Innervated primarily by C 5 -C6.
1
Arm abduction
New
Fact
DEGREE
MUSCLE
NERVE
0-15
Supraspinatus
Suprascapular
15-100
Deltoid
> 100
Serratus anterior
Long thoracic
Axillary-
Neural tube defects
Spina bifida occulta

Meningocele
Meningomyelocele
EMBRYOLOGY
SECTION III
459
Neuropores fail to fuse (4th week) -* persistent connection between amniotic cavity and spinal
canal . Associated with maternal diabetes as well asjlow folic acid intake before conception and
during pregnancy, t a-fetoprotein (AFP ) in amniotic fluid and maternal serum (except spina
bifida occulta ) t acetylcholinesterase (AChE) in amniotic fluid is a helpful confirmatory test (fetal
AChE in CSF flows through defect into amniotic fluid ).
Failure of rostral neuropore to close no forebrain, open calvarium . Clinical findings: t AFP,
polyhydramnios ( no swallowing center in brain ) .
Failure of caudal neuroporejto close, but no herniation. Usually seen at lower vertebral levels. Dura
is intact . Associated with tuft of hair or skin dimple at level of bony defect. Normal AFP
Meninges ( but no neural tissue) herniate through bony defect . Associated with spina bifida cystic
Meninges and neural tissue (eg, cauda equina ) herniate through bony defect .
,
Anencephaly
NEUROLOGY
f /- Tuft of hair
Skin defect/thinning
- Skin thin or absent
+/- Skin dimple
Skin
subarachnoid
spai
Jjia
Leptomeninges
J
-j
Spinal
cord
Transverse
Normal
Holoprosencephaly
Spina bifida occulta

(most common)
Meningocele
Meningomyelocele
Failure of left and right hemispheres to separate; usually occurs during weeks 5-6. May be related
to mutations in sonic hedgehog signaling pathway. Moderate form has cleft lip/palate, most severe
form results in cyclopia . Seen in Patau syndrome and fetal alcohol syndrome.
RENAL
RENAL EMBRYOLOGY
SECTION III
547
Inferior poles of both kidneys fuse

abnormally Q. As they ascend from pelvis
/
fetal development, horseshoe kidneys
during
Renalartery
get trapped under inferior mesenteric
artery and remain low in the abdomen.
Kidneys function normally. Associated
with hydronephrosis (eg, ureteropelvic
^'CMnfeno
junction obstruction), renal stones, infection,
mesenteric
,
artery
chromosomal aneuploidv syndromes (eg,
Turner syndrome; trisomies 13, 18, 21), and
rarely renal cancer.
Horseshoe kidney
Horseshoe
Aorta
kidney
Ureteral
Unilateral renal
agenesis
Ureteric bud fails to develop and induce differentiation of metanephric mesenchyme -* complete
absence of kidney and ureter. Often diagnosed prenatally via ultrasound.
Multicystic dysplastic
kidney
Predominantly non-hereditarv condition where ureteric bud fails to induce differentiation of
Duplex collecting
Bifurcation of ureteric bud before it enters the metanephric blastema creates a Y-shaped bifid
ureter. Duplex collecting system can alternatively occur through two ureteric buds reaching and
interacting with metanephric blastema. Strongly associated with vesicoureteral reflux and/or
ureteral obstruction, t risk for UTIs.
system
New
Fact
metanephric mesenchvmet nonfunctional kidney consisting of cysts and connective tissue.

Often diagnosed prenatally via ultrasound.
Congenital solitary
functioning kidney
Condition of being born with only one functioning kidney. Majority asymptomatic with
compensator} hypertrophy of contralateral kidney, but anomalies in contralateral kidney are
common.
Posterior urethral
valves
Membrane obstructs the urethra due to abnormal development in utero. Found only in males. Can
be diagnosed prenatally by hydronephrosis and dilated bladder on ultrasound. Most common
cause of urinary obstruction in male infants.
460
SECTION III
Posterior fossa malformations
Chiari I malformation!
Ectopia of cerebellar tonsils ( 1 structure ) > 3-5 mm; congenital, usually asymptomatic in
childhood, manifests in adulthood with headaches and cerebellar symptoms. Associated with
spinal cavitations ( eg, syringomyelia ) , i
Chiari II malformation
Herniation of low-lying cerebellar vermis and tonsils ( 2 structures) through foramen

hydrocephalus. Usually associated with lumbosacral
magnum )] with aqueductal stenosis
meningomyelocele (may present as paralysis/sensory loss at and below the level of the lesion ) .
Dandy-Walker
syndrome|
Agenesis of cerebellar vermis with cvstic enlargement of 4th ventricle ( red arrow in ), fills the
enlarged posterior fossa. Associated with noncommunicating hydrocephalus, spina bifidaj
B=
New
Image
r#vV
wan
Syringomyelia
Cystic cavity (syrinx) within central canal

of spinal cord ( yellow arrow in Q). Fibers
crossing in anterior white commissure
(spinothalamic tract) are typically damaged
first. Results in a cape-like, bilateral loss
of pain and temperature sensation in upper
extremities (fine touch sensation is preserved).
Associated with Chiari malformations (red
arrow in EJ), trauma, and tumors.
Syrinx = tube, as in syringe.

Most common at C8-T1
Tongue development
Anterior tongue
Arches
land 2
Sensation
vnaV
Taste
via VII
Revised
Figure |
Sensation
and taste
via IX
a cues
Sand 4
Sensation
and taste
NEUROLOGY ANATOMY AND PHYSIOLOGY
1st and 2nd branchial arches form anterior 2A

(thus sensation via CN V,, taste via CN VII).
3rd and 4th branchial arches form posterior A
(thus sensation and taste mainly via CN IX,
extreme posterior via CN X ).
Motor innervation is via CN XII to hyoglossus
(retracts and depresses tongue), genioglossus
(protrudes tongue), and styloglossus (draws
sides of tongue upward to create a trough for
swallowing).
Motor innervation is via CN X to palatoglossus
(elevates posterior tongue during swallowing).
SECTION III
461
Taste CN VII, IX, X (solitary nucleus).

Pain-CN V IX, X.
Motor-CN X, XII.
Posterior tongue

Neurons
Signal-transmitting cells of the nervous system. Permanent cells do not divide in adulthood.
Signal-relaying cells with dendrites (receive input), cell bodies, and axons (send output). Cell bodies
and dendrites can be seen on Nissl staining (stains RER). RER is not present in the axon.
Injury to axon Wallerian degeneration degeneration distal to injury and axonal retraction
proximally; allows for potential regeneration of axon (if in PNS).
Astrocytes
Physical support, repair, buffers extracellular K4! removal of excess neurotransmitter, component
of blood-brain barrier, glycogen fuel reserve buffer. Reactive gliosis in response to neural injury.
Astrocyte marker: GFAP Derived from neuroectoderm.
Microglia
Phagocytic scavenger cells of CNS

(mesodermal, mononuclear origin). Activated
in response to tissue damage. Not readily
discernible by Nissl stain.
HIV-infected microglia fuse to form

multinucleated giant cells in CNS.
462
SECTION III
Myelin
t conduction velocity of signals transmitted

down axons saltatory conduction of action
potential at the nodes of Ranvier, where there
are high concentrations of Na+ channels.
CNS oligodendrocytes; PNS Schwann
Wraps and insulates axons (red arrow in H):

t pace constant and t conduction velocity,
cells.
Schwann cells
Nucleus -v
Node of Ranvier
Myelin sheath -*
Each Schwann cell myelinates only 1 PNS axon. May be injured in Guillain-Barre syndromeJ
Also promote axonal regeneration. Derived
from neural crest
V Schwann cell
Myelinates axons of neurons in CNS. Each

oligodendrocyte can myelinate many axons
(~ 50). Predominant type of glial cell in white
Oligodendroglia
-Node of Ranvier
Axon
matter.
Derived from neuroectoderm.

Fried egg appearance histologically.
Injured in multiple sclerosis, progressive
multifocal leukoencephalopathy (PML),
leukodystrophies.
Sensory receptors
RECEPTOR TYPE
SENSORY NEURON FIBER TYPE
LOCATION
SENSES
Free nerve endings
C slow, unmyelinated fibers

A8 fast, myelinated fibers
All skin, epidermis, some
Pain, temperature
Meissner corpuscles
Large, myelinated fibers; adapt
Glabrous (hairless) skin
Dynamic, fine/light touch,

position sense
Deep skin layers, ligaments,
Vibration, pressure
Pacinian corpuscles
Merkel discs
Ruffini corpuscles
quickly
quickly
slowly
Dendritic endings with
capsule; adapt slowly
viscera
joints
Finger tips, superficial skin
Pressure, deep static touch (eg,

shapes, edges), position sense
Finger tips, joints
Pressure, slippage of objects

along surface of skin, joint
angle change
Peripheral nerve
Nerve trunk
Epineurium
Perineurium
Endoneurium
Nerve fibers
Chromatolysis
' .
***
Endoneurium invests single nerve fiber layers

(inflammatory infiltrate in Guillain-Barre
syndrome).
Perineurium ( blood-nerve Permeability
barrier) surrounds a fascicle of nerve fibers.
Must be rejoined in microsurgery for limb
reattachment.
Epineurium dense connective tissue that
surrounds entire nerve (fascicles and blood
vessels).
SECTION III
Endo = inner.
Peri = around.
Epi = outer.
Reaction of neuronal cell body to axonal injury. Changes reflect t protein synthesis in effort to
repair the damaged axon. Characterized bv:
Round cellular swelling H
Displacement of the nucleus to the periphery
Dispersion ofNissl substance throughout cytoplasm
Concurrent with Wallerian degeneration degeneration of axon distal to site of injury.
Macrophages remove debris and mvelin.
Neurotransmitter changes with disease!

LOCATION OF
ANXIETY
DEPRESSION
SCHIZOPHRENIA
SYNTHESIS
Acetylcholine
Basal nucleus
of Meynert
Dopamine
Ventral
ALZHEIMER
DISEASE
HUNTINGTON
DISEASE
PARKINSON
tegmentum,
SNj
GABA
Nucleus
accumbens
Norepinephrine
Locus ceruleus
Serotonin
Raphe nucleus
DISEASE
463
464
SECTION III
Blood-brain barrier
processes
light
-4' ll
.i' y '
Sasement
membrane
Hypothalamus
Prevents circulating blood substances

(eg, bacteria, drugs) from reaching the CSF/
CNS. Formed by 3 structures:
Tight junctions between nonfenestrated
capillary endothelial cellsw
Basement
membrane
Astrocyte foot processes

Glucose and amino acids cross slowly by carriermediated transport mechanisms.
Nonpolar /1ipid-soluble substances cross rapidly
via diffusion.
A few specialized brain regions with fenestrated

capillaries and no blood-brain barrier allow
molecules in blood to affect brain function (eg,
area postrema vomiting after chemo; OVLT
[organum vasculosum laminar terminalisl
osmotijsensing) or neurosecretory products to
enter circulation (eg, neurohypophysis ADH
release).
Infarction and/or neoplasm destroys endothelial
cell tight junctions vasogenic edema.
Other notable barriers include:
Blood-testis barrier
* Maternal-fetal blood barrier of placenta
The hypothalamus wears TAN HATS Thirst and water balance, Adenohypophysis control
(regulates anterior pituitary), Neurohypophysis releases hormones produced in the hypothalamus
Hunger, Autonomic regulation, Temperature regulation, Sexual urges.
Inputs (areas not protected by blood-brain barrier): OVLlt senses change in osmolarity), area
postrema (found in medulla, responds to emetics)]
If you zap your lateral area, you shrink laterally.
Lateral area
Hunger. Destruction anorexia, failure

to thrive (infants). Stimulated by ghrelin,
inhibited by leptin.
Ventromedial area
Satiety. Destruction (eg, craniopharyngioma)

hyperphagia. Stimulated by leptin.
Anterior
hypothalamus
Cooling, parasympathetic.
Anterior nucleus = cool off (cooling,

pArasympathetic). A /C = anterior cooling.
Posterior
hypothalamus
Heating, sympathetic.
Posterior nucleus = get fired up (heating,

sympathetic). If you zap your posterior
hypothalamus, you become a poikilotherm
(cold-blooded, like a snake).
Suprachiasmatic
nucleus
Circadian rhythm.
You need sleep to be charismatic (chiasmatic).
Supraoptic nucleus
Releases ADI 1
Paraventricular
nucleus
Releases oxvtocin
ADH and oxvtoxin are carried by neurophvsins

down axons to posterior pituitary , where they arc
stored and released.
If you zap your ventromedial area, you grow

ventrally and medially.
Sleep physiology
SECTION III
465
Sleep cycle is regulated by the circadian rhythm, which is driven by suprachiasmatic nucleus (SCN)
of hypothalamus. Circadian rhythm controls nocturnal release of ACTH, prolactin, melatonin,
norepinephrine: SCN norepinephrine release pineal gland melatonin. SCN is regulated
by environment (eg, light).
Two stages: rapid-eve movement (REM) and non-REM|
Alcohol, benzodiazepines, and barbiturates are associated with l REM sleep and delta wave sleep;
norepinephrine also i REM sleep.
Oral desmopressin ( ADI 1 analog) is useful in treatment of bedwetting (sleep enuresis) j preferred over
imipramine because of the latters adverse effects.
Benzodiazepines are useful for night terrors and sleepwalking by decreasing N3 and REM sleep!
SLEEP STAGE (% OF TOTAL SLEEP
TIME IN YOUNG ADULTS)
DESCRIPTION
EEG WAVEFORM
Awake (eyes open)
Alert, active mental concentration
Beta ( highest frequency, lowest amplitude)
Alpha
Awake (eyes closed)

Non- REM sleep
Stage N1 (5%)
Light sleep
Theta
Stage N2 (45%)
Deeper sleep; when bruxism occurs

Deepest non-REM sleep (slow -wave sleep);
when sleepwalking, night terrors, and
bedwetting occur
Delta (lowest frequency, highest amplitude)
Stage N3 (25%)
REM sleep (25%)
Loss of motor tone, t brain O-, use, t and

variable pulse and blood pressure; when
dreaming, nightmares, and penile/clitoral
tumescence occur; may serve memory
processing function. Depression increases total
REM sleep but decreases REM latencvi
Extraocular movements due to activity of PPRF
( paramedian pontine reticular formation /
conjugate gaze center)
Occurs every 90 minutes, and duration
t through the night
t ACh in REM
Sleep spindles and K complexes
Beta
At night, BATS Drink Blood
466
SECTION III
Ventral
FJpsteroLjateral
Major relay for all ascending sensory information except olfaction.
Thalamus
NUCLEUS
INPUT
SENSES
DESTINATION
Spinothalamic and dorsal columns/

medial lemniscus
Vibration, Pain,
Pressure,
1 somatosensory-
MNEMONIC
cortex
Proprioception,
Light touch,
temperature!
nucleus
Face sensation,
1 somatosensory -
Ventral
posteroMedial
nucleus
Trigeminal and gustatory pathway
Lateral
geniculate
nucleus
CN II
Vision
Calcarine sulcus
Lateral = Light
Medial
geniculate
nucleus
Superior olive and inferior colliculus of
Hearing
Auditory cortex of
temporal lobe
Medial = Music
Motor
Motor cortex
cortex
taste
tectum
Ventral lateral Basal ganglia, cerebellum

nucleus
Collection of neural structures involved in

emotion, long-term memory, olfaction,
behavior modulation, ANS function.
The Pape / circuit consists of the following
Limbic system
jiCpA
- v;
;
Makeup goes on
the face (VPM)
The famous 5 Fs.
*
Dopaminergic
pathways
structures: hippocampus ( red arrows in H),

mammillary bodies, anterior thalamic nuclei,
cingulate gyrus ( yellow arrows in D),
entorhinal cortex ]Responsible for Feeding,
Fleeing, Fighting, Feeling, and Sex.
Commonly altered by drugs (eg, antipsychotics) and movement disorders (eg, Parkinson disease).
PATHWAY
SYMPTOMS OF ALTERED ACTIVITY
Mesocortical
1 activity
Mesolimblc
t activity -* positive symptoms (eg, delusions,

hallucinations).
Primary therapeutic target of antipsychotic drugs

-* 1 positive symptoms (eg, in schizophrenia).
Nigrostriatal
1 activity extrapyramidal symptoms

(eg, dystonia, akathisia, parkinsonism, tardive
dyskinesia).
Major dopaminergic pathway in brain.

Significantly affected by movement disorders
and antipsychotic drugs.
Tuberoinfundibular
1 activity -* t prolactin
NOTES
negative symptoms (eg, anergia,

apathy, lack of spontaneity!).
1 libido, sexual
dysfunction, galactorrhea, gynecomastia (in
men).
Antipsychotic drugs have limited effect.
Cerebellum
Modulates movement; aids in coordination and

balance.
Input:
Contralateral cortex via middle cerebellar
peduncle.
Ipsilateral proprioceptive information via
inferior cerebellar peduncle from spinal
cord.
Output:
The only output of cerebellar cortex =
Purkinje cells (always inhibitorydeep
nuclei of cerebellum contralateral cortex
via superior cerebellar peduncle.
Deep nuclei (lateral -* medial) Dentate,
Emboliform, Globose, Fastigial ( Dont Eat
Greasy Foods ).
SECTION III
467
Lateral lesions affect voluntary movement of

extremities ( Limbst when injured, propensity
to fall toward injured (ipsilateral) side.
Medial lesions involvement of Mjjdline
structures (vermal cortex, fastigial nuclei)
and/or flocculonodular lobe truncal ataxia
(wide-based cerebellar gait), nystagmus, head
tilting. Generally result in bilateral motor
deficits affecting axial and proximal limb
musculature.
NEUROLOGY
SECTION III
469
Cerebral cortex functions

Premotor
Re
located
Fact
Somatosensory
association cortex
Central sulcus
cortex
0i
Frontal eye
held
Frontal
ibc
'
Prefronl 3
T
Broca area
Wernicke area
Occipital
lobe
Temporal
mpo
lobe
Sylvian fissure
Limbic
Primary
visual cortex
Primary
auditory cortex
association area
Topographic representation of motor (shown )

and sensory areas in the cerebral cortex.
Distorted appearance is due to certain body
regions being more richly innervated and thus
having t cortical representation .
Homunculus
Re located
Fact
oooo0
-,x
fV i %
'
<
Tongue
Swallowing
Medial
11
Lateral
470
SECTION III
Cerebral perfusion
Re -
located
Fact
Brain perfusion relies on tight autoregulation .

Cerebral perfusion is primarily driven by
Pco7 ( Po2 also modulates perfusion in severe
hypoxia).
Cerebral perfusion relies on a pressure gradient
between mean arterial pressure ( MAP) and
ICP. i blood pressure or t ICP -* 1 cerebral
perfusion pressure ( CPP ).
normal Po2
Normal
Hypoxemia increases
cerebral perfusion pressure
only when Po2 < 50 mm Hg
NEUROLOGY
Therapeutic hyperventilation 1 Pco?

-* vasoconstriction i cerebral blood flow
1 intracranial pressure ( ICP) . May be used
to treat acute cerebral edema (eg, 2 to stroke )
unresponsive to other interventions.
CPP = MAP - ICP. If CPP = 0, there is no
cerebral perfusion brain death .
Cerebral perfusion
pressure * Pco2 until
Pco2 > 90 mm Hg
--02
I
Normal
normal Pco2
50
Re -
ISO
100
Arterial gas pressure (mm Hg )
120
80
Arterial gas pressure 1mm Hg)
40
located Cerebral arteries cortical distribution

Fact
Anterior cerebral artery (supplies anteromedial surface )
[ j Middle cerebral artery (supplies lateral surface)

| | Posterior cerebral artery (supplies posterior and inferior surfaces)
?T
A
Watershed zones
Between anterior cerebral /middle cerebral , posterior cerebral /middle cerebral arteries. Damage by
severe hypotension -* upper leg /upper arm weakness, defects in higher-order visual processing.
Re -
Circle of Willis
located
Fact
System of anastomoses between anterior and posterior blood supplies to brain.

ACom I Anterior
Optic chiasm
communicating
cerebral
Anterior
ACA
ICA
MCA
Anterior
ACA
circulation
MCA
Internal carotid | ICA
AT
Middle
zerebi ri
Posterior
communicating
PCA
-ni
CA
erebi il
cerebellar
if ^
Anterior inferior
cerebellar
> I i . l .TI
I/A
cephalic
- Basilar | BA
Posterior inferior
.
GCA
Ht
rr A Superior
PICA
BA
PCom
Posterior
AICA
Dural venous sinuses
CA
ft
WILLIS
9TPCA
INFERIOR VIEW
ACA
CIRCLE
OF
PCom
circulation
471
SECTION III
Aorta
- Vertebral | VA
OBLIQUE- LATERAL VIEW
Anterior spinal | ASA
Large venous channels that run through the dura. Drain blood from cerebral veins and receive CSF
from arachnoid granulations. Empty into internal jugular vein.
Venous sinus thrombosis presents with signs/symptoms of t ICP (eg, headache, seizures, focal
neurologic deficits). May lead to venous hemorrhage. Associated with hypercoagulable states (eg,
pregnancy, OCP use, factor V Leiden).
Superior sagittal sinus

(main location of CSF return
via arachnoid granulations )

Inferior sagittal sinus
Superior ophthalmic vein
Great cerebral vein of Galen
Sphenoparietal sinus
Straight sinus
Cavernous sinus
Confluence of the sinuses
Sigmoid sinus
Occipital sinus
Transverse sinus
Jugular foramen
Internal jugular vein
NEUROLOGY PATHOLOGY
SECTION III
Effects of strokes ( continued )

ARTERY
AREA OF LESION
SYMPTOMS
NOTES
Basilar artery
Pons, medulla , lower niidbrain
RAS spared , therefore preserved

consciousness
Quadriplegia; loss of voluntary
facial , mouth , and tongue
Locked-in syndrome.
Corticospinal and corticobulbar

tracts
Posterior
cerebral
Ocular cranial nerve nuclei,

paramedian pontine reticular
formation
Occipital cortex, visual cortex.
movements
Loss of horizontal, but not vertical ,
eye movements
Contralateral hemianopia with

macular sparing.
artery
a
I New I
llmaqel
\
r
483
514
SECTION III
NEUROLOGY
PHARMACOLOGY
Suvorexant
MECHANISM
I NeW I CLINICAL USE

| Fact |
ADVERSE EFFECTS
Triptans
MECHANISM
Hvpocretin (orexin) receptor antagonist.

Insomnia.
CNS depression , headache, dizziness, abnormal dreams, upper respiratory tract infection .
Contraindicated in patients with narcolepsy. Not recommended in patients with liver disease.
Sumatriptan
5- HT|B/1 p agonists. Inhibit trigeminal nerve
activation ; prevent vasoactive peptide release;
induce vasoconstriction .
CLINICAL USE
Acute migraine, cluster headache attacks.
ADVERSE EFFECTS
Coronary vasospasm (contraindicated in

patients with CAD or Prinzmetal angina),
mild paresthesia , serotonin syndrome ( in
combination with other 5 - HT agonists).
A SUMo wrestler TRIPs ANd falls on your

head
,
HIGH- YIELD PRINCIPLES IN
Psychiatry
A Freudian slip is when you say one thing but mean your mother.
Psychology
522
Pathology
524
Pharmacology
539
Anonymous
Men will always be mad , and those who think they can cure them are the
maddest of all.
Voltaire
Anyone who goes to a psychiatrist ought to have his head examined ."
Samuel Goldwyn
Words of comfort , skillfully administered , are the oldest therapy known to

man.
Louis Nizer
This chapter has been updated with PSM- 5 criteria .
521
522
SECTION III
PSYCHIATRY
PSYCHIATRY PSYCHOLOGY
Usually deals with involuntary responses.

Pavlovs classical experiments with dogs
ringing the bell provoked salivation.
Classical conditioning
Learning in which a natural response

(salivation) is elicited by a conditioned,
or learned, stimulus (bell) that previously
was presented in conjunction with an
unconditioned stimulus (food).
Operant conditioning
Learning in which a particular action is elicited because it produces a punishment or reward.

Usually deals with voluntary responses.
Reinforcement
Target behavior (response) is followed by desired reward (positive reinforcement) or removal of

aversive stimulus (negative reinforcement).
Punishment
Repeated application of aversive stimulus

(positive punishment) or removal of desired
reward (negative punishment) to extinguish
unwanted behavior.
Extinction
Skinners Operant Conditioning Quadrant

Decrease Behavior
Increase Behavior
Positive
Punishment
Positive
Reinforcement
Negative
Negative
Punishment
Reinforcement
<
Discontinuation of reinforcement (positive or negative) eventually eliminates behavior. Can occur
in operant or classical conditioning.
Transference and countertransference

Transference
Patient projects feelings about formative or other important persons onto physician (eg, psychiatrist
is seen as parent).
Countertransference
Doctor projects feelings about formative or other important persons onto patient (eg, patient
reminds physician of younger sibling).
Ego defenses
Mental processes (unconscious or conscious) used to resolve conflict and prevent undesirable
feelings (eg, anxiety, depression).
IMMATURE DEFENSES
DESCRIPTION
EXAMPLE
Acting out
Expressing unacceptable feelings and thoughts

through actions.
Tantrums.
Denial
Avoiding the awareness of some painful reality.
A cancer patient plans a full-time work schedule

despite being warned of significant fatigue
Displacement
Redirection of emotions or impulses to a neutral
Mother yells at her child, because her husband

yelled at her.
during chemotherapy
person or
Dissociation
object (vs projection)!
Temporary, drastic change in personality,

memory, consciousness, or motor behavior
to avoid emotional stress. Extreme forms can
result in dissociative identity disorder (multiple
personality disorder ]
Patient has incomplete or no memory of

traumatic event ]
PSYCHIATRY
SECTION III
523
Ego defenses ( continued )

IMMATURE DEFENSES
DESCRIPTION
EXAMPLE
Fixation
Partially remaining at a more childish level of
Adults that suck their thumbs (oral fixation!
Idealization
Identification
development (vs regression).

Expressing extremely positive thoughts of self
and others while ignoring negative thoughts.
Modeling behavior after another person who
is more powerful (though not necessarily
A patient boasts about his physician and his

accomplishments while ignoring any flaws.
Abused child later becomes a child abuser.
admired).
Intellectualization
Using facts and logic to emotionally distance

oneself from a stressful situation.
In a therapy session, patient diagnosed with
Isolation (of affect)
Separating feelings from ideas and events.
Describing murder in graphic detail with no

emotional response.
Passive aggression
Project hostile feelings in a non-confrontational
Disgruntled employee is repeatedly late to work.
cancer
focuses only on rates of survival.
manner ]
Projection
Attributing an unacceptable internal impulse to

an external source (vs displacement).
A man who wants to cheat on his wife accuses
Rationalization
Proclaiming logical reasons for actions actually

performed for other reasons, usually to avoid
self-blame.
After getting fired, claiming that the job was not

important anyway.
Reaction formation
Replacing a warded-off idea or feeling by an

(unconsciously derived) emphasis on its
A patient with libidinous thoughts enters a

monastery.
Regression
Involuntarily
Seen in children under stress such as illness,

punishment, or birth of a new sibling (eg,
bedwetting in a previously toilet-trained child
when hospitalized).
Repression
Involuntarily withholding an idea or feeling

from conscious awareness (vs suppression).
A 20-vear-old does not remember going to

counseling during his parents divorce 10 years
earlier.
Splitting
Believing that people are either all good or

all bad at different times due to intolerance
of ambiguity. Commonly seen in borderline
personality disorder.
A patient says that all the nurses are cold and

insensitive but that the doctors are warm and
Sublimation
Replacing an unacceptable wish with a course

of action that is similar to the wish but does
not conflict with one's value system (vs
Teenagers aggression toward his father is

redirected to perform well in sports.
Altruism
Alleviating negative feelings via unsolicited
opposite (vs sublimation).

turning back the maturational
clock and going back to earlier modes of
dealing with the world (vs fixation).
his wife of being unfaithful.
friendly.
MATURE DEFENSES
reaction formation).
Mafia boss makes large donation to charity.
generosity.
Suppression
Intentionally withholding an idea or feeling

from conscious awareness (vs repression);
temporary.
Choosing to not worry about the big game until

it is time to play.
Humor
Appreciating the amusing nature of an anxietyprovoking or adverse situation.
Nervous medical student jokes about the boards.
Mature adults wear a SASH.
524
SECTION III
PSYCHIATRY
PSYCHIATRY PATHOLOGY
Psychiatric genetics
Both genetic and environmental factors are involved in development of most psychiatric disorders.
For example, in bipolar disorder and schizophrenia, lifetime risk in general population (~ 1%)
< parent or sibling of someone affected (~ 10%) < monozygotic twin of someone affected (~ 50%).
Infant deprivation
effects
Long-term deprivation of affection results in:

Failure to thrive
Poor language/socialization skills
Lack of basic trust
Reactive attachment disorder (infant
withdrawn/unresponsive to comfort)
(Deprivation for > 6 months can lead to

irreversible changes.
Severe deprivation can result in infant death.
Child abuse
Physical abuse
Sexual abuse
Fractures (eg, ribs, long bone spiral, multiple

in different stages of healing), bruises (eg,
trunk, ear, neck; in pattern of implement),
burns (eg, cigarette, buttocks/thighs), subdural
hematomas, retinal hemorrhages. During
exam, children often avoid eye contact.
Genital, anal, or oral trauma; STIs; UTIs.
ABUSER
Usually biological mother.
Known to victim, usually male.
EPIDEMIOLOGY
40% of deaths related to child abuse or neglect

occur in children < 1 year old ]
Peak incidence 9-12 years old.
EVIDENCE
Child neglect
Failure to provide a child with adequate food, shelter, supervision, education, and/or affection.
Most common form of child maltreatment. Evidence: poor hygiene, malnutrition, withdrawal,
impaired social/emotional development, failure to thrive.
As with child abuse, suspected child neglect must be reported to local child protective services.
Vulnerable child
syndrome
Parents perceive the child as especially susceptible to illness or injury. Usually follows a serious
illness or life-threatening event. Can result in missed school or overuse of medical services.
PSYCHIATRY
PSYCHIATRY
PATHOLOGY
525
SECTION III
Childhood and early-onset disorders
Attention -deficit
hyperactivity
disorder
Onset before age 12. Limited attention span and poor impulse control. Characterized by
hyperactivity, impulsivity, and /or inattention in multiple settings (school , home, places of worship,
etc). Normal intelligence, but commonly coexists with difficulties in school . Continues into
adulthood in as many as 50% of individuals. Treatment: stimulants (eg, methylphenidate) +/
cognitive behavioral therapy (CBT ) ; alternatives include atomoxetine, guanfacine, clonidine.
Autism spectrum
disorder
Characterized by poor social interactions, social communication deficits, repetitive /ritualized

behaviors, restricted interests. Must present in early childhood. May be accompanied by
intellectual disability; rarely accompanied by unusual abilities (savants). More common in boys.
Associated with t head/brain size.
Rett syndrome
X-linked dominant disorder seen almost exclusively in girls (affected males die in utero or
shortly after birth ) . Symptoms usually become apparent around ages 1 4, including regression
characterized by loss of development , loss of verbal abilities, intellectual disability, ataxia ,
stereotyped hand-wringing.
Repetitive and pervasive behavior violating the basic rights of others or societal norms (eg,
aggression to people and animals, destruction of property, theft ). After age 18, many of these
patients will meet criteria for diagnosis of antisocial personality disorder. Treatment for both:
psychotherapy such as CBT.
Enduring pattern of hostile, defiant behavior toward authority figures in the absence of serious
violations of social norms. Treatment: psychotherapy such as CBT.
Common onset at 7-9 years. Overwhelming fear of separation from home or loss of attachment
figure. May lead to factitious physical complaints to avoid going to or staying at school . Treatment:
CBT, play therapy, family therapy.
Onset before age 18. Characterized by sudden , rapid , recurrent, nonrhythmic, stereotyped motor
and vocal tics that persist for > 1 year. Coprolalia ( involuntary obscene speech ) found in only
10-20% of patients. Associated with OCD and ADHD. Treatment: psychoeducation , behavioral
therapy. For intractable and distressing tics, high -potency antipsychotics (eg, fluphenazine,
pimozide), tetrabenazine, a,-agonists (eg , guanfacine and clonidine), or atypical antipsychotic
may be used.
Onset before age 10. Severe and recurrent temper outbursts out of proportion to situation . Child
is constantly angry and irritable between outbursts. Treatment: psychostimulants, antipsychotics.
behavioral therapy.
Conduct disorder
Oppositional defiant
disorder
Separation anxiety
disorder
Tourette syndrome
Disruptive mood
dysrequlation
disorder
Orientation
Patients ability to know who he or she is, where

he or she is, and the date and time.
Common causes of loss of orientation : alcohol,
drugs, fluid /electrolyte imbalance, head
trauma , hypoglycemia , infection, nutritional
deficiencies.
Order of loss: 1st time; 2 nd place; last
person .
PSYCHIATRY
Dementia
Psychosis
PSYCHIATRY
I in intellectual function without affecting

level of consciousness. Characterized by
memory deficits, apraxia, aphasia , agnosia ,
loss of abstract thought , behavioral / personality
changes, impaired judgment. A patient
with dementia can develop delirium (eg,
patient with Alzheimer disease who develops
pneumonia is at t risk for delirium ).
Irreversible causes: Alzheimer disease, Lewy
body dementia , Huntington disease, Pick
disease, cerebral infarct , Creutzfeldt-Jakob
disease, chronic substance abuse (due to
neurotoxicity of drugs).
Reversible causes: hypothyroidism, depression,
vitamin B ) 2 deficiency, normal pressure
hydrocephalus, neurosyphilis.
t incidence with age. EEG usually normal .
PATHOLOGY
SECTION III
is characterized by memory loss .

Usually irreversible.
In elderly patients, depression and
hypothyroidism may present like dementia
Dememtia
( pseudodementia). Screen for depression ,

exclude neurosyphilis with RPR if high clinical
suspicion!and measure TSH , Bp levels.
Distorted perception of reality characterized by delusions, hallucinations, and/or disorganized

thought /speeclj Can occur in patients with medical illness, psychiatric illness, or both .
Delusions
Unique, false beliefs that persist despite the facts, not typical of a patient s culture or religion ( eg,
thinking aliens are communicating with vouj Types include erotomanic, grandiose , jealous,
persecutory, somatic, mixed , and unspecified!
Disorganized thought
Speech may be incoherent ( word salad ), tangential , or derailed ( loose associations ).
Hallucinations
Perceptions in the absence of external stimuli (eg, seeing a light that is not actually present).
Contrast with illusions, misperceptions of real external stimuli. Types include:
a
Visual more commonly a feature of medical illness (eg, drug intoxication ) than psychiatric
illness.
Auditory more commonly a feature of psychiatric illness (eg, schizophrenia) than medical
illness.
Olfactory often occur as an aura of temporal lobe epilepsy (eg, burning rubber) and in brain
tumors.
Gustatory rare, but seen in epilepsy.
Tactile common in alcohol withdrawal and stimulant use (eg, cocaine, amphetamines),
delusional parasitosis, cocaine crawlies.
Hypnagogic occurs while going to sleep. Sometimes seen in narcolepsy.
Hypnopompic occurs while waking from sleep ( pompous upon awakening ). Sometimes
seen in narcolepsy.
527
528
SECTION III
Schizophrenia
PSYCHIATRY
PSYCHIATRY
PATHOLOGY
Chronic mental disorder with periods of

psychosis, disturbed behavior and thought,
and decline in functioning lasting > 6
months. Associated with t dopaminergic
activity, i dendritic branching.
Diagnosis requires at least 2 of the following,

and at least 1 of these should include 1-3
(first 4 are positive symptoms ):
1 . Delusions
2 . Hallucinations often auditory
3. Disorganized speech
4. Disorganized or catatonic behavior
5. Negative symptoms (affective flattening,
avolition , anhedonia , asociality, alogia)
Brief psychotic disorder lasting < 1 month ,
usually stress related.
Frequent cannabis use is associated with

psychosis/schizophrenia in teens.
Lifetime prevalence 1.5% ( males = females,
African Americans = Caucasians). Presents
earlier in men ( late teens to early 20s vs late
20s to early 30s in women ). Patients are at t
risk for suicide.
Ventriculomegaly on brain imaging.
Treatment: atypical antipsychotics (eg,
risperidone) are first line.
Negative symptoms often persist despite
resolution of positive symptoms.
Schizophreniform disorder lasting 1-6
months.
Schizoaffective disorder Meets criteria for

schizophrenia in addition to major mood
disorder ( major depressive or bipolar ) . To
differentiate from a major mood disorder
with psychotic features, patient must have
> 2 weeks of hallucinations or delusions
without major mood episode
Delusional disorder
Fixed , persistent, false belief system lasting > 1 month. Functioning otherwise not impaired
(eg, a woman who genuinely believes she is married to a celebrity when , in fact , she is not).
Can be shared by individuals in close relationships (folie a deux).
Mood disorder
Characterized by an abnormal range of moods or internal emotional states and loss of control over
them . Severity of moods causes distress and impairment in social and occupational functioning.
Includes major depressive disorder, bipolar disorder, dysthymic disorder, and cyclothymic
disorder. Episodic superimposed psychotic features (delusions or hallucinations) may be present.
Manic episode
Distinct period of abnormally and persistently elevated , expansive, or irritable mood and
abnormally and persistently t activity or energy lasting at least 1 week . Often disturbing to
patient .
Diagnosis requires hospitalization or at least 3 of the following ( manics DIG E\ST):
Flight of ideas racing thoughts
Distractibility
t in goal-directed Activity/psychomotor
Irresponsibility seeks pleasure without
Agitation
regard to consequences ( hedonistic)
1 need for Sleep
Grandiosity inflated self-esteem
Talkativeness or pressured speech
PSYCHIATRY
SECTION III
529
Hypomanic episode
Like a manic!episode except mood disturbance is not severe enough to cause marked impairment
in social and/or occupational functioning or to necessitate hospitalization. No psychotic features.
Lasts at least 4 consecutive days.
Bipolar disorder
Bipolar I defined by presence of at least 1 manic episode +/ a hypomanic or depressive episode,

Bipolar II defined by presence of a hypomanic and a depressive episode.
Patient s mood and functioning usually return to normal between episodes. Use of antidepressants
can precipitate mania. High suicide risk. Treatment: mood stabilizers (eg, lithium, valproic acid,
carbamazepine, lamotriginc!), atypical antipsychotics.
Cyclothymic disorder milder form of bipolar disorder lasting at least 2 years, fluctuating
between mild depressive and hypomanic symptoms.
(manic depression )
Major depressive
disorder
Episodes characterized by at least 5 of the

9 D+SIGECAPS symptoms for 2 or more
weekj(symptoms must include patientreported depressed mood or anhedonia).
Treatment: CBT and SSRIs are first line.
SNRIs, mirtazapine, bupropion can also be
considered. Electroconvulsive therapy (ECT)
in select patients.
Persistent depressive disorder (dysthymia)
depression, often milder, lasting at least
2 years. May be caused by low self- esteem.
SIG E CAPS:
" Depressed mood

Sleep disturbance
Loss of Interest (anhedonia)
Guilt or feelings of worthlessness
* Energy loss and fatigue
8
Concentration problems
Appetite/weight changes
x Psychomotor retardation or
agitation
Suicidal ideations
Patients with depression typically have the
following changes in their sleep stages:
c
1 slow-wave sleep
1 REM latency
t REM early in sleep cycle
t total REM sleep
Repeated nighttime awakenings

Earlv-morning awakening (terminal
insomnia)
Depression with
atypical features
pharacterized by mood reactivity ( being able to experience improved mood in response to positive
events, albeit briefly), reversed vegetative symptoms ( hypersomnia, hyperphagia), leaden
paralysis ( heavy feeling in arms and legs), long-standing interpersonal rejection sensitivity. Most
common subtype of depression. Treatment: CBT and SSRIs are first line. MAO inhibitors are
effective but not first line because of their risk profile.
PSYCHIATRY
SECTION III
529
Hypomanic episode
Like a manic!episode except mood disturbance is not severe enough to cause marked impairment
in social and/or occupational functioning or to necessitate hospitalization. No psychotic features.
Lasts at least 4 consecutive days.
Bipolar disorder
Bipolar I defined by presence of at least 1 manic episode +/ a hypomanic or depressive episode,

Bipolar II defined by presence of a hypomanic and a depressive episode.
Patient s mood and functioning usually return to normal between episodes. Use of antidepressants
can precipitate mania. High suicide risk. Treatment: mood stabilizers (eg, lithium, valproic acid,
carbamazepine, lamotriginc!), atypical antipsychotics.
Cyclothymic disorder milder form of bipolar disorder lasting at least 2 years, fluctuating
between mild depressive and hypomanic symptoms.
(manic depression )
Major depressive
disorder
Episodes characterized by at least 5 of the

9 D+SIGECAPS symptoms for 2 or more
weekj(symptoms must include patientreported depressed mood or anhedonia).
SNRIs, mirtazapine, bupropion can also be
considered. Electroconvulsive therapy (ECT)
in select patients.
Persistent depressive disorder (dysthymia)
depression, often milder, lasting at least
2 years. May be caused by low self- esteem.
SIG E CAPS:
" Depressed mood

Sleep disturbance
Loss of Interest (anhedonia)
Guilt or feelings of worthlessness
* Energy loss and fatigue
8
Concentration problems
Appetite/weight changes
x Psychomotor retardation or
agitation
Suicidal ideations
Patients with depression typically have the
following changes in their sleep stages:
c
1 slow-wave sleep
1 REM latency
t REM early in sleep cycle
t total REM sleep
Repeated nighttime awakenings

Earlv-morning awakening (terminal
insomnia)
Depression with
atypical features
pharacterized by mood reactivity ( being able to experience improved mood in response to positive
events, albeit briefly), reversed vegetative symptoms ( hypersomnia, hyperphagia), leaden
paralysis ( heavy feeling in arms and legs), long-standing interpersonal rejection sensitivity. Most
common subtype of depression. Treatment: CBT and SSRIs are first line. MAO inhibitors are
effective but not first line because of their risk profile.
530
SECTION III
Postpartum mood
disturbances
PSYCHIATRY
PSYCHIATRY
PATHOLOGY
Onset within 4 weeks of delivery.
Maternal
( postpartum ) "blues"
50-85% incidence rate. Characterized by depressed affect , tearfulness, and fatigue starting 2-3
days after delivery. Usually resolves within 10 days. Treatment: supportive. Follow up to assess for
possible postpartum depression .
Postpartum
depression
10-15% incidence rate. Characterized by depressed affect , anxiety, and poor concentration .
0.1-0.2% incidence rate. Characterized by mood-congruent delusions, hallucinations, and
thoughts of harming the baby or self. Risk factors include history of bipolar or psychotic disorder,
first pregnancy, family history, recent discontinuation of psychotropic medication . Treatment:
hospitalization and initiation of atypical antipsychotic; if insufficient, ECT may be used .
Postpartum psychosis
Grief
The five stages of grief are denial , anger, bargaining, depression , and acceptance, not necessarily
in that order. Other normal grief symptoms include shock, guilt , sadness, anxiety, yearning, and
somatic symptom Hallucinations of the deceased person are common . Duration varies widely;
usually < 6 months.
Pathologic grief is persistent and causes functional impairment . Can meet criteria for major
depressive episode.
Electroconvulsive
therapy
Used mainly for treatment-refractory depression, depression with psychotic symptoms, and acutely
suicidal patients. Produces grand mal seizure in an anesthetized patient . Adverse effects include
disorientation, temporary headache, partial anterograde /retrograde amnesia usually resolving in 6
months. Safe in pregnancy.
Risk factors for suicide
Sex ( male)
Age ( young adult or elderly)
Depression
)
Previous attempt ( highest risk factor!
Ethanol or drug use
Rational thinking loss ( psychosis)
Sickness (medical illness)
Organized plan
No spouse or other social support
Stated future intent
completion
Anxiety disorder
SAD PERSONS are more likely to complete
suicide.
Most common method in US is firearms; access
to guns t risk of suicide completion.
Women try more often; men complete!more
often.
Inappropriate experience of fear/worry and its physical manifestations (anxiety) incongruent with
the magnitude of the perceived stressor. Symptoms interfere with daily functioning. Includes
panic disorder, phobias, generalized anxiety disorder, and selective mutism . Treatment: CBT,
SSRIs, SNRIs.
PSYCHIATRY
Panic disorder
SECTION III
531
Defined by recurrent panic attacks ( periods

PANICS
of intense fear and discomfort peaking in
Diagnosis requires attack followed by 1 month
10 minutes with at least 4 of the following):
(or more) of 1 (or more) of the following:
Persistent concern of additional attacks
Palpitations, Paresthesias, dePersonalization or
derealization, Abdominal distress or Nausea,
Worrying about consequences of attack
Behavioral change related to attacks
Intense fear of dying, Intense fear of losing
control or going crazy, light-headedness,
Symptoms are the systemic manifestations of
fear.
Chest pain, Chills, Choking, Sweating,
Shaking, Shortness of breath. Strong genetic
component t risk of suicide! Treatment:
CBT, SSRIs, and venlafaxine are first line.
Benzodiazepines occasionally used in acute
setting.
,
Specific phobia
Severe, persistent (> 6 months) fear or anxiehidue to presence or anticipation of a specific object or
situation. Person recognizes fear is excessive. Can be treated with systematic desensitization.
Social anxiety disorder exaggerated fear of embarrassment in social situations (eg, public
speaking, using public restrooms). Treatment: CBT, SSRIs, venlafaxine. For only occasional
anxiety-inducing situations, benzodiazepine or P-blocker.

Agoraphobia exaggerated fear of open or enclosed places, using public transportation, being in
line or in crowds, or leaving home alone. Associated with panic disorder. Treatment: CBT, SSRI4
Generalized anxiety
disorder
Anxiety lasting > 6 months unrelated to a specific person, situation, or event. Associated with
restlessness, irritability, sleep disturbance, fatigue, muscle tension, difficulty concentrating.
Treatment: CBT, SSRIs, SNRIs are first line. Buspirone, TCAs, benzodiazepines are second line.
Adjustment disorder emotional symptoms (anxiety, depression) causing impairment following
an identifiable psychosocial stressor (eg, divorce, illness) and lasting < 6 months (> 6 months in
presence of chronic stressor). Treatment: CBT, SSRIs.
Obsessive- compulsive
disorder
Recurring intrusive thoughts, feelings, or sensations ( obsessions) that cause severe distress;
relieved in part by the performance of repetitive actions (compulsions). Ego-dystonic : behavior
inconsistent with ones own beliefs and attitudes (vs obsessive-compulsive personality disorder).
Associated with Tourette syndrome. Treatment : CBT, SSRIs, and clomipramine are first line.
Body dysmorphic disorder preoccupation with minor or imagined defect in appearance
significant emotional distress or impaired functioning; patients often repeatedly seek cosmetic
treatment. Treatment: CBT.
Post- traumatic stress

disorder
Exposure to prior trauma (eg, witnessing death, experiencing serious injury or rape) -* persistent
Hyperarousal Avoidance of associated stimuli, intrusive Reexperiencing of the event ( nightmares,
flashbacks), changes in cognition or mood (fear, horror Distress! Disturbance lasts > 1 month
with significant distress or impaired social-occupational functioning. Treatment: CBT, SSRIs, and
venlafaxine are first line. Having PTSD is HARD!
Acute stress disorder lasts between 3 days and 1 month. Treatment: CBT; pharmacotherapy is
usually not indicated.
532
SECTION III
PSYCHIATRY
PSYCHIATRY
PATHOLOGY
DSM -5 Timinq Criteria

DISORDER
DURATION OF SYMPTOMS FOR DIAGNOSIS
Brief psychotic
disorder
< 1 month
Schizophreniform
1-6 months
disorder
Schizophrenia
Schizoaffective
disorder
> 6 months
> 2 weeks
Maior depressive
disorder
> 2 weeks
Patholoqic qrief
> 6 months
> 2 weeks
Dysthvmia ,
cyclothymia
Delusional disorder
Generalized anxiety
disorder
> 1 month
> 6 months
Separation anxiety
disorder
Adjustment disorder
< 6 months
(> 6 months if presence of chronic stressor )
Acute stress disorder
3 days-1 month
PTSD
> 1 month
Malingering
Patient consciously fakes, profoundly exaggerates, or claims to have a disorder in order to attain a
specific 2 (external ) gain (eg, avoiding work , obtaining compensation ). Poor compliance with
treatment or follow-up of diagnostic tests. Complaints cease after gain (vs factitious disorder).
Factitious disorders
Patient consciously creates physical and/or psychological symptoms in order to assume sick role
and to set medical attention and sympathy (1 [ internal! gain ).
Factitious disorder
imposed on self
( Munchausen
syndrome)
Chronic factitious disorder with predominantly physical signs and symptoms. Characterized by
a history of multiple hospital admissions and willingness to undergo invasive procedures. Often
associated with healthcare worker
Factitious disorder
imposed on another
( Munchausen
syndrome by proxy)
Illness in a child or elderly patient is caused or fabricated by the caregiver. Motivation is to assume
a sick role by proxy. Form of child /elder abuse.
PSYCHIATRY
Somatic symptom and

related disorders
Somatic symptom
disorder
SECTION III
533
Category of disorders characterized by physical symptoms causing significant distress and

impairment . Both illness production and motivation are unconscious drives. Symptoms not
intentionally produced or feigned. More common in women.
Variety of bodily complaints (eg, pain, fatigue) lasting for months to years. Associated with
excessive, persistent thoughts and anxiety about symptoms. May co-occur with medical illness.
Treatment: Regular office visits with the same physician
Conversion disorder
(functional
neurologic symptom
disorder)
Loss of sensory or motor function ( eg, paralysis, blindness, mutism), often following an acute
stressor; patient is aware of but sometimes indifferent toward symptoms ( la belle indifference );
more common in females, adolescents, and young adults.
Illness anxiety
disorder
Excessive preoccupation with acquiring or having a serious illness, often despite medical
evaluation and reassurance; minimal somatic symptoms.
(Hypochondriasis|
]
Pseudocyesis
False, nondelusional belief of being pregnant. May have signs and symptoms of pregnancy but is
not pregnant.
Personality
Personality trait
An enduring, repetitive pattern of perceiving, relating to, and thinking about the environment and
Personality disorder
Inflexible, maladaptive, and rigidly pervasive pattern of behavior causing subjective distress
and/or impaired functioning; person is usually not aware of problem. Usually presents by early
adulthood.
Three clusters, A, B, and C; remember as Weird, Wild, and Worried based on symptoms.
oneself.
Cluster A personality
disorders
Odd or eccentric; inability to develop

meaningful social relationships. No psychosis;
genetic association with schizophrenia.
Weird ( Accusatory, Aloof, Awkward),
Paranoid
Pervasive distrust and suspiciousness; projection

is the major defense mechanism.
Schizoid
Voluntary social withdrawal, limited emotional

expression, content with social isolation (vs
avoidant).
Schizoid = distant,
Schizotypal
Eccentric appearance, odd beliefs or magical

thinking, interpersonal awkwardness.
Schizotypal = magical thinking
534
SECTION III
Cluster B personality
disorders
Antisocial
PSYCHIATRY
PSYCHIATRY
PATHOLOGY
( Bad to the Bone).
Dramatic, emotional , or erratic; genetic

association with mood disorders and substance
abuse.
"Wild
Disregard for and violation of rights of others

with lack of remorse, criminality, impulsivitw
Antisocial = sociopath.
males > females; must be > 18 years old and

have history of conduct disorder before age 15.
Conduct disorder if < 18 years old.
Borderline
Unstable mood and interpersonal relationships,

impulsivity, self-mutilation , suicidality, sense
of emptiness; females > males; splitting is a
major defense mechanism.
Histrionic
Excessive emotionality and excitability,

attention seeking, sexually provocative, overly
concerned with appearance.
Narcissistic
Grandiosity, sense of entitlement ; lacks empathy

and requires excessive admiration ; often
demands the best and reacts to criticism
with rage.
Cluster C personality
disorders
Avoidant
Obsessive-compulsive
Dependent
Anxious or fearful ; genetic association with

anxiety disorders.
Treatment: dialectical behavior therapy.
Worried ( Cowardly, Compulsive, Clingy).
Hypersensitive to rejection , socially inhibited ,

timid , feelings of inadequacy, desires
relationships with others (vs schizoid ).
Preoccupation with order, perfectionism , and
control ; ego-syntonic: behavior consistent with
ones own beliefs and attitudes (vs OCD).
Submissive and cling); excessive need to be
taken care of, low self-confidence.
Patients often get stuck in abusive relationships.
PSYCHIATRY
Eating disorders
Anorexia nervosa
SECTION III
535
Most common in young females. Note that bupropion should be avoided for management of
depression
Excessive dieting, exercise, or binge eating/purging with BMI < 18.5 kg/m2; intense fear of gaining
weight; and distortion or overvaluation of body image. Associated with A bone density, severe
weight loss, metatarsal stress fractures, amenorrhea (due to loss of pulsatile GnRH secretion),
lanugo, anemia, electrolyte disturbances. Commonly coexists with depression. Psychotherapy
and nutritional rehabilitation are first line. Refeeding syndrome ( t insulin hypophosphatemia
-* cardiac complications) can occur in significantly malnourished patients.
Bulimia nervosa
Binge eating with recurrent inappropriate compensatory behaviors (eg, self-induced vomiting,
using laxatives or diuretics, fasting, excessive exercise) occurring weekly for at least 3 months and
overvaluation of body image. Body weight often maintained within normal range. Associated with
parotitis, enamel erosion, electrolyte disturbances ( eg, hypokalemia, hvpochloremui metabolic
alkalosi dorsal hand calluses from induced vomiting ( Russell sign). Treatment: psychotherapy',
nutritional rehabilitation, antidepressants.
Binge eating disorder
Regular episodes of excessive, uncontrollable eating without inappropriate compensatory behaviors,

t risk of diabetes. Treatment: psychotherapy such as CBT is first-line; SSRIs, lisdexamfetaminel
Gender dysphoria
Strong, persistent cross-gender identification that leads to persistent discomfort with sex assigned at
birth, causing significant distress and/or impaired functioning. Transgender individuals may have
gender dysphoric disorder.
Transsexualism desire to live as the opposite sex, often through surgery or hormone treatment.
Transvestism paraphilia, not gender dysphoria. Wearing clothes (eg, vest) of the opposite sex
(cross-dressing).
Sexual dysfunction
Includes sexual desire disorders ( hypoactive sexual desire or sexual aversion), sexual arousal
disorders (erectile dysfunction), orgasmic disorders (anorgasmia, premature ejaculation), sexual
pain disorders (dyspareunia, vaginismus).
Differential diagnosis includes:
Drugs (eg, antihypertensives, neuroleptics, SSRIs, ethanol)
Diseases (eg, depression, diabetes, STIs)
Psychological (eg, performance anxiety)
0
Sleep terror disorder
Periods of terror with screaming in the middle of the night; occurs during slow-wave/deep (stage
N3) sleep. Most common in children . Occurs during non-REM sleep (no memory of arousal )
as opposed to nightmares that occur during REM sleep (memory of a scary dream). Cause
unknown, but triggers include emotional stress, fever, or lack of sleep. Usually self limited.
536
SECTION III
Narcolepsy
Substance use
disorder
PSYCHIATRY
PSYCHIATRY
PATHOLOGY
Disordered regulation of sleep-wake cycles; 1

characteristic is excessive daytime sleepiness
(awaken feeling rested ).
Caused by 1 hypocretin (orexin ) production in
lateral hypothalamus.
Also associated with:
" Hypnagogic ( just before sleep) or
hypnopompic ( just before awakening)
hallucinations.
Nocturnal and narcoleptic sleep episodes
that start with REM sleep ( sleep paralysis!
e Cataplexy loss of all muscle tone following
(
strong emotional stimulus, such as laughter)
in some patients.
Strong genetic component . Treatment: daytime
stimulants (eg, amphetamines, modafinil ) and
nighttime sodium oxybate (GHB).
Hypnagogic going to sleep

Hvpnopompic pompous upon awakening
Maladaptive pattern of substance use defined as 2 or more of the following signs in 1 year related
specifically to substance
uset
Tolerance need more to achieve same effect

Withdrawal
Substance taken in larger amounts, or over longer time, than desired
Persistent desire or unsuccessful attempts to cut down
Significant energy spent obtaining, using, or recovering from substance
Important social, occupational , or recreational activities reduceq
Continued use despite knowing substance causes physical and /or psychological problems
Craving
Recurrent use in physically dangerous situations
Failure to fulfill major obligations at work, school , or homq
Social or interpersonal conflict
Stages of change in
overcoming substance
addiction
1. Precontemplation not yet acknowledging that there is a problem

2. Contemplation acknowledging that there is a problem , but not yet ready or willing to make a
change
3. Preparation /determination getting ready to change behaviors
4. Action/willpower changing behaviors
5. Maintenance maintaining the behavior changes
6. Relapse returning to old behaviors and abandoning new changes
538
SECTION III
PSYCHIATRY
PSYCHIATRY
PATHOLOGY
Psychoactive drug intoxication and withdrawal ( continued )

DRUG
INTOXICATION
WITHDRAWAL
Hallucinogens
Phencyclidine ( PCP,
anqel
dustil
Lysergic acid
diethylamide ( LSD|
)
Marijuana
(cannabinoid )
Violence, impulsivity, psychomotor agitation ,

nystagmus, tachycardia , hypertension ,
analgesia , psychosis, delirium , seizures.
Trauma is most common complication.
Treatment: benzodiazepines, rapid-acting
antipsychotic.
Perceptual distortion (visual, auditory),
depersonalization, anxiety, paranoia ,
psychosis, possible flashbacks.
Irritability, anxiety, depression, insomnia ,
Euphoria , anxiety, paranoid delusions,
restlessness, 1 appetite. Generally detectable in
perception of slowed time, impaired judgment,
social withdrawal, t appetite, dry mouth,
urine for up to 1 month
conjunctival injection, hallucinations.
Pharmaceutical form is dronabinol
( tetrahydrocannabinol isomer): used as
antiemetic (chemotherapy) and appetite
stimulant ( in AIDS).
Hallucinogenic stimulant: euphoria ,
Depression , fatigue, change in appetite, difficulty
concentrating, anxiety
disinhibition , hy peractivity, distorted sensory
and time perception , teeth clenching Lifethreatening effects include hypertension ,
tachycardia , hyperthermia , hyponatremia ,
serotonin syndrome.
,
MDMA (ecstasy )
Heroin addiction
Users at t risk for hepatitis, HIV, abscesses, bacteremia , right-heart endocarditis. Treatment is
described below.
Methadone
Long-acting oral opiate used for heroin detoxification or long-term maintenance.
Naloxone +
buprenorphine
Antagonist + partial agonist. Naloxone is not orally bioavailable, so withdrawal symptoms occur
only if injected (lower abuse potential ).
Naltrexone
Long-acting opioid antagonist used for relapse prevention once detoxified .
Alcoholism
Wernicke- Korsakoff
syndrome
Physiologic tolerance and dependence with symptoms of withdrawal ( tremor, tachycardia ,

hypertension , malaise, nausea , DTs) when intake is interrupted .
Complications: alcoholic cirrhosis, hepatitis, pancreatitis, peripheral neuropathy, testicular atrophy.
Treatment: disulfiram ( to condition the patient to abstain from alcohol use), acamprosate,
naltrexone, supportive care. Support groups such as Alcoholics Anonymous are helpful in
sustaining abstinence and supporting patient and family.
Caused by vitamin Bj (thiamine) deficiency. Triad of confusion , ophthalmoplegia , ataxia ( Wernicke
encephalopathy ). May progress to irreversible memory loss, confabulation , personality change
( Korsakoff syndrome) . Associated with periventricular hemorrhage /necrosis of mammillary
bodies. Treatment: IV vitamin Bj .
PSYCHIATRY
Delirium tremens
PSYCHIATRY
PHARMACOLOGY
SECTION III
539
Life-threatening alcohol withdrawal syndrome that peaks 2-4 days after last drink .
Characterized by autonomic hyperactivity (eg, tachycardia, tremors, anxiety, seizures). Classically
occurs in hospital setting (eg, 2-4 days postsurgery) in alcoholics not able to drink as inpatients.
Treatment: benzodiazepines ( eg, chlordiazepoxide, lorazepam , diazepam
Alcoholic hallucinosis is a distinct condition characterized by visual hallucinations 12-48 hours after
last drink . Treatment: benzodiazepines (eg, chlordiazepoxide, lorazepam , diazepam ).
PSYCHIATRY
PHARMACOLOGY
Preferred medications
for selected
psychiatric conditions
PSYCHIATRIC CONDITION
PREFERRED DRUGS
ADHD
Stimulants ( methylphenidate, amphetamines)
Alcohol withdrawal
Bipolar disorder
Benzodiazepines (eg, chlordiazepoxide,

lorazepam, diazepam )
Lithium , valproic acid , carbamazepine,
Bulimia nervosa
SSRIs
Depression
SSRIs
Generalized anxiety disorder

Obsessive-compulsive disorder
SSRIs, SNRIs
SSRIs, venlafaxine, clomipramine
Panic disorder
SSRIs, venlafaxine, benzodiazepines
PTSD
SSRIs, venlafaxine
Atypical antipsychotics
SSRIs, venlafaxine
Performance only: P-blockers, benzodiazepines
Antipsychotics (eg, fluphenazine, pimozide),
lamotrigine, aty pical antipsychotics
Schizophrenia
Social anxiety disorder
Tourette syndrome
tetrabenazine
Central nervous system! Methylphenidate, dextroamphetamine, methamphetamine .

stimulants
MECHANISM
t catecholamines in the synaptic cleft , especially norepinephrine and dopamine.
CLINICAL USE
ADHD, narcolepsy, appetite control.
ADVERSE EFFECTS
Nervousness, agitation , anxiety, insomnia , anorexia , tachycardia , hypertension .
540
SECTION III
Antipsychotics
( neuroleptics )
MECHANISM
CLINICAL USE
PSYCHIATRY
PSYCHIATRY
PHARMACOLOGY
Haloperidol , pimozide , trifluoperazine , fluphenazine , thioridazine, chlorpromazinej
All typical antipsychotics block dopamine D2

receptors ( t [cAMP] ).
Schizophrenia ( primarily positive symptoms),
psychosis , bipolar disorder, delirium , Tourette
Highly lipid soluble and stored in body fat; thus,
very slow to be removed from body.
Extrapvramidal system side effects (eg,
dyskinesias). Treatment: benztropine,
diphenhydramine , benzodiazepines.
Endocrine side effects (veg, dopamine

v
receptor antagonism hyperprolactinemia
galactorrhea , oligomenorrhea .
gynecomastia ) .
Side effects arising from blocking muscarinic
(dry mouth , constipation ), a (orthostatic
hypotension ), and histamine (sedation)
tors
Can cause QT prolongation .
OTHER TOXICITIES
'
Low potency: Chlorpromazine , Thioridazine

(Cheating Thieves are low) non-neurologic
side effects (anticholinergic, antihistamine, and
arblockade effects).
Chlorpromazine - Comeal deposits;
.
. .
.
.1
rmal, ,
rrllnoridazine
reI
I
deposit
Onset of EPS: ADAP 1

* Hours to da> s: Acute Dystonia (muscle
sPasm stiffness oculyric crisis)
* Da >s to months: Akathisia (restlessness) and
Parkinsonism ( bradykinesia ) .
" Months to years: Tardive dyskinesia
For NMS> think FEVER :
Fever
Neuroleptic malignant syndrome ( NMS)

rigidity, myoglobinuria , autonomic instability,
,
hyperpyrexia Treatment: dantrolene, D
agonists (eg. bromocriptme).
Encephalopathy
\ jt fls unstable
Enzymes
Tardive dyskinesia orofacial chorea as a result

of long-term antipsychotic use .
Atypical
antipsychotics
Haloperidol NMS, tardive dy skinesia .
syndrome, Huntington disease , OCD.

ADVERSE EFFECTS
High potency: Trifluoperazine , Fluphenazine ,

Haloperidol ( Try to Fly High) neurologic
s dc c ec s
extrapyramidal symptoms
of muscles
Aripiprazole , asenapine , clozapine , olanzapine , quetiapine , iloperidone , paliperidone , lurasidone,
risperidoneT ziprasidonej
MECHANISM
Not completely understood . Most are D?

antagonists; aripiprazole is D-, partial agonist .
Varied effects on 5 -HT2, dopamine, and
a- and Hj-receptors.
CLINICAL USE
Schizophrenia both positive and negative
Also used for bipolar disorder,

OCD, anxiety disorder, depression , mania ,
symptoms .
Use clozapine for treatment-resistant

schizophrenia .
Tourette syndrome .
ADVERSE EFFECTS
All prolonged QT interval , fewer EPS and

anticholinergic side effects than typical
antipsychotics.
- pines metabolic syndrome (weight gain ,
diabetes , hyperlipidemia ).
Clozapine agranulocytosis ( monitor WBC

w eekly) and seizures ( dose-relatedl) .
Risperidone hyperprolactinemia (amenorrhea ,

galactorrhea , gynecomastia ).
Olanzapine
Obesity
Must watch bone marrow clozely with clozapine
PSYCHIATRY
PSYCHIATRY
PHARMACOLOGY
SECTION III
541
Lithium
MECHANISM
Not established; possibly related to inhibition of

phosphoinositol cascade.
CLINICAL USE
Mood stabilizer for bipolar disorder; blocks

relapse and acute manic events.
ADVERSE EFFECTS
Tremor, hypothyroidism, polyuria (causes

nephrogenic diabetes insipidus), teratogenesis.
Causes Ebstein anomaly in newborn if taken
by pregnant mother. Narrow therapeutic
window requires close monitoring of serum
levels. Almost exclusively excreted by kidneys;
most is reabsorbed at PCT with Na+. Thiazide
use is implicated in lithium toxicity in bipolar
patients.
LiTHIUM:
Low Thyroid ( hypothyroidism )
Heart ( Ebstein anomaly)
Insipidus ( nephrogenic diabetes insipidus )
Unwanted Movements ( tremor)
Buspirone
MECHANISM
Stimulates 5- HTJ A receptors.
CLINICAL USE
Generalized anxiety disorder. Does not cause

sedation , addiction, or tolerance. Takes 1-2
weeks to take effect. Does not interact with
alcohol (vs barbiturates, benzodiazepines).
Im always anxious if the bus will be on time, so

buspirone.
Antidepressants
SEROTONERGIC
NORADRENERGIC
AXON
AXON
MAO inhibitors .
Metabolites
MAO
MAO
Metabolites
Bupropion
oc
V*
Oi 2 ( autoreceptor )
TCAs, SNRIs
adrenergic
receptor
/
1
Mirtazapme
NE reuptake
5- HT
:>
'
V 5-HT reuptake k
ô
&S
NE receptor
POSTSYNAPTIC NEURON
-o-
TCAs SSRis,
SNRIs, trazodone
542
SECTION III
Selective serotonin
reuptake inhibitors
PSYCHIATRY
PSYCHIATRY PHARMACOLOGY
Fluoxetine, fluvoxamine, paroxetine, sertraline, escitalopram, citalopramll
MECHANISM
5-HT-specific reuptake inhibitors.
CLINICAL USE
Depression, generalized anxiety disorder,

panic disorder, OCD, bulimia, social anxiety
disorder, PTSD, premature ejaculation,
premenstrual dysphoric disorder.
ADVERSE EFFECTS
Fewer than TCAs. GI distress, SIADH, sexual

dysfunction (anorgasmia, 1 libido).
Serotonin-
It normally takes 4-8 weeks for antidepressants

have an effect,
Venlafaxine, desvenlafaxine, duloxetine, levomilnacipran, milnacipran.
norepinephrine
reuptake inhibitors
MECHANISM
Inhibit 5 -HT and norepinephrine reuptake.
CLINICAL USE
Depression, general anxiety disorder, diabetic neuropathy. Venlafaxine is also indicated for social
anxiety disorder, panic disorder, PTSD, OCD. Duloxetine is also indicated for fibromyalgia!
ADVERSE EFFECTS
t BP most common; also stimulant effects, sedation, nausea._

Serotonin syndrome Can occur with any drug that t 5 -HT (eg, MAOIs, SSRIs, SNRIs, TCAs,
tramadol, ondansetron, triptans). Characterized by 3 As: neuromuscular hvperActivity (clonus,
hyperreflexia, hypertonia, tremor, seizure) Autonomic stimulation (hyperthermia, diaphoresis,
diarrhea), and Agitation. Treatment: cyproheptadine ( 5 -HT, receptor antagonist).
Tricyclic
antidepressants
Amitriptyline, nortriptyline, imipramine, desipramine, clomipramine, doxepin, amoxapine.
MECHANISM
Block reuptake of norepinephrine and 5-HT.
CLINICAL USE
Major depression, OCD (clomipramine), peripheral neuropathy, chronic pain, migraine

prophylaxis. Nocturnal enuresis (imipraminej
ADVERSE EFFECTS
Sedation, (Xj-blocking effects including postural hypotension, and atropine-like (anticholinergic)

side effects (tachycardia, urinary retention, dry mouth). 3 TCAs (amitriptyline) have more
anticholinergic effects than 2 TCAs (nortriptyline). Can prolong QT interval.
Tri-Cs: Convulsions, Coma, Cardiotoxicity (arrhythmia due to Na+ channel inhibition);
also respiratory depression, hyperpyrexia. Confusion and hallucinations in elderly due to
anticholinergic side effects (nortriptyline better tolerated in the elderl . Treatment: NaHCO, to
prevent arrhythmia.
PSYCHIATRY
Monoamine oxidase
inhibitors
MECHANISM
PSYCHIATRY PHARMACOLOGY
SECTION III
543
Tranylcypromine, Phenelzine, Isocarboxazid, Selegiline (selective MAO-B inhibitor).

(MAO Takes Pride In Shanghai).
Nonselective MAO inhibition t levels of amine neurotransmitters (norepinephrine, 5 -HT,

dopamine).
CLINICAL USE
Atypical depression, anxiety. Parkinson disease (Selegiline!
ADVERSE EFFECTS
Hypertensive crisis (most notably with ingestion of tyramine, which is found in many foods such
as aged cheese and wine); CNS stimulation. Contraindicated with SSRIs, TCAs, St. Johns wort,
meperidine, dextromethorphan (to prevent serotonin syndrome).
Wait 2 weeks after stopping MAO inhibitors before starting serotonergic drugs or stopping dietary
restrictions.
Atypical antidepressants
Bupropion
t norepinephrine and dopamine via unknown mechanism. Also used for smoking cessation.
Known to cause weight losi Toxicity: stimulant effects (tachycardia, insomnia), headache,
seizures in anorexic /bulimic patients. May help alleviate sexual dvsfunctioli
Mirtazapine
a-,-antagonist (t release of NE and 5-HT), potent 5-HT? and 5 -HT5 receptor antagonist and Hj
antagonist. Toxicity: sedation ( which may be desirable in depressed patients with insomnia),
t appetite, yveight gain (yvhich may be desirable in elderly or anorexic patients), dry mouth.
Trazodone
Primarily blocks 5 -HT-,, apadrenergic, and H receptors; also weakly inhibits 5 -HT reuptake. Used
primarily for insomnia, as high doses are needed for antidepressant effects. Toxicity: sedation,
nausea, priapism, postural hypotension. Called traZZZobone due to sedative and male-specific
side effects.
Varenicline
Tyramine
Nicotinic ACh receptor partial agonist. Used for smoking cessation. Toxicity: sleep disturbance.
Normally degraded by monoamine oxidase (MAO). Levels t in patients
taking MAO inhibitors

who ingest tyramine-rich foods (eg, cheese, yvine). Excess tyramine enters presvnaptic vesicles and
displaces other neurotransmitters (eg, NE) t active presvnaptic neurotransmitters -* t diffusion
of neurotransmitters into synaptic cleft t sympathetic stimulation. Classically results in a
hypertensive crisis (treatment: phentolamine).
Placement of "Tyramine ' fact here OK ? Added per

comment ("pis delete Tyramine Fact here, moving
to Psych chapter") on page 243 in Pharmacology
1
chapter.
Renal
But I know all about love already. 1 know precious little still about
Embryology
546
Anatomy
547
Physiology
549
Pathology
560
Pharmacology
572
kidneys."
Aldous Huxley, Antic Hay

This too shall pass. Just like a kidney stone."
Hunter Madsen
I drink too much. The last time I gave a urine sample it had an olive
in it.
Rodney Dangerfield
545
RENAL
RENAL
as
II
11
SECTION III
549
HIKIN': High K+ INtracellularly.
Body mass: 70 kg
X Non water mass (NWM) 1
Total body water (TBW )

60% of body mass = 42 kg = 42 L
60-40-20 rule (% of body weight for average

person ):
60% total body water
40% ICF
20% ECF
Plasma volume can be measured by
40% of body mass * 28 kg
Interstitial fluid
fit
75% ECF 10.5 L 10.5 kg
ss
radiolabeling albumin .
Extracellular volume can be measured by inulin
or mannitol .
Osmolality = 285-295 mOsm /kg H ^ O.
2/ 3
PHYSIOLOGY
PHYSIOLOGY
Fluid compartments
1/ 3
RENAL
85
Ij
Is
Normal HCT = 45%
HCT (%) ~ 3 x|Hbl in g/dL
Glomerular filtration
barrier
:
if
Renal clearance
Responsible for filtration of plasma according to

size and charge selectivity
Composed of:
e Fenestrated capillary endothelium (size
barrier)
Fused basement membrane with heparan
sulfate ( negative charge and size barrier)
Epithelial layer consisting of podocvte foot
processes Q ( negative charge barrier)
Charge barrier is lost in nephrotic syndrome

-* albuminuria , hypoproteinemia, generalized
edema , hyperlipidemia .
Cx = UXV/PX = volume of plasma from which the Cx = clearance of X (mL/min).

substance is completely cleared per unit time.
Ux = urine concentration of X (eg, mg/mL).
If Cx < GFR: net tubular reabsorption of X.
Px = plasma concentration of X (eg, mg/mL).
V = urine flow rate ( mL /min ).
If Cx > GFR: net tubular secretion of X.
If Cx = GFR: no net secretion or reabsorption .
RENAL PHYSIOLOGY
RENAL
Filtration fraction ( FF) = GFR / RPF.

Normal FF = 20% .
Filtered load (mg/min) = GFR (mL/min )
x plasma concentration ( mg/mL).
Filtration
NSAIDs I
Prostaglandins preferentially
dilate afferent arteriole
( T RPF, T GFR, so noAFF)
551
SECTION III
GFR can be estimated with creatinine
clearance.
RPF is best estimated with PAH clearance .
Parietal layer of
Bowman capsule
ocuNmaf1 s space
Juxtaglomerular
cel :
PS
* "
"
Macula densa
Excreted
Filtered
rP
Reabsorbed
Distal renal
Mb - e
Secreted
iecreie
Peritubular
'- capillary
Net filtration pressure

Endothelia ce Is
PK + 7tas ) - (PBS + Tt^ )
Basement
Mesangial
c e .l:
membrane
Cerent arteriole
Angiotensin II preferentially
ACE inhibitors
OH
constricts efferent arteriole

(4 RPF, T GFR, so T FF)
Changes in glomerular dynamics
Effect
Afferent arteriole constriction
Efferent arteriole constriction
t plasma protein concentration
i plasma protein concentration
Constriction of ureter
Dehydration
Calculation of
reabsorption and
secretion rate
GFR
RPF
l
t
i
t
i
i
1
l
Filtered load = GFR x .

Excretion rate = V x Ux.
Reabsorption rate|= filtered - excreted .
Secretion rate|= excreted filtered .
Px
FENa = Na+ excreted/Na + filtered = V X UNa /GFR x PNa (GFR = UCr X V/PCr) =
PCr X UNi/UCr X FNa
FF (GFR/ RPF )
t
t
t
1
t
554
SECTION III
Renal tubular defects

Fanconi syndrome
RENAL
RENAL
PHYSIOLOGY
Fanconi syndrome is first ( PCT ), the rest are in alphabetic order.
Generalized reabsorptive defect in PCT.

_
Associated with t excretion of nearly all amino acids, glucose, HCCX-, and PO . May result in
metabolic acidosis ( proximal renal tubular acidosis).
Causes include hereditary defects (eg, Wilson disease, tyrosinemia , glycogen storage disease,
cystinosis), ischemia, multiple myeloma , nephrotoxins/drugs (eg, ifosfamide, cisplatin, tenofovir,
expired tetracyclines), lead poisoning.
Bartter syndrome
Reabsorptive defect in thick ascending loop of Henle . Affects Nai/ Ki/ 2C1- cotransporter. Results
in hypokalemia and metabolic alkalosis with hypercalciuria. Presents similarly to chronic loop
Gitelman syndrome
Reabsorptive defect of NaCl in DCT. Leads to hypokalemia, hypomagnesemia, metabolic

alkalosis, hvpocalciuria. Similar to using lifelong thiazide diuretics. Autosomal recessive. Less
severe than Bartter syndrome]
Liddle syndrome
Gain of function mutation

t Na+ reabsorption in collecting tubules ( t activity of epithelial Na+
channel ). Presents like hyperaldosteronism , but aldosterone is nearly undetectable.
Autosomal dominant . Results in hypertension , hypokalemia , metabolic alkalosis, i aldosterone.
diuretic use. Autosomal recessive
Treatment: Amiloride.
Syndrome of
Apparent
Mineralocorticoid
Excess
Hereditary deficiency of HP-hydroxysteroid dehydrogenase, which normally converts cortisol (can

activate mineralocorticoid receptors) to cortisone (inactive on mineralocorticoid receptors ) in cells
containing mineralocorticoid receptors. Excess cortisol in these cells from enzyme deficiency
t mineralocorticoid receptor activity -* hypertension, hypokalemia , metabolic alkalosis. Low
serum aldosterone levels. Can acquire disorder from glycvrrhetinic acid ( present in licorice),
which blocks activity of llp-hydroxysteroid dehydrogenase.
Treatment: corticosteroids (exogenous corticosteroids 1 endogenous cortisol production
1 mineralocorticoid receptor activation ).
Cortisol tries to be the SAME as aldosterone.
558
SECTION III
Potassium shifts
RENAL
RENAL
PHYSIOLOGY
SHIFTS K + OUT OF CELL (CAUSING HYPERKALEMIA )
SHIFTS
Digitalis ( blocks Na + / K+ ATPase)

HyperOsmolarity
Lysis of cells (eg, crush injury, rhabdomyolysis,
tumor lysis syndrome)
Acidosis
P-blocker
r INTO CELL (CAUSING HYPOKALEMIA )
Hypo-osmolarity
Alkalosis
p-adrenergic agonist ( t Na+/K+ ATPase)
Patient with hyperkalemia? DO LApSj
Insulin ( t Na+ / K+ ATPase)

Insulin shifts K+ into cells
ELECTROLYTE
LOW SERUM CONCENTRATION
HIGH SERUM CONCENTRATION
Na +
Nausea and malaise, stupor, coma , seizures
Irritability, stupor, coma
K*
U waves and flattened T waves on ECG ,

arrhythmias, muscle cramps, spasm , weakness
Wide QRS and peaked T waves on ECG,

arrhythmias, muscle weakness
Ca 2+
Tetany, seizures, QT prolongation , twitching

(Chvostek sign ), spasm ( Trousseau sign )
Stones (renal ), bones ( pain ), groans (abdominal

pain), thrones ( t urinary frequency), psychiatric
overtones (anxiety, altered mental status), but
not necessarily calciuria
Mg2+
Tetanv, torsades de pointes, hypokalemia ,

hypocalcemia (when [ Mg 1 < 1.2 mg/dLi
Bone loss, osteomalacia (adults), rickets
(children )
1 DTRs, lethargy, bradycardia, hypotension ,

cardiac arrest , hypocalcemia
High blood Sugar ( insulin deficiency)
Electrolyte disturbances
43-
PO
Renal stones, metastatic calcifications,
hypocalcemia
Features of renal disorders

CONDITION
BLOOD PRESSURE
PLASMA RENIN
ALDOSTERONE
SERUM Mg2+
URINE Ca 2+
Bartter syndrome
Gitelman syndrome
t
t
t
t
Liddle syndrome
SIADH
Primary
hyperaldosteronism
(Conn syndrome)
Ji
II
Renin secreting tumor
562
SECTION III
Nephritic syndrome
RENAL
RENAL PATHOLOGY
Nephritic syndrome = Inflammatory process. When it involves glomeruli, it leads to hematuria

and RBC casts in urine. Associated with azotemia, oliguria, hypertension (due to salt retention),
proteinuria.
Acute
poststreptococcal
glomerulonephritis
LM glomeruli enlarged and hypercellular Q.

IF (starry sky) granular appearance
( lumpy-bumpy) due to IgG, IgM, and C 3
deposition along GBM and mesangium.
EM subepithelial immune complex (IC )
humps.
Most frequently seen in children. Occurs

~ 2-4 weeks after group A streptococcal
infection of pharynx or skin. Resolves
spontaneously. Type III hypersensitivityreaction.
Presents with peripheral and periorbital edema,
cola-colored urine, hypertension.
Positive strep titers/serologies, i complement
levels (C3) due to consumption
Rapidly progressive
(crescentic)
glomerulonephritis
LM and IF crescent moon shape Q. Crescents

consist of fibrin and plasma proteins (eg, C 3b)
with glomerular parietal cells, monocytes,
macrophages.
Several disease processes may result in this
pattern, in particular:
u
Goodpasture syndrome type II
hypersensitivity reactioij antibodies to
GBM and alveolar basement membrane
Poor prognosis. Rapidly deteriorating renal

function (days to weeks).
JinearjF
Granulomatosis with polyangiitis (Wegener)

Microscopic ijplyangiitis
Diffuse proliferative
glomerulonephritis
IgA nephropathy
(Berger disease)
Hematuria/hemoptysis.
Treatment: emergent plasmapheresis.
PR 3-ANCA/c-ANCA. Pauci-immune (no Ig/C3

deposition).
MPO-ANCA /p-ANCA. Pauci-immune (no Ig/C3
deposition).
Due to SLE or membranoproliferative

glomerulonephr itis.
LM wire looping of capillaries.
EM subendothelial and sometimes
intramembranous IgG-based ICs often with
C3 deposition.
IF granular.
A common cause of death in SLE (think wire

lupus ). DPGN and MPGN often present as
nephrotic syndrome and nephritic syndrome
LM mesangial proliferation.
EM mesangial IC deposits.
IF IgA-based IC deposits in mesangium.
Renal pathology of Henoeh-Schonlein purpura.
Episodic gross hematuria that occurs

concurrently with respiratory or GI tract
infections (IgA is secreted by mucosal linings).
Not to be confused with Buerger disease
(thromboangiitis obliterans).
concurrently.
562
SECTION III
Nephritic syndrome
RENAL
RENAL PATHOLOGY
Nephritic syndrome = Inflammatory process. When it involves glomeruli, it leads to hematuria

and RBC casts in urine. Associated with azotemia, oliguria, hypertension (due to salt retention),
proteinuria.
Acute
poststreptococcal
glomerulonephritis
LM glomeruli enlarged and hypercellular Q.

IF (starry sky) granular appearance
( lumpy-bumpy) due to IgG, IgM, and C 3
deposition along GBM and mesangium.
EM subepithelial immune complex (IC )
humps.
Most frequently seen in children. Occurs

~ 2-4 weeks after group A streptococcal
infection of pharynx or skin. Resolves
spontaneously. Type III hypersensitivityreaction.
Presents with peripheral and periorbital edema,
cola-colored urine, hypertension.
Positive strep titers/serologies, i complement
levels (C3) due to consumption
Rapidly progressive
(crescentic)
glomerulonephritis
LM and IF crescent moon shape Q. Crescents

consist of fibrin and plasma proteins (eg, C 3b)
with glomerular parietal cells, monocytes,
macrophages.
Several disease processes may result in this
pattern, in particular:
u
Goodpasture syndrome type II
hypersensitivity reactioij antibodies to
GBM and alveolar basement membrane
Poor prognosis. Rapidly deteriorating renal

function (days to weeks).
JinearjF
Granulomatosis with polyangiitis (Wegener)

Microscopic ijplyangiitis
Diffuse proliferative
glomerulonephritis
IgA nephropathy
(Berger disease)
Hematuria/hemoptysis.
Treatment: emergent plasmapheresis.
PR 3-ANCA/c-ANCA. Pauci-immune (no Ig/C3

deposition).
MPO-ANCA /p-ANCA. Pauci-immune (no Ig/C3
deposition).
Due to SLE or membranoproliferative

glomerulonephr itis.
LM wire looping of capillaries.
EM subendothelial and sometimes
intramembranous IgG-based ICs often with
C3 deposition.
IF granular.
A common cause of death in SLE (think wire

lupus ). DPGN and MPGN often present as
nephrotic syndrome and nephritic syndrome
LM mesangial proliferation.
EM mesangial IC deposits.
IF IgA-based IC deposits in mesangium.
Renal pathology of Henoeh-Schonlein purpura.
Episodic gross hematuria that occurs

concurrently with respiratory or GI tract
infections (IgA is secreted by mucosal linings).
Not to be confused with Buerger disease
(thromboangiitis obliterans).
concurrently.
564
SECTION III
Nephrotic syndrome
RENAL
RENAL PATHOLOGY
NephrOtic syndrome massive prOteinuria (> 3.5 g/day) with hypoalbuminemia , resulting
edema , hyperlipidemia. Frothy urine with fatty casts. Due to podocyte damage disrupting
glomerular filtration charge barrier. May be 1 (eg, direct sclerosis of podocytes) or 2 (systemic
process [eg, diabetes) secondarily damages podocytes). Associated with hypercoagulable state (eg,
thromboembolism ) due to antithrombin ( AT) III loss in urine and t risk of infection (due to loss of
immunoglobulins in urine and soft tissue compromise by edema ).
Severe nephritic syndrome may present with nephrotic syndrome features (nephritic-nephrotic
syndrome) if damage to GBM is severe enough to damage charge barrier.
Minimal change
disease ( lipoid
nephrosis)
LM normal glomeruli ( lipid may be seen in

PCT cells).
IF .
EM effacement of foot processes Q.
Focal segmental
glomerulosclerosis
Most common cause of nephrotic syndrome in

LM segmental sclerosis and hvalinosis Q.
IF often , but may be for nonspecific focal African Americans and Hispanics. Can be 1
deposits of IgM, C3, Cl
( idiopathic ) or 2 to other conditions (eg, HIV7
infection, sickle cell disease, heroin abuse,
EM effacement of foot process similar to
massive obesity, interferon treatment , chronic
minimal change disease.
kidney disease due to congenital malformations).
1 disease has inconsistent response to steroids.
May progress to chronic renal disease.
LM diffuse capillary and GBM thickening Q. Most common cause of 1 nephrotic syndrome
IF granular as a result of immune complex
in Caucasian adults. Can be 1 (eg, antibodies
to phospholipase A7 receptor) or 2 to drugs
deposition. Nephrotic presentation of SLE .
(eg, NSAIDs, penicillamine, gold ), infections
EM spike and dome appearance with
(eg, HBV, I ICV, syphilis SLE , or solid tumors.
subepithelial deposits.
1 disease has poor response to steroids. May
progress to chronic renal disease.
Kidney is the most commonly involved organ
LM Congo red stain shows apple-green
(systemic amyloidosis). Associated with
birefringence under polarized light due to
chronic conditions that predispose to amyloid
amyloid deposition in the mesangium .
deposition (eg, AL amyloid , AA amyloid ).
LM mesangial expansion , GBM thickening, Nonenzyinatic glycosylation of GBM
- t permeability, thickening.
eosinophilic nodular glomerulosclerosis
( Kimmelstiel -Wilson lesions, arrows in Q).
Nonenzyinatic glycosylation of efferent arterioles
( hyaline arteriosclerosis )
t GFR mesangial
expansion .
Most common cause of end -stage renal disease in
the United States.
Membranous
nephropathy
( membranous
glomerulonephritis)
Most common cause of nephrotic syndrome

in children . Often 1 (idiopathic) and may be
triggered by recent infection , immunization,
immune stimulus. Rarely, may be 2 to
lymphoma (eg, cytokine-mediated damage). 1
disease has excellent response to corticosteroids.
Amyloidosis
Diabetic glomerulo nephropathy
rv
JI
r-
V:
1 Vr
&
Vr
nmmssmiife:<
*.
v4 ,
jtw
566
SECTION III
Hydronephrosis
Renal cell carcinoma
RENAL
RENAL PATHOLOGY
Distention/dilation of renal pelvis and calyces Q. Usually caused by urinary tract obstruction (eg,
renal stones, BPH, cervical cancer, injury to ureter); other causes include retroperitoneal fibrosis,
vesicoureteral reflux. Dilation occurs proximal to site of pathology. Serum creatinine becomes
elevated only if obstruction is bilateral or if patient has only one kidney. Leads to compression and
possible atrophy of renal cortex and medulla.
Originates from PCT cells polygonal clear

cells Q filled with accumulated lipids and
carbohydrates. Often golden-yellow [] due to
t lipid content. Most common in men 50-70
years old. t incidence with smoking and
obesity. Manifests clinically with hematuria,
palpable mass, 2 polycythemia, flank pain,
fever, weight loss. Invades renal vein (may
develop varicocele if left sided ) then IVCjand
spreads hematogenouslv; metastasizes to lung
and bone.
Treatment: resection if localized disease.
Immunotherapy (eg, aldesleukin) or targeted
therapy for advanced/metastatic disease.
Resistant to chemotherapy and radiation
therapy.
Most common 1 renal malignancy Q.

Associated with gene deletion on chromosome
5 (sporadic or inherited as von Hippel-Lindau
syndrome). RCC = 3 letters = chromosome 3.
Associated with paraneoplastic syndromes (eg,
ectopic EPO, ACTH, PTHrP, renin).
Silent cancer because commonly presents as a
metastatic neoplasm.
:
*
SS;a
Renal oncocytoma
P5
M
J
Benign epithelial cell tumor arising from

collecting ducts (arrows in Q point to wellcircumscribed mass with central scar).
Large eosinophilic cells with abundant
mitochondria without perinuclear clearing
O (vs chromophobe renal cell carcinoma).
Presents with painless hematuria, flank pain,
abdominal mass.
Often resected to exclude malignancy (eg, renal
cell carcinoma).
m- n
RENAL
Nephroblastoma
( Wilms tumor ) j
>r .
RENAL
PATHOLOGY
SECTION III
567
Most common renal malignancy of early childhood (ages 2-4). Contains embryonic glomerular
structures. Presents with large, palpable, unilateral flank mass Q and/or hematuria.
Loss of function mutations of tumor suppressor genes WTl or WT2 on chromosome 11 .
May be a part of several syndromes:
WAGR complex: Wilms tumor, Aniridia (absence of iris), Genitourinary malformations, mental
Retardation /intellectual disability (WTl deletion )
* Denys-Drash : Wilms tumor, early- onset nephrotic syndrome, male pseudohermaphroditism
( WTl mutation )
Beckwith Wiedemann: Wilms tumor, macroglossia , organomegaly, hemihyperplasiaj ( WT2
mutation)
Transitional cell
carcinoma
Most common tumor of urinary tract system

(can occur in renal calyces, renal pelvis,
ureters, and bladder) Q EDI Painless hematuria
( no casts) suggests bladder cancer.
Associated with problems in your Pee SAC:
Phenacetin , Smoking, Aniline dyes, and
Cyclophosphamide.
m
Squamous cell
carcinoma of the
bladder
pillary turn
\ .* # ' * <&
i in
: ** *
mm
S.'J*
tic urothelium ..
Chronic irritation of urinary bladder - squamous metaplasia dysplasia and squamous cell
carcinoma.
Risk factors include Schistosoma haematobium infection ( Middle East), chronic cystitis, smoking,
chronic nephrolithiasis. Presents with painless hematuria .
Urinary incontinence
Stress incontinence
Outlet incompetence ( urethral hypermobility or intrinsic sphincteric deficiency) - leak with

t intra-abdominal pressure (eg, sneezing, lifting) t risk with obesity, vaginal delivery, prostate
surgery. bladder stress test (directly observed leakage from urethra upon coughing or Valsalva
maneuver). Treatment: pelvic floor muscle strengthening ( Kegel ) exercises, weight loss, pessaries.
Overactive bladder (detrusor instability) -* leak with urge to void immediately. Treatment: Kegel
exercises, bladder training (timed voiding, distraction or relaxation techniques), antimuscarinics
(eg, oxybutynin).
Features of both stress and urgency incontinence.
,
Urgency incontinence
Mixed incontinence
Overflow
incontinence
Incomplete emptying (detrusor underactivity or outlet obstruction ) -* leak with overfilling t post
void residual ( urinary retention ) on catheterization or ultrasound. Treatment: catheterization,
relieve obstruction (eg, a-blockers for BPH ).
,
568
SECTION III
Urinary tract infection

(acute bacterial
cystitis)
RENAL PATHOLOGY
RENAL
Inflammation of urinary bladder. Presents as suprapubic pain, dysuria , urinary frequency, urgency,
Systemic signs (eg, high fever, chills) are usually absent .
Risk factors include female gender (short urethra ), sexual intercourse ( honeymoon cystitis ),
indwelling catheter, diabetes mellitus, impaired bladder emptying.
Causes:
E coli ( most common ).

Staphylococcus saprophyticus seen in sexually active young women (E coli is still more
common in this group ).
Klebsiella.
Proteus mirabilis urine has ammonia scent .
Lab findings: leukocyte esterase. nitrites (indicate gram organisms, especially E coli ). Sterile
pyuria and urine cultures suggest urethritis by Neisseria gotiorrhoeae or Chlamydia trachomatis .
Pyelonephritis
Acute pyelonephritis
Neutrophils infiltrate renal interstitium Q. Affects cortex with relative sparing of glomeruli /vessels.
Presents with fevers, flank pain (costovertebral angle tenderness), nausea /vomiting, chills.
Causes include ascending UTI ( E coli is most common ), hematogenous spread to kidney. Presents
with WBCs in urine +/ WBC casts. CT would show striated parenchymal enhancement QJ.
Risk factors include indwelling urinary catheter, urinary tract obstruction , vesicoureteral reflux,
diabetes mellitus, pregnancy.
Complications include chronic pyelonephritis, renal papillary necrosis, perinephric abscess,
urosepsis.
Treatment: antibiotics.
Chronic
pyelonephritis
The result of recurrent episodes of acute pyelonephritis. Typically requires predisposition to

infection such as vesicoureteral reflux or chronically obstructing kidney stones.
Coarse, asymmetric corticomedullary scarring, blunted calyx. 7ubules can contain eosinophilic
casts resembling thyroid tissue Q (thyroidization of kidney).
Xanthogranulomatous pyelonephritis rare; grossly orange nodules that can mimic tumor
nodules, characterized b\lwidespread kidney damage due to granulomatous tissue containing
foamy macrophages.
iV \
>
>
>
it
1
Diffuse cortical
necrosis
-5
Acute generalized cortical infarction of both

kidneys. Likely due to a combination of
vasospasm and DIC.
Z
Associated with obstetric catastrophes (eg,
abruptio placentae), septic shock ,
570
SECTION III
Acute interstitial
nephritis
( tubulointerstitial
nephritis)
Acute tubular necrosis
RENAL
RENAL PATHOLOGY
Acute interstitial renal inflammation. Pyuria

(classically eosinophils) and azotemia
occurring after administration of drugs that
act as haptens, inducing hypersensitivity (eg,
diuretics, penicillin derivatives, proton pump
inhibitors, sulfonamides, rifampin, NSAIDs).
Less commonly may be 2 to other processes
such as systemic infections (eg, mycoplasma)
autoimmune diseases (eg, Sjogren syndrome,
SLE, sarcoidosis).
Associated with fever, rash, hematuria, and

costovertebral angle tenderness, but can be
asymptomatic.
Remember these Ps:
Pee (diuretics)
u
Pain-free (NSAIDs)
Penicillins and cephalosporins
Proton pump inhibitors
RifamPin
Most common cause of acute kidney injury- in hospitalized patients. Spontaneously resolves in
many cases. Can be fatal, especially during initial oliguric phase t FENa.
Key finding: granular (muddy brown ) casts Q.
3 stages:
,
;
. H
\
A In
1. Inciting event
2. Maintenance phase oliguric; lasts 1-3 weeks; risk of hyperkalemia, metabolic acidosis,
uremia
3. Recovery phase polvuric; BUN and serum creatinine fall; risk of hypokalemia
Can be caused by ischemic or nephrotoxic injury:
Ischemic 2 to i renal blood flow (eg, hypotension, shock, sepsis, hemorrhage, HF). Results
in death of tubular cells that may slough into tubular lumen []] (PCT and thick ascending limb
are highly susceptible to injury).
Nephrotoxic 2 to injury resulting from toxic substances (eg, aminoglycosides, radiocontrast
agents, lead, cisplatin, ethylene glycot. crush injury (myoglobinuria), hemoglobinuria. PCT is
particularly susceptible to injury.
' iiMr \m 0 TTI i

Renal papillary
necrosis
m
i
Sloughing of necrotic renal papillae Q gross

hematuria and proteinuria. May be triggered
by recent infection or immune stimulus.
Associated with sickle cell disease or trait,
acute pyelonephritis, NSAIDs, diabetes
mellitus.
SAAD papa with papillary necrosis:

Sickle cell disease or trait
Acute pyelonephritis
Analgesics (NSAIDs)
Diabetes mellitus
RENAL PATHOLOGY
RENAL
571
SECTION III
Renal cyst disorders
Autosomal dominant
polycystic kidney
disease
Numerous cysts in cortex and medulla Q causing bilateral enlarged kidneys ultimately destroy
kidney parenchyma. Presents with flank pain, hematuria, hypertension, urinary infection,
progressive renal failure in ~ 50% of individuals.
Mutation in PKD1 ( 85% of cases, chromosome 16 ) or PKD2 ( 15% of cases, chromosome 4). Death
from complications of chronic kidney disease or hypertension (caused by t renin production).
Associated with berry aneurysms, mitral valve prolapse, benign hepatic cysts, diverticulosij
Treatment: ACE inhibitors or ARBs.
Autosomal recessive
polycystic kidney
disease
Cystic dilation of collecting ducts Q. Often presents in infancy. Associated with congenital
hepatic fibrosis. Significant oliguric renal failure in utero can lead to Potter sequence. Concerns
beyond neonatal period include systemic hypertension, progressive renal insufficiency, and portal
hypertension from congenital hepatic fibrosis.
Medullary cystic
disease
Inherited disease causing tubulointerstitial fibrosis and progressive renal insufficiency with inability
to concentrate urine. Medullar}' cysts usually not visualized; shrunken kidneys on ultrasound.
Poor prognosis.
Simple vs complex
renal cysts
Simple cysts are filled with ultrafiltrate (anechoic on ultrasound Q). Very common and account for
majority of all renal masses. Found incidentally and typically asymptomatic.
Complex cysts, including those that are septated, enhanced, or have solid components on imaging
require follow-up or removal due to risk of renal cell carcinoma.
P'f
,4.c.
ra
-L
RENAL
RENAL PHARMACOLOGY
573
SECTION III
Mannitol
MECHANISM
CLINICAL USE
ADVERSE EFFECTS
Osmotic diuretic, t tubular fluid osmolarity

-* t urine flow, I intracranial /intraocular
pressure.
Drug overdose, elevated intracranial /intraocular
pressure.
Pulmonary edema , dehydration .
Contraindicated in anuria , HF.
Acetazolamide
MECHANISM
Carbonic anhydrase inhibitor. Causes self

limited NaHCO, diuresis and i total body
HCO - stores.
CLINICAL USE
ADVERSE EFFECTS
Glaucoma , urinary alkalinization, metabolic

alkalosis, altitude sickness, pseudotumor
cerebri .
Proximal renal tubular acidosis, paresthesias,
NFL toxicity, sulfa allergy; hypokalemial
ACID azolamide causes ACIDosis.
Loop diuretics
Furosemide, bumetanide, torsemide

MECHANISM
Sulfonamide loop diuretics. Inhibit cotransport

system ( Na + / K+ /2C1-) of thick ascending limb
of loop of Henle. Abolish hvpertonicity of
medulla , preventing concentration of urine.
Stimulate PGE release (vasodilatory effect
on afferent arteriole ); inhibited by NSAIDs.
t Ca 2+ excretion . Loops Lose Ca +.
CLINICAL USE
Edematous states ( HF, cirrhosis, nephrotic

syndrome, pulmonary edema), hypertension ,
ADVERSE EFFECTS
Ototoxicity , Hypokalemia , Hy pomagnesemia,
hypercalcemia.
m
OHH DANG!
ft
r -J
Dehydration , Allergy (sulfa ) /metabolic

Alkalosis, Nephritis (interstitial ), Gout .
Ethacrynic acid
MECHANISM
CLINICAL USE
ADVERSE EFFECTS
Nonsulfonamide inhibitor of cotransport system

( Na +/ K+ /2C1 ~ ) of thick ascending limb of loop
of Henle.
Diuresis in patients allergic to sulfa drugs.
Similar to furosemide, but more ototoxic.
V
Loop earrings hurt your ears.
RENAL PHARMACOLOGY
RENAL
Angiotensin
converting enzyme
inhibitors
SECTION III
Captopril, enalapril, lisinopril, ramipril.
MECHANISM
Inhibit ACE i AT II i GFR by preventing

constriction of efferent arterioles, t renin due
to loss of negative feedback. Inhibition of ACE
also prevents inactivation of bradvkinin, a
potent vasodilator.
CLINICAL USE
Hypertension, HF (i mortality), proteinuria,

diabetic nephropathy. Prevent unfavorable
heart remodeling as a result of chronic
hypertension.
In diabetic nephropathy, i intraglomerular

pressure, slowing CBM thickening
Cough, Angioedema (due to t bradvkinin;

contraindicated in Cl esterase inhibitor
deficiency), Teratogen (fetal renal
malformations), t Creatinine (1 GFR),
Hyperkalemia, and Hypotension. Used with
caution in bilateral renal artery stenosi
because ACE inhibitors will further 1 GFR
Captopril's CATCHH.
ADVERSE EFFECTS
Angiotensin II receptor
blockers
renal failure.
Losartan, candesartan, valsartan.
MECHANISM
Selectively block binding of angiotensin II to ATj receptor. Effects similar to ACE inhibitors, but
ARBs do not increase bradvkinin.
CLINICAL USE
Hypertension, HF, proteinuria, or diabetic nephropathy with intolerance to ACE inhibitors (eg,
cough, angioedema).
ADVERSE EFFECTS
Hyperkalemia, i GFR, hypotension; teratogen.
Aliskiren
MECHANISM
Direct renin inhibitor, blocks conversion of angiotensinogen to angiotensin I.
CLINICAL USE
Hypertension.
ADVERSE EFFECTS
Hyperkalemia, i GFR, hypotension, angioedema Relatively contraindicated in patients already

taking ACE inhibitors or ARBs.
575
HIGH - YIELD SYSTEMS
Reproductive
Artificial insemination is when the farmer does it to the cow instead of the
bull.
Student essay
Whoever called it necking was a poor judge of anatomy."
Groucho Marx
See , the problem is that Cod gives men a brain and a penis, and only
enough blood to run one at a time.
Robin Williams
Embryology
578
Anatomy
589
Physiology
593
Pathology
601
Pharmacology
616
I think you can say that life is a system in which proteins and nucleic
acids interact in ways that allow the structure to grow and reproduce. It s
that growth and reproduction , the ability to make more of yourself , thats
important.
Andrew H . Knolli
577
578
SECTION III
REPRODUCTIVE
REPRODUCTIVE
REPRODUCTIVE
EMBRYOLOGY
EMBRYOLOGY
Important genes of embryogenesis
Sonic hedgehog gene
Produced at base of limbs in zone of polarizing activity. Involved in patterning along

anteroposterior axis and CNS development; mutation can cause holoprosencephaly.
Wnt -7 gene
Produced at apical ectodermal ridge (thickened ectoderm at distal end of each developing limb ).
Necessary for proper organization along dorsal-ventral axis.
FGF gene
Produced at apical ectodermal ridge. Stimulates mitosis of underlying mesoderm, providing for
lengthening of limbs.
Homeobox ( Hox )
genes
Involved in segmental organization of embryo in a craniocaudal direction . Code for transcription

factors. Hox mutations appendages in wrong locations.
Early fetal development
Early embryonic
development
DAY 1
Faun ' i
mo
,
.
DAY 4
Morula
Degenerated
DMoping corpus litojm
follicle v
DAY 5
Blastocyst
*
2 oocyte
En kxneb uni
Within week 1
hCG secretion begins around the time of
Blastocyst sticks at day 6:
Within week 2
implantation of blastocyst.
Bilaminar disc (epiblast , hypoblast).
2 weeks = 2 layers.
Within week 3
Gastrulation forms trilaminar embryonic disc.

Cells from epiblast invaginate -* primitive
streak -* endoderm , mesoderm , ectoderm.
Notochord arises from midline mesoderm ;
overlying ectoderm becomes neural plate.
3 weeks = 3 layers.
Weeks 3-8
(embryonic period )
Neural tube formed by neuroectoderm and

closes by week 4.
Extremely susceptible to teratogens.
Organogenesis.
Week 4
Week 6
Week 8
Week 10
Heart begins to beat .

Upper and lower limb buds begin to form .
Fetal cardiac activity visible by transvaginal
ultrasound .
Fetal movements start .
Genitalia have male /female characteristics.
4 weeks = 4 limbs and 4 heart chambers.
Gait at week 8.
TENitalia
REPRODUCTIVE
REPRODUCTIVE
EMBRYOLOGY
SECTION III
579
Embryologic derivatives
External /outer layer
Ectoderm
Surface ectoderm
Epidermis; adenohypophysis (from Rathke

pouch); lens of eye; epithelial linings of oral
cavity, sensor}- organs of ear, and olfactory
epithelium;final canal below the pectinate line;
parotid , sweat, mammary glands.
Neural tubel
Brain ( neurohypophysis, CNS neurons, oligo-
Neural crest
Craniopharyngioma benign Rathke pouch

tumor with cholesterol crystals, calcifications.
Neuroectoderm think CNS.

dendrocytes, astrocytes, ependymal cells, pineal
gland ), retina, spinal cord.
PNS (dorsal root ganglia , cranial nerves
Neural crest think PNS and non-neural
structures nearby.
autonomic ganglia , Schwann cells),
melanocytes, chromaffin cells of adrenal
medulla , parafollicular (C ) cells of thyroid,
pia and arachnoid , bones of the skull ,
odontoblasts, aorticopulmonary septum ,
endocardial cushions, myenteric (Auerbach )
plexuj
Mesoderm
Muscle, bone, connective tissue, serous

linings of body cavities (eg, peritoneum ),
spleen (derived from foregut mesentery),
cardiovascular structures, lymphatics, blood
wall of gut tube, upper vagina , kidneys,
adrenal cortex, dermis, testes, ovaries.
Notochord induces ectoderm to form
neuroectoderm ( neural plate). Its only
postnatal derivative is the nucleus pulposus of
the intervertebral disc.
MiddleAneat layer.
Mesodermal defects = VACTERL:
Gut tube epithelium ( including anal canal

above the pectinate line), most of urethra and
lower vagina (derived from urogenital sinus),
luminal epithelial derivatives (eg, lungs,
liver, gallbladder, pancreas, eustachian tube,
thymus, parathyroid, thyroid follicular cells).
Enter nal layer.
Endoderm
Vertebral defects
Anal atresia
Cardiac defects
Tracheo-Esophageal fistula
Renal defects
Limb defects ( bone and muscle)
Types of errors in organ morphogenesis
Agenesis
Absent organ due to absent primordial tissue.
Aplasia
Absent organ despite presence of primordial tissue.
Hypoplasia
Incomplete organ development; primordial tissue present.

2 breakdown of previously normal tissue or structure (eg, amniotic band syndrome).
Extrinsic disruption ; occurs after embryonic period .
Disruption
Deformation
Malformation
Sequence
Intrinsic disruption ; occurs during embryonic period (weeks 3-8).

Abnormalities result from a single 1 embryologic event (eg, oligohydramnios
Potter sequence).
580
SECTION III
Teratogens
TERATOGEN
REPRODUCTIVE
REPRODUCTIVE EMBRYOLOGY
Most susceptible in 3rd 8th weeks (embryonic period organogenesis) of pregnancy. Before week
3, all-or-none effects. After week 8, growth and function affected.
EFFECTS ON FETUS
NOTES
Medications
ACE inhibitors
Renal damage
Alkylating agents
Absence of digits, multiple anomalies
Aminoglycosides
Ototoxicity
Neural tube defects, cardiac defects, cleft
palate, skeletal abnormalities (eg, phalanx/nail
hypoplasia, facial dysmorphism)
Antiepileptic drugs
Diethylstilbestrol
Folate antagonists
Vaginal clear cell adenocarcinoma, congenital

Mullerian anomalies
Neural tube defects
Lithium
Multiple severe birth defects

Ebstein anomaly (apical displacement of
tricuspid valve)
Isotretinoin
A mean guy hit the baby in the ear.
High-dose folate supplementation

recommended. Most commonly valproate,
carbamazepine, phenytoin, phenobarbital.
Includes trimethoprim, methotrexate,

antiepileptic drugs.
Contraception mandatory. IsoTERATinoin.
Methimazole
Aplasia cutis congenita
Tetracyclines
Discolored teeth, inhibited bone growth
Teethracyclines.
Thalidomide
Limb defects (phocomelia, micromelia

flipper limbs)
Limb defects with tha-limb-domide.
Warfarin
Bone deformities, fetal hemorrhage, abortion,
Do not wage warfare on the baby; keep it heppy

with heparin (does not cross placenta).
ophthalmologic abnormalities
Substance abuse
Alcohol
Cocaine
Smoking
(nicotine, CO)
Common cause of birth defects and intellectual
disability; fetal alcohol syndrome

Low birth weight, preterm birth, IUGR,
placental abruption
Low birth weight (leading cause in developed
countries), preterm labor, placental problems,
IUGR, SIDS
Cocaine - vasoconstriction.
Nicotine - vasoconstriction.
CO -* impaired 02 delivery.
Other
Iodine ( lack or excess)
Maternal diabetes
Congenital goiter or hypothyroidism (cretinism)

Caudal regression syndrome (anal atresia
to sirenomelia), congenital heart defects,
neural tube defects, macrosomia, neonatal
hypoglycemia
Methylmercury
Neurotoxicity
Vitamin A excess
Extremely high risk for spontaneous abortions

and birth defects (cleft palate, cardiac)
Microcephaly, intellectual disability
X- rays
Highest in swordfish, shark, tilefish, king

mackerel.
Minimized by lead shielding.
REPRODUCTIVE
SECTION III
Fetal alcohol
syndrome
Leading cause of intellectual disability in the US. Newborns of alcohol-consuming mothers

have t incidence of congenital abnormalities, including pre- and postnatal developmental
retardation, microcephaly, facial abnormalities (eg, smooth philtrum, thin Vermillion border
[upper lip], small palpebral fissures), limb dislocation, heart defects. Heart-lung fistulas and
holoprosencephalv in most severe form. Mechanism is failure of cell migration.
Twinning
Dizygotic ( fraternal ) twins arise from 2 eggs that are separately fertilized by 2 different sperm
(always 2 zygotes) and will have 2 separate amniotic sacs and 2 separate placentas (chorions).
Monozygotic ( identical) twins arise from 1 fertilized egg ( 1 egg + 1 sperm) that splits in early
pregnancy. The timing of cleavage determines chorionicitv (number of chorions) and amnionicity
(number of amnions).
Dizygotic ( fraternal) [- tys)
Note
581
Monozygotic (identical) [~ tyj]
No twinning
spelling
change to
Dizygotic
O'
2 egjs
1egg, 1sperm
2 sperm
<D
2-cell stage
2- cell stage
iRevised
I Figure l
2-cell stage
0-4 days
0>*
Cleavage
2-cell stage
Morula
Blastocyst
Dichorionic
diamniotic 125%)
Moi J a
Moruta
Monochonomc
4- 8 days
diamniotic (75%)
3 astocysl
Cleavage
8 12 days
Monochonomc
IMM DammotK
rare
Chonomc
.Q
cavity -
armed
Amniotic
cavity
Fort ed
embryonic disc
embryonic disc
> 13 days
Cleavage or
axis duplication
Lhorion
o utei
Ammon
Dichorionic
diamniotic
Endometrium
No twinning if
no cleavage
Monodvononk
monoammatK
[conjoined rarel
582
SECTION III
REPRODUCTIVE
REPRODUCTIVE
EMBRYOLOGY
1 site of nutrient and gas exchange between mother and fetus.
Placenta
Fetal component
Cytotrophoblast
Inner layer of chorionic villi .
Syncytiotrophoblast
Outer layer of chorionic villi ; synthesizes and

secretes hormones, eg, hCG (structurally
similar to LH; stimulates corpus luteum to
secrete progesterone during first trimester).
Cytotrophoblast makes Cells.

Syncytiotrophoblast synthesizes hormones.
Lacks MHC-I expression 1 chance of attack
by maternal immune system.
Maternal component
Derived from endometrium . Maternal blood in

lacunae.
Decidua basalis
Branch villus
Umbilical vein
( rich)
02
Umbilical arteries ^
(02 poor ) \
Endometrial vein
Endometrial artery
Maternal
circulation
Maternal circulation
9
Hormones
laG
Drugs
Fetal circulation
H20
Urea, waste products
Hormones
Syncytium
Cytotrophoblast
endothelial cell
Amnion
Chorionic plate
Maternal blood
Decidua basalis
REPRODUCTIVE
REPRODUCTIVE
EMBRYOLOGY
587
SECTION III
Genital embryology
Default development . Mesonephric duct

degenerates and paramesonephric duct
Female
develops.
Indifferent gonad
SRY gene on Y chromosome produces testis

determining factor -* testes development.
Sertoli cells secrete Mullerian inhibitoryfactor ( MIF ) that suppresses development of
paramesonephric ducts.
Leydig cells secrete androgens that stimulate
development of mesonephric ducts.
Male
Develops into female internal structures

fallopian tubes, uterus, upper portion of vagina
( lower portion from urogenital sinus). Male
Paramesonephric
( Mullerian ) duct
Paramesonephric duct
Urogenital sinus
-Gubernaculum
Testis-devetoping factor
Androgens
No androgens
MIF
Epididymis
remnant is appendix testis.

Mullerian agenesis ( Mayer- RokitanskyKuster- Hauser syndrome) may present
as 1 amenorrhea (due to a lack of uterine
development ) in females with fully developed
2 sexual characteristics (functional ovaries).
ddra ,
Develops into male internal structures (except

prostate) Seminal vesicles, Epididymis,
Ejaculatory duct, Ductus deferens (SEED ).
Mesonephric
( Wolffian ) duct
JV d id
Unnary
bladder
Degenerated
mesonephric
Degenerated
paramesonephric duct
duel
- Uterus
- Vagina
Vas deferens /
In females, remnant of mesonephric duct

-* Gartner duct.
EJ
SRYgene
O No Sertoli cells or lack of Mullerian inhibitory-
SRI'gene on V chromosome
I
Testis-determining factor
. Testes
Leydig cell
Sertoli cell
~t~
| Mullerian inhibitory factor |

Testosterone
Degeneration of
paramesonephric ( Mullerian)
duct (female internal
genitalia)
Genital tubercle,
urogenital sinus
-0
(i
Wolffian duct
Male internal genitalia

( except prostate)
DHT
Male external genitalia,
prostate
factor develop both male and female

internal genitalia and male external genitalia
5a-reductase deficiency inability to convert
testosterone into DHT male internal
genitalia , ambiguous external genitalia until
puberty (when t testosterone levels cause
masculinization)
Sertoli Shuts down female developmental
pathway.
Leydig Leads to male developmental pathway.
588
SECTION I I I
REPRODUCTIVE
Uterine ( Mullerian duct ) anomalies
Septate uterus
Common anomaly vs normaluterusJQ. Incomplete resorption of septum Q. 1 fertility. Treat with

septoplasty.
Bicornuate uterus
Incomplete fusion of Mullerian ducts Q. t risk of complicated pregnancy.

Complete failure of fusion - double uterus, cervix, and vaginalEl. Pregnancy possible.
Uterus didelphys
Normal
Didelphys
Bicornuate
Septate
Male/female genital homologs

Male
Female
Undifferentiated
Gians penis
Genital
Genital groove
Penile urethra
tubercle
Urogenital
fold
Labioscrotal
swelling
Urogenital
Clitoris
Labia
minora
Opening of
urethra
sinus
Scrotum
Labia
majora
Opening of
vagina
Anus
*
Urachus
Urinary
bladder
Allantois
Testis
Gians
penis
part
Genital
tubercle
Pehric
part
Ureter
Spongy
urethra
Ductus
deferens
Prostate gland
Ventral shaft of penis

(penile urethra)
Scrotum
.
-^
Urinary
bladder
Clitoris
"\
part
Kidney
^
^
Dihydrotestosterone
Gians penis
Corpus cavernosum
and spongiosum
Bulbourethral glands
(of Cowper)
Urogenital
sinus
Phallic
Rectum
Uterine
tube
Urachus
vesica
Kidney
Estrogen
Genital tubercle
Genital tubercle
Urogenital sinus
Ovary
Uterus
Vagina
Gians clitoris
Vestibular bulbs
Greater vestibular glands
(of Bartholin)
Urogenital sinus
Urethral and paraurethral

glands (of Skene)
Urogenital folds
Labia minora
Labioscrotal swelling
Labia majora
REPRODUCTIVE ANATOMY
REPRODUCTIVE
591
SECTION III
Male reproductive anatomy

Ureter
Bladder
ieir
naI vesicle
Apulia
Vas deferens
Bulbourethral
'
Corpus cavernosa
Efferent ductule
Prostate
.e
Jrethi i
Head of epididymis
Ejaculatory duct
Js
Symphysis pubis
gland (Cowper )
Epididymis
Sem nlferous
iubules
\>r
Rete testis
Vas deferens
Prepuce
Tunica
albuginea
Q ans
Testis
Scrotum
Tail of epididymis -
na
Pathway of sperm during ejaculation

SEVEN UP:
Seminiferous tubules
Epididymis
Vas deferens
Ejaculatory ducts
(Nothing)
Urethra
Penis
Urethral injury
Suspect if blood seen at urethral meatus. Urethral characterization contraindicated

Posterior urethra membranous urethra prone to injury from pelvic fracture. Injury can cause urine
to leak into retropubic space.
Anterior urethra bulbar Jarethra at risk of damage due to perineal straddle injury. Can cause urine
to leak beneath deep fascia of Buck. If fascia is torn, urine escapes into superficial perineal space.
Autonomic
innervation of the
male sexual response
Erection Parasympathetic nervous system

(pelvic nerve):
NO -* t cGMP smooth muscle
relaxation -* vasodilation proerectile.
Norepinephrine t [Ca-+]in -* smooth
muscle contraction vasoconstriction
D
-* antierectile.
Emission Sympathetic nervous system

( hypogastric nerve).
Ejaculation visceral and Somatic nerves
(pudendal nerve).
Point, Squeeze, and Shoot.

PDE-5 inhibitors (eg, sildenafil) 1 cGMP
breakdown.
REPRODUCTIVE
REPRODUCTIVE PATHOLOGY
601
SECTION III
Sex chromosome
disorders
Klinefelter syndrome
[male] (47,XXY )
Turner syndrome
[female] (45,XO)
l.
Aneuploidy most commonly due to meiotic nondisjunction.

Testicular atrophy, eunuchoid body shape,
Dysgenesis of seminiferous tubules
tall, long extremities, gynecomastia, female
t FSH.
1 inhibin B
Abnormal Leydig cell function 1 testosterone
hair distribution Q. May present with
t LH t estrogen.
developmental delay. Presence of inactivated
X chromosome (Barr body). Common cause of
hypogonadism seen in infertility work-up.
Short stature (if untreated), ovarian dysgenesis

(streak ovary), shield chest, bicuspid aortic
valve, coarctation (femoral < brachial pulse),
lymphatic defects (result in webbed neck or
cystic hygroma; lymphedema in feet, hands),
horseshoe kidney Q.
Most common cause of 1 amenorrhea. No Barr
body.
Double Y males ( XYY )
Phenotypically normal (usually undiagnosed),

very tall. Normal fertility. May be associated
with severe acne, learning disability, autism
Ovotesticular disorder
of sex development
46,XX > 46,XY.

Both ovarian and testicular tissue present
(ovotestis); ambiguous genitalia. Previously
called true hermaphroditism.
spectrum disorders.
Menopause before inenarche.

1 estrogen leads to t LH, FSH .
Sometimes due to mitotic error mosaicism (eg,

45,XO/46,XX).
Pregnancy is possible in some cases (IVF,
exogenous estradiol-17P and progesterone).
Can use growth hormone to achieve normal
height .
602
SECTION III
Diagnosing disorders
of sex hormones
Other disorders of sex

development
REPRODUCTIVE
Testosterone
LH
Diagnosis
Defective androgen receptor
Testosterone-secreting tumor, exogenous

steroids
Hvperqonadotrophic hypogonadism (1)l
Hypogonadotropic hypogonadism (2)
Disagreement between the phenotypic (external genitalia) and gonadal (testes vs ovaries) sex.
Include terms pseudohermaphrodite, hermaphrodite, and intersex.
46,XX DSD
Ovaries present, but external genitalia are virilized or ambiguous. Due to excessive and
inappropriate exposure to androgenic steroids during early gestation (eg, congenital adrenal
hyperplasia or exogenous administration of androgens during pregnancy).
46,XY DSD
Testes present, but external genitalia are female or ambiguous. Most common form is androgen
insensitivity syndrome ( testicular feminization).
Placental aromatase
deficiency
Inability to synthesize estrogens from androgens. Masculinization of female (46,XX ) infants

(ambiguous genitalia), t serum testosterone and androstenedione. Can present with maternal
virilization during pregnancy (fetal androgens cross the placenta).
Androgen insensitivity
syndrome (46,XY )
Defect in androgen receptor resulting in normal-appearing female; female external genitalia with
scant sexual hair, rudimentary vagina; uterus and fallopian tubes absent. Patients develop normal
functioning testes (often found in labia majora; surgically removed to prevent malignancy),
t testosterone, estrogen, LH (vs sex chromosome disorders).
5a- reductase
deficiency
Autosomal recessive; sex limited to genetic males (46,XY ). Inability to convert testosterone to DHT.
Ambiguous genitalia until puberty, when t testosterone causes masculinization/t growth of
external genitalia. Testosterone/estrogen levels are normal; LII is normal or t . Internal genitalia
are normal.
Kallmann syndrome
Failure to complete puberty; a form of hypogonadotropic hypogonadism. Defective migration of

GnRH cells and formation of olfactory bulb; i synthesis of GnRH in the hypothalamus; anosmia;
1 GnRH, FSH, LH, testosterone. Infertility (low sperm count in males; amenorrhea in females).
REPRODUCTIVE
SECTION III
605
Pregnancy complications (continued )
Vasa previa
Fetal vessels run over, or in close proximity

to, cervical os. May result in vessel rupture,
exsanguination, fetal death. Presents with
triad of membrane rupture, painless vaginal
bleeding, fetal bradycardia (< 110 beats/min).
Emergency C-section usually indicated.
Frequently associated with velamentous
umbilical cord insertion (cord inserts in
chorioamniotic membrane rather than
placenta fetal vessels travel to placenta
unprotected by Wharton jelly).
Placenta
Placenta
I succenturiate
lobe)
Postpartum
hemorrhage
Due to 4 Ts: Tone (uterine atony; most

common), Trauma (lacerations, incisions,
uterine rupture) Thrombin (coagulopathy),
Tissue (retained products of conception).
Ectopic pregnancy
Most often in ampulla of fallopian tube

( shows 10-mm embryo in oviduct at 7
weeks of gestation). Suspect with history of
amenorrhea, lower-than-expected rise in hCG
based on dates, and sudden lower abdominal
pain; confirm with ultrasound. Often
clinically mistaken for appendicitis.
C
I
New
Asherman syndrome
I Fact 1
Pain +/ bleeding.
Risk factors:
Prior ectopic pregnancy
History of infertility
Salpingitis ( PID)
Ruptured appendix
Prior tubal surgery
5
Condition characterized by adhesions and/or fibrosis of the endometrium, often associated with
dilation and curettage of the intrauterine cavity.
Amniotic fluid abnormalities
Polyhydramnios
Too much amniotic fluid; associated with fetal malformations (eg, esophageal /duodenal atresia,
anencephaly; both result in inability to swallow amniotic fluid), maternal diabetes, fetal anemia,
Oligohydramnios
Too little amniotic fluid; associated with placental insufficiency, bilateral renal agenesis, posterior
urethral valves (in males) and resultant inability to excrete urine. Any profound oligohydramnios
can cause Potter sequence.
multiple gestations.
REPRODUCTIVE
SECTION III
607
Vaginal tumors
Squamous cell
carcinoma
Usually 2 to cervical SCC; 1 vaginal carcinoma rare.
Clear cell
Affects women who had exposure to DES in utero.
adenocarcinoma
Sarcoma botryoides|
Embryonal rhabdomyosarcoma variant.
Affects girls < 4 years old; spindle-shaped cells; desmin .

Presents with clear, grape-like, polypoid mass emerging from vagina.
Cervical pathology
Dysplasia and
carcinoma in situ
Disordered epithelial growth; begins at basal layer of squamocolumnar junction (transformation

zone) and extends outward. Classified as CIN 1, CIN 2, or CIN 3 (severe dysplasia or carcinoma
in situ), depending on extent of dysplasia. Associated with HPV 16 and HPV 18, which
produce both the E6 gene product (inhibits pS 3 suppressor gene) and E7 gene product (inhibits
RB suppressor gene). May progress slowly to invasive carcinoma if left untreated. Typically
asymptomatic (detected with Pap smear) or presents as abnormal vaginal bleeding (often
postcoital).
'
Risk factors: multiple sexual partners (#1), smoking, starting sexual intercourse at young age, HIV
V
Invasive carcinoma
Premature ovarian
failure
Most common causes
of anovulation
Polycystic ovarian
syndrome ( SteinLeventhal syndrome )
infection.
Often squamous cell carcinoma. Pap smear can detect!cervical dysplasia (koilocytes Q) before it
progresses to invasive carcinoma. Diagnose via colposcopy and biopsy. Lateral invasion can block
ureters -* renal failure.
Premature atresia of ovarian follicles in women

of reproductive age. Patients present with signs
of menopause after puberty but before age 40.
i estrogen, t LH, t FSH.
Pregnancy, polycystic ovarian syndrome, obesity, HPO axis abnormalities, premature ovarian
failure, hyperprolactinemia, thyroid disorders, eating disorders, competitive athletics, Cushing
syndrome, adrenal insufficiency.
Hvperinsulinemia and/or insulin resistance hypothesized to alter hypothalamic hormonal feedback

response t LH:FSH, t androgens (eg, testosterone) from theca interna cells, 1 rate of follicular
maturation unruptured follicles (cysts) + anovulation. Common cause of subfertility in women.
Enlarged, bilateral cystic ovaries Q; presents with amenorrhea /oligomenorrhea, hirsutism, acne,
i fertility. Associated with obesity, t risk of endometrial cancer 2 to unopposed estrogen from
repeated anovulatory cycles.
Treatment: cycle control weight reduction ( 1 peripheral estrone formation), OCPs ( prevent
endometrial hyperplasia due to unopposed estrogen); infertility cloniiphene, metformin (induce
ovulation); hirsutism spironolactone ( androgen receptor inhibitor ), OCPs, ketoconazolej
REPRODUCTIVE
REPRODUCTIVE
PATHOLOGY
SECTION III
609
Ovarian neoplasms ( continued )
Malignant ovarian neoplasms

Granulosa cell tumor
Most common malignant stromal tumor. Predominantly women in their 50s. Often produces
estrogen and/or progesterone and presents with postmenopausal bleeding, sexual precocity
( in pre-adolescents), breast tenderness. Histology shows Call-Exner bodies 0 ( granulosa cells
arranged haphazardly around collections of eosinophilic fluid , resembling primordial follicles).
Serous
cystadenocarcinoma
Most common malignant ovarian neoplasm , frequently bilateral. Psammoma bodies,
Mucinous
Pseudomyxoma peritonei-intraperitoneal accumulation of mucinous material from ovarian or

appendiceal tumor.
Aggressive, contains fetal tissue, neuroectoderm . Commonly diagnosed before age 2Qt Typicallyrepresented by immature/embryonic-like neural tissue.
cystadenocarcinoma
Immature teratoma
Dysgerminoma
Most common in adolescents. Equivalent to male seminoma but rarer. 1% of all ovarian tumors;
30% of germ cell tumors. Sheets of uniform fried egg cells Q. hCG, LDH = tumor markers.
Yolk sac (endodermal

sinus) tumor
Aggressive, in ovaries or tested and sacrococcygeal area in young children . Most common tumor in
male infants. Yellow, friable ( hemorrhagic), solid mass. 50% have Schiller Duval bodies ( resemble
glomeruli ) Q. AFP = tumor marker.
Krukenberg tumor
GI malignancy that metastasizes to ovaries -* mucin-secreting signet cell adenocarcinoma.
I*
as
HR
m
m
SSMI
r-
ssfcsi
7k
610
SECTION III
REPRODUCTIVE
REPRODUCTIVE
PATHOLOGY
Endometrial conditions
Polyp
Well-circumscribed collection of endometrial tissue within uterine wall. May contain smooth
muscle cells. Can extend into endometrial cavity in the form of a polyp. May be asymptomatic or
present with painless abnormal uterine bleeding.
Adenomyosis
Extension of endometrial tissue ( glandular) into uterine myometrium . Caused by hyperplasia of

basal layer of endometrium . Presents with dysmenorrhea , menorrhagia , uniformly enlarged , soft,
globular uterus.
Treatment: GnRH agonists, hysterectomy.
Leiomyoma (fibroid )
Most common tumor in females. Often presents with multiple discrete tumors Q. t incidence in
African Americans. Benign smooth muscle tumor; malignant transformation to leiomyosarcoma is
rare. Estrogen sensitive tumor size t with pregnancy and i with menopause. Peak occurrence at
20-40 years old . May be asymptomatic, cause abnormal uterine bleeding, or result in miscarriage.
Severe bleeding may lead to iron deficiency anemia. Whorled pattern of smooth muscle bundles
with well-demarcated borders Q.
Endometrial
hyperplasia
Endometrial
carcinoma
Endometritis
Endometriosis
Abnormal endometrial gland proliferation Q usually caused by excess estrogen stimulation t risk for
endometrial carcinoma ; nuclear atypia is greater risk factor than complex (vs simple) architecture.
Presents as postmenopausal vaginal bleeding. Risk factors include anovulatory cycles, hormone
replacement therapy, polycystic ovarian syndrome, granulosa cell tumor.
Most common gynecologic malignancy Q. Peak occurrence at 55-65 years old. Presents with
vaginal bleeding. Typically preceded by endometrial hyperplasia. Risk factors include prolonged
use of estrogen without progestins, obesity, diabetes, hypertension , nulliparity, late menopause,
early menarchej Lynch syndrome.
Inflammation of endometrium Q associated with retained products of conception following
delivery, miscarriage, abortion, or with foreign body (eg, IUD). Retained material in uterus
promotes infection by bacterial flora from vagina or intestinal tract.
Treatment: gentamicin + clindamycin +/ ampicillin.
Non-neoplastic endometrial glands/stroma outside endometrial cavity Q- Can be found anywhere;
most common sites are ovary (frequently bilateral ), pelvis, peritoneum . In ovary, appears as
endometrioma ( blood-filled chocolate cyst ). May be due to retrograde flow, metaplastic
transformation of multipotent cells, transportation of endometrial tissue via lymphatic system .
Characterized by cyclic pelvic pain , bleeding, dysmenorrhea , dyspareunia, dyschezia ( pain with
defecation ), infertility; normal-sized uterus.
Treatment: NSAIDs, OCPs, progestins, GnRH agonists, danazol , laparoscopic removal .
,
v
; t.
/
<
m:
mamr- -wmm
r -:
sw
*1
ti m11
1i|
isssb* r
K
*
,t.
'
'
612
SECTION III
REPRODUCTIVE
REPRODUCTIVE
PATHOLOGY
Commonly
Risk factors: t estrogen exposure, t total number

of menstrual cycles, older age at 1st live birth,
obesity ( t estrogen exposure as adipose tissue
converts androstenedione to estrone), BRCA1
oi[ BRCA2 gene mutations, African American
ethnicity ( t risk for triple breast cancer).
CHARACTERISTICS
NOTES
Ductal carcinoma in
situ
Fills ductal lumen ( black arrow in Q indicates

neoplastic cells in duct ; blue arrow shows
engorged blood vessel ). Arises from ductal
atvpia. Often seen early as microcalcifications
on mammography.
Early malignancy without basement membrane

penetration .
Comedocarcinoma
Ductal , central necrosis (arrow in Q). Subtype

ofDCIS.
Results from underlying DCIS or invasive breast
cancer. Eczematous patches on nipple Q.
Paget cells = intraepithelial adenocarcinoma
cells.
Malignant breast
tumors
TYPE
postmenopausal . Usually arise from

terminal duct lobular unit. Overexpression
of estrogen / progesterone receptors or c-erbB2
( HER-2 , an EGF receptor) is common; triple
negative ( ER 0, PR , and Her2/ Neu ) more
aggressive; type affects therapy and prognosis.
Axillary lymph node involvement indicating
metastasis is the most important prognostic
factor in early-stage disease. Most often located
in upper-outer quadrant of breast.
Noninvasive
Paget disease
Invasive
Invasive ductal
carcinoma
Firm , fibrous, rock-hard mass with sharp

margins and small , glandular, duct-like
cells 0. Can have dimpling of breast due to
deformation of suspensory ligaments by tumor.
Grossly see classic stellate infiltration .
Most common (~ 75% of all breast cancers).
Invasive lobular
carcinoma
Orderly row of cells ( single!file
Medullary carcinoma
Fleshy, cellular, lymphocytic infiltrate.

Dermal lymphatic invasion by breast
carcinoma. Peau d orange ( breast skin
resembles orange peel Q); neoplastic cells
block lymphatic drainage.
Often bilateral with multiple lesions in the same

location.
Lines of cells = Lobular.
Good prognosis.
Poor prognosis ( 50% survival at 5 years).
Often mistaken for mastitis or Paget disease.
Inflammatory breast
cancer
i E-cadherin expression .
0), due to
REPRODUCTIVE
SECTION III
613
Malignant breast tumors (continued )
m*
m
u
mmm
.
S';
urn
m
mm
Penile pathology
Peyronie disease
Ischemic priapism
New
Fact
&T
Abnormal curvature of penis due to fibrous plaque within tunica albuginea. Associated with
erectile dysfunction. Can cause pain, anxiety. Consider surgical repair once curvature stabilizes.
Distinct from penile fracture (rupture of corpora cavernosa due to forced bending).
Painful sustained erection lasting > 4 hours. Associated with sickle cell disease (sickled RBCs
? ), medications (eg, sildenafil,
block venous drainage of corpus cavernosum vascular channel!
trazodone). Treat immediately with corporal aspiration, intracavernosal phenylephrine, or surgical
decompression to prevent ischemia.
Squamous cell
carcinoma
More common in Asia, Africa, South America. Precursor in situ lesions: Bowen disease (in
penile shaft, presents as leukoplakia), erythroplasia of Quevrat (cancer of glans, presents as
erythroplakia), Bowenoid papulosis (carcinoma in situ of unclear malignant potential, presenting
as reddish papules). Associated with HPV and lack of circumcision.
Cryptorchidism
Undescended testis (one or both); impaired spermatogenesis (since sperm develop best at
temperatures < 37C ); can have normal testosterone levels (Leydig cells are mostly unaffected
by temperature); associated with t risk of germ cell tumors. Prematurity t risk of cryptorchidism.
1 inhibin B, t FSH, t LH; testosterone 1 in bilateral cryptorchidism, normal in unilateral.
Testicular torsion
Rotation of testicle around spermatic cord and vascular pedicle.

Commonly presents 12-18 years of age. Characterized by acute, severe pain, high riding testis, and
absent cremasteric reflex .
Treatment: surgical correction (orchiopexy) within 6 hours, manual detorsion if surgical option
unavailable in timeframe. If testis is not viable, orchiectomy. Bilateral orchiopexy must always be
performed, contralateral testis at risk for subsequent torsion.
614
SECTION III
Varicocele
REPRODUCTIVE
Dilated veins in pampiniform plexus due to t venous pressure; most common cause of scrotal
enlargement in adult males; most often on left side because of t resistance to flow from left
gonadal vein drainage into left renal vein; can cause infertility because of t temperature;
diagnosed by standing clinical exam (distension on inspection and bag of worms on palpation)
or ultrasound with Doppler Q; does not transilluminate.
Treatment: varicocelectomy, embolization.
Extragonadal germ cell Arise in midline locations. In adults, most commonly in retroperitoneum, mediastinum, pineal, and
suprasellar regions. In infants and young children, sacrococcygeal teratomas are most common.
tumors
Scrotal masses
Benign scrotal lesions present as testicular masses that can be transilluminated (vs solid testicular
tumors)
Congenital hydrocele
Common cause of scrotal swelling in infants,

due to incomplete obliteration of processus
vaginalis. Most spontaneously resolve by 1 year
of a gej
Acquired hydrocele
Scrotal fluid collection usually 2 to infection,

hematocele.
trauma, tumor. If bloody
Spermatocele
Cyst due to dilated epididymal duct or rete

testis.
Testicular germ cell

tumors
Seminoma
Transilluminating swelling,
Paratesticular fluctuant nodule,
testicular tumors. Most often occur in young men. Risk factors: cryptorchidism,
Klinefelter syndrome. Can present as a mixed germ cell tumor. Testicular mass that does not
transilluminate.
~ 95% of all
Malignant; painless, homogenous testicular enlargement; most common testicular tumor. Does
not occur in infancy. Large cells in lobules with watery cytoplasm and fried egg appearance
t placental ALP. Radiosensitive. Late metastasis, excellent prognosis.
Yellow, mucinous. Aggressive malignancy of testes, analogous to ovarian yolk sac tumor. SchillerDuval bodies resemble primitive glomeruli t AFP is highly characteristic. Most common
testicular tumor in boys < 3 years old.
,
Yolk sac (endodermal

sinus) tumor
Choriocarcinoma
Teratoma
Embryonal carcinoma
Malignant, t hCG. Disordered syncytiotrophoblastic and cytotrophoblastic elements.

Hematogenous metastases to lungs and brain. May produce gynecomastia, symptoms of
hyperthyroidism (hCG is structurally similar to LH, FSII, TSH).
Unlike in females, mature teratoma in adult males may be malignant. Benign in children .
Malignant, hemorrhagic mass with necrosis; painful; worse prognosis than seminoma. Often
glandular /papillary morphology. Pure" embryonal carcinoma is rare; most commonly mixed
with other tumor types. May be associated with t hCG and normal AFP levels when pure ( t AFP
when mixed).
REPRODUCTIVE
Testicular non germ

cell tumors
Leydig cell
Sertoli cell
Testicular lymphoma
Benign prostatic
hyperplasia
REPRODUCTIVE
PATHOLOGY
615
SECTION III
5% of all testicular tumors. Mostly benign .
Golden brown color; contains Reinke crystals (eosinophilic cytoplasmic inclusions). Produce
androgens or estrogens -* gynecomastia in men, precocious puberty in boys.
Androblastoma from sex cord stroma .
Most common testicular cancer in older men. Not a 1 cancer; arises from metastatic lymphoma to
testes. Aggressive.
Common in men > 50 years old . Characterized

by smooth, elastic, firm nodular enlargement
( hyperplasia not hypertrophy) of periurethral
( lateral and middle) lobes, which compress the
urethra into a vertical slit. Not premalignant .
Often presents with t frequency of urination ,
nocturia , difficulty starting and stopping urine
stream, dvsuria. May lead to distention and
hypertrophy of bladder, hydronephrosis, UTIs.
t free prostate-specific antigen ( PSA).
Treatment: (Xj-antagonists ( terazosin ,
tamsulosin ), which cause relaxation of
smooth muscle; 5a-reductase inhibitors (eg,
finasteride); PDE-5 inhibitors (eg, tadalafil j
Benign
prostatic
hyperplasia
Anterior lobe
Urethra
Middle lobe
m
Posterior
ior lobe
K\
Lateral lobe
____
I
m
Prostate
Pf ostai cancer
Prostatitis
Dvsuria , frequency, urgency, low back pain . Warm , tender, enlarged prostate. Acute bacterialmost common cause is E coli in older men , young males consider C trachomatis, N gonorr /ioec/e;
chronic bacterial or abacterial
Prostatic
adenocarcinoma
Common in men > 50 years old . Arises most often from posterior lobe ( peripheral zone) of prostate
gland and is most frequently diagnosed by t PSA and subsequent needle core biopsies. Prostatic
acid phosphatase ( PAP) and PSA are useful tumor markers ( t total PSA, with i fraction of free
PSA) . Osteoblastic metastases in bone may develop in late stages, as indicated by lower back pain
and t serum ALP and PSA.
REPRODUCTIVE
REPRODUCTIVE PHARMACOLOGY
SECTION III
619
Testosterone, methyltestosterone
MECHANISM
Agonists at androgen receptors.
CLINICAL USE
Treat hypogonadism and promote development of 2 sex characteristics; stimulate anabolism to

promote recovery after burn or injur)'.
ADVERSE EFFECTS
Mbsculinization in females; 1 intratesticular testosterone in males by inhibiting release of LH (via

negative feedback)
Antiandrogens
gonadal atrophy. Premature closure of epiphyseal plates, t LDL, 1 HDL.
Finasteride
Testosterone ^-reductase f)HT (more potent).

Sex-reductase inhibitor (i conversion of
testosterone to DHT). Used for BPH and malepattern baldness.
Flutamide
Nonsteroidal competitive inhibitor at androgen

receptors. Used for prostate carcinoma.
Ketoconazole
Inhibits steroid synthesis (inhibits 17,20

desmolase/17a-hvdroxylasd).
Spironolactone
Inhibits steroid binding, 17,20 desmolase / 17a-
hydroxylase
Used for polycystic ovarian syndrome to reduce

androgenic symptoms. Both have side effects of
gynecomastia and amenorrhea.
used to treat BPH by inhibiting smooth muscle contraction. Selective for <XjA D
receptors (found on prostate) vs vascular ajB receptors.
Tamsulosin
OC ]-antagonist
Phosphodiesterase
type 5 inhibitors
Sildenafil, vardenafil, tadalafil.
MECHANISM
Sildenafil, vardenafil, and tadalafil fill the

Inhibit PDE- 5 -* t cGMP -* prolonged
penis.
smooth muscle relaxation in response to NO
-* t blood flow in corpus cavernosum of penis,
1 pulmonary vascular resistance.
CLINICAL USE
Erectile dysfunction, pulmonary hypertension,

BPH (tadalafil only).
ADVERSE EFFECTS
Headache, flushing, dyspepsia, cyanopia

( blue-tinted vision). Risk of life-threatening
hypotension in patients taking nitrates.
Hot and sweaty but then Headache,

Heartburn, Hypotension.
Minoxidil
MECHANISM
Direct arteriolar vasodilator.
CLINICAL USE
Androgenetic alopecia; severe refractory hypertension.
HIGH - YI E LD SYSTEMS
Respiratory
Theres so much pollution in the air now that if it werent for our lungs,
there 'd he no place to put it all.
Robert Orben
Mars is essentially in the same orbit. Somewhat the same distance from
the Sun , which is very important. We have seen pictures where there are
canals, we believe, and water. If there is water, that means there is oxygen.
If there is oxygen, that means we can breathe.
Former Vice President Dan Quayle

Whenever I feel blue , I start breathing again.
Embryology
622
Anatomy
624
Physiology
626
Pathology
632
Pharmacology
643
L. Frank Baum
Life is not the amount of breaths you take; its the moments that take
your breath away."
Hitch
621
622
SECTION III
RESPIRATORY
RESPIRATORY
RESPIRATORY
EMBRYOLOGY
EMBRYOLOGY
Lung development
Occurs in five periods. Initial development includes development of lung bud from distal end of
.
respiratory diverticulum during week 4|
STAGE
IMPORTANT TERMS
Embryonic
( weeks 4-7 )
Lung bud -* trachea bronchial buds!

mainstem bronchi secondary ( lobar)
bronchi -* tertiary (segmental ) bronchi .
Errors at this stage can lead to TE fistula.
Pseudoglandular
( weeks 5-1
Endodermal tubules terminal bronchioles.

Surrounded by modest capillary network .
Respiration impossible, incompatible with life.
Canalicular
( weeks 16-2
Terminal bronchioles respiratory bronchioles

-* alveolar ducts. Surrounded by prominent
capillary network .
Alveolar ducts terminal sacs. Terminal sacs
separated by 1 septae. Pneumocytes develop.
Airways increase in diameter.

Respiration capable at 25 weeks.
Terminal sacs adult alveoli (due to 2

septation ).
In utero, breathing occurs via aspiration
and expulsion of amniotic fluid -* t vascular
resistance through gestation.
At birth , fluid gets replaced with air A in
pulmonary vascular resistance.
At birth: 20-70 million alveoli.

By 8 years: 300-400 million alveoli .
Saccular
( weel
426-birth)
Alveolar
( weel
436j-8 years)
NOTES
Embyronic
Fetal
Postnatal
Alveolar
Saccular
Canalicular
BIRTH
Pseudoglandular
Embryonic
Surfactant
10 12 14 16
18
20
22
24
26 28 50
52 54 56
58 40
<
2 4 6
Weeks Years *
<D
X
Congenital lung malformations
bronchial tree with abnormal histology. Associated with congenital diaphragmatic

hernia ( usually left-sided ), bilateral renal agenesis ( Potter sequence [syndrome!1
Pulmonary hypoplasia
Poorly developed
Bronchogenic cysts
Caused by abnormal budding of the foregut and dilation of terminal or large bronchi . Discrete,
round , sharply defined and fluid-filled densities on CXR ( air-filled if infected!Generally
asymptomatic but can drain poorly causing airway compression and /or recurrent respiratory
infection
RESPIRATORY
RESPIRATORY EMBRYOLOGY
SECTION III
623
Pneumocytes
97% of alveolar surfaces. Line the alveoli.
Type I cells
Squamous; thin for optimal gas diffusion.
Type II cells
Type II pneumocyte
u*%*
Secrete pulmonary surfactant I alveolar

surface tension, prevents alveolar collapse,
1 lung recoil, and t compliance. Cuboidal and
clustered Q. Also serve as precursors to type
I cells and other type II cells. Type II cells
proliferate during lung damage.
Collapsing pressure ( r ) =
2 (surface tension)
radius
Alveoli have t tendency to collapse on expiration

as radius 1 (law of Laplace).
Pulmonary surfactant is a complex mix of
lecithins, the most important of which is
dipahnitoylphosphatidvicholine ( DPPCj
Surfactant synthesis begins around week 26 of
gestation, but mature levels are not achieved
until around week 35.
Nonciliated; low-colunmar /cuboidal with

secretory granules. Secrete component of
surfactant; degrade toxins; act as reserve cells.
Club cells
Neonatal respiratory
distress syndrome
:o
Surfactant deficiency t surface tension

alveolar collapse (ground-glass appearance
of lung fields) Q. j
Risk factors: prematurity, maternal diabetes ( due
to t fetal insulin), C-section delivery ( 4 release
of fetal glucocorticoids; less stressful than
vaginal delivery!
Complications: fDA, necrotizing enterocolitis.
Treatment: maternal steroids before birth;
exogenoujsurfactant for infant.
Therapeutic supplemental 0-> can result in
Retinopathy of prematurity, Intraventricular
hemorrhage, Bronchopulmonary dysplasia
(RIB).
Screening tests for fetal lung maturity: lecithinsphingomyelin ( L /S ) ratio in amniotic fluid
(> 2 is healthy; < 1.5 predictive of NRDS ), foam
stability index test, surfactant-albumin ratio.
Persistently low Q-, tension
risk of PDA.
r-
Mature
'
15-
Transitional
10 -
us *22
i
26
Immature
i
30
35
Gestational age (wk )
40
Plasma cell
!<
'
387
SECTION III
Multiple myeloma is a plasma cell cancer,
Produces large amounts of antibody specific to

a particular antigen. Clock-face chromatin
distribution and eccentric nucleus, abundant
RER, and well-developed Golgi apparatus
(yellow arrows in Q). Found in bone marrow
and normally do not circulate in peripheral
blood.

Fetal erythropoiesis
Hemoglobin
development
Young Liver Synthesizes Blood.
Fetal erythropoiesis occurs in:

Yolk sac ( 3-8 weeks)
Liver ( 6 weeks-birth)
Spleen ( 10-28 weeks)
Bone marrow ( 18 weeks to adult)
Embryonic globins: and e.
Fetal hemoglobin (HbF) = CX2Y2 Adult hemoglobin (HbAj) = a2P2.
HbF has higher affinity for O? due to less avid
binding of 2,3-BPG, allow ing HbF to extract
02 from maternal hemoglobin (HbAj and
HbA2) across the placenta. HbA -? ( ObS? ) is a
minor form of adult hemoglobin present in
small amounts.
From fetal to adult hemoglobin:

Alpha Always; Gamma Goes, Becomes Beta.
BIRTH
Site of
erythropoiesis
Yolk
sac
L vc 1
0.1
Bone marrow
crn
'
40
Fetal (HbF )
Adult (HbAj)
If
% of total 30
globin synthesis
20
tmbryomc globins
10
Weeks: 6
12
18
FETUS (weeks)
24
50
12
18
POSTNATAL (months)
24
40
40
L
ADULT
0
RESPIRATORY
RESPIRATORY
Right lung has 3 lobes; Left has Less Lobes (2)

and Lingula ( homolog of right middle lobe).
Right lung is more common site for inhaled
foreign body because the right main stem
bronchus is wider and more vertical than
the left.
Lung relations
ANATOMY
625
SECTION III
Instead of a middle lobe, the left lung has a

space occupied by the heart.
The relation of the pulmonary artery to the
bronchus at each lung hilum is described by
RALS Right Anterior; Left Superior.
If you aspirate a peanut:

While upright enters inferior segment of
right lowed lobe.
While supine enters posterior segments of
right upper lobe or superior segment of right
lower lobcj
Trachea
Upper lobe
HON:: r t
1
fissure
Oblique
Assure
Middle lobe
Oblique fissure
Inferior lobe
Right
bronchus
Diaphragm structures
Central tendon
Inferior vena cava (T8)
Esophagus (T10)
< 10
Aorta CT12 )
Vertebrae
Inferior view
'
Lingula
Left
bronchus
Structures perforating diaphragm :

At T8: IVC , right phrenic nervel
At T10: esophagus, vagus (CN 10; 2 trunks)
* At T12: aorta ( red ), thoracic duct (white ),
azygos vein ( blue) ( At T-l-2 it's the red ,
white, and blue )
Diaphragm is innervated by C3, 4, and 5
( phrenic nerve). Pain from diaphragm
irritation (eg, air, blood , or pus in peritoneal
cavity) can be referred to shoulder (C 5 ) and
trapezius ridge (C3, 4).
*
R
Lower
Lowei
lobe
L
Anterior view
Posterior view
Number of letters = T level :

T8: vena cava
T10: oesophagus
T12: aortic hiatus
I ( IVC ) ate (8) ten ( 10) eggs (esophagus) at

(aorta ) twelve ( 12 ).
C 3, 4, 5 keeps the diaphragm alive.
Other bifurcations:
The common carotid bifourcates at C 4.
The trachea bifourcates at T4.
The abdominal aorta bifourcates at L4.
Revised
Figure
626
SECTION III
RESPIRATORY
RESPIRATORY
RESPIRATORY
PHYSIOLOGY
PHYSIOLOGY
Lung volumes
Inspiratory reserve
volume
Air that can still be breathed in after normal

inspiration
Tidal volume
Air that moves into lung with each quiet

inspiration, typically 500 mL
Expiratory reserve
volume
Air that can still be breathed out after normal

expiration
Air in lung after maximal expiration ; any lung
volume or capacity that includes RV cannot be
measured by spirometnj
Residual volume
Inspiratory capacity
Functional residual
capacity
IRV + TV
RV + ERV
Volume of gas in lungs after normal expiration ;
includes RV, cannot be measured bv
Lung volumes (LITER ):
6.0
Volume
(L)
IRV
TV
1C
VC
TLC
2.7
AAA)
2.2
ERV
1.2
RV
FRC
RV
A capacity is a sum of > 2 physiologic volumes.
spirometry!
Vital capacity
TV + 1RV + ERV
Maximum volume of gas that can be expired
after a maximal inspiration
Total lung capacity
IRV + TV + ERV + RV
Volume of gas present in lungs after a maximal
inspiration; includes RV, cannot be measured
by spirometry
Determination of
physiologic dead
space
,, . Paco2 - Pi .co:
V d ~ V t *.
VD = physiologic dead space = anatomic dead
w
space of conducting airways plus alveolar

dead space; apex of healthy lung is largest
contributor of alveolar dead space. Volume
of inspired air that does not take part in gas
exchange.
V j = tidal volume .
Paco2 = arterial Pco? .
PECO? = expired air Pco?.
Ventilation
Minute ventilation
< VE)
Alveolar ventilation
(VA
>
^ VEJLVD
Taco, Paco, PECO, Paco (refers to order of

variables in equation )
Physiologic dead space approximately
equivalent to anatomic dead space in normal
lungs. May be greater than anatomic dead
space in lung diseases with V/Q defects.
Pathologic dead space when part of the
respiratory zone becomes unable to perform
gas exchange. Ventilated but not perfused .
Total volume of gas entering lungs per minute

VE = VT x RR
Volume of gas per unit time that reaches alveoli
VA = ( VT - VD) x RR
Normal values:
Respiratory rate ( RR) = 12-20 breaths/min
VT = 500 mL/breath
VQ = 150 mL/breath
RESPIRATORY PHYSIOLOGY
RESPIRATORY
Lung and chest wall
Elastic recoil tendency for lungs to collapse

inward and chest wall to spring outward.
At FRC, inward pull of lung is balanced by
outward pull of chest wall, and system pressure
is atmospheric.
Elastic properties of both chest wall and lungs
determine their combined volume.
At FRC, airway and alveolar pressures are 0,
and intrapleural pressure is negative (prevents
atelectasij). PVR is at minimum.
Compliance change in lung volume for a
change in pressure; expressed as AV/AP and is
inversely proportional to wall stiffness. High
compliance = lung easier to fill (emphysema,
normal aging!lower compliance = lung
harder to fill ( pulmonary fibrosis, pneumonia,
NRDS, pulmonary edema!(Surfactant
increases compliance.
Hysteresis lung inflation curve follows a
different curve than the lung deflation curve
SECTION III
627
Chest wall
'
LC
Lung -chest
wall system
7
S
vT
FRC
Lung
-20
-10
30
0
10
20
Transorgan static pressure (cmH20)
40
Compliant lungs comply (cooperate) and fill

easily with air.
due to need to overcome surface tension forces

in inflation.
Hemoglobin ( Hb) is composed of 4 polypeptide

subunits ( 2 a and 2 (3) and exists in 2 forms:
T (taut; deoxvgenated) form has low affinity
for 02, thus promoting release /unloading of
Hemoglobin
07.
Heme
Fetal Hb ( 2a and 2y subunits) has a higher

affinity for 07 than adult Hb, driving diffusion
of oxygen across the placenta from mother to
fetus t 07 affinity results from i affinity of
HbF for 2,3-BPG.
Taut in Tissues.
Relaxed in Respiratory area.
,
R (relaxed; oxygenated) form has high

affinity for 07 ( 300x). Hb exhibits positive
cooperativitv and negative allostery
t Cl-, 11+, C07, 2,3 -BPG, and temperature favor
taut form over relaxed form (shifts dissociation Hemoglobin acts as buffer for H+ ions.
t 07 unloading).
curve right
,
628
SECTION III
Hemoglobin
modifications
Methemoglobin
RESPIRATORY
Lead to tissue hypoxia from 1 07 saturation and i 07 content.
Oxidized form of Hb (ferric, Fe +) that does

not bind 07 as readily, but has t affinity for
cyanide.
Iron in Hb is normally in a reduced state
(ferrous, Fe2+).
Methemoglobinemia may present with cyanosis
and chocolate-colored blood.
Induced methemoglobinemia (using nitrites,
followed by thiosulfate) may be used to treat
Methemoglobinemia can be treated with

methylene blue and vitamin C.
Nitrites (eg, from dietary intake or polluted/high
altitude water source j) and benzocaine cause
poisoning by oxidizing Fe2+ to Fe+.
Fe2+ binds 07.
cyanide poisoning.
Carboxyhemoglobin
Form of Hb bound to CO in place of 07.

Causes l oxygen-binding capacity with left
shift in oxygen-hemoglobin dissociation curve.
i 07 unloading in tissues.
CO binds competitively to Hb and with 200x
greater affinity than 07.
Presents with headaches, dizziness, and cherry
red skin. May be caused by fires, car exhaust,
or gas heaters.
Treat with 100% 07 and hyperbaric 07.
-'
'
''' Nor
nal|100% Ibl
50% COHb
/i
4
0
^ 50% Hb
anemia)
20
40
60
80
100
Po ? (mm Hg)
Oxygen-hemoglobin dissociation curve
Sigmoidal shape due to positive cooperativitv

(ie, tetrameric Hb molecule can bind 4 07
molecules and has higher affinity for each
subsequent 07 molecule bound). Myoglobin
is monomeric and thus does not show
positive cooperativitv; curve lacks sigmoidal

appearance.
When curve shifts to the right, 1 affinity of Hb
for 07 (facilitates unloading of 07 to tissue).
An t in all factors (including H+) causes a shift
of the curve to the right.
A I in all factors (including H+) causes a left
shift 1 07 unloading -* renal hypoxia
t EPO synthesis compensatory
erythrocytosis. Lower = Left.
Fetal Hb has higher affinity for O-, than adult
Hb (due to low affinity for 23-BPG j so its
dissociation curve is shifted left.
Right shift ACE BATs right handed:

Acid
co7
Exercise
2,3-BPG
Altitude
Temperature
Myoglobin
Hemoglobin
Oxygenated blood
leaving the lungs
25
C
25
75
50
Po2 (mm Hg)
100
RESPIRATORY
Oxygen content of
blood
SECTION III
629
O, content = (134 x Hb x Sao7) + (0.003 x Pao?)

Hb = hemoglobin level
Sao7 = arterial 07 saturation
Pao7 = partial pressure of Q,- in arterial blood
Normally 1 g Hb can bind 134 mL O,- ; normal Hb amount in blood is 15 g/dL.

07 binding capacity * 20.1 mL 07 /dL blood.
With 1 Hb there is 1 O-, content of arterial blood, but no change in 07 saturation and Pao7 .
07 deliver}' to tissues = cardiac output x O, content of blood.
CO poisoning
Hb concentration % 02 sat of Hb
Dissolved 02
(Pao2)
Normal
Normal
1 (CO competes
Total 02 content
with 07)
Pulmonary circulation
Anemia
Normal
Normal
Polycythemia
Normal
Normal
Normally a low-resistance, high-compliance

system. Po7 and Pco, exert opposite effects
on pulmonary and systemic circulation. A
i in PAO7 causes a hypoxic vasoconstriction
that shifts blood away from poorly ventilated
regions of lung to well-ventilated regions of
lung.
Perfusion limited Oz (normal health), CO,- ,
N70. Gas equilibrates early along the length of
the capillary. Diffusion can be t only if blood
flow t.
Diffusion limited 07 (emphysema, fibrosis),
CO. Gas does not equilibrate by the time
blood reaches the end of the capillary.
Perfusion limited (eg, C02, N20)
Diffusion limited (eg CO)
Equilibration
Length along pulmonary capillary
A consequence of pulmonary hypertension is cor

pulmonale and subsequent right ventricular
failure ( jugular venous distention, edema,
hepatomegaly).
Diffusion: Vgas = A x Dk x
hzh where
blood!
Oxygen
Normal
Partial pressure
difference between
alveolar air and
pulmonary capillary
blood
Pa = partial pressure of gas in pulmonary capillary blood

PA = partial pressure of gas in alveolar air
A = area, T = alveolar wall thickness,

Dj.(Pj P7) = difference in partial pressures:
A 1 in emphysema.
T t in pulmonary fibrosis.
D rn is the extent to which CO, a surrogate
tor oxygen, passes from air sacs of lungs into
*
^ *
Exercise
----
Fibrosis
632
SECTION III
RESPIRATORY
RESPIRATORY
RESPIRATORY
PATHOLOGY
Rhinosinusitis
PATHOLOGY
Obstruction of sinus drainage into nasal cavity inflammation and pain over affected area
( typically maxillary sinuses , which drain into the middle meatus, in adults).
Most common acute cause is viral URI; may cause superimposed bacterial infection, most
commonly S pneumoniae, H influenzae, M catarrhalis.
Epistaxis
Nose bleed. Most commonly occurs in anterior segment of nostril ( Kiesselbach plexus). Lifethreatening hemorrhages occur in posterior segment (sphenopalatine artery, a branch of maxillary
artery ). Common causes include foreign body, trauma , allergic rhinitis, and nasal angiofibroma
Head and neck cancer
Deep venous
thrombosis
Mostly squamous cell carcinoma . Risk factors include tobacco, alcohol , HPV-16 (oropharyngeal ),
EBV ( nasopharyngeal ). Field cancerization : carcinogen damages wide mucosal area multiple
tumors that develop independently after exposure
Blood clot within a deep vein swelling,

redness Q, warmth , pain. Predisposed by
Virchow triad (SHE ):
Stasis (eg, post-op, long drive /flight )
Hypercoagulability (eg, defect in
coagulation cascade proteins, such as
factor V Leiden )
Endothelial damage (exposed collagen
triggers clotting cascade)
D-dimer lab test used clinically to rule out DVT
( high sensitivity, low specificity).
Most pulmonary emboli arise from proximal

deep veins of lower extremity.
Homan sign forced dorsiflexionjof foot -* calf
pain .
Use unfractionated heparin or low-molecularweight heparins (eg, enoxaparin) for
prophylaxis and acute management .
Use oral anticoagulants (eg, warfarin,
rivaroxaban ) for treatment ( long-term
prevention ).
Imaging test of choice is compression ultrasound
with Doppleij
RESPIRATORY
Pulmonary emboli
RESPIRATORY PATHOLOGY
V/Q mismatch -* hypoxemia -* respiratory

alkalosis. Sudden-onset dyspnea, pleuritic
chesjl pain, tachypnea, tachycardia. Large
emboli or saddle embolus Q may cause
sudden death.
Lines of Zahn are interdigitating areas of pink
( platelets, fibrin) and red ( RBCs) found only in
thrombi formed before death; help distinguish
pre- and postmortem thrombi Q.
Types: Fat, Air, Thrombus, Bacteria, Amniotic
fluid, Tumor.
Fat emboli associated with long bone fractures
and liposuction; classic triad of hypoxemia,
neurologic abnormalities, petechial rash.
Amniotic fluid emboli can lead to D1C,
especially postpartum.
Air emboli nitrogen bubbles precipitate
in ascending divers (caisson disease,
decompression sickness); treat with hyperbaric
O-,; or, can be iatrogenic 2 to invasive
procedures (eg, central line placement).
SXZE
Nr
SECTION III
CT pulmonary angiography is imaging test of

choice for PE ( look for filling defects) Q.
An embolus moves like a FAT BAT.
633
634
SECTION III
RESPIRATORY
LONG PAGE Please edit to lose lines.
Obstructive lung
diseases
Obstruction of air flow resulting in air trapping in lungs. Airways close prematurely at high lung
volumes t RV and T FRC, t TLC. PFTs: U FEVj, 1 FVC iFEV /FVC ratio ( hallmark),
V/Q mismatch. Chronic, hypoxic pulmonary vasoconstriction can lead to cor pulmonale. Digital
clubbing can be caused by bronchiectasis, but not COPD or asthmai
TYPE
PATHOLOGY
OTHER
Chronic bronchitis
("blue bloater " )
Hypertrophy and hvperplasiajof mucus-
Productive cough for > 3 months in a yea jfor

consecutive years.
Findings: wheezing, crackles, cyanosis (earlyonset hypoxemia due to shunting), late-onset
dyspnea, CO-, retention 2 polycythemia.
Chronic complications: pulmonary
hypertension, cor pulmonale.
secreting glands in bronchi - Reid index

(thickness of mucosal gland layer to thickness
of w all between epithelium and cartilage)
>po%.
Emphysema ("pink
puffer ")
Enlargement of air spaces, 1 recoil,

t compliance, 1 JQiresulting from
destruction of alveolar walls (arrow in Q). Tw o
types:
e
Centriacinar associated with
smoking Q Q. Frequently in upper lobes.
Panacinar associated w ith oq-antitrypsin
t elastase activity -* loss of elastic fibers

-* t lung compliance.
Exhalation through pursed lips to t airway
pressure and prevent airway collapse
Barrel-shaped chest 0. X-ray shows t AP
diameter, flattened diaphragm, t lung field
lucency.
deficiency. Frequently in lower lobes.

Asthma
Bronchial hyperresponsiveness causes reversible

bronchoconstriction. Smooth muscle hyper
trophy, Curschmann spirals Q (shed epithelium
forms whorled mucus plugs), and CharcotLeyden crystals (eosinophilic, hexagonal,
double-pointed, needle-like crystals formed
from breakdown of eosinophils in sputum).
Can be triggered by viral URIs, allergens, stress.

Aspirin-induced asthma: COX inhibition
leukotrienc overproduction airway
constriction. Associated with nasal polvpsj
Chronic necrotizing infection of bronchi
Associated with bronchial obstruction, poor

ciliary motility (eg, smoking, Kartagener
syndrome), cystic fibrosis 0, allergic
Bronchiectasis
permanently dilated airways, purulent

sputum, recurrent infections, hemoptysis,
-*
digital clubbing.
Clinical diagnosis can be supported by

spirometry and methacholine challenge.
Findings: cough, wheezing, tachypnea,
dyspnea, hypoxemia, l inspiratory/expiratory
ratio, pulsus paradoxus, mucus plugging Q.
Peribronchial cuffing on CXR .
bronchopulmonary aspergillosis.
U
\
&
A
->
7
*
RESPIRATORY
SECTION III
635
Restricted lung expansion causes i lung volumes (I FVC and TLC). PFTs: FEVj /FVC ratio > 80%.
Patient presents with short, shallow breaths.
Restrictive lung
diseases
Types:
Poor breathing mechanics (extrapuhnonarv, peripheral hypoventilation, normal A-a gradient):
Poor muscular effort polio, myasthenia gravis, Guillain-Barre syndrome
Poor structural apparatus scoliosis, morbid obesity
Interstitial lung diseases ( pulmonary 1 diffusing capacity, t A-a gradient):
* Acute respiratory distress syndrome ( ARDS)
Neonatal respiratorv distress syndrome (NRDS; hyaline membrane disease)
Pneumoconioses (eg, coal workers pneumoconiosis silicosis, asbestosis)
Sarcoidosis: bilateral hilar lymphadenopathy, noncaseating granuloma; t ACE and Ca-+
Idiopathic pulmonary fibrosis Q (repeated cycles of lung injury and wound healing with
t collagen deposition, honeycomb lung appearance and digital clubbing)
pranulomatosis with polyangiitis ( Wegener)
H
W
T
Pulmonary Langerhans cell histiocytosis (eosinophilic granuloma)

Hypersensitivity pneumonitis
Drug toxicity (bleomycin, busulfan, amiodarone, methotrexate)_
Hypersensitivity pneumonitis mixed type III/IV hypersensitivity reaction to environmental
antigen. Causes dyspnea, cough, chest tightness, headache. Often seen in farmers and those
exposed to birds.
Obstructive lung volumes > normal ( t TLC, t FRC, t RV ); restrictive lung volumes < normal. In
obstructive, FEV| is more dramatically reduced compared with FVC
decreased FEVj /FVC
ratio. In restrictive, FVC is more reduced or close to same compared with FEV )
increased or
normal FEVi /FVC raticj
Flow volume loops
NORMAL
OBSTRUCTIVE
RESTRICTIVE
Loop shifts to the left
A
V /
vV
Loop shifts to the right
i; o
>
I
8
8.
\v_y7w
TLC-
0
4
Volume (L)
636
SECTION III
Pneumoconioses
Asbestosis
RESPIRATORY
RESPIRATORY
PATHOLOGY
Coal workers pneumoconiosis, silicosis, and

asbestosis t risk of cor pulmonale, cancer,
and Caplan syndrome ( rheumatoid arthritis
and pneumoconioses with intrapulmonary
)
nodules!
Associated with shipbuilding, roofing,
plumbing. Ivory white, calcified ,
supradiaphragmatic!El and pleural Q
plaques arej pathognomonic of asbestosis.
Risk of bronchogenic carcinoma > risk of

mesothelioma.
Berylliosis
Associated with exposure to beryllium in

aerospace and manufacturing industries.
Granulomatous on histology and therefore
occasionally responsive to steroids.
Coal workers'
pneumoconiosis
Prolonged coal dust exposure macrophages

laden with carbon -* inflammation and
fibrosis.
Also known as black lung disease.
Associated with foundries, sandblasting,
mines. Macrophages respond to silica
and release fibrogenic factors, leading to
fibrosis. It is thought that silica may disrupt
phagolysosomes and impair macrophages,
increasing susceptibility to I B .
Silicosis
'P,
Asbestos is from the roof (was common in

insulation ), but affects the base ( lower lobes ).
Silica and coal are from the base ( earth ), but
affect the roof ( upper lobes ).
Affects lower lobes.

Asbestos (ferruginous) bodies are golden-brown
fusiform rods resembling dumbbells 0,
found in alveolar sputum sample!visualized
using Prussian blue stain , often obtained by
bronchoalveolar lavage,
t risk of pleural effusions.
Affects upper lobes.

Anthracosis asymptomatic condition found in
many urban dwellers exposed to sooty air.
Chest x-rav shows eggshell calcification of
hilar lymph nodeil
:: i f
r?
<
RESPIRATORY
RESPIRATORY
Acute respiratory
distress syndrome
Diagnosis of exclusion characterized by

respiratory failure w ithin 1 week of alveolar
insult, bilateral lung opacities, I PaCVFIO-,
( hypoxemia due to t intrapulmonary shunfmg
and diffusion abnormalities ), no evidence
of HF/fluid overload . Caused by sepsis,
pancreatitis, pneumonia , aspiration , trauma ,
"
or shock . Endothelialdamage -*
PATHOLOGY
637
?
>
t alveolar
capillar}- permeability -* protein-rich leakage

into alveoli diffuse alveolar damage and
noncardiogenic pulmonary edema ( normal
PCWP) Q- Results in formation of intraalveolar hyaline membranes Q. Initial damage
SECTION III
rr r:
WL
'
due to release of neutrophilic substances

toxic to alveolar wall and pulmonary capillary
endothelial cells, activation offcoagulation
cascade, and oxygen-derived free radicals.
Management: mechanical ventilation with low
tidal volumes, address underlying cause.
Sleep apnea
Obstructive sleep
apnea
Repeated cessation of breathing > 10 seconds during sleep disrupted sleep -* daytime
somnolence. Normal Pao? during the day.
Nocturnal hypoxia systemic/pulmonary hypertension , arrhythmias (atrial fibrillation /flutter),
sudden death .
Hypoxia t EPO release t erythropoiesis.
Respiratory effort against airway obstruction . Associated with obesity, loud snoring. Caused by
excess parapharyngeal tissue in adults, adenotonsillar hypertrophy in children . Treatment: weight
loss, CPAP, surgery.
Central sleep apnea
No respiratory effort due to CNS injurv/toxicitv, HF, opioids. May be associated with CheyneStokes respiration . Treat with bilevel positive airway pressure (cm H -,Oi
Obesity
hypoventilation
syndrome
Obesity ( BMI
> 30 kg /m ~ ) hypoventilation t PaCO-, during waking hours ( retention ); 1 PaOi

and t PaCOo during sleep]
638
SECTION III
Pulmonary
hypertension
RESPIRATORY
Normal mean pulmonary artery pressure = 10-14 mm Hg; pulmonary hypertension > 25 mm I Ig at
rest. Results in arteriosclerosis, medial hypertrophy, intimal fibrosis of pulmonary arteries. Course:
death from decompensated cor pulmonale.
severe respiratory distress cyanosis and RVH
ETIOLOGIES
Pulmonary arterial
hypertension
Idiopathic PAH.
Heritable PAH often due to an inactivating mutation in BMPR2 gene (normally inhibits vascular
smooth muscle proliferation); poor prognosis.
Other causes include drugs (eg, amphetamines, cocaine), connective tissue disease, HIV infection,
portal hypertension, congenital heart disease, schistosomiasis.
Left heart disease
Causes include systolic /diastolic dysfunction and valvular disease (eg, mitral lung).
Lung diseases or
hypoxia
Destruction of lung parenchyma (eg, COPD), lung inflammation/fibrosis ( eg, interstitial lung
diseases), hypoxemic!vasoconstriction (eg, obstructive sleep apnea, living in high altitude).
Chronic
Recurrent microthrombi -* 1 cross-sectional area of pulmonary vascular bed.
thromboembolic
Multifactorial
Causes include hematologic, systemic, and metabolic disorders.
Lung physical findings

ABNORMALITY
BREATH SOUNDS
PERCUSSION
FREMITUS
TRACHEAL DEVIATION
Pleural effusion
Dull
or away from side of

lesion (if large)
Atelectasis ( bronchial
obstruction)
Dull
Toward side of lesion
Simple pneumothorax
Hyperresonant
Tension
pneumothorax
Hyperresonant
Away from side of lesion
Consolidation
( lobar pneumonia,
pulmonary edema )
Bronchial breath
sounds; late inspiratory
crackles, egophonv,
Dull
bronchophonv,
whispered pectoriloqu\|
RESPIRATORY
Pleural effusions
639
SECTION III
Excess accumulation of fluid between pleural layers Q -* restricted lung expansion during
inspiration. Can be treated with thoracentesis to remove fluid Q.
Transudate
1 protein content. Due to t hydrostatic pressure (eg, CHFj) or 1 oncotic pressure (eg, nephrotic
syndrome, cirrhosis).
Exudate
t protein content, cloudy. Due to malignancy, pneumonia, collagen vascular disease, trauma
(occurs in states of t vascular permeability). Must be drained due to risk of infection.
Lymphatic
Also known as chylothorax. Due to thoracic duct injury from trauma or malignancy. Milkyappearing fluid; t triglycerides.
Gf)
V
Pneumothorax
Pretreatment
Accumulation of air in pleural space Q. Dyspnea, uneven chest expansion. Chest pain, 1 tactile
fremitus, hvperesonace, and diminished breath sounds, all on the affected sidej
Primary spontaneous
pneumothorax
Due to rupture of apical subpleural bleb or cysts. Occurs most frequently in tall, thin, young males.
Secondary
Due to diseased lung (eg, bullae in emphysema, infections), mechanical ventilation with use of
high pressures barotrauma.
spontaneous
pneumothorax
Traumatic
Caused by blunt (eg, rib fracture) or penetrating (eg, gunshot) trauma.
pneumothorax
Tension
pneumothorax
Can be any of the above. Air enters pleural space but cannot exit. Increasing trapped air
pneumothorax. Trachea deviates away from affected lung Q. Needs immediate needle
decompression and chest tube placement.
r
r''
.
4
m.
tension
640
SECTION III
RESPIRATORY
RESPIRATORY
PATHOLOGY
Pneumonia
TYPE
TYPICAL ORGANISMS
Lobar
S pneumoniae most frequently, also
CHARACTERISTICS
Legionella,
Klebsiella
Bronchopneumonia
S pneumoniae, S aureus, H influenzae,
Klebsiella
Interstitial (atypical )
pneumonia
Mycoplasma , Chlamydophila pneumoniae

Chlamydia psittaci Legionella , viruses ( RSV,
CMV, influenza , adenovirus)
Bronchiolitis
obliterans organizing
Intra-alveolar exudate
consolidation Q; may
involve entire lobe Q or lung.
Acute inflammatory infiltrates H from
bronchioles into adjacent alveoli; patchy
distribution involving > 1 lobe 0.
Diffuse patchy inflammation localized to
interstitial areas at alveolar walls; diffuse
distribution involving > 1 lobe Q. Generally
follows a more indolent course ( walking
pneumonia ).
Noninfectious pneumonia characterized bv
inflammation of bronchioles and surrounding
structures. Caused bv chronic inflammatory
pneumonia
diseases (eg, rheumatoid arthritis ) or medication

side effects ( eg, amiodarone ). Negative sputum
and blood cultures, no response to antibiotics.
Lung abscess
1
*
Localized collection of pus within

parenchyma Q. Caused by aspiration of
oropharyngeal contents (especially in patients
predisposed to loss of consciousness [eg,
alcoholics, epileptics] ) or bronchial obstruction
(eg, cancer).
Treatment: clindamycin .
Air-fluid levels Q often seen on CXR. Fluid

levels common in cavities; presence suggests
cavitation . Due to anaerobes (eg, Bacteroides ,
Fusobacterium, Peptostreptococcus ) or S aureus.
Lung abscess 2 to aspiration is most often found
in right lung. Location depends on patient's
position during aspiration :
Upright inferio segments of right lower
5
lobe
Supine posterior segments of right upper
lobe or superior segment of right lower lobe
RESPIRATORY
SECTION III
Mesothelioma
Malignancy of the pleura associated with

asbestosis. May result in hemorrhagic pleural
effusion (exudative), pleural thickening.
Pancoast tumor
( superior sulcus
tumor )
Carcinoma that occurs in the apex of lung Q may cause Pancoast syndrome by invading cervical
Psammoma bodies seen on histology.

Cytokeratin and calretinin in almost all
mesotheliomas, in most carcinomas.
Smoking not a risk factor.
sympathetic chain.
Compression of locoregional structures may cause array of findings:
Recurrent laryngeal nerve hoarseness
Stellate ganglion!- Horner syndrome (ipsilateral ptosis, miosis, anhidrosis)
s
Superior vena cava -* SVC syndrome_
Brachiocephalic vein brachiocephalic syndrome (unilateral symptoms)
Brachial plexus - sensorimotor deficit!
Superior vena cava

syndrome
An obstruction of the SVC that impairs blood

drainage from the head ( facial plethora;
note blanching after fingertip pressure in Q),
neck ( jugular venous distention), and upper
extremities (edema). Commonly caused by
malignancy ( eg, mediastinal mass, Pancoast
tumod) and thrombosis from indwelling
catheters Q. Medical emergency. Can raise
intracranial pressure (if obstruction is severe)
headaches, dizziness, t risk of aneurysm/
rupture of intracranial arteries.
MfU
LV
641
642
SECTION III
RESPIRATORY
Leading cause of cancer death.

Presentation: cough, hemoptysis, bronchial
obstruction, wheezing, pneumonic coin
lesion on CXR or noncalcified nodule on CT.
Sites of metastases from lung cancer:
adrenals, brain, bone (pathologic fracture),
liver ( jaundice, hepatomegaly).
In the lung, metastases (usually multiple
lesions) are more common than 1
neoplasms. Most often from breast, colon,
prostate, and bladder cancer.
Lung cancer
TYPE
Superior vena cava syndrome

Pancoast tumor
Horner syndrome
Endocrine (paraneoplastic)
Recurrent laryngeal nerve compression
(hoarseness)
Effusions ( pleural or pericardial)
Risk factors include smoking, secondhand smoke,
radon, asbestos, family history.
Squamous and Small cell carcinomas are Sentral
(central) and often caused by Smoking.
LOCATION
CHARACTERISTICS
Central
Undifferentiated very aggressive.

Neoplasm of
neuroendocrine
May produce ACTH (Cushing syndrome), SI ADII, or
Antibodies against presynaptic Ca 2+ channels (LambertKulchitsky cells - small
dark blue cells CJ.
Eaton myasthenic syndrome) or neurons (paraneoplastic
myelitis, encephalitis, subacute cerebellar degeneration). Chromogranin A ,
neuron-specific
Amplification of myc oncogenes common. Managed
enolase .
with chemotherapy +/- radiation.
Peripheral
Most common lung cancer in nonsmokers and overall

(except for metastases). Activating mutations include
KRAS , EGFR , and ALK . Associated with hypertrophic
osteoarthropathy (clubbing).
Bronchioloalveolar subtype ( adenocarcinoma in situ):
CXR often shows hazy infiltrates similar to pneumonia;
better prognosis.
Bronchial carcinoid and bronchioloalveolar cell
carcinoma have lesser association with smoking.
Glandular pattern on
histology, often stains
mucin Q.
Bronchioloalveolar subtype:
grows along alveolar septa
apparent thickening
of alveolar walls. Tall,
columnar cells containing
Keratin pearls 0 and
Small cell
Small cell (oat cell )
carcinoma
SPHERE of complications:
HISTOLOGY
Non- small cell

Adenocarcinoma
Squamous cell
carcinoma
Central
Hilar mass arising from bronchus Q; Cavitation;

Cigarettes; hyperCalcemia (produces PTHrP).
Large cell
carcinoma
Peripheral
Highly anaplastic undifferentiated tumor; poor prognosis.

Less responsive to chemotherapy; removed surgically.
Strong association with smoking
Bronchial carcinoid
tumor
Excellent prognosis; metastasis rare.

Symptoms due to mass effect or carcinoid syndrome
(flushing, diarrhea, wheezing).
mucus.
intercellular bridges.
Pleomorphic giant
cells Ql
Nests of neuroendocrine
cells; chromogranin A .
Wm
m1& .
H
<
Is
ilti
nr,
0 '
1 V
RESPIRATORY
RESPIRATORY PHARMACOLOGY
SECTION III
643
Antihistamines
Reversible inhibitors of Hj histamine receptors.
First generation
Diphenhydramine, dimenhydrinate,
chlorpheniramine.
CLINICAL USES
Allergy, motion sickness, sleep aid.
ADVERSE EFFECTS
Sedation, antimuscarinic, anti-a-adrenergic.
Second generation
Loratadine, fexofenadine, desloratadine,

cetirizine.
CLINICAL USES
Allergy.
Far less sedating than 1st generation because of
ADVERSE EFFECTS
Names contain -en /-ine or -en/-ate.
Names usually end in -adine.
i entry into CNS.
Guaifenesin
Expectorant thins respiratory secretions; does not suppress cough reflex.
!V-acetylcysteine
Mucolytic liquifies mucous in chronic bronchopulmonary diseases (eg, COPD, CF) by disrupting
disulfide bonds. Also used as an antidote for acetaminophen overdose.
Dextromethorphan
Antitussive (antagonizes NMDA glutamate receptors). Synthetic codeine analog. Has mild opioid
effect when used in excess. Naloxone can be given for overdose. Mild abuse potential. May cause
serotonin syndrome if combined with other serotonergic agents.
Pseudoephedrine, phenylephrine
-adrenergic agonists, used as nasal decongestants.
MECHANISM
(X
CLINICAL USE
Reduce hyperemia, edema, nasal congestion; open obstructed eustachian tubes. Pseudoephedrine
also illicitly used to make methamphetamine.
ADVERSE EFFECTS
Hypertension. Can also cause CNS stimulation/anxiety ( pseudoephedrine).
Pulmonary hypertension drugs

DRUG
MECHANISM
CLINICAL NOTES
BosENtan
Competitively antagonizes ENdothelin-1

receptors 1 pulmonary vascular resistance.
Hepatotoxic (monitor LFTs).
Sildenafil
Inhibits PDE-5 which t cGMP, thereby

prolonging vasodilatorv effect of nitric oxidej
Also used to treat erectile dysfunction
Epoprostenol, iloprost
PGI? (prostacyclin) with direct vasodilator)'

effects on pulmonary and systemic arterial
vascular beds. Inhibits platelet aggregation.
Side effects: flushing, jaw pain,
644
SECTION III
Bronchoconstriction is mediated by (1) inflammatory processes and ( 2) parasympathetic tone;

therapy is directed at these 2 pathways.
Asthma drugs
RESPIRATORY
Albuterol relaxes bronchial smooth muscle (short acting ( -agonist) Used during acute
exacerbation.
agonists
Salmeterol, formoterol long-acting agents for prophylaxis. Adverse effects are tremor and
arrhythmia.
Inhaled
corticosteroids
Fluticasone, budesonide inhibit the synthesis of virtually all cytokines. Inactivate NF-KB, the
transcription factor that induces production of TNF-a and other inflammatory agents, lst-line
therapy for chronic asthma. May cause oral thrusht
Muscarinic
antagonists
Tiotropium, ipratropiumj competitively blocks muscarinic receptors, preventing

bronchoconstriction. Also used for COPD. Tiotropium is long acting.
Antileukotrienes
Montelukast, zafirlukast block leukotriene

receptors (CvsLTl ). Especially good for
aspirin-induced and exercise-induced asthmqj
Zileuton 5 -lipoxygenase pathway inhibitor.
Blocks conversion of arachidonic acid to
leukotrienes Hepatotoxic.
Exposure to antigen
(dust, pollen, etc)
I (3)
Avoidance
Antigen and IgE [-{3) Omalizumab

on mast cells
Omalizumab binds mostly unbound serum

IgE and blocks binding to FceRI. Used in
allergic asthma with t IgE levels resistant to
inhaled steroids and long-acting [ -agonists.
Anti- lgE monoclonal

therapy
I (3} Steroids
Theophylline likely causes bronchodilation

by inhibiting phosphodiesterase t cAMP
levels due to i cAMP hydrolysis. Usage is
limited because of narrow therapeutic index
(cardiotoxicity, neurotoxicity); metabolized
by cytochrome P- 450. Blocks actions of
adenosine.
Methylxanthines
Mediators
(leukotrienes, histamine, etc)
p -agonists
Theophylline
Muscarinic
antagonists
-GH
Steroids
H5>- Antileukotrienes
ATP
( )
AC | <
Bronchodilation
Q
ACh
Bronchial tone
0-agonists
Early response:
bronchoconstriction
Late response:
inflammation
cAMP
I PDEji
O
AMP
Adenosine
Muscarinic
antagonists
Theophylline
Symptoms
Bronchial
hyperreactivity
Theophylline
Bronchoconstriction
Methacholine
Muscarinic receptor (MJ agonist. Used in bronchial challenge test to help diagnose asthma.

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c Health Sciences

Public Health Sciences

The Well Patient

up and the kind you

PUBLIC HEALTH SCIENCES

PUBLIC HEALTH SCIENCES EPIDEMIOLOGY / BIOSTATISTICS

PUBLIC HEALTH SCIENCES EPIDEMIOLOGY / BIOSTATISTICS

Cross- sectional study

Collects data from a group of people to assess

Compares a group of people with disease to a

Looks for prior exposure or risk factor.

Compares a group with a given exposure or risk

Odds ratio (OR ).

Relative risk ( RR).

Compares the frequency with which both

Measures hcritability and influence of

Compares siblings raised by biological vs

Measures heritability and influence of

Experimental study involving humans. Compares therapeutic benefits of 2 or more treatments,

TYPICAL STUDY SAMPLE

Small number of healthy volunteers.

Is it safe? Assesses safety, toxicity,

Small number of patients with disease of

Does it work? Assesses treatment efficacy,

pharmacokinetics, and pharmacodynamics.

large number of patients randomly assigned

Is it as good or better?" Compares the new

Postmarketing surveillance of patients after

Can it stay? " Detects rare or long-term

treatment to the current standard of care tanv

PUBLIC HEALTH SCIENCES

EPIDEMI 0 L06 Y / BI0 STATISTICS

Uses 2 x 2 table comparing test results with the

PUBLIC HEALTH SCIENCES

Proportion of positive test results that are true

POSSIBLE CUTOFF VALUES

lowenna the cutoff point

Raising the cutoff point

Proportion of all people without disease who

Proportion of all people with disease who lest

A measure indicating how likely a given test

PUBLIC HEALTH SCIENCES

PUBLIC HEALTH SCIENCES

Definitions and formulas are based on the classic

Typically used in case-control studies. OR

Typically used in cohort studies. Risk of

divided by risk in the unexposed group ( eg. if

Relative risk reduction

The difference in risk between exposed and

T he difference in risk (not the proportion )

PUBLIC HEALTH SCIENCES EPIDEMIOLOGY / BIOSTATISTICS

PUBLIC HEALTH SCIENCES

Incidence looks at new cases ( incidents).

II of existing cases (at a point in

Prevalence - pretest probability.

t PPV and t NPV

large II of existing cases ( eg diabetes).

The consistency and reproducibility of a teslj

Random error 1 precision in a test,