HUSAIN A. SATTAR, MD Pathoma A mass of pathology! TO MY PARENTS AND EACH OF MY TEACHERS—YOUR SACRIFICE FORMS THE FOUNDATION UPON WHICH OUR WORK IS BUILT >\_ Pathoma 1/777 12/23/12 NGROWTH ADAPTATIONS BASIC PRINCIPLES A. An organ is in homeostasis with the physiologic stress placed on it. B. An increase, decrease, or change in stress on an organ can result in growth adaptations. HYPERPLASIA AND HYPERTROPHY: > An increase in stress leads to an increase in organ size. > Occurs via an increase in the size (hypertrophy) and/or the number (hyperplasia) of cells. > Hypertrophy involves gene activation, protein synthesis, and production of organelles. > Hyperplasia involves the production of new cells from stem cells. > Hyperplasia and hypertrophy generally occur together (e.g., uterus during pregnancy). > Permanent tissues (e.g., cardiac muscle, skeletal muscle, and nerve), however, cannot make new cells and undergo hypertrophy only. For example, cardiac myocytes undergo hypertrophy, not hyperplasia, in response to systemic hypertension ( Fig 1.1) > Pathologic hyperplasia (e.g., endometrial hyperplasia) can progress to dysplasia and, eventually, cancer. >A notable exception is benign prostatic hyperplasia (BPH), which does not increase the risk for prostate cancer. Note: in hypertrophy, cell organelles are doubled including the # of chromosomes (i.e. the cell will be 4N, and the cell cycle is blocked before G2 phase and after S phase ). All hormone stimulated glands undergo hyperplasia, not hypertrophy. So there is no way to benign prostatic hyperatrophy. It benign prostatic hyperplasia.Fig 1.1 Very thick left ventricle. This increase in size has occurred via hypertrophy and no hyperplasiaATROPHY > A decrease in stress (e.g., decreased hormonal stimulation, disuse, or decreased nutrients/blood supply) leads to a decrease in organ size (atrophy). > Occurs via a decrease in the size and number of cells > Decrease in cell number occurs via apoptosis. > Decrease in cell size occurs via ubiquitin-proteosome degradation of the cytoskeleton and autophagy of cellular components. > In ubiquitin-proleosome degradation, intermediate filaments of the cytoskeleton are "tagged" with ubiquitin and destroyed by proteosomes. > Autophagy of cellular components involves generation of autophagic vacuoles. > These vacuoles fuse with lysosomes whose hydrolytic enzymes breakdown cellular components. Regulatory site Active side ( degradation site ) Kn Ubiquitin binds to the The protein to regulatory site and opens up Ubiquitin be degraded the proteosome. The tagged protein degraded. Proteosome Examples of ubiginated proteins: 1. Mollary bodies: ubiquinated keratin seen in hepatocytes of alcogolics. 2. Tau protein: ubiginated neurofilament that leads to formation of neurofibrillary tangles seen in Alzheimer and CJ disease. 3. Lewy body: ubiqinated neurofilament seen in subtantia nigra of Parkinsonians. Pathoma 41777 12/23/12METAPLASIA > A chang in stress on an organ leads to a change in cell type (metaplasia). > Most commonly involves change of one type of surface epithelium (squamous, columnar, or urothelial) to another. > Metaplastic cells are better able to handle the new stress. > Barrett esophagus is a classic example. Esophagus is normally lined by nonkeratinizing squamous epithelium (suited to handle friction of a food bolus). > Acid reflux from the stomach causes metaplasia to nonciliated, mucin-producing columnar cells (better able to handle the stress of acid, Fig. 1.2). > Metaplasia occurs via reprogramming of stem cells, which then produce the new cell type. This is the normal squamous epithelium | Metaplastic columnar epithelium. Fig. 1.2 Pathoma 5/777 12/23/12> Metaplasia is reversible, in theory, with removal of the driving stressor. > For example, treatment of gastroesophageal reflux may reverse Barrett esophagus. > Under persistent stress, metaplasia can progress to dysplasia and eventually result in cancer. > For example, Barrett esophagus may progress So adenocarcinoma of the esophagus. > A notable exception is apocrine metaplasia of breast, which carries no increased risk for cancer. > Vitamin A deficiency can also result in metaplasia: > Vitamin A is necessary for differentiation of specialized epithelial surfaces such as the conjunctiva covering the eye. > In vitamin A deficiency, the thin squamous lining of the conjunctiva undergoes metaplasia into stratified keratinizing squamous epithelium. This change is called keratomalacia (Fig. 1.3). Remember that vitamin A is used to treat promyelocytic leukemia. Note: Mesenchymal (connective) tissues can also undergo metaplasia. A classic example is myositis ossificans in which muscle tissue changes to bone during healing after trauma (Fig. 1.4). Pathor 6 12/23/12Normally the conjectivia of the eye is transparent. Fig. 1.3, keratomalacia Skeletal muscle converting to a bone after trauma. Note: this is different than osteosarcoma because: 1. The bone that is adjacent is normal. 2. There is a clear line separating the mass Fig. 1.4 Myositis Ossificans from the bone. Pathoma 7/777 12/23/12DYSPLASIA > Disordered cellular growth. > Most often refers to proliferation of precancerous cells. For example, cervical intraepithelial neoplasia (CIN) represents dysplasia and is a precursor to cervical cancer. > Often arises from longstanding pathologic hyperplasia (e.g. endometrial hyperplasia) or metaplasia (e.g. Barrett esophagus) > Dysplasia is reversible, in theory, with alleviation of inciting stress. E.g. After treating GERD, Barrett reverts to normal epithelium. > If stress persists, dysplasia progresses to carcinoma (irreversible). APLASIA AND HYPOPLASIA > Aplasia is failure of cell production during embryogenesis (e.g., unilateral renal agenesis), > Hypoplasia is a decrease in cell production during embryogenesis, resulting in a relatively small organ (e.g. streak ovary in Turner syndrome). Pathoma 8/777 12/27/12CELLULAR INJURY BASIC PRINCIPLES > Cellular injury occurs when a stress exceeds the cell's ability to adapt. > The likelihood of injury depends on the type of stress, its severity, and > Neurons are highly susceptible to ischemic injury; whereas, skeletal muscle is relatively more resistant. > Slowly developing ischemia (e.g, renal artery atherosclerosis) results in atrophy, whereas, acute ischemia (e.g., renal artery embolus) results in injury. > Common causes of cellular injury include: # inflammation, # nutritional deficiency or excess, # hypoxia, # trauma, and # genetic mutations. Pathoma 9/777 12/28/12Hypoxia is a nice model for studying cellulr injury. The following is from Julian. Hypoxia: inadequate oxygenation of tissue (same definition of as shock). Causes of hypoxia: 1, Ischemia: which is most commonly caused by atherosclerosis. Cardiogeni¢ shock is also another cause. 2. Hypoxemia: this is caused by: A. Resp. acidosis B. Ventilation defect: best C. Perfusion defect D. Diffusion defect Note: these are disscused in the next page... 3. Hemoglobin related hypoxia: A. CO B. Met Hb C. Other causes of left shift of O2-Hb curve 4. Problems related to oxidative pathway: A. Cytochrome oxidase inhibitors: remeber the 3 Cs: cytochrome oxidase, Cyanide, CO. B. Uncoupling1. Resp. acidosis: when the Partial pressure of CO2 goes up in the lung, that of O2 must go down because the sum of all gases must equal to 760 mmHg ( Dalton’s law ). 2. Ventilation defect: best example is resp distress syndrome (aka hyaline membrane dz in children). In adults, this is called Adult RDS, and has a ventilation defect. Lost ventilation to the alveoli, but still have perfusion; therefore have created an intrapulmonary shunt. Exam question: pt with hypoxemia, given 100% of O02 for 20 minutes, and pO2 did not increase, therefore indicates a SHUNT, massive ventilation defect. 3. Perfusion defects: MCC is pulmonary embolus. If you give 100% O2 for a perfusion defect, pO2 will go UP (way to distinguish vent from perfusion defect), b/c not every single vessel in the lung is not perfused. Therefore, perfusion defects cause an increase in dead space, while ventilation defects cause intrapulmonary shunts. To tell the difference, give 100% O2 and see whether the pO2 stays the same, ie does not go up (shunt) or increases ( dead space). 4. Diffusion defect: e.g. Due to pulm. Fibrosis.Back to Pathoma... HYPOXIA > Low oxygen delivery to tissue; important cause of cellular injury > Oxygen is the final electron acceptor in the electron transport chain of oxidative phosphorylation. > Decreased oxygen impairs oxidative phosphorylation, resulting in decreased ATP production. > Lack of ATP (essential energy source) leads to cellular injury Causes of hypoxia include: # ischemia, # hypoxemia, and # decreased 02 -carrying capacity of blood. Ischemia is decreased blood flow through an organ. Arises with: 1. Decreased arterial perfusion (e.g., atherosclerosis) 2. Decreased venous drainage (e.g., Budd-Chiari syndrome). Note: The MCC of Budd-Chiari is polycythemia rupra vera. This syndrome is also occur in lupus patients ( because of lupus anticoagulant ) 3. Shock—generalized hypotension resulting in poor tissue perfusion Pathoma 12/777 12/28/12Hypoxemia is a low partial pressure of oxygen in the blood (PaO2 < 60 mmHg, SaO2 < 90%). Arises with: 1. High altitude—Decreased barometric pressure results in decreased Pao,. 2. Hypoventilation—Increased PaCO2, results in decreased PaQ2. 3. Diffusion defect-PAO2 not able to push as much O2 into the blood due to a thicker diffusion barrier (e.g., interstitial pulmonary fibrosis) 4. V/Q mismatch—Blood bypasses oxygenated lung (circulation problem, e.g., right-to-left shunt), or oxygenated air cannot reach blood (ventilation problem, e.g. atelectasis). Remember .. The atmospheric O2 pressure = FiO2. The lung bring that to alveoli at which its called PAO2. This pressure is used to squeeze O02 via the alveolar wall, interstitium and capillary wall to reach the blood creating PaQ2. This PaO2 is used to push O2 through the red cell membrane creating Sade Thick membrane will make it harder for PAO2 to squeeze O2 into the blood, e.g. In fibrosis, pulm. edema. High altitudes have low FiO2 and so, by extension, affects FAQ2 and Anything increase Pao2. PACO2 decrease PAO2. Hypoxemia ane. e.g. Hypoventilation, describes low PaQ2 copp, ete. Pathoma 13/777 12/28/12Decreased 02 carrying capacity: Arises with hemoglobin (Hb) loss or dysfunction. Examples include 1,_ Anemia (decrease in RBC mass)—Pa02 is normal; Sa02 is normal ( no problem in any pressure ). 2. Carbon monoxide poisoning: CO binds hemoglobin more avidly than oxygen—PaO2 normal; Sa02 decreased . > Exposures include smoke from fires and exhaust from cars or gas heaters. > Classic finding is cherry-red appearance of skin. > Early sign of exposure is headache; significant exposure leads to coma and death. 3. Methemoglobinemia Tron in heme is oxidized to Ferric which cannot bind oxygen — PaO2 is normal; Sa02 is decreased > Seen with oxidant stress (e.g., sulfa and nitrate drugs) or in newborns ( their enzymatic machine to reverse ferric to ferrous is immature ). > Classic finding is cyanosis with chocolate-colored blood. > Treatment is intravenous methylene blue, which helps reduce Ferric back to Ferrous state. Pathoma 14/777 12/28/12REVERSIBLE AND IRREVERSIBLE CELLULAR INJURY # Hypoxia impairs oxidative phosphorylation resulting in decreased ATP. # Low ATP disrupts key cellular functions including 1. Na/K pump, resulting in sodium and water buildup in the cell 2. Ca pump resulting in Ca buildup in the cytosol of the cell. Ca in the cytosol is normally kept very low using energy. That is because high cytosolic Ca will activate enzymes that might not be needed or might be damaging. 3. Aerobic glycolysis, resulting in a switch to anaerobic glycolysis. Lactic acid buildup results in low pH, which denatures proteins and precipitates DNA. # The initial phase of injury is reversible. The hallmark of reversible injury is cellular swelling. > Cytosol swelling results in loss or microvilli and membrane blebbing. > Swelling of the rough endoplasmic reticulum (RF.R) results in dissociation of ribosomes and decreased protein synthesis. # Eventually, the damage becomes irreversible. The hallmark of irreversible injury is membrane damage. There are important 3 membranes 1. Plasma membrane damage results in cytosolic enzymes leaking into the serum {e.g., cardiac troponin, indicating that an irreversible myocardial cell damage has occurred ). Additional calcium entering into the cell. 2. Mitochondrial membrane damage results in loss of the electron transport chain (inner mitochondrial membrane). Cytochrome C leaking into cytosol (activates apoptosis). 3. Lysosome membrane damage results in hydrolytic enzymes leaking into the cytosol, which, in turn, are activated by the high intracellular calcium. # The end result of irreversible injury is cell death. Pathoma 15/777 12/28/12CELL DEATH BASIC PRINCIPLES # The morphologic ‘hallmark’ of cell death is loss of the nucleus, which occurs via nuclear condensation (pyknosis, L. For ink dot), fragmentation (Karyorrhexis), and dissolution (Karyolysis). # The two mechanisms of cell death are necrosis and apoptosis. NECROSIS # Death of large groups of cells followed by acute inflammation, e.g. After an MI. 4 Due to some underlying pathologic process; never physiologic # Divided into several types based on gross features GROSS PATTERNS OF NECROSIS 1. Coagulative necrosis # Necrotic tissue that remains firm (Fig, 1.5A); cell shape and organ structure are preserved by coagulation of proteins, but the nucleus disappears (Fig. 1.5B). # Characteristic of ischemic infarction of any organ except the brain # Area of infarcted tissue is often wedge-shaped (pointing to focus of vascular occlusion) and pale. # Red infarction arises if blood re-enters a loosely organized tissue (e.g., pulmonary or testicular infarction, Fig. 1.6). Pathoma 16 N q q 12/28/12Though the shape of glumerulus and tubules is maintained, nuclei are lost. Cells of the glumerulus and tubules contain nuclei. Pathoma 47/777 12/28/12The wedge shaped pale area, the red dot represents the occluded vessel Pathoma 18/777 12/28/12Hemorrhagic infarction of testicle. This occurs because in testicluar torsion, the artery remains relactive open comoered to the vein. As such, blood will continue coming into the testicle but would not be able to get out, leading to ischemia and, since the testicle is a loose tissue, red infarction.2. liquefactive Necrosis # Necrotic tissue that becomes liquefied; enzymatic lysis of cells and protein results in liquefaction. # Characteristic of: i. Brain inlarclion-Proteolytic enzymes from microglial cells liquefy the brain. ii Abscess—Proteolytic enzymes from neutrophils liquefy tissue. iii. Pancreatitis—Proteolytic enzymes from pancreas liquefy parenchyma. Note: in pancreatitis, there would be a fat necrosis of the peripancreatic tissue. 3. Gangrenous necrosis # Coagulative necrosis that resembles mummified tissue (dry gangrene, Fig. 1.7) # Characteristic of ischemia offléwWer limb»and GI tract # If superimposed infection of dead tissues occurs, then liquefactive necrosis ensues (wet gangrene). Fig 1.7 Dry gangrene Pathoma 20/777 12/28/124. Gaseous necrosis # Soft and friable necrotic tissue with "cottage cheese-like” appearance (Fig. 1.8) # Combination of coagulative and liquefactive necrosis # Characteristic of granulomatous inflammation due to tuberculous or fungal infection Fig 1.8 Pathoma 21/777 12/28/12Fat necrosis # Necrotic adipose tissue with chalky-white appearance due to deposition of calcium ( Fig. 1.9) # Characteristic of trauma to fat (e.g., breast) and pancreatitis-mediated damage of peripancreatic fat # Fatty acids released by trauma (e.g. to breast) or lipase ( e.g. pancreatitis) join with calcium via a process called saponification. # Saponification is an example of dystrophic calcification in which calcium deposits on dead tissues (e.g. psammoma bodies ). In dystrophic calcification, the necrotic tissue acts as a nidus for calcification in the set ting of normal serum calcium and phosphate. # Dystrophic calcification is distinct from metastatic calcification, in which high serum calcium or phosphate levels lead to calcium deposition in normal tissues (e.g., hyperparathyroidism leading to nephrocalcinosis), Pathoma 22/777 12/28/12Fibrinoi : # Necrotic damage to blood vessel wall # Leaking of proteins (including fibrin) into vessel wall results in bright pink staining of the wall microscopically (Fig. 1.10). # Characteristic of malignant hypertension ( very high blood pressure that Pathoma 23/777 12/28/12APOPTOSIS L.For falling of leaves # Energy (ATP)-dependent, genetically programmed cell death involving single cells or small groups of cells. # Examples include: 1. Endometrial shedding during menstrual cycle 2. Removal of cells during embryogenesis ( syndactyly results from apoptosis failure. 3. CD8+ T cell-mediated killing of virally infected celts # Morphology: > Dying cell shrinks, leading cytoplasm to become more eosinophilic (pink, Fig. 1.11). > Nucleus condenses (pyknosis) and fragments (karyorrhexis). > Apoptotic bodies fall from the cell and are removed by macrophages; apoptosis is not followed by inflammation. This cell has a more pinks cytoplasm and smaller nucleus Pathoma 241777 12/28/12> Apoptosis is mediated by caspases that activate proteases and endonucleases: # Proteases break down the cytoskeleton. This would leading to cell shrinkage. E DNA. Thi ing ¢ shrinkage. Pathoma 25/777 12/28/12Caspases are activated by multiple pathways: 1. Intrinsic mitochondrial pathway: i. Cellular injury, DNA damage, or loss of hormonal stimulation leads to inactivation of Bcl2. ii. Lack of Bel2 allows cytochrome c to leak from the inner mitochondrial matrix into the cytoplasm and activate caspases. Bcl2 Stabilizes the mitochondrial from entering the cytoplasm and AI) activating caspases. 3) Bcl2 membrane, preventing Cytochrome C External_link: # Bcl2 is overexpressed in follicular lymphoma, # +(14:18) moves Bcl2 (chromosome 18) to the lg heavy chain locus (chromosome 14), resulting in increased Bcl2. # Mitochondrial membrane is further stabilized, prohibiting apoptosis, leading to cancer. Pathoma 26/77; 12/28/122. Extrinsic receptor-ligand pathway: # FAS ligand binds FAS death receptor (CD95) on the target cell, activating caspases (e.g., negative selection of thymocytes in thymus). # Tumor necrosis factor (TNF) binds TNF receptor on the target cell, activating caspases. Fas ligand en ig ee Fas death receptor ( CD95 ) Granzymes Perforins cos Pathoma 12/28/123. Cytotoxic CD8+ T cell-mediated pathway: # Perforins secreted by CD8+ T cell create pores in membrane of target cell. # Granzyme from CD8+ T cell enters pores and activates caspases. # CD8+ T cell killing of virally infected cells is an example.FREE RADICAL INJURY BASIC PRINCIPLES # Free radicals are chemical species with an unpaired electron in their outer orbit. # Physiologic generation of free radicals occurs during oxidative phosphorylation. # Cytochrome c oxidase (complex IV) transfers electrons to oxygen. # Partial reduction of yields superoxide (02'), hydrogen peroxide (H202), and hydroxyl radicals (OH'). H20 Glutathione pathwa' The most damaging -e -e oz por Ns1:202 H20 NADH-oxidase soD cl Catalase pathway Myeloperoxidase HOCL Pathoma 12/28/12# Pathologic generation of free radicals arises with: 1. Ionizing radiation—water hydrolyzed to hydroxyl free radical 2. Inflammation—NADPH oxidase generates superoxide ions during oxygendependent killing by neutrophils. 3. Metals (e.g., copper and iron}-Fe generates hydroxyl free radicals (Fenton reaction). 4. Drugs and chemicals—P450 system of liver metabolizes drugs (e.g., acetaminophen), generating free radicals. 5. Carbon tetrachloride ( CCI4 ) is discussed below # Free radicals cause cellular injury via peroxidation of lipids and oxidation of DNA and proteins; DNA damage is implicated in aging and oncogenesis. 1.H20 — oy Tonizing radiation 2. 02 ——— 02! NADPH Oxidase athoma 30/77 12/29/12Elimination of tree radicals occurs via multiple mechanisms: 1. Antioxidants (e.g. glutathione and vitamins A , C, and E) 2. Enzymes: i. Superoxide dismuiase (in mitochondria) — Superoxide (02' to H202 ) ii. Glutathione peroxidase (in mitochondria) —bOH' to H2O iii Calalase (in peroxisomes) — H202 to OH' 3. Metal carrier proteins (e.g., transferrin and ceruloplasmin). Because iron and copper are capable of generating free radicles, these proteins bind those metals, protecting us. or Neo 2 Re piaor Nene A 20 Catalase Glutathione perioxidase # Carbon tetrachloride (CCl) 1. Organic solvent used in the dry cleaning industry 2. Converted to CCI3, free radical by P450 system of hepatocytes 3. Results in cell injury with swelling of RER; consequently, ribosomes detach, impairing protein synthesis. 4. Decreased apolipoproteins lead to fatty Fig. 1.12 change in the liver (Fig. 1.12). Pathoma 31/777 12/29/12Reperfusion injury: L Return of blood to ischemic tissue results in production of O2 derived free radicals, which further damage tissue. 2. Leads to a continued rise in cardiac enzymes (e.g., troponin) after reperfusion of infarcted myocardial tissue 32/77 12/29/12AMYLOIDOSIS BASIC PRINCIPLES: # Amyloid is a misfolded protein that deposits in the extracellular space, thereby damaging tissues. # Multiple proteins can deposit as amyloid. So, amyloid is not one protein. # Shared features include: 1. Beta-pleated sheet configuration 2. Congo red staining and apple-green birefringence when viewed microscopically under polarized light (Fig. 1.13) # Deposition can be systemic or localized. A. Congo red B. Apple-green birefringence Pathoma 33/777 12/29/12SYSTEMIC AMYLOIDOSIS Is divided in primary and secondary: # Primary amyloidosis is systemic deposition of AL amyloid, which is derived from immunoglobulin light chain. # Associated with plasma cell dyscrasias (e.g., multiple myeloma) # Secondary amyloidosis is systemic deposition of AA amyloid, which is derived from serum amyloid-associated protein (SAA). > SAA is an acute phase reactant that is increased in chronic inflammatory states, malignancy, and Familial Mediterranean fever (FMF). > FMF is due to a dysfunction of neutrophils (autosomal recessive) and occurs in persons of Mediterranean origin. i. Presents with episodes of fever and acute serosal inflammation (can mimic appendicitis, arthritis, or myocardial infarction) ii. High SAA during attacks deposits as AA amyloid in tissues. Clinical_ findings of systemic idosis include: 1. Nephrotic syndrome; kidney is the most common organ involved. Renal failure is the MCC of death. 2. Restrictive cardiomyopathy or arrhythmia 3. Tongue enlargement, malabsorption, and hepatosplenomegaly # Diagnosis requires tissue biopsy. Abdominal fat pad and rectum are easily accessible biopsy targets. # Damaged organs must be transplanted. Amyloid cannot be removed. Pathoma 34/777 12/29/12LOCALIZED AMYLOIDOSIS Amyloid deposition usually localized to a single organ. 1. Seni : wt cig i F : > Non-mutated serum transthyretin deposits in the heart. > Usually asymptomatic; present in 25% of individuals > 80 years of age. 2. Familial_amyloid cardiomyopathy is another example: > Mutated serum transthyretin deposits in the heart leading to restrictive cardiomyopathy. > 2. 5% of African Americans carry the mutated gene. 3. NIDDM (type 11) > Amylin (co-secreted with insulin) deposits in the islets of the pancreas. 4. Alzheimer disease: > A-Beta amyloid (derived from beta-amyloid precursor protein) deposits in the brain forming amyloid plaques. > Gene for beta-APP is present on chromosome 21. > Most individuals with Down syndrome (trisomy 21) develop Alzheimer disease by the age of 40 (early-onset). 5. Dialysis-associated_ amyloidosis: > beta2-microglobulin ( the globular protein that support MHC calss 2 ). > In dialysis, this protein is not filtered well from the blood Be bem > Deposits in joints. Qe | / 6. Medullary carcinoma of the thyroid: - > Calcitonin (produced by tumor cells) deposits within the tumor (‘tumor cells in an amyloid background’). See the next page ... a Pathoma 35/77 12/29/12Glassy pink material ( amyloid ) in the background of spindle-shaped tumor cells. Pathoma 36/777 12/29/12Amyloidosis Systemic amyloidosis: Primary: Secondary: Localized amyloidosis: Senile cardiac amyloidosis Familial amyloid cardiomyopathy NIDDM (type II) Alzheimer disease Dialysis-associated Medullary carcinoma AL ( from Ig light chain ) AA ( derived from SAA ) Non Mutated serum transthyretin Mutated serum transthyretin Amylin (co-secreted with insulin) A-Beta amyloid (derived from beta- amyloid precursor protein) AKA beta-amyloid or amyloid-beta or Tao prorein. Beta2-microglobulin a \ fe) Lf KS Calcitonin 12/29/12Inflammation, Inflammatory Disorders, and Wound Healing —$—_—_ Global picture: Neutrophil Inflammation is the process by Acute inflammation which white blood cells are driven out form blood stream to tissues. If these WBCs are neutrophils, then its an acute Chronic inflammation: Lymphocyte inflammation, or, if they are lymphocytes, then its a chronic. INFLAMMATION # Allows inflammatory cells, plasma proteins (e.g., complement), and fluid to exit blood vessels and enter the interstitial space # Divided into acute and chronic inflammation Neutrophil Fluid phase Macrophage phase hase 24hrs 2-3 days Phases of acute inflammation Pathoma 38/777ACUTE INFLAMMATION BASIC PRINCIPLES # Characterized by the presence of: 1. edema and 2. neutrophils in tissue (Fig. 2.1 A) # Arises in response to infection (to eliminate pathogen) or tissue necrosis (to clear necrotic debris) # Immediate response with limited specificity (innate immunity) Image Description: acute cellulitis. High power view of the deep dermis and subcutaneous tissue of the skin reveals cellulitis as a rapidly spreading acute exudative process. The inflammatory cells are polymorphonuclear leukocytes (neutrophils). Adipocytes can be seen as the large clear cells, some collagen fibers are seen at lower right. Compare this to chronic inflammation image next page. 12/30/12 8 N q q Pathoma 3af? a Chronic inflammation. This response is mediated by chemical mediators and any or all of these cells: lymphocytes, plasma cells, histocytes, benign giant cells, mast cells and eosinophils. This image shows lymphocytes ( arrows ). Most of inflammatory lymphocytes are T cells with small population of polyclonal B cells. Pathoma 40/777 12/30/12MEDIATORS OF ACUTE INFLAMMATION - Toll-like receptors . Arachidonic acid metabolites . Mast cells . Complements . Hegeman factor OPwne FIO III II II IIIT. Toll-like receptors: # Present on cells of the innate immune system (e.g., macrophages and dendritic cells) # Activated by pathogen-associated molecular patterns (PAMPs) that are commonly shared by microbes. The classic example is CD14 (a TLR) on macrophages recognizes a lipopolysaccharide (a PAMP) on the outer Membrane of gram-negative bacteria. # TLR activation results in upregulation of NF-kB (NF-kapaB ), a nuclear transcription factor that activates immune response genes leading to production of multiple immune mediators. # TLRs are also present on cells of adaptive immunity (e.g., lymphocytes) and, hence, play an important role in mediating chronic inflammation.Pathoma 42/777 12/30/12Arachidonic acid (A i # AA is released from the phospholipid cell_ membrane by phospholipase A2 and then acted upon by cyclooxygenase or 5-lipoxygenase. > Cyclooxygenase produces prostaglandins (PG): 4 PGI2, PGD2 and PGE2 mediate vasodilation and increased vascular permeability ( note: vasodilation occurs at the level of the arteriole and increased vascular permeability occurs at the level of the post capillary venule ). # PGE2 also mediates fever ( fEvEr ) and pain. > 5-lipoxygenase produces leukotrienes (LT): # LTB4 attracts and activates neutrophils (a long with C5a, IL-8 and bacterial products ) # LTC4, LTD4, and LTE4 (slow reacting substances of anaphylaxis) mediate vasoconstriction, bronchospasm, and increased vascular permeability (in other words, these cause smooth muscles to contract ).Mast Cells # Widely distributed throughout connective tissue. # Activated by: (1) tissue trauma, (2) complement proteins C3a and C5a, or (3) cross-linking of cell-surface IgE by antigen # Immediate response involves release of preformed histamine granules, which mediate vasodilation of arterioles and increased vascular permeability. # Delayed response involves production of araehidonic acid metabolites, particularly leukotrienes, which allow for maintenance of the response of the acute inflammation.Complement # Proinflammatory serum proteins that "complement" inflammation # Circulate as inactive precursors; activation occurs via: i. Classical pathway: CI binds IgG or IgM that is bound to antigen. Alternative pathway: Microbial products directly activate complement. iii. Mannose-binding lectin (MBL) pathway: MBL binds to mannose on microorganisms and activates complement. # All pathways result in production of C3 convertase (mediates C3 —° C3a and C3b), which, in turn, produces C5 convertase (mediates C5 —e C5a and C5b). > C5b complexes with C6-C9 to form the membrane attack complex (MAC). > C3a and C5a (anaphylatoxins)-trigger mast cell degranulation, resulting in histamine-mediated vasodilation and increased vascular permeability > C5a—chemotactic for neutrophils > C3b—opsonin for phagocytosis > MAC-—lyses microbes by creating a hole in the cell membrane Pathoma 45/77 12/30/12Hageman factor (Factor XII) # Inactive proinflammatory protein produced in liver # Activated upon exposure to subendothelial or tissue collagen; in turn, activates: i. Coagulation and fibrinolytic systems ii. Complement iii. Kinin system—Kinin cleaves high-molecular-weight kininogen (HMYVK) to bradvkinin, which mediates vasodilation and increased vascular permeability (simitar to histamine), as well as pain. C3 /\* xil | C3a Complement f. system system Plasminogen Prokallikrein Plasmin@_§» Fibrinolytic system Kaltikrehr Vasodilation 7 oN { Increased HMWK Bradyckinin. ——* permeability Pain ( a long with PGE2 ) Pathoma 46/777 12/30/12CARDINAL SIGNS OF INFLAMMATION # Redness (rubor) and warmth (calor): > Due to vasodilation, which results in increased blood flow > Occurs via relaxation of arteriolar smooth muscle; key mediators are histamine, prostaglandins, and bradvkinin. # Swelling (tumor): > Due to leakage of fluid from postcapillary venules into the interstitial space (exudate) > Key mediators are (1) histamine, which causes endothelial cell contraction and (2) tissue damage, resulting in endothelial cell disruption. # Pain (dolor): > Bradvkinin and PGE2 sensitize sensory nerve endings. # Fever: > Pyrogens (e.g. LPS from bacteria) cause macrophages to release IL-1 and TNF, which increase cyclooxygenase activity in perivascular cells of the hypothalamus. > Increased PGE2 raises temperature set point. Pathoma ATIT77 12/30/12NEUTROPHIL ARRIVAL AND FUNCTION Remember form this previous picture that neutrophil phase is phase 2 and it peaks at around 24 hrs Neutrophil phase Fluid_phase Macrophage phage 24hrs Step_1— Margination 1. Vasodilation slows blood flow in postcapillary venules. 2. Cells marginate from center of flow to the periphery. Step _2=Rolling 1. Selectins ( speed bumps ) are upregulaled on endothelial cells. i. P-seleclin release from Weibel Palade bodies is mediated by histamine. ii. E-selectin is induced by TNF and IL-1. 2. Selectins bind sialyl Lewis X on leukocytes. 3. Interaction results in rolling of leukocytes along vessel wall. Pathoma 48/77 12/30/12Step 3—Adhesion 1. Cellular adhesion molecules (CAMs such as ICAM and VCAM) are upregulated on endothelium by TNF and IL-1. 2. Integrins are upregulated on leukocytes by C5a and LTB4 3. Interaction between CAMs and integrins results in firm adhesion of leukocytes to the vessel wall. # Leukocyte adhesion deficiency is most commonly due to an autosomal recessive defect of integrins (CD18 suhunit). # Clinical features include delayed separation of the umbilical cord, increased circulating neutrophils (due to impaired adhesion of marginated pool of leukocytes, which represents 50% of total neutrophil count ), and recurrent bacterial infections that lack pus formation. Rolling Adhesion Sialyl Lewis X Intergins Selectins C5a, LTB4 E-Selectin by TNF, Ib=1 - CAM WP bodies TNF, IL-1 Selectins : Sialyl Lewis Pathoma 49/777 12/31/12Step 4—Transmioration and Chemotaxis: 1. Leukocytes transmigrate across the endothelium of postcapillary venules and move toward chemical attractants (chemotaxis) using PECAM-1. 2. Neutrophils are attracted by bacterial products,C5a, IL-8, and LTB4 and Kallikrein. Bacterial products plus CLIK Step 5—Phagocytosis: 1. Consumption of pathogens or necrotic tissue; phagocytosis is enhanced by opsonins (IgG and C3b). 2. Pseudopods extend from leukocytes to form phagosomes, which are internalized and merge with lysosomes to produce phagolysosomes. # Chediak-Higashi_syndrome is a protein trafficking defect (autosomal recessive) characterized by impaired phagolysosome formation. # Clinical features include: i. Increased risk of pyogenic infections ii. Neutropenia (due to intramedullary death of neutrophils). Remember, microtubules are necessary for cellular division. iii. Giant granules in leukocytes (due to fusion of granules arising from the Golgi apparatus) iv. Defective primary hemostasis (due to abnormal dense granules in platelets) v. Albinism vi. Peripheral neuropathy Pathoma 50/777 12/31/12Step 6—Destruction of phagocytosed material # O2-dependent killing is the most effective mechanism. # HOCI generated by oxidative burst in phagolysosomes destroys phagocytosed microbes. i. 02 is converted to 02', by NADPH oxidase (oxidative burst). ii. 02" is converted to H202 by superoxide dismutase (SOD). iii. H202 is converted to HOCI (bleach) by myeloperoxidase (MPO). # Chronic_granulomatous disease (CGD) is characterized by poor O.- dependent killing. i. Due to NADPH oxidase defect (X-linked or autosomal recessive) ii. Leads to recurrent infection and granuloma formation with catalase- positive organisms, particularly Staphylococcus aureus, Pseudpmonas cepacia, Serratia marcescens, Nocardia, and Aspergillus iii. Nitrobiue tetrazolium test is used to screen for CCD. Leukocytes are incubated with NBT dye, which turns blue if NADPH oxidase can convert 02 to O2', but remains colorless if NADPH oxidase is detective. # MPO deficiency results in defective conversion of H202 to HOCI. i. Increased risk for Candida infections; however, most patients are asymptomatic. ii. NBT is normal; respiratory burst (02 to H202 is intact ). Note: O2-independent killing is less effective than O2-dependent killing and occurs via enzymes present in leukocyte secondary granules (e.g. lysozyme in macrophages and major basic protein in eosinophils). See next page for charts ... Pathoma 51/777 12/31/12This pathway is knocked out in patients with CGD. However, a little pit of H2O2 If this reaction is is produced naturally by bacteria, which intact, NBT will the patient could use to produce bleach. In catalase 4ve bacteria, this is also NADPH oxidase turn blue. In CGD, converted to H20, making it harder for CGD the dye remains the patient to produce bleach (i.e. the pathway in the red box is also knocked out. | Glutathione I perioxidase | Catalase 7° OH Oo colorless [seme dismutase H202 ¢————- Bacterial metabolism IMyleoperoxidase ( MPO) MPO Defi. HOCcI Bleach Gotolase Positive Bugs: Staphylococcus aureus, Pseudomonas cepacia, Serratia marcescens, Nocardia, and Aspergillus PathomaStep 7—Resolution 4 Neutrophils undergo apoptosis and disappear within 24 hours after resolution of the inflammatory stimulus. Pathoma 53/777 12/81/12MACROPHAGES # Macrophages predominate after neutrophils and peak 2-3 days after inflammation begins. # Derived from monocytes in blood # Arrive in tissue via the margination, rolling, adhesion, and transmigration sequence # Ingest organisms via phagocytosis (augmented by opsonins) and destroy phagocytosed material using enzymes (e.g. lysozyme) in secondary granules (02-independent killing) # Manage the next step of the inflammatory process. # Outcomes include: 1. Resolution and healing—Anti-inflammatory cytokines (e.g. IL-10 and TGF- beta ) are produced by macrophages. 2. Continued acute inflammation—marked by persistent pus formation; IL-8 from macrophages recruits additional neutrophils. So acute inflammation is determined by duration, its determined by response. In other word, even if its 8 weeks to infection, its an acute inflammation as long as the patient is still coughing pus. 3. Abscess—acute inflammation surrounded by fibrosis; macrophages mediate fibrosis via fibrogenic growth factors and cytokines. 4. Chronic inflammation—Macrophages present antigen to activate CD4T helper T cells, which secrete cytokines that promote chronic inflammation. athor 5 12/31/12CHRONIC INFLAMMATION BASIC PRINCIPLES # Characterized by the presence of lymphocytes and plasma cells in tissue (Fig. 2. IB) # Delayed response, but more specific (adaptive immunity) than acute inflammation. # Stimuli include: (1) persistent infection (most common cause); (2) infection with viruses, mycobacteria, parasites, and fungi; (3) autoimmune disease; (4) foreign material; and (5) some cancers. Plasma cell with perinuclear clearing. Pathoma 55/777 4AN3.TLLYMPHOCYTES # Produced in bone marrow as progenitor T cells # Further develop in the thymus where the T-cell receptor (TCR) undergoes rearrangement and progenitor cells become CD4 helper T cells or CD8 cytotoxic T cells. #T cells use TCR complex (TCR and CD3) for antigen surveillance. # TCR complex recognizes antigen presented on MHC molecules. i. CD4+ T cells—MHC class IT ii. CD8+ T cells-MHC class I # Activation of T cells requires: (1) binding of antigen/MHC complex and (2) an additional 2nd signal. Pathoma 56/777 4AN3.CD4+ helper T-cell_activation 1. Extracellular antigen (e.g., foreign protein) is phagocytosed, processed, and presented on MHC class II, which is expressed by antigen presenting cells (APCs). 2. B7 on APC binds CD28 on CD4+ helper T cells providing 2nd activation signal. 3. Activated CD4+ helper T cells secrete cytokines that "help" inflammation and are divided into two subsets: i. TH1 subset secretes IL-2 (T cell growth factor and CD8+ T cell activator) and IFN-y (macrophage activator). ii. TH2 subset secretes IL=4 (facilitates B-cell class switching to IgG and_IgE), IL-5 (eosinophil chemotaxis and activation, maturation of B cells to plasma cells, and class switching to IgA), and IL-10 (inhibits TH1 phenotype). See the next page ... TH cell recognizing an antigen presented on MHC-II on an APC. cbs ‘ [c eptor APC. rT) @ (_. 87 } p28 Numoneic 28/7=4 Pathoma 57/777 4AN3.Th-4 Helps CD8 Gamma interferon: IL-2 Macrophage activator D8 growth Inhibits Th-2 IL-4 class switching to IgG, IgE. IL-10: inhibits Th-1 IL-5 eosinophil chemotaxis and activation maturation of B cells to plasma cells and class switching to IgA. Pathoma 58/777 1/13,CD8 cytotoxic T-cell activation: 1. Intracellular antigen (derived from proteins in the cytoplasm) is processed and presented on MHC class I, which is expressed by all nucleated cells and platelets. 2. IL-2 from CD4+THI cell provides 2nd activation signal. 3. Cytotoxic T cells are activated for killing. 4. Killing occurs via: i. Secretion of perforin and granzyme; perforin creates pores that allow granzyme to enter the target cell, activating apoptosis ( via caspases ). ii. Expression of FasL, which binds Fas on target cells, activating apoptosis Granzymes from CD8 get into target cell via holes created Intrinsic Extrinsic pathway by perforins. mitochondri (e.g. FasL ) al pathway PathomaB_LYMPHOCYTES. # Immature B cells are produced in the bone marrow and undergo immunoglobulin rearrangements to become naive B cells that express surface IgM and IgD. # B-cell activation occurs via: 1. Antigen binding by surface IgM or IgD; results in maturation to IgM- or IgD-secreting plasma cells 2. B-cell antigen presentation to CD4 helper T cells via MHC class II: i. CD40 receptor on B cell binds CD40L on helper T cell, providing 2nd activation signal. ii. Helper T cell then secretes IL-4 and IL-5 (mediate B-cell isotype switching, hypermutation, and maturation to plasma cells).GRANULOMATOUS INFLAMMATION # Subtype of chronic inflammation # Characterized by granuloma, which is a collection of epithelioid histiocytes (macrophages with abundant pink cytoplasm), usually surrounded by giant cells and a rim of lymphocytes. # Divided into noncaseating and caseating subtypes: 1. Noncaseating granulomas lack central necrosis (Fig. 2.24). Common etiologies include reaction to foreign material, sarcoidosis, beryllium exposure, Crohn disease, and cat scratch disease ( stellate granuloma in the neck ) 2. Caseating granulomas exhibit central necrosis and are characteristic of tuberculosis and fungal infections (Fig. 2.2B). > The defining feature of GRANULOMATOUS INFLAMMATION is. epithelioid histiocytes. Note: the histologic hallmark of ulcerative colitis is crypt abscesses, while that of Crohn is noncaseating granuloma. crypt abscesses, UC Pathoma 61/77 1/13,This is a granuloma because is contains aggregate of these histiocytes with pink cytoplasm. Additionally, it contains a rim of lymphocytes ( the green cycle ) and giant cells in the center ( the yellow circles ). Fig. 2.2 Granuloma. A. Noncaseating, B. Caseating. Pathoma 62/777 4AN3.Steps involved _in_ granuloma formation: 1. Macrophages process and present antigen via MHC class II to CD4+ helper T cells. 2. Interaction leads macrophages to secrete IL-12, inducing CD4+ helper T cells to differentiate into Th=1 subtype. 3. Th-1 cells secrete IFN-Gamma, which converts macrophages to epithelioid histiocytes and giant cells. Step 1: Macrophages process and present . . Macrophage antigen via MHC class II to CD4+ helper AO @ T cells. @ D4 Jaa ppb Step2 | ep @ 3) Th-1 IL-12 JES Step3 Epithelioid INF-gamma Pathoma 63/777 4AN3.PRIMARY IMMUNODEFICIENCY I_DIGE E SY! E # Developmental failure of the third and fourth pharyngeal pouches # Due to 22q11 microdeletion # Presents with T-cell deficiency ( lack of thymus ); hypocalcemia (lack of parathyroids); and abnormalities of heart, great vessels, and face. Pathoma 64/777 1/2113IL_SEVERE COMBINED IMMUNODEFICIENCY (SCID) # Defective cell-mediated and humoral immunity # Etiologies include: 1. Cytokine receptor defects—Cytokine signaling is necessary for proliferation and maturation of B and T cells. 2. Adenosine deaminase (ADA) deficiency—ADA is necessary to deaminate adenosine and deoxyadenosine for excretion as waste products; buildup of adenosine and deoxyadenosine is toxic to lymphocytes ( inhibits Ribonucleotide Reductase ). 3. MHC class II deficiency-MHC class II is necessary for CD4+ helper T celt-activation and cytokine production. # Characterized by susceptibility to fungal, viral, bacterial, and protozoal infections, including opportunistic infections and live vaccines # Treatment is sterile isolation ( bubble baby ) and stem cell transplantation. Pathoma 65/777 1/2/13ALLXCUNKED AGAMMAGLOBULINEMIA | # Complete lack of immunoglobulin due to disordered B-cell maturation # Naive B cells cannot mature to plasma cells. # Due to mutated Bruton tyrosine kinase; X-linked # Presents after 6 months of life with recurrent bacterial, enterovirus (e.g., polio and coxsackievirus), and Giardia lamblia infections; maternal antibodies present during the first fi months of life are protective. # Live vaccines (e.g., polio) must be avoided. Pathoma 66/777 4/2113,IV, COMMON _VARIABLE_IMMUNODEFICIENCY (CVID) # Low immunoglobulin due to B-cell or helper T-cell defects # Increased risk for bacterial, enterovirus, and Giardia lamblia infections, usually in late childhood # Increased risk for autoimmune disease and lymphoma.Valo DEFICIENCY # Low serum and mucosal IgA; most common immunoglobulin deficiency # Increased risk tor mucosal infection, especially viral; however, most patients are asymptomatic. Note: one of association of celiac disease is IgA. athoma 68 1/2/13VIL_LHYPER-lgM_ SYNDROME # Characterized by elevated IgM # Due to mutated CD4OL (on helper T cells) or CD40 receptor (on B cells). # Second signal cannot be delivered to helper T cells during B-cell activation. # Consequently, cytokines necessary for immunoglobulin class switching are not produced, # Low IgA, IgG, and IgE result in recurrent pyogenic infections (due to poor opsonization), especially at mucosal sites. Pathoma 69/777 4/2113,VIL WISKOTT-ALDRICH SYNDROME # Characterized by thrombocytopenia, eczema, and recurrent infections (defective humoral and cellular immunity) # Due to mutation in the WASP gene; X-linked Pathoma 70/77 1/2113VIII.COMPLEMENT DEFICIENCIES # C5-C9 deficiencies—increased risk for Neisseria infection (N. gonorrhoeae and N. meningitidis) # C1 inhibitor deficiency—results in hereditary angioedema, which is characterized by edema of the skin (especially periorbital, Fig. 2.3) and mucosal surfaces. Fig. 2.3 Periorbital Edema Pathoma 71/777 4/2113,AUTOIMMUNE DISORDERS BASIC PRINCIPLES # Characterized by immune-mediated damage of tissues # 1% prevalence in the US # Involves loss of self-tolerance # Self-reactive lymphocytes are regularly generated but undergo apoptosis (negative selection) in the thymus (T cells) or bone marrow (B cells) or become anergic (due to recognition of antigen in peripheral lymphoid tissues with no 2nd signal). # More common in women; classically affects women of childbearing age # Etiology is likely an environmental trigger in genetically susceptible individuals (increased incidence in twins and associated with certain HLA subtypes). Pathoma 721777 4/3/13SYSTEMIC LUPUS ERYTHEMATOSUS # Systemic autoimmune disease # Antibodies against the host damage multiple tissues via type II (cytotoxic) and type III (antigen-antibody complex) hypersensitivity. # More common in women, especially African American females # Clinical features include: 1. Fever and weight loss . Malar ‘butterfly’ rash (Fig, 2.4), especially upon exposure to sunlight . Arthritis . Pleuritis and pericarditis (involvement of serosal surfaces) . CNS psychosis . Renal damage—Diffuse proliferative glomerulonephritis is the most common injury, though other patterns of injury also occur. 7. Endocarditis, myocarditis, or pericarditis (can affect any layer of the heart). Libman-Sacks endocarditis is a classic finding and is characterized by small, sterile deposits on both sides of the mitral valve. 8. Anemia, thrombocytopenia, or leukopenia (due to autoantibodies against nuPpwn cell surface proteins) 9. Renal failure and infection are common causes of death See eee Libman-Sacks Other endocarditis: Vegitations on one side of the valve Vegitations of both sides of the valve Pathoma 73/777 4/3/13Fig. 2.4: Malar ‘butterfly’ rash Pathoma 741777 4/3/13# Characterized by antinudear antibody (ANA; sensitive, but not specific) and anti dsDNA antibodies (highly specific). # Antihistone antibody is characteristic of drug-induced SLE. > Hydralazine, procainamide, and isoniazid are common causes, > Removal of drug usually results in remission. # Antiphospholipid antibody syndrome is associated with SLE (30% of cases). > Characterized by autoantibody against proteins bound to phospholipids. > Anlicardiolipin and lupus anticoagulant are the most common antibodies. They lead to false-positive syphilis test and falsely-elevated PTT lab studies, respectively. > Results in arterial and venous thrombosis including deep venous thrombosis, hepatic vein thrombosis, placental thrombosis (recurrent pregnancy loss), and stroke. > Requires lifelong anticoagulation. Pathoma 75/777 4/3/13SJOGREN SYNDROME # Autoimmune destruction of lacrimal and salivary glands. # Lymphocyte-mediated damage (type IV hypersensitivity) with fibrosis. # Classically presents as dry eyes (keratoconjunctivitis), dry mouth (xerostomia), and recurrent dental carries in an older woman (50-60 years)—"Can't chew_a cracker, dirt in my eyes". # Characterized by ANA and anti-ribonucleoprotein antibodies (anti-SS- A/Ro and anti-SS-B/La). # Often associated with other autoimmune diseases, especially rheumatoid arthritis. # Increased risk for B-cell (marginal zone) lymphoma, which presents as unilateral enlargement of the parotid gland late in disease course. Pathoma 76/777 4/3/13SCLERODERMA, % Autoimmune tissue damage with activation of fibroblasts and deposition of collagen (fibrosis). # Divided into diffuse and localized Lypes. 1. Diffuse type exhibits skin and early visceral involvement. > Almost any organ can be involved; esophagus is commonly affected, resulting in disordered motility (dysphagia for solids and liquids). > Characterized by ANA and anti-DNA topoisomerase I (Scl-70) antibody. 2. Localized type exhibits local skin and late viscera! involvement. 1. Prototype is CREST syndrome: Calcinosis/anti-Centroniere antibodies, Raynaud phenomenon. Esophageal dysmotility, Sclerodactyly, and Telangiectasias of the skin. Pathoma 771777 4/3/13MIXED CONNECTIVE TISSUE DISEASE # Autoimmune-mediated tissue damage with mixed features of SLE, systemic sclerosis, and polymyositis # Characterized by serum antibodies against U1 ribonucleoprotein Pathoma 78/777 4/3/13