j0305257 General pathology histopath. practice General pathology II. Circulation disorders Inflammation I j0305257 Circulation disorders j0305257 Circulation disorders ûLocal ûSystemic ûShock j0305257 Circulation disorders LOCAL ûThrombosis ûEmbolism ûHaemorrhage ûOedema ûHyperemia ûIschemia ûInfarction û j0305257 Thrombosis ûmain cause of local circulation disorders û û »intravital formation of a pathological blood clot (thrombus) within vascular system, due to platelets aggregation + transformation of fibrinogen into fibrin ûpossible obstruction of the blood flow through the circulatory system« ûCirculation disorders û ûLocal ðthrombosis ðembolism ðhemorrhage ðoedema ûSystemic ðcardial ðextracardial j0305257 Thrombosis û3 basic pathogenetic mechanisms: ðendothelial cell injury • the most importatnt (trauma, AS, immune complexes, viruses, bacteria, inflammations, toxins) – FXII activation ðblood flow disturbance • stagnation past the point of injury, venous stasis in leg veins ðblood constituents change, coagulopathy –congenital: e.g. genetic mutation FV (Leiden) –acquired: hormonal contraception, tumor dissemination, DIC, hyperlipidemia, smoking ûCirculation disorders û ûLocal ðthrombosis ðembolism ðhemorrhage ðoedema ûSystemic ðcardial ðextracardial j0305257 Pathogenetic mechanism THROMBOSIS Abnormal blood flow Coagulopathy Endothelial cell injury j0305257 Thrombosis ûGROSS: ðmural thrombus (cardial cavities, arteries) ðobturating (veins) ûCirculation disorders û ûLocal ðthrombosis ðembolism ðhemorrhage ðoedema ûSystemic ðcardial ðextracardial j0305257 Thrombosis ûMICRO: ðred • erythrocytes, in leg veins - stasis ðwhite • thrombocytes, fibrin – cardial valves – turbulent flow ðmixed • combination of both (stratified thrombus, e.g. cardial and aortic aneurysm) ðfibrin thrombus • microscopic size, in small calibre arteries and capillaries, fibrin + platelets, CNS, kidney, lungs by shock, infections ûCirculation disorders û ûLocal ðthrombosis ðembolism ðhemorrhage ðoedema ûSystemic ðcardial ðextracardial j0305257 Thrombosis ûFATE OF THROMBI ðvessel wall hypoxia » platelet grow factors » reparative fibroproductive inflammation» thrombus fixation to the vessel wall » fibroblasts » thrombus retraction » recanalization + ORGANIZATION ðgrowth of the thrombus ðbreaking off of the thrombus ð embolism ðfibrinolysis ûCirculation disorders û ûLocal ðthrombosis ðembolism ðhemorrhage ðoedema ûSystemic ðcardial ðextracardial j0305257 Source: Robbins basic pathology j0305257 Coronary artery thrombosis j0305257 organizace trombu 20x2 Organized mixed thrombus 1 arterial wall 2 structures of thrombus 1 2 j0305257 hemorrhoidy 400x Mixed thrombus - organization (detail 600x) Æ fibroblasts j0305257 Microcirculation thrombosis DIC ûAcquired coagulopathy, mortality 40% û ûEtiopathogenesis: ð release of tissue factor (a part of the cell membranes) into blood or endothelial damage ð ûCauses: ðObstetric complications: • intravenous embolism of amniotic fluid • placental abruption ðInfections • menigococcal, stafylococcal sepsis, acute pancreatitis ðShock ðTissue trauma (burns, major surgery) ð j0305257 DIC û1st phase: hypercoagulation ðMorphology: • multiple fibrin thrombi in the microcirculation • brain, lungs, kidney, heart, liver – ischemia, multi-organ failure • microangiopathic haemolytic anaemia ð û2nd phase: hypocoagulation: ðconsumption of coagulation factors/fibrin degradation products ðextreme hypocoagulability, fatal bleeding (surgical wounds, mucous membranes) j0305257 Fibrin thrombus hyalinní trombus Copy j0305257 Embolism û = a mass of movable material in the vascular system able to become lodged within a vessel and block its lumen. û ûthrombembolism: ð most commonl ð from veins (deep v. of legs) into pulmonary arteries ð from heart/aorta into systemic arteries ð ûparadoxical embolism: ðfrom veins into arteries via foramen ovale apertum ûCirculation disorders û ûLocal ðthrombosis ðembolism ðhemorrhage ðoedema ûSystemic ðcardial ðextracardial j0305257 Embolism û Localization: ðvenous embolism ðarterial embolism ðparadoxical embolism ðportal embolism ûCirculation disorders û ûLocal ðthrombosis ðembolism ðhemorrhage ðoedema ûSystemic ðcardial ðextracardial j0305257 Embolism ûClassification: ðthrombotic ðair ðfat ðcellular (tumor dissemination) ðsubcelullar (DNA) ðamniotic fluid ûCirculation disorders û ûLocal ðthrombosis ðembolism ðhemorrhage ðoedema ûSystemic ðcardial ðextracardial j0305257 trombus 20x Partially organized mixed blood clot 1 1 vascular wall 2 structures of the thrombus Ævascular lumen 2 j0305257 Haemorrhage û = loss of blood from the circulatory system, accumulation of blood in the intersticium – HAEMATOMA û ûlocalization: ðexternal x internal ûorigin: ðarterial, venous, capillary ûappearance: ðpetechiae, ecchymosis (subcutaneous), apoplexy (massive) ûCirculation disorders û ûLocal ðthrombosis ðembolism ðhemorrhage ðoedema ûSystemic ðcardial ðextracardial j0305257 Oedema ûAbnormal accumulation of fluid in the intersticium. û ûTypes: ðlocalized ðgeneralized ûCirculation disorders û ûLocal ðthrombosis ðembolism ðhemorrhage ðoedema ûSystemic ðcardial ðextracardial j0305257 Oedema ûCauses: ðvenous: ↑ intravenous pressure (e.g. chronic cardiac failure) ðinflammatory: increase of endothelial permeability ðhypoalbuminaemic: reduced oncotiic pressure ðlymphostatic oedema ûCirculation disorders û ûLocal ðthrombosis ðembolism ðhemorrhage ðoedema ûSystemic ðcardial ðextracardial j0305257 Pulmonary oedema edem plic 100x 1 oedematous fluid 2 septal widening 3 capillary dilatation 1 1 2 3 j0305257 Circulation disorders SYSTEMIC ûCAUSES: ûHEART ð(ischemic heart disease, myocarditis, cardiomyopathy, pericarditis, valvular heart disease, endocarditis) û ûVESSELS ð(systemic hypertension, pulmonary hypertension) û ûBLOOD DISORDERS ð(polycytemia vera, anemia) ûCirculation disorders û ûLocal ðthrombosis ðembolism ðhemorrhage ðoedema ûSystemic ðcardial ðextracardial j0305257 Circulation disorders SYSTEMIC ûAll causes subsequently manifest as HEART FAILURE ûLeft ventricle failure ûRight ventricle failure ûCongestive heart failure – both ventricles û ð„forward“ failure – usually low cardiac output ð„backward“ failure – venous congestion ð û cardiogenic shock ûCirculation disorders û ûLocal ðthrombosis ðembolism ðhemorrhage ðoedema ûSystemic ðcardial ðextracardial j0305257 Circulation disorders MORPHOLOGICAL ASPECTS ûHEART: ðDilatation (without hypertrophy) • acute cardiac failure (pulmonary embolism) • ðHypertrophy • concentric x ecccentric (+ dilatation) • Starling`s principle, depletion of adaptation mechanisms ûCirculation disorders û ûLocal ðthrombosis ðembolism ðhemorrhage ðoedema ûSystemic ðcardial ðextracardial j0305257 Circulation disorders MORPHOLOGICAL ASPECTS ûEXTRACARDIAL ðvenous congestion +/- cyanosis ðoedema (pulmonary, systemic) ðinduration ð ûCirculation disorders û ûLocal ðthrombosis ðembolism ðhemorrhage ðoedema ûSystemic ðcardial ðextracardial j0305257 Heart failura ûLV x RV ûACUTE x CHRONIC failure j0305257 Heart failure ûLV failure: ðacute - morphology: • congestion in pulmonary circulation • pulmonary oedema • ðchronic - morphology: • chronic pulmonary venous congestion – „brown“ lung induration (siderophages), later signs of RV failure j0305257 Pulmonary oedema ûLeft-sided heart failure ð(LV insufficiency, mitral stenosis) ð ûcongestion in pulmonary veins, capillaries j0305257 Pulmonary oedema ûGROSS: ðenlarged, heavy lung of tougher consistency, ðfluid running out from tissue and bronchi ðin chronic venous congestion: superimposed oedema in the setting of tougher, rusty tissue j0305257 Pulmonary oedema ûMICRO: ðdilatated septal capillaries filled with blood ðwidened septa ðintraalveollar homogennous eosinophilic material (oedematic fluid) ðlong-standing: extravasation and breakdown of red blood cells (haemosiderin, siderophages) j0305257 Pulmonary oedema edem plic 100x 1 oedematic fluid 2 widening of septa 3 capillary dilatation 1 1 2 3 j0305257 chron venostáza plíce Chronic pulmonary venous congestion 1 1 1 oedematic fluid è hyperemic septa Æ siderophages j0305257 chron venostáza plíce- detail Chronic pulmonary venous congestion (detail) 1 oedematic fluid è hyperemic septa Æ siderophages 1 j0305257 Heart failure û RV insufficiency: ðacute - morphology: • acute cor pulmonale (massive thrombembolism) • acute congestion in systemic circulation (splanchnic region) → congestive necrosis ðchronic - morphology: • chronic hepatic venous congestion, congestion in portal region (spleen, mucous membranes of GIT), kidneys • congestive skin/soft tissue changes – trophic, • oedemas • venous congestion in brain j0305257 Hepatic venous congestion ûGROSS: ðenlarged, heavy liver ðdark – reddish brown color ðcardiac fibrosis (induration) ðcombination with chronic hypoxemic steatosis – nutmeg liver j0305257 Hepatic venous congestion (“nutmeg” liver) j0305257 Hepatic venous congestion ûMICRO: ðcentral veins and sinusoidal dilatation • ðcentrolobular hepatocytic atrophy, necrosis • ð„lines“ of congestion • j0305257 Hepatic venous congestion městnání v játrech 20x 1 2 2 1 1 1 Portal spaces 2 Congestive lines (severe congestion with hepatocyte necrosis) --- pseudolobule: confluent remnants of 3 lobules, centrally portal space j0305257 Hepatic venous congestion (“nutmeg” liver), detail městnání v játrech2 40x 3 1 5 4 2 1 Portal space-dilatation of portal vein branch 2 Pseudolobule 3 Congestion lines 4 Bile duct 5 Hepatic artery branch j0305257 Hepatic venous congestion (“nutmeg” liver), portal area detail městnání v játrech 100x 3 2 1 1 Congestive liver cell necrosis, reticulum peristence 2 Regressive changes of hepatocytes (steatosis) 3 Residual trabeculae j0305257 Shock û »Life-threatening medical condition that occurs due to inadequate substrate for aerobic cellular respiration. In the early stages this is generally an inadequate tissue level of oxygen (low organ perfusion).« û ûLethal without adeqaute medical therapy. j0305257 Shock ûFactors: ðInsufficient circulating volume (hypovolaemic) • ↓ periferal vascular resistance • ↑ vascular wall permeability • blood loss ðLow cardiac output (cardiogenic) • Acute heart failure – (acute myocardial infarction, massive pulmonary embolism, cardiac tamponade, tension pneumothorax) ðInfection (bacterial toxaemia) j0305257 Shock - MORPHOLOGY ûMultiple organ failure (organ ischemia) ðbrain ðheart ðkidney – acute tubular necrosis (ATN) ðlungs – diffuse alveolar damage/ acute respiratory distress syndrome (DAD/ARDS) ðadrenal glands, gastrointestinal tract) j0305257 ARDS DAD/ARDS 1 oedematic fluid 2 hyperemic vessels Æ hyaline membranes 1 1 2 j0305257 ARDS-detail DAD/ARDS (detail) 1 oedematic fluid Æ hyaline membranes j0305257 Inflammation j0305257 Inflammation û = PROTECTIVE RESPONSE intended to eliminate harmful agents, accompanied with alterative, exudative, proliferative components and immune response. • ûtypes: ðacute inflammation ðchronic inflammation ð ðnonspecific inflammation ðgranulomatous inflammation (specific) j0305257 Inflammation ûMacroscopic appearances: ðrubor (redness) ðcalor (heat) ðdolor (pain) ðtumor (swelling) ðfunctio laesa (loss of function) j0305257 Inflammation ûMicroscopic appearances: ðALTERATION: • regressive changes, necrosis ðEXUDATION: • vascular leakage of protein-rich fluid and blood cells • exudate X transudate j0305257 Inflammation ðPROLIFERATION: • proliferation of fibroblasts and capillaries • formation of granulation and fibrous tissue û ðIMMUNE RESPONSE: • antigen presentation • T and B-lymphocytes reaction • production of antibodies by plasma cells • memory cells j0305257 NONSPECIFIC inflammation ûClassification: ðalterative: • alteration of tissue • viral hepatitis, prion diseases [Creutzfeld-Jacob, BSE], diphteric myocarditis ðexudative: • most common, exudation prevails • superficial and deep • serous, fibrinous, nonpurulent, purulent, gangrenous ðproliferative: • formation of fibrous tissue j0305257 Alterative inflammation (liver necrosis) copy j0305257 Alterative inflammation (massive necrosis) 1 Portal areas 2 Necrotic areas  Residual parenchym 1 1 1 2 2 2 j0305257 Alterative inflammation (massive necrosis - detail) 1 Necrotic cell 2 Regressively changed hepatocytes 3 Sinusoids 4 Kupffer cells 1 2 3 2 3 4 j0305257 Exudative inflammation ûtopography of inflammatory changes: ðsuperficial (mucous membrane, serous membranes, skin) ðdeep (interstitium) û ûexudate components: ðserous ðfibrinous ðnonpurulent ðpurulent ðgangrenous j0305257 Exudative inflammation ûserous: ðwatery exudate • few proteins (fibrinogen) • in mucous membranes – catarrhal (mucus) ðheals by inhibition of exudation ðexamples: • superficial: catarrhal appendicitis • deep (interstitial): urticaria (hives) j0305257 Acute catarrhal appendicitis (superficial serous inflammation) 1 Lumen of the appendix 2 Mucus-purulent exudate 3 Mucosal crypt 4 Lymph follicle 2 1 3 4 j0305257 Acute catarrhal appendicitis (superficial serous inflammation) 1 Lumen of the appendix 2 Mucus-purulent exudate 3 Columnar epithelium 4 Capillary 5 Neutrophils going through the epithelium into the exudate 2 1 3 4 5 5 j0305257 Polypous chronic rhinitis (superficial serous inflammation) 1 Epithelium with squamous metaplasia 2 Thickened basal membrane 3 Oedematous stroma with eosinophilic and plasma cell infiltration, dilatated lymphatic vessels 2 1 3 j0305257 Polypous chronic rhinitis (superficial serous inflammation) 1 Ciliated epithelium 2 Oedematous stroma with inflammatory infiltrate 2 1 j0305257 polyp4002 Polypous chronic rhinitis (superficial serous inflammation) 1 Congested capillary 2 Eosinophils 3 Oedematous stroma 2 1 3 j0305257 Exudative inflammation ûfibrinous: ðcontent of fibrinogen - fibrin • gross: yellow-greyish plaques • micro: eosinophilic fine fibers ðhealing is more complicated (productive inflammation) ðexamples: • superficial inflammation of serous membranes: –fibrinous pericarditis (upon uremia) = cor villosum, hirsutum • superficial infl. of mucous membranes (PSEUDOMEMBRANES): –plaque-like inflammations • deep: –rheumatic fever j0305257 Fibrinous pericarditis – cor villosum (superficial fibrinous inflammation of serous membranes) copy j0305257 Fibrinous pericarditis (superficial fibrinous inflammation of serous membranes) 1 Epicardium 2 Fibrin 3 Myocardium 1 3 2 j0305257 Fibrinous pericarditis (superficial fibrinous inflammation of serous membranes) 1 Epicardium 2 Mass of fibrin 1 2 2 j0305257 Exudative fibrinous mucosal inflammation ûClassification due to mucosal damage: • ûcroupous ðlittle alteration, plaque is loose on the surface ð (croupous pneumonia) ð ûdiphteric ðdeeper mucosal necrosis, after the pseudomembrane is peeled off » ð ulcus ð (pseudomembranous colitis) ð ûescharotic ðextensive deep necrosis ð (necrotising tracheitis in flu) j0305257 Lobar pneumonia (superficial fibrinous mucosal inflammation)  Interalveolar walls 1 Alveolar spaces fulfilled with fibrinous exudate 1 1 1 j0305257 Lobar pneumonia (superficial fibrinous mucosal inflammation)  Interalveolar walls 1 Alveolar spaces fulfilled with fibrinous exudate 1 1 1 j0305257 Lobar pneumonia - detail (superficial fibrinous mucosal inflammation)  Interalveolar wall 1Croupous (fibrinous) exudate 2Fibrinous exudate with fibroblasts (beginnig of organization) 2 1 j0305257 Pseudomembranous colitis (superficial fibrinous mucosal inflammation)  Fibrin 1Mucosal necrosis with inflammatory infiltrate 2Bacteria 3Mucus 2 1 3 1 j0305257 Pseudomembranous colitis (superficial fibrinous mucosal inflammation)  Fibrin 1Mucosal necrosis with inflammatory infiltrate 2Normal mucous membrane 1 2 1 j0305257 Rheumatic fever ûRelapsing inflammatory disease esp. in children (1-5 weeks after streptococcal A infection) ûforming of antibodies cross-reactive with antigens in the heart, joints… ûdg. based on anamnesis and 2 of 5 main (Jones) criteria: ð erythema marginatum, chorea, carditis, subcutaneous nodules, migratory polyarthritis of the large joints j0305257 Rheumatic fever ûGROSS: ðvegetations - (friable, bulky, wart-like outgrowths) on the edges of the heart valves (mainly aortic and mitral) ðafter years leaflet thickening and commissural fusion ðthickening, shortening and fusion of the chordae tendinae û ûMICRO: ðAschoff bodies – inflammatory lesion within the heart ðfibrinoid necrosis of fibrous tissue ðcentral zone of degenerating with surrounding chronic inflammatory infiltrate (lymphocytes, plasma cells, histiocytes, activated macrophages called Antischkow cells) j0305257 Exudative inflammation ûpurulent: ðPRODUCTION OF PUS: ð neutrophil-rich exudate ðGROSS: ð superficial pus, pus accumulation (abscess) ðheals by inhibition of exudation and/or by proliferative inflammation ðexamples: • superficial inflammation of meninges: –purulent meningitis • superficial mucosal inflammation: –catarrhal-purulent bronchopneumonia • deep (interstitial): –phlegmona (e.g. phlegmonous appendicitis) –abscess j0305257 Purulent leptomeningitis ûAetiology: ûEscherichia coli and  streptococci ðin newborns ûHaemophilus influenzae ð in infants and children ûNeisseria meningitis ð in adolescents and young adults ûStreptococcus pneumoniae and Listeria monocytogenes ð in old people j0305257 Purulent leptomeningitis ûSYMPTOMS: ûmeningeal irritation: ðheadache, photophobia, irritation, nuchal rigidity, consciousness failures ð ûlumbar puncture: ðopaque or purulent liquor with higher CSF pressure j0305257 Purulent leptomeningitis MORPHOLOGY ûGROSS: ðcongested and leaked pia mater with pus ðpurulent-opaque liquor ð ûMICRO: ðmeninges infiltrated with neutrophils ðvessels congested with blood, thrombosis » hemorrhagic brain infarction ð ûCOMPLICATIONS: ð possible fibrosis of meninges resulting in hydrocephalus; ðepilepsy j0305257 Purulent leptomeningitis (superficial purulent inflammation) copy j0305257 Purulent leptomeningitis (superficial purulent inflammation) 2 2 1 1 1 Brain tissue 2 Neutrophils Pia mater j0305257 Purulent leptomeningitis (superficial purulent inflammation - detail) 1 Brain cortex 2 Pia mater with purulent infiltrate 3 Neutrophils  Arteriole in pia mater 1 2 3 j0305257 Bronchopneumonia (Superficial purulent mucosal inflammation) ûGROSS: ðvarious stages of inflammation in the lung at the same time û ûMICRO: ðalveolar spaces fulfilled with neutrophils ðsmall amount of fibrin in the exudate compared to lobar pneumonia j0305257 Bronchopneumonia copy j0305257 Purulent bronchopneumonia (superficial purulent mucosal inflammation) 1 Alveolar spaces fulfilled with neutrophils  Congested vessels 1 1 1 j0305257 Purulent bronchopneumonia - detail (superficial purulent mucosal inflammation) BP 200x 1 Alveoli Æ Neutrophils è Macrophages 1 1 j0305257 Abscessing bronchopneumonia (abscessing purulent inflammation) plíce povrch abscesy plíce řez abscesy j0305257 Abscessing bronchopneumonia (abscessing purulent inflammation) plíce 20x Æ Residual alveolar walls 2 Diffuse purulent exudate 3 Vessel 3 3 2 2 j0305257 plíce 40x Abscessing bronchopneumonia (abscessing purulent inflammation) Æ Destruction of alveolar walls 1 Acute abscess (dense mass of neutrophils) 1 1 j0305257 Phlegmonous appendicitis (interstitial purulent inflammation) ûmost common cause of „acute abdomen“, surgical intervention necessary. û ûCLINICALLY: ð in any age, commonly children – young adults. ð right mesogastric or hypogastric pain; nausea, vomiting, rectal raised temperature, sensitive abdomen, leukocytosis. j0305257 Phlegmonous appendicitis ûMORPHOLOGY: ðGROSS: • hyperemic serosa, hemorrhage, pus. ðMICRO: • diffuse interstitial neutrophilic infiltration (phlegmona), purulent periappendicitis. • ûCOMPLICATIONS: ðperforation, purulent peritonitis, pyelophlebitis, portal thrombosis, pyemia, liver abscessi, sepsis. j0305257 Appendix - normal apendix norma j0305257 Phlegmonous appendicitis (interstitial purulent inflammation) apendix zánět copy j0305257 Phlegmonous appendicitis (interstitial purulent inflammation) HE2 20x 1 Luminal purulent exudate 2 Mucous membrane 3 Muscularis propria 4 Subserosa 4 2 3 1 j0305257 Phlegmonous appendicitis (interstitial purulent inflammation) HE 100x 1 Luminal purulent exudate 2 Mucosa with diffuse neutrophilic infiltration – absence of epithelium 3 Muscularis propria 1 2 3 j0305257 Acute pyelonephritis ûCommon purulent renal inflammation, bacterial infection by Escherichia coli, Proteus, Klebsiella, Enterobacter ûAscending infection by urine reflux in urinary tract inflammation ûDescending (haematogenous) infection in septicaemia, rare j0305257 Acute pyelonephritis ûFacilitated by DM, gout, all causes of obstructive uropathy (e.g. nephrolithiasis, tumors, urinary tract anomalies incl. vesicoureteric and intrarenal reflux) û ûInstrumental interventions (cathetrization, cystoscopy) û ûGROSS: ðenlarged kidney, cortical and medullary abscessses ð ûMICRO: ðpurulent neutrophilic exudate in tubules and interstitium, oedema j0305257 Acute pyelonephritis schemapyelonefritidy j0305257 Acute pyelonephritis with nephrolithiasis pyelo j0305257 pyelonefritis 40x Purulent pyelonephritis (interstitial purulent inflammation) 1 Interstitial purulent exudate è Glomeruli Æ Tubular neutrophilic infiltration 1 1 j0305257 pyelonefritis 200x Purulent pyelonephritis (interstitial purulent inflammation) 1 Interstitial neutrophilic infiltration Æ Tubulus filled with neutrophils 1 1 j0305257 Exudative inflammation ûgangrenous: ðnecrosis modified with putrid bacteria ðexamples: • gangrenous cholecystitis j0305257 gangrena zlucniku 20x Gangrenous cholecystitis (gangrenous inflammation) 1 Necrosis 2 Bacterial contamination 3 Inflammatory infiltration Æ Fibrin 1 2 2 3 j0305257 Exudative inflammation ûnon-purulent: ðexudate made by chronic inflammatory cells (lymphocytes, plasma cells = mononuclear inflammatory infiltration) ð ðexamples: • interstitial pneumonia • Hashimoto`s lymphocytic thyreoiditis j0305257 Primary (atypical) interstitial pneumonia û etiology: ð viral (influenza A, B; RSV, adenoviruses, rhinoviruses, HSV, CMV) ð small bacteria (Mycoplasma pneumoniae) ð fungi (Pneumocystis carinii). û symptoms: ð fever, dyspnoea, dry cough, auscultation may be normal (empty alveoli), x massive changes on X-ray û possible in normal hosts, more common in immunosuppressed j0305257 Primary (atypical) interstitial pneumonia û GROSS: ð focal or diffuse regions of hyperaemia, in fulminant cases with consolidation (ARDS – adult respiratory distress syndrome). û MICRO: ð interstitial pneumonitis - oedematous septa with mononuclear infiltrate. ð hyaline membranes (ARDS) ð common secondary bacterial infection j0305257 Interstitial pneumocystic pneumonia (non-purulent inflammation) HE 100x 1 Alveolar septa filled with mononuclear infiltration Æ Alveolar content (parasite shells) 1 1 j0305257 HE400x Interstitial pneumocystic pneumonia - detail (non-purulent inflammation) 1Alveolar content (parasite shells) Æ Capillary in septum surrounded with lymphocytes and plasma cells 1 j0305257 Hashimoto thyroiditis û autoimmune û antibodies against various th. antigenes û loss of th. follicular cells û lymphocytic infiltration û neoformation of lymphoid follicles û risk of other autoimmune diseases, thyroid tumors j0305257 Chronic thyreoiditis chrthyr-ma j0305257 Hashimoto`s lymphocytic thyreoiditis (non-purulent inflammation) Hashimoto 100x 01 1Folicles 2Germinative centre Æ Lymphocytes 1 1 2 2 j0305257 Hashimoto`s lymphocytic thyreoiditis – detail (non-purulent inflammation) Hashimoto 200x 1Folicles 2Lymphocytes Æ Atypical elements 1 1 2 2