Define endocarditis
Why rheumatic heart and valve replacement patients are more susceptible to IE?
What is seen in ECHO
Common organisms
Criteria for IE
Investigations
RFs
Complications
Inflammation of the endocardial surfaces of the heart including heart valves which is caused by certain microorganisms.
Blood usually flows smoothly over valves, when these valves are damaged (as in RH) or in valve replacement. there will be an increased chance for bacterial colonization on damaged tissue
ECHO
1) Valvular regurgitation: A regurgitant jet >1 cm in length and peak velocity >2.5 m/s
2) Leaflet: Prolapse, Coaptation failure, Thickening (>4 mm), Reduced mobility, Nodules
3) Annular dilatation
4) Chordal elongation/rupture
5) Increased echogenicity of subvalvular apparatus
6) Pericardial effusion
7) Ventricular dilatation and dysfunctio
- staph aureus
- Viridans Strep or Staph edimeridis
- Coagulase negative staph.
- Enterococci
HACEK - Eikenella corrodens, and Kingella - 2 Major Criteria and 0 Minor Criteria * 1 Major Criteria and 3 Minor Criteria * 0 Major Criteria and 5 Minor Criteria
Ix
ESR CRP Blood cultures
Aetiology of aortic stenosis
Symptoms of AS
Signs of AS
define aortic sclerosis
Mx of AS
Define thrombus
Calcification
Biscupid valve
Rheumatic valvular disease
SLE
Dyspnoea/syncope/angina
ejection systolic murmur
quiet S2
LVH
AF
signs of IE/anaemia
slow rising pusle
narrow pusle pressure
sclerosis - calcific aortic valve without a significant gradient
Mx
valve replacement
transcatheter aortic valve replacement
balloon valvuloplasty
Thrombus is defined as solid material formed from the constituents of blood in flowing blood
Define pathogenesis of calcification
If metallic valve replacement was done and the patient developed IE, why the valve should be removed?
Lipid accumulation
Inflammation
Calcification
septic focus and dehiscence
Define rheumatic fever
Pathophysiology of RHD
Gross findings of RF
Microscopic findings RF
If we found microscopic branching hyphae on a
removed metallic valve, what’s the cause?
Group A haemolytic streptococci due to type 2 hypersensitivity reaction
Acute rheumatic fever results from host immune responses to group A streptococcal antigens that cross-react
with host proteins. In particular, antibodies and CD4+ T cells directed against streptococcal M proteins can also
in some cases recognize cardiac self-antigens
Recurrent inflammation, progressive fibrosis, narrowing and stiffening of the valve leaflets with commissural
fusion, retraction of the leaflet edges, valve thickening, calcification leading to stenosis.
Findings: Chronic phase: Commissural fibrosis, valve thickening, and calcification + shortened and fused chordae tendinea (fish mouth shape)
Microscopic findings: Aschoff bodies, a form of granulomatous inflammation which consists of a central zone of degenerating ECM infiltrated by lymphocytes, plasma cells and Anitschkow cells
Candida * Aspergillus * Microsporum * Trichophyton * Epidermophyton
Risk faactors for IE
Complications
Mx
Acquired valvular heart disease with stenosis or
regurgitation
* Valve replacement
* Structural congenital heart disease, including
surgically corrected, but excluding isolated ASD,
fully repaired VSD/PDA
* Previous IE
* HOCM (hypertrophic obstructive
cardiomyopathy)
* Devices (Implantable cardioverter-defibrillators)
Cyanotic congenital heart defects * Colorectal cancer (Streptococcus bovis) * UTI (enterococci) * IVDA * RHD * HIV * Malignancy * DM * Alcohol * Tooth extractions
Complications
AMI * Pericarditis * Arrhythmia * Valvular insufficiency * CCF (congestive cardiac failure) * Sinus of Valsalva (aneurysm of the aortic sinus) * Aneurysm * Intra-cardiac abscess * Arterial embol
IV abx vancomycin and ceftriaxone
Restrictions:
- Valves do not have specific blood supply so antibiotics cannot reach * Organisms lie inside the vegetations * Bacteria form a biofilm (glycocalyx covering) that shields them from antibiotics
if above dont work - valve replacement/heart transplant - HLA ANTIGEN
How to prevent graft rejection
side effects of steroids long term
tacrolimus
mycophenolate
steroids
Opportunistic bacterial and viral infections such as EBV, CMV —> leukemia, lymphoma
* Cushingoid features: obesity, muscle weakness, hirsutism, striae
* Cardiovascular: fluid retention, hypertension
* Endocrine: DM
* Musculoskeletal: osteoporosis, AVN, proximal myopathy
GCA - which part of vessel is affected
Pathologic
Blood test
Diagnostic test
Complication
Management
Tunica medium
lnvolved arterial segments develop intimal thickening (with occasional thromboses) that reduces the luminal
diameter. * Classic lesions exhibit medial granulomatous inflammation centered on the internal elastic lamina that produce
elastic lamina fragmentation. * There is an infiltrate of T cells (CD4+ > CD8+) and macrophages.
ESR
Temporal biopsy - tunica media should be on high steroids
Blindness- ophthalmic artery end artery
Treatment? Corticosteroids. Start prednisolone 60mg/d PO immediately or IV methylprednisolone if evolving visual loss or history of amaurosis fugax. Typically a 2-year course.
Pathological changes seen in osteoporosis
other causes of pathological fracutres
increase in osteoclast activity
The trabecular plates become perforated, thinned, and lose their interconnections, leading to progressive micro
fractures and eventual vertebral collapse
Skeletal metastasis * Paget’s disease * Multiple myeloma * Rickets * Osteomalacia * Osteogenesis imperfecta * Radiotherapy
Diagnosis of multiple myeloma
- Punched-out lytic skull lesions on x-ray
- M spike on protein electrophoresis
- Ig light chains in urine (Bence Jones proteins
CRAB:
o HyperCalcemia (corrected calcium > 2.75 mmol/l, > 11 mg/dL) o Renal insufficiency attributable to myeloma o Anemia (hemoglobin < 10 g/dl) o Bone lesions (lytic lesions or osteoporosis with compression fractures)
Appendicitis
what is the obtruator sing
which nerve does appendicitis visceral travel through
second decade of your life
more common in males
reterocaecal
flexion and internal rotation of the hip causing pain as the appendix irritate obtruator internus
lesser splanchnic nerve
Define hyperplasia
Macoscopic picture of hyperplasia in MEN 1 syndrome
what is insulinoma
Blood tests of insulinoma
other pathology seen in MEN1
Gene mutations seen in MEN 1
Increase in the number of cells in tissue or organ in response to a stimulus
Man with parathyroidectomy,
chief cell hyperplasia, which may involve the glands in
a diffuse or multinodular pattern.
islands of oxyphils, and poorly developed, delicate fibrous strands may envelop the
nodules
hypoglyxaemia
stupor/confusion/LOC - precipitated by fasting or exercise. releived by feeding/parenteral administration of glucose
high circulating levels of insulin, hypoglycaemia, Cpeptide/proinsulin
3Ps - pituitary/parathyroid/pancreatic adenoma
MEN1/PTEN + TSC2 / ATXR/DAXX - involved in telomere maintenace - lose cell poliferation
define telomere\
define two hit hypotehsis
apoptosis
A telomere is a region of repetitive nucleotide sequences at each end of a chromosome, which protects the end of the chromosome from deterioration or from fusion with neighboring chromosomes
in order for a particular cell to become cancerous, both of the cell’s tumor suppressor genes must be mutated. This idea is known as the “two hit” hypothesis
Programmed cell death
female with thyroid nodule with elevated calcitonin levels
type of cancer
best test to diagnose
MEN 2 syndrome
medullary thyroid cancer
- amyloid deposits and calcitonin positive on IHC
FNAC - malignant celll features/amyloid depostis
defune immunohistochemistry
What is the type of Ag- Ab reaction in IHC
is a method of localizing specific antigens in tissues or cells based on antigen antibody recognitio
How does it work? The antibodies are usually linked to an enzyme or a fluorescent dye. When the antibodies bind to the antigen in the tissue sample, the enzyme or dye is activated, and the antigen can then be seen under a microscope.
complement fixation
FNAC findings
granuloma TB
malignant melanoma
lymphoma
- If you find Langerhans giant cell + lymphocytes + necrotic material → granuloma (TB) * If you find Brown pigmented cell + epithelioid cells → malignant melanoma * If you find Reed Sternberg cell + lymphoid cell + blast cell → lymphoma
Define high sensitivity
high specificity test
Sensitivity is the ability of a test to correctly classify an individual as ′diseased′ (true positive rate) High sensitivity = low number of false negatives
Specificity is the ability of a test to correctly classify an individual as disease-free (true negative rate). High specificity = low number of false positives
Features of malignant cells
anaplastic features
invasion
increased mitotic rate
differentiation and anaplasia
Loss of normal tissue architecture:
Pleomorphism
Hyperchromatic nuclei
High nuclear-cytoplasmic ratio:
Giant cells:
what us tge SI units of radiotherapy
- Coulomb/kg: Exposure * Gray (Gy): Dose * Sievert (Sv): Dose equivalent * Becquerel: Activit
examples of hypercoagulable state
Surgery
malignancy
Protein C/S deficiency
Pregnancy
dehydration
Factor V leiden
how does steroids cause osteoporosis
Direct inhibition of osteoblast formation
* Direct stimulation of bone resorption
* Inhibition of GIT calcium absorption
* Stimulation of renal calcium losses
* Inhibition of sex steroids
define ascites
classification
causes
abnormal fluid collection in the peritoneal cavity
exudate - malignancy
transudate - cirrhosis
transudate
hypoalbunaemia - cirrhosis/starvation/nephrotic syndrome
portal HTN - cirrhosis/right sided heart failure/Budd chiari syndrome
EXUDATE
- 4Ps
Peritonitis
Post irradiation
Peritoneal mets
Pancreatitis
what is fibroadenoma
another example of biphasic tissue
proliferation of epithelium and stromal tissue of the duct lobules
phyllodes tumor - over proliferation of stromal tissue
