Pathology: Introduction & Neoplasia

Table of Contents
Interface of Pathology and Clinical Medicine .............................................................................................................1
Cellular Pathology I .....................................................................................................................................................2
Cellular Pathology II ....................................................................................................................................................4
Inflammation I – Acute Inflammation ........................................................................................................................6
Inflammation II – Chronic Inflammation ....................................................................................................................9
Biology of Human Neoplasia: Introduction and Overview ...................................................................................... 12
Pathology of Human Neoplasia (The Practical Issues) ............................................................................................ 15
Molecular genetics of cancer .................................................................................................................................. 18

Interface of Pathology and Clinical Medicine

Pathology: pathos = suffering; logos = the study of

Identical clinical presentations can be caused by dramatically different pathologies; different pathologies will
require different treatments.

Famous people with pathology include Hubert Humphrey, Sergi Grinchov, the anonymous roofer, Elvis, and JFK.

Osler is responsible for 95% of all medical aphorisms.

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 Cellular Pathology I

Four pillars of pathology:

 Etiology: what initiates a process?
 Pathogenesis: what is its mechanism?
 Morphology: how is it recognized?
 Functional consequences: how does it produce disease?

Disturbance of homeostasis:
 Stress or increased demand can be met by adaptation; injurious stimuli may lead to cell injury / death.
 Failure to adapt can lead to injury/death as well: e.g. adaptations to long-standing hypertension can
predispose to sudden MI.

 Hypoxia: reduction or absence of a normal oxygen supply to an organ

(may result from ischemia = ischemic hypoxia)
 Ischemia: reduction / absence of blood supply to an organ or tissue
 Infarction: death of portion of tissue as result of ischemia (infarction = process, infarct = result)
 White infarct: organs where there’s one blood supply (liver, kidneys, spleen) – wedge shaped infart
downstream of blockage
 Red infarct: main blood supply cut off, reperfused by secondary blood supply (e.g. lung)

Mechanisms of cell injury (inter-dependent & synergistic):

 Decrease in ATP
o Example toxin: cyanide
 Increased (or dec.) intracellular Ca+2
o Increase because Ca/Mg pumps shut down (↓ATP)
o Leads to overactive enzymes (phospholipase, endonuclease, ATPase, protease) – damage
membrane, DNA, etc.
o Example toxin: glutamate excitotoxicity in neurons
 Reactive oxygen species – unpaired e- in outer orbit; leads to oxidative damage
o Superoxide, H2O2, OH- or reactive nitrogen species too
o Endogenous sources (metabolism, enzymes, ox-phos, inflammatory cells)
o Exogenous sources (O2 toxicity, chemicals, radiation, reperfusion injury)
o Usually in balance, but oxidative stress may occur if endogenous anti-oxidants overwhelmed
 Aging, diabetes, alzheimer’s, smoking, cancer, atherosclerosis, etc.
o Example toxin: acetaminophen in liver
 Membrane damage  if irreversible damange, considered the “point of no return”
o Example toxin: complement from immune system

Reversible injury: shut down ox-phos, ↓ATP. Morphological features:

 Swelling of organelles – ER, mito – and membrane blebbing (Na/K pumps shut down). Organelle
changes a.k.a. hydropic/vacuolar degeneration
 Clumping of chromatin (↑anaerobic glycolisis (lactic acid),↓pH, chromatin begins to clump)
 Lipid deposition (↓ protein synthesis; lipids can’t be attached to proteins & build up in cell). A.k.a. fatty
change (steatosis), seen in liver & myocardium
Irreversible when membrane damage starts to occur; time to “point of no return” depends on tissue.

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Reperfusion injury: previously ischemic area reperfused; inflammatory cells all enter at once; big influx of ROS
and calcium (pumps damaged) – may cause irreversible changes in cells.

Necrosis: morphological changes in nucleus & cytoplasm occurring after cell death in a living tissue. (two key
points: cell now dead but host was alive when it happened). Features:
 Eosinophilia (loss of RNA/ribosomes; proteins denatured). Looks more pink.
 Nuclear features: pyknosis (dark, shrunken), karyorrhexis (broken down), karyolysis (totally dissolved)
 Interstitial features: inflammation (need to be alive for this to happen

Subtypes of necrosis:
 Coagulative: after infarction (ischemic cell death) in solid tissues except brain. Most common.
o Tissue architecture looks same, “tombstones” of hyper-eosinophilic cells (more pink)
o Usually resolves as scar after neutrophils, macrophages scavange
 Liquefactive: after infarction in brain.
o Tissue architecture lost, complete hydrolysis / digestion of dead cells
o Resolves by cyst/cavity formation
o Abscess: Liquefactive necrosis as result of localized bacterial infections (fungal, parasitic)
 Accumulation of neutrophils within abscess cavity (making hydrolytic enzymes)
o Pus: dead neutrophils / cell debris
 Requires surgical drainage
 Caseous: “cheese-like”; after TB/fungal infections in immunocompetent individual
 Granuloma: Necrotic center surrounded by rim of inflammatory cells
 Fat necrosis: post-release of pancreatic lipase
o Membrane lipids broken down to FFAs, add calcium = saponification (calcium/fat deposits)

Amount of tissue damaged permanently can depend on quickness of reperfusion (e.g. post-MI or stroke).
Functional consequences can vary for same etiology, pathology, etc.

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 Cellular Pathology II

Hyperplasia: increase in the number of cells in tissue/organ. May or may not include hypertrophy.
 Physiologic: e.g. compensatory hyperplasia (e.g. liver), lactating breast.
 Pathologic
o endometrial hyperplasia (pituitary-gonadal axis abnormalities, menorrhagia = heavy bleeding),
o benign prostatic hyperplasia (includes secondary hypertrophy of bladder muscle)

Hypertrophy: increase in individual cell mass, leading to increase in organ mass. Reversible, response to stimulus
 Physiologic: muscle hypertrophy after working out
 Pathologic: hypertrophic myocardium (↑cytoplasm, ↑nucleus size = “boxcar nucleus”). Could be from
chronic hypertension, aortic valve disease, or some other chronic hemodynamic overload.
 Etiology:
o hormone-induced (uterus & breast in pregnancy),
o increased workload (pumping iron or pathologic / cardiac muscle)
o genetic causes (myostatin mutation)

Atrophy: cellular shrinkage due to loss of substance.

 Denervation (e.g. poliovirus infecting neurons innervating skeletal mm)
 Disuse (e.g. hand with a cast on)
 Hormonal: menopause (↓estrogen, endometrium from proliferative to cystic atrophy, can lead to
irritation & atrophic vaginitis)
 Senile atrophy (brain decreases in size with age)
 Nutritional atrophy
o Marasmus: protein-calorie malnutrition, swollen stomach b/c of lowered oncotic pressure
o Cachexia: severe muscle wasting (AIDS, cancer, other chronic inflammation)
Cellular atrophy may include progressive cell loss so tissue / organ can shrink as well (gross scale atrophy too)

Metaplasia: reversible replacement of one differentiated cell type by another differentiated cell type.
Adaptive substitution (new cells can better withstand environment)
 Smoking-associated squamous metaplasia – better able to withstand tobacco insult
o Reserve cell metaplasia (change in reserve cell population, which are reprogrammed over time
to develop into squamous cells rather than columnar epithelium)
o May undergo neoplastic progression (normal  metaplasia  dysplasia  cancer) especially if
insult continues.
o Example: Barrett esophagus (squamous  columnar to withstand acid at gastroesophageal
junction).

Dysplasia: epithelium starts to exhibit abnormal changes; pre-cancerous but mutations starting to occur

Intracellular accumulations: cells can accumulate exogenous or endogenous substances

 Anthracosis: universal finding in people who have lived in city. Black streaks = macrophages that
phagocytosed carbon. No clinical importance
 Lipofuscin: golden brown “wear-and-tear” pigment; tombstone of lipid peroxidation
 Fatty change: absolute increase in intracellular lipids. Potentially reversible. Most common in liver
o Causes: Morbid obesity (diffuse), alcohol abuse (may have central lobule sparing)

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 o Does have clinical implications – can be irreversible if hepatocytes die  fibrosis  cirrhosis
Apoptosis: programmed cell death.
 Physiologic: embryogenesis, hormone-dependent (menstruation), mature tissue homeostasis
 Pathologic:
o Response to DNA damage from radiation, free radicals, etc. (via p53)
o Viral infections (viral hepatitis)
o Cytotoxic T-cell mediated injury (transplant rejection or autoimmune conditions)
 Mediators (KNOW THIS)
o Caspases: cysteine proteases that play essential role in execution phase of apoptosis. Require
activation from inactive form via activation cascade
o Bcl-2: anti-apoptotic protein (but bcl-2 family contains both pro- and anti-apoptotic proteins)
o p53: stops cell division in response to DNA damage to facilitate recovery; if recovery fails 
apoptosis.
Morphology of apoptosis:
Characteristic Apoptosis Necrosis
 Specific cells affected Stimulus Usually physiologic Pathologic
(necrosis = sheet of cells)
Involvement Single cells Groups of cells
 Organized process;
Chromatin Uniformly dense masses No pattern
systematic breakdown of
DNA fragmentation Inter-nucleosomal Random
DNA (necrosis = smear)
Cell morphology Apoptotic bodies Swelling, degen.
Inflammation Absent Present

Inhibit apoptosis = facilitate tumorigenesis

 HPV: carcinogen (squamous cell carcinoma of cervix) – HPV abrogates function of p53, p21
 Follicular lymphoma – constitutive activation of Bcl-2

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 Inflammation I – Acute Inflammation

Inflammation: a complex response of vascularized tissues to various stimuli, leading to the accumulation of
fluids and leukocytes in the extravascular tissues.

Triggers include trauma, ischemia, neoplasm, infection, foreign matter, immune rxns, etc.

Edema: excess of fluid in interstitial spaces or serous cavities (e.g. pleuroa, pericardium, peritoneum)
 Transudate: edema with low protein content due to ↑ hydrostatic pressure
 Exudate: edema with high protein content, often containing blood cells, due to ↑hydrostatic pressure
and ↑ vascular permeability
o Serous: exudate with few inflammatory cells (pale yellow)
o Serosanginous: exudate with erythrocytes (red tinged)
o Fibrinous: contains large amounts of fibrin (after coagulation of clotting factors)
o Purulent: high inflammatory cell content (often with bacterial infections)
o Supperative: purulent exudate with significant pus (liquefactive necrosis)

What is inflammation trying to do? Deliver effector cells and molecules, provide physical barrier via
microvascular coagulation to prevent spread, promote repair of offending tissue.

Acute inflammation: early & immediate response (minutes to days).

 Characteristics:
o Edema (exudate of fluids & plasma proteins)
o Emigration of leukocytes (esp. neutrophils)
 Triple response of Lewis (histidine mediated):
1. Transient vasoconstriction
2. Wheal (fluid leakage)
3. Flare (vasodilation)
 Steps:
1. Changes in vascular caliber and flow
 Continuity equation: velocity = flow rate / cross sec. area (wider = slower velocity)
 Poiseuille’s law: flow rate increases with r4 (wider = more flow through)
 Bernoulli’s principle: velocity & pressure related inversely
 In acute inflammation: transient vasoconstriction of arterioles followed by vasodilation
of arterioles & capillary beds
 Blood flow increases (Poiseuille’s): heat & redness
 Blood velocity decreases (continuity): blood stasis
 Hydrostatic pressure increases (Bernouilli): extravasation & exudate
2. Increased vascular permeability (leakage)
 Plasma proteins lost so intravascular oncotic pressure drops (higher now in interstitum).
Flow of water out (oncotic & hydrostatic pressure too) when normal balance disrupted
 Results in tumor = swelling (edema)
 Mechanisms
 Contraction of endothelial cells in venules (most common: separation of
junctions; chemically mediated by histidine, reversible & short-lived – 15-30m)
 Reorganization of cytoskeleton in endothelial cells, transcytosis, direct
endothelial injury can play a role too

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 3. Leukocytes extravasate & phagocytose
 Want to kill microbes, ingest offending agents, degrade necrotic tissue
 Lots of blood cells extravasate, not just leukocytes (RBC, platelets, etc)
 Glucocorticoids help reduce inflammation by decreasing extravasation

Role of leukocytes (extravasation & phagocytosis)

Granulocytes are key in acute inflammation
 Neutrophils especially (eosinophils for allergies / parasitic infections, basophils & mast cells release
histadine for allergic hypersensitivity, monocytes in chronic inflammation)
 Time course:
1. Neutrophils (6-24h)
2. Monocytes / macrophages (24-48 hrs)
3. Lymphocytes (end, except viral infections where they can be first)
Sequence:
1. Extravasation
a. Margination: larger cells pushed to edge of vessel (RBC in central column) – pushed out even
farther during inflammation
b. Rolling: tumbling & transient halting.
i. Selectins: bone-marrow-derived & endothelial cell expression only
1. Slow down leukocyte under flow & signalling properties (rolling)
2. Ca dependent, carbohydrate binding proteins
3. Example: l-selectin on leukocyte, binds to GlyCam1 addressin (lymph node HEV)
ii. Addressins: expressed on endothelial cells on different sites, bind to homing receptors
on lymphocytes
c. Adhesion: firm attachement to endothelial surfaces. Mediated by complementary molecules.
i. Integrins: α/ß subunit heterodimers from IgG family with lots of types.
1. Classical examples are VLA4 (leukocyte) – VCAM1 (endothelial cell) and LFA1
(leukocyte) – ICAM1 (endothelial cell).
2. LFA1-ICAM1 binding is Mg dependent (↑affinity) and Ca dependent (↑avidity)
d. Diapedesis: passage across endothelium through intercellular junctions
i. Happens in venules (no smooth mm in wall)
ii. Endothelium to basement membrane, where they secrete collagenase to break down
e. Chemotaxis: direction to site of injury under influence of chemotactic agents; move using
pseudopod
i. Exogenous: bacterial products
ii. Endogenous: complement (c5a), lipoxygenase pathway products, chemokines (specific
for cell types, lots known)
2. Phagocytosis
a. What to eat?
i. Opsonic phagocytosis: target covered by something (Fc receptors for Ab Fc segment,
complement receptors for C3b)
ii. Non-opsonic phagocytosis: pathogen associated molecular patterns (PAMPs) (Mannose,
formyl-peptide, toll-like receptors for LPS, etc)
b. Target identified, internalized via Ca-dependent process, phagosome fuses with lysosomes &
secretory vessels to destroy & excrete waste.
3. Microbial killing
a. Neutrophils make microbicidal free radicals
i. NADPH oxidase reduces O2 to superoxide anion

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 ii. Superoxide converted hydrogen peroxide by spontaneous dismutation
iii. H2O2 is killing molecule (and other ROS/RNS)
b. Microbial response: catalase degrades H2O2 to H2O and O2
i. Pts with Chronic Granulomatous Disease lack NADPH oxidase system genes, susceptible
to infections by catalase positive microganisms

Chemical mediators of inflammation: vasoactive amines (histamine, serotonin), plasma proteases

(complement, kinins, clotting), arachadonic acid metabolites (prostaglandins, leukotrienes), cytokines – most
involved in vascular permeability regulation too (no surprise)

Complement puts holes in the target, kinin is involved in vasodilation and smooth mm relaxation, clotting
involves fibrin depositing, cyclooxygenase is involved in prostaglandin formation (COX), cytokines & others get
in play too.

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 Inflammation II – Chronic Inflammation

Outcomes of acute inflammation:

1. Complete resolution
2. Healing by connective tissue replacment (granulation tissue / organization; fibrosis)
3. Abcess formation
4. Chronic inflammation

Granulation tissue / organization

 After big tissue damage / fibrin exudation
 Buds of endothelial cells  grow and canalize / anastamose
 Macrophages migrate in
 Myofibroblasts & fibroblasts appear, proliferate, form collagen fibers
o Fibrosis: excessive deposition of collagen fibers
 Appearance: packed with cells, juicy, capillaries, collagen with fibroblasts, macrophages removing stuff
 Organization: granulation tissue replacing damaged tissue
o Inflammation
o Wound healing
o Infarct
o Thrombus

Fibroblasts: cytokine-mediated; produce collagen and ECM proteins

Keloid: excessive formation of collagenous tissue resulting in raised area of scar tissue (broad bands of
collagen replacing normal dermal structures
Cirrhosis in liver is result of inflammation  fibrous tissue (collagen) process

Example of organization: pleura following pneumonia, fibrin exudate, forms pleural adhesion

Abcess: focal, localized collection of pus in a newly formed cavity

 Pus in other cavities has different names (empyema in lungs, pyosalpinx in fallopian tubes, etc.)
 Pus = purulent exudate with neutrophils, necrotic cells, edema fluid
 Typically caused by Staphylococci (pyogenic bacteria)
 Appearance:
o Central: necrotic white cells & tissue cells
o Around that: preserved neutrophils
o Outer region: vascular dilation and fibroblastic proliferation (“pyogenic membrane”)
 Can become walled off by connective tissue (body can’t access)
 Can empty through fistula: pathologic channel connecting abcess to internal cavity / body surface

Phlegmon = cellulitis = opposite of an abcess (acute, overwhelming infection spreading along skin – S.
aureus & group A streptococci)

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 Chronic Inflammation:
a prolonged process where acute inflammation and destruction
proceed at the same time as healing / immune response (balance)

Causes: anything that causes acute inflammation (if it persists), infections, autoimmunity (most common in US),
alloimmunity (transplants), foreign materials (insoluble, inanimate)

Clinical classification:
 Primary: de novo cause (no clinically evident acute inflammation)
 Secondary to acute inflammation
Histological classification:
 Macrophagic (diffuse or granulomatous), e.g. TB
 Lymphocytic (diffuse or focal / follicle formation), e.g. autoimmunity
 Supperative (lots of neutrophils, abcess formation) e.g. osteomyelitis

Macrophages: most important cell in chronic inflammation

 From bone marrow precursor
 Circulate in blood as monocytes (half life of 1 day)
 Migrate into tissue, transform into macrophages (half life of several months)
 Roles of macrophages / monocytes: phagocytosis, induce immune reactions via antigen presentation,
release signalling molecules
 Activation: macrophages with increased inflammatory capacities; main function is phagocytosis but also
release lots more substances (NO, ROS, proteases, cytokines, enzymes, grotwh factors, complement…)\
 Can also cause significant tissue damage (hallmark of chronic inflammation)

Macrophagic infiltration:
1. Granulomatous: macrophages arranged into compact masses (follicles); epitheloid appearance like a
fence or barracade.
a. Granuloma = focal area of granulomatous inflammation.
i. Small cluster of epitheloid cells surrounded by lymphocytes
ii. Caseation in middle, then epitheloid layer & macrophagic giant cells; ring of
lymphocytes then fibrous tissue walling off on outside.
iii. E.g. tuberculosis
b. Epitheloid cells: pale, pink, granular cytoplasm & indistinct cell boundaries; hypodense
elongated nucleous
c. Giant cells: fusion of 6-8 macrophages (epitheloid); can contain 20+ small nuclei
i. Langhans giant cell (peripheral/horse-shoe nuclei arrangement): chronic immune
granulomata like TB or sarcoidosis
ii. Foreign body giant cell (scattered nuclei throughout cytoplasm) – e.g. asbestosis
d. Foreign body granuloma: particulate mater in middle (too large for phagocytosis by one Mφ)
e. Immune granuloma: inducing cell-mediated immmunity, Mφ present to T-cells, T-cells produce
cytokines to transform Mφ to epitheloid & giant cells
i. E.g. TB: granuloma (“tubercle”) caused by M. tuberculosis (acid-fast), usually caseating
f. GRANULOMA ≠ GRANULATION TISSUE

2. Non-granulomatous: diffuse spread of macrophages

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Lymphocytic infiltration: hallmark of autoimmune diseases
 Collection of lymphocytes in an organ that doesn’t usually have them
 Diffuse or focal lymphocytic infiltrations
o Focal infiltrations: “ectopic follicles” – look just like lymph node follicles but elsewhere in body
 B-cells in center, T-cells in cortex
 Hashimoto’s thyroiditis: autoimmune reaction against thyroid (focal)
 MS: collection of lymphocytes like follicle in brain

Systemic effects of inflammation

 Fever
o Improve efficiency of leukocyte killing, impair replication of microorganisms
o Coordinated by hypothalamus
 Leukocytosis
o WBC >11,000/uL blood
o Accelerated release of cells from bone marrow (immature neutrophils = bands; “left shift”)
 Bacterial infection: neutrophilia
 Viral infection: lymphocytosis
 Parasitic infection: eosinophilia
 Leukopenia
o WBC < 4,000 / uL
o Typhoid fever, other infections, or when pts overwhelmed (disseminated TB, cancer, HIV)

INFLAMMATION SUMMARY
ACUTE CHRONIC
DURATION Short (days) Long (months-years)
ONSET Acute Insidious
INFLAMMATORY CELLS Neutrophils, macrophages Macrophages, Lymphocytes, Fibroblasts
VASCULAR CHANGES Vasodilation, leakage Angiogenesis (granulation tissue)
EDEMA Yes Usually no
CARDINAL CLINICAL SIGNS Yes Usually no
TISSUE NECROSIS No Yes (ongoing)
FIBROSIS No Yes (ongoing)
SYSTEMIC EFFECTS High fever Low-grade fever, weight loss, anemia
BLOOD CHANGES Neutrophilia, lymphocytosis Variable. Polyclonal
hypergammaglobulinemia

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 Biology of Human Neoplasia: Introduction and Overview

Neoplasia: clonal proliferation of cells with somatic genetic alterations and aberrant regulation of growth
 Benign: don’t threaten life of neoplasm
 Malignant (cancer): ability to invade into normal tissues and metastasize into distant tissues

Neoplasms generally form masses (tumors) but some (e.g. pre-invasive or in situ neoplasms) don’t form visible
masses.

Key genetic defects in cancer cells:

 activate genes that stimulate cell replication (e.g. growth factor receptor kinases)
 inactivate genes that suppress cell replication

Many cancers do have increased growth (↑mitotic figures & growth fraction = proportion of cycling cells).
Others replicate at normal rate & suppress apoptosis (p53, bcl-2, BAX). So if tx only focuses on proliferating cells,
may miss these that are suppressing apoptosis.

Some of these pathways do both (regulate replication & apoptosis) – so these oncogenes can be very important;
blocking their functions can even lead to regression of cancer via ↑apoptosis (“oncogene addiction”)

Invasion & Metastasis

Invasion:
1. Penetrate basement membrane, degrade ECM, migrate in stroma
a. Cancer cells have active role (matrix metalloproteinases & other proteolytic enzymes)
b. Invasion leads to tissue remodeling: stromal reaction (akin to chronic inflammation)
c. Reactive stroma key to diagnosing invasion (is this tissue somewhere where it shouldn’t be?)
d. Invasive cancer actively migrates (reprogramming of integrin gene expression  changes in cell-
substrate adhesions & cytoskeletal dynamics)
e. Microenvironmental cues (oxygen tension, pH) may guide cancer cells to specific stromal structures
2. Adapt to foreign environment
a. Loss of cell-surface receptors (e.g. ↓e-cadherin, ↑other cadherins)
b. Both begin to be able to bind to ECM & lose requirement to be bound to each other
c. Called “epithelial-mesenchymal transition” (EMT) although not as complete as in embryology
(invasive cells still look like epithelial cells of origin)

Metastasis: spread of cancer to distant sites of body (not surgically treatable)

1. Vascular dissemination of malignant cells
a. Spread via lymphatics or blood vessels
b. Pre-requisites: invasion into vascular space & ability to survive in circulation
i. Most non-hematopoietic cells / non-metastatic cancer cells can’t survive shear stress in
circulation. But small % of cancer cells have “stem-like” properties & can survive in circulation.
ii. Most non-malignant cells undergo apoptosis when not attached to solid matrix (“anoikis”). But
resistance to apoptosis already present in cancer cells.
c. Adhere to endothelium & extravasate through vascular walls (processes not well understood
d. Usually inefficient (e.g. peritoneal-venous shunts in cancer pts don’t lead to widespread metastasis)
2. Growth of tumor in secondary site

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 a. Determined in part by routes of vascular & lymphatic drainage
(GI to mesenteric LN / liver, others to regional lymph nodes & lungs)
b. Not entirely dictated by drainage (breast, prostate, lung  bone; breast/lung  CNS)
3. Paget (1889) – “dependence of seed on the soil” (cancer cell on organ)
a. current research: chemokines from cancers & chemokine receptors in receptor organ tissue

Cancer progression (classical paradigm): confined neoplasms  invasive  metastatic.

 Classical: metastasis happens late
 But there is big variability among neoplasms. Probably more likely that certain neoplasms are
programmed to be aggressive or benign from the start depending on mutations. Even small tumors in
some cancers can invade / metastasize early.
 One explanation of why screening hasn’t resulted in huge reduction in cancer mortality

Ability to modify the host environment

 Tumor not just cancer cells: stroma, inflammatory cells, blood vessels
 Angiogenesis: many cancers produce angiogenic substances (e.g. vascular endothelial growth factor,
VEGF; fibroblastic growth factor, FGF); some also produce anti-angiogenic factors.
o Anti-VEGF Ab (bevacizumab) – Tx for some types of cancers
o Low vascularity (hypoxic environment) helps some cancers (e.g. pancreatic) grow. Also makes
resistant to chemotherapeutic drugs because they don’t reach hypoxic areas
 Suppression of immune surveillance: from “self” but altered enough to produce immune response
o Cancer cells evade by secreting things (proteins to inhibit immune cells, cytokines /
prostaglandins to suppress immune response, decoy antigens) or express dummy receptors
 Systemic effects of human cancers: May also secrete humoral factors that affect host physiology
o Ectopic hormones (ACTH, parathyroid-related proteins)
o Cachexins (e.g. TGF) – most not identified yet

Extended doubling potential of tumor cells

 Normal cells: replicate, then eventually reach senescence (telomere shortening). Telomere important in
chromosomal integrity
 Cancer cells: immortality. Increased expression of telomerase to extend the telomeres.
o Kicks in late so cancer cells still have reduced telomere length.
o Could maybe detect cancer via telomerase expression or inhibit telomerase for therapy.

Genomic instability
 Many somatic genetic mutations  Multiple phenotypic alterations
 Most cancer cells aneuploid (abnormal # & structure of chromosomes)
 Continuous rearrangement as cancer cells divide
o Shortening of telomeres – “anaphase bridging” where ends stick together in anaphase
o Inadequate mitotic spindle checkpoint (imperfect alignment & segregation)
o Problems maintaining structure: from defective DNA repair mechanisms (p53, BRCA1&2)
 Leads to non-homologous recombination of broken chromosomes & translocatiosn
o Defective mismatch repair: ↑mutations at sequence level
 Increased microsatellite instability (MSI)
Genomic instability important in carcinogenesis (need many mutations to make cancer) & development of
resistance to chemotherapy.

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Morphology: abnormal, with hyperchromatism (increased chromosomal material) & abnormal, irregular
shape. Structurally abnormal mitosis.

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 Pathology of Human Neoplasia (The Practical Issues)

Classification & nomenclature

 Prefixes = tissue of origin
Benign tumors
 -oma (chondroma = cartilage, adenoma = glandular epithelial)
 Hepatoma, melanoma, astrocytoma are exceptions (malignant)
Malignant tumors
 -carcinoma = epithelial origin
 -sarcoma = mesenchymal (stromal) origin

Ways to characterize:
1. Patterns of differentiation (Epithelial, Mesenchymal, Hematopoetic, Melanocytic, Glial)
2. Sub-types: e.g. for epithelial neoplasm: squamous, glandular (adeno), basal/basaloid, transitional
(urothelial), undifferentiated. Each pattern of differentiation has its own sub-types
3. Morphology: papillary, cystic, polypoid, mucinous, etc.
4. Benign (have very minimal risk of progressing to malignancy) and malignant tumors

Borderline or low malignant potential tumors: don’t fall into these categories well
 E.g. carcinoid tumor – neuroendocrine differentiation; respiratory / digestive systems; big range of
malignancy.
Multiple patterns of differentiation:
 epithelial + mesenchymal = fibroadenoma (benign) or carcinosarcoma (malignant).
 Tetroma: more than one germ cell layer from pleuripotential cells

Pattern of differentiation Benign Malignant

Epithelial
Glandular/ ductal epithelium Adenoma Adenocarcinoma
Squamous epithelium Squamous papilloma Squamous cell carcinoma or epidermoid carcinoma
Liver Hepatic adenoma Hepatoma (a.k.a., hepatocellular carcinoma)
Mesenchymal
Smooth muscle Leiomyoma Leiomyosarcoma
Adipocytes Lipoma Liposarcoma
Cartilage Chondroma Chondrosarcoma
Bone Osteoma Osteosarcoma
Endothelial hemangioma Hemangiosarcoma
Melanocytic Melanocytic nevus Melanoma
Glial Astrocytoma, ependymoma, oligodendroglioma
Hematopoetic Leukemia, lymphoma

Morphological characteristics of neoplasms:

 Solid tissues form tumors (except in situ neoplasia, which is more spread out)
 See below for benign vs. malignant cells

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Characteristics of benign cells
Relatively low nuclear: cytoplasmic ratio
Round nucleus, even distribution of chromatin, small or
inconspicuous nucleoli
Maintenance of cellular polarity and differentiation
Mitoses are uncommon, are located in usual location
(e.g., basal layer), and have typical appearance
Characteristics of malignant cells
Increased nuclear size (high N:C ratio)
Irregular nuclear shape, irregular distribution of
chromatin, prominent nucleoli
Loss of cellular polarity and variable loss of
differentiation
Mitoses are common, located above basal cell layer,
and have atypical appearance.

These are descriptive characteristics, not rules (consideration of all features in context is important)
Cytopathology: characterizing malignancy, etc. based on these features (e.g. Pap smear for aspirated cervical tissue)

Clinical considerations for diagnosis of malignancy (based on clinical experience)

1. Site: smooth mm. tumor in uterus with certain # mitosis = leiomyoma, in colon = leiomyosarcoma
2. Gender: teratoma in ovary with benign appearance = benign course; in testis of adult male = high metastasis potential
3. Age: Benign-appearing teratoma in testis of child = benign course, benign appearance in adult male = malignant

Pre-invasive neoplasia (defies traditional definitions)

 Tubular adenoma – precursor to colorectal cancer, low potential to invade (if excised, good prognosis)
 Carcinoma in situ = “severe dysplasia of squamous mucosa” (e.g. cervix) – high % develops to invasive

Grading & staging neoplasia

 Grade: degree to which cells have malignant features.
o Low grade = close to normal, high grade = large, irregular nuclei & atypical mitosis
o Poorly differentiated / well differentiated (how well does it resemble normal tissue)? Well
differentiated = low grade, poorly differentiated = high grade
o Standardized criteria (differentiation + nuclear features; nuclear dominate). Has variable
predictive validity depending on type of cancer
 Stage: extent of spread of cancer. Better clinical predictor.
o American Joint Committee on Cancer: TNM staging (Tumor, Lymph Nodes, Metastasis)
o Combine information to make TNM grouping (T1, N2, M0 for example) – cut-offs depend on the
type of cancer
o Grouped staging: 0, I-IV (0 = in situ, no invasion; IV = metastatic) – for surgery, etc.

Ancillary techniques
Immunohistochemistry
 No single marker but some are useful (e.g. p63 for normal basal cell layer in prostate; if missing =
cancerous; AMACR overexpressed in most prostate cancers)
 Mostly not helpful for benign vs malignant but can be used to phenotype tumor (e.g. heomatopoetic
neoplasms – use on suspended cells post-flow-cytometry.

Detection of Cancer via Molecular Markers

 Ideal situation: detect & monitor cancer via small markers with minimal invasiveness
 Current: secreted proteins (tumor-specific antigens, e.g. prostate specific antigen/PSA)

16
 o PSA: mortality has declined post-PSA introduction
o Associated with over-Dx and over-Tx of disease
o Some mixed studies on benefits in terms of mortality
 Research: better early detection, monitoring disease (mass spec, DNA from cancer cells).
 Still need tissue diagnosis before Tx currently (limits of sensitivity & specificity)

Predictive markers / molecular classification

 Want markers to predict response to therapy or subclassify tumors
 E.g.: Estrogen receptor (ER) in breast cancer: predicts good response to anti-estrogen therapy & better
prognosis.
 Subclassify according to molecular features: e.g. measure multiple genes in parallel (microarray) to form
prognostic indices & determine need for chemotherapy.

17
 Molecular genetics of cancer
Theory of genetic basis: need social controls on cells; have a high mutational load of a complex organism.
Average human gene mutated 1010 times in lifetime (almost all somatic)
We handle our mutational load well:
 Protect the germline cells (separation from somatic cells early in embryological development)
 Innate resistance to tumorigenesis (single mutation inadequate)

Neoplasia requires accumulation of somatic mutations: a microevolutionary process

 5-7 rate-limiting events needed (but how?)

 Clonal selection theory: tumorigenesis occurs as serial expansion of successive clones of cells,
punctuated by acquisition of certain mutations which give a cell and progeny a selective growth
advantage over neighboring cells
o Why are so many mutations needed? Downregulation mechanisms protect cells (need multiple
mutations to inactivate downregulatory syndromes & accumulate small effects to cause
selective advantage)
o Clonal changes (present in all cells of a neoplasm) indicate important events
o Genetic / epigenetic heterogeneity arises (even though genetic instability not universal in
neoplasms) – genetic instability just accelerates
o Clone is population that derives from single cell; offspring (subclones) compete to see who can
dominate neoplasm (with selection). Otherwise you’d just end up with heterogenous group &
benign neoplasm. Have to select each time one by one or else tumor mass would be huge
o Subsets with worse prognosis = those with more mutations
o Neoplasms arise from chance events so genetic profile varies from pt to pt (individualize
therapy)
 Pediatric tumors may be exception (arise in window of opportunity & don’t resemble
adults: maybe need fewer mutations & not as many steps)

 Mitogenesis is as important as mutagenesis in tumorigenesis

o Not just environmental exposure to mutagens, but also inflammation & regeneratory processes
 Changes in production of stem cells & ability to differentiate are key for neoplasia (commonly mutated)

Frequently mutated genes:

1. Dominant oncogenes: function activated by mutations
o Think about the signal transduction system from outside to nucleus
o Growth factors
o Growth factor receptors (e.g. EGFR)
o Signal transducers (e.g. RAS, ABL-BCR)
o Nuclear oncoproteins
o Agonists of apoptosis (BCL-2)
o Antagonists of tumor-suppressors (e.g. antagonists of p53)
2. Tumor-suppressor genes: function inactivated by mutations (selective advantage)
o Cell-cell, cell-ECM, differentiation-inducing interactions (e.g. E-cadherin)
o Cytoskeletal
o Regulators of signal transduction
o Cell-division cycle regulation (e.g. p53)
o Apoptosis (ultimate negative regulation: p53, BAX)

18
 o Chromatin structure
3. DNA-maintenance genes: genes inactivated by mutations, often before tumorigenesis (need second hit
for selective advantage)
o DNA repair genes (e.g. xeroderma pigmentosum genes)
o Chromosome stability genes (BRCA2, etc.)
4. Passenger mutations: have no special meaning in the neoplasm

Types of mutations:
 Amplification: overproduction of proteins
 Rearrangement / translocation: fusion of two genes from different proteins or oncogene placed behind
strong promoter
 Small mutation: e.g. point mutation, can activate or inactivate gene
 Large deletion: often a second hit – cause inactivation of suppressor gene, or loss of heterozygosity
(LOH), exposing first hit’s mutation
 Viral insertion: can allow viral oncogenes to continue to be expressed
 Telomere shortening: can cause genetic instability, deletions, translocations. Re-activation in
malignancy helps prevent extreme of this process (cell death) in malignant tumor cells

Inherited syndromes: can be due to germline mutations in:

1. Dominant oncogenes (examples are rare: embryonic lethal?)
2. Tumor suppressor genes (more common). Two-hit model: maybe the first hit is inherited, increasing
rate of neoplasm’s occurrence. E.g. familial adenomatous polyposis (FAP)
a. For instance: recessive gene but get LOH with second hit
b. Other examples: hereditary retinoblastoma (RB1), familial breast/ovarian cancer (BRCA 1), Li-
Fraumeni syndrome (p53 – lots of cancers possible)
3. DNA maintenance genes
a. True examples of higher mutation rates (“genomic instability”)
b. Hard to find “genetic instability” in lab, but some conditions do have true chromosomal
instability
c. Examples:
i. Xeroderma pigmentosa (inadequate repair of UV-induced DNA damage if have 2 mutant
copies of the gene)
ii. Hereditary nonpolyposis colorectal carcinoma (can be heterozygous) – inherited cause
of cancer susceptibility
iii. Ataxia telangiectasia (2 mutant copies)
iv. Fanconi anemia & familial breast/ovarian/pancreatic cancer (BRCA2). Two mutant
copies = highest risk, Fanconi anemia. One mutant copy still increases risk (get LOH in
neoplasm)
4. Susceptibility genes: may be very common & are being studied currently

Rational therapy:
Old model: screen all kinds of toxins for ability to kill cancer cells in culture
New model: look for specific biochemical properties

New ideas: augment deficient function(p53 – hard); replace function (hard without gene therapy working);
inactivate a function (Gleevec – very successful); take advantage of neoplastic defect; re-express genes;
augment immune responses

19
Acquired drug resistance via mutations: from mutations in drug-binding pocket; mutations causing
compensatory increase in activity, or mutations eliminating cell’s toxic response

Carcinogens
 Dietary / environmental:
o can use Ames assay (expose to potential mutagen; count colonies on plate that have mutated,
subtract background rate), others (cheaper in bacteria, really expensive in animal models).
o End up only screening things that are pretty certain to be carcinogenic
o Some are suspected carcinogens
o Example: Aflatoxin causes p53 mutations in hepatocellular carcinomas in Africa & China
 Infectious causes:
o Indirect mechanism: mitogenesis & inflammation (e.g. HBV & hepatocellular carcinoma, H.
pylori & gastric cancer)
o Direct mechanism: viral proteins that inactivate tumor-suppressor genes (e.g. HPV & cervical
cancer)

Non-mutated genes can also play a role (may be over- or under-expressed in neoplasms & provide good
background for neoplastic development

What is a neoplasm
“A clone of cells distinguished from other tissues by autonomous growth and somatic mutations”
 Mutations in growth-controlling genes
 Supporting, reactive tissues accompany tumor growth
 Grow in conditions that would otherwise be limiting

Caveats:
 All neoplasms have been found to have somatic mutations
 Inciting stimulus usually not shown for neoplasms
 Neoplasms often do control their own proliferation, but control is altered & cell # increases (evidence:
most neoplasms are benign)
 Other masses & proliferations
o Keloids, developmental abnormalities, granulation tissue, synovitis, etc.
o As long as it’s not clonal, it’s not a neoplasm
 Neoplasms are not always masses (e.g. leukemias, etc.)
 Neoplasms are not just a proliferative abnormality (this would just be hyperplasia) but rather a large
increase in stem cell # (clonal)
 Mutations in growth controlling genes can be inherited rather than acquired (insufficient to cause
neoplasms on their own). ADDITIONAL SOMATIC MUTATIONS ALWAYS REQUIRED.

FAP VS HNPCC (Familial Adenomatous Polyposis vs. hereditary nonpolyposis colorectal cancer)
 FAP: first change occurs quickly (lots of early adenomas) but it takes around 20 years to accumulate more hits
 HNPCC: first change occurs slowly, but fast progression afterwards (2 years) – harder to treat

20
Pathophysiology: Neoplasia
Table of Contents
Pathophysiology of Cancer: Basic Principles ........................................................................................................................... 1
Cancer screening and prevention ........................................................................................................................................... 6
Breast Cancer Symposium ...................................................................................................................................................... 8
Radiobiology as applied to the clinic .................................................................................................................................... 11

Pathophysiology of Cancer: Basic Principles

Cancer: 2nd leading cause of mortality in US (23% all deaths). More cancer survivors now than ever.
Women: lung, breast, colon, rectum = 50% cancers; Men: lung, prostate, colorectal

Metastasis: set of host-tumor interactions involved. A failure in any step will halt metastasis.
(proliferation, angiogenesis of primary tumor  detatchment, invasion of lymphatics or blood  embolism &
circulation  transport & survival  arrest in organs  adherence & extravasation  survival in new tissue,
proliferation, angiogenesis)

Natural history of cancer

1. Formation of the primary tumor
a. Cross-talk between
cancer cells & host Cell type Promotion of metastasis Inhibition of metastasis
stromal cells (up or Tumor Activation of growth factor pathways Antigenicity
down-regulated Angiogenic factors Angiogenesis inhibitors
Motility/invasiveness Cohesion (E-cadherin)
gene expression in
Aggregation/deformability Tissue inhibitors of proteolysis
both)
Host Paracrine/endocrine growth factors Tissue barriers
b. Nutrients supplied
Neovascularization Endothelial cells/blood turbulence
by simple diffusion Platelets Tissue inhibitors of proteolysis
(avascular tumor) Immune cells Immune cells
c. Balanced rate of Antiproliferative factors
tumor cell Inhibitors of angiogenesis
proliferation &
death (until “switch” to pro-angiogenic phenotype) – see table
2. Progressive growth & angiogenesis
a. Tumor cells can either directly secrete angiogeneic substances or release / activate them from ECM
i. Can also recruit lymphocytes, macrophages (release angiogenic substances too)
ii. Leads to activation of endothelial cells & neovascularization
b. Process of angiogenesis
i. Capillary basement membrane degraded (vascular deformity in existing vessel)
ii. Endothelial cells migrate out (pro-angiogenic stimulus)
iii. Proliferation @ leading edge of endothelial cell column
iv. Reorganization and canalization of endothelial cell tube
v. Anastamosis to establish blood flow
c. Proangiogenic substances include fibroblast growth factors, epidermal growth factors, vascular
endothelial growth factor (VEGF)
d. Antiangiogenic factors include the statins (angiostatin, endostatin, etc).
e. Tumor angiogenesis is different from physiological angiogenesis
 i. Aberrant vasculature & blood flow formed
ii. Altered endothelial cell-pericite interactions
iii. Increased permeability
3. Invasion
a. Tumor cells & invading mononuclear cells from host produce degradative enzymes which facilitate
invasion of stroma
b. Host response: lay down fibrous ECM (desmoplasmic response)
c. Tumor cell downregulates adhesion molecules (e.g. E-cadherin) which normally need to be stimulated
to promote cell survival
d. Invasion: thin-walled vessels (lymphatics, capillaries, venules) – easily penetrated
4. Embolization & transport
a. Single cells or aggregates
b. Blood stream is hostile environment (shear forces, host hematopoetic defenses, etc.)
i. Most die & those that survive rarely produce metastases
ii. Aggregates more likely to survive & become trapped in microvasculature of distant organs
(“safety in numbers”)
c. Not always a simple picture (e.g. malignant ascites from ovarian cancer treated with peritoneavenous
shunts, dumping tons of cancer cells into jugular vein, but no increase in lung metastases).
5. Arrest, adhesion, extravasation
a. Adhere to capillary endothelial cells or subendothelial basement membrane if exposed – primarily a
mechanical process
b. Extravasate & invade stroma
c. Metastasis often but not always explained by drainage patterns to areas of microvasculature (via blood
or lymph drainage)
i. Colon cancer  liver metastases (portal circ)
ii. Breast cancer  lung metastases (systemic circ)
6. Subsequent growth
a. Inefficient & dependent on suitability of “soil” organ (not all observed metastasis sites are compatible
with simple drainage hypothesis)
i. E.g. melanoma to brain, liver, bowel; prostate carcinoma to bone, testicular carcinoma to liver
b. Factors at play:
i. “Seed” = tumor cell: growth factor expression, specific chemokine receptors, cell adhesion
molecules
ii. “Soil” = target organ: chemokine milieu (match of chemokine receptors), etc.
1. Example: breast cancer cells express CXCR4, CCR7 receptors; their normal target organs
express the conjugate chemokine ligands
iii. Certain tumor cell subsets may be genetically predisposed to metastatic phenotype
1. Inactivation of metastasis suppressor genes may be key (genes which prevent
metastasis without impacting growth of the primary tumor)
7. Progressive growth
a. Cancer cells need to grow further to actually establish a metastasis:
i. Establish a microenvironment
ii. Proliferate
iii. Begin angiogenesis (tpo grow beyond 1-2 mm in diameter)
iv. Evade host immune system

Dormancy: can have a relapse decades after primary treatment (e.g. breast cancer, melanoma) – not well understood
 Possible mechanisms: persistent pre-angiogenic micrometastases (dividing & apoptosing @ same rate) and then
undergo angiogenic shift; or maybe persistence of solitary tumor cells in secondary organs

How does cancer make people sick?

1. local effects (compression of vital structures, replacement of tissues)
a. Headaches, seizures, change in personality: brain involvement?
 b. Hematuria: urinary tract?
c. Productive cough – postobstructive pneumonia?
d. Bone pain: bone metastases?
2. systemic effects (humoral factors)
3. metastasis

Oncologic emergencies:

1. Spinal cord compression

a. 10-40% pts presenting with acute SCC have undiagnosed cancer
b. Most important: status @ presentation (80% ambulatory pts will retain ability to walk vs 25% non-
ambulatory)
c. Motor function & sphincter control are two big issues
d. Pathophysiology: compression of anterior spinal cord / nerve roots from vertebral body collapse = most
common. Can also have invasion of paraspinous tumor through vertebral foramen
e. Thoracic = 70%; lumbrosacral (20%); cervical (10%)
f. Most from prostate, breast, lung cancer.
g. Back pain is initial symptom in 95% of pts. RESPECT ANY COMPLAINT OF BACK PAIN IN KNOWN
CANCER PTS. THINK SCC!
h. MRI with gadolinium contrast is imaging modality of choice. Plain films can be abnormal if SCC present,
but do not exclude SCC if normal
i. Treatment: steroids, local radiation; anterior decompression & rod placement if unstable

2. Superior Vena Cava Syndrome

a. 80% pts with SVC syndrome have underlying cancer (most frequently small cell lung cancer).
b. Pathophysiology: obstruction of blood flow in SVC from thrombosis or external compression. Both can
occur simultaneously.
c. Symptoms: dyspnea, facial puffiness, fullness in head / dusky complexion, cough
d. Findings: engorgement of neck veins, development of collaterals over chest wall, facial edema (50%),
plethora / peripheral cyanosis (25%)
e. Evaluate with chest radiograph and/or CT to look for chest mass. If chemosensitive; give chemotherapy;
if not, give radiotherapy. If thrombosis, give blood thinners
f. Only use emergency radiotherapy empirically if symptoms are rapidly progressive and there’s no time
for a tissue diagnosis.

3. Leukostasis
a. True oncologic emergency (requires expert management by oncologist with significant experience
b. Most common in AML (acute myelogenous leukemia) or accelerated / blast phases of chronic myelocytic
leukemia (CML)
c. Pathophysiology: plugging of capillaries with immature leukocytes (organ dysfunction results)
i. Not just simple obstruction: white cell thrombi also compete for oxygen, causing further hypoxia
ii. Endothelial injury  invasion of surrounding tissue  pulmonary edema, hypoemia in lung /
risk for hemorrhage in brain
d. Symptoms: dyspnea, tachypnea, cough, chest pain, progressive hypoxemia, fever, headache, dizziness,
visual change, tinnitus, ataxia, lethargy, stupor, somnolence, seizure, coma. Think: microvasculature
(lungs, brain, retina)
e. Findings: tachypnea, bilateral crackles, papilledema, retinal vein distension
f. Treatment: hydration, urine alkalinization & allopurinal (prevent tumor lysis syndrome & uric acid
buildup), chemotherapy. May need leukapheresis to reduce WBC count quickly

4. Hypercalcemia of malignancy
a. Most common life-threatening metabolic disorder in cancer patients
b. Most common causes of hypercalcemia: hyperparathyroidism (45%), malignancy (45%)
 i. Multiple myeloma and breast cancer are big two cancers
c. Pathophysiology: direct involvement of cancer metastatic to bone, or humoral secretion at distant cyte.
d. Humoral mediators:
i. 1,25-dihydroxyvitamin D in hypercalcemia associated with melanoma, multiple myeloma,
Hodgkins / Non-Hodgkin’s lymphoma
ii. PTHrP (parathyroid hormone-related peptide) associated with squamous cell carcinoma of
lung, small cell / anaplastic lung carcinoma, melanoma, prostate cancer, breast cancer, renal
carcinoma
e. Immobilization can also play a role in some pts with advanced cancer (bone loss)
f. Symptoms: fatigue, weakness, confusion, lethargy, constipation, nausea, vomiting, polyurea.
g. Normal Ca = 8.4-10.5
h. Therapy: IV fluids, diuretics (lasix), bisphosphonates to inhibit Ca relase from bone (interfere with
osteoclasts). Steroids used too – but need to treat the underlying tumor.
Paraneoplastic syndromes: systemic effects of cancer that are not related to direct invasion or compression from tumor
or to metastatic spread (endocrine, neurologic, hematologic derangements).

Endocrine paraneoplastic syndromes:

 Ectopic ACTH syndrome (most common)
o Results in Cushing’s-type manifestation (weight gain in trunk/face, “buffalo hump”, weight loss
elsewhere, hypertension, hyperpigmentation, hypokalemia, metabolic alkalosis, excess sweating,
hirstutism, etc) with a pulmonary mass usually
o ½ due to small cell lung cancer, remainder pheochromocytoma, thymoma, medullary thyroid cacner,
carcinoid tumors

Neurologic paraneoplastic syndromes:

 Cerebellar and neuropsychiatric are most common; subacute but progressive
 Eaton Lambert myasthenic syndrome: rare manifestation of small cell lung cancer (<1% pts)
o Proximal mm weakness (pelvic girdle, thighs)
o Muscle strength improves with repeated activity; response to edrophonium chloride poor (opposite of
real myasthenia gravis)

Hematologic manifestations of cancer: erythrocytosis, anemia, granulocytosis, granulocytopenia, thrombocytopenia,

eosinophilia, basophilia, thrombocytopenia, thrombo-phlebitis, coagulopathies

Trousseau’s syndrome: thrombophlebitis (venous blood clots) with cancer – Trousseau diagnosed himself.
 Risk is highest for migratory thrombophlebitis in pancreatic cancer but can also be present in other
adenocarcinomas (breast, prostate, ovarian cancers)
 Manage with anticoagulation & tx of underlying malignancy

Gastronintestinal manifestations of cancer: anorexia, cachexia, protein-losing enteropathy

 Significant weight loss associated with shorter survival
 Can result from neurologic dysfunction, GI dysfunction, alterations in taste, depression

Cancer pain
 Grossly undertreated: 90% can be well controlled
 Most due to direct tumor infiltration
 Three types of pain
o Somatic pain: dull, aching, well-localized. E.g. metastatic bone pain
o Visceral pain: deep, squeezing, pressure-like, poorly localized. Infiltration / compression of viscera. Can
be associated with nausea/vomiting if acute (e.g. pancreatic cancer)
o Neuropathic pain: direct injury to PNS/CNS from direct tumor infiltration or compression, or therapy-
related injury.
 Assessment: believe the patient (esp. in cancer); do Hx & physical exam, use pain assessment tools as fifth vital
sign, individualize approach, educate patient
 Treatment: assess & treat underlying cause (including palliative treatment of tumors), match medications to
type of pain, titrate medication to patient response, give on schedule rather than prn basis, use oral meds if
possible, anticipate side effects and treat, be aware of tolerance
o Tolerance: ability to take large dose of drug without ill effect (reduction of desired effects from
continued use)
o Dependence: physical, biological need for a drug to prevent withdrawal syndrome
o Addiction: psychological craving for drug; rare result in appropriate cancer pain management
 Performance status: global assessment of ability to conduct activities of daily living (not QOL).
o Major prognostic factor for pts with cancer, predictor of toxicity of treatment, indicator of comorbid
disease and other host factors.
o Two major scales: Karnofsky performance status (0-100), Eastern Cooperative Oncology Group (0-4)
 Cancer screening and prevention
Fundamental assumptions:
1. Disease can be identified in pre-clinical phase
2. Treatment is more effective at earlier rather than usual time of Dx
3. In absence of intervention, all cases proceed to clinical disease
and eventual mortality
4. Disease follows a natural history course
a. DPCP = detectable pre-clinical period (1st point detectable
by screening to first onset of symptoms)

Screening: classification of healthy (asymptomatic) individuals who

probably have a disease from those who probably do not. (vs.
diagnostic test: already have signs & symptoms; surveillance: follow-
up in those already diagnosed)
 Sensitivity: correctly determine patients with the disease;
specificity: correctly identify pts without the disease
 Type I error: false positive; Type II error: false negative
 Validity (accuracy): identification of correct results,
Reliability (precision): reproducibility of results
 Positive predictive value: likelihood that an individual has a
disease if test comes back positive. Depends on prevalence
and specificity

Study types & designs from cancer screening:

 Randomized clinical trial is gold standard (esp. double-blind
& matched experimental / control groups) but expensive &
difficult
 Cohort study: good for more common conditions; groups
unified by a characteristic & entered into study before
appearance of disease in question; control from general
population
 Case-control: compare pts with disease to group of healthy patients; less expensive & difficult (but not as good)
 Cross-sectional study: observing a subset of population at a specific time

More frequent screening is not always better (more false positives = more $$, more unnecessary procedures, etc.)
 Should be determined from rate of disease progression and sensitivity of test
 Also need to determine when to stop screening – balance benefits of screening vs. decreasing life expectancy
from other causes in the aging population
 Screening may not be good in cancers where there’s a good prognosis for disease, in people with a limited life
expectancy, or if you can’t detect disease during a preclinical phase (or short pre-clinical phase)

Identifying high-risk populations (fam Hx, BRCA mutations, exposure to carcinogen like smoking or afalotoxin) causes a
higher “prevalence” in your screened population and therefore increases positive predictive value.

Biases in cancer screening trials

 Volunteer bias: people who volunteer can be different from general pop (those who choose screening = better
health behaviors: screening looks beneficial, or poorer risk profiles so more worried: screening looks worse)
 Lead time bias:
o Lead time: period between early detection of disease from screening program & normal detection time
o Screening catches disease earlier, so survival appears longer even if it’s not: need to correct for lead
time using natural history information & compare age-specific mortality rates instead of 5yr survivals
  Length bias:
o DPCP = detectable pre-clinical phase
o Screening can catch more cases with longer DPCP which can be less aggressive disease
o Better prognosis, so screening appears too beneficial
o Affects case-fatality rate (CFR)
 Over-diagnosis bias:
o Diagnose cases with screening that would normally be undetected in normal lifetime (would not
progress / regress over time)
b. Can cause extra psychological stress, unneeded interventions / treatments

Where should we focus our resources?

 Non-aggressive cancers
 More prevalent cancers
 Effective current treatments

When should we screen? Need to consider the properties of the test & the population effectiveness
 Burden (mortality/morbidity)
 Good detectable clinical phase, early detection beneficial & effective
 Screening test is safe & effective
 Prevalent in population
 Feasible & acceptable to patient and physician
 Want a high precision, high PPV, high accuracy (specificity is especially important because most cancers are rare)

Example: PSA & prostate cancer. Multiple studies:

 no difference in mortality in US study but maybe the PSA cut-off was too high, PSA screening was common in
control group, improvements in Tx masked difference, longer-follow-up needed?
 European study showed some benefit: maybe better control because PSA screening isn’t as common?
 Breast Cancer Symposium
Breast cancer: 15% of cancer-related deaths; most common Dx & second most common cause of cancer death in women
1:100 Male:Female; 1 in 50 women by age 50 (1:8 lifetime)

Risk factors
 Reproductive: prolonged estrogen exposure
o early menarche, late menopause, nulliparity / late first pregnancy, lactation (?)
 Environmental: radiation=yes (not pesticides or electromagnetic fields
 Lifestyle: Diet, alcohol, physical activity, tobacco use (big cancer risk)
 Endogenous hormones: high hormone levels, post menopausal obesity (metabolic syndrome), increased bone
density (may be marker for high E instead of risk factor)
 Exogenous hormones: hormone replacement therapy=yes (estrogen replacement therapy = ?, oral
contraceptives = no)

Pathology: atypical ductal or lobular hyperplasia; lobular carcinoma in situ are risk factors

Inheritance: family history important; major inherited susceptibility (DNA repair defects are key)
 About 75% breast cancer has no family influence
 15-20% “clustered” (no clear inheritance); 5-10% directly inheritable
 BRCA1 (20-40%), BRCA2 (10-30%) are two big players in heritability (% of heritability attributable)
 Undiscovered genes (30-70%) are still very important

BRCA MUTATIONS
 BRCA-1
Increased likelihood of having BRCA mutation:
o 50-80% lifetime risk of BC; often early age at onset; o Multiple cases of early onset BC in family
40-60% chance of having second primary BC o Ovarian cancer with FHx of breast/ovarian cancer
o Ovarian cancer 15-45% risk o Breast & ovarian cancer in same woman
o Possible increase in risk of other cancers o Bilateral breast cancer
 BRCA-2 o Ashkenazi Jewish heritage
o 50-85% lifetime risk of BC; 6% male breast cancer o Male breast cancer
o Ovarian cancer 10-20% risk
o Increased risk prostate, laryngeal, pancreatic cancers
 Management: test other relatives; increase surveillance & institute lifestyle changes, chemoprevention
(tamoxifen), possibly prophylaxic surgery if lots of risk
 Risk assessment:
o Gail model (age, repro history, benign breast disease history, FHx in first degree). Doesn’t incorporate
age @ Dx, other cancers, other relatives
o Claus tables: only considers FHx of breast cancer

Prevention:
 Lifestyle changes (exercise, alcohol, tobacco) Signs & Symptoms of Breast Cancer
 Chemoprevention (tamoxifen, raloxifene)  Breast lump or thickening
 Skin or nipple changes
Screening:  Nipple discharge
 Breast self exam (beginning in 20s; some negative RCT)  Regional adenopathy
 Clinical breast exam (annual)  Abnormal mammogram
 Mammography: (good evidence for 50-69, uncertain in 40-
49yo, no data 70+)
o Looking for calcification
 New approaches: ductoscopy (endoscope in duct); ductal lavage (inject fluid, aspirate to get some cells)
Diagnostic tests: bilateral mammography, ultrasound/MRI, biopsy
Pathophysiology & Treatment
 Ductal epithelial cells are site of origin for 95% BC
 Classification:
o Invasive vs non-invasive
o Ductal vs lobular (“origin”)
o Histiologic grade
o Special stains (ER = estrogen receptor, PR = progesterone receptor, HER-2 = human epidermal growth
factor receptor 2 = more aggressive cancer)
 Staging: establish prognosis & guide therapy Staging Breast Cancer
o Use: hx, physical exam; mammorgraphy, CBC/chemistry,
 I: T < 2 cm, N0
X-rays/scans if symptoms, pathological exam on axillary
 II: T > 2 cm – 5 cm or N1
nodes after surgery, analysis of tumor for ER/PR/HER-2
 III: locally advanced breast cancer
 Prognostic factors: predict natural history for individual dz.
 IV: metastases
Nodal status, tumor size, steroid receptors, grade/subtype,
proliferation, age.
 Predictive factors: predict how well tumor will respond to specific therapies. Steroid receptors, HER-2 presence
 Tumor subtypes: different natural histories, different types of responses to therapy
o Best is “luminal A”
o Worst is “basal” & “HER-2+”
 Good example of personalized medicine: “Oncotype dx” – figure out what therapy in combination will work best
for patient’s tumor algorithmically & then apply.
 Surgery & radiation with adjuvant systemic chemo is generally how treatment works.

Surgery
 Halsted pioneered the radical mastectomy
 Less surgery causes less lymphedema, less mobility problems, etc.
 RCTs: mastectomy vs. lumpectomy & radiation showed no survival difference.
 Breast conserving therapy (BCT) is now preferred unless contraindicated (multifocal, poor cosmetic outcome,
patient preference, previous radiation, etc.)

Systemic treatment
 Chemotherapy:
o Alkylators (cyclophosphamide, etc.)
o Antimetabolites (MTX, 5-FU, etc)
o Topoisomerase inhibitors (doxorubicin)
o Antimitotics too
 Hormonal: endocrine therapy
o Ovarian ablation (surgery/radiation or LHRH agonists)
o SERMs like tamoxifen antagonize ER gene products in breast tissue
o Aromatase inhibitors (if post-menopausal)

o Progestins, estrogens, androgens are bad

o Note: pre-menopausal women have ovarian estrogen as primary source, so ovarian ablation is good
therapy. Post-menopausal women have androgens as primary source of e, so aromatase inhibitors are
indicated.
 Growth-factor-receptor targeted (trastuzumab & lapatinib)
o trastuzumab
 For HER-2 positive tumors (15-20%)
 Blocks the mutated, constitutive activation of epidermal growth factor receptor on tumor cells
 Cytotoxic & inhibitory (host immune response, promotes other chemotherapies, etc.)
o lapatinib
  small molecule inhibitor; prevents phosphorylation of HER-2 and EGFR receptors & blocks
signaling in that way
 Anti-angiogenesis (bevacizumab)
o Targets VEGF (vascular endothelial growth factor)

Treating metastatic breast cancer (Stage IV)

 Want to relieve / prevent symptoms from tumor (usually can’t cure)
 Chronic therapy – balance side effects of disease & therapy
 Common sites: lung, liver, bone, soft tissue

Treating locally advanced breast cancer (Stage III)

 Note: swelling of nipple (lymph blocked), peau d’orange (like skin of orange)
 Want to control local disease & eradicate micrometasteses
 Surgery, radiation, chemotherapy – want to be aggressive (eg neoadjuvant therapy - shrink & then surgery)

Treating early breast cancer (Stage I & II)

 Eradicate micrometastatic disease
 Give drugs around time of surgery
 Need effective drugs & high risk population
 Intent: cure (tolerate toxicity because you can beat it)

ER (-) pts don’t’ usually benefit from endocrine therapy

Post-menopausal patients with ER (+) usually don’t give chemo (less aggressive dz; may not respond as well)
Adjuvant chemotherapy: important to keep to dose schedule; short duration (months)
Adjuvant endocrine therapy: need steroid receptor (+) patients; long duration of therapy (years)

Toxicities of adjuvant therapy:

 Acute: nausea, vomiting, hair loss, bone marrow suppression, weight gain, mucositis, fatigue
 Chronic: ovarian failure, late end organ damage, second malignancy, cognitive dysfunction (“chemo brain”)
 Radiobiology as applied to the clinic

Basic physics:
 X-ray is a stream of photos with energy inversely proportional to wave length. Ionizing if it can knock an orbital
election out from an atom that it encounters (electron cloud is big, so most likely to hit an electron)
 Electron flies out and deposits energy distant to site of ejection
o Energy reaches a maximum at some distance from site of ejection (distance to maximum depends on
energy)
o this is “sparing” of high dose to tissue right under surface (so for instance skin not always harmed
because it’s closer than the maximum distance

 Indirect action on DNA:

o Tissues are mostly water, so electron hits usually hits water and generates a hydroxyl radical
o Hydroxyl radical leads to base damage, breakage of phosphodiester backbone
 Direct action on DNA also possible: hits DNA, protein, etc. directly (less frequent)

DNA strand breaks / chromosomal aberrations (what happens after DNA gets damaged)
 Single strand break = easily repaired (use complementary strand)
 Double strand break = irreparable
o Need two breaks close to each other in time and space
o Chromosomal aberrations: sticky ends at each broken part
 Common formations: dicentrics, rings (sticky ends stick together – lethal)
 May fail to rejoin: deletion(lethal)
 Rate of aberrations (and resultant cell death) increases with
amount of radiation

Cell survival curves:

 Low doses: less radiation; unlikely to get DSB (two breaks near each
other in time and space). Lethal events caused by single hit (varies
with Dose=D)
 High doses: more likely to get DSB; two events will interact (varies
with Dose2 = D2)
 Curve can therefore be defined by “linear-quadratic formula”.

Four “R’s” of Radiobiology

Most clinical radiation is delivered in a fractionated scheme where total dose is delivered in many small doses instead of
several large doses: why?
Early experiment: try to sterilize a French goat. Big doses hurt the scrotum; smaller doses achieve same sterilization but
without all the agony.

1. Sublethal damage Repair:

a. Increase in cell survival if you split a dose into two fractions with a time interval (the normal cells can
repair themselves)
b. Tumor cells repair less well, with less fidelity (part of why they become tumors in the first place) but still
repair themselves somewhat.
2. Reassortment
a. Cells redistribute into radiosensitive phases of the cell cycle after DNA-damaging events (e.g. G2/M
checkpoint – highly radiosensitive & also arrest checkpoint)
b. If you hit cells with more radiation after they redistribute, they’ll mostly be at the G2/M checkpoint and
will be more vulnerable (killing increases).
3. Repopulation
 a. Cells can divide after doses of radiation, increasing
their apparent survival (tumor & normal)
b. See graph on right: first three R’s
i. Survival increases if you deliver the first
dose after a little break (repair)
ii. Then survival decreases if you wait until
reassortment happens
iii. “Survival” increases if you wait until later
(repopulated)
4. Reoxygenation
a. Cells that are hypoxic at time of radiation become
oxygenated afterwards
b. Oxygen is required to make DNA damage permanent
c. Some solid tumors have hypoxic/anoxic areas in the center (farther away from vasculature; tumor cells
are using increased amounts of oxygen)
d. As you hit the cells with radiation, the oxygenated outer cells die & tumor shrinks, allowing oxygenation
of formerly hypoxic cells (ready to be killed with next round)

So in summary: Fractionated irradiation spares normal tissue by allowing repair of sublethal damage and repopulation
of cells. Fractionation increases tumor damage by allowing reassortment of cells into more radiosensitive cell cycle
phases and permits reoxygenation to occur in order to make DNA damage permanent.

Why is exposure to radiation different in tumors vs. normal tissue?

 Early-responding tissue: tumor or normal tissue that when irradiated shows reactions early during the course of
treatment (e.g. skin, mucosa)
 Late-responding tissue: normal tissue where proliferative
rate is low (peripheral nerves, spinal cord)

For early-responding tissue, there’s a beginning of repopulation early

on in treatment. If your time of treatment is lengthy, you would
theoretically have to increase the dose to get the same effect. For
late-responding tissues, that point is much later.

So longer treatment time spares some of the early-responding

tissue (skin, tumor) but has no significant difference in late-
responding tissue (brain spinal cord).

You might think that you’d want to get the treatment done ASAP then
(bigger dose per day to decrease # fractions) to avoid sparing the early
responding tissue (including the tumor).

At higher doses per day, though, effect on late-responding tissues is

proportionally greater, since it has a more curved dose-response curve
(hurts therapeutic index).

If you multifractionate your regimen, you can reduce this problem (top
graph shows that your killing of early-responding tissue is slightly less, but
bottom graph shows that your killing of late-responding tissue is much
less) – improving your therapeutic ratio.

A few new radiation treatment designs:

 Hyperfractionation: use twice the number of fractions & same
amount of time).
 o Dose per fraction decreased; total dose increased to give same overall tumor killing.
o Decreases side effects in late-responding normal tissue (not to increase tumor killing significantly)
 Accelerated treatment: get the treatment time done ASAP (avoid repopulation in tumor)
o Increased killing of early-responding tissue but also more side effects in early-responding normal tissue
o Study: use accelerated in pts with high doubling times for tumors: showed much better amount of local
control for pts with fast-dividing tumors
 Trade-off: decreased late side effects (hyperfractionation) vs. increased tumor control with increased acute side
effects (accelerated)
 Pharmacology : Introduction & Neoplasia

Table of Contents:
Overview of pharmacology ........................................................................................................................................2
Drugs and enzymes.....................................................................................................................................................3
Receptors: Targets for Drug Action ............................................................................................................................4
Drug Metabolism ........................................................................................................................................................6
Principles of drug development .................................................................................................................................8
Complementary & alternative medicines ............................................................................................................... 10
Molecular Imaging ................................................................................................................................................... 11
Pharmacokinetics .................................................................................................................................................... 12
Autonomic Pharmacology I - Parasympathetic ....................................................................................................... 16
Autonomic Pharmacology II - Sympathetic ............................................................................................................. 19
An Overview of Cancer Chemotherapy ................................................................................................................... 23
Principles of antibody therapy for cancer ............................................................................................................... 26
Mechanisms and uses of antimetabolite drugs, signal transduction inhibitors, and anti-angiogenesis drugs in
antineoplastic therapy............................................................................................................................................. 28
Cancer Chemoprevention........................................................................................................................................ 32
Antineoplastic alkylating agents and platinum compounds ................................................................................... 34
DNA Topoisomerase-targeted drugs and mitotic spindle poisons .......................................................................... 39

1
 Overview of pharmacology

Egyptians had all kinds of prescriptions: active constituents, carriers, formulations, deliveries.
Greeks & Romans used drugs like juniper oil (diuretic & abortifacient). Homer described opiates, Socrates took
hemlock (glycine receptor agonist), Hippocraties didn’t like drugs, and Pedanius discordies (physician for Nero)
wrote about 900+ drugs. Claudius Galenius made one of the best discoveries: don’t use urine & feces as drugs,
but also advocated polypharmacy (which didn’t work, so people stopped studying drugs)

16th-18th c.: Ascorbate (vit. C) for scurvy , Quinine for malaria, Digitalis for dropsy (=CHF edema) from foxglove.

Modern approaches:
1. Natural products – through 1960, usually studying extracts’ effects on animals or disease models, and
then purifying compounds to study (in vivo / cellular, etc.). Analogs then synthesized & optimized
2. Drug target screens with synthetic compounds – “magic bullets” (Ehrlich’s approach, 1900-present).
Screen compounds against organisms / receptors / enzymes & use “hits” as basis for more specific /
potent analogs. E.g. salvarsan for syphilis. Precursor of combinatorial chemistry
3. Rational drug design (1970-present). Examine molecular target (protein target, ligand, substrate) &
design high affinity molecules (e.g. ACE inhibitors, protease inhibitors). Manipulate synthetically as
needed.
4. Biotechnology (1980-present). Genetically engineer proteins (e.g. recombinant insulin), monoclonal Ab
(e.g. rituximab), maybe gene therapy in the future.

Challenges:
 Few well-validated human gene targets identified
 Need “blockbusters” for big pharma to invest
 Need to expand “chemical space” (more new classes of drugs)
 Need rational approaches to ADME (absorption, distribution, metabolism, excretion)

2
 Drugs and enzymes

Constant Percent Effect

 Many systems: function on a % effect basis (that is, constant % of cellular units affected per unit time
regardless of # of units in the system.
 E.g. same % of enzyme inhibited if you keep inhibitor concentration the same, same % of max velocity
obtained if you keep substrate the same, same % of cancer cells killed if you keep chemo or radiation
the same.
 If X>>A (drug >> target, etc.), then it doesn’t matter how many targets there are – the same % will be
affected (“field effect”). Absolute numbers will differ, however

Graphing:
 You can plot [AX] vs [X] (e.g. velocity vs.
substrate, response vs. drug, binding vs.
receptor) and get a saturated curve
(rectangular hyperbola). If you use
log([X]), you get a sigmoid curve (semilog
plot).
 The point where you’re at half max (inflection in semi-log plot) goes by different names: Km for enzyme,
Ki for inhibitor, ED50 for drug, Kd for receptor binding. But it’s all the same – a measure of how the
thing you’re analyzing works & at what concentration it’s effective.
 If you vary the enzyme or target, when you’ve got a high amount of substrate, you see zero order
kinetics (e.g. the amount doesn’t matter because you’re usually saturated).
 In a rectangular hyperbola example, you’re usually in zero order situations at the point of saturation –
you’re processing a constant amount of something per unit time.
 When you’re in the linear early part of the curve, you’re in first order kinetics: processing a constant
percentage per unit time.

Inhibitors:
 Competitive inhibitors change Km, not Vmax (changing how well it binds, but can be overwhelmed by
more drug). Efficacy is the same (maximum effect)
 Noncompetitive inhibitors change Vmax, not Km (same binding, just taking some enzyme out of
picture). Efficacy is lowered.
 So look at the graph: is Vmax changing? Then it’s noncompetitive. Is Km changing? Competitive.
 Potency means you can get the same effect if you just use more of a dose (effect per dose)

Scatchard plot has drug bound/ drug free on Y axis, drug bound on X-axis.
 The x-intercept is Bmax, the highest amount of bound drug possible.
 The slope is -1/Kd
 Scatchard plot and Eadie-hofstee plots are reciprocals of the same graph.

Therapeutic index: LD50/ED50. You want a big therapeutic index

Kinetics: first order rate means that a constant % is removed per unit time. 𝐷𝑡 = 𝐷0 𝑒 −𝑘𝑡
Example: ethanol. One of very few substances that gets into zero order metabolism (constant amount) because
you ingest in grams scale.

3
 Receptors: Targets for Drug Action

Receptor attributes: discrimination (selective subtypes), sensitivity Random interesting fact:

(respond to range of concentrations; range varies based on receptor),  KD is an intrinsic / fundamental
amplification (big downstream effects). relationship (KI too)
 ED50 is an experimentally
Have different targets: membrane receptors, nuclear receptors observed relationship (IC50 too)
Different signals: hormones, neurotransmitters, drugs, toxins

Model for receptor action:

R + L ↔ RL ↔ RL   E (receptor binds ligand, undergoes conformational change, downstream effect results)

Occupancy theory: biological effect (E) proportional to the concentration of the receptor-ligand complex ([RL])

Bioassay and ligand binding

Effect of a drug/hormone/ligand is based on:

1. Ligand concentration around receptor
2. Receptor concentration
3. Affinity between ligand & receptor
4. Nature of post-binding cellular response

Bioassay: quantitative analysis of Agonist action

 Vary total ligand concentration (Lt) and measure 𝜸 = occupancy
biological effect (E) KD = equilibrium dissociation constant
 Assume: occupancy theory holds, only one class of Emax = maximum biological effect
receptor, each receptor is independent Rt= total receptor concentration
𝑹𝑳 𝑬 𝑳
 𝜸= 𝑹𝒕
=𝑬 =𝑲
max 𝑫+ 𝑳

 Plot results as log dose response curve (LDR)

At 1/10th KD, you get 10% of the max response
o X-axis: log ([ligand])
At 10 times KD, you get 90% of the max response
o Y-axis: effect
o Estimate KD from ED50: SMALLER KD = MORE POTENT DRUG
o Can use to compare drugs (multiple curves) or analyze
antagonists vs agonists

 Agonist vs. Antagonist vs. Partial agonist

o This only applies to competitive inhibitors.
(noncompetitive inhibitors would lower the maximum
effect – lower maximum on y-axis)
o Competitive ligands compete for binding at the same
receptor
o Biological effect depends on
 Concentration of each ligand
 Their respective binding constants

4
 Apply to receptor with no ligand Apply to receptor along with ligand
Agonist Full effect (stimulation) No effect
Antagonist No effect Full effect (inhibition)
Partial agonist Partial effect (some stimulation) Partial effect (some inhibition)

(Note that to detect an antagonist, you need to start

the system with some activity. Otherwise it might just
be inert)

Bioassay for antagonist action

 Add ligand at constant concentration and then
vary inhibitor concentration [I]
 Plot as a log dose inhibition curve (like LDR
curve but with inhibitor concentration on X-
axis on a log scale). IC50 is approximation for KI
 Can use to compare various inhibitors as well
 SMALLER KI = MORE POTENT INHIBITOR

Ligand Binding
 Use labeled (radiolabeled) ligand
 Vary ligand concentration [Lt]
 Measure receptor-bound ligand concentration
([RL]) and free ligand concentration ([L])
 Plot as either rectangular hyperbola or
scatchard plot (RL/L vs RL on linear scale)
where slope = -1/KD, intercept = Bmax (Rt)
o Steeper line = higher affinity

 Can also use the same method to see

binding of inhibitor, but it won’t actually
tell you what it’s doing: need to do a
bioassay.
o This method has no info about
biological effect – could be
agonist, antagonist, or partial
agonist.

Receptors: can belong to different families; ligand binding & effector domains usually linked. Subtypes exist for
most ligands (hormones, neurotransmitters, drugs). Subtypes can have different downstream effects & patterns
of expression (in different tissues or at different times in development.

5
 Drug Metabolism
Drug metabolism: generally producing more polar / water soluble conjugates (better excretion). Can sometimes
make more active/toxic compound
Liver is key for majority of drug metabolism.
Important for:
 Toxicity: sometimes you can generate toxic/teratogenic metabolites (e.g. thalidomide)
 Activity: metabolites can be active (e.g. terfenadine)
 Drug interactions (inhibition of metabolism): another drug can increase to toxic levels (e.g.
ketoconazole and terfenadine)
 Drug interactions (induction of metabolism): another drug can decrease to sub-therapeutic levels (e.g.
rifampin and oral contraceptives)

Almost no oral drugs are absorbed in stomach. Most absorbed in small intestine like food & have to pass
through portal circulation to the liver (makes sense – want to detoxify them first.)
First-pass metabolism: metabolism that drug goes through in that first pass through the liver (before reaching
systemic circulation / “central compartment”)
 “high extraction”: drugs that are taken up & heavily metabolized by hepatocytes during first pass; their
hepatic clearance is dependent on liver blood flow
 “low extraction”: negligible first-pass effect
 How to circumvent:
o Change the route of delivery (IV, sublingual, transdermal, rectal – distal colon to IVC)
o Change the rate of metabolism (co-administer inhibitor of metabolism)

Hepatic drug metabolism

 Phase I: oxidation, reduction, hydrolysis. Cytochrome P450 enzymes or mixed-function oxidases.
o CP450s: oxidation rxns, distinct classes, metabolize different groups of drugs
 Similar to e- transport chain
 Vast majority of drugs metabolized by CYP3A4 (and CYP2D6)
 Example: thalidomide (metabolized to teratogenic metabolite by phase I rxn)
 Phase II: glucuronidation (glucuronyl transferases), acetylation (N-acetyltransferases), methylation
(methionine transferases), sulfation (sulfotransferases)
o E.g. sulfanilamide
 Both phases’ enzymes present in microsomal fraction of liver homogenate (located in SER, membrane-
associated)

Non-microsomal & extra-hepatic metabolism

 Cytosolic / mitochondrial fractions: alcohol/aldehyde dehydrogenase, monoamine oxidase, proteases
 Intestinal CYP450s: intestinal enzymes (including 3A4) may contribute to apparently poor oral
bioavailability or high first pass metabolism (up to 50%).
o Good for hepatotoxic toxins (teleologically)
 Also glucuronyl transferases (e.g. kidney) but liver does most work
 N-acetyltransferase in muscle – may play a role for “slow acetylators”

CYP450s & drugs

Drugs can be: substrates, inhibitors, & inducers of CYP450s (one drug can actually do all 3)
 P450 inhibitor: any drug that inhibits the metabolism or biotransformation of another drug by enzymes
in the cytochrome P450 family (competitive & reversible) – usually substrates too

6
 o Can inhibit one or several classes of P450s
o Major offenders: cimetidine (anti-ulcer), macrolide antibiotics (erythromycin), antifungal azoles
(ketoconazole)
o Example: terfenadine levels increase if administered with ketoconazole; original form of drug
causes arrhythmias (before metabolized)
 P450 Inducer: Any drug that causes increased production of enzymes responsible for the metabolism or
biotransformation of another drug (drug acts as promoter, increases transcription)
o Increased mRNA levels (drug binds to enhancer elements upstream from enzyme coding region)
o Major offenders: phenobarbitol (anticonvulsant); rifampin (antibiotic) – e.g. with contraceptives

Effects of aging, disease, genetics

Neonates: low levels of functional glucuronosyl transferases (until ~1 mo) – can be particularly susceptible to
toxicity from toxins & drugs that are inactivated / cleared through glucuronidation

Elderly: can have reduced liver blood flow / reduced Phase I capacity (underlying disease, aging)
 Cirrhosis can affect drug clearance via 2 mechanisms
o Liver fibrosis (reduced blood flow through portal circulation: less 1st pass effect, higher systemic
concentrations of parent drugs
o Decrease in functional hepatocytes = less phase I capacity (mostly late in liver dz)
 Phase I reactions: impaired in acute & chronic liver disease;
 Phase II (conjugations) usually only in end-stage liver disease

Pharmacogenetics: polymorphisms in drug metabolism (altered amounts of enzymes or mutations in enzymes),

mostly affecting promoter region (altered amount more common)
 Classic example: Isoniazid (some are rapid metabolizers, some are slow metabolizers).

7
 Principles of drug development
Five major players: pharma, regulatory agencies (FDA), consumers, academia, legislature)

History of drug development: chance observation  trial and error  targeted screening (Ehrlich’s “magic
bullet”, pasteur’s “anti-bodies” & “lock & key” model)

Discovery vs Development
 Discovery: identify the “lock”, develop a pattern of chemical “keys”, rapid-throughput screening, in vitro
or in vivo model systems – or can exploit a chance observation (still possible)
 Development: getting the drug discovered, through the system & to the patient.
o 15-20% of overall health care expenditures, but changes from year to year (can regulate – and
there’s a trade-off with savings from reduced hospital days / morbidity / mortality)
o $420B in 2005; increasing market for generics (2/3 Rx in 2009) and worldwide
 1:30,000 chemicals  licensed drug
 1:10 drugs in clinical testing  licensed drug
 1:5 licensed drugs  covers R&D expenditure
o Costs ~ $1B and patent life is 8-10 years so need $50-100M/year
o So pharma focuses on blockbusters (high use & profitability – prevalent chronic conditions)

Phases of drugs
 Pre-clinical drug development
o Efficacy, mechanism of action, toxicology
o Pharmacokinetics (ADME) – Absorption, Distribution, Metabolism, Excretion
o Pharmaceutics (formulation development)
 Phase I: short-term safety & tolerability; pharmacokinetics
o 10s of healthy volunteers; days to weeks
 Phase II: medium-term safety and tolerability; initial evidence of beneficial activity
o 100s of patients; weeks to months
o “proof of concept”
 Phase III: long-term safety and tolerability; clinical efficacy
o 1000s of patients; years
o “proof of effectiveness” – convince FDA that drug’s ready for market
o Very expensive phase – imaging, testing monitoring
 Phase IV: post-marketing surveillance; develop new indications
o study special pt populations, “real-world” effectiveness
o 1000s of patients; often retrospective

DEFINITIONS  KNOW THIS STUFF

Drug: any chemical administered with therapeutic intent.

 Different from foods, health foods (legistlative artifact), GRAS substances

Orphan drugs: intended for conditions affecting <200,000 people (get a little break on some regulations)

IND: Investigational New Drugs: application required for investigational new drugs or approved drugs if:
 Change in drug label (package insert: the only info anywhere that’s FDA approved)
 Significant advertising changes

8
  New route of administration, formulation, dose, pt. population with increase in risk
 IRB asks for it

New Drug Application: data submitted to support marketing approval of investigational new drug
 Reviewed by advisory committee who make recommendation (approve / disapprove)
 FDA not obliged to follow advisory committee recommendations

9
 Complementary & alternative medicines
CAMs are important. 11.2% of all out-of-pocket spending in US, 38% of pts use CAMs

Extracts are combinations, supplements, not isolated

Drugs are isolated, pure chemical entities
Herbals are a subset of CAMs (also chiropractics, meditation, acupuncture)

Echinacea is the most common herbal product (cold remedy)

No evidence that any of these are safe or effective.

Healing is belief based and science based. Whereas scientific medicine is evidence based & changing,
traditional medicine is belief-based, anecdotal, static, and authoritarian. Science = good, other stuff = bad.

THIS IS WHAT YOU NEED TO MEMORIZE

ALL MEDICINE (TRADITIONAL, SCIENTIFIC, HOLISTIC) NEEDS TO FOLLOW THESE 3 PRINCIPLES:

1. Product must be standardized & rigorously regulated

2. Product must be proven to be effective for something that is of value to the patient
3. Product must be proven to be acceptably safe

1994: Dietary supplement health and education act (DSHEA) effectively neutered FDA (health food lobby won
out; FDA has very little control)

CAM development circumvents the 8-10 year, $1B drug development process: but at the cost of safety/toxicity
studies, effectiveness proven, standardization of the product

Example: PC-SPES (for prostate cancer – even in NEJM) but turned out to have synthetic drugs (hoax)

Herbal medicines generally not standardized (so you can’t study them well or refute claims). Many are
adulterated or inconsistent with their labeling.
 Ethically need to be able to know what you’re giving patients.
 Scientifically need to be able to replicate a study.
NEEDS TO BE EFFECTIVE & ACCEPTABLY SAFE

Only one herbal medicine has been approved (veregen for topical tx of genital & perianal warts in
immunosuppressed patients) – and even that doesn’t have great results

Several others (witch hazel = cuts & scrapes, senna & psyillum = laxatives) have been approved for modest value
in some illnesses.

CAMS can cause drug interactions.

E.g. St. John’s Wort increases metabolism of cyclosporin (an immunosuppressant) by ↑P450 3A4, which caused
transplant patients to lose their new hearts (immune response & rejection)

10
 Molecular Imaging
Molecular imaging: the remote sensing of cellular processes at the molecular level in vivo
 (people or lab animals)
 Allows early detection of changes in tissue; manage changes in real time for patient (personalized
medicine), facilitates drug development (where is drug going?)

Modalities:
 Keys: spatial resolution of techniques, sensitivity (what quantities can be measured – e.g. optical =
picomolar, MRI = micromolar), specificity of probe (just hit target, not normal tissue)
 Can be combined with anatomic techniques like CT
 Four modalities: Optical, Nuclear (radiopharmaceutical), Magnetic Resonance (MR), or Ultrasound

Nuclear imaging:
 PET (Positron emission tomography) – currently the most clinically translatable modality
o More expensive; requires cyclotron, quantitative, 4mm resolution
o Physiologic tracers (15O, 13N, 11C, 18F, 124I)
o Combine with CT: PET-CT to see anatomy
o Receptor/enzyme/transporter mapping; assess metabolism; calculate drug receptor occupancy;
monitor biomarkers for therapy & patient selection for treatments
 SPECT (Single photo emission computed tomography)
o Less expensive ($500k), qualitative, 1.5cm resolution
o Uses chelation chemistry
o Example: image for prostate-specific membrane antigen (PSMA) for prostate cancer (if present
outside of prostate, could be recurrance of cancer

Tracer principle: use concentrations of a probe that are so low that they won’t alter the physiology of the
system under study (no pharmacological effect). Makes use in humans more easily approved. Especially good
for radiopharmaceuticals.

Receptor pre-blockade: saturate the target sites with a normal nonlabeled ligand, then apply your probe /
imaging agent. If there’s any signal detected, that shows non-specific / background signal (should only be
binding to your site of interest). Shows specificity. Could also use knockout animals

Direct imaging: probe binds directly to target (e.g. PSMA)

Indirect imaging: for instance, a reporter gene / reporter probe system (e.g. introduce a certain kinase gene
that will phosphorylate your probe & trap it in the cell, and put it behind a promoter that also controls
your gene of interest. When your gene of interest is turned on, the kinase will also be made, and your
probe will be trapped in those cells to be imaged)

Signal amplification: enzymatic reporters can be useful because they amplify the signal (your probe, for
instance) – keep working inside the cell (especially good for less sensitive modalities like MR)

Example: C. novyi (anaerobic, goes to anoxic center of tumor). How to image bacteria as they home in? image
with 125I (FIAU) – the toxin produced by a bacterial kinase . Turned out to be toxic (5 deaths) so not a Tx now.

Can also image breast cancer using PET (18F-fluorothymididine = FLT-PET) to detect early cancers.

11
 Pharmacokinetics
Pharmacodynamics: what the drug does to the body (deciding on the target) – effect vs. concentration
Pharmacokinetics: what the body does to the drug (hitting the target) – concentration vs. time

What we’re really interested in: PK/PD interrelationship (effect vs. time)

Movement across membranes depends on various factors (size, dynamic polarity, water:octanol distribution,
protein binding, pKa, membrane transporters). Needs to be uncharged to get across (low dynamic polar
surface area < 140 angstoms, lower for brain/blood barrier)

Absorption determinants:
 Passive movement: middle ground for hydrophobicity is best to move between compartments
 Protein binding: generally only unbound drug can move across membranes
 Efficiency issue: high binding is not failure (if approved, it has effect)
 Albumin & α-acid glycoprotein are major proteins
 Varies with time (↑ α-a-g with inflammation, ↓ albumin with cirrhosis & nephrotic syndrome) so can
change concentrations of highly bound drugs
 Affinity can also change (uremia in renal failure decreases binding)
 Displacement theoretically possible but no known drug-drug examples

Henderson-Hasselbach Equation
 pH = pKa + log(A-/HA); pH = pKa when HA = A-
 Acid uncharged when pH < pKa (HA+)
 Base uncharged when pH > pKa (HA)
 Disease conditions (alkalosis or acidosis) can change how drug moves across membrane
o Gastric fluid 1.5-7, urine 4.5-7.5, blood etc. 7.4. Some drugs can be trapped depending on pH
o pH can change with other drugs (e.g. gastric fluid pH & omeprazole)

Transporters: active movement

 Can block transporters to keep drug in or to keep from being pumped out, but usually work to pump out
range of drugs
 E.g. organic ion (pumps from cell into lumen); P-glycoprotein (pumps from capillary into cell)

Basic definitions

AUC (mg/mL * hours): drug exposure per time

F: Bioavailability (unitless): fraction reaching systemic circulation. Limited by failure to enter solution, short
exposure to absorptive surface, failure to pass across membrane, pre-systemic metabolism so less than 1 in
almost all circumstances.
𝑨𝑼𝑪
 Bioavailability= 𝑨𝑼𝑪𝑬𝑽 (where EV = after extravascular dose, IV = after intravascular dose)
𝑰𝑽
 EV peaks later, around longer than IV
 Low bioavailability affects ability to dose po (may need frequent doses or IV) & can be a feasibility issue
 F<1.0 because drugs fail to enter solution, have short exposure to absorptive surface, limited passage
across membranes, and/or or pre-systemic metabolism
 Adjust for F when logically required

12
S: Salt (unitless): some drugs are composed of other stuff by weight too
𝒂𝒎𝒐𝒖𝒏𝒕 𝒂𝒄𝒕𝒊𝒗𝒆 𝒅𝒓𝒖𝒈 𝒊𝒏 𝒂𝒅𝒎𝒊𝒏𝒊𝒔𝒕𝒆𝒓𝒆𝒅 𝒇𝒐𝒓𝒎
 𝑺 = 𝒂𝒎𝒐𝒖𝒏𝒕 𝒐𝒇 𝒕𝒐𝒕𝒂𝒍 𝒅𝒓𝒖𝒈 𝒔𝒂𝒍𝒕 𝒊𝒏 𝒂𝒅𝒎𝒊𝒏𝒊𝒔𝒕𝒆𝒓𝒆𝒅 𝒇𝒐𝒓𝒎
 Analogous to F
 E.g. aminophylline is 80% theophyilline by weight

Vd: Volume of distribution (L): Volume into which dose appears to be uniformly distributed
𝑫𝒐𝒔𝒆
 𝑽
= 𝒄𝒐𝒏𝒄𝒆𝒏𝒕𝒓𝒂𝒕𝒊𝒐𝒏
𝒅
 Affected by drug movement across membrane (less movement = higher conc in central compartment)
 Use population Vd (adjust for weight – given in L/kg) as first estimate. Can be “lean weight” if not fat
soluble
 Generally a theoretical concept: measuring only total, not free drug; only sampling central compartment

ke: Elimination rate constant (1/time): fraction of drug eliminated in a unit of time
 Not the elimination rate
 First order (not saturated) – constant value (constant fraction eliminated); goes down as saturation
occurs (zero order – constant amount eliminated)
 𝑪𝒕 = 𝑪𝟎 𝒆−𝒌𝒕 for elimination
 Plot ln(Concentration) vs. Time and your slope is –k
 Can backwards-extrapolate to get C0, your initial concentration
 𝒌 = 𝑪𝒍/𝑽𝒅

t1/2 : half life (time): how long it takes concentration to drop by half.
 Only works for first order.
 When Ct/C0 = ½ , equation above simplifies
𝟎.𝟕
o 𝒕 =𝒌
𝟏/𝟐
 Another way to look at it
𝟏
o 𝒆−𝒌𝒕 = 𝒏
𝟐
o n = number of half lives elapsed post dose, or number of half lives in dosing interval to find
trough.
 Or:
𝟏 𝒏
o 𝑪𝒕 = 𝑪𝟎
𝟐

Cl: Clearance (L/hr)

 Relates concentration to rate of elimination (First order, saturable process).
 𝑬𝒍𝒊𝒎𝒊𝒏𝒂𝒕𝒊𝒐𝒏 𝒓𝒂𝒕𝒆 = 𝑪𝒍 ∙ 𝑪
 Varies with drug and patient
 Cl = Q * E (depends on flow and extraction ratio across organ)
o E.g. hepatic clearance is a function of hepatic blood flow and extraction ratio, which in turn
depends on metabolizing enzyme function
o Renal clearance varies with protein binding (filtration + secretion – absorption)
 Total clearance = renal + hepatic + other
 “Apparent clearance” = Clearance / bioavailability
𝑪𝒍 𝑫𝒐𝒔𝒆
o 𝑭𝒕𝒐𝒕𝒂𝒍
= 𝑨𝑼𝑪
𝒃𝒍𝒐𝒐𝒅

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Rac: Rate of accumulation
𝐶𝑚𝑎𝑥 ,𝑠𝑠 1 1
 𝑅𝑎𝑐 = 𝐶 = 1−𝑒 −𝑘𝜏 = 1
𝑚𝑎𝑥 ,1𝑠𝑡 𝑑𝑜𝑠𝑒 1− 𝑛
2
 If you’re dosing a drug with a long half life and dosing, say, every 1/5 half life, you can get a big variation
over time. If you’re dosing ever 4-5 half-lives, you don’t get much buildup

Loading dose: achieve a desired drug concentration.

 Assumes instantaneous, uniform distribution throughout body with no account for time
 𝑫𝒐𝒔𝒆 = ∆𝑪 ∙ 𝑽𝒅
 Adjust for F and S as needed

Calculating an individual’s Vd and t1/2

 Measure drug concentrations at two timepoints during decay
 Plot ln(concentration) vs time
 Find slope (-k) and calculate using k = 0.7 / t1/2
 Find intercept = C0 and then calculate Vd (Vd = dose * C0, corrected for F)

Continuous infusion: elimination rate matches infusion rate exactly (quasi-steady-state)

𝑫𝒐𝒔𝒆
 = 𝑪𝒍 ∙ 𝑪𝒔𝒔
𝝉
 Adjust for F as needed
 Note that things that change clearance (other drugs, etc) will affect this concentration at SS

If you give a loading dose & follow up with continuous infusion, the curves sum to be almost square (infusion
accumulates as loading dose decays.

Intermittent & continuous dosing

 Average dose is the same by either method (elimination rate is slow at first for intermittent dosing but
then evens out)
 Fixed daily dose, different interval: peak/trough changes, concentration at steady state doesn’t
 Same dose, different interval: same peak/trough, different Css

Basic half-life equations:

1
o Rise: 𝐶𝑡 = 𝐶𝑠𝑠 1 − 𝑒 −𝑘𝑡 = 𝐶𝑠𝑠 (1 − 2𝑛 )
1
o Fall: 𝐶𝑡 = 𝐶0 𝑒 −𝑘𝑡 = 𝐶0 (2𝑛 )
Time to 95% (up or down)= 4 to 5 half-lives

Concentration-constrained dosing: how to calculate dose & interval for peak & trough
 Shortcut: if you want Cmax / Cmin to be 2, max interval is t(1/2). If you want 4, 2t(1/2) is your interval
 Interval (Rate = ratio) – Cmax/Cmin = 2n
𝐶 𝑚𝑎𝑥 ,𝑠𝑠
ln
𝐶 𝑚𝑖𝑛 ,𝑠𝑠
o 𝜏𝑚𝑎𝑥 = where 𝑘 = 0.7/𝑡1
𝑘 2
 Dose=Difference
o Single loading dose (get up to the max SS)
o 𝐷 = 𝐶𝑚𝑎𝑥 ,𝑠𝑠 − 𝐶𝑝𝑟𝑒𝑠𝑒𝑛𝑡 ∗ 𝑉𝑑
o Correct for F, S when needed
 Intermittent maintenance dose (given every 𝜏𝑚𝑎𝑥 )

14
 o 𝐷 = 𝐶𝑚𝑎𝑥 ,𝑠𝑠 − 𝐶𝑝𝑟𝑒𝑠𝑒𝑛𝑡 ∗ 𝑉𝑑
o Correct for F, S when needed

A few other topics:

Distribution: at first, both drug moving out of central compartment (distribution) and being eliminated, so rate
of drop in concentration is higher.
 Implications
o Delayed effect if peripheral site of action
o Big distribution phase increases risk for central toxicity (if narrow therapeutic index)
o Need to monitor post-distribution levels (otherwise artificially overestimate initial
concentration)
Short infusions are more common than IV bolus infusions: distribution can apply though

Ka (absorption rate constant) – if a lower Ka, then slower abosorption. Peak is lower, trough is higher, and AUC
is the same. Peak is also later.
 Slower absorption can be good – keeps a narrow window in your peaks and troughs (e.g. extravascular
dosing)

Things to adjust away from population values if needed

 Loading dose: altered Vd (linearly proportional)
 Maintenance intermittent dosing (if t1/2 changes, not linearly proportional)
 Maintenance infusion dosing rate: altered Cl (linearly proportional)
 Time to steady state: linearly proportional to t1/2

Renal clearance: can adjust for creatinine clearance if drug is cleared by the kidney (age, weight, gender taken
into account). If creatinine clearance is lower, you can drop your infusion to get to the same steady state
concentration (but it will take longer! T1/2 is larger)

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 Autonomic Pharmacology I - Parasympathetic

Basics:
 Nervous system: afferent (sensory information), integration in ganglia in CNS structure, efferent
(somatic motor = voluntary skeletal mm, autonomic – involuntary smooth mm), mostly antagonistic
 Parasympathetc = homeostasis, sympathetic = fight or flight

Parasympathetic Nervous System

 Anatomy: originates from midbrain, medulla, sacral spinal cord, long presynaptics, ganglia near targets
so stimulation gives localized effects
 Ganglionic receptors = nicotinic AcH (gated ion channel)
 Target receptors = muscarinic AcH (GCPR)

PNS Actions:
 Homeostasis, opposes sympathetic activity generally
 Constricts smooth muscle, increases glandular secretions usually
 Classical actions: pupil constriction, bronchial constriction, decreased heart rate, relax sphincters &
contract GI segmental/longitudinal mm, contract bladder (relax sphincter)

Cholinergic synapse:
 AcH synthesized by choline acetyltransferase
 Ca+ dependent release (+ B-bungarotoxin, black widow venom, - botulism toxin by cleaving SNARE)
 Muscarinic AcH receptor (+pilocarpine, - atropine)
o 7-membrane-spanning GPCR
o M1-M5 subtypes with selective tissue expression, specific functions but overlap
o M2 is cardiac-selective; subtyping hasn’t really been exploited clinically so far
 Acetylcholinesterase breaks it down (- neostigmine, soman)
o This is the turnoff (compare to sympathetic)
o Neuronal AchE and also serum/liver (butrylcholinesterase) so you can’t just inject Ach into gut
 Choline uptake

MUSCARINIC AGONISTS

Generally: choline esters & other cholinomimetics

pilocarpine Mechanism of Action: muscarinic AcH receptor agonist

Effects: generalized muscarinic (incl. ocular-pupillary constriction, fall in intraocular pressure after
sudden rise, miosis = constriction of pupil lasts several hours)
Indications: glaucoma (esp. open angle)
Administration: aqueous opthalmic solution (prevent cardiac effects)

16
metoclopramide Mechanism of Action: Muscarinic AcH receptor agonist
Effects: increases gastric emptying; anti-emetic (dopamine receptor agonist), also enhances cholinergic
effects
Indications: First-line gastroparesis & anti-emetic agent
Administration: oral
Other: a.k.a. "Reglan"

MUSCARINIC ANTAGONISTS

atropine Mechanism of Action: competitive antagonist of muscarinic Ach receptors

Effects: dry mouth, constipation, urinary retention, dry skin, flush, bronchodilation, mydriasis (=pupil
dilation), delirium. Mad as a hatter, red as a beet, dry as a bone
Indications: Stop asystole (code blue), diarrhea, antidote to AchE toxins, pupil dilation
Administration: po, opthalmic, or by injection

scopolamine Mechanism of Action: muscarinic Ach receptor antagonist

Indications: motion sickness
Administration: oral or transdermal

ipratropium Mechanism of Action: muscarinic Ach receptor antagonist

bromide Effects: bronchodilation
Indications: asthma, COPD
Administration: metered dose inhaler
Other: a.k.a. atrovent

ACETYLCHOLINESTERASE INHIBITORS
 May be therapeutics (physostigmine for glaucoma), antidotes to poisons (pyridostigmine), or toxins
themselves (sarin) depending on their affinity for AchE, route of administration, dose, etc.
 Many insecticides, nerve gases, etc. fall in this category
 AchE is a serine protease that cleaves Ach to acetate & choline in synaptic cleft
 Found in high molecular weight aggregates (stable = low turnover = really bad if you mess it up)

neostigmine Mechanism of Action: reversible covalent inhibitor of AchE

Indications: can be used for prophylactic protection to AchE inhibitor nerve gases (fills up site, then
wears off unlike sarin, etc.)

sarin Mechanism of Action: "irreversible" covalent inhibitor of AchE

Effects: signs of AchE poisoning: bronchial spasm, salivation, lacrimation, defecation, urination,
bradycardia, hypotension, muscle weakness, death in minutes to hours
Administration: nerve gas / chemical warfare agent
Other: can be reversed with pralidoxime rescue if "aging" doesn't occur first (irreversible complex
formed with AchE over time, preventing palidoxime's nucleophilic attack). Treatment also includes large
quantities of atropine

17
pralidoxime Mechanism of Action: nucleophilic attack on AchE-sarin covalent complex
Effects: Reversal of sarin AchE poisoning
Indications: sarin AchE poisoning
Other: used along with atropine for sarin & other similar AchE poisons

18
 Autonomic Pharmacology II - Sympathetic
Anatomy:
 From thoracolumbar spinal cord; ganglia are paraverterbral & longer post-synaptic fibers
 Ganglionic receptors: nicotinic cholinergic
 Target receptors: adrenergic
 Primary postganglionic neurotransmitter: norepinephrine
 Adrenal medulla is like a big postganglionic neuron, releases epinephrine
 Stimulation results in a widespread reaction

Physiology:
 “Fight or flight”response
 Smooth mm: relax or constrict
 Classical actions: dilate bronchi, ↑glucose from liver, ↑rate & stroke volume from heart (↑ cardiac
output), ↑blood flow to skeletal mm, ↓motility & ↑ sphincter tone in gut
 Activation via enervation of target and adrenaline (=epinephrine) in blood circulation from adrenals

Adrenergic synapses
 NE synthesized in neuron (tyrDOPA dopamineNE). Epinephrine synthesized in adrenal gland
 Tyrosine hydroxylase is the rate-limiting step of synthesis & activated by sympathetic stim.
o α-methyltyrosine blocks tyrosine hydroxylase, used in management of pheochromocytoma
(usually benign tumor of adrenal that fires out too much catecholamine)
 Release of NE is Ca-dependent
o Some agents can act as false neurotransmitters, replacing NE in secreted vesicle & ↓NE effect
o Tyramine, amphetamine, ephedrine: sympathomimetic (enhance NE secretion)
 Adrenergic receptor (many agonists & antagonists) on post-synaptic side
o GPCR
 NE transporter brings NE back into pre-synaptic neuron (blocked by tricyclic antidepressants)
o Turnoff mechanism is re-uptake (not breakdown like parasympathetic)
 Monoamine oxidase breaks down NE & deaminated products extruded (target of antidepressants)

Adrenal glands have PNMT which converts NE (noradrenaline) to ephinephrine (adrenaline), major adrenal
medulla hormone. NE and ephinephrine have different pharmacological effects

Subtypes of the adrenergic receptors:

 α1 (with 3 subtypes α1A, α1B, α1C): mixed effects
 α2 (with 3 subtypes α2A, α2B, α2C): ↓adenylate cyclase, ↓Ca channels, ↑K channels
 β (with 3 subtypes β1, β2, β3): ↑ adenylate cyclase
 Dopamine receptors (D1-5) in vascular bed (D1) and CNS (all 5) can also bind catecholamine derivatives;
dopamine can bind α-receptor

α-receptor pharmacology

Non-selective α-receptor agonists: epinephrine, NE, phenylephrine, dopamine (see end of section)
Non-selective α-receptor antagonists:

19
phenoxybenzamine Mechanism of Action: nonselective antagonist of α adrenergic receptors
Effects: Reduces NE effect via inhibition
Indications: pheochromocytoma: adrenal tumor producing large amounts of
catecholamines (tumor usually benign; reverse effects)

α1-receptor agonists:
phenylephrine Mechanism of Action: selective agonist of the α1 adrenergic receptor
Effects: induces vasoconstriction
Indications: hypotension, nasal congestion
Administration: po or nasal spray as decongestant

α1-receptor antagonists:
prazosin Mechanism of Action: selective antagonist of the α1 adrenergic receptor
Effects: blocks smooth muscle constriction (relaxes ureters); vasodilation (can help with
hypertension)
Indications: enhances urine flow in benign prostatic hyperplasia, especially with hypertension

α2-receptor agonists:
clonidine Mechanism of Action: selective agonist of the α2 adrenergic receptor.
Effects: decreases NE release pre-synaptically (α2 is on pre-synaptic side, for feedback inhibition).
Indications: hypertension (reduces blood pressure), used for withdrawal in substance abuse
Administration: orally (both indications) or patch (substance abuse)

α2-receptor antagonists: yohimbine but questionable clinical use

β -receptor pharmacology
Non-specific β receptor agonists:
isoproterenol Mechanism of Action: nonselective agonist of the ß adrenergic receptors
Effects: stimulates cardiac output, dilates bronchial smooth muscle, dilates vascular smooth
muscle
Indications: bradychardia or heart block; rarely used to treat asthma

Non-specific β receptor antagonists:

propranolol Mechanism of Action: nonselective antagonist of ß adrenergic receptors (general ß blocker)
Effects: decreased cardiac output, bronchial smooth mm constriction
Indications: used to treat hypertension, angina, anxiety, vasovagal syncope (when heart rate
rises, blood vessels dilate too much, decreased brain perfusion, patient faints), arrythmias

β1 receptor agonists:

20
dobutamine Mechanism of Action: selective agonist of ß1 adrenergic receptor
Effects: increases cardiac rate & force of contraction (increased cardiac output); dilates
coronary arteries to reduce afterload
Indications: cardiomyopathy with CHF, especially in anginal states
Administration: IV
Other: doesn't work indefinitely

β1 receptor antagonists:
metoprolol Mechanism of Action: selective antagonist of ß1 adrenergic receptor (beta-blocker)
Effects: reduces cardiac output, reducing demand on heart
Indications: hypertension & angina
Other: also may promote better filling of coronary arteries by increasing length of diastolic phase

β2 receptor agonists:
albuterol Mechanism of Action: selective agonist of ß2 adrenergic receptor
Effects: dilates bronchial smooth muscle & uterine smooth muscle
Indications: asthma; stopping premature labor
Other: very few cardiac side effects because of ß2 selectivity. Also promotes glycogenolysis in liver
(be careful not to precipitate diabetic state)

β2 receptor antagonists: not useful clinically

Some interest in β3 receptor agonists to reduce adipose tissue in adiposity

Epi, NE, and dopamine

epinephrine Mechanism of Action: predominantly an agonist of ß adrenergic receptors (over α)
Effects: increases cardiac output & systolic arterial blood pressure; large metabolic effect
(increases O2 comsumption & blood glucose)
Indications: stopping anaphylactic response, used in code blue settings

norepinephrine Mechanism of Action: Primarily an agonist of α adrenergic receptors

Effects: Increases systolic and diastolic blood pressure; less effect on cardiac output &
metabolism
Indications: Hypotensive shock (largely replaced by phenylephrine now)

dopamine Mechanism of Action: Acts on D1 receptor in vasculature; also α and ß in high doses
Effects: Pressor (increases blood pressure), used in cardiac situations.
Indications: Low dose (renal dose) can be used to impact D1 receptor only if patient has low renal
perfusion; higher doses impact D, α, and ß receptors and is first pressor in most instances of
shock (low BP)
Misc: Adenosine receptor pharmacology: treating asthma, for example, by antagonizing adenosine at airways;
Nitric oxide signaling is also autonomic.

21
SUMMARY TABLE (autonomic I and II)

22
 An Overview of Cancer Chemotherapy

 Current treatment strategies: prevent, cure, or palliate

 Cancer can cause morbidity & mortality by disrupting physiology locally (invade/disrupt vital organ function)
or systemically (metastatic spread) – so treatment can be directed locally or systemically as well
 Important rise in # of cancer survivors in US – have to re-calibrate their health risks (Tx after-effects, etc.)

Local treatments
 Surgery (solid organ malignancy; need systemic disease, need staging before surgery to determine extent)
 Radiation therapy (localized cancers that can’t be removed surgery; also as adjuvant with surgery &
palliation of metastases that can cause morbidity)
 Chemotherapy (sometimes given regionally – e.g. hepatic artery for colonic cancer liver metasteses)
 Other (immunotherapies, etc. – often experimental)
Cancers vary in responsiveness to
Systemic treatments cytotoxic chemotherapy
 Hormone / Growth Factor (remove / antagonize trophic
hormones, e.g. estrogen for breast cancer, androgens for  Highly responsive (Hodgkin’s, Wilm’s
prostate cancer) tumor)
o Tamoxifen (anti-estrogen) – adjuvant after resection of  Responsive (acute leukemia in
breast cancer or systemic for metastatic children, retinoblastoma, testicular
 Chemotherapy: for systemic cancers, for cure (leukemia, testis, cancer)
lymphoma) or pallation (solid organ cancers)  Moderately responsive (acute
o Can be used as adjuvant to improve local treatment leukemia in adults, multiple myeloma,
potential breast cancer, prostate, ovarian)
 Other (immunotherapy, gene therapy, etc.)  Partially responsive (glioblastoma,
colorectal, pancreatic islet cell
Treatments can target: carcinoma, bladder)
 Minimally responsive: (liver,
 Targets unique to cancer cells (mutant gene products,
pancreatic cancer; melanoma)
oncogenic virus products)
 Qualitative/quantitative differences in cancer cells (cell cycle
effectors, macromolecules, biosynthetic enzymes, signal transduction pathway components) that are also
present in normal cells
o Therapeutic index (LD50/ED50)usually low for anti-cancer drugs (bad) because of this

Antineoplastic drugs: cytotoxic mechanisms of action

(based on the idea that cancer cells divide more rapidly; not actually that
simple)
 Damage cancer cell DNA (alkylating agents)
 Limit supply of precursors for DNA synthesis (antimetabolites)
 Interfere with DNA replication (topoisomerase poisons)
 Interfere with mitotic segregation
Cancer cells in an exponential growth phase are more sensitive to cytotoxic
agents than those in plateau phases

Log-linear kill kinetic behavior of antineoplastic drugs:

23
 Fractional cell kill: a specific dose of chemotherapeutic drug kills a specific fraction of tumor cells regardless
of tumor cell population (see logarithmic decline with therapy)

Norton-Simon hypothesis
 Based on observation that improvements in response rates from
chemotherapy doesn’t lead to improvements in survival
 General idea: a more effective treatment will kill lots of cells, get
down to the exponential growth part of the curve; cancer cells
replicate quickly and “catch up” to a similar less-effective
treatment. Mortality occurs way out in plateau phase.

Activation of apoptosis by antineoplastic drugs

 Accumulation of neoplastic cells = ↑division, ↓death, or both
 Cancer cells can escape apoptosis by activating senescence or autophagy
 ↓p53 or ↑Bcl-2 are common mutations to avoid
 Antineoplastic agents can stabilize p53 or use other strategies to induce apoptosis
o Many classes create DNA strand breaks to increase p53 activity & apoptosis
 New pathways for targeting: caspase cascade, other cell-death signal transduction pathways

Antineoplastic drug resistance

 Cancers arise clonally but have heterogeneity in later populations (tumor cell heterogeneity)
 Subclones can be resistant to drugs
o ABC transporter family: pump out lots of kinds of drugs in ATP-dependent manner. Blocking is
difficult therapeutic target (also pump drugs out in kidney, etc.  increased toxicity)

Goldie-Coldman hypothesis
 Luria and Delbruck: in bacteria, rate of genetic variants appearing related to rate of cell division &
probability of variant arising with each division (genetic instability)
 Goldie / Coldman: considered in cancer cells & anti-neoplastic drof genetic instability in population
o Although rate of appearance is independent of total number, absolute number of subclones is
greater for a greater size of cancer cell population (need to detect early!)
 Experiment (L-D Fluctuation Analysis): culture cells and then:
o Plate concentration of mixture of cultured cells on a bunch of plates: about the same amount of
resistance occurs in each plate (Poisson distribution = random)
o Pick out individual cells, grow up clonal population, and plate same concentration. Non-Poisson
distribution in amount of resistance on each plate (mutation can occur early or late in clonal
growth process)

24
So: cancer might respond well but eventually these subclones can emerge and treatment fails.
Rationale for combination chemotherapy, combined modality treatments, debulking surgery: rapidly reduce
the total # cancer cells and absolute # drug-resistant subclones

Why are some cancers readily curable & others poorly responsive?
1. Cancer cell kinetic properties. Curable cancers may have more rapid growth (antineoplastic drugs kill
them better).
2. Cancer cell biochemical properties. Noncurable cancers can detoxify, extrude, or otherwise escape
antineoplastic drugs.
3. Cancer cell phenotypic properties. Related to cells of origin of cancer (not well defined) – e.g. testis
cancer more responsive than prostate.

Cancer “stem cells”

 Normal renewing cell populations have rare stem cells around (differentiate to “transient amplifying”
then fully differentiated, non-proliferative cells)
 Cancer may be similar
 Theory (controversial):
 Tx that kill differentiated cancer cells show treatment response but not improved survival or cure
 Tx that kill stem cells might prolong surviva but not show initial response

Developing new drugs:

 Historically: Phase I (tolerance, dose-limiting toxicities, maximally tolerated dose = MTD), Phase II
(efficacy: complete & partial responses), Phase III (comparative efficacy & toxicity vs current regimens),
Phase IV (integrating into standard treatment after FDA marketing). 10 years, $1 Billion.
 Now: more common Phase I/II combinatorial trials after molecular biomarker use. Cheaper & quicker
 Big bottleneck: not discovery but rather clinical trials / approval

25
 Principles of antibody therapy for cancer

Antibody clearance:
 Abs are too big to go through glomeruli (except in renal disease)
 Fab fragments are small and are therefore cleared within hours
 Chimeric Ab have mouse variabble region, human constant region
 Humanized Ab have partially human variable regions too

Polyclonal antibodies (therapeutic uses)

 Anti-venins (against toxic proteins from snakes, spiders)
 Drug overdose (e.g. digoxin OD)
 Immune modulation (e.g. antithymocyte globulin)
 Treat infection (pre-antibiotics)
 Replacement IgG for X-linked agammaglobulinemia (XLA) – administer human IgG every 3-4 weeks (t1/2
= ¾ weeks)

Lymphoma:
 Ron Levy:
o B-cells display “idiotype” (specific B-cell receptor expressed on surface)
o Use the clonal nature of B-cell lymphomas (same idiotype) as target
o Follicular lymphoma: slow growing, could wait for treatment, expected to live several years, IgG
on cell membrane
o Made IgG for each pt’s lymphoma in lab and treated them (1st patient was big success, mixed
results afterwards)
o Serum sickness: immune reaction against foreign antigens
o One problem: Human Anti-Mouse Antibody (HAMA) – retreatment difficult (already have
HAMA)
o Recurrence: anti-idiotype ab no longer bound to tumor cells (somatic hypermutation in B-cells
& in this lymphoma = development of new lymphocytes)
o Precise but time consuming & recurrence possible
 CD20 & Rituximab
o CD20 only expressed on B cells (not plasma cells, not precursor stem cells)
 Lets you regenerate your B cells after treatment
o When anti-CD20 Ab bind, no internalization of complex & Cd20 not downregulated

Rituximab
 Toxicity: More adverse events in first infusion (killing most B-cells at first) – opposite of other Ab
therapies, where serum sickness sets in more with more immune reaction to foreign Abs. Due to large
number of dead B-cells.
 THINGS TO KNOW:
o HAMA don’t develop because rituximab is killing B cells, which would generate the human anti-
mouse antibodies
o Serum IgG levels don’t fall because plasma cells make most of the IgG in serum. No CD20
means they’re not killed
o Why do B cells recover? Hematopoetic stem cells don’t have CD20 so aren’t killed.
 Efficacy of rituximab depends on CD20 expression; often used with other therapies
 Mechanisms of Action:

26
 o Directly induces apoptosis (lymphocytes’ own self-destruct mechanism triggered by CD20
binding)
o Antibody dependent cell-mediated cytotoxicity (ADCC) – killed by NK cells & others
o Complement fixed & cells lysed.
 Reistance
o CD20 not downregulated & escape mutations are rare
o Major mechanisms:
1. Failure to generate ADCC (genetic variant in Fc binding receptor)
2. Variations in apoptotic pathways (probably most common)
o Overall: Ab still binds to tumor, just doesn’t kill it
 Treatment considerations:
o Everyone eventually relapses
o Maintenance therapy?
1. inhibits ability to generate new IgG
2. ↑ susceptibility to certain infections
o Retreatment generally works if pts have not received rituximab recently (but not if on
maintence)
Nomenclature
Antibody conjugates Ri-tu-xi-mab; 1-2-3-4
 Radioimmunoconjugates 1. Anything
o Murine Ab; target CD20 and conjugated to 2. tu(m) = tumor is target
radioactive isotopes 3. type of antibody
o Crossfire increases action (overcomes resistance) a. o = mouse
because neighboring cells are killed too by b. xi = chimeric
radiation (those which are apoptosis-resistant) c. zu = humanized
4. mab = monoclonal antibody
 Immunotoxins work by a similar idea
 If tumor is radiosensitive, conjugate radioactivity; if not,
conjugate a toxin (but toxin may be antigenic, preventing
Half-lives
retreatment
 Fab = hours
Consequences of Ab therapy  Mouse = days
 Targets  Chimera = days to weeks
o Looking for muntant proteins, only in cancer, etc.  Human = months
– but now maybe some tissues (e.g. b-cells) are
disposable? Thyroid / prostate?

27
Mechanisms and uses of antimetabolite drugs, signal transduction inhibitors, and anti-
angiogenesis drugs in antineoplastic therapy

General notes:
 Antimetabolites: In the end, these pretty much all work by leading to DNA double-strand breaks
(↓nucleotide pool or ↓DNA polymerase speed; causing DNApol to get stuck & cause DBS without
repair)
o All pretty much have bone marrow toxicity
 In traditional treatment, all roads lead to DNA (now more of a targeted approach

Antimetabolites:
 Mimic structure of normal metabolic species; inhibit enzymes in both normal and tumor cells
 Administered as prodrugs that require metabolic activation
 Inhibit deoxynucleotide and DNA synthesis; kill cells in S phase

 Targeting tumor cells: take advantage of different transport or enzymatic activation of prodrug, or of
cells that are progressing through cell cycle
 Nonneoplastic cells most affected: rapid cell division
o Hair follicle, bone marrow, intestinal epithelium cells
o Therapy induced leukemia is major complication

 Limitations: drug delivery (central hypoxic zone of solid tumors), not all tumor cells are cycling, fixed
percentage killed with each treatment, need active immune system, drug resistance common

Folate antagonists:
 Inhibit dihydrofolate reductase (DHFR) which reduces folic acid to dihydrofolate (DHF) and
tetrahydrofolate (THF)
 THF is required to carry methyl & methylene (1-C) groups for thymidine and purine biosynthesis

methotrexate Mechanism of Action: Folic antagonist (antimetabolite). Inhibits dihydrofolate reductase (DHFR).
Effects: Inhibits DHFR which is involved in synthesis of THF from folic acid. THF is the methyl/methelyne
carrier for purine and thymidine synthesis.
Indications: wide variety of cancer breast cancer, colorectal cancer, lymphoma
Administration: often paired with leucovorin shortly after MTX given ("leucovorin rescue") - replentishes
folate stores
Toxicity: mucositis, kidney damage, hepatotoxicity
Resistance: Reduced uptake; reduction in enzymes that add polyglutamate; DHFR gene amplification
Other: Actively transported into cells. Requires activation by addition of several glutamates (traps in cell;
enhances inhibition). Aka MTX

Deoxynucleotide synthesis antagonists

28
hydroxyurea Mechanism of Action: Inhibits ribonucleotide reductase. Antimetabolite antineoplastic agent.
Effects: Ribonucleotide reductase reduces NDPs to dNDPs for DNA synthesis
Indications: Leukemias; head and neck cancers
Toxicity: Standard (bone marrow, etc.)
Resistance: Overexpression of reductase

Note: Nucleoside analogs (5-FU, 6-percaptopurine, 6-thioguanine, etc.) are able to be transported into cell via
nucleoside transporter, and are then p-lated and trapped in cell. They must fit into a kinase in the cell, however
(resistance mechanism)

Pyrimidine biosynthesis antagonists

5-fluorouracil Mechanism of Action: Covalently modifies thymidylate synthase, the enzyme which converts dUMP to
TMP. Triphosphate form can also be incorporated into DNA and cause strand breaks
Effects: Antimetabolite antineoplastic agent.
Indications: Colorectal and breast cancer
Administration: IV and oral. Often co-administered with leucovorin. TS uses folate as a cofactor (also when
5-FU binding), so adding a folate analog like leucovorin pushese the inhibitory equilibrium through
(LeChatlier's). Also often co-administered with 5-ethynyluracil, which inhibits dihydropyrimidine
dehydrogenase in intestine.
Toxicity: Bone marrow suppression
Resistance: Decreased activity of activating enzyme. Intestinal enzyme dihydropyrimidine dehydrogenase
can inactivate by converting it to dihydroform and preventing absorption.
Other: Transported in via nucleoside transporter, then P-lated and trapped in cell (needs to fit in kinase)

Purine biosynthesis antagonists

6-mercaptopurine, Mechanism of Action: Competitive inhibitor of several enzymes in purine synthesis pathways (looks
6-thioguanine, like guanine); also gets incorporated into DNA
azathioprine Effects: Purine biosynthesis antagonist; antimetabolite antineoplastic agent.
Indications: leukemias
Administration: oral
Toxicity: Bone marrow suppression
Resistance: inactivated by xanthine oxidase (XO). Decrease in HGPRTase activity is common resistance
mechanism.
Other: Must undergo activation to form mononucleotide (add sugar) via HGPRTase. Also inactivation,
elimination in urine pathways competing.

Inhibitors of DNA polymerase

29
gemcitabine (2', 2' difluorodeoxycitidine)
cytosine arabinoside (cytarabine, Ara-C.)
fludarabine (arabinosyl-2-fluoroadenine)
5-azacytidine (5-aza-C)
2-chlorodeoxyadenosine (cladribine, 2-CdA)
Mechanism of Action: Inhibits DNA polymerase by blocking DNA strand
elongation (substrate but can't elongage afterwards)
Effects: Antimetabolite antineoplastic agent
Indications: pancreatic cancer (gemcitabine), chronic lymphocytic leukemia
(CLL – fludarabine), acute myelogenous leukemia (AML – cytosine
arabinoside)
Toxicity: myelosuppression
Resistance: decreased activity of activating enzymes; decreased nucleoside
transport across cell membrane
Other: Must be activated by deoxycytidylate kinase and nucleoside
diphosphate kinase

New strategies: signal transduction inhibitors

Receptor & non-receptor protein kinases

Resistance to all of these is via amplifaction of oncogenic protein kinase gene, resistance mutations in kinase
catalytic domain. Second-generation protein kinase inhibitors have bene developed (active against mutant PKs)

imatinib Mechanism of Action: inhibits tyrosine kinases (BCR-ABL, c-KIT, PGDF receptor kinase)
Effects: Tyrosine kinase inhibitor; antineoplastic agent. BCR-ABL is a hyperactive fusion kinase implicated in
CML (philadelphia chromosome). PGDF RK = platelet-derived growth factor receptor kinase
Indications:CML, gastrointestinal stromal cancer.
Resistance: amplifaction of oncogenic protein kinase gene, resistance mutations in kinase catalytic domain.
Second-generation protein kinase inhibitors have bene developed (active against mutant PKs)
Other: aka Gleevec. BCR-ABL + cells are resistant to apoptosis, proliferate more, and have altered adhesion
properties.

trastuzumab Mechanism of Action: monoclonal antibody that binds to extracellular region of HER2, a
transmembrane receptor tyrosine kinase from epidermal growth factor receptor family
Indications: Antineoplastic agent. Breast cancer (25% invasive primary breast cancers have HER2
overexpression)
Resistance: amplifaction of oncogenic protein kinase gene, resistance mutations in kinase catalytic
domain. Second-generation protein kinase inhibitors have bene developed (active against mutant
PKs)Resistance:
Other: a.k.a. Herceptin

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cetuximab Mechanism of Action: monoclonal antibody against epidermal growth factor receptor (EGFR).
Indications: Antineoplastic agent. Epithelial tumors (colorectal cancer, head and neck tumors)
Resistance: amplifaction of oncogenic protein kinase gene, resistance mutations in kinase catalytic
domain. Second-generation protein kinase inhibitors have bene developed (active against mutant PKs)

gefitinib Mechanism of Action: Tyrosine kinase inhibitor (inhibits epithelial growth factor receptor kinase)
Indications: Non-small-cell lung cancer (NSCLC)
Resistance:amplifaction of oncogenic protein kinase gene, resistance mutations in kinase catalytic domain.
Second-generation protein kinase inhibitors have bene developed (active against mutant PKs)
Other: Higher response if EGFR mutated or overexpressed.

Anti-angiogenesis drugs (investigational)

Basic idea: formation of new blood vessels essential for tumor progression.
 Protease inhibitors block ECM breakdown
 Inhibitors of endothelial cell proliferation (small molecule receptor protein kinase inhibitors like
Gleevec & endogenous peptides)

Proteosome inhibition

Basic idea:
 NF-kappa-B controls expression of stress response genes & others that promote cell survival
 I-kappa-B inhibits NF-kappa-B, degraded in proteosome after ubiquination to activate NF-kappa-B
 Less proteosome activity = more NF-kappa-B inhibition

Velcade Mechanism of Action: Proteosome inhibitor. Antineoplastic agent

Effects: Inhibits the chymotrypsin-like active site of proteosome.
Indications: myeloma
Other: Boronic acid dipeptide; mimics tetrahedral peptidase reaction site.

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 Cancer Chemoprevention

As many as 80% cancers in men, 77% in women can be prevented – idea is to detect early for public health
intervention before clinical appearance. For instance, Japanese migrants to US assume US-type cancer risk
profile, and their sons even more so (even without genetic mixing).

Long latency for many cancers helps in potential for chemoprevention.

Tobacco and diet are the big risks (30%, 35% cancer deaths attributable respectively)

Can be synergistic interactions between risk factors (e.g. alcohol & tobacco use in squamous carcinoma of
esophagus – 150x higher risk if heavy use of both)

Principles for control of human cancer:

1. Prevention (requires knowledge of carcinogens). Diet, exercise, tobacco, alcohol, etc.
2. Protection: inhibit or attenuate carcinogen effect. Doesn’t require knowledge of carcinogens
3. Treatment of premalignancy (screening).

Cancer chemoprevention: the use of natural or synthetic agents that retard, block, or reverse carcinogenesis
before invasive malignancy develops. (chemotherapy is for those who already have cancer)

To determine preventive measure, need to consider cancer risk, treatment risk, and treatment benefit: low risk
requires low intervention like lifestyle modification, high risk can require high-level intervention like surgery.
Medium-high risk might require chemoprevention.

Breast cancer and Selective Estrogen Receptor Modifiers (SERMs)

Estrogen has good and bad effects (improves cognition, lowers cholesterol, prevents bone loss… but also
increases breast / endometrial cancer & thromboembolism risk).

Tamoxifen and raloxifene are two examples of SERMS – can act like estrogen in some tissues and antagonize
estrogen in others

Several big randomized trials (MORE, STAR, etc.):

1. Tamoxifen vs. placebo (↓ER+ breast cancer but ↑ endometrial cancer, blood clots, stroke)
2. Raloxifene vs placebo(↓ER+ breast cancer but ↑ endometrial cancer, no change in blood clots, stroke)
3. Tamoxifen vs raloxifene – similar but raloxifene fewer endometrial cancers, blood clots

5-α Reductase Inhibitors and Prostate Cancer

Idea: reduce androgen activity. There are a bunch of inihibitors of all steps of androgen synthesis.
In some prostate cancers, oncogene translocated behind androgen-based promoter.

Finasteride and duasteride approved for male pattern baldness, BPH (PC chemoprevention)
 Two big trials (PCPT & REDUCE): big prevalence of prostate cancer already; couldn’t use PSA because
PSA production related to androgens so had to use biopsy
 Outcomes: both saw reduction in prostate cancer, but one showed increase in high grade cancer.

32
  Random area biopsy – maybe shrinking prostate with inhibitors increased chance that high grade cancer
would be found?

Aspirin and Coxibs for Colorectal Cancer Prevention

Basic idea: arachidonic acid, inflammation might be part of adenoma  cancer recurrence in colorectal cancer.
Wanted to use COX-2 inihbitors like celecoxib (Celebrex) and rofexocib (Vioxx) to selectively inhibit COX-2
(NSAIDs, originally for arthritis). COX-2 makes prostaglandins around epithelial cells of GI tract.

Multiple randomized trials

 Aspirin vs. placebo: decrease in colorectal cancer but increased risk of serious GI bleeding
 APC: celecoxib vs placebo. Reduction in polyp recurrence but increase in cardiovascular events 2.6x
 Approve: rofecoxib vs placebo (similar reduction in polyps & increase in CV events 1.8x)

More stuff:
Cruciferous vegetables might help cancer chemoprevention: sulforaphane

Problems that you might run into in chemoprevention

 Toxicity in a large population
 Side effects could be significant & hurt adherence
 No easily identifiable end-point to study (like cholesterol, for instance)
 Need big population and long durations
 Poor definition of the best dose (no dose-response curve easily made)

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 Antineoplastic alkylating agents and platinum compounds

Alkylating agents: basic principles

Akylating agents react with certain nucleophilic areas in DNA (e.g. N7 of guanine) with several consequences:
 Mispairing of modified base
 Crosslinking of DNA bases on same strand (intrastrand) or opposite strands (interstrand)
 Crosslinking DNA to proteins, RNA, other macromolecules
 DNA strand scission (weaken sugar-phosphate backbone; endonucleases attack during repair attempt)

Monofunctional alkylating agents have one arm to react with DNA

Bifunctional agents have two and therefore are the only ones that can crosslink. CROSSLINKING IS KEY.
If bifunctional agents react with water, they can behave like monofunctional agents. Bifunctional agents are
more selective for replicative-based effects because they can work via crosslinking mechanisms

Types of alkylating agents

1. Nitrogen mustards: mechlorethamine is basic nitrogen mustard; very active & used up quickly.
mechlorethamine Mechanism of Action: Bifunctional alkylating agent; antineoplastic agent.
Effects: Forms interstrand or intrastrand DNA cross-links. Can also cross-link DNA to other
macromolecules, cause DNA strand scission, or mispairing of modified base.
Indications: Hodgkin's disease, mycosis fungoides (cutaneous lymphoma)
Administration: part of MOPP regimen. IV, very short half-life
Toxicity: nausea, vomiting, phlebitis, bone marrow suppression
Other: nitrogen mustard. Very reactive (reacts with everything even in blood, so have to give IV)

2. Substituted nitrogen mustards (melphalan & chlorambucil) which are less reactive & can be given po.
melphalan, Mechanism of Action: Bifunctional alkylating agent; antineoplastic agent.
chlorambucil Effects: Forms interstrand or intrastrand DNA cross-links. Can also cross-link DNA to other macromolecules,
cause DNA strand scission, or mispairing of modified base
Indications: multiple myeloma (mephlan), chronic lymphocytic leukemia (CLL), indolent lymphomas,
Waldenstrom's macroglobulinemia (chlorambucil)
Administration: can give PO
Toxicity: bone marrow suppression, amenorrhea, sterility
Other: substituted nitrogen mustard; less reactive than mechlorethamine

3. Nitrogen mustards that require metabolic activation (cyclophosphamide & ifosfamide).

Cyclophosphamide is most commonly used.

34
cyclophosphamide, Mechanism of Action: Bifunctional alkylating agent
ifosfamide Effects: Must first undergo metabolic activation (P450). Forms interstrand or intrastrand DNA cross-
links. Can also cross-link DNA to other macromolecules, cause DNA strand scission, or mispairing of
modified base.
Indications: Cyclophosphamide: Many human cancers (non-Hodgkin's lymphoma, breast cancer).
Can also be used with bone marrow or peripheral hematopoietic stem cell transplantation therapy
(high-dose). Used to treat auto-immune diseases as well. Ifosfamide: sarcomas & many other cancers
Administration: Administering with 2-mecaptoethane sulfonate and vigorous hydration can help
prevent cystitis
Toxicity: bone marrow suppression, alopecia, gonadal toxicity, and hemorrhagic cystitis (diffuse
inflammation of the bladder leading to dysuria, hematuria, and hemorrhage) resulting from excretion
of a reactive metabolite (acrolein). Ifosfamide has more hemorrhagic cystitis, less bone marrow
suppression than cyclophosphamide
Other: Most commonly used alkylating agent. Stem cells have aldehyde dehydrogenase, which
protects from the active form of cyclophosphamide (which means they won't get killed)

Platinum compounds: basic principles

 Early experiments: cis platinum compounds had effect on E. coli, while trans didn’t (from electrodes)
 DNA is target (interstrand & intrastrand crosslinking of DNA, or crosslinking to other macromolecules).
 Difference is in speed of aquation & elimination. Slower aquation (carboplatin, oxaliplatin) means less
kidney damage than cisplatin.

cisplatin Mechanism of Action: DNA cross-linking agent (antineoplastic platinum compound)

Effects: Intra- and inter-strand crosslinking of DNA; crosslinking of DNA to other molecules.
Indications: Wide variety of cancers, esp. epithelial (carcinomas of lung, bladder, stomach, ovary) & testis
cancer.
Toxicity: nephrotoxicity, ototoxicity, peripheral neuropathy
Resistance: chemical detoxification, DNA repair
Other: more side effects (shorter half-life) than carboplatin, oxaliplatin (which have bone marrow toxicity as dose
limiting side effect rather than nephrotoxicity)

carboplatin, Mechanism of Action: DNA cross-linking agent (antineoplastic platinum compound)

oxaliplatin Effects: Intra- and inter-strand crosslinking of DNA; crosslinking of DNA to other molecules.
Indications: Wide variety of cancers, esp. epithelial (carcinomas of lung, bladder, stomach, ovary) & testis
cancer.
Toxicity: bone marrow suppression
Resistance: chemical detoxification, DNA repair
Other: shorter half life than cisplatin (less nephrotoxicity)

35
Mechanisms of resistance to antineoplastic drugs generally fall under two categories:
1. Chemical detoxification. E.g. glutathione, glutathione-S-transferases, etc. Resistance usually comes
from this pathway (think phase II enzymes, etc. – could be upregulated, for instance)
2. DNA repair. Less common – excision repair, mismatch repair, etc.

Side effects related to antineoplastic drug treatment

Think: these are very near to their maximum tolerance, so lots of side effects will happen - low therapeutic index
 Nausea and vomiting
o Profound before; less now
o Complex neurological interactions: chemo triggers pretty much all of these
 Chemoreceptor trigger zone (metabolic disorders, drugs like chemo)
 Peripheral receptors (vagal/splanchnic nerves) – e.g. in gut (damage from chemo)
 Vestibular center (motion sickness)
 Cerebral cortex (anticipatory emesis from chemotherapy)
o All converge to vomiting center in brainstem
o What matters: which drug & how much
 Cisplatin is notorious (as is cyclophosphamide in high doses) for causing nausea
 Less for less dose
o Brainstem receptors use dopamine pathways, so now
selective 5-HT3 receptor agonists work well for
cisplatin nausea and vomiting
 Alopecia
o Usually a few days into 1st or 2nd cycle (1-2 weeks after
chemo)
o Hair will grow back but big psychological effect
o Hair follicle: anagen (growth), categen (involution),
telogen (resting)
 Hair damaged during anagen (growth phase)
 Falls out in order of most growing (most in
anagen) scalp>eyebrows, eyelashes, face, axilla,
body, etc.

 Bone marrow toxicity (granulocytopenia, anemia,

thrombocytopenia, etc.)
o Usually dose limiting toxicities
o Fall & recover in predictable ways
o Chemotherapy-induced neutropenia
 Like clockwork (around 10th day) – PNMs
affected 10-14 days because of speed of
production (stem cells resistant to
cyclophosphamide because of aldehyde
dehydrogenase expression so they don’t die)
 Dose-response doesn’t change timing, just the
depth of the nadir
 Hematopoetic cytokines (e.g. G-CSF) can be
used to shorten the length of the nadir (same

36
 depth, just less broad)
o Transfusion of RBC or platelets can sometimes be used

 Gonadal dysfunction
o Lots of ongoing mitosis/meiosis & proliferation in this area
o Testes > ovarian follicles for dysfunction (ongoing spermatogenesis vs arrested ova)
o Important factors:
 Age/gender (pubertal gonads resistant; women < men for dysfunction)
 Chemo agent & dose (alkylating agents & platinum compounds especially bad
 Make sure to bank sperm / store eggs if possible!
 Some regimens have huge differences in recovery rates

 Secondary cancers (leukemia, etc.)

o Really worrisome – genome damage could lead to malignant transformations
o Limited mostly to alkylating agents: monofunctional agents are carcinogens (modify the base &
cause damage but not necessarily lethal)
 If cell doesn’t die (e.g. if only one arm able to fire for bifunctional agent) normal tissues
can get mutations
o Very hard cancers to treat; up to 10% in Hodgkin’s pts with radiation+alkylators can get AML

37
Additional drugs (maybe know?) Under “other” (alkylating agents?)

Nitrosureas
 Carmustine: lipophilic; treat brain tumors (drug-implanted wafer: glioblastoma multiforme)
o (toxicities: bone marrow suppression, nausea & vomiting)
 Streptozotocin: antibiotic that is retained in beta-islet cells of pancreas; treats islet cells tumors
o Nephrotoxicity, hepatotoxicity, diabetes

Aziridines
 Thiotepa: breast cancer; instill in bladder for superficial bladder cancer
o Usual toxicities
 Mitomycin C: antibiotic – limited use in recta / pancreatic cancer; superficial bladder cancer as instillate
o Usual toxicities
o Rare but significant: interstitial pneumonitis, nephrotoxicity, hepatic veno-occlusive disease,
hemolytic-uremic syndrome

Alkane sulfonates
 Busulfan: high dose chemo for bone marrow or peripheral hematopoetic stem cell transplants
o Usual toxicities + pulmonary fibrosis, hepatic veno-occlusive disease, skin pigment changes

Methylating agents
 Procarbazine: Hodgkin’s disease. Normal toxicities + peripheral neuropathy, sterility, secondary
leukemia
 Dacarbazine: Hodgkin’s disease. Normal side effects + “flu-like” syndrome, Budd-Chiari syndrome,
photosensitivity

38
 DNA Topoisomerase-targeted drugs and mitotic spindle poisons

Many of the other drugs (alkylating agents, etc.) were rationally designed; these are screened natural products

Topoisomerase-targeted drugs

All topoisomerases: reversible nucleophilic substitution; active site tyrosine as nucleophile

 Preserves energy of initial phosphodiester bond; prevents loss of end of DNA
 All form covalent enzyme-DNA intermediates (keep ends of DNA together to minimize recombination /
DSB; reversible – after unwinding, DNA can re-attack the tyrosine-DNA linkage & rejoin
 Help relieve supercoiling / superhelical strain from normal DNA activities (transcription, replication,
segregation, chromosone condensation, etc.)

Type I topoisomerase: monomeric, single tyrosine, Type II topoisomerase: dimeric, two tyrosines, cleave both
cleave one strand of DNA, no ATP requirement strands of DNA, ATP / Mg required
 DNA can freely rotate around remaining  Enzyme holds in place – prevents DSB
strand’s axis  Forms gate – for duplexed DNA to pass through
 Removes one supercoil per cleavage  Removes two supercoils per cleavage

Cell killing mechanism of topo poisons:

 Stabilize covalent complex  DNA replication fork arrest & breakage (DSB)
 (also RNA transcription arrested)
 Topo I: G2 cell cycle arrest
 Induce apoptosis through these mechanisms

Type I topoisomerase-targeting drugs

 Stabilize covalent DNA-enzyme complex by:
o DNA intercalation (“direct block”): wedge in between 5’ leaving group and 3’ phosphate to
sterically block the reversal of the covalent enzyme-DNA binding. E.g. camptothecins
camptothecin Mechanism of Action: Topoisomerase I-targeted drug (antineoplastic agent)
Effects: Intercalates into & stabilizes topo-I / DNA covalent complex (sterically blocks DNA-DNA nucleophilic
topotecan attack & reversal of enzyme-DNA complex formation).
Indications: Solid tumors (first line for colorectal cancer in US/europe), also ovarian & other adult
irinotecan maligancies
(CPT-11) Toxicity: myelosuppression, nausea, hair loss, fatigue. Irinotecan: liver toxicity in patients with
gluconconjugation deficiencies. Early and late onset diarrhea.
Resistance: MDR drug efflux pumps (ABC-type)
Other: lactone ring is not stable at neutral or basic pH (converts to inactive form). Irinotecan: Administered
as a prodrug; more bioavailable but gives diarrhea / liver toxicities from cleaved off prodrug part. Must be
activated by carboxyesterase

o DNA bending (“indirect block”): bend DNA in a way that puts active site in conformation where
reversal of attack isn’t favorable. E.g. minor groove binding agents (investigational).
 Curved structure and positive charges let them fit in to minor groove well

39
  Increase amount of covalent complex by DNA bending; S-phase specific
 Can increase/decrease effects of other topo I poisons

o Actinomycin D
 Induces DNA bending / structural pertubations
 Precise genomic target not known (maybe RNApol instead of topo I)
actinomycin D Mechanism of Action: "hybrid" minor groove binding antineoplastic agent
Effects: Precise target not known. Probably induces DNA bending / structural pertubations (may target
RNA polymerase instead of topoisomerase I)
Indications: Childhood malignancies (Wilm's tumor, Ewing's sarcoma, embryonal rhabdosarcoma)
Toxicity: Usual (myelosupression, hair loss, oral / GI ulceration)
Resistance: MDR drug efflux pumps (ABC-type)

Type II topoisomerase-targeting drugs

 Probably a similar stabilization of covalent complex (not well understood)

Epipodophylotoxins (non-intercalative)
etoposide Mechanism of Action: Topoisomerase II-targeted antineoplastic agent.
teniposide Effects: Nonintercalative; increases covalent DNA-enzyme complex by unknown structural mechanism
Indications: Many types of cancers
Toxicity: Usual (myelosuppression, mucositis, nausea, anaphylaxis)
Resistance: MDR drug efflux pumps (ABC-type)

Anthracyclines (intercalative)
doxorubicin Mechanism of Action: Topoisomerase-II-targeted antineoplastic agent.
daunorubicin Effects: Intercalates into & stabilizes DNA-topo II covalent complex by direct or indirect interaction
Indications: solid tumors (doxorubicin); ALL, AML (acute leukemias) (daunorubicin)
Toxicity: Dose-limiting acute & chronic cardiotoxicity. Liver toxicity (where metabolism occurs -
hydrophobic, so bile excretion).
Resistance: MDR drug efflux pumps (ABC-type). Cardiotoxicity from quinone groups (generates hydroxyl
radicals)

Mitotic spindle poisons

Spindle basics:
 Made of microtubules (α & β subunits; dynamic structure ; bind GTP & hydrolize to GDP)
 Assemble: heterodimers  protofilaments  microtubules
 Important in mitosis (don’t get good DNA segregation without it)
 Lots of tubulin in neurons for axonal transport  neurologic toxicity of tubulin-binding agents

Basic idea: spindle poisons slow microtubule polymerization dynamics.

 Freezing/slowing down the dynamic equilibrium interferes with spindle action during mitosis

40
Vinca alkaloids
 Bind to β-tubulin (as monomer?), which disturbs polymerization & disrupts protofilament structure
vincristine Mechanism of Action: Mitotic spindle poison (antineoplastic agent). Vinca alkaloid
vinblastine Effects: binds to beta-tubulin (distorts protofilament structure / polymerization, slows dynamics, affecting
vinorelbine ability to undergo mitosis)
Indications: ALL, lymphoma, hodgkin's, childhood malignancies (vincristine), germ cell tumors, Hodgkin's
disease (vinblastine), lung, breast cancer (vinorelbine)
Toxicity: liver toxicity, myelosuppression. Vincristine: neurotoxicity (limits dosage)
Resistance:MDR drug efflux pumps (ABC-type)

Taxanes
 Bind to β-tubulin, stabilizing lateral tubulin contacts (freezing filaments in place)
paclitaxel Mechanism of Action: Mitotic spindle poison. Taxane.
docetaxel Effects:Binds to beta-tubulin, maybe stabilizing lateral contacts & freezing protofilament in place. Slows down
microtubule dynamics, hurting ability to undergo mitosis.
Indications: ovarian, breast cancers (paclitaxel), metastatic breast cancer (docetaxel)
Toxicity: dose-limiting myelosuppression. Peripheral neuropathy (paclitaxel more effects than docetaxel)
Resistance: MDR drug efflux pumps (ABC-type)

Mechanisms of drug resistance

1. Multidrug resistance: ATP-dependent transporter proteins (ABC family = ATP-binding cassette).

a. Cellular drug efflux
b. Intracellular redistribution of drug away from target (?)

Drug needs to accumulate in cell before it has an effect.

Also important in antibiotic therapy (bacteria have these too)
These pumps are very non-specific

2. Atypical drug resistance

o Mutation of drug binding site (e.g. HIV drugs)
o Downregulation of gene expression of protein target (e.g. topo I/II)
o Ubquitination & proteolysis of target protein (topo I/II)
o Decreased enzyme activity for activation of prodrug (e.g. carboxylesterase & irinotecan)

3. Detoxification by metabolism (e.g. phase I, phase II enzymes) – overexpress or increase activity

41
 Pathology: ID & Micro
Pathology of Bacterial Infections ............................................................................................................................................ 2
Streptococci (I & II) ................................................................................................................................................................. 5
Enterococci.............................................................................................................................................................................. 9
Listeria & Other Gram-Positive Rods .................................................................................................................................... 10
Introduction to Gram-negative Bacilli................................................................................................................................... 14
Fastidious Gram Negative Rods ............................................................................................................................................ 17
Non-fermentative Gram Negative Bacteria .......................................................................................................................... 20
Neisseria Species ................................................................................................................................................................... 23
Anaerobic Gram Positive Bacteria ........................................................................................................................................ 25
Emerging and Re-emerging Bacterial Zoonoses ................................................................................................................... 28
Pathology of Mycobacteria Infection.................................................................................................................................... 31
Vector-Borne Zoonoses ........................................................................................................................................................ 34

1
 Pathology of Bacterial Infections
Final outcome determined by host & bacterial pathogen: can direct Tx towards both
Examples: think about what bacteria has to overcome to get in!
 Respiratory entry: eyes (blinking, tears, lysozyme, secreted IgA, lactoferrin sequesters iron); nasopharynx
(microflora, secretions); lungs (resident macrophages)
 GI tract entry: mouth (sloughing cells, flow of saliva, lysozyme, sIgA, microflora, lactoferrin); stomach (low pH,
proteolytic enzymes), small intestine (fast flow, mucous, sloughing cells); colon (slow flow, sloughing cells,
mucus, lots of resident microflora)

Pathologic & histopathologic correlates of bacterial infection

Acute inflammation:
 PMNs (purulent): marginate & extravasate, eventually followed by mononuclear cells (48h: Mφ & plasma cells)
 Can have necrosis (suppuration)

Chronic inflammation:
 Key: Lymphocytes & Macrophages (= histiocytes)
1. Granulomas: aggregates of lymphocytes & histiocytes; often with fibroblasts & giant cells
2. Granulomatas: poorly aggregated infiltrates of lymphocytes / histiocytes
3. Chronic nonspecific inflammation: mostly infiltrates of lymphocytes, fewer histiocytes

Major types of histopathologic inflammatory responses to bacterial pathogen infections

1. Exudative +/- necrosis

o Usually localized
o Vascular permeability ↑; recruitment of PMN & other WBC ↑
o Non-necrotizing: examples
 S. pyogenes
 Pharyngitis (“strep throat”): pus on tonsils; swollen (edema) – lots of PMNs
 S. pneumonia
 Pneumonia: lobar, generally resolves well (not necrosis, just fill up alveoli with exudate
& PMNs. Turn firm because filled up = consolidation)
 Meningitis: meninges / septae too wide (inflammatory cells); inflammation can cause
bystander damage (neurological sequelae). Gross pathology: meninges cloudy (filled
with leukocytes)
o Necrotizing
 Exudative with necrosis = suppuration
 Host damage: can be from bacterial virulence factors
 P. aeruginosa
o Pneumonia: consolidation with infiltrate; makes lots of toxins (cell damage &
death); lots of hemorrhage and necrosis
 Clostridium perfringens
 Myonecrosis (gas gangrene): big gas bubbles produced; inflammation & necrosis

2. Chronic inflammation +/- granulomas

o Granulomas & granulomatous inflammation
 activated epitheliod Mφ, lymphocytes, etc.
 Response to bacteria that withstand PMN phagocytosis
o Granulomas:
 M. tuberculosis: granulomas (nodular) with giant cells; caseous necrosis in center
 Little red bacilli with acid fast stain within or outside cells
2
 o Granulomatous inflammation (more diffuse; same cells but less organized)
 M. leprae: foamy Mφ; more diffuse organization; acid-fast rods inside cells
o Interstitial Inflammation
 Nonspecific morphology (chronic, nonspecific inflammation)
 Virus, Mycoplasma, Rickettsia, spirochete infections (if in infectious clinical setting)
 Mycoplasma pneumonia: Interstitial pneumonitis
 Thickening of alveolar spaces, lots of cells & fluid in interstitium (hurts O2 exchange)

o When do granulomas form and when does general chronic inflammation happen?
 Cytokines IL-1B, IFN-γ, CXCL, CCL  granuloma forms
 Different cytokines IL-4, IL-10  chronic inflammation
 Each type of cytokine suppresses the other response

3. Cytopathic
o Most typical of viral infections
o Can be seen with intracellular bacterial infections
 Chlaymydia trachomatis – U/G infections
 Cervix red, swollen; purulent mucoid exudates
 Chlamydia grows within vacuoles intracellularly
4. Cytoproliferative inflammation
o Bartonella spp. (henslae) – angioproliferative responses (cause blood vessels to overgrow)
 Esp. in HIV patients, causes dermis to be replaced by vascular structures
 From cats (also causes cat scratch fever)
5. “Null reaction”
o Absence of inflammatory, necrotizing, or cytopathic responses
o Rare in bacterial infections
o Can occur with neutropenia, immune compromise (HIV, cancer chemo, genetic defects) or by rapid,
unrestricted bacterial growth
o Vibrio vulinficus with neutropenia: tons of Gram (-) bacteria but just a few inflammatory cells
o Bacillus anthracis (anthrax): skin, meninges, inhalational. Bacteria grows faster than immune response
is mounted (also suppress immune response)

Extracellular vs Intracellular bacteria: differences in response

Extracellular:
 Acute inflammation (PMNs) +/- necrosis (depends on virulence factors)
1. Acute inflammation with edema
2. Necrosis  pus formation (suppuration) or abscess formation
 Eventually gives way to mixed acute & chronic inflammation
 Examples: S. pneumonia, S. aureus, P. aeruginosa, most other bacteria

Intracellular: both facultative & obligate

 Chronic nonspecific or granulomatous inflammation
1. Granulomas (e.g. M. tuberculosis)
2. Chronic nonspecific or lymphohistiocitic inflammation (e.g. mycoplasma, rickettsiae, chlamydiae,
spirochetes)
 Initially chronic inflammation +/- acute inflammation (chronic or mixed)
 Can cause necrosis
1. Caseous (e.g. granulomas)
2. Microabscesses (granulomatous inflammation)
3. Host-cell-specific necrosis or apoptosis
 Examples: M. tuberculosis, R. rickettsii (Rocky Mountain Spotted Fever), C. trachomatis (U/G infections)

3
 Effects of alterations in host defense, inflammation, immunity

1. Physiologic defects
 Cystic fibrosis (no appropriate mucous production = ↑ lung infiltrates)
 Achlorhydria (can’t generate acid in stomach = ↑ lower GI infections)
2. Host can’t make inflammatory cells: no inflammatory infiltrates (congenital neutropenia, etc.)
3. Host inflammatory cells can’t accumulate: no inflammatory infiltrates
 Leukocyte adhesion molecule deficiency (don’t see WBC at site of infection)
4. Host immune suppressed (HIV, Rxs): modified inflammatory response
 Chronic granulomatous disease (↓ superoxide radicals in phagocytes: see bacteria ingested but not
destroyed)
 Complement deficiency, asplenia = ↑ susceptibility to encapsulated bacteria (need C’ to opsonize)
 Hypogammaglobulinemia = ↓ opsonization
 HIV, cancer therapy, corticosteroid, immune suppressive therapy = ↓ T-cell responses
 Interferon-γ receptor deficiencies = recurrent Mycobacteria and Salmonella infections

Hosts that lack inflammatory response = not well protected against effects of infection

Laboratory tests to identify bacterial infections

I. During active infection: Finding Organism

1. Nonspecific morphological PMNs in gastric mucosa H. pylori
identification (Gram stains, tissue Abscesses with “sulfur granules” Actinomyces spp
sections) Caseating granulomas M. tuberculosis
o Initial inflammatory response Lymphocytic vasculitis R. rickettsii
usually stereotypical and (Rocky Mountain Spotted Fever)
nonspecific
o Can use inflammation type, special stains, anatomic location, other clues
 H. pylori: seagull-shaped; on surface of mucosal epithelium; can use silver stain. PMNs in pits of
gastric epithelium
 Actinomycosis: huge GPR collecting in abscesses with fibrous appearance; sulfur granules
 M. tuberculosis: acid-fast stain, or can use fluorochrome
 R. rickettsii: petichae, lymphocytic vasculitis (lots of lymphocytes around / in vessels & walls; R.
rickettsii in endothelial cells
2. Culture
3. Direct detection in clinical samples (fluorescent Ab, in situ hybridization, PCR)

II. Examining host immune response

 Serological (Ab detection): antibody present, seroconversion – looking at humoral immunity
o Ab titer increase: usually want to look @ onset of illness & follow titer level. Compare acute phase (low
titer) to chronic phase (higher titer) to confirm Dx.
o Fluorescence tests for Abs too (indirect)
o Agglutination (mix serum with antigen & look for agglutination)
o Western blots (HIV, Lyme disease)
 Cellular immunity tests (e.g. PPD)
 Lymphocyte proliferation test
 IFNγ production test

4
 Streptococci (I & II)
General Features of Streptococci:
Structure Streptococci: Major Pathogens
 Gram (+) cocci (GPC) in very nice Str. pyogenes Group A Most frequent cause of bacterial
chains and pairs (division in 1 plane). infection globally
Remain attached via thin cell wall Str. agalactiae Group B Peri-natal & opportunistic
bridges Str. pneumoniae Primary cause of pneumonia &
 Non-motile, non-spore bearing meningitis globally
 Gram (+) cell wall +/- capsule (major Viridans group Relative wimps
pathogens do have capsule)
Physiology Organism Normal flora in…
 Fastidious: enriched media, narrow pH/temp ranges Viridans #1 aerobic colonizer of upper
 Aerobic & facultative anaerobes resp tract (#2 aerobic on skin)
 Fermentative metabolism (glucose  lactic acid, not Group A Small #s of individuals
Krebs cycle) Group B Normal below the belt
 Catalase NEGATIVE Str. pneumoniae Depends on country & season
o No cytochrome oxidative system (Gram
negatives, S. aureus, etc. do have)
Classification
 Hemolytic reaction
Hemolysis Examples Blood agar
Beta (produce H2O2, lyse RBC) Groups A & B (also C,D,F,G) Clear
Alpha (degrade Hb to met-Hb) Viridans group Green
Str. pneumoniae
Non-hemolytic (“gamma”) Red
 Immunologic
o Grouping: based on C-polysaccharide antigen on cell wall
o Typing (for Group A): based on M-protein
 Genetic: 45+ strains known

Str. pyogenes
Group A strep virulence factors: Cytolysis and spreading factors

Cell-associated:
 Hyaluronic acid capsule (unusual – most just complex
polysaccharide) – INHIBITS PHAGOCYTOSIS
 M-protein (typing)
1. Inhibits C’ fixation
2. Major adherence factor: binds with LTA so cells can adhere
to pharynx, skin & not be washed away
 Protein F: binds to fibronectin, adherence factor
 Lipoteichoic acid (LTA): binds with M-protein; adherence factor
 Cell-bound peptidase: inhibits C’
 Peptidoglycan layer
 Has fimbrae (M-protein + LTA) to help adhere

Extracellular:
 Hemolysins O (oxygen labile) and S (oxygen stable)
5
 o Large zone of beta-hemolysis; most strains have both but if they’ve only got one, it’s O
o O: very antigenic (make Ab)
 Endonucleases: digest nucleic acids, nuclei of leukocytes.
o Fewer WBC around than Staph infections, etc. because of endonucleases
 Streptokinase: liquefies material around cells; dissolves clots
 Pyrogenic exotoxins (A, B, C)
 Toxic shock toxin (like S. aureus toxin)
 Many others (so organism can diffuse throughout body)

Clinical features: Local manifestations: edema, heat, erythema, pain, spreads with extreme rapidity, few PMN-rich
abscesses, systemic manifestations too

Toxigenic strains: toxic shock, scarlet fever

Disease presentations:
 Pharyngitis (also other URI: otitis, sinusitis). Pus; grayish-white discharge; edematous tonsils. Complications:
clotting / obstruction / jugular vv infections. Common in children, closed populations (college, military). 3-5
days: transmissibility decreases
 Skin / soft tissue: erythema, edema, pain
o Impetigo: frequently staph/strep mix; painful, swelling, little clear fluid-filled vesicles if strep only.
Different M-protein types than pharyngitis types
o Celulitis: superficial skin infection. rapid spread, advances up lympathics (reddish streaks). Huge
vesicles with clear fluid later
o Necrotizing fasciitis / myositis (killing skin / muscle cells). Abx don’t reverse damage – need surgical
intervention. Path: dead mm cells, no PMNs
 Puerperal (post-delivery) sepsis – more historically no.
 Scarlet fever
o Str. pyogenes strain producing pyrogenic toxin (plasmid-mediated). Usually pharyngitis-associated
o Scarlatiniform sandpaper rash (upper chest to trunk, extremities); strawberry tongue
o Desquamation follows
 Toxic shock syndrome: strep TSS parallels S. aureus’
 Post-streptococcal diseases (immunologic cross-reactions between strep antigens & heart or kidney)
o Rheumatic fever (9-10d post-infection)
 Any M-protein type; reinfection has same latency
 Heart (myocarditis, valves); joints (arthraligias, arthritis), skin (erythema marginatum), CNS
(Sydenham’s chorea)
o Glomerulonephritis (few days post-infection)
 Specific M-types implicated
 Proliferative disorder of renal glomerulus
 Edema, hypertension, hematuria, proteinuria
 Can have no sequellae or progress to end-stage renal disease

More likely to transmit if high amount, in nose/throat; less likely if you’ve been a carrier for a while.

Str. agalactiae
Regular polysaccharide capsule (inhibits phagocytosis & C’)
 9 serotypes (M-proteins) with different capsule composition
CAMP factor (hemolysin)
Small zone of B-hemolysis
Found in normal GI flora; vaginal tract of 5-30% sexually active women

6
Can be primary or co-pathogen in immunocompromised

Clinical presentation: causes neonatal sepsis and meningitis (early & late forms)
 Associated with prolonged rupture of membranes in colonized mother
 Early onset: 1st 6 days. Septicemia (60%), also pneumonia (30%), meningitis (10%). 10% mortality
 Late onset: 7d-3mo. Majority due to type III; may be fulminant with septic shock & severe meningitis
 Neurologic sequellae: 25-50% children
Prevention:
 Maternal screening
 Prophylactic antibiotics (if colonized mother or any mother with prolonged membrane rupture)
Str. viridians Group
General characteristics:
 Alpha-hemolytic (green pigment)
 Relatively non-virulent
 Normal flora of respiratory tract, vaginal tract, skin, other

Pathogenicity
 Endocarditis: relatively indolent, really needs damaged setting (e.g. IV drugs, then lands on already damaged
heart valve)
 Abcesses(most common cause of liver abscesses. Complications: rupture  hemorrhage, high mortality rate.)
o Str. anginosis, Str. intermedius, Str. constillatus
 Dental caries: Str. mutans (part of gingival flora, clings to enamel)
o To get caries: need right microflora, diet, and host/teeth situation.
o Str. viridians is most common aerobe in oral flora
o Virulence: from high acid production
 Septicimia in immunocompromised patients
 Co-pathogens in mixed flora infections (e.g. Gram + and – together)
 Non-infectious events: chronic gingivitis  atherosclerotic plaques?

Str. pneumonia (“the pneumococcus”)

 Gram positive, in pairs & chains like others (prominent pairs)
 Physiology: fastidious, narrow pH/temp ranges, fermentative Lab diagnosis:
metabolism, catalase negative (like other strep), prefer 5% CO2  GPC in pairs (& chains)
 Alpha hemolytic
Polysaccharide capsule: high MW, complex polysaccharides  inhibited by optochin
 Types defined by capsule antigens  Bile soluble
 Different types have different virulence, C’ and cytokine reactivity,  Quellung reaction (add anti-
Abx resistance, and preferred sites of pathogenicity pneumococcal Ab, see swelling)
 Lots of cross-reactions (other microbial capsules, blood group
antigens, other foreign polysaccharides)
o Can get antibodies very early in life via cross-reactivity
o Capsule very antigenic; repeat infection with same type is rare

Genetic features
 Transfer of DNA via transformation, phages, conjugation
o Transformation ability varies with capsule type, inflammation (cytokine activation), other types of
stress, antibiotics, starvation, chemical exposure. E.g. Abx can induce ability to acquire resistance!

Virulence factors: major one is the capsule (blocks phagocytosis if specific antibody not present).
 Need capsule for virulence (capsule + rest of pneumococcus too)

7
  Cell-surface-associated:
o pili (adherence)
o cell wall polysaccharides (induce inflammation, activate C’)
o surface protein A: inhibits activation of C’,
o autolysin (how pneumococci commit suicide when they don’t like where they are)
 Cytoplasmic (release of these as cells lyse are primary cause of death within 48 hours despite abx):
o Autolysin: releases pnemolysin & cell wall products
o Pneumolysin: cytotoxin, activates C’/cytokines
o Neurominidase: exposes host cell receptor sites
o Peptide permeases: enhance adhesion
o Others (hemolysin, hydrogen peroxide, etc.)

Pathogenicity:#1 cause worldwide of pneumonia, meningitis, otitis, sinusitis

 Normal flora in 20-100% individuals (colonization: normally host makes protective Ab preventing blood-based
spread, from this normal exposure)
o Direct infections (otitis, sinusitis) can still occur
 Facultative pathogen; produces intense inflammatory response without necrosis
 Major cause of death at age extremes

Pneumonia
 Occurs with newly acquired type that patient doesn’t have Ab to
 Typical case: respiratory viral infection, fever recurs 4-7d post viral infection, pneumonia sets in
o Virus damages ability to clear tracheobronchitic tree, destroys ciliary epithelial cells, produces excess
mucus & fluid, blocking normal clearance
 Often begins with aspiration of oropharyngeal contents (alcoholism, neurologic impairment, etc.)
 Purulent nasal discharge, lobar pneumonia, intact alveolar structure, inside of alveoli jammed with
inflammatory cells. Radiology: alveolar infiltrate
 Little residual morbidity – can resolve well (not destroying alveoli)

Meningitis: Meninges jammed with PMNs, not in brain tissue

 3x mortality of N. meningitis; more frequent, more sequelae (CNS, deafness)

Pneumococcal septicemia: especially common in sickle cell children (give PCN prophy until vaccination possible)

Management:
1. Antibiotics (Penicillins, others).
a. Rapidly emerging resistance
i. PBP mutations: “intermediate” resistance, can overcome with ↑ dose sometimes. Increasing
doses doesn’t help for endocarditis or meningitis (just can’t get *drug+ high enough in there)
ii. B-lactamase development
b. Less active: cephalosporins (used to be 2nd line, now resistance emerging too)
c. Varies with location
2. Prevention (vaccines)
a. 23-component vaccines (23 different types / polysaccharides)
b. Different kinds: peds vs adults
c. Vaccine works less well in older patients (although mandated to offer to all pts > 55yo on discharge
from hospital & document reasons for refusal)

8
 Enterococci
General features:
 Look like strep (GPC in chains); metabolism like strep (facultative anaerobes, fermentative metabolism)
 Catalase negative (but can make a little bit if they receive DNA from other spp)
 Not fastidious (permissive pH range, no enriched media required, etc.).
o Survive heating, dessication, resistant to disinfectant products (good at health care spread)
o Not damaged by gastric pH
 Part of normal gut flora (E. faecalis & E. faecium are most prevelant)
 Mostly non-hemolytic (some spp alpha-hemolytic; very rare strains beta-hemolytic)
 Grow as small grayish colonies on blood agar

Structure: normal gram+ cell wall, no flagellae, +/- capsule

Infectivity:
 Commensals (below diaphragm – colonic flora, vaginal flora, external genitalia)
 Facultative pathogens

Virulence factors (importance unknown): adherence factors, cytolysins, permeability factor, gelatinase, aggregation
factor (clumping), superoxide production
 LTA: can exhibit endotoxin-like features of septic toxicity (incl. hypotensive shock) in large amounts
 Biofilm formation (especially hearty)

Diseases:
 E. faecalis (60-70%) & E. faecium (10-20%)
 Most commonly: mixed infections (e.g. abscesses below the diaphragm)
o Intra-abdominal abscesses, colonic diverticulitis, urinary tract, gall bladder
 Enterococcal endocarditis
o Classic presentation: elderly male with obstructive uropathy
o Unlike S. aureus, symptoms commonly indolent; low grade fever often ignored
o (especially big abx diffusion problem)
 Septicemia (predominantly in debilitated / immunocompromised; mortality 42-68%)

Resistance:
 VRE: vancomycin-resistant enterococci (esp. E. faecium). Hospitals, nursing homes (where abx are used
commonly); hand-spread; 50%+ mortality
o Some strains have developed resistance to all new alternatives – no effective antimicrobial choices
 Can transmit resistance genes to S. aureus: MAJOR CONCERN

9
 Listeria & Other Gram-Positive Rods

Listeria Monocytogenes
Characteristics:
 Short, gram-positive rods, can live intracellularly
 Survives & grows at low temp (fridge), low pH (stomach acid), high [salt]: overcomes food prep barriers
Colonizes: animals, humans, soil, vegetative matter
 Food-borne illness (listeriosis): contaminated meat, dairy, fruits, vegetables (rinse!)

Pathogenesis:
 GI tract  blood  meninges
 Invades, survives in variety of cell types

 Intestine: provokes active endocytosis (“internalins”) to cross mucosal barrier; survives intracellularly
o Escapes death in lysozome: formes pores to get out of phagolysosomes
o Replicates in cytoplasm (molecular mimicry: proteins look like host proteins)
o Promotes actin polymerization, makes “comet’s tail” that pushes organism out into adjacent cell
o Covered by host cell membrane (more molecular mimicry) in
next cell Lab diagnosis of Listeria:
 Spread hematogenously  Culture: grows well (30-37 °C best)
 Virulence factors: many; survival & invasion. Internalin helps  Blood agar:
internalize, listeriolysin O (LLO) helps organism escape from o small white colonies
phagocytic vacuoles (inserts pore), Act A induces actin polymerization o beta-hemolytic
 Catalase positive
Epidemiology: major cause of bacteremia & meningitis
 Characteristic tumbling motility
 Immunocompromised (especially cell-mediated immunity) and
elderly patients
 Colonized mothers (can be asymptomatic)  can pass to fetus
 High mortality (500-600 deaths; 2500 cases in US/yr)

Clinical presentation:
 Febrile gastroenteritis (6-48h incubation) in healthy persons. Self-limited. Many asymptomatic.
o Fever/chills, abdominal pain, diarrhea, nausea/vomiting, myalgias
 Bactermia: (pregnancy or immunocompromise)
o “bactermia without an obvious source”
o Fever/arthalgias, headache, GI symptoms, backache: or asymptomatic.
 Meningitis: 2nd most common cause of bactermia in adults > 50 yo; 5th overall
o Usual presentation of meningitis (stiff neck, headache) but:
 CSF glucose not low
 Mononuclear cells can predominate (intracellular; others = PMNs)
 Pregnancy: somewhat immunocompromised (predisposition)
o Can be infected in last ½ 2nd trimester & 3rd trimester
10
 o Listeria can proliferate in placenta (infect child in utero)
o Stillborn / neonatal death: up to 20%
 Neonatal infection
o Disseminated form of disease: granulomatosis infantisepticum
o Late onset up to 2 wks post-partum; meningitis
o Hepatomegaly

Treatment: Ampicillin; TMP+SMX for PCN allergic (but watch out for kernicterus!?)
Bacillius spp.
General Characteristics:
 Aerobic, Gram positive rod
 Spore forming; ubiquitous
 Major pathogens: B. anthracis (anthrax), B. cereus (bacteremia, wound / eye infections, food poisoning)

Bacillus anthracis
Acquisition: Soilherbivoreshumans acquire via inoculation with spores:
 Inhalation*, ingestion*, or trauma (*=more lethal)
 Mostly in agrarian societies
 Category A biological terrorism agent (easy dissemination, high mortality, social disruption)

Pathogenesis
 Spores  skin, GI tract, lung  germinate in Mφ to regional lymph nodes  local production of
toxinsedema, necrosis  bacteremia, toxemia
 Virulence factors:
o Capsule: inhibit phagocytosis
o Protective antigen: binds to cell membranes (better binding/transport of edema factor & lethal factor)
o Edema factor:
 ↑ cellular cAMP; ↑membrane permeability (↑edema)
 ↓PMN function, ↓cytokine pathways (↑ proliferation, bacteremia, systemic infection)
o Lethal factor: Zn-dependent protease. Cleaves MAP kinases, oxygen radicals released
 Leads to Mφ lysis and cell death
Pruritic: itchy
Eschar: scab
Clinical presentations: Papule: circumscribed, solid elevation
 Cutaneous anthrax: of skin with no visible fluid, varying in
o Pruritic papule  enlarges (round ulcer)  painless, black size from a pinhead to 1 cm
eschar (dries, falls off); regional lymphadenitis FYI: Anthracis = “coal” (black eschar)

 Inhalational anthrax: mortality close to 100%

o 1-6d incubation; initial Sx flu-like (non-specific:
Anthrax Dx:
malaise, fever, non-productive cough, chest
 Hx of exposure; appropriate presentation
discomfort)
 Gram stain
o Rapid progression: dyspnea, cyanosis, shock
o Large, gram(+) rods in chains
o Hemorrhagic mediastinitis
 Culture:
o Meningitis can occur
o Blood, CSF, pleural fluid
o Radiography: mediastinal enlargement (hilar,
o 6-24h growth on 5% sheep’s blood
mediastinal lymphadenopathy  hemorrhage)
o Medium gray irregular colonies, swirling
o Pathology: tons / sheets of purple anthrax bacilli, tons
projections
of hemorrhage
o Non-hemolytic & non-motile
o PCN susceptible
 Gastrointestinal anthrax: 25-60% mortality

11
 o Ingestion of vegetative bacteria (not spores) from poorly cooked, contaminated meat  ulcers in all
areas of GI tract  regional lymphadenopathy  nausea, vomiting, bloody diarrhea, sepsis
(excruciating pain)
o Pathology: intense submucosal hemorrhage

Treatment:
 EARLY administration of antibiotics is crucial
 Penicillin, doxycycline, ciprofloxacin
 Vaccine: military use only unless exposed to spores (lots of side effects; anthrax is rare)

Bacillus cereus
Soil organism; broad range of clinical syndromes
B. cereus Dx:
 Gram’s stain: GPR in chains
Clinical presentations:
 Culture
 Food-borne illness (especially rice that was left sitting out)
o Grows well on 5% sheep’s blood
o Diarrheal type: heat-labile enterotoxin; 8-16h post exposure
o Large, feathery, spreading colonies
o Emetic type: heat-stable enterotoxin; 1-5h post-exposure
o Beta-hemolytic (not anthrax)
 Ocular disease (penetrating trauma: bacteria in soil; almost always
o Organisms are motile, lecthinase
lose eye) & Wound infections (healthy persons): extensive damage,
(+) (not anthrax)
liquefactive necrosis
 Bacteremia, endocarditis, abscesses in immunocompromised pts & IV drug users

Treatment:
 Food poisoning: usually self-limited
 Produces broad-spectrum β-lactamase: resistant to PCNs & cephalosporins
 Vancomycin, clindamycin are active

Cornyebacterium diptheriae
General characteristics of Cornyebacterium spp.
 Aerobic bacteria, non-spore forming, Gram-positive bacilli
 Curved or club-shaped (corney = club)
 Catalase positive
 Normal flora of skin, mucous membranes of mammals; hard to distinguish colonization/contamination/infection
 Need to ID to species level when isolated from normally sterile sites, urine (if lots), clinical material

Cornyebacterium diptheriae: most important pathogen

 Humans = only known reservoir; Asx carriers = important for epidemics
 Spread: airborne respiratory droplets, direct contact with resp. secretions or exudates from skin lesions,
contaminated milk
 Most cases: colder months
 N. America: mostly disadvantaged groups (skin infections)
 Vaccine-preventable

Pathogenesis
 Non-invasive
 Exotoxin: major virulence factor
o 2-segment polypeptide
 B-segment (binding): bind to receptors on susceptible cells
 A-segment (active): inhibits protein synthesis in mammalian cells

12
 o Can affect all cells in body (heart, nerves, kidney most common)
o Also contributes to pseudomembrane production

Clinical presentation:
 Respiratory tract disease: 2-4d incubation period; can have local inflammation at various sites
o Pharyngeal (most common)
1. Abrupt onset (fever, malaise, sore throat)
2. Pseudomembrane forms & spreads
 one or both tonsils  oropharynx, nasopharynx, soft palate
 white then dirty gray with black necrosis
 Can compromise & distort lower airway: “bull’s neck”
o Systemic complications from toxin: myocarditis, neurotoxicity (cranial neuropathies)
 Cutaneous:
o Non-healing ulcers, dirty gray membranes, C. diptheriae Dx:
superinfected with other bacteria  Presumptive dx: clinical
o Outbreaks among alcoholic homeless, impoverished
 Definitive dx: isolate, ID organism
(no boosters, poor sanitation)
 Notify state lab (reportable) & send
o Rarely associated with toxigenic illness
material
 Others: can have invasive disease (e.g. endocarditis) with
 Lab dx: sheep’s blood & selective medium
non-toxigenic C. diptheriae

Treatment & prevention

 Strict isolation
 Antibiotics: PCN or erythromycin for 14 days
 Supportive care
 Vaccine: part of childhood DTaP series (4 doses total); booster at school entry, every 10 years with tetanus

13
 Introduction to Gram-negative Bacilli
Gram negative bacilli: rods that stain red by Gram’s stain;
 large, diverse group
 Classification: growth requirements, phenotypic or genotypic characteristics, disease associations

Major categories of GNRs:

 Enterobacteriaceae – fermenters. Enteric pathogens & non-enteric infections
 Glucose non-fermenting GNRs
 Oxidase positive fermenters (cause diarrhea)
 Fastidious GNRs: require specialized media / growth conditions
 Anaerobic GNRs
 GNRs associated with zoonoses

Can use selective material which is inhibitory to Gram (+), e.g. MacConkey agar, to isolate Gram (-)
 Red/pink: acid produced, lowers pH, lactose fermenter
 Clear: non-lactose fermenter; diarrheal pathogens
 No growth: not Gram (-)

Enterobacteriaceae (this lecture)

General characteristics:
 Tons of diversity, found in GI tracts of humans, animals, fish, etc. Some Enterobacteriaceae:
also in environment: soil, water, plants. Certain kinds (Salmonella,  Ferment glucose (often with
Shigella, Yersinia) shouldn’t be in humans ever. gas production)
 Facultative anaerobes (rapid growth with or without O2)  Reduce nitrates to nitrites
 Grow readily on simple material (12-8h incubation).  Catalase: positive
 Diseases: all major categories except STDs  Cytochrome oxidase: negative
Morphology: large, parallel sides, rounded ends
 Some strains: peritrichous flagella (go around whole circumference)
 Some: encapsulated
 Many: surface pili for adherence
 Do NOT form spores

Antigenic structure (serotyping):

 O (somatic) antigen (= LPS = endotoxin): cell-wall LPS, heat-stable (IgM response)
 K or Vi (capsular) antigens: cell surface polysaccharide (Vi = virulence, for salmonella)
 H antigens: externally located flagellar proteins (IgG response)

Remember the gram (-) cell wall: has porins in OM; antimicrobial resistance: mutate porin so drugs can’t get in

Urinary tract infections

Community-acquired:
Types of UTIs
 80% from uropathogenic E. coli, then Klebsiella and Proteus
 Urethritis (urethra)
 Predisposition: anatomy, density of mucosal receptors, sexual activity
 Cystitis (bladder)
Hospital-acquired  Pyelonephritis (kidney)
 Frequently in patients with indwelling bladder catheters
Usually ascending; can be
 E. coli still main cause; also other resistant Gram (-)s
descending (from kidneys)
14
E. coli: Need uropathogenic strains: low pH in urine, lots of antimicrobial compounds in urine
 Specific fimbriae (type 1, good for colon/vagina colonization), pili (P pili:
E. coli: Lab Dx
adherence to urinary tract)
 β-hemolytic on sheep’s blood
 Toxins: endotoxin and α-hemolysin (pore forming cytotoxin; explains
 Lactose fermenter
hemolysis, causes toxicity to uroepithelial cells too)
 Rapid indole positive
 Aerobactin – siderophore (chelates iron)

Proteus spp.
 Associated with UTIs, urolithiasis (stones) Proteus: Lab Dx
 Proteus mirabilis, Proteus vulgaris  Non-lactose fermenter
 Cycle: Proteus produces urease, hydrolyzes urea to CO2 + NH3   Very motile (swarming over
neutralize/alkalinize urine  inorganic compounds fall out of solution & agar plate)
crystallize  stones  become embedded & reinfected

Klebsiella pneumoniae
 UTIs, pneumonia; hospital-acquired infections with multidrug resistance Klebsiella pneumoniae: Lab Dx
 Mucoid capsule (important for virulence)  Non-lactose fermenter
 Get in lungs/urine; huge inflammatory response  Non-motile
 Disgusting mucoid colonies

Gram-Negative Pneumonia
Predisposing factors: Gram (-) pneumonia Pneumonia
NON-HOSPITALIZED HOSPITALIZED 1. Rapid growth
 Underlying cirrhosis (↑ encapsulated infections)  Diminished cough reflex, anesthesia 2. Inflammation (intense,
 Loss of consciousness, alcoholism, drug abuse  Mechanical ventilation PMNs)
 Elderly, immunocompromised  Immunocompromised 3. Inefficient killing of organism
(varies with host)
Klebsiella pneumoniae 4. Obstruction, obliteration of
 Pneumonia: necrotizing, develop cavitation in areas of consolidation lung tissue
o If you survive: chronic lung disease (pulmonary fibrosis) 5. Death (tissue / host)

Aerobic Gram-Negative Rod Meningitis

0-4 wks Grp B strep, E. coli, L. monocytogenes, Salmonella
Aerobic GNR meningitis
4-12 wks Grp B strep, E. coli, H. influenza, S. pneumoniae, N. meningitidis
3mo – 50 yrs S. pneumoniae, N. meningitides (H. influenza in adolescents)  E. coli (75% capsular type K1)
> 50 yrs S. pneumoniae, N. meningitides, L. monocytogenes, aerobic GNR  Klebsiella sp
 Predominantly neonates, elderly, neurosurgery pts  Salmonella sp
 Don’t let your babies play with snakes & iguanas! (salmonella)  Pseudomonas aeruginosa
 Other factors: immunocompromise, head trauma/neurosurgery, CNS
shunt (↑ aerobic GNR meningitis)
Bacterial meningitis: Lab Dx:
Neonatal meningitis: Exposure/colonization (Asx?) during birth + poor immune
LP: response  bactermia  meningitis
Other agents:  ↑: pressure, WBC, PMNs, protein, lactate
 Citrobacter koseri (sporadic cases, utilize citrate);  ↓: glucose
 Enterobacter sp (yellow pigmented, highly virulent, MDR) Gram stain & culture: GNRs & PMNs
Gross path: cloudy, pus in meninges
High mortality with GNR meningitis

15
 Intestinal infections
Salmonella (S. enterica = most pathogens; also S. bongori)
 Various virulence factors (Vi = salmonella typhi) Salmonella: Lab Dx
 Exposure: poultry or products (eggs)  Gram (-), non-motile
 Stays in vacuoles inside cells; enters submucosa, basal membrane; goes to  Produces H2S (black colonies)
mesenteric lymphocytes  blood stream  Use selective media to
 Clinical presentations: recover from stool
o Gastroenteritis (S. typhimurium mostly)
 6-24h post-exposure: nausea, vomiting, abd. pain, diarrhea; 50% have fever
o Bacteremia (non-typhoidal): much more frequently found in blood than Shigella
o Typhoid fever (S. typhi, S. paratyphi)
 1-4wk incubation; fever, multi-organ system infection, may or may not have diarrhea
 Multiplication in spleen, liver  gall bladder during infection

Shigella
 Four serotypes: S. sonnei (major in US), S. flexneri, S. boydii, S. dysenteriae (epidemic dysentery, produces
Shiga toxin),
 Presentation: fever, severe, cramping abd. pain, bloody diarrhea Shigella: Lab Dx
 Virulence factors plasmid associated; LPS in all  Gram (-), non-motile
 More severe pain than Salmonella, lower abd. (colon)
 Pathogenesis:
o Through stomach acid & small bowel  terminal ileum/colon
o Engineers own phagocytosis
o Escapes from vacuole! Stays in mucosa(fecal WBC confined to mucosal layer)
o Non-motile; cause invasive infection by spreading cell-cell via actin polymerization.
o Destroys colonic epithelial cells in process (blood, pus in stool); self-limiting 2-5d

E. coli
 EnteroToxigenicEC (traveler’s diarrhea), EnteroInvasiveEC
(uncommon, invasive) EnteroPathogenicEC (infantile, ST E. coli: Lab Dx
childhood diarrhea), EnteroAggregativeEC (traveler’s  Gram (-)
diarrhea): from previous lecture  Hand-deliver quickly!
 Direct detection of SLT in STEC pts’ stool
 Shiga-toxin-producing E. coli: STEC  Culture: grows well on standard lab material;
o Hemorrhagic Colitis selective material can be usd
o Hemolytic-Uremic Syndrome (thrombocytopenia,  PMNs + GNRs: think this family!
renal failure, hemolytic uremia) – associated with production of Stx-2 (Stx-1 only: EPEC)

Yersinia can cause diarrhea too

Antibiotics & GNRs

 Order susceptibility testing on organisms from

clinical material (disk diffusion / microbroth
dilution)
o Look for MIC
 MDR control: hand hygiene, contact
precautions, antimicrobial stewardship
 Klebsiella can be especially bad (resistant to
almost everything!)

16
 Fastidious Gram Negative Rods
Haemophilus sp
Characteristics: normal resp flora of humans & animals
 Pleomorphic, GNRs
 Invasive strains = encapsulated
 Requires special growth factors in vitro: X factor, V factor. Optimal growth on chocolate agar

Lots of different kinds. No capsule = not invasive (H. influenza non-typeable for instance)
 H. influenzae type b (a-f are other types).
o Type b causes epiglottitis, sinusitis, meningitis, pneumonia, septic arthritis, etc.
 H. influenzae non-typeable (unencapsulated): now #1 cause pediatric acute otitis media; sinusitis too
o Replaced S. pneumoniae

H. influenzae type B (HiB)

 Fallen 99% post-vaccine area (22 cases 2007, unvaccinated/incompletely vaccinated children)
Haemophilus: Lab Dx
Epidemiology/pathogenesis
 Gram Stain (pleomorphic GNR)
 Nasopharynx of 3-5% healthy people colonized with Hib
 Culture (chocolate agar)
 Pathogenesis: penetrates submucosa of nasopharynx  o Look for X, V factor requirements
bloodstream  CNS  meningitis o Hemolysis?
 Virulence factors: capsular polysaccharide, fimbriae, IgA protease,
OM proteins, ciliostatic glycopeptides (paralyzes cilia to make colonization easier)

Treatment/prevention:
 33% produce plasmid-mediated beta-lactamase (PCN resistant)
 Invasive disease: 3rd gen cephalosporin
 Non-invasive disease: amoxicillin + clavulanate
 HiB Vaccine x 4: 2,4,6,12-15 mo of age

Bordetella pertussis
 Gram (-) coccobacilli (single or pairs; faintly-staining); strict aerobe; needs special media (have to ask for it)

Epidemiology: B. pertussis: Lab Dx

 Can’t survive in environment: requires direct, person-person  Gram Stain (single/pairs, Gram (-)
spread via airborne droplets coccobacillus)
 Adults can be reservoir for infection  Strict aerobe
o (unexplained cough = avoid babies!)  Best specimens: NP aspirates/swabs
 Children < 1yo: most severe disease (immune system not at peak)  *Culture (special media)
 Vaccine preventable! o Can require up to 10d to recover
(way too long for Dx)
Pathogenesis: Non-invasive (secretes toxins)  *Nucleic acid detection: faster &
1. Adheres to non-ciliated resp. epithelium (fimbrae) most sensitive
2. Produces local damage; disrupts host defenses
 Serology = only retrospective
3. Systemic disease
Key virulence factor: pertussis toxin (all stages)
* = recommended by CDC
Clinical presentation: Pertussis syndrome (more atypical presentation in adult)
0. Incubation period (1-3 weeks)
1. Catarrhal stage (1-2 weeks): Most contagious; rhinorrhea, malaise, sneezing, low-grade fever
17
 2. Paroxysmal stage (2-4 weeks): paroxysmal coughing with inspiratory whoops; post-cough vomiting, air hunger /
apnea / cyanosis, peripheral lymphocytosis (hallmark: tens of thousands!)
a. Basically can’t get air! Whooping = trying to inspire against closed glottis. Really sucks to have.
b. Radiography: Peri-hilar infiltrates, distal airways spared,
3. Complications: secondary bacterial pneumonia (damaged resp. epithelium), pulmonary hemorrhage (exertion
of coughing), encephalopathy (toxin to brain), seizures (hypoxemia), coma/sudden infant death

Treatment / Prevention
 Supportive care (vent, ICU, fluids, etc.)
 Erythromycin: doesn’t alter course but decreases bacterial load (less infective)
 Vaccine:
o used to use whole cell (DTP); high reactogenicity, 50-90% efficacy, wanes in adolescents/adults
o Discontinued in some countries  pertussis outbreaks
o Acellular vaccine now in use: DTaP (diphtheria, tetanus, aceullular pertussis)
 Immunogens of B. pertussis, no endotoxins (less side effects) with equal efficacy
 5 doses (2mo-5yr); one-time booster for adults (Tdap)

Legionella
General characteristics:
 thin, poorly-staining GNRs
 Require L-cysteine for growth; use AA for growth (non-fermenters)
 Biochemically inert (weak oxidase rxn; catalse positive, liquefy gelatin)
 Motility: polar flagella

Epidemiology: tons of species; L. pneumophila is responsible for >90% disease (rest named by where they’re from)
 Ubiquitous, widely distributed in environment (aquatic settings: natural or man-made)
 Wide temperature range (0-63C)
 Parasitize & survive in free-living amoebae!
 Form biofilms in water systems
Transmission: inhalation of droplets; aspiration of water; wound infection (more rare) by contaminated water

Pathogenesis:
1. Adhere to resp epithelium Risk factors for Legionella infections
2. Phagocytosed  Cigarette smoking, chronic lung
3. Intracellular survival / multiplication disease, alcoholism
a. Inhibits acidification of lysosome  Immunosuppresion (corticosteroids,
b. No fusion of lysosome with phagosome malignancies, HIV, transplantations)
c. Lysosome associates with rER (molecular mimicry; lined  Diabetes, end-stage renal dz, CV dz,
with ribosomes); bacteria replicates here advanced age
4. Cell rupture & release
24 kD protein macrophage infectivity potentiator (mip): target of many Legionella: Lab Dx
molecular tests  Culture: need special medium
(request!) to inhibit normal flora (abx,
Clinical presentations: etc). Can take up to 7 days (slow
 Legionella pneumonia: 2-15% cases of CAP growing)
 Legionnaire’s disease: systemic illness with pulmonary and  Legionella urinary antigen: only
extrapulmonary manifestations (rare to have extrapulmonary serotype 1, but that causes most dz
alone)  Nucleic acid amplification (no FDA but
o Radiologically indistinguishable from other some in-house depending on lab)
pneumonias
 Direct fluorescent antibody
 unilateral, lower-lobe alveolar infiltrates; some

18
 pleural effusion
 cavities/abscesses can occur if immunocompromised
o Slight, non-productive cough (no PMNs because intracellular)
o GI: watery diarrhea; abd. pain
o CNS: mental confusion, headache
o Bradycardia; hyponatremia, hypophosphatemia, elevated CK, increased transaminases
o Doesn’t respond to beta-lactams
Getting a sample: no special transport, room temp OK, refrigeration if delayed.
 Send sputum, aspirates, BAL fluids, pleural, lung tissue.

Legionella urinary antigen detection

 Detects LPS of cell wall
 Serotype 1 only (80% of dz though)
 Antigen shows up day 1-3 of Sx; can persist for weeks/months

Treatment: 10-14d
 Newer macrolides (azithromycin, clarithromycin); quinolones (levofloxacin)
 Can also use tetracyclines or TMP+SMX

Prevention:
 Routine culture surveillance of hospital water distribution systems
 Treat If pathogenic legionella found (hard to get biofilm out). Chemicals, heating, etc.

19
 Non-fermentative Gram Negative Bacteria
General features:
 White on MacConkey agar = non-fermenter (pink=fermenter)
 Complex mix (opportunistic pathogens of plants, animals, (most) Non-Fermentive Gram (-)s:
humans)  Aerobic, Non-spore forming, Bacilli
 75% in clinical specimens are one of these four  Cytochrome oxidase positive
1. Psudomonas aeruginosa  Catalase positive
2. Acinetobacter baumanii  Don’t ferment CHOs; may oxidatively
3. Burkholderi cepecia metabolize some sugars
4. Stenotrophomonas maltophilia  Motile, nutritionally versatile
 Opportunistic pathogens: most often hospital-acquired  Grown on MacConkey Aga

Pseudomonas spp

 Ubiquitious (soil, water, decaying organic matter, vegetation)

 Found throughout hospital environment (moist reservoirs, incl. dialysis equipment, mops, toilets, etc.)
 Simple growth requirements: wide temp range; can use lots of nutrients for C&N source
o Can even grow in distilled water and disinfectant solutions!
 Lab classification: fluorescent (make pyoverdin green under UV) & non-fluorescent
o Fluorescent group includes P. aeruginosa and P. fluorescens, most important for clinical
o P. aeruginosa also makes pyocyanin
 Important for invasiveness & characteristic of aeruginosa on plate

Pseudomonas aeruginosa
 Aerobic, straight/slightly curved, non-spore forming, Gram(-) rod
 Motile (1+ polar flagella)
 Grows well on SBA, chocolate, MacConkey; wide temp range; Pseudomonas aeruginosa: definitive Lab Dx
 Catalase positive  Gram (-) rod
 Makes both pyoverdin & pyocyanin  Oxidase positive (rapid oxidase test)
 Grape-like or corn-tortilla odor
Virulence: multifactorial (structural components, toxins, enzymes)  Recognizable colony morphology
 Structural: o SBA/chocolate: large colonies, metallic
sheen, mucoid/rough/pigmented
o LPS (endotoxin), Pili (adhesion; neuraminidase to remove
o MacConkey: lactose negative; green
sialic acid from pili receptor); capsule (adhesion &
pigmentation or metallic sheen
suppression of phagocytosis / immune response);
pyocyanin (tissue damage: hydroxyl radical products; IL-8 stimulus)
 Toxins/enzymes:
o Exotoxin A & S(inhibits protein synthesis); cytotoxin (leukocydin) (cytotoxic for eukaryotic membranes;
microvascular injury); Elastase (disrupts elastin-containing tissues, collagen)

Clinical presentation:
 Bacteremia, pneumonia top 2
 Others: pretty much all sites of body but particularly adapted to respiratory tract
o CF patients; chronic colonizer of pts with chronic lung P. aeruginosa: Predisposing factors
disease
 Chronic debilitating illness (lots of hosp)
o #1-2 cause of Ventilator-Associated Pneumonia (VAP)
 Prior therapy with broad-spectrum abx
 Can produce disease far away from initial site of tropism
 Breach of airway (tracheostomy,
 Intact host defenses: not at much risk (opportunist) endotracheal tube)
 Imparied host immunity (primary disease
Pulmonary infections in CF patients: colonization  tracheobronchitis or iatrogenic)

20
 necrotizing bronchopneumonia
 Tropism for CF epithelial cells; actually switches to a CF phenotype (rough LPS, mucoid, less motility)
o Increased Abx resistance because of prior broad-spectrum abx in CF pts

Skin infections from P. aeruginosa:

 Ecthyma gangrenosum secondary to P. aeruginosa bacteremia (pretty classic for P.aerug)
 Folliculitis (e.g. after hot-tub)
 Burn wounds: P. aeruginosa very important!
o Colonization  local vascular damage / necrosis  bacteremia
o Risk correlates to extent of burned surface
o Commonly <1wk from burn injury

“Community-acquired” P. aeruginosa infections: can happen in outpatient setting

 Corneal ulcers, keratitis (extended wear contact lenses / abrasions / scratches)
 Endopthalmitis (deeper eye infection; after eye trauma or surgery)
 Exposure to moist environment (hot tub, whirlpool, swimming pool)
 Otitis externa : “swimmer’s ear”; malignant external otitis can extend to cartilage & bones (pts with diabetes,
elderly, etc.)
 Puncture wounds (through tennis shoes, etc.)  osteochondritis
 Endocarditis (IV drug users)

Treatment, prevention, control: recognize high level antimicrobial resistance worldwide; carbapenems may be driving
emerging resistance; lots of MDR Pseudomonas.
 Might be able to use old drug (colistin) despite bad side effect profile
 Can’t eliminate from hospital environment: need infection control (safeguard patients)
o Keep equipment sterile; prevent health care worker  pt transfer; responsible ABx use

Acinetobacter spp
 Widely distributed (nature & hospital)
 2nd most common non-fermenter found in humans after P. aeruginosa Acinetobacter spp
 Can survive on moist & dry surfaces; present in food & on skin  Gram(-) coccobacillary rods
 Increased frequency: immunocompromised, debilitated pts  Strictly aerobic
 Grow on MacConkey (colorless)
Acinteobacter baumanii:  Non-motile, non-fermentative
 Most frequently isolated from human specimens  >> Oxidase negative << (key)
 Most often responsible: hospital-acquired infections  Usually nitrate negative

Clinical presentations: Risk factors: Acinetobacter

 Hospital acquired:  Stay in ICU
o Respiratory tract infection  Abx treatment
o UTI, Wound infection, Bacteremia
 Surgery
o Nosocomial pneumonia / VAP
 Mechanical ventilation
o Digestive tract of ICU patients can be reservoir for MDR strains
 Community-acquired:
o CA-Pneumonia with fatal outcome (initially misdiagnosed; wrong Tx)
o Wound infections & osteomyelitis (e.g. battlefield infections)

Tx & prevention: Need Abx susceptibility testing for every clinically significant isolate!
 Intrinsic resistance to cephalosporins; carbapenem resistance ~ 20%; high frequency of MDR
 Ampicillin-sulbactim, ticarillin-clavulanate or imipenem are most effective
 Also: TMP-SMX, quinolones, doxycycline. Can add aminoglycoside if severe infection; colistin possible if MDR
21
 Stenotrophomonas maltophilia
 Similar profile to Burkholderia cepacia
 Widely distributed: nature & hospital S. maltophilia
 Can colonize resp tract in pts. with prolonged hospitalization (e.g.  Gram(-) rod
immunocompromised)  Motile, non-fermentative
 Virulence factors unknown, opportunistic human pathogen  Grows well on MacConkey
 Oxidase negative
Clinical presentation:
 Nosocomial; high morbidity/mortality
o Bacteremia, pneumonia, UTI, wound infctions
o Increasing incidence: resp tract infections in CF patients
Treatment:
 Intrinsic resistance to almost every antimicrobial commonly used (B-lactams, AGs, others)
 TMP+SMX is primary choice for treatment

Burkholderia cepacia complex

B. cepacia: most commonly isolated Burkholderia sp. in clinical specimens; consists of 9 complex genovars
 Plants, soil, water as reservoir
 NOT part of normal human flora; can colonize resp tract
 Nosocomial: associated with contaminated hosp equipment, medications, and disinfectants
o (even iodine & chloride solutions! Albuterol! Sterile blood culture systems!)
Clinical presentation: opportunistic pathogen, variety of infections
 Bacteremia, UTI, septic arthritis, peritonitis, pneumonia
 Risk factor: chronic granulomatous disease or CF pts

B. cepacia and cystic fibrosis

 Emerged in 1980s; require special infection control practices
 Approx 3% CF pts in US infected with B. cepacia, 6-7% adults
 Most strains inherently resistant (broad spectrum abx)
 May be absolute contraindication for lung transplant
 20% develop cepacia syndrome: bacteremia, fatal outcome

Treatment: resistant to most antimicrobials (B-lactams, AGs, others)

 Susceptible: TMP+SMX, ceftazime, imipenem, meropenem, some fluroquinolones

Burkholderia pseudomalli
 Found in soil, water, vegetation: SE Asia, Northern Australia (watch out for travelers)
 Wrinkled colonies on plate
 Acquisition: inhalation or inoculation (trauma/wounds); Potential bioterrorism agent

Clinical presentation:Causes melioidosis

 Can be acute, subacute, or chronic (chronic can mimic TB)
 Pneumonia = most common clinical presentation (abscess formation, cavitation)
 Protean manifestation (assumes many forms)
o Asx, cutaneous, pulmonary dz
o High propensity for bacteremia
o Diabetes, renal dz, cirrhosis, thalassemia, alcoholism (& immunocompromise) predispose

Treatment: TMP+SMX and broad-spectrum cephalosporin

22
 Neisseria Species
General characteristics:
 Gram (-) diplococci, inhabit mucous membrane surfaces Features of Neisseria
 Group contains:  Aerobic
o Non-pathogens (upper resp tract dwellers)
 Non-motile, non-spore forming
o Strict pathogens:
 Oxidase, catalse positive
 N. gonorrhoeae (STI: gonorrhea);
 Chocolate agar (best)
 N. meningitidis (epidemic/endemic meningitis)
 Use CHO oxidatively

Neisseria gonorrhoeae
Same characteristics as other Neisseria
Nutritionally: more fastidious
 Requires cysteine for growth; other requirements too

Epidemiology: STI except in newborns

 humans are only host; huge incidence (355,000/yr), mostly in sexually active teens & young adults
 Women (men too) can be asymptomatic and transmit infection
 Risk factors:
o Social: lower SES, urban, lack of education, unmarried, STD history)
o Behavioral: unprotected intercourse, multiple / high risk partners, drug use, MSM

Pathogenesis: adherence  cell entry/transport  evade  stimulate PMN host response (pyogenic)
 Special features of surface structure:
o Oligosaccharide endotoxin (smaller than LPS)
o Pili (attachment), peptidoglycan (toxic to fallopian tubes), membrane proteins (survival & invasion)
 Adheres to non-ciliated cells (e.g. fallopian tubes); adjacent ciliated cells damaged, slough off, more can attach
o Loss of ciliated cells  obstruction, infertility, ectopic pregnancy, etc.

Clinical presentation N. gonorrhoeae: Lab Dx

 Women: Mucopurulent cervicitis is typical, also urethral
syndrome (distal urethra), pelvic inflammatory disease
(ascending disease; scarring, etc.).
 Neonates: perinatal transmission; Ophthalmia neonatorum
(purulent conjunctivitis); also gonococcal scalp abscesses or
systemic infections.
 Men: Urethritis, epididymitis, rectal infections (if MSM)
 Common features: purulent exudates, inflammation,
erythema (penis/os). Burning on urination (men)
o Unusual adult manifestations: conjunctivitis, disseminated gonococcal infection (vesicle  purulent papule,
erythema, central necrosis)
 Gram stain (better in male urethral samples)
 Culture-based: sexual abuse, treatment
failures, test of cure
o Multiple methods (need 2nd to confirm:
important to be right, esp. child abuse)
 Nucleic acid amplification (PCR) – very
sensitive (can’t use for test of cure)

Culture: selective media; supplemented with growth factors; 72h, small, glistening, raised.
 Glucose metabolizer(not maltose or sucrose)

Treatment:
 Uncomplicated: Ceftriaxone IM or Cefixime PO
o Treat for CHLAMYDIA TRACHOMATIS (lots of coinfection): AZI PO x1 dose or doxycycline PO bid x 7d)
 Report & contact-trace infected persons
Prevention: sex ed, abstinence, condoms, no vaccine
 use 1% silver nitrate or macrolide antibiotic prophylax for newborns
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 Neisseria meningitidis (“meningococcus”)
All age groups, both individual (sporadic) & epidemic
Multiple serotypes: B,C,Y most severe in US
Immunization possible (esp. closed populations)

Epidemiology
 All age groups, both individual (sporadic) & epidemic
 Multiple serotypes: B,C,Y most severe in US
 Asymptomatic nasopharyngeal carriage (8-25%), precedes infection
o Colonization ↑ in closed populations (college, military)  need vaccination
 Terminal C’ deficiency (C5-9): recurrent, severe infections
 Worldwide: Epidemics in some countries (at end of rainy season)
 USA: Vast majority sporadic with localized outbreaks
o Case fatality: 10-14% !!

Pathogenesis
 Virulence factors: Pili, engulfment, transport in host cells; Polysaccharide capsule (↓ phagocytosis, C’); Lipo-
oligosaccharide endotoxin (very toxic!)
 Process: HAPPENS REALLY FAST
1. Pili adhere to non-ciliated resp epithelium invades submucosa
2. Capsule prevents phagocytosis
3. Replicates in submucosa; evades
4. Spreads into bloodstream
5. Endotoxin in blood: cytokine & alternative C’ activation

Clinical presentations: N. meningitidis Lab Dx:

1. Bacteremia without sepsis (rare)  Direct exam of CSF (presumptive, quick)
2. meningitis with neurologic sequelae  Culture: CSF, blood, other
3. meningococcemia (overwhelming sepsis & DIC) o Chocolate agar
a. with adrenal insufficiency: Waterhouse-Frederichsen  Definitive ID: glucose & maltose use
Syndrome

Meningitis  Meningococcemia
 Like other meningitis but faster.
 Sudden onset: Fever, chills, myalgias, arthralgias, headache, confusion, nuchal rigidity
 CSF: 1200 WBC/mL, Glc↓, protein ↑
 Meningococcemia
o Rash: palpable purpura (infection of endothelial cells  DIC, small hemorrhages)
o Can get peripheral gangrene; lose digits
 Adrenal hemorrhage can cause insufficiency (W-F syndrome)

Treatment:
 Meningitis/meningococcemia: Penicillin (alternatives: ceftriaxone, chloramphenicol in other countries)
o Not PCN resistant!
 Prophylaxis (close contacts) – trace! Rifampin, cipro, ceftriaxone
Vaccines:
 Old: polysaccharide tetravalent (poor immunogenicity, not long-lasting, no reduction in NP carriage)
 New: tetravalent conjugate vaccine (Menactra) for 2-55yo (give 11-12 or entry to HS; should have for college)
o Capsular polysaccharide conjugated to diphtheria toxin; induces T-cell dep response (good for infants)
o Reduces Asx carriage
o Indications: asplenia, C’ deficient, traveling to endemic areas, closed pops, prevention, lab workers
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 Anaerobic Gram Positive Bacteria
General characteristics:
 Don’t grow in presence of oxygen
Anaerobic infections (Clinical Dx)
 Two groups:
 Foul-smelling discharge
o Obligate anaerobes (strict or moderate)
 Proximity to mucosal surface
o Aerotolerant anaerobes
 Gas in tissues
 Tons of different kinds (many part of normal microflora, protective)
 Negative aerobic cultures
 Classification (pathogenic): shape, gram, spore formation, toxin
production
 Widespread: environment (soil, sewage, foods, etc.)
o animals & humans: oral cavity around teeth, GI tract, skin (some), G/U tract
o habitats with low oxygen tension & reduced oxidation reduction potential

Pathogenesis:
 Disruption of normal mucosal barriers
 Anaerobic infections often mixed (synergy with aerobes, other anaerobes)
 Virulence factors: capsules, adhesions, enzyme production, toxin production (some very potent toxins)

Presentations:
 brain abscess (usually anaerobes or microaerophilic strep)
 bacteremia (need virulence factors to get into bloodstream)
 lots of others (mixed) – e.g. empyema (pus in pleural cavity)

Lab Dx:
 Get a good specimen (not anything where anaerobes would be in normal flora; Exception: C. diff & feces)
o gastric washings, urine, vagina/cervix, feces, upper resp. secretions, etc. are bad
 Swabs are bad specimens, aspirates & tissue biopsies are best (transport immediately)
o Inject into anaerobe transport media
 Semi-solid, 5% CO2, reducing agent  shows anaerobiosis
o Culture in complex media: supplemented; chopped meat glucose; use anaerobe chamber

The following are GRAM POSITIVE ANAEROBES

Peptostreptococcus
 Anaerobic, Gram (+) cocci; variable shape & size
 Found on skin, mucous membranes
 Importance: Causes bacteremia & mixed infections

Propionibacterium spp
(Major metabolic product = propionic acid)
 Anaerobic, Gram (+) rods, highly pleomorphic (curved, clubbed, pointed ends)
 Normal flora of skin, mucous membranes; major contaminant of blood cultures
 Non-spore forming
 Importance: acne, also opportunist with medical devices(shunts, caths, prosthetic valves)

Actinomyces
Anaerobic, Gram (+) rods, pleomorphic (short/club shaped, long/thin/beaded rods, branching)
Slow-growing – makes a “ molar tooth” colony. Reason why labs hold AnO2 cultures for up to 1 wk

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Actinomycosis
 Indolent, progressive infection that progresses across tissue boundaries
 Purulent foci with dense fibrotic tissue around
 Can look like neoplasia/tumor (mass)
 Later: sinus tract; drainage with “sulfur granules” (yellowish)
 E.g. cervical actinomycosis (cervicofacial is most common)

Clostridium species: overview

 Obligate anaerobes, Gram (+) bacilli
 spore-forming, pleomorphic, most motile
 Large group; ubiquitous in nature (GI tract of humans/animals; soil)

Clostridium perfringens
Clostridial myonecrosis (“gas gangrene”)
 Pathogenesis: production of phospholipase C (very potent alpha toxin)tissue destruction
 Diagnosis: clinical: septic appearance, gas in tissues (palpable bubbles),
o Necrosis with gas & no inflammatory cells: phospholipase C kills them too quickly!
 Treatment: need extensive surgical debridement! (can’t contain with abx & host immune system)
o Supportive care
o Abx: penicillin G + clindamycin
o Hyperbaric oxygen for some locations
Food poisoning: toxin made after food ingested
Necrotizing enterocolitis: beta-toxin production after poorly cooked pork, rare in US

Clostridium difficile
Pseudomembranous colitis & antibiotic associated diarrhea;
 Pathogenesis: Toxin A (enterotoxin), Toxin B (cytotoxin)
o Extra toxins: epidemic strain
 Clinical presentation: bloody diarrhea; can include toxic megacolon (distended)
 Diagnosis: DIRECT DETECTION OF TOXIN IN STOOL is major way to diagnose
 Treatment:
o Withdraw offending antibiotic
o Metronidazole PO or vancomycin
o Surgery if toxic megacolon, intestinal perforation, severe illness

Clostridium botulinum
Botulinum toxin: most potent neurotoxin known; bioterrorism agent
Botulism: three types
1. Foodborne: typically adults; from ingestion of preformed toxin in contaminated food (poorly-made jams, etc)
2. Infant: organism in GI tract; toxin produced in vivo, most common form of disease
3. (Wound) – rare

Pathogenesis: toxin production; potent neurotoxin that blocks Ach release at neuromuscular junctions

Clinical presentation:
1. Incubation: 18-36h, dose dependent
2. Afebrile, alert, oriented, normal sensory exam; early nausea/vomiting, diarrhea
3. Cranial nerve symptoms (ptosis, blurry/double vision, trouble swallowing/talking, ↓ salivation)
4. Progressive motor symptoms: BILATERAL DESCENDING FLACCID PARALYSIS  resp paralysis
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 5. Death in 60% (untreated; 5% with Tx)

Lab Dx: toxin in serum, gastric fluid, stool

Treatment:
1. Supportive care (airway support)
2. Administer antitoxin (equine serum for adults – 9-20% hypersensitivity – or human botulism Ig for infants)
3. (if wound: debride too)

Clostridium tetani
VACCINE PREVENTABLE!
Widespread distribution of spores in soil & aquatic environments
Pathogenesis:
1. Spores contaminate puncture wounds, etc.
2. Spores germinate (low oxidation-reduction from poor vascular flow)
3. Vegetative cells multiply; release tetanospasmin (attaches to peripheral nerve endings; travels up to CNS)
4. Toxin: binds gangliosides in CNS and blocks inhibitory impulses (PROLONGED MUSCLE SPASMS)

Clinical presentation
 Spastic muscle contractions
 Difficulty opening the jaw (“lock-jaw”)
 Characteristic smile (“risus sardonicus”)
 Contractions of back muscles can result in arching – can actually snap spine!

Treatment:
1. Supportive care (airway maintenance, antispasmodics)
2. Antitoxins: human tetanus Ig, tetanus toxoid
3. Antibiotics: metronidazole

Prevention: vaccine!

Clostridium septicum
Bacteremia associated with malignancy
 Pathogenesis: high dose chemo damages GI; organisms translocate at site of mucosal damage
 Blood cultures positive
 Treatment: Penicillin G, supportive care, sometimes surgery

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 Emerging and Re-emerging Bacterial Zoonoses
 Zoonosis: any infectious disease that may be transmitted from other animals (wild & domestic) to humans or
from humans to animals
 Vector: any animal that transmits an agent of human disease or plays an essential role in the agent’s life cycle
o E.g. mosquitos / malaria; snail hosts / schistosomiasis; rodents / leishmaniasis
o Typically arthropod vectors (mosquitos, ticks, flies, lice, fleas)
 Emerging infections: diseases that have recently appeared or are growing in incidence. Lots!
o Zoonotic, vector-borne, bacterial  high RR for disease to emerge

Transmission of bacterial zoonoses

Direct contact: animals/infected materials Leptospirosis (Leptospira); Brucellosis (Brucella)
Animal bites / scratches Cat scratch disease / bacillary angiomatosis (Bartonella henselae)
Arthropod vectors Plague (Yersinia pestis)
Contaminated food Lyme disease (Borrelia burgdorferi), Rocky Mountain Spotted Fever
(Rickettsia rickettsi)

Leptospirosis
Leptospira: spirochete (spiral-shaped); Enormous taxonomic group

Leptospirosis:
 Estimated >10M cases worldwide, uncommon in US
(Hawaii, Wisconsin?), more common in tropics
 Acquisition: contaminated animal or rodent urine: lives in
bladder, urinary tract of asymptomatic animals
o Water/soil
o Skin abrasions; conjunctivae
o Domestic pets (dogs) / livestock too
Clinical presentation:
 Fever, headache, myalgia, abdominal pain, conjunctival suffusion (inflammation / red eyes)
 5-10%: Icteric form (Weil’s disease)
o Can precede worse outcomes: renal failure, pulmonary hemorrhage, cardiac arryhmias
 Uveitis (late manifestation, can lead to blindness)
 Death in 5-15% (esp old age)
Histopathology:
 Cholestasis: brown pigment in liver (jaundice too)
 Pulmonary hemorrhage(mechanism not known)
 Interstitial nephritis: chronic inflammatory cells in interstitial around tubules

Pathogenesis:
 urine contaminated water  mucous membrane / skin abrasion  liver, CNS, kidney, all organs  localized in
kidneys  patient sheds Leptospira in urine
 Virulence factors: motility, hemolysins, adhesions / invasions (bind & localize), hemostasis & coagulation genes
 Immunologic pathogenesis:
o Proinflammatory response to LPS (via TLR2); activates host inflammation
o Multi organ-system failure due to DIC
o Pulmonary hemorrhage (Ig, C’ fixation on host cells; more common with high Ab titers)
o Ocular disease: uveitis during “immune phase” – Ig & C’? uvea = iris, choroid, ciliary body

Dx: can culture during acute phase (1st week); IHC / microscopy / PCR not great.

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  Microagglutination test (MAT): detect Abs as early as 5-7d post-onset;
o single high titer acceptable; seroconversion preffered
Tx: doxycycline, penicillin, cefotaxime.
 Jarisch-Herxheimer reaction (proinflammatory cytokine cascade; like sepsis, should anticipate possibility)

Brucellosis (Brucella spp)

α-2 proteobacteria
Gram (-) coccobacillus; facultative intracellular
 B. melitensis is key organism. Not sure if 1 or 3 species

Epidemiology: worldwide distribution (Eurasia, Africa, S. America most) ;

domestic wild populations coexisting
 Human transmission:
o Oral contamination (domestic farm animals)
o Consumption of unpasteurized dairy products
o Inhalation of aerosolized contaminated animal products

Pathogenesis:
1. Enters via mucosa, endocytosed by phagocytes
2. Survives in acidified phagolysosome; enters into ER (abx resistant), delays apoptosis
3. Regulates TNFα by translocating a protein into cell’s cytoplasm

Granulomas everywhere = characteristic of intracellulars like brucella

Clinical presentations

Classic febrile brucellosis: acute infection

 insidious onset (fever, sweating, malaise, headache, weight loss; aches/pains  frank arthritis)

Relapsing / undulant brucellosis (Malta fever)

 > 2mo after classical febrile brucellosis if un/der treated
 Liver involvement, arthritis, uveitis, orchiepididymitis
 Can be chronic; > 1 yr

Complications:
 Osteoarticular disease
o Peripheral arthritis (acute infection, non-erosive, knees, hips, ankles, wrists)
o Sacroilitis (acute infection)
o Spondylitis (lumbar spine; often irreparable damage)
 Epididymoorchitis (granulomatous inflammation with lots of lymphocytes in epididymis; enlarged testicles)
 Abortion in pregnant females, liver, CNS (meningitis, etc  grave prognosis)
 ENDOCARDITIS: main cause of mortality, usually aortic valve, generally requires surgery
 Relapse: inadequate treatment; usually 1st year

Diagnosis:
 Blood or bone marrow culture: need Biosafety level 3 (easily aerosolized)
 Detect Abs (serum agglutination test: draw pt serum, add antigens for Brucella). Safer, for presumptive Dx

Treatment:
 Doxycycline + rifampin (or streptomycin/netilomycin) for 4-6 weeks

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 Bartonella spp
 Small, Gram (-) rods; facultative intracellular bacterium; α-2 proteobacteria, related to Brucella
 Mammalian, arthropod reservoirs (rodents, felids, lice, fleas, ticks)
 Infects erythrocytes & endothelial cells

Bartonella henselae: Cat-scratch disease

Epidemiology:
 ↑risk: kitten exposure, ownership, bites/scratches
 Cats: often seropositive; persistently infected with B.
henselae (“normal blood flora”-ish)
 Fleas: vector between cats, not humans (except maybe
immunocompromised?)

Clinical diagnosis:
 Regional lymphadeopathy with or without fever
 Cat/kitten scratch/bite
 Papule at inoculation site (small, red, elevated lesion)
 Characteristic histopathological features
o Stellate microabscess in granuloma (in lymph nodes)
 Apoptotic cells, macrophages, PMNs, epitheliod histiocytes, etc.
o Clusters of bartonella inside lesions

Pathogenesis:
 Fleas on infected cats defecate; cats clean, flea feces under claws
 Inoculation of bacteria in cat scratch
 Spread: draining lymph nodes  infection
 Occasional: systemic spread but resolves spontaneously in most cases

Clinical manifestations:
 Cat-scratch episcleritis (Parinaud’s oculoglandular syndrome)
o Inoculation in/around eye; drains to post-auricular node
o Neuroretinitis: CNS involved; fluffy infiltrates (bacteria in retina)
 Usually in immunocompromised pts:
o Bacillary angiomatosis / peliosis
 Proliferation of blood vessels & capillaries in skin (angiomatosis) or liver/spleen (peliosis)
 Inflammatory cells in interstitium; bacteria cluster there
o Endocarditis – very important
 Thrombus-like material forms; most of necrotic lesion filled with Bartonella

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 Pathology of Mycobacteria Infection
M. leprae: Leprosy
 Caused by M. leprae (acid-fast; obligate aerobe)
 Prefers cooler parts of body (lesions on skin prominences, nose, URT, peripheral nerves, testes)
o Neuropathy secondary damage to fingers, etc – secondary infection; loss of digits.
 2 types: tuberculoid (nothing to do with TB) & lepromatous
LEPROMATOUS TUBERCULOID
 Weak host immune response  Strong host immune response
 Numerous bacilli (MB: multibacillary)  Few bacilli (PB: paucibacillary)
 Sheets of macrophages, not granulomas  Granulomatous reaction
 Non-reactive lepromin (skin) test  Reactive lepromin (skin) test
o Note how immune reaction is responsible for other differences
 Extremely rare in USA; more common in other countries (esp. Africa, Nepal) – usually travelers if in US

M. tuberculosis: TB
 Epidemic waves of morbidity/mortality: sharp rise; peak, gradual decline over 100s of years
 Worldwide: #2 ID killer (HIV, 2.7M; TB: 2.2M; Malaria: 1.1M)
o 2 billion infected with M. tb; 8M new cases/yr, 1 death every 10 seconds; 500k infected with HIV too
o One untreated pt infects 10-15 new pts / yr
 Epidemiology: poverty, overcrowded housing, undernourishment (airborne)
o Slums of US, etc. where poor, elderly together

Mycobacterium tuberculosis:
 Acid-fast bacteria (high lipid content of cell walls; Ziehl-Neelsen stain)
o Red dye, washed away from other cells by acid alcohol, counterstain blue
 Obligate aerobes, hard to detect in tissue, slow to grow in culture
 Can survive intracellularly

Transmission:
 Person-person (small airborne droplet nuclei)
o Have to be small to avoid mucociliary apparatus
o Produced when coughing/sneezing/speaking/singing
o Remain airborne; disperse uniformly throughout enclosed space (can’t use regular surgical mask)
 Expt: guinea pigs in cages on roof infected via aerosolization; distance didn’t matter
 MDR-TB is more easily spread!

Primary TB:
Initial spread & development of Ghon focus / complex
1. Goes to middle, lower lung fields (in periphery) – greatest
volume of air goes there
2. Nuclei implant on respiratory bronchioles/ alveoli (past
mucociliary system, way out into lungs)
3. Initially: non-specific PMN response (usually not observed)
4. Alveolar Mφ engulf mycobacteria  multiply within Mφ
5. Some mycobacteria are killed by Mφ  process/present
antigen to T-helper lymphocytes  release lymphokines to
attract more Mφ & activate  monocytes infiltrate;
activated histiocytes  granuloma forms
o Caseous center, etc. If you hear caseous or AFB,
think TB!
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 6. Some Mφ with M. TB transported to regional lymph nodes, then throughout body
o Ghon focus: initial site of implantation
o Ghon complex: Ghon focus + lymph node (classic for primary TB)
Simon foci: some bacteria  lung apacies (higher oxygenation, lower blood flow so lymphostasis)
 Apical scars: common in tuberculin + pts; harbor more bacilli (dormant) than other areas of lung
 1st part driven by anatomy/physiology; this is driven by metabolic character of the organism

Outcomes of this part:

 >90% heal; have positive PPD; viable bacilli remain! (calcified granule in lung can harbor dormant M. TB)
 5% go on to develop progressive primary TB

Progressive Primary TB
 5-10% of patients (especially lowered immunity, kids, elderly) progress to primary progressive TB
 If granulomata erode, can discharge into different spaces
1. Miliary TB: erode into vessel
 Characteristics:
 tons of evenly-sized, tiny foci throughout lung (bacteria well mixed in blood)
 larger foci towards apex (better oxygenation)
 Worst prognosis
 Pulmonary vein: left heart; to rest of body: new lesions in both lungs
 Pulmonary artery: back into that lung; new lesions in one lung
2. TB Bronchopneumonia: erode into airway
 Characteristics: larger pieces of granuloma breaking off  unevenly sized, clustered nodules
3. TB empyema: erode into pleural space
 Characteristics: can see granulomatous change, caseation in former pleural space

Post-primary TB
Infections which develop in individuals with immunity to bacillus.
1. Reactivation of previously healed TB (Simon foci)
a. Begins in posterior segment of upper lobe
b. About 1-2% untreated PPD + pts will reactivate <
5yrs
2. Reinfection of previously infected individual (with
different strain)
a. Not totally prevented; suggests BCG vaccine not
effective

CAVITATION IS HALLMARK OF POST-PRIMARY TB:

 Granulomata eroding, eventually leave cavitation where
they were before (especially near apex)
 Can manifest as TB bronchopneumonia (airway), Miliary
TB (vein), TB empyema (pleura) like before or…
o Massive hemorrhage (erode into artery)  specific for post-primary TB
o Leads to hemoptysis
 Cavity can also heal (risk of aspergilloma – fungal - infection)

Preventing post-primary TB: treat PPD+ even if asymptomatic!

 Cuts risk of developing active disease; can treat while still healthy!

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 Non-Tuberculous Mycobacteria
 A.k.a. “atypical” mycobacteria, “anonymous” mycobacteria, “pseudotubercule bacilli”
 Classified into 4 groups, don’t produce disease in guinea pigs
 Acquired from ENVIRONMENT (soil, water) – not person-person like M. tb
 Opportunists: usually infect people with underlying lung dz or decreased immunity

HIV & Mycobacterium tuberculosis

 HIV: depletes CD4+ cells; decreases monocyte/macrophage function
 HIV+ & +PPD: very high active disease rate
 Highest AIDS demographic groups: blacks/Hispanics 22-44 = greatest increase in TB
 Reversal of downward TB trend (1985-6: AIDS)

HIV patients & TB: TB usually diagnosed 6mo before opportunistic infections (more virulent); now an AIDS-defining dz
 More often extrapulmonary TB
 TB in lungs often non-apical, non-cavitary; poorly-developed granuloma (no good immune response)
 Drug-resistance higher; PPDs more often negative
 Complications: crushing spine (Pott’s disease); ocular involvement
 Rest of world: TB is leading cause of death in HIV+ individuals

Worrisome: TB form in Africa resistant all known drugs; usually fatal.

HIV & NTM

 NTM (e.g. mycobacterium avium complex) common in pts with AIDS (need low CD4 count)
 Enter via GI tract; occur late (less virulent), no person-person transmission
 No granulomas, histiocytes packed with bacilli (look pale blue & striated)

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 Vector-Borne Zoonoses
Vector: any animal that transmits an agent of human disease or plays an essential role in the agent’s life cycle
 typically refers to arthropod vectors (mosquitos, ticks, fleas, flies, lice, etc.)
 Vector transmission only: Lyme disease, RMSF
 Direct-contact and vector transmission: plague
Yersinia pestis (Plague)
Gram-negative coccobacillus; stains in a bipolar pattern; facultative intracellular bacterium
Ecology: endemic foci maintained; persistant rodent hosts; flea vector active year round
 Epizootic hosts; low resistance to infection (squirrels / chipmunks), high mortality/population density
 Rural rats  fleas  urban rats  fleas  humans(bubonic)  humans(pneumonic)
Potential bioterrorism agent (pneumonic)

Transmission:
 Flea bite: bubonic plague
1. Rat flea bites patient
2. Inoculate flea material into wound  drain to local lymph nodes  bubo (hyperplasia & necrosis of LN)
3. Fever, headache, chills, malaise, painful lymphadenopathy (2-6d later)
4. With Tx: cure in 3-5 days
 Aerosol: pneumonic plague
 Pulmonary infection  rapid spread & septicemia
 Either: septicemic plague
 Invade blood without buboes; high frequency of death
 Endotoxin / cytokine release / Gram (-) sepsis; resp. distress syndrome (ARDS); SIRS
 Complications: endophthalmitis, mmeningitis, tissue abscesses

Epidemiology: endemic in Africa, Asia, N/S America; >2,000 cases / yr in world, high case fatality rate
 Human transmission: depends on environment, host mammals, arthropods

Pathophysiology: rapid spread & growth in tissue & blood

 PMN: engulf & kill Yersinia
 Mφ: just get infected; Yersinia propogates inside, kills Mφ
 Bacteria suppresses leukocyte function
o Yops: suppress inflammation
o LcrV: stimulates TLR-CD14 on MφIL-10(anti-inflammatory )
 LPS activates systemic inflammatory responses, coagulation, fibrinolytic pathways (SEPSIS)
 Pla protease (plasmid)  tissue destruction & C’degradation (required for bubo)

Pathology: Extensive tissue necrosis without extensive inflammation

Diagnosis: clinical suspicion, blood culture, bipolar staining

Treatment: streptomycin, doxycycline, sulfonamides

Borrelia burgdorferi (Lyme Disease)

Borrelia burgdorferi:
 Spiral-shaped (corkscrew / twisting motility); small, obligate parasite found with mammals, birds, ticks
 Transmitted exclusively through tick bites
 Maintained in small mammal via Ixodes species tick cycle (mammal reservoir, tick vector varies with location)
o Tick: larvae  nymph  adult; nymphs do most of the biting (small tick = immature)
o Larvae needs to acquire borrellia from mammal reservoir (last season’s nymphs did the infecting!)
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Tick-bite (ixodes scapularis, “deer tick”) transmitted
 Tick life cycle:
 Tick bite: inserts through epidermis into dermis; both insert/secrete saliva & aspirate tissue (infects & can be
infected); spirochete to tick midgut
o Mild inflammatory lesion where bite occurs

Epidemiology: N. America (northeast, Wisconsin/Michigan area, etc.), Europe, Asia

 Seasonality: bimodal distribution (most May-July: nymphal deer ticks; secondary peak in late fall: adult ticks)
 Incidence increasing

Clinical presentation:
 Early localized infection: erythema migrans (“bull’s eye”)
o EM +/- draining lymphadenopathy; usually 1st week post-tick bite. EM not always present!
o Nonspecific inflammation; perivascular lymphocytes: looks like chronic inflammation
 Early disseminated infection: systemic manifestation (disseminates to lymphatics, blood vessels, capillaries)
o Fever (infrequent in early-localized)
o Multiple erythema migrans
o CN VII palsy, Carditis (arrhythmias), Oligoarticular arthritis, Meningitis
 Late infection: oligoarticular, chronic arthritis, encephalopathy (very rare), chronic pain/memory loss/etc.
 Post-Lyme disease syndrome: no response to antibiotics, not present in vaccine placebo group from trial,
independent of serological results, no resistance to Abx: NO EVIDENCE FOR LONG TERM ABX and this cluster of
symptoms really seems unrelated to Borrelia!

Pathogenesis: inflammatory response to spirochetal lipoproteins in specific anatomical sites

 OpsA (adhesion for borreliae in tick midgut)
 OpsC (transmission from tick salivary gland; infection in mammal)
 Dissemination: spirochetes blind plaminogen; converted to plasmin, helps in interstitial / cell invasion
o Host plasmin + spirochete: better movement through ECM (degrade); activate matrix metalloproteases
to cleave ECM more
 Lots of lipoproteins (interact with TLRs host proinflammatory cytokine & chemokine production)
o Joints: arthritis; heart: carditis; neural structures: neuritis

Diagnosis: Clinical (Hx exposure; endemic region, erythema migrans), culture, SEROLOGY
 Serology: enyzme immunoassay (sensitive, not specific) first, then western blot to confirm
Treatment: amoxicillin, doxycycline, ceftriaxone (CNS infections)
Prevention:
 Vaccine no longer available
 Prophylatic doxycycline for tick bites in highly endemic areas (85-90% effective < 24 hrs)
 Remove attached ticks, avoid areas, etc.

Rickettsia rickettsii (Rocky Mountain Spotted Fever)

Gram (-), Obligate intracellular bacteria (Rickettsia = intracytoplasmic; Erlichia & Anaplasma = intravacuolar)
True bacteria (debated at first: DNA, RNA, ribosomes, binary fission)
Close relative to mitochondria (ATP transporter to steal ATP from cell: opposite of mito, etc.)
Tick-bite transmitted

Epidemiology: SE USA, emerging in Southwest. North, Central, South America

 Case-fatality rate: up to 8% overall, higher in children & elderly.
 Lyme disease: non-fatal; RSMF: can be deadly!
35
Pathogenesis:
 attach & enter endothelial cells  escape from phagosome & inhibit phagolysosome fusion  escape, cell dies
 Causes lymphocytic vasculitis

Clinical presentation: SUDDEN ONSET Rash progression in RSMF
 High fever, severe headache, severe myalgias  Macular: flat, pink-red
 Maculopapular-petechial rash after 3-5d  Maculopapular: raised; blanches
 Normal WBC with left shift; thrombocytopenia  Petichiae: blood extravasated
 Lymphocytic vasculitis  loss of intravascular fluid (won’t blanch)
o Hypotension; shock, end-organ ischemic injury
 GI system, renal system (acute tubular necrosis secondary to hypotension)
o Cerebral edema; meningoencephalitis
 E.g. herniated brainstem through foramen magnum, crush respiratory centers
o Non-cardiogenic pulmonary edema
 Pathology: inflammation, damage to endothelium, damage to dermis, not epidermis (around endothelial cells)

Diagnosis: clinical (h/o tick bite, fever, headache); SEROLOGY

 5x risk death after 5d of illness
 Most not treated until after 5d: “hallmark” rash comes in late!
o Presentation during non-peak tick activity, early presentation (1st 3 days) higher risk for missed Dx
 Culture not advocated: VERY HAZARDOUS (use PCR or skin biopsy with antigen)
o Serology not useful in first 7-14 days

Treatment: doxycycline (or tetracycline; doxy has better outcome than chloramphenicol; tooth-staining uncommon
with these doses in kids)

36
 Pathophysiology: ID & Micro
Introduction to Infectious Diseases ........................................................................................................................................ 2
Prokaryotic Structure & Physiology ........................................................................................................................................ 5
Bacterial Toxins ....................................................................................................................................................................... 9
Fever & Sepsis ....................................................................................................................................................................... 12
Diarrheal Disease Caused by Bacteria................................................................................................................................... 15
Staphylococci ........................................................................................................................................................................ 22
Prion Disease......................................................................................................................................................................... 25
Academy Awards of Infectious Diseases .............................................................................................................................. 27
Anaerobic Infections ............................................................................................................................................................. 28
Chlamydia & Mycoplasma .................................................................................................................................................... 30
Non-Tuberculous Mycobacteria (NTM) & Nocardia ............................................................................................................. 32
Antimicrobial Stewardship .................................................................................................................................................... 36
Syphilis (& other STIs) ........................................................................................................................................................... 39

1
 Introduction to Infectious Diseases
Infectious Disease: When an interaction with a microbe causes damage to the host, Steps in microbial
resulting in clinical signs and symptoms of disease pathogenesis
1. Contact
Pathogen: Any organism that has the capacity to cause disease 2. Attachment
3. Invasion
Factors that affect pathogenicity: Host, Agent, and Environment 4. Evasion
5. Cell Damage
I. Host: WHO IS THE PATIENT? (must develop a specific plan for that pt) 6. Spread

a. Age: According to P. Murphy, all organ functions decline at about 1% per year.

Immunologic parameters which decline with age
 Thymus atrophies (by age 40)
 Primary antibody responses ↓
 Skin reactivity ↓
 T cell proliferation to mitogens ↓
 # naïve T cells ↓
 T cells make less IL-12 (immunostimulatory)
Immunologic parameters which increase with age
 Variability of response to a new antigen ↑
 Incidence of monoclonal immunoglobulins ↑
 Incidence of auto-Ab against DNA (anti-nuclear),
immunoglobulins (rheumatoid factor), and organs
(thyroid) ↑
 # memory T cells ↑
 T cells make more IL-10 (immunosuppressive)

b. Nutritional status
 Need mixed protein (40g/day, all 20 amino acids in correct proportions) for protein synthesis
 Can’t store amino acids – unused ones used as energy
 Protein deficiency & immunity: T-cell function ↓ (main problem); PMN production also ↓ but less obvious.
Liver makes less albumin
 Lots of hospital pts. malnourished (esp in ICU, etc.) Can be a big predictor of outcome

c. Host genetics
 E.g. breed susceptible/resistant animals, N. Europe may have been selected for TB, measles, smallpox
resistance, certain human mutations lower resistance to certain organisms, genetic basis for some HIV
resistance in certain patients.

d. Host co-morbidities
 Most clinical infections are situational: reason exists for why pt. became infected
o Chronic medical illnesses (diabetes, etc); immunosuppressive
drugs (steroids, transplants, chemo, rheumatoid arthritis tx); Types of Pathogens:
IV access for many reasons  Prions (single protein molecule,
II. Pathogen PrP)
a. Endogenous vs. Exogenous Flora  Viruses (Nucleic acid –RNA or DNA
 Endogenous flora: organisms which are long-term residents of - & proteins)
body surfaces (“commensals”)  Bacteria (prokaryotes; nucleic acid
o Colonization by endogenous flora happens right after birth - DNA & RNA – not separated from
o Good for nutrient acquisition, differentiation of mucosal sites, rest of cell by membrane)
stimulates immune system, provides accessory growth factors  Fungi (eukaryotes)
o Harder for pathogenic organisms to establish residence on  Parasites (eukaryotes)
body surface or multiply & cause problems
 Exogenous flora: organisms which can’t survive indefinitely in a single individual but depend on transmission
from one person to the next

2
 b. Better classification scheme
 Commensals: Very normal to have; rarely cause disease
 Facultative Pathogens: some patients get sick, others don’t (who’s the patient?)
 Obligate pathogens: never should be there; is essentially always causing disease if present

c. Human microbiome: effort to categorize what kinds of flora live where in / on humans

Probability of disease equation:

inoculum size × growth rate × virulence

𝑷𝒅𝒊𝒔𝒆𝒂𝒔𝒆 =
host resistance

Inoculum size:
 If you brush teeth, some bacterial always entering your blood, but you’re ok (small size so neutrophils take care
of it).
 If you have an abscess burst of the same bacteria, you’re in trouble (tons entering blood stream at once)
 About 1011 Gram-negative bacilli (1 mL stool), 1012 Gram-positive bacilli can kill you

Growth rate:
 Doubling time varies among organisms
 Bacteria = minutes (exceptions: mycobacteria, chlamydia, etc. are slower)
 Virus = hours (poliovirus @ 5hrs is fastest)
 Fungi, parasites = slower

Virulence factors: properties that enable a microorganism to establish itself on or within a host & enhance its potential
to cause disease (resist host defenses, multiply from small inoculum to concentration that causes disease)
 Growth @ 37 C, for instance; toxicity, etc).

Host resistance
 Non-immunological: HOST RESISTANCE
o Skin impermeable to most bacteria Immunological
Nonimmunological
o Mucous membranes allow small #s bacteria Innate (“Natural”) Acquired
to pass through (induce immunity)  Skin  Macrophages  B-cells
o Constant flow in body tubes washes out  Mucous membranes  Neutrophils (PMNs)  T-cells
bacteria (saliva, bile, urine)  Constant flow in  NK cells
o Lungs protected by cilia and cough reflex body tubes  Complement
o Breaking these barriers (e.g. central lines, IV  Clilia, cough in lungs  Interferon
drugs, Foley cath) is a great way to cause infection

 Innate (“Natural”)
o Macrophages & Dendritic cells
 Roles: Phagocytosis, antigen presentation, secrete cytokines to drive acquired immune
response differentiation,
 use pattern recognition receptors (CD14, Toll-like Receptors) to recognize molecules from
pathogens (e.g. LPS in Gram (-), peptidoglycan in Gram (+))
o Polymophonuclear cells (PMNs = neutrophils)
 Roles: phagocytosis (opsonic, PAMPs, etc.)
 Microbes can escape phagocytosis:
o have a capsule to protect
o inhibit fusion of phagolysosome
o escape into cytoplasm & replicate there
3
 o resist killing (e.g. catalase)
 Reach infection site via chemotaxis (chemicals from initial host-pathogen interaction) and
adhesion interactions (sticking & migration from vessel)

o Complement: series of plasma proteins, cell receptors that mediate inflammation

 Liver produces complement (starvation: protein ↓, complement ↓)
 Most important effects: activated C3 and C5-9
 Pathways:
 Classical pathway (Ag-Ab complexes)
 Alternative pathway (polysaccharides via C3)
 Lectin-binding pathway
 Mechanisms of action:
 opsonization (C3b) – increase attachment & phagocytosis (Mφ & PMN)
 chemotaxis (C5a) - attracts PMNs
 cell destruction (membrane attack complex)

o NK Cells: large, low-density, granular cells without T-cell receptors or surface IgG
 Don’t require activation before function
 Triggered by cells that do not display self class I MHC
 Mostly antiviral activity

o Interferons: cytokine (glycoprotein) cell-signaling molecules produced by

immune system cells in response to challenge (immunuloregulatory Responses to infection
signals) (will discuss in detail later)
 Interferon α – “leukocyte”interferon; from all cells in response to  Fever
viral infection or dsRNA, upregulate MHC class I  Anorexia
 Interferon β – “fibroblast”interferon; from all cells in response to  Lethargy
viral infection or dsRNA, upregulate MHC class I  Myalgia
 Interferon γ - “immune” interferon, from T-cells in response to
antigen/mitogen, upregulate macrophages & MHC classes I & II

 Acquired immunity
o T-cells (cell-mediated immunity)
 Roles: directly kill infected cells, generate DTH responses, promote Ab formation
 TH (CD4+) cells: work with MHC class II molecules
 facilitate immune response by T-cells & B-cells
 secrete products that promote antiphagocytic activity
 TCTL (CD8+) cells: work with MHC class I molecules
 Lyse infected cells
o B-cells (humoral immunity)
 Produce immunoglobulins which recognize unique antigenic structures

NB: Good review slides for the end of the block at the end of this “Healthy people who are well-fed,
lecture: defect in ____, increased susceptibility to_____. reasonably separated from each other, and have
access to pure water
seldom have serious infectious illnesses”
– P. Murphy

4
 Prokaryotic Structure & Physiology
Prokaryotes vs. Eukaryotes PROKARYOTE EUKARYOTE
SIZE OF CELL Small Bigger
NUCLEUS No nuclear membrane / nucleoli Nuclear membrane / nucleoli
Important things: differences between MEMBRANE-ENCLOSED Nope Yep
prokaryotes and eukaryotes are good ORGANELLES
targets for antibiotics (cell wall, ribosomes, FLAGELLA Simple (2 building blocks) Complex (microtubules)
etc.) GLYCOCALYX Capsule / slime layer Present in some cells (if no
cell wall)
CELL WALL Usually present; complex When present, simple
Bacterial shape & size PLASMA MEMBRANE No CHO; mostly lacks sterols Sterols & CHO as receptors
CYTOPLASM No cytoskeleton Cytoskeleton
 Cocci (round) RIBOSOMES Smaller (70S) Bigger (80S); smaller (70S) in
 Bacilli (rods) organelles
CHROMOSOME (DNA) Single circular chromosome Multiple linear chromosomes
 Pleomorphic (shape is variable or shape No histones Histones
is “in-between”, e.g. “coccobacilli”) CELL DIVISION Binary fission Mitosis
 Also vibrio (=commas), spirochetes SEXUAL REPRODUCTION Transfer of DNA fragments only Meiosis
(=spirals), etc.
 Size: about 0.2-5 μm

Gram’s Stain
Process:
 Get sample, fix by air drying (don’t heat – could hurt cell wall)
 Crystal violet (all purple) iodine (stabilizes)  alcohol (decolorizes G- ) Safranin (counterstains G- red)
 End result: Gram (+) = purple, Gram (-) = red
 Gram stain adheres to gram+ peptidoglycan layer & resists decolorization

Exception:
 Acid-fast bacteria cannot be Gram-stained
 Resist decolorziation with alchol because of a high lipid concentration in cell walls)
 Mycobacteria, etc: have to use an acid-fast stain (show up red)

Uses:
1. Bacterial identification (especially in low resource areas, or quick ID)
2. Early identification of an appropriate antibiotic (e.g. could start empiric treatment to cover Gram (+) )

Tips:
 Try to minimize epithelial cells (would take up safranin, so would be red)
 Neutrophils usually show up but are much bigger than your bacteria
o Can use neutrophils to judge the decoloration (pale red = too declored, too blue = not declored enough)
o If you leave alcohol on too long, could decolor even Gram (-) bacteria

Structural differences: Gram Positives vs Gram Negatives

Cell membrane in prokaryotes:

 no sterols (unlike eukaryotes)
 Important: active transport, energy generation, cell wall precursor synthesis, secretion of enzymes/toxins
Gram Positive Gram Negative
1. Phospholipid cell membrane, then 1. Inner phospholipid membrane, then a
2. large peptidoglycan layer anchored to cell 2. small peptidoglycan layer in the periplasmic space, covered by
membrane by lipoteichoic acids (LTA) 3. outer phospholipid membrane with lipopolysaccharide (LPS)

5
Important features of bacterial cell walls:

Teichoic Acids: (Gram + only)

 antigenic (glycerol or ribitol phosphate)
 anchor to cytoplasmic membrane or NAM of peptidoglycan
 useful for anchoring cell wall & adherence to cell membrane

Peptidoglycan (Gram + and -, but more & more exposed in Gram +)

 Cross linked chains of monomers (NAG-NAM pentapeptide)
 Transglycosidase enzymes join monomers to make chains
 Transpeptidase enzymes make peptide cross-links between
chains (strength & enable bacterium to resist lysis)
o Penicillin blocks this transpeptidase
o Note the peptide side chains coming out at right angle

Gram + (A) and Gram - (B) Cell Walls

Lipopolysaccharide (LPS): (Gram – only)

 Lipid A: “endotoxin”
o Conserved among Gram (-)
o Highly immunostimulatory
o Causes unforgettable sepsis
o Made of sugars & fatty acids
 Core polysaccharide somewhat conserved among species
 O-specific polysaccharide different even within species

Gram Negative Sepsis

 Gram (-) sepsis is really bad – death not due to organism but rather immune system going crazy
 Tx: give fluid (will accumulate in extremities after leaking out: puffy appearance)
 Short-term Tx: Abx expose lipid A, cause worse short-term consequences
o Why can’t we get mortality in gram (-) sepsis to 0% (around 30% for years)?
o Maybe because Abx precipitate some LPS/Lipid A release & toxicity results
 Lipid A is key player: actions include
o Febrile response
o Activation of complement, granulocytes, macrophages
o ↑ interferon production
o ↑TNF (↓ capillary endothelial cell permeability; development of shock)
o ↑ colony-stimulating-factor production
o B-cell mitogen

Bacterial capsule:
 Gelatinous layer, covers bacterium, found in some spp, usually polysaccharide
o Sugars vary spp to spp; can use to do serological typing
6
 o Virulence: prevents phagocytosis
o Swells if homologous Ab around: QUELLUNG REACTION
 Example: think you have strep; mix with an anti-strep-capsule Ab, get Quellung reaction to
confirm that you’re right (organism has that capsule)
o Can be used as antigen with some vaccines

Spore formation:
 Clostridium and Bacillus produce them (e.g. recurrence of C. diff, etc.)
 Response to adverse conditions
 Form inside the cell (DNA, cytoplasm, cell membrane, peptidoglycan, thick keratin-like structure around it)
 No metabolic activity (can be dormant for years)
 When environment more favorable, enzyme degradation of coat, germination into bacterium
 Highly resistant to heat and chemicals

Bacterial division (Binary Fission)

 1 parent cell  2 identical progeny cells
 Exponential growth (2n where n = # generations)
 Doubling time: 20 minutes to days

Bacterial growth cycle

1. Lag phase: get used to environment, get ready to
start dividing (A)
2. Log growth phase (C)
3. Run out of space & food; equal # die & divide (E)
4. No more food, etc. death (F)

NB: Many Abx work best in log growth phase

Aerobic & Anaerobic Growth

Using oxygen generates two toxic molecules: H2O2 and O2•
(superoxide). Bacteria need two enzymes to use oxygen.
1. Superoxide dismutase (2 O2• + 2 H+  H2O2 + O2)
2. Catalase (2 H2O2  2 H2O + O2)

 Obligate aerobes cannot grow without oxygen (ATP-generating system needs oxygen as hydrogen acceptor)
 Faculative anaerobes can use oxygen for respiration if it’s around, but they can also go anaerobic
 Obligate anaerobes lack one or both of these enzymes so they can’t generate ATP via respiratory pathway

Bacterial genetics: bacteria are haploid with a single chromosome (usually circular, ~2000 proteins; can transfer to
other bacteria, e.g. as plasmid); fission results in identical progeny.

Mutations are changes in base sequence of DNA that results in altered phenotype
 Substitutions (missense, nonsense); frame shift, transposons / insertion sequences.
 Can occur randomly & may be caused by chemicals, radiation, viruses – but genetic diversity not generated
during reproduction like in eukaryotes

Transfer of DNA within bacterial cells

 Transposons: DNA from one site on chromosome to another site or to plasmid. Can lead to antimicrobial drug
resistance
 Programmed reagrangements: movement of gene from silent site to site where it’s transcribed & translated.
Can lead to antigenic variation

7
  These are two ways that inducible resistance can arise, or production of a toxin which wasn’t previously
produced, for example.

Transfer of DNA between bacterial cells

 Conjugation: mating of bacterial cells, DNA transferred via sex pilus, etc.
 Transduction: transfer of genetic material via a bacteriophage (bacterial virus)
 Transformation: transfer of DNA (extracellular) itself from one cell to another

Bacteria & Iron

 All organisms need exogenous iron source; free-living bacteria commonly use siderophores to chelate iron from
environment for their use
 Human host: iron not found in unbound form (maybe a way to control bacterial growth?). Instead bound to
proteins (transferring, lactoferrin, ferritin, myoglobin, hemoglobin, etc.)
 How do bacteria get iron?
o Produce special siderophores (compete with iron-binding proteins)
o Direct uptake by stealing from tranferrin / lactoferrin
o Use of heme from breakdown of tissues
 Clinical importance: host sequestration
o chronic infections can lead to anemia
o not iron-deficiency anemia – instead, host tries to hold onto iron more
o iron stores are actually increased in the red cells that are present).

8
 Bacterial Toxins
Toxins: molecules produced by microbes that can produce disease
Toxoids: detoxified toxins that retain antigenicity / immunogenicity)  vaccinations (diphtheria, tetanus)

Categorization: chemical composition (protein/lipid/LPS), cell/tissue target (enterotoxin/neurotoxin), mechanism of

action (proteolytic/adenylate cyclase toxin) biologic effect(lethal factor / edema factor), organism (pertussis toxin,
cholera toxin), intracellular target, specificity (broad/targeted)

EXOTOXIN
 molecule (usually protein) produced and released by a
microorganism to affect target cells at a distance
 Act enzymatically or directly with host cells; stimulate
variety of host responses
ENDOTOXIN
 intracellular / cell-associated structural component
of Gram (-) bacteria (e.g. LPS)
 Most located in cell envelope & act locally

Exotoxins
Toxin genes:
 chromosomes (cholera),  bacteriophage (diphtheria),
 plasmids (E. coli heat-labile),  combination (Staph enterotoxin)

Control & regulation of exotoxin synthesis & release:

 Diptheria toxin: production↓when iron around; Cholera toxin / virulence factors: environmental osmolarity, temperature
 Toxin often required for virulence & pathogenicity
 Distinct pathways for secretion; details have significant impact on toxin/pathogen virulence
o Direct injection, series of pores, assembly in periplasmic space, etc.

Structure: A-B toxins

 Most exotoxins: A (active, enzymatic  toxin effects) and B (binding) domains
 Need both for effects to be exerted on cells (binding & activity)
 Permutations: A:5B, A-B, A+B, etc.
 Attachment & entry: direct entry (B-subunit  pore formation), receptor-mediated endocytosis, both

Mechanisms of action of A-B exotoxins (organism can have more than 1 toxin too)
1. ADP-ribosylating toxins. Remove ADP ribosyl group from NAD & stick it on host-protein, inactivating or
modifying function
2. Adenylate cyclase toxins. Synthesize cAMP after binding host cell calmodulin
3. RNA glycosidase toxins. Cleave host cell rRNA, stopping protein synthesis  cell death
4. Metalloprotease toxins. Proteolytic  disrupt cell function

Attatchment & entry: different types

 Non-selective (e.g. cholera toxin) so clinical manifestation is from localization of organisms / toxin
 Coupling between toxin-receptor complex; lipid rafts in host cell plasma membrane (anthrax LF/EF)
 Some could act against most cells, but only can bind to certain surface receptors on certain cells (pertussis)
 2 toxins may catalyze the same intracellular reaction (e.g. diphtheria toxin, pseudomonas exotoxin A) but have
different clinical manifestations (different receptors, different cell distributions)

Membrane-damaging toxins: release of host cell nutrients (cell death) & better direct injection of bacterial components
 Pore-forming toxins: trans-membrane pores into phospholipid bilayer; disrupt selective ion movement.

9
 o B. anthracis edema factor, S. aureus α-toxin (abscesses), streptolysin O of S. pyogenes (strep throat)
 Cytotoxins: hydrolyze / solubilize phosopholipid bilayer
o (α-toxin of C. perfringens)

Exotoxin examples:

Anthrax: uncommon, risk factors: animals & hides, industrial activities, bioterrorism. Cutaneous/inhalational/GI; any
can be associated with hemorrhagic meningitis. Radiography: widened mediastium (hemorrhagic lymphadenitis).
Substantial edema (around lesions on skin).

Produces three toxin components (need all 3 together)

 A: Edema factor (EF): an adenylate cyclase (↑cAMP in phagocytes, forms ion-permeable pores). Edema,
phagocytosis inhibition, impaired host defenses.
 A: Lethal factor (LF): a protease (cytokine release, cytotoxicity: lysis of Mφ, ↓PMN activity)
 B: Protective antigen. Binds glycoprotein receptor; cleaved by host protease, then binds EF or LF; complex
endocytosed, increased cAMP.

Diptheria: uncommon (universal vaccination with diphtheria toxoid); endemic in Latin America / Carribean, immunity
does not prevent carriage, adult immunity wanes without booster.

Diphtheria toxin: produced as single polypeptide; cleaved by trypsin

 A: catalytic domain
 B: binding domain (receptor for cell attachment)
 T: hydrophobic domain (insertion into endosome membrane, secure A release)
 Process: B binds, RME  endosome; acidification  unfolding of A&B to expose T  T inserts into endosome 
A translocated to cytoplasm  enzymatic activity (ADP-ribosylates)
 Causes systemic toxicity proportional to the burden of pharyngeal exudates
 Most severe manifestations:
o Cardiac toxicity (myocarditis): arrhythmia, can lead to heart failure & hemodynamic collapse
o Neurotoxicity: cranial neuropathies, paralysis of pharyngeal wall / soft palate, delayed peripheral
neuritis

Endotoxins
Endotoxin: LPS, located in outer membrane of Gram (-) bacteria.
 Released from lysed bacteria (host defense and/or Abx)
 Generally acts locally.
 Structure:
o O-antigen: variable among Gram (-) bacilli. Facilitates tissue adherence, carrier for lipid A, antigenic
variation, phagocyte resistance, protection from Ab & C’
o Core (R) polysaccharide: conserved within / distinct between genera
o Lipid A: highly conserved
 Generates febrile response (direct: hypothalamus; induces endogenous pyrogens like IL-1,
prostaglandins)
 Directly activates Mφ, coagulation cascade
 Activates C’: histamine release PMN chemotaxis
 Induces interferon production, TNFα (↑capillary endothelial cell permeability  shock)
 ↑colony stimulating factor production; polyclonal B-cell production, immunoglobulin secretion
 Inject LPS: fever, leukocytosis, disseminated intravascular coagulation (DIC), hypotension, shock, death.

Mechanism of action:

10
 1. Lysis  release of LPS  binds to circulating LPS-binding protein; complex then binds to CD14 on Mφ cell
membranes (associates with other proteins)
2. Triggers secretion of pro-inflammatory cytokines (IL-1, IL-6, IL-8, TNFα, PAF) from Mφ.
3. Cytokines bind cytokine receptors on target cells (inflammation, C’ activation, coagulation pathway)
4. Leads to endotoxic shock, multi-organ systemic failure
 High fevers, severe back pain, pain on urination; CVA tenderness (costovertebral angle  kidneys);
PMNs in urine, Gram (-) on gram stain
 Hypotension, tachycardia, dyspnea

Summary: Endotoxin vs. Exotoxin

PROPERTY ENDOTOXIN EXOTOXIN
Chemical nature Lipopolysaccharide Protein
Relationship to cell Part of outer membrane Extracellular, diffusible
Antigenic Yes Yes
Form toxoid No Yes
Potency Relatively low Relatively high
Enzymatic activity No Often
Pyrogenicity Yes Occasionally

Superantigens
Biological activities: overstimulation of immune system, pyrogenicity, shock
Mechanism:
 Superantigen mediates non-specific interaction between class II MHC on APCs and specific Vβ chains of TCR on
T-lymphocytes
 Massive stimulation of T-cells (20% activated  massive cytokine release)
 Toxic shock syndrome: Hypotension, fever, diffuse erythematous rash

Examples: pyrogenic exotoxins of Group A strep and Staph enterotoxins

Scarlet fever:
 Pharyngitis from Group A Streptococcus usually self-limited (2-5d); Tx: prevent complications
 Scarlet fever: pyrogenic exotoxin (Group A strep): complication from pharyngitis
 “Sandpaper rash”: 1-2d after onset; upper chest  rest of body, texture key in Dx
o Rash fades  desquamation
 “Strawberry tongue”: bright red tongue

Toxins as friends:
1. Immunogens in vaccines directed against toxin (toxoid)
2. Direct targeting of cells with receptor can exploit toxin B subunits (e.g. fusion proteins in cancer chemo)
3. Botulinum toxin (Botox ®)
a. Control of disorders with uncontrolled muscle spasms
i. Blepharospasm (uncontrollable blinking)
ii. Torticollis (relentless turning of neck to one side)
b. Chronic anal fissures
c. Temporary reduction of skin wrinkles

11
 Fever & Sepsis
Fever: “a state of elevated core temperature which is often, but not necessarily, part of the defensive response of a
multicellular organism (host) to the invasion of live or inanimate matter recognized as pathogenic or alien by the host.”
 Drugs, cancers, etc. can also cause fever – not just infection

Variability of temperature:
1. observer (calibration, etc.)
2. anatomic (oral is best – easily accessible & responds promptly to core changes; also rectal & tympanic)
3. physiological: ↓(age, in morning), ↑(ovulation, exercise, at night)
a. No set “normal body temperature”: normally distributed among individuals
b. Varies : 96°F 101.3°F (> 101.3 usually defined as fever)

Thermoregulation:
 Heat derived from internal work (peristalsis, myocardial contraction), biochemical reactions, external work
(exercise, shivering)
 Core heat distributed via circulatory system (e.g. ↑core temp, ↑cutaneous blood flow to dissipate via skin)
o Turn red with fever (dilating vessels)
 Pre-optic area controls body temp
o If over set point: activate heat loss responses (lower body temp)
 Pyrogens affect temperature regulation (drugs too!)
o Endogenous: PGE2 (from COX-2, PGE2 synthase via arachadonic acid pathway)  to preoptic area
o Pyrogenic cytokines: IL-1 (most commonly associated, also TNF, IL-6, IFN)
 Source: Mφ (response to endotoxin, peptidoglycan, fungal cell walls, bacterial toxins, drugs)
 Example: LPS + LPS-binding protein  Mφ CD14 reeptor  cytokines  PGE2 production from
endothelial cells  pre-optic area  increase body temperature (feeds back on cytokine
expression)
o Non-infectious pyrogens: non-infectious febrile disease from pyrogens produced in immune response
 Fever in malignancy: generally infection or body’s attempts to reject tumor
 Certain tumors (e.g. Hodgkin’s disease): malignant cells can produce endogenous pyrogens

FEVER GOOD! FEVER BAD!

 Closely regulated, purposeful response (evolved)
 Stimulates the immune response
 1°C rise in temp = 10x the stimulatory effect of IL-1 on T-
cells  more B-cell activity, more Mφ activity, more
cytotoxic lymphocyte output
 Most organisms have growth optima ~ 37C (want to
make environment inhospitable)
 Basal metabolic rate ↑10% for 1°C rise in temp
 3rd world countries: chronic infection & fever in children;
food supply already marginal, metabolic needs can’t be
met, promotes more infection (cycle)
 Hospitals: gross malnutrition common in chronically
infected adults; don’t heal surgical wounds, ↑risk more
infections

Treatment:
 Antipyretics: if you’re going to give, GIVE CONSISTENTLY AND CONTINUOUSLY
o nontoxic, analgesic effects, reduces metabolic demands & fever-induced alterations in mentation
 People feel worse when temperatures are changing (e.g. chills & sweats)
 No definitive studies to show benefits or harmful effects for moderate fever
 Temperature > 106°F: enzymatic processes start to break down (big trouble)

Acute-phase response (APR):

 various physiological reactions mediated by same group of pyrogenic cytokines that activate the thermal
response of fever (mostly IL-6)

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  Stimuli: infections, trauma, cancer, burns, exercise, childbirth
 Body trying to limit actions of what it perceives to be invader:
o IL-6: changes in hepatic protein synthesis
 ↓ albumin
 ↑ fibrinogen, haptoglobins (increased amounts);
 ↑ C reactive protein and serum amyloid A associated protein (not present in normal plasma)
o IL-1: ↓ serum iron/zinc (withhold from bacteria), ↑ PMNs & bands
 C-reactive protein:
o binds phosphocholine on microorganism, damaged host cells;
o activates C’ & ↑phagocyte adherence (better clearance)
o Good marker for following Tx of chronic infection (e.g. osteomyelitis). (Can also look at anemia of
chronic disease: Iron increased)
 Serum amyloid A: ↑adhesiveness, chemotaxis of phagocytic cells & lymphocytes

SEPSIS
Definitions:
 SIRS: systemic inflammatory response syndrome:
o “abnormal, generalized inflammatory reaction in organs remote from the initial insult
o (fever, tachycardia, leukocytosis / PMNs)
o Could also be from drug rxn, tumor, etc.
 Sepsis: when SIRS occurs in pt with suspected or proven infection, then SIRS = sepsis
 Severe sepsis: sepsis + hypotension
 Septic shock: severe sepsis + organ dysfunction that cannot be reversed by fluids (usually liver, kidney)

Sepsis: (85% SIRS have bacterial causes = sepsis): Caused by host reaction to agents (all good things but too magnified)

Syndrome of injury to small vessels

1. Mφ secrete cytokines (TNF, IL-1,etc.) producing inflammation in capillaries all over body
a. Endothelial cells lose contact with each other; express proteins to bind PMNs
b. Secretion of:
i. Prostaglandins (vasodilation, low BP, vascular permeability ↑)
ii. Leukotrines (permeability ↑)
iii. Thromboxanes
iv. Platelet activating factor (↓BP, ↑aggregation)
v. Nitric oxide (vasodilation) Clinical Features of Sepsis
2. Vessels: dilated & leaky (obstruction of vessels / plugs of platelets &  High cardiac output
PMN)  Low systemic vascular resistance
a. Lightly bound PMN: emigrate into tissue, cause damage there  Tachycardia
b. Tightly bound PMN: degranulate directly onto vessel walls  A-V shunting with poor tissue
c. Vessel walls destroyed: lipid peroxidation, proteolysis, extraction of O2
induction of apoptosis  Acidosis / elevated blood lactate
d. ↑ thrombin production, ↑ clotting  Increased gut permeability
3. Blood shunted around tissues, fluid & protein lost from blood, tissues
waterlogged, tissue ischemia DDx: conditions where BP decreases
4. Organ dysfunction:  MI, bleeding: SVR↑, CO↓
a. Lungs fill with fluid, oxygen uptake fails (further ischemia)  Sepsis: SVR↓, CO↑ (HR↑)
b. Heart: acidotic, ischemic: fails
Treatment:
Clinical problems:  support vital functions (FLUIDS) &
 Antibiotics can control infection oxygenation if needed
 give ANTIBIOTICS,
 hope for the best
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  Fluid infusions restore volume & BP, but fluid doesn’t stay intravascular (tissue edema gets worse)
 Ventilator support: restores oxygenation temporarily but can damage lungs (O2 toxicity, high pressures)
 Often survive a few days, then die of progressive multi-organ failure (MOF)

Role of activated Protein C (not CRP)

 Activated by thrombin bound to thrombomodulin
 Normally inhibits clotting cascade (↓thrombosis, ↑fibinolysis)
 Body runs out of protein C during sepsis
 Protein C levels predict mortality
 Replete protein C as Tx (inhibit thrombosis, promote fibrinolysis): cut mortality from 30% to 25%
o (other interventions post-antibiotics didn’t affect long-term mortality)

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 Diarrheal Disease Caused by Bacteria
Diarrhea: #2 cause child death worldwide (#1 = acute respiratory disease)
 5 million /yr in 1980  1.5-1/7 million today because of ORS)
 Most cases: 1st 2 years of life; mortality highest in < 1yo.

Frequency of bowel movements: most 1-2 per day (varies in general population, not impossible for 3/day to be normal)

Diarrhea defined by frequency, consistency, volume, change from normal habits

 Acute: Secretory (mostly viral & bacterial) or invasive (mostly bacterial)
 Chronic (2-3wks+): mostly parasitic, less commonly bacterial; can be non-infectious (eg. inflammatory bowel dz)
 Traveler’s diarrhea: mostly bacterial, reflecting organisms that cause diarrhea in local children

Diagnosis: clinical symptoms, microscope exam, culturing stool (primary), ELISA, PCR.
 Looking at Ab can be used only retrospectively (takes too long)

Normal GI function: 2L fluid in, 200mL out in stool (98% absorbed, most in small bowel).
 Villus cells absorb, crypt cells secrete.
 Continuous removal of intestinal epithelial cells (shed in stool ~2-3d)
o Divide @ crypt, travel up & sloughed at top. Normal: # cells entering villus = # cells dying
 Normal microbial flora: few in small intestine; abundant in large bowel (also in mouth)
o Mostly anaerobes (99%); facultative anaerobes (e.g. E. coli) ~1%
o Provide protection against enteric pathogen colonization (Salmonella, C. difficile)
o Non-immunologic control: gastric acid, normal peristalsis, bile
o Immunologic control: sIgA from mucosal immune system, cell-mediated immunity in gut
 FYI: lactating mammary gland makes these Ab too; important for newborns

Pathophys: Mechanisms for Diarrhea

1. Decreased absorption
a. inhibited/defective absorption from villous cells Oral vaccines for diarrheal dz prevention
b. luminal presence of osmotically active agents  Typhoid
c. decreased contact time (rapid transit time)  Cholera
2. Increased secretion  ETEC, Shigella, Campylobacter in
a. Stimulated anion secretion from crypt cells development

Bacterial agents of acute diarrhea: mostly Gram (-) rods

 E. coli: Enterotoxigenic (ETEC), Enteropathogenic (EPEC),
Enterohemorrhagic (EHEC)
 Vibrio: V. cholerae O1 & O139, V. parahemolyticus, V. vulnificus
 Shigella: S. dysenteriae, S. flexneri, S. sonnei, S. boydii
 Salmonella: Salmonella (non-typhoid), S. typhi
 Campylobacter jejuni
 Yersinia entercolitica
 Anaerobes: C. difficile, C. perfringens, B. fragilis (enterotoxigenic
strains)
 Others: aeromonas, plesiomonas, L. monocytogenes, more

Fecal-oral transmission
 Developing countries: contaminated water supply, inadequate latrines, poor sanitation
15
  Developed countries: contamination of processed foods
Virulence factors
 Inoculum size: variable (Shigella, EHEC: 10-100 organisms for; cholera, ETEC: 105-8)
o Person-person requires small inoculum size; food/water requires large inoculum size
 Enterotoxigenic vs Invasive
o Enterotoxigenic: V. cholerae, ETEC. Attach to mucosal
cells in intestine by pili, other mechanism; sit on border
& secrete toxins
o Enteropathogenic: attatch & efface microvilli; cause
some damage to the border (EPEC, EHEC)
o Invasive: Shigella, Campylobacter, Salmonella, Yersinia,
Listeria. Enter cells & replicate there

Enterotoxins:
 Cholera toxin (CT); E. coli heat-labile toxin (LT): large MW toxins,
5B:1A, arranged like donut
 Heat stable (ST) E.coli toxin is Enterotoxigenic Invasive
smaller (E. coli, Cholera) (Campylobacter, Shigella)
 Shiga and Shiga-like toxins (S. Diarrhea Severe Moderate
dysenteriae, EHEC) also large MW , Major site of disease Small bowel Colon
different action Major defect Increased secretion Decreased absorption,
 Bacteriophage control (horizontal Increased secretion
gene transfer): CT & Shiga-like Character of fecal loss Isotonic electrolyte Same + mucus, ±blood,
 Plasmid control: LT & ST E. coli solution ± pus
toxins Primary Rx Fluid-electrolyte Fluid-electrolyte + Abx

Incubation period generally 1-3 days, rarely 4-5 days; very rare 30d+

Secretory Diarrhea: Vibrios & ETEC

Both Gram (-) rods

V. cholerae:
 O1, O139 only serogroups that cause epidemic cholera
 Most severe of all diarrheas (60-70% mortality untreated; 12-24h  death, > 1L/hr)
 Result of the cholera toxin
 Clinical course: exposed, 1d incubation, vomiting at first / “rice water” diarrhea, low BP, tachycardic
 Findings: “washerwoman’s hands”, skin turgor, sunken eyes (severe dehydration), no real histological changes
 May see metabolic acidosis (losing bicarbonate): huffing & puffing
 Potassium lost may lead to hypotension & even renal failure
 Stool: NO RBC, NO PROTEIN (similar to serum: isoelectric!)

ETEC: most common bacterial cause of diarrhea in developing world; most frequent cause of traveler’s diarrhea. Very
similar to V. cholerae.

Both V. cholerae & ETEC: similar mechanisms of pathogenesis (CT & ETEC LT are very similar)
 Large inoculum size (105-8 organisms); achlorhydria can predispose
 Colonize small bowel via fimbriae attaching to mucosal receptors
 Produce enterotoxins while sitting on surface
o B subunits of CT/LT attach to GM1 ganglioside receptors; ST attaches to different one)
o A subunits of CT/LT activate adenylate cyclase: ↑cAMP
 ↑ Cl secretion from crypt cells
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  ↓ NaCl absorption from villus cells
o ST: activates guanylate cyclase; ↑cGMP, same changes
o Coupled Na/glucose absorption NOT affected: important for ORS
Lab diagnosis:
Treatment: FLUID REPLACEMENT (IV or oral)
 If cholera, antibiotics help decrease stool output & shorten disease. Tetracycline, Cholera: use special
erythromycin, cipro. media to culture
 Oral rehydration therapy (ORS): Na, Cl, K, Citrate + carbohydrate. Does not (TCBS agar)
decrease severity/duration of diarrhea. Uses coupled Na/glucose transport to
efficiently absorb sodium. Universal therapy for all dehydrating diarrhea. ETEC: need
o Keep osmolarity lower than normal serum (don’t want to suck fluid out) molecular methods
o Use citrate because it’s more stable than bicarbonate (no easy culture)
 With good treatment: mortality <1%

Vibrio parahaemolyticus
Gram (-) rod, halophilic (thrives on high salt); normal inhabitant of costal waters
 Common cause of diarrheal disease after eating undercooked shellfish (especially oysters)
 Major cause of diarrheal illness in Asia (esp. Japan)  eating raw fish
 Mechanism of action not well understood (heat-stable toxin?)
 One serotype “pandemic”: O5:K6 (Asia Europe, US)

Clinical presentation:
 Seasonal: summer months predominate (warmer water)
 24h incubation, mild diarrhea (±nausea, vomiting, low-grade fever)

Diagnosis: difficult, need special media (TCBS agar)

Treatment: Abx usually NOT required (self-limiting; 2-3d)

Vibrio vulnificus
Gram(-) rod, lives in sea water (mostly in summer along Gulf Coast)
 Blood stream infections (ingestion in seafood like raw oysters, wounds after exposure to salt water)
 Pts with liver disease or severe immunocompromise almost exclusively affected (very rare in normal pts)
 Sepsis results

Treatment: infections very difficult to treat; mortality very high in spite of Abx & surgery

Invasive diarrheas: Shigella & more

Shigella (prototype of invasive diarrhea): Gram (-), non-spore-forming rod
 Low inoculum size (101-2): person-person spread is usual The 4 Shigellas
 Pass through small bowel  invade large bowel; move laterally causing  S. dystereria (Shiga bacillis) =
cell death. most severe
o inflammatory changes of mucosa (huge changes on histology  S. flexneri: most prevalent in
o diarrhea with blood & pus developing countries
o fever & abdominal pain  S. sonnei: most prevalent in
 Dx: stool culture (non-lactose fermenting, non-pigmented colonies) developed countries &
 Tx: antimicrobials. Increasing resistance in developing countries travelers to developing
o Cipro when resistance is high countries
o Loss of fluid isn’t huge, but ORS can be used when necessary  S. boydii: relatively uncomon

17
 o Nutritional therapy can be important (not absorbing nutrients from damaged bowel)

Campylobacter jejuni
Gram (-), slightly curved rod
 Common in small children of developing world, young adults of developed world
 Present in >50% supermarket chicken packages (prevalent in poultry and other mammals too)
o Transmission: food preparation; on outside of meat (easily cooked away)
 Mechanism for diarrhea production not known
 Requires 42C incubation, microaerophilic conditions to grow

Clinical presentation: invasive diarrhea, much like Shigella

 Stool: pus, RBC
 Fever, abdominal pain; can be Asx in yong children in tropics
 Association with Guillain-Barré syndrome (autoimmune, ascending paralysis): serotype O19 may have
immunologic cross-rxns with GM1 ganglioside in nerve tissue

Treatment: antimicrobial therapy useful (azithromycin is drug of choice; erythromycin, fluroquinolones too).
 Often cipro-resistant
 Dx can take several days, pt may recover by then.
 Oral therapy not too helpful

Enterohemorrhagic E. coli (EHEC)

Gram (-) rod
 Most common E. coli in USA
 Can cause bloody diarrhea with possible life-threatening sequelae: hemolytic uremic syndrome (HUS)

Source: food industry failures. Healthy young cows are reservoir; contamination from stool
 Low inoculum size so big mixtures of hamburger meat can still be infectious
 Irradiation can control but not widely used

Pathogenesis: colonize large bowel mucosa; attach & efface microvilli of mucosal cells
 Produce two shiga-like enterotoxins (SLT-1, SLT-2) controlled by bacteriophages
o 5B:1A toxins; A subunit inhibits 60S ribosomal subunit (kills cells)

Clinical presentation: 1-2d incubation  hemorrhagic colitis (blood in stool); HUS can develop in 10% pts after 6 days
(diarrhea has already disappeared)
 HUS: hemolysis, renal failure, thrombocytopenia. 3-5% HUS pts die, 3-5% get chronic renal dz

Dx: stool cultures on special media (Sorbitol MacConkey agar); otherwise look like normal E. coli
 ID toxin in stool; look for serological responses to toxin & O antigens too

Tx: supportive
 ANTIMICROBIALS ARE CONTRAINDICATED (can increase the production/release of the toxins!) 

Prevention:
 Avoid undercooked hamburger, unpasteurized milk / apple cider (steaks=OK because not a big mixture).
 Wash hands after petting zoos
 Food industry: improve methods, culture all hamburger prior to shipping, irradiate to sterilize meat

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 Enteropathogenic E. coli (EPEC)
Gram (-) rod
 Limited to children < 2yo; previously big cause of nursery diarrhea
 Mild illness; can use ORS as tx (no evidence for Abx)
 Not as frequent as ETEC; particularly common in Brazil

Pathophys: attach to small intestine (attach & efface microvilli), do not produce enterotoxins
 doesn’t cause too much damage
Dx: serotype E. coli in stool

Non-typhoid Salmonella
Gram (-), non-lactose-fermenting rods Non-typhoid Salmonella:
 Fecal-oral transmission; generally through prepared foods in developed world  S. typhimurium
 Chickens thought to be primary reservoirs (eating contaminated chicken or  S. enteritidis
infected eggs via shell contamination or transovarial passage)
 S. Heidelberg
o Also: amphibians, reptiles (turtles!)
 S. Newport
 One of the most common causes of large food-borne illnesses in USA

Clinical presentation:
 Inflammatory changes in small bowel
 Generally mild disease except in children, elderly, immunocompromised (sepsis, mortality↑)
 Strains can differ in virulence (some produce enterotoxins)

Dx: stool culture, blood culture if bacteremia suspected

Tx: Abx optional for mild cases, essential in severe cases. Fluoroquinolones/ceftriaxone/cipro

Typhoid Fever (S. enterica, serotype typhi)

Gram (-), non-lactose fermenting rod, single clone worldwide
 Only infect humans (chronic carriers important: food handlers, etc.)
o Chronic carriers: ID via stool cultures, Ab to Vi antigen
 Can treat with prolonged Abx, may require removal of gall bladder (previously more common)

Typhoid fever: a.k.a. enteric fever, also caused by Salmonella paratyphi A & B
 Primarily in the developing world, rare in developed world except for travelers
 Found in all age groups, normally mild in young children

Fecal-oral transmission (from chronic carriers); carried primarily in gall bladder

 Requires high inoculum size (104-7)

Pathogenesis: Incubation: 7-14 days

 Invade small intestine through M-cells (in Peyer’s patches, take up antigens & present to T-cells)
 Transported to lymphatics  blood stream  all parts of body
 Persist in mononuclear cells

Clinical presentation: prolonged fever, constipation, hepatomegally, occasionally rose spots on abdomen/chest
 Mortality 10-20% w/o tx; 1% with good tx
 Complications: intestinal hemorrhage, intestinal perforation, cholecystitis (can affect any organ system)

Dx: cultures: blood, bone marrow, stool, duodenal fluid

19
  (string test: swallow string to obtain sample of upper small intestine)
 Some serological tests but not diagnostic acutely

Tx:
 Antimicrobials (fluoroquinolones, AZI, ceftriaxone = 1st line; chloramphical, ampicillin, TMP+SMX = 2nd line if
susceptible). Increasing resistance.
 Vaccines: two effective ones now
o Live vaccine: oral, 70% protection for 5 yrs
o Injectible vaccine: 70% protection, 2 years, not for kids

Clostridium difficile
Gram (+), spore-forming, anaerobic rod
 Part of normal flora of large bowel (3% normal stools, 25% hosp pts); cause disease infrequently
 Seen after use of broad-spectrum Abx (grow to high concentrations)
 Produce toxins leading to illness
o TxA, TxB – mechanism not known

Risk factors: use of broad-spectrum Abx, intestinal surgery, age

Clinical presentation:
 Diarrhea, colitis (fever, pain, cramping), ↑ WBC, hypoalbuminemia
 Advanced form: pseudomembranous enterocolitis
 Mostly hospitals & medical institutions; responsible for ~25% antibiotic-related diarrheal illness

Dx: toxins A/A+B in stool (enzyme immunoassay or tissue culture), also endoscopy for pseudomembranes
 Stool culture not useful (high frequency of normal colonization)

Tx: Stopping/changing antimicrobial therapy, metronidazole (250 mg po qid x 10d) or vancomycin (po) if failure
 Relapses are common (spore-forming) – can treat with same drugs, longer duration
 Also: cholestyramine, probiotics

Prevention: infection control procedures; controlling use of antimicrobials

 Doxycycline, macrolides, aminoglycosides, fuloroquinolones less likely to result in C.diff overgrowth
 Isolation, use disposable materials, careful hand washing
 Bacterial spores survive on inanimate objects (wash & decontaminate hospital rooms)

Listeria monocytogenes
Small, Gram (+), intracellular rods
 Can be part of normal bowel flora in adults
 Soil / animals
Transmission: contaminated foods (cheese, pork, milk)  can be outbreaks (esp. soft-cheese related)

Epidemiology:
 Long incubation period (~30d)
 Can be asymptomatic
 Can cause disseminated infections (e.g. acute meningitis) especially in immunocompromised
 Pregnant women: especially susceptible (spontaneous abortion)

Diagnosis: culture of normally sterile body fluids (CSF, blood). Difficult to culture from stool; not diagnostic if found
 Serology can be useful (outbreaks)

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Treatment: ampicillin +/- gentamicin (gentamicin accumulates in Mφ, Listeria killed when they escape cytoplasm)
Prevention: avoid contaminated foods (soft cheese, pork products, esp. for immunocompromised / pregnant)
 TMP+SMX prophylaxis for AIDs patients

Yersinia enterocolitica
Gram (-) coccobacillus; intracellular

Reservoir: environment, animals (especially pigs)

 Grows at refrigerator temperature (fairly unique for food-borne); found in most colder temperate areas
(Canada, not tropics)
Transmission: ingesting contaminated foods (raw milk, contaminated water, pig tongues)

Clinical presentation:
 self-limited, mild gastroenteritis;
 can provoke mesenteric adenitis which can present as “pseudo-appendicitis”

Dx: culture of stool, blood

Tx: not needed except in severe cases (gentamicin, fluoroquinolones used)
 Avoid unnecessary surgery
Prevention: avoid undercooked meat (e.g. pigs) & unpasteurized milk

Helicobacter pylori
Small microaerophilic Gram (-) rods; colonize stomach
 Don’t cause diarrhea (dyspepsia)
 Can be Asx for life, very common in developing countries
 Major cause of peptic ulcer disease; major contributor to gastric cancer

Dx: serology or hydrogen breath test

Tx: combination of 2+ antibiotics and proton pump inhibitor to reduce gastric acid; reinfection is common

Organisms not covered in this lecture

 Clostridium perfringens: anaerobic Gram (+) spore-forming rod; normal inhabitants of GI tract; produce lots of
toxins, responsible for multiple diarrheal diseases (enteritis necroticans) & “Pig Bel”
 Bacteroides fragiles: anaerobic Gram(-) rod; produces enterotoxin; responsible for mild diarrhea (developed &
developing countries)
 Enteroadherent E. coli (EAEC): diarrheal dz in children (developing & developed countries); relatively common
cause of traveler’s diarrhea
 Enteroinvasive E. coli (EIEC): dz resembles shigellosis; closely related to Shigella spp.

Summary of treatment:
1. Rehydration (IV/oral) most important in secretory diarrheas, where stool output is great
2. Antimicrobials critical for tx of shigellosis & invasive diarrheas but should be withheld if EHEC is suspected
3. Nutritional therapy important in children in developing countries (Zn therapy if zinc deficiency common)

Control by vaccines:
1. Typhoid: two vaccines on market
2. V. cholerae & ETEC: live, killed oral vaccines being tested
3. Shigella/Campylobacter: live, killed oral vaccines being tested in military
4. EHEC, Helicobacter: vaccines being developed

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 Staphylococci
General characteristics:
 Staphyle = “a bunch of grapes”, kokkus = “berry”
 Gram (+) cocci
 Divide randomly in 3 planes; daughter cells don’t
separate completely: grape-like clusters
Distinguishing staph:
 Blood agar:
o S. epidermidis: white colonies, no hemolysis
o S. aureus: golden yellow colonies, beta-
hemolysis
 Coagulase test (rabbit plasma + staph: does it coagulate?)
o S. aureus: coagulase positive
o All other staph: coagulase negative
Medically important Staphylococci
1. Staph. aureus (most virulent)
 Most important
 Healthy & hospitalized (“staph infections”)
2. Staph. epidermidis (less virulent)
 Opportunist, oncology pts, implanted
medical equipment (biofilm), neonates
3. Staph. saphrophyticus (less virulent)
 UTI in young women

Virulence factors:
 Polysaccharide capsule (some species)
o Most S. aureus infections caused by 2 types (5+8)
 Peptidoglycan: minor differences between Staph species (major scaffold anchoring surface adhesions)
 Teichoic acids: water soluble polymers, linked covalently to peptidoglycan backbone, site of attachment of cell-
wall active enzymes / proteins (not virulence factor; may be important in adhesion to nasal epithelium)
 NO LPS (Gram positive!)

Coagulase negative Staphylococci

Examples: S. epidermidis, et al.
 No virulent exotoxins
 Form biofilms (secreted polymeric carbohydrate gel; surrounds micro-colonies of bacteria)
o Acts like capsule (keeps out Ab, C’, PMN, Abx)
o Adheres to plastic (catheters, pacemakers!) Rule of thumb: less virulent =
o Hard to eradicate more abx resistant

Pathogenesis: e.g. attach during insertion and/or migrate down cath (sterile technique important!)
 Virtually non-pathogenic in normal people
 Resistant to many antibiotics

Clinical presentation: variety of clinical disease; usually indolent, rarely fulminant or life-threatening
 Risk factors: hardware/foreign material (IV cath, dialysis access, implants/implanted devices)
 Pre-term infants at risk (fragile skin, low integrity)
 Can lead to:
o neonatal septicemia (NEC = neonatal necrotizing enterocolitis, bowel wall injury / necrotizing infection)
o endocarditis

S. aureus
Extremely common in N. America
 Can acquire/integrate accessory genetic elements (↑pathogenicity)
 Evolves to elude antimicrobials

Epidemiology: pretty much everyone infected between birth & death

22
  NOSE, skin/appendages (hair follicles, sweat glands), GI tract, vagina common colonization sites
 Minor skin infections: pretty much everybody (intact immunity prevents spread)
 Major disease: immunosuppressed; normal people after initial insult (wound/injury, IV drugs, influenza)

Virulence factors most associated with S. aureus:

 Surface proteins
o Protein A: binds Fc of Ab; exposes Fab to phagocytes (don’t recognize; so antiphagocytic)
o Coagulase: binds prothrombin; forms staphylothrombin, which catelyzes fibrinogen  fibrin
o A & B clumping factors: bind fibrinogen, with coagulase lead to localized clotting (other spp mostly)
 Why promote clotting? Wall off from immune system & response; leads to ischemic injury
 Toxins
o Exoenzymes (proteases, lipases, allow spread through tissues)
o Hemolysins (4 types; lyse RBC & other eukaryotic cells)
o Leucocidins: e.g. Panton-Valentine Leukoidin, pore-forming hemolysin; results in degranulation/lysis of
PMNs, associated with aggressive infections (furunculosis, necrotizing pneumonia)
o Superantigens: stimulate T-cells nonspecifically (cytokine release, clinical shock)
 Enterotoxins (food poisoning), exfolatins (scalded skin syndrome), TSST-1 (toxic-shock-syndrome
toxin)

Transmission: person-person (direct or indirect: intermediary

person’s hands)
 Hospitals: patient-patient or via healthcare worker’s
hands
 Community-based: household contact
 Environmental surfaces commonly contaminated (role in
MRSA spread controversial)

Immunity: conditions with increased susceptibility

 PMNS are primary defense against S. aureus
 Deficient neutrophil number
o Congenital: congenital neutropenia; bone marrow aplasia/failure
o Acquired: leukemia, chemotherapy
 Defective neutrophil function
o Chronic granulomatous disease (CGD): defect in oxidative burst, still opsonize/internalize
 Path: see PMNs packed with bacteria (chronic infection; can’t kill)
o Leukocyte adhesion deficiency (LAD): make normal PMNs but can’t extravasate
 Path: see tons of bacteria, no PMNs in infected area
o Chediak Higashi syndrome (# & function), Hyper immunoglobin E syndrome (Job’s syndrome)

Clinical presentation: TONS of clinical presentations (see below) Toxic shock syndrome
1. Impetigo (infected eczema, etc.)  E.g. following introduction of high-
2. Cellulitis (deeper than impetigo) absorbency tampons (overgrowth of
3. Cutaneous abscesses (MRSA most common cause of staph)
skin/soft tissue infection in US EDs)  Fever, profound hypotension,
o Boils (= furuncle; skin infection involving entire hair erythematous rash
follicle & nearby skin tissue)  Vomiting/diarrhea common
o Carbuncles (involves group of hair follicles)  Multisystem organ dysfunction
4. Wound infections  Usually no bacteremia
5. Deep abscesses  TSST-1 and other superantigen toxins to
o Abdominal, neck/sinus blame (Ab against TSST-1 = protective)
o E.g. pyomyositis: bacterial infection of skeletal
23
 muscle leading to pus-filled abcess
6. Osteomyelitis (bone infection)
7. Septic arthritis
8. Septicemia
9. Endocarditis
10. Toxin-mediated
o Toxic-shock syndrome
o Scalded skin syndrome (esp. children & neonates)
 Basement membrane destroyed, skin sloughing off, follows cellulitis
o Food poisoning
o Necrotizing fasciitis
NOTE: S. aureus usually causes non-severe infection (celulitis, boils, etc.) but fulminant infections make the headlines

Antibiotic resistance:
 Abx pressure  acquisition / transfer of resistance genes (between and within species)
 Penicillinase: plasmid-encoded; opens beta-lactam penicillin ring, no cephalosporin action
o Inhibited by most beta-lactamase inhibitors
o Present in 95%+ of S.aureus isolates: never choose PCN for empiric S.aureus treatment!

 MRSA: Methacillin-resistant S. aureus

o Chromosomal (mecA): on a mobile genetic element (SCCmec, staphylococcal cassette chromosome)
o Results in resistance to all beta-lactam antibiotics (includes cephalosporins)
o 2 types of MRSA: different SCCmec types, different abx resistance genes/toxins

 Hospital-acquired MRSA (HA-MRSA)- “USA 100-200”

 Hosp. pts, often very old/young, major illness, surgical incisions, IV cath, trach tubes,
dialysis, etc.; more likely to have implanted foreign bodies
 Handled frequently & all over by other people
 2008: 60% HA-S. aureus = MRSA!
 Multidrug resistant (type I,II,III SCCmec); no PVL

 Community-acquired MRSA (CA-MRSA) - “USA 300-400”

 Up to 75% SSTI now CA-MRSA in most areas of country
 Now also causing hospital outbreaks/infections
 Nosocomialcommunitynosocomial
 Not multidrug resistant (type IV SCCmec); produces PVL (cytolytic toxin)
 CA-MRSA (PVL-producing) clinical manifestations
o Skin infections (Children, athletes, prisons, previously healthy persons)
o CA-pneumonia (esp. after influenza; necrotizing; associated bone infection,
thrombi; unusually severe/high mortality, previously healthy persons!)

 Vancomycin-resistant S. aureus
o Has been mainstay of treatment for serious MRSA
o MIC levels for vancomycin keep rising (some isolates have popped up with high MICs); now MIC of 4 is
no longer “susceptible” (4-8mcg/mL from “susceptible” to “intermediate”)
o Limited right now but will likely change
o Worry: Staph are good at horizontal gene transfer – could pick up VanA from VRE?

24
 Prion Disease
Prion: a proteinaceous infectious particle which is resistant to inactivation by most procedures that modify nucleic acids

Transmissible spongiform encephalopathies: Prion Diseases

 Animals:
1. Scrapie (sheep)
2. Bovine spongiform encephalopathy (BSE)
3. Wasting disease of deer & elk
 Humans:
1. Kuru (no longer around)
2. Creutzfeldt-Jakob disease (most common TSE in USA)
a. Incidence: 1 per million per year
b. Incubation: up to 50 years
c. Mortality: 100%
3. Variant CJD (what people mean when they say a human has “mad cow disease”)

Scrapie: ataxic sheep; wasting, cerebellar dysfunction, commonest fatal genetic disease of sheep
 Studied agent:
o Resistant to things that inactivate nucleic acids: formaldehyde, ethanol, proteases, nucleases, UV/ionizing radiation, etc.
o Inactivated by things that inactivate proteins: autoclaving, pH extremes, inorganic salts, detergents
o Isolated the protein: had same sequence as naturally occurring proteins
 PrPC is normal form (α-helical, monomeric, on cell surface, soluble)
 PrPSC is changed form (β-sheets, big aggregates, insoluble amyloid fibrils/rods, found in
intracellular vesicles / extracellular space)
 Misfolded: nobody knows how it starts

Kuru: Fore people group in Papua New Guinea; very isolated.

 Big epidemic of Kuru (= “trembling”) especially among women and children (7 of 8)
o Cerebellar dysfunction, then rapid decline
 Autopsy: no inflammation, no characteristic cellular changes, just loss of Purkinje cells
 Similarities to scrapie identified; inoculated primates with Kuru pt. brain, 2-4 yrs later had kuru (1st transmission
of human infection to subhuman primates, nobel prize, etc.)
 Ritual cannibalism was the cause: started in 1900s, suppressed in 1960s by Australians
o Men would eat more choice cuts
o Women & children would eat brains & other parts
o 50+ year incubation: cases from 50s  today (last few)

CJD
 Transmitted, rare (1:1,000,000/yr), no regional pattern, varied presentation
 Vacuolization in neurons; like pathology of scrapie & kuru
 Presentation: myoclonic jerking  dementia  death
o No recovery, rapid progressive decline (~5 months on average, no good days), 90% dead < 1yr
NATURAL SPREAD OF CJD
LACK OF COMMUNICABILITY EVIDENCE OF TRANSMISSIBILITY
 Absence of temporal/geographical  Transmission to experimental host (brain, viscera, CSF inoculation)
clustering  Transmission by physician (corneal transplantations, cerebral
 Lack of conjugal cases corticography, dural grafts)
 Lack of predominance by occupation  Transmission to children (growth hormone injection from human
pituitary glands)

25
  Growth hormone: 1985: from human pituitary, combined many sources, some children infected. Resulted in
development of recombinant GH
 Lack of transmission by blood products: case control studies (transfusion ≠ higher vCJD risk), no CJD in 342
recipients from donors who developed CJD, 12,000 hemophiliacs & no CJD

Mad cow disease (BSE)

 Started 1985, England
 Looks like scrapie in cow; didn’t do anything about it, big explosion of cases
 Pattern: throughout England, Scotland, Wales; one case pretty much everywhere (opposite of kuru/scrapie)
o Point-source epidemic
 Bone meal: from all kinds of sources. Cook “greaves” (random animal parts), extract tallow (candles/fat/etc),
get bone meal (for cattle feed; helps calves grow faster)
o 1980s: Iranian gas crisis: short-cuts on cooking of various bone meal prep steps
o 1979: tallow market crash: people decided animal fats were bad for you, switched to vegetable fats
 Stopped processing tallow & left fat (with infectivity) in
 1988: banned cattle carcasses in cattle feed; 1989: banned cattle offal in human food
o After 5-year lag (incubation period), cases started to drop

vCJD
 Colloquially “mad cow” but not technically BSE; only 2 cases in US
 Different from CJD: younger patients, psychiatric abnormalities (not myoclonic movements & dementia)
o CAN be transmitted by transfusion: 2 cases in UK

US food chain concerns:

 imported BSE cattle
 spontaneous BSE in cattle/other animals
 chronic wasting disease in deer and elk (clearly spreading among captive and live deer)

New: BSE diagnosed in cow in Washington, transfusion cases of vCJD, reports of possible BSE strains

Response to BSE in US: increased cattle testing, prohibited non-ambulatory cattle for human consumption, SRM &
mechanically separated meat prohibited from human food, carcasses of tested animals not passed until negative test

Deterrents to risk assessment: unknown mode of natural transmission, species barriers, dose/route of entry, strains,
differences in pathogenesis

Needs:
 Blood test for humans & animals
 Better understanding of pathogenesis (transmission, species barriers, strains, etc)
 Neuropathological exams on all degenerative diseases
 Worldwide surveillance of TSEs (humans & animals)

Current situation:
 Kuru gone (incubation > 50 yr)
 Iatrogenic CJD (hGH & dural graphs) ↓ but will continue for decades
 BSE / vCJD outbreaks ↓ in UK but isolated cases worldwide
 Chronic wasting disease: no spread to cattle or humans but spreading in N. America; wide host range in lab

26
 Academy Awards of Infectious Diseases
New diseases: 58% from animals (zoonosis)
Most important ID events in 20th century (survey):
 smallpox eradication, penicillin, HIV, 1918 influenza, childhood immunization, clean water

Most likely to be eradicated: probably guinea worm (Jimmy Carter’s campaign!), but talked about polio.
 Poliovaccine: 1000 children paralyzed per day (1988)  herd immunity in US (early 90s)
 Down to 6 countries / 575 cases/yr

New vaccine: Hepatitis B. 60% hepatocellular carcinoma; 300,00 cases / 5,000 deaths/yr
 1st: anti-STD vaccine, anti-cancer vaccine. Can’t cultivate virus in artificial media (impressive)
 Big drop in HBV in USA, Taiwain (decided to vaccinate in 80s). HBV endemic in Asia (lots of perinatal trans)

New bacterium: H. pylori. Role in Type B gastritis, achlorhydria, peptic ulcers, gastric carcinoma & lymphoma, others?
 Some crazy guy drank a glass of it & got sick (achlorhydria, etc.) Non-invasive; tons of polys.
 Abx shown to have better prevention of recurrence than ranitidine
 More and more chronic diseases shown to have microbial components

New viral agent: HIV.

 14,000 new infections/day, 42M living with HIV, 4.3M newly infected 2006, 2.9M deaths/year, 2.2M on ART
 Huge reduction in life expectancy in some African countries (negated all health gains since 1950s)
 PEPFAR continuing to give aid to developing countries; widely expanded in ’08 & focused on across-the-board
health care systemic improvements (and monitoring outcomes, not just # treated or prevented anymore)

New antiviral agents: HAART (HIV) INTERVENTION PER-PERSON SURVIVAL GAIN

 1996 AIDS conference, Vancouver: viral dynamics / # copies Cancer chemo 10 months
explored; clinical trials of triple therapy reported Coronary bypass 20 months
 Protease inhibitors: great example of rational drug design HAART-HIV 43 years
 Now 26 drugs across 6 classes; huge improvements in outcome & survival
 New focuses: Cure HIV (2009 case; empty latent pool); eradicate HIV (test & treat)
 (FYI: HCV antiviral agents represent 28% new drug apps for antimicrobials)

New antibacterial agent: the bacteria

 Great achievement; abused  microbes win!
 MRSA: USA-300, community-acquired; USA-100: hospital-acquired; necrotizing fasciitis & pneumonia
 Pipeline of Abx drying up (fewer approved & just one new class in 20 years): pharma wants to make drugs you
have to take every day!

Infectious disease epidemic: Influenza

 H1N1 (1918): 25-30% world’s population ill; >40 million deaths worldwide (60% in 20-45yo)
o Influenza usually kills old (85+) but avg age in 1918: 28 years old (same with avian influenza today)
 Bird flu today: controlled in birds (vaccines / culling), by isolating patients, and because virus hasn’t gotten good
at human-human transmission yet
H1N1 challenges
 H1N1 today: people born before 1957 not getting this one – H1N1
circulating until 1957.  Vaccine production (solved – 15 μg,
no adjuvant, single dose – but late)
 Seasonal = 65+yo, swine flu = young people
 Antivirals (OK for now)
 Currently at pandemic alert level: 4 influenza pandemic, totally
th

unpredicted, projected US toll: 50% infected, 1.8 mil  Surge capacity (biggest US challenge)
hospitalized, 30-90,000 deaths; will be tracked in real time!  Global sharing unlikely

27
 Anaerobic Infections
Anaerobes: dominant form of life on/in people
“Organisms of neglect”- important but not much known about them Most anaerobic infections:
 Mixed (polymicrobial)
History: Pasteur (Clostridum butyricum); Veillon & Zuber: intraabdominal sepsis  Endogenous (host flora)
(IAS) & B. fragilis, “classical studies”(1889 – 1938) looking at genitourinary tract  Microbial dx rare
flora, lung abscesses, IAS; “renaissance” (1965-1980) – clinical studies, culture,  Empiric tx with abx
taxonomy, antibiotic development
Classification of anaerobes
Growing anaerobes: commonly use a chopped meat glucose  EOS (extremely O2 sensitive): tolerates
broth seconds/minutes of O2 exposure
 Strict anaerobe: tolerates > 0.4% O2
Much less anaerobic bacteremia now than in past (people
 Moderate anaerobe: tolerates 0.8-2.5% O2
learned how / when to treat anaerobic infections)
 Microaerophilic: tolerates >2.5% O2
 Facultative anaerobes: tolerates anaerobic
Major pathogens:
condition but also grows in air or 10% CO2
 Gram negative bacilli (Bacteroides, Prevotella)
 Gram positive cocci (Peptostreptococci, a.k.a. “peptococci”)
 Gram positive bacilli (Clostridia) – pretty much the only anaerobe transmitted human-human because it’s
spore-forming; the spores can exist aerobically)
SITE RATIO ANO2 : O2
 Hopless (Lactobacillus, Bifidobacteria, Veillonella)
Saliva, tooth 1:1
How to diagnose anaerobes: Stomach, Ileum
Gingiva 1000:1
 Microbiologic diagnosis: get specimen from a normally sterile site;
Colon
transport while protecting from too much O2, think if it makes sense / from
an anaerobic site Vagina 5:1
 Clinical diagnosis: think of site of infection (not pharyngitis, etc. but maybe a peritonsilar abscess); putrid
discharge, polymicrobial flora Gram Stain.

Growing anaerobes: get anaerobic transport media; often grow in anaerobic chamber, etc.
 Is it pratical?
o Specimens are hard to obtain; microbiology is polymicrobial, tedious; the process is expensive &
prolonged, treatment is empiric anyway because susceptibilities are high; patients are often discharged
before report comes in
o Antibiotic sensitivities are of poor quality and not recommended, clinical clues are good
o One exception: blood infections (usually take a sample & put in both aerobic and anaerobic bottles)
 If E. coli, would grow in both; if Bacteroides Fragilis, would grow just in AnO2

Recognizing anaerobes:
 Often see polymicrobial mix
 AnO2 GNRs have an unique morphology (e.g. long & fusiform); AnO2 GPCs just look like cocci

Infection site: ANO2: FREQUENT ANO2: RARE

 Why not UTIs? Urine isn’t
appropriate for replication of
anaerobes (reduction potential)
 Almost all abdominal abscesses
(except those in table) usually
have anaerobic involvement
 Dental infections: 1000:1
anaerobes:others in gingival
Brain abscess, dental
HEAD & NECK infections, space infections,
chronic sinusitis, chronic otitis
Aspiration pneumonia, lung
CHEST
abscess, empyema
ABDOMEN Peritonitis, phlegmon/abscess
GU TRACT Female genital tract
Meningitis, pharyngitis,
acute sinusitis, acute otitis
Bronchitis
Non-aspiration pneumonia
Cholecystitis, spontaneous
bacterial peritonitis
UTIs, STDs
28
 crease; during extraction or other damage, anaerobes can pass to perimandibular space (through mandible &
underneath) and set up infection there.
 “Clenched fist injury” – punch somebody in the mouth & their anaerobes get you back with a nasty infection
 When you see abscess or aspiration pneumonia, think ANAEROBE

Abscesses & IAS (Intra-abdominal sepsis): often E. coli & B. fragilis (if polymicrobial, probably anaerobes involved!)
 If you perforate your colon, tons of anaerobes headed inside
 Flow is slower in colon so anaerobes can grow; by the time stool gets out, it’s almost purely anaerobes (just
about as much as could fit in the space that the stool occupies!)
 Often E. coli early (peritonitis stage; recovery); B. fragilis late (abscess stage, higher mortality).
o Different roles: E. coli causes bacteremia & shock; B. fragilis causes abscess
o Not synergestic: each has its own role
 Remember that other organisms (e.g. S. aureus) can cause abscesses commonly too!

B. fragilis
 bacteremia without septic shock (no active endotoxins)
 capsular polysaccharide: need capsule for sepsis (capsule itself can actually cause an abscess!)
 In vitro resistance to abx: very little
o Metronidazole is best against B. fragilis
o Imepenem or Pip-Tazo work too

Clostridial syndromes
Clostridium sp. Syndrome
C. botulinum Botulism
C. tetanus Tetanus
C. perfringens Gas gangrene
C. perfringens enterotoxigenis Food poisoning
C. difficile Antibiotic-associated colitis
C. sordellii Septic absorption
C. septicum Neutropenic colitis

Anaerobes & Anaerobic Infections: Summary

 Important, neglected, predominant flora, 1 quadrillion per person
 Endogenous infections, abscessogenic or clostridial toxins
 Dx: clinical clues; Rx: empiric

29
 Chlamydia & Mycoplasma
Chlamydia
 Obligate intracellular organism; tiny
 Thought to be a virus for a time: DNA, RNA, ribosomes; make own proteins & nucleic acid (true bacteria)
 Inner & Outer membrane (like gram neg) but no peptidoglycan layer (don’t Gram stain at all: too small)
 Energy parasite (can’t make own ATP)

Biphasic life cycle:

1. Elementary body (like spore) attaches to, ingested by cell
2. Phagosome fusion; EB  reticulate body (RB)
3. RB multiplies, condenses (RB  EB), forms inclusion body
4. Inclusion body releases EB (infectious particle)
(EB: infectious, not metabolically active; RB: metabolically active, not infectious)

Chlamydiaceae:
 Chlamydia trachomatis: trachoma, oculogenital, LGV: STIs & conjunctivitis
 Chlamydia pneumoniae: atypical pneumonias
 Chlamydia psittaci: psittacosis (from birds)

Chlamydia trachomatis
 Infects non-ciliated, columnar epithelial cells; infection doesn’t confer much resistance to reinfection
 Doesn’t grow on normal lab media: need to use tissue culture (like a virus)
 Culture isn’t great for Dx: use PCR for LGV & D-K (more sensitive)
o Trachoma: clinical diagnosis

Multiple serotypes with different diseases (note conjunctivitis ≠ trachoma)

Serovars D-K:
Common genital infections, conjunctivitis (neonates)
 Presentations
o Men: urethritis  epididymitis (70% due to CT!)
 Serosanguinous penile discharge (gonorrhea more purulent)
o Women: urethritis, cervicitis, (PID, ectopic pregnancy, chronic pelvic pain if untreated)
 Majority asymptomatic
 Cervicitis: mucopurulent discharge (can use swab to test)
o Both: pharyngitis, pneumonia, proctitis (anal sex), conjunctivitis
 Proctitis: direct inoculation from anal sex; rectal bleeding, pain, mucous discharge, diarrhea
o Neonatal conjunctivitis (30-50% exposed babies)
 Highest in women, blacks, ages 15-25; most frequently reported STD & ID in US (2-4M new cases/yr)
 high partner co-infection rate

Remember: notifiable disease; must treat all sex partners from previous 60 days or reinfection is likely
 High reinfection rate
 Screen: all women <25yo yearly; re-screen 2-4 months after Tx

Serovars L1-L3:
Lymphogranuloma venereum (LGV)
 Worldwide; higher in tropical/subtropical; MSM mostly in US
 More invasive strains; cause thrombolymphangitis
30
  Stages:
1. Primary: genital lesion (painless) – transient ulcer
 Ulcer most often undetected; 30d incubation
 Heal without scarring; can get anal/rectal reinfection with anal intercourse/contaminations
2. Secondary: regional lymphadenopathy; systemic Sx
 2-6wks later: buboes (swelling of lymph node); painful!
 “Groove sign” – groove between two LNs
 Rupture or harden, then resolve
 Inguinal LAD is most common (less in Treating Chlamydia
women so go undiagnosed)  Tetracyclines (doxycycline)
 Rectal involvement: MSM, anal sex  macrolides (azithromycin: only need one dose)
3. Tertiary: genital elephantiasis; strictures,  Resistance: extremely uncommon
fistulas, abscesses, frozen pelvis
 More common in women (lack of Sx in 1st 2 stages)
 Elephantiasis! Nasty!

Serovars A-C:
Trachoma: leading cause of preventable (infectious) blindness worldwide
 A chronic keratoconjunctivitis endemic to Africa, Asia, Middle East, Australia (aboriginal groups)
 Transmission: children & women who care for them; Via hand-eye, fomites, flies
 Developing world only
 Pathogenesis:
o repeated reinfection  chronic follicular conjunctival inflammation (active trachoma) 
o tarsal conjunctival scarring distorts tarsal plate 
o entropion (turning in of edges of eyelid so that lashes rub against eye surface) & trichiasis (cicatricial
trachoma) 
o corneal abrasions, scarring, opacification: blindness

Chlamydia pneumoniae

 Same life cycle as C. trachomatis; spread via respiratory route

 Common cause of upper & lower resp. infections
o 7-10% of CAP
o “Atypical pneumonia” – interstitial, not lobar like S. pneumoniae, etc.

Chlamydia psittaci

 Birds (parrots pigeons, hens, turkeys  pet owners, pet shop employees, poultry farmers)
 Severe Atypical Pneumonia, also typhoidal-form fevers, splenomegaly, malaise possible
 Culture is DANGEROUS – use serology or PCR

Mycoplasma
Tiny prokaryotes, lack a cell wall; Cell membrane bound: contain sterols; has RNA, DNA; hard to grow (special agar)

Mycoplasma pneumoniae: URTI & atypical pneumonia (respiratory aerosols)

 Can have complications (derm, cardiac arrhythmias/CHF, neuro: meningitis, encephalitis)
Mycoplasma genitalium: urethritis & cervicitis
 No cell wall; unknown prevalence, not reportable; sequelae unknown
o Smallest prokaryote bacteria capable of self-replication; culture often missed, PCR?
Treatment: Doxycycline, macrolides, fluoroquinolones

31
 Non-Tuberculous Mycobacteria (NTM) & Nocardia
 NTM & Nocardia: both in same order (Actinomycetales); both found in environment and only cause disease if
immune system compromised somehow
NTM vs Nocardia
Mycobacteria Nocardia
Route of Infection Inhaled Inhaled, direct inoculation
Source/Reservoir NTM-soil,water; leprosy-human Soil
Host range MOTT-large; leprosy-narrow Large
Clinical 1o lung or skin (GI?), can 1o lung or skin, can disseminate
disseminate
Cell Wall PG, AG, mycolates (C60-C90: long!) PG, AG, mycolates (C44-C66: shorter!)
Microbiology Acid fast, aerobic, rod Weakly acid fast, aerobic,
filamentous rod
Host Defense Cell mediated immunity Cell mediated immunity
Evasion Phagosome-lysosome non-fusion Phagosome-lysosome non-fusion

 NTM: large; diverse group

o M. tuberculosis complex
 M. TB; others including M. bovis (attenuated to vaccine strain, M. bovis BCG)
 Mycobacterial cell wall: like a Gram (+) at heart but covered with an outer lipid layer
o Mycolic acid & certain glycolipids are unique to mycobacteriae & nocardia
Diagnosing Mycobacteria
AFB Test
 Rapid diagnostic test (real time!); specific for mycobacteria, but don’t know which species!
 Sensitivity only 40-70%: need high amount of AFB to visualize. CAN’T EXCLUDE TB WITH NEGATIVE SMEAR
 Fluorescent acid-fast stains make visualization quicker & easier to read (e.g. auramine-rhodamine fluorescence)

Decontaminating specimens:
 Mycobacteria grow slowly (1x/day vs. E. coli ~20m); can be overgrown by other bacteria/fungi
o Sterile specimens: blood, CSF  inoculate directly onto media
o Non-sterile specimens: sputum chemical decontamination to remove normal flora/contaminants
 Abx to inhibit other bacteria; decontaminate with pH
 Suppresses both mycobacteria & others but less for myco (suppression can be problem)

Culture: more sensitive than smear, TAKES WEEKS to grow, may require special conditions (low temp, etc.)
 Importance: species ID, drug susceptibility, monitoring response to Tx
 Need low temp (environmental organism needs environmental temperatures): need to notify lab for NTM
 Liquid media faster (1-3wks vs 4-6 for solid)
 Can’t grow M. leprae!

Speciation: traditionally growth characteristics; biochemical tests (slow)  DNA probes, other methods
 M. tuberculosis, M. avium complex, M. kansasii = important pathogens
 M. gordonae: not a pathogen but common lab contaminant

Rapid Dx: Nucleic acid amplification (like PCR)

 More sensitive than smear; less sensitive than culture (90% sputum+ samples; 50% sputum- )
 Positive test: supports TB Dx; NEGATIVE TEST DOES NOT EXCLUDE TB
 Good for specimens other than sputum

32
 Mycobacterium leprae & Leprosy
 A.k.a. Hanson’s disease, big historical significance (& >500K new cases/yr), mostly Brazil & India
M. leprae
 Obligate intracellular parasite; cannot be cultivated in lab
 50% genes “pseudogenes” (evolutionary reduction: from environment to humans, had excess genes left over)
 Armadillos are a natural reservoir (SE US) & tool for research

Pathogenesis:
 URT transmission (inefficient)  multiples in tissue Mφ & Schwann cells around nerves  mostly skin,
peripheral nerves disease: local effects of multiplication / host cell-mediated immune response; lose sensory
input around lesions, etc,
 Neuropathic effects: neuropathy  trauma/burns  autoamputation of digits
 Sunken nose: bacillary multiplication (low temp)  destroys bone & cartilage

Leprosy spectrum:
Tuberculoid (TT) BB: Lepromatous (LL)
Paucibacillary (few bacteria) borderline Multibacillary (lots of bacteria)
BT: BL:
↑ peripheral nerve thickness Unstable:
borderline borderline
Flat granules, well-defined usually go
tuberculoid lepromatous Leonine facies (lesions heaped up wth
granulomatous lesions one way skin cells; filled with mycobacteriae)
Good TH-1 mediated immunity or other Mostly TH-2 mediated response

Immunologic reactions: (can occur after Tx: unleash immune response)

 Reversal reaction
o Treatment of BB (borderline) disease can cause Leprosy Dx
immune reconstitution  DTH reaction Examination:
o Inflammation of existing lesions  erythematous / hypopigmented skin lesions
o Requires corticosteroid Tx (prevent further  + sensory loss
motor/sensory loss)  ± enlarged peripheral nerves
 Erythema nodosum leprosum
o BL/LL disease: can develop fever, eruption of red Lab: skin smear / biopsy; PCR-based if available
nodules, other inflammatory manifestations
o Already have high burden of organism; may be due to immune complexes
o Can require corticosteroids
Non-tuberculosis Mycobacteria (NTM)

 Free-living, environmental, opportunistic pathogens Main clinical scenarios of NTMs

o Need to distinguish contamination from actual infection 1. Lymphadenitis
2. Inhalational pulmonary disease
Slow-growers: M. avium complex; M. kansasii, M. marinum, M. ulcerans 3. Disseminated disease
Rapid-growers: M. abscessus, M. chelonae, M. fortuitum 4. Skin/skin structure infection
(following inoculation)

Mycobacterium Avium Complex (MAC/MAI)

= Mycobacterium avium-intracellularae: really two organisms
 Environmental organism (soil/water)

Main clinical syndromes

33
  Lymphadenitis (cervical lymphadenitis: MAC is most common entity; need to excise LN)
 Pulmonary MAC: underlying lung disease is common (e.g. COPD,
emphysema, CF: prevent clearance) Diagnostic criteria: NTM lung dz
o Patterns: Solitary pulmonary nodule, fibrocavitary, nodular Clinical (need 2)
bronciectatic (small nodules, esp. in periphery  larger 1. Typical Sx & radiology
bronchi) 2. Exclusion of other Dx
o Hot tub lung: hypersensitivity pneumonitis caused by reaction
to MAC in hot tub water Microbiologic (need 1)
 Subacute SOB, cough, fever 1. + culture x2 (sputa)
 + MAC culture in hot tub & lung 2. + culture x1 (bronchoscopy)
 May not require Abx 3. Biopsy evidence of granulomas
 Disseminated (AIDS pts) + culture x1
o CD4 VERY LOW (<50), Incidence way down (HAART)
o Entry: GI tract; Subactute presentation: fever/abd pain/diarrhea/wt loss; hepatosplenomegaly,
pancytopenia, adenopathy
o Dx: blood culture (can grow from blood = tons of organism)/biopsy
o Path: phagocytes jammed with MAC

M. kansasii
 TB mimic: most likely to present like TB (upper lobe cavitary dz)
 Strictly transmitted via water supply (midwest, SE)
 Risk factor: underlying lung disease (COPD, smoker)

M. marinum
 Aquatic/marine environments; natural pathogen of fish
 Human dz: inoculated into skin post-trauma (fishermen, watermen, aquarium hobbyists)
 Chronic ulceronodular skin disease: “Fish tank granuloma”
o Chronic: dx often after weeks/months
 Grows best at low temp: 28-30 C (notify lab)

M. ulcerans
 Close relative of M. marinum; presumed aquatic
 ONLY TOXIN PRODUCING MYCOBACTERIUM (has a huge PLASMID that encodes)
 Buruli ulcer: emerging dz of sub-saharan Africa; chronic painless cutaneous ulcer
 Major cause of disability (esp. children – aquatic environment) because of scarring, fibrosis (e.g. over joint!)
 Tx: streptomycin + rifampin x 8wks

Rapidly-growing Mycobacteria
 Colonies in ≤ 7days (relatively fast next to others; still pretty
slow) – can be longer for primary isolate
 M. abscessus, M. chelonae, M. fortuitum: 90% clinical
isolates
 Ubiquitous in home & hospital; common contaminants of
fluids & devices
 Pseudo-outbreak of M. fortuitum pulmonary dz at JHH: from
ice machine!
RGM: Diagnosis
 Grow on mycobacterial media (may also
grow on normal blood agar/culture systems)
 Need to notify lab if suspect RGM:
1. More readily decolorized in AFB stain
2. More susceptible to decontamination
3. Require cooler temperatures for growth

Opportunistic pathogens: surgical site infections, implant-associated, pulmonary infection of diseased lungs (M.
abscesses), disseminated in immunocompromised pts.
 Example: surgeon’s dye to mark incision sites contaminated; inoculated pt when cuts made
34
 Nocardia
 Aerobic, Gram (+), filamentous rod
o Require modified acid-fast stain (weaker decolorization)
o Various spp with varying Abx susceptibility
 Ubiquitous in soil, decaying vegetation
 Infection: inoculation or inhalation
o NO PERSON TO PERSON TRANSMISSION

Cutaneous Nocardosis: immunocompentent host

 Manifestations: Celulitis / abscess / lymphocutaneous (can track up lymph vessels)
1. Mycetoma (N. brasiliensis only)
 Common where shoes aren’t worn
 Host & microbe interact, chronic inflammation
 Huge exophytic (growing outward) ulcerative masses; ooze & pus)

Pulmonary & Disseminated Nocardosis

 Host: reduced cell-mediated immunity
 Nodular/cavitary infiltrates; disseminates to brain / skin
 Diagnosis: difficult: no pathognomonic features; often not suspected; may delay Dx procedure (pt
immunocomporomised); may be partially treated / difficult to isolate after empiric Tx
 THINK NOCARDIA IF:
1. Pulmonary AND brain disease
2. Nodular / cavitary
3. Immunosuppresed

M. TUBERCULOSIS NOCARDIA
Order: Actinomycetales
SIMILARITIES

Cavitary lung disease;

risk for dissemination if immunocompromised
Risk: impaired cell-mediated immunity
Acid-fast (mycolates in cell wall)

Can be cultured on blood agar

Filamentous rods
DIFFERENCES

Ubiquitous in environment
Latent infection; gives +
tuberculin skin test
Slower generation time
Longer mycolates
(more resistant to
decolorization; more acid-fast)

35
 Antimicrobial Stewardship
Why is this important?
 200-300M abx annually, 45% outpatient
 25-40% hosp pts get abx; 10-70% unnecessary or suboptimal; 5% adverse reaction
 Abx unlike other drugs: use in one pt can compromise use in another!
 Resistance (up), really expensive ($30B annually)
 # new abx (down), and mostly just modifications of existing classes
o Timeline for development:9 -10yrs, really hard

Definitions
 Prophylaxis: use of antimicrobial agents to prevent the development of an infection
o Pre-exposure: e.g. surgical prophylaxis
o Post-exposure: e.g N. meningitidis prophylaxis
 Empiric treatment: use of antimicrobial agents when infection is suspected and patient is ill enough to require
treatment
o e.g. tx of pt with possible sepsis
 Pathogen-directed treatment: use of antimicrobial agents to treat a proven infection
o e.g. tx of pt with blood cultures growing S. aureus

Principles of antibiotic treatment

1. Develop differential diagnosis
o Most likely disease states based on history and
physical exam
 Demographics: age, race, geography,
speed of onset, rapidity of progression,
course
 Organ systems affected,
signs/symptoms, prior Dx & therapies
o Is there an infectious process on the short list?
Principles of Antibiotic Treatment (overview)
1. Develop differential diagnosis
2. Determine if antibiotics are necessary
3. Choose an antibiotic
4. Refine antibiotic choice
5. Have a plan for length of therapy

2. Determine if antibiotics are necessary right now

o Does antibiotic therapy alter the course of disease?
 No effect on some mild bacterial infections: especially those with primary viral problem (acute
bronchitis, acute sinusitis, acute otitis media) or natural mechanism to clear (infectious
diarrheas)
o Are antibiotics required immediately?
 Risk/benefit: risk of deferring therapy vs benefit of waiting to confirm dx
GIVE ABX! DON’T GIVE ABX (WAIT!)
 known focus of infection that requires tx with  Stable patient with subacute process in
abx to prevent the patient from getting sicker whom culture data may be hard to obtain but
(acute meningitis, pneumonia, acute is critical to management
endocarditis, epidural abscess with cord
compromise, etc.) (pt with fever of unknown origin: get origin
first, suspected vertebral osteomyelitis w/o
 no known focus of infection but other neurological sx, pt with wt loss & mass-like
important feature lesion in right middle lobe of lung:
(neutropenia/cancer + fever, asplenia + fever, malignancy?)
high immunosuppression + fever, toxic-
appearing patients with unstable vital signs)

36
 o Avoid "antibiotics for every fever"
 Fever is not an illness: it's a sign of illness
 Non-specific, host response to inflammation, not always an infectious cause, don't
always need abx even if infectious
 Same goes for "antibiotics for increased WBC"

3. Choose an antibiotic
o Empiric therapy: when we don’t know what’s causing the disease, but we need to start something
 What bacteria are likely to be involved & what antibiotics cover these bacteria?
 Common error: try to cover every possible organism
 Cover most likely & tailor to sickness of patient
o Pathogen-directed therapy: ID’d organism & have antibiotic susceptibilities
 Choose antibiotic with narrowest coverage that will treat organism.

4. Refine antibiotic choice

o Keep an open mind. Follow progress over time; reassess DDx if not progressing as expected
o Watch for & anticipate side effects:
 Allergies: PCNs, other drugs
 Drug-drug interactions (know current meds)
 Rifampin (oral contraceptives), voriconazole/posaconazole, erythromycin
 Look out for pts on warfarin, oral contraceptives
 Drug-food interactions: antacids inactivate oral fluoroquinolones

5. Have a plan for length of therapy

When to stop antibiotics?
o Empiric treatment:
 trust cultures & stop if from sputum/blood/urine before antibiotics started aren’t growing
organisms (not pneumonia, bacteremia, UTI)
 MRSA and pseudomonas grow easily: if they’re not isolated in culture, they’re most likely not
there and you don’t have to cover them
 NO REQUIREMENT TO “COMPLETE A COURSE” just because you started empirically
o Pathogen-directed treatment
 Length of most courses of therapy: arbitrary multiples of 7 days!
 Some have been clinically investigated: S. aureus bacteremia w/o endocarditis (14-28d); N.
meningitidis meningitis (7d), uncomplicated UTI in woman (3d)
 Try to give shortest course possible

Cultures & Antibiotics

Common error: antibiotics for every possible culture. Make sure to evaluate the culture!
Blood cultures
EXAMPLE ORGANISMS CLASSIFICATION WHAT TO DO
S. aureus (coag +)
Gram (-) rods NEVER A CONTAMINANT ALWAYS treat
Yeast
Usually don’t treat
Coag (-) Staph Usually a contaminant Exceptions:
Gram (+) rods (skin organisms)  patients with indwelling hardware
 signs of infection & >1 positive culture
Evaluate clinical picture for possible source (e.g.
Strep viridans
50/50 oral, GI, endocarditis)
Enterococcus
 signs of infection & >1 positive culture

37
Urine cultures
4 questions
1. What is source of urine? (clean catch good; cath/foley bag not good)
2. Does patient have symptoms of a UTI? ( dysuria, frequency, suprapubic pain, fever: don’t culture if none!)
3. What does urinalysis show? (should be sterile & uncontaminated. Suggestive of UTI: > 5-10 WBC/µL, no
epithelial cells – don’t rely on dipstick only)
4. What does the culture show? (positive ≥ 105 colonies; common UTI pathogens = E. coli, K. pneumoniae)

Wound cultures
 Superficial cultures of chronic ulcers & cultures from drains: usually polymocribial; contaminated/colonized
 More reliable: cultures from newly incised / drained abscesses
o Can be polymicrobial too; significant pathogens = heavy growth (S. aureus, GNR)
o Organisms like coag neg staph, enterococcus, strep viridans: if light growth, don’t need abx coverage
unless they’re only organism present
o Think of anaerobes in abdominal infections (might not grow in culture)

Sputum cultures
 Lab classification of quality of sputum sample: PMNs = good, epithelial cells = bad (want lower resp secretions)
o Type 1: discarded; lots of squamous cells, problem in specimen collection
o Type 2: adequate; PMNs=epithelial
o Type 3: good! PMNs > epithelial (rare or none)
o Type 4: just spit (bad)
 From endotracheal tubes: often colonized (look out) – should have clinical evidence of pneumonia to start abx

Cases:
1. 68 yo diabetic male; osteomyelitis, no systemic sx – don’t start abx right away (wait & check it out – stable pt)
2. 35 yo male, no comorbidity, picture of CA-pneumonia: want to start abx right away (pneumonia), thinking of S.
pneumoniae, HiB, (M. catarralis)+ atypical (legionella, Chlamydia, etc.) as common, give ceftriaxone (GPC) + azithromycin
(atypical) as empiric coverage. Find out susceptible to PCN! Give PCN (actually amoxicillin – easier PO because you don’t
have to give it as often) as pathogen-directed therapy.
3. 45 yo woman, severe Crohn’s disease, on TPN via central venous cath, fever 101 F & fatigue. Start abx (has cath!); probably
want to cover staph (vanco empirically for MRSA possibility), get a blood culture. Comes back MSSA; give oxicillin for
definitive Tx.
4. 50 yo man; central venous cath, took blood culture for no clinical reason, doing fine at home, culture comes back GPCC
(don’t start abx! Asymptomatic)
5
5. 55yo woman HT/high cholesterol; has acute MI; U/A & Cx show >10 colonies of E. coli. Find out if she has Sx, check U/A
results, think about source before starting abx.

Explaining antibiotic control to patients:

 educate physicians + patients + office staff (not effective to focus on one group, have office-based materials,
reinforce education during well-patient visits)
 Patients: explain, share facts (not for viral infections), build cooperation & trust, don’t say “just a viral infection”,
get pt involved, give alternative Tx for symptoms when possible, be confident

Pharmaceutical representatives: varying perception about appropriateness of gifts; people think that it only affects
other doctors & not me, etc.

38
 Syphilis (& other STIs)
NB: Most STIs are ASYMPTOMATIC  ask about BEHAVIOR, not Genital ulcer diseases:
just symptoms!  Syphilis (Treponema pallidum)
 Herpes (HSV 1&2)
Syndromes & causes:
 Chancroid (Haemophilus ducreyi) – mostly in
 Genital ulcer diseases: syphilis & herpes are the big
the south; uncommon
ones
 Lymphogranuloma venereum (Chlamydia
 “Drips” (discharges): gonorrhea, chlamydia,
trachomatis L1-L3)
trichonomiasis are main ones
o Possible presentation esp in developing
o Pt presents with a drip: treat for gonorrhea &
world; usually causes proctitis (MSM, etc.)
chlamydia empirically & then trich if sx don’t
 Granuloma inguinale or donovanosis
resolve
(Klebsiella granulomatiosis)
 Urethral/vaginal/cervical inflammation; proctitis (receptive anal sex), pediculosis pubis too.

Syphilis (Treponema pallidum)

“The great imitator / imposter” – can cause disease in pretty much any internal organ

Treponema pallidum
 Spirochete (slender, tightly coiled, unicellular, helical)
 Can’t culture in vitro (hard to study – inject into bunny testicles)
 Has very few proteins on outer membrane – relatively inert; has very little genetic diversity

Transmission: primarily sexual contact; also kissing, in utero, blood transfusions

Pathogenesis:
1. Penetrates skin through little microabscesses common with intercourse 
disseminates quickly (hours/days) via lymphatics/blood to any organ Stages of syphilis:
(especially CNS: in 1st few days!) divides ~30h
2. T. palladium gets to deep tissues (induces matrix metalloprotease-1 “early syphilis”
production) quickly, induces endothelial cells to express ICAM-1/VCAM- 1. Primary syphilis
1/E-selectin  inflammatory cells migrate to tissues 2. Secondary syphilis
a. PMNs respond first 3. Latent syphilis
b. Dendritic cells stimulated (TLR2 recognizes T. pallidum PAMPs)  a. Early latent
phagocytosis  taken to regional LNs  T-cells activated (slow
process b/c T. pallidum outer membrane is relatively inert) “late syphilis”
3. [CD4] & [CD8] peak 13-18d post-exposure (ulcers resolve); T. pallidum b. Late latent
survives in an unknown reservoir 4. Late syphilis
4. Incubation period: ~3wks 5. (Neurosyphilis: early &
5. Very low inoculum size (~10 spirochetes = infection!) late)

Stages (natural history: assume no treatment)

1. Primary syphilis Early neurosyphilis
a. Chancre: single papule at site of inoculation  ulcer;  CNS involvement can be
painless, well demarcated, heaped-up edges, smooth base, symptomatic during primary or
highly vascularized. secondary syphilis
i. Heals in 3-6wks without therapy  Presentation like meningitis (stiff
ii. If grouped, painful ulcer neck, headache, photophobia)
iii. Harder to recognize in women (more likely to have  Usually self-resolving ( immune
worse outcomes with syphilis) system can control)
 More common in HIV patients
39
 2. Secondary syphilis
a. Lymph nodes  blood, multiplication & dissemination
b. 2-8 wks after chancre if untreated: most common = skin manifestations (rash on palms & soles is classic
for secondary syphilis, but can look like anything! Macular/popular/ulcers/pustules/psoriasis/etc)
c. Skin lesions: filled with tons of spirochetes, very infectious (only if both people have abrasions on skin)
i. Condyloma lata: gray raised lesions; look papillomatous, almost like genital/anal warts
ii. Mucous patches in mouth, etc.
d. Other manifestations: all organ systems possible or even asymptomatic (even without rash)
i. Fever, lymphadenopathy, meningitis, optic neuritis, gastritis, hepatitis, glomerulonephritis, arthritis

3. Latent syphilis: no manifestations at all!

a. Immune system controls secondary manifestation; patient becomes Asx (latency)
b. Early latency: 1st year, pt. can have relapses of secondary syphilis; still infectious
c. Late latency: > 1 yr, pt is immune to relapse or reinfection
i. CAN STILL TRANSMIT (BLOOD TRANSFUSION or IN UTERO)
ii. 60% will stay in late-latent forever! (even without treatment)
iii. 30% will develop late syphilis & its manifestations if untreated

4. Late syphilis: a.k.a. “tertiary syphilis”; occurs decades later

a. Cardiovascular syphilis
i. Endarteritis obliterans of vasa vasorum of the aorta  aortitis  sacular aneuyrisms
1. FYI: Endarteritis obliterans = “inflammatory condition of the lining of the arterial walls in which the intima
proliferates, narrowing the lumen of the vessels and occluding the smaller vessels”
2. Usually ascending aorta; used to be most common cause of aortic aneuyrisms
b. Gummatous syphilis: almost like TB
i. Benign, granulomatous-like lesions usually affecting skin / bones but can occur in any organ;
causes local destruction via immune response
ii. Called “Gummas”, especially common in face & nasal cartilage (path: look like TB granulomata)
iii. “Benign” unless they’re in a bad place (heart, etc).
c. Late neurosyphilis: can be symptomatic or asymptomatic
i. Symptomatic: >10yr after primary infection; 2 main groups (meningovascular/parenchymatous)

ii. Meningovascular: endarteritis of small blood vessels (meninges, brain, spinal cord)
1. Strokes, seizures
2. MCA STROKE is especially common site

iii. Parenchymatous: actual destruction of nerve cells “Argyll Robertson (AR) pupil”
1. Tabes dorsalis: affects spinal cord  a.k.a. “Prostitute’s Pupil”, although
(shooting pains down leg, ataxia, cranial that’s probably not too PC these days
nerve abnormalities)  small pupils, accommodate (to near
2. General Paresis: affects brain (dementia, objects) but don’t react (to bright light)
psychosis, slurring speech, “Argyll  Wikipedia notes this fun mnemonic:
Robertson” pupil). Schizophrenia-type “like a prostitute, they ‘accommodate
but do not react.’”
symptoms of general paresis are big in
literature, Law & Order: SVU
Transmissibility
 Sexual transmission: only possible prior to late-latent syphilis
 In utero transmission: possible at any time
o All pregnant women need a syphilis test at their 1st visit
Congenital syphilis
 In utero infection can occur at any stage of syphilis; tends to happen after 4th month of gestation
 Baltimore has a number of cases each year (marker of public health quality)

40
  Perinatal manifestations: rhinitis (“snuffles”) followed by diffuse rash (esp. soles of feet), splenomegaly,
anemia, jaundice, thrombocytopenia; osteochondritis not uncommon (predilection for long bones & cartilage in
nasal area; causes deformity)
 Later manifestations: neurosyphilis, deafness, keratitis, recurrent arthropathy, Hutchinson’s teeth (widely-
spread incisors; look kind of like Dracula)

Diagnosis
 Dark-field microscopy: gold standard test for primary syphilis (serology negative in ~ 30% cases); not often
used (unavailable), can’t use for oral /GI lesions (lots of oral/GI nonpathogenic spirochetes)
 Serology: primary tests used, not sensitive in primary syphilis (prior to Ab formation); pt can become non-
reactive in secondary, early latent, early-late-latent syphilis

1. Non-treponemal tests: RPR & VRDL

 RPR = rapid plasmid reagent; VRDL = venereal disease research laboratory
 Nonspecific but very sensitive (almost 100%); quantitative
 testing for anticardiolpin IgM & IgG (marker of host cell – treponeme interaction: looking for Ab
against mitochondrial self-antigens; treponemes make cells explode & immune response against
these Ag follows)
 VERY CHEAP: 1st test to get if you suspect syphilis
 Result negative & don’t suspect primary syphilis: unlikely to have syphilis, no more tests
 Result positive: confirm by ordering treponemal test
 Provide titer that can be followed (1:1 = low, 1:2048 = very high; want 4-fold reduction in 12
months to indicate a cure)
 Re-test to follow treatment & check for re-infection

2. Treponemal tests: test for treponemal-specific antibodies;

 Tests are specific but expensive (use RPR/VRDL first)
 Don’t provide a titer that can be followed after therapy; once-positive = always positive

Treatment: need both a good immune system and penicillin to cure

 PENICILLIN; dose depends on stage of disease
o Early: 2.4M units PCN x1 dose
o Late-latent (gummas, etc.): 2.4M units PCN x3 doses over 3 weeks
o If patient is PCN-allergic: desensitize & use PCN anyway
 Treat patient and ALL SEX PARTNERS (track down & treat, even if you have to use the police to do it)
 ALWAYS TEST FOR OTHER STIs (including HIV)

Other diseases (DDx)

STI DDx: Genital ulcers
 Granuloma inguinale donovanosis:
o From Klebsiella granulomatis, rare in US (more SE Asia, Africa)
o Painless, progressive, ulcerative lesions without regional lymphadenopathy
o “beefy red” & highly vascular
Painless ulcers Painful ulcers
o Dx: tissue biopsy (no culture; PCR not FDA approved)
Syphilis, LGV, Herpes,
o Rx: doxycycline (100 mg po BID x 3wks)
granuloma inguinale chancroid
 Chancroid
o From Haemophilus ducreyi, endemic in some parts of southern US
o Painful genital ulcer & tender supperative inguinal adenopathy; often co-infected (syphilis / HSV)
o Dx: culture
o Rx: azithromycin 1g po x1 or ceftriaxone 250mg IM x1

41
 STI DDx: urethral / vaginal / cervical inflammation
 N. gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis
 Symptoms: dysuria (pain with urination), increased urinary frequency, urethral/cervical/vaginal discharge,
occasionally epididymitis / orchitis (testicular pain) in men

STI DDx: Pelvic inflammatory disease

 Infection spreading to upper genital tract in women (uterus/fallopian tubes/ovaries) (STIs in general)
 Symptoms: abdominal pain, fever
 Signs: uterine tenderness and cervical motion tenderness
 Complications: infertility, chronic pelvic pain, ectopic pregnancy

STI DDx: Proctitis

 N. gonorrhoeae, Chlamydia trachomatis, HSV 1&2
 Can be infected but asymptomatic
 Generally via receptive anal sex
 Symptoms: pain on defecation, rectal discharge with blood & mucus

General principles of STI management:

 NO SEX (even with a condom) until patient and partners are treated
 Find one STI  test for ALL THE OTHERS
 Most STIs are reportable infections: report to health department
 When possible, use a treatment that you can watch them take(e.g. PCN injection)
 Don’t judge patient (better to get partners treated, etc)

42
 Pharmacology: ID & Micro

Introduction to Antibiotics ...................................................................................................................................................... 2

Cell Wall Active Antibiotics (I & II) .......................................................................................................................................... 5
Sulfonamides and Antimicrobial Antifolates ........................................................................................................................ 11
Ribosomal Inhibitors ............................................................................................................................................................. 14
Drugs for Mycobacterial Infections....................................................................................................................................... 21
Quinolones ............................................................................................................................................................................ 25
Antibiotic Resistance ............................................................................................................................................................. 27

1
 Introduction to Antibiotics
Antibiotic Definition:
 Classic: substances produced by one microorganism to inhibit growth or destroy another
 Functional: Drugs that kill “bugs” (mostly bacteria but also others)
Therapeutic objectives:
Example: for a given clinical syndrome, figure out what the most common organism is, 1. Right drug
then choose an appropriate class & drug and individualize therapy (all depends on who 2. Right place
& where pt is). After empiric therapy, get lab results (if applicable) & give definitive tx. 3. Right time

Empiric therapy: begin broad

 “What’s likely?” - depends on probability of organism in given clinical syndrome (pt.,geography, hospital vs
community, etc.)
 Worst-case scenario – what’s the worst that could happen even if less probable
 Local antibiotic sensitivity patterns (community, esp. hospital)

Definitive therapy: go narrow

 Get culture & know sensitivity
 Side effects, co-morbidities, other patient characteristics inform choice
 Not probability-dependent

Narrowest spectrum good: ↓ resistance, adverse effects, cost; ↑ adherence, simplicity

Obstacles: tons of organisms, tons of abx with different characteristics; agents can cause many syndromes & vice versa,
many causes still unknown, causes for a syndrome can vary with population, geography, age

RIGHT DRUG
Selective toxicity: less sensitivity to toxicity in humans than bacteria
host efficacy bacterial toxicity
 Therapeutic window = Selective toxicity =
host toxicity host toxicity
 Relies on the distant genetic relationship between humans & bacteria (as opposed to fungi, parasites, viruses)
 Various mechanisms (see table)

Adverse effects
 Often unrelated to antimicrobial effects
 Large therapeutic index usually (can give
a high molar quantity)

Coverage: individualize for organism, local

epidemiology / resistance, patient
 E.g. antibiotic guidelines / susceptibility grids for each hospital.

Bactericidal vs. Bacteriostatic

 Microbiologic definition = MBC:MIC > 4 for ‘cidal
o Minimum bactericidal concentration : minimum bacteriostatic concentration > 4
 Clinical definition:
o ‘Cidal = Dead bugs
o ‘Static + good immune system & good penetration = Dead bugs
o ‘Static drug alone (immune dysfunction or sanctuary) = Sleeping bugs

2
  Table has good summary but not hard & fast rules.
 Bacteriostatic are mainly ribosome inhibitors.
 Can be variable even for a given drug (‘static against
some, ‘cidal against others)
 Clinical relevance: sometimes ‘static drugs penetrate
better, or ‘cidal drugs are needed (see table)
o Endocarditis: poor penetration, slow growth
o Meningitis: poor penetration, immune
sanctuary
o Osteomyelitis: poor penetration
o Neutropenia: immunosuppresion

Combinations of antibiotics: save for special situations

 Mixed infection: at least 2 microorganisms growing and
causing disease, e.g. intra-abdominal infection
 Resistance prevention: e.g. anti-TB therapy
 Initial empiric therapy with serious infection
 Synergy: a few situations where 1+1 > 2 in the clinic
RIGHT PLACE
Antibiotic Tissue Penetration
 Recall first unit: []blood, size, protein binding in plasma, lipid
solubility, ionic charge, tissue binding, active transport,
excretion pathways
 Inflammation: some drugs can penetrate better in places of
inflammation (e.g. get into sanctuary like past BBB if
inflammation present).
o Example: penicillin <1% CSF penetration without
inflammation, 5% with inflamed meninges
o Penicillins usually pumped out across BBB;
inflammation reduces this efflux

Extravascular penetration of drugs

 Interstitial fluid: rapid equilibrium with vascular space
 Large reservoir (e.g. pleural fluid): equilibrium occurs slowly, smaller fluctuations (akin to oral dosing)
 Specialized site with barrier (e.g. CSF): much lower concentrations overall

 Loading dose can rapidly achieve target concentration

o Especially relevant if reservoir situation
o How fast you can get it up to 95% still depends on half-life!

Bacterial penetration:
 Outer membrane of Gram (-) bacteria, periplasmic β-lactamases around cell wall,
 Need to get past cytoplasmic membrane & cytoplasmic pumps
 Think: how does drug work? Where? How does it get there? How could resistance block its arrival?

RIGHT TIME
Pharmacokinetics / pharmacodynamics:
 time course of drug concentration often doesn’t parallel time course of drug effect

Time vs. Concentration-dependent killing

3
  Concentration-dependent killing (aminoglycosides, quinolones)
o Increased killing rate as concentration rises above MIC
o Therapeutics: get concentration up high & fast
 Time-dependent killing (β-lactams)
o Killing rate doesn’t rise past a point (~4x MIC)
o No correlation between drug peak/MIC or AUC/MIC
o Instead, killing increases with % time spent above MIC
o Therapeutics: get concentration to effective level &
keep it there

Post-Antibiotic Effect (PAE)

 Suppression of bacterial growth that persists after short
exposure of organisms to antibiotic agents
 Means effect-time relationship might be different from drug-time relationship
 So something with a short half-life but with a PAE might be able to be dosed less frequently than you’d expect

PAE against…
PAE
Gram (+) Gram (-)
β-lactam Abx YES No
Aminiglycosides (yes,but not clinically YES
Quinolones relevant)

4
 Cell Wall Active Antibiotics (I & II)
Cell Wall Basics
Gram (+): large pepditoglycan cell wall on outside, β-lactamases on surface of cell wall
Gram (-): small cell wall in periplasmic space between OM & IM; β-lactamases in periplasmic space

Cell wall: NAM/NAG make long CHO strands; tied together by peptide cross links
 Cross-links differ in AAs, # between GPC (L-lysine, pentaGlycine) & GNR (m-DAP)
 Both have terminal D-Ala-D-Ala that is reactive for cross-linking

E. coli division: elongation; incorporation of new material, formation of septum, splitting into daughter cells

Peptidoglycan “3-for-1” Growth model

1. Synthesize 3 new strands
2. Chew up an existing strand
3. Insert 3 new strands for existing strand (“3 for 1”)
4. Cross-link via transpeptidase at D-ala-D-ala
a. D-alanine not present in vertebrates
b. Terminal D-ala cleaved off
c. Cross-linkage formed by acylation at CO-N bond (m-DAP in GNR, Gly in GPC)
5. Expand

 Involves big multienzyme complex that assembles in cell wall area to form new cell wall
 Just behind this cassette is a point of transition and vulnerability: where the cross-links have been broken but
not yet reformed (so inhibiting cross-linking = multienzyme complex just breaking apart the wall)

Penicillin & general β-lactam mechanisms

β-lactams inhibit cross-linking of peptidoglycan strands
 Suicide substrate for transpetidase
 Forms covalent linkage: leaves acylated, inactivated enzyme
 Structural analogs of D-ala-D-ala with β-lactam ring in place of peptide
bond
o Ring constrains the structure to keep homology
o Cleave ring = lose structure
 Autolysins (peptidoglycan hydrolases) usually break apart cell wall during
synthesis; here simply degrading wall
 Selective toxicity: humans don’t have cell walls (no D-ala / transpeptidase)

Penicillin binding proteins:

 Multiple kinds, located in cell membrane of both GNR and GPC
 Transpeptidases, transglycosylases
 Localization depends on function (elongation, shape maintenance, septa formation, cell divison)
 Inhibiting some can be lethal to cell, others won’t be lethal

β-lactam effects: leads to dramatic morphologic changes (failure to divide, failure to form septa, etc.)

Penicillin G
Classic penicillin: as development continues, pick up more gram (-) and more anaerobes
Key points:
 Inflammation inhibits organic anion transport pump, so better CSF penetration (not pumped out as much)

5
  Time-dependent killing (no need to go above 4x MIC)
 Post-antibiotic effect in GPC, NOT GNR – can dose less frequently than 45m half life suggests

Allergic reactions:
 Most dermatologic, idiopathic, drug fever, etc. – less severe and have longer onset (~72h)
 Most worrisome: anaphylaxis – very severe & quick onset (~1 h)
 Management:
o No Hx allergy: no skin test (2% positive skin tests, much rarer anaphylaxis)
o Hx penicillin allergy: order skin test
 Positive skin test: avoid penicillins or desensitize first. 50-70% will have anaphylaxis &
accelerated urticaria!
 Negative skin test: can use (3% will have cutaneous reactions)
 Up to 30% cross-reactivity with cephalosporins (if positive skin test, avoid cephalosporins or desensitize!)

β-lactamase inhibitors
Resistance:
 β-lactamases (can use inhibitors)
o Hydrolyze β-lactam ring; no longer has constrained D-ala-D-ala steric homology
 Also alteration in PBP site, ↓ permeability too

Clavulanate:
 competes with penicillin for β-lactamase active site access
 β-lactamase hydrolyzes clavulanate & forms irreversible complex (suicide substrate)

Augmentin: Amoxicillin + Clavulanate.

 Much lower MIC than just amoxicillin if β-lactamase producing bug

Other β-lactamase inhibitors: Sulbactam, Tazobactam

Limitations of β-lactamase inhibitors
 Only active against one class (A) of serine hydrolases (exception: Tazobactam on class C&D too)
 Degraded by β-lactamase after binding
 Clavulanate induces expression of β-lactamase
 Emergence of inhibitor-resistance Class A enzymes; multiple classes produced by one organism; multiple-
organism infections can have different β-lactamases
Development of more penicillins
Problems with Penicillin G:
 short half-life
 unstable to gastric acidity (hard to give PO for lower GI stuff)
 inactivated by β-lactamase
 poor Gram(-) spectrum
 allergenic

Goals of penicillin’s spawn:

 Improve activity against GNR (anti-pseudomonals like
piperacillin, etc. and extended GNR spectrum of
amox/ampicillin)
 PCN-ase resistance (anti-staph like oxacillin, methicillin, etc.)
 Pharmokinetic advantage (prolonged half-life like penicillin G
benzathine/procaine, etc.)

6
Goals of modifying penicillin side chains:
 ↑ β-lactamase stability; ↑PBP affinity, better PK, more acid stable
 better permeability across outer membrane (↑ Gram (-) coverage)

Dorothy Crowfoot Hodgkin: x-ray crystal structure of penicillin (β-lactam) and pretty much everything else.

MODIFICATIONS OF PENICILLIN
Improved Pharmacokinetics
Longer acting: good because of time-dependent killing (more efficient than high peaks)
 Procaine penicillin: 1:1 salt (penicillin G:procaine). Given IM, near painless
 Penzathine penicillin: 2:1 salt (penicillin G: dibenzylethylene diamene). VERY slowly absorbed IM
 Both of these: penicillin molecule has same t½ but absorption from IM slow: almost like continuous infusion

Orally available: lower peak, a few hours of action (along with PAE, makes for acceptable po dosing)
 Penicillin V: acid stable

Improved Gram (-) Spectrum (Aminopenicillins)

In general: cover penicillin’s spectrum (GPC, above-the-belt anaerobes) + enterococcus & some “dumb GNR”
Ampicillin (can add sulbactam to cover β-lactamase producers) – often IV
ampicillin Like penicillin but with improved Gram (-) spectrum
Indications: Penicillin's spectrum + enterococcus and "dumb gram negatives". GPC: pneumococcus,
streptococcus, enterococcus (faecalis, not faecium); GNR: H. influenzae, E. coli, P. mirabilis, Salmonella.
Administration: often IV; can be paired with β-lactamase inhibitor (amp + sulbactam = Unasyn, given IV) to
improve spectrum to include β-lactamase producing S. aureus, H. influenzae, M. catarrhalis, many GNR
Resistance: β-lactamase, PBP mutations, etc.
Toxicity: Diarrhea, skin rash (macular, evanescent). Not allergy.
Other: 50% orally bioavailable. PAE against GPC, not GNR.

Amoxicillin (can add clavulanate to cover β-lactamase producers) – often PO

amoxicillin Like penicillin but with improved Gram (-) spectrum; like ampicillin but with 100% bioavailability
Indications: Penicillin's spectrum + enterococcus and "dumb gram negatives". GPC: pneumococcus,
streptococcus, enterococcus (faecalis, not faecium); GNR: H. influenzae, E. coli, P. mirabilis, Salmonella.
Administration: often PO, can give 3 times a day (q8h); can be paired with β-lactamase inhibitor (amoxicillin +
clavulanate = Augmentin, given po) to improve spectrum to include β-lactamase producing S. aureus, H.
influenzae, M. catarrhalis, many GNR
Resistance: β-lactamase, PBP mutations, etc.
Toxicity: Diarrhea, skin rash (macular, evanescent). Not allergy.
Other: 100% orally bioavailable. Just ampicillin with one OH group added. PAE against GPC, not GNR.

Amoxicillin = Ampicillin + one hydroxyl (bioavailability 50% for amp 100% for amox)

Antipseudomonal (aminoacylpenicillins)
Piperacillin (can add tazobactam to cover β-lactamsae producers)

7
 piperacillin Like ampicillin but with coverage of more serious GNRs (e.g. pseudomonas)
Indications: Ampicillin's spectrum + more nosocomial GNRs ("more serious GNR"). Adds pseudomonas
aeruginosa & bacteroides fragilis
Administration: Can pair with tazobactam to increase coverage (β-lactamase producing staphylococci and
many GNR). Doesn't help against pseudomonas! In combination for serious Gram (-) infections (e.g.
nosocomial / empirical)
Resistance: β-lactamase, PBP mutations, etc.
Other: PAE against GPC, not GNR. (Ampicillin coverage = GPC: pneumococcus, streptococcus, enterococcus
(faecalis, not faecium); GNR: H. influenzae, E. coli, P. mirabilis, Salmonella.)

Penicillinase-resistant
Methicillin: historic interest only; not hydrolyzed by β-lactamase
 “Methicillin resistant S. aureus” (MRSA) or S. epidermidis (MRSE): means it’s not resistant because of β-
lactamase
o Resistance due to altered PBP
o Resistance extends to ALL OTHER β-LACTAMS! Includes cephalosporins, imipenem

Oxacillin:
oxacillin Like penicillin but pencillinase resistant
Indications: Penicillin's spectrum + penicillinase-producing staph, pneumococcus, Group A streptococci
Resistance: PBP mutations, like MRSA or MRSE. (resistance to one of these extends to ALL β-lactams)
Other: PAE against GPC, not GNR.

Dosing penicillins Things to remember

 Half-life 0.5-1.5 hrs but PAE allows dosing q4h about all these penicillins:
 Not good for PO dosing 1. PAE against GPC, not GNR
 Exceptions: 2. B-lactamase inhibitors only help if B-
o Meningitis: dose q2h lactamase is mechanism of inhibition
o Amoxicillin: 3x/day (q8h) 3. Time-dependent killing! (continuous
o Benzathine & procaine: very long half life infusion increases % time > MIC, so
better killing. E.g. piperacillin study)
4. Renal clearance predominates
5. Low penetration (CSF, eye, brain,
prostate) unless inflammation

8
Other β-lactam classes: Cephalosporins (cephalosporin ring instead of azothine); Monobactams (one ring only),
carbapenems (different 5-membered ring) – but all have β-lactam ring

Cephalosporins
General characteristics:
 β-lactam ring, resistant to β-lactamases  Time-dependent killing (continuous infusion
 Spectrum: broad (GPC, GNR incl. pseudomonas) more efficient)
 Safety: betterthan penicillins  PAE vs. Gram (+)
 Four “generations”  Allergy: Up to 1/3 cross-reactivity with PCNs!

GENERATION SPECTRUM EXAMPLES

1st Strep, S. aureus. No activity against Enterococci, Listeria Cephalexin (Keflex)
2nd E. coli, Klebsiella, Proteus, H. influenza, M. catarrhalis Cefuroxime
Less activity against Gram (+) than 1st gen Cefotetan (also B. fragilis)
3rd Enterobacteria, Serratia, N. gonorrhea. Ceftriaxone*(Rocephin)
GPC: S. aureus & Str. pyogenes covered as well as 1st gen
4th Comparable to 3rd generation but more β-lactamase Cefepime
resistant
Used for pseudomonas too

*Dose all q8h except ceftriaxone (once daily)

Special ones: cefotetan (anti-anaerobe) & cefepime (anti-pseudomonal)

Carbapenems
General characteristics:
 Actively transported into bacteria: imipenem-specific porin
o Helps reach periplasmic space & cell wall in Gram (-) like pseudomonas
 PAE FOR GRAM (-): only one in class
 Renal toxicity: filtered by kidney;
o β-lactam ring hydrolyzed by proximal tubular dehydropeptidase I, producing renal tubular toxin
o Coadministration with cilastatin fixes the problem by blocking renal dehydropeptidase I
o ↑ *active drug]urine, so more efficacy for UTI treatment
o ↓ *toxic metabolite], so less renal tubule toxicity

Imipenem – Cilastatin
imipenem Indications: Very broad spectum: Gram (+) incl. enterococcus, Gram (-) incl. pseudomonas, anaerobes including
bacteroides
Administration: q8h (half life short but PAE for all)
Toxicity: Seizures (incidence not defined). Renal clearance; urinary carbopenem hydrolyzed by proximal tubular
dehydropeptidase I; results in metabolite: renal tubular toxin. Co-administration with cilastatin (inhibits renal
dehydropeptidase I) both 1) increases efficiency for UTI tx and 2) decreases renal tubular toxicity
Resistance: Rare (so far). Imipenem + cilistatin = Primaxin
Other: PAE against Gram (+) AND GRAM (-)! Renal metabolism.

9
 Monobactams
Aztreonam: like a non-aminoglycoside “aminoglycoside”
 Totally different spectrum: good Gram (-) coverage
 No cross-allergenicity with penicillins
aztreonam Indications: "Non-aminoglycoside aminoglycoside". Gram (-) coverage
Toxicity: No cross-allergenicity with penicillins
Resistance: β-lactamase, etc.

Vancomycin
Key features:
 Not β-lactam, so β-lactamase doesn’t hurt it.
 VRE: multiple genes mutated (D-ala-D-Lac instead of D-ala-D-ala)
 Allergenicity: skin rash, eosinophilia, drug fever; Phlebitis, “Red Man” flushing if IV dose too rapid
 Time-dependent killing (continuous IV best)
 No absorption (actually good for C.diff colitis – want it all to go on surface of GI; otherwise IV)

vancomycin Mechanism of Action: H-bonds to D-Ala-D-Ala so transpeptidase can't access (not β-lactam)
Effects: Inhibits cross-linking of peptidoglycan layer of bacterial cell wall
Selective Toxicity: Humans don't have bacterial cell wall
Indications: Great against S. aureus (e.g. MRSA); C. difficile colitis, Enterococci if susceptible
Administration: No absorption (good for C. diff). Enters CSF poorly without inflammation. Usually dose IV a
few times per day.
Toxicity: Allergenicity: skin rash, eosinophilia, drug fever. Phlebitis, "Red Man" (flushing if dose IV too fast),
ototoxicity & nephrotoxicity are doubtful
Resistance: NOT β-LACTAM so not affected by β-lactamase. Vancomycin resistance emerging (e.g. in E
faecium. - VRE). Mechanism: changing D-ala-D-ala to D-ala-D-lac (9 genes required)
Other: Renally excreted. Half life 6 hrs; 9 days if anuric. Time-dependent killing (continuous dose best)

10
 Sulfonamides and Antimicrobial Antifolates
Paul Ehrlich = Mr. Magic Bullet (“die Zauberkugel”) & the father of Uber Modern Chemotherapy.
 Things he came up with: new principles for discovering anti-infectives (synthesized, not just natural, structure-activity relationships, used
standardized animal infectious models, came up with the idea of chemotherapeutic index, had a “receptor theory” – selective toxicity to
pathogen; drug resistance is characteristic of the infecting organism, not the host.
 Worked with organic arsenicals & azo dyes; voted “historical figure I’d most like to have a baby with” by pharmacology lecturers

Gerhard Domagk came up with prontosil around 1932-5, a red dye with azo link and sulfonamide group
 First big time antibacterial agent (highly effective, relatively
nontoxic) SA: active form of prontosil
 Turns out that it’s really a prodrug; cleavage @ azo linkage 1. SA: active in vitro & in vivo; prontosil
in metabolism yields sulfanilamide (active part) only in vivo
2. Equally active on molar basis
Sulfanilamide 3. SA produced from prontosil in tissues
 Active part of prontosil 4. Patients / lab animals given prontosil or
 Looks like PABA; reacts with 7,8-dihydropterin SA excrete SA
pyrophosphate via DHP synthase but leads to a metabolic
dead end (further steps inhibited – product isn’t a substrate for dihydrofolate reductase)

Sulfonamides: how they work in general

Folate metabolism in bacteria

1. 7,8-Dihydropterin pyrophosphate + para-amino benzoic acid (PABA) 7,8-DHP (via DHP synthase)
2. 7,8-DHP + several glutamates  dihydrofolate (FH2)
3. FH2 + NADPH tetrahydrofolate (THF or FH4) + NADP+ (via dihydrofolate reductase)
4. TH4 needed for TMP synthesis from dUMP; DNA synthesis down the line

KEY to SELECTIVE TOXICITY:

 HUMANS TRANSPORT DIHYDROFOLATE INTO CELLS; BACTERIA CAN’T (impermeable membrane)
 BACTERIA SYNTHESIZE DIHYDROFOLATE IN CELLS; HUMANS CAN’T (no DHP synthase)

Mechanisms of resistance
 ↓ bacterial permeability to sulfonamides
 Mutations in DHP synthase – so the sulfonamides don’t fit as well
 ↑ DHP synthase activity (constant % inhibition, so increase in # of enzymes increases overall activity)
 ↑ PABA to outcompete for enzyme spots

Structure / Activity Relationships

 Sulfanilamide crystallizes in urine (not cool)
 New versions: better solubility in water & longer half-life by substituting R and R’ groups

Clinical uses
 Cheap, easy to administer, orally bioavailable, narrow spectrum, well tolerated
 Rarely monotherapy
 Prophylaxis of simple UTI from Gram (-) bacteria
 Drug of choice for Nocardia
 Occasionally: H. ducrei, Chlamydia, Lymphogranuloma venereum (not so much anymore)

Pharmokinetics
 Shorter half lives (sulfamethoxazole = 11h, sulfisoxazole = 6h) are more manageable
11
  Longer half lives (sulformethoxine = 150h) aren’t really used anymore: can give infrequently (good) but also side
effects take a long time to go away (big problem)

Toxicity of sulfonamides
 Most hypersensitivity or idiosyncratic (only partially dose-dependent)
 Flu-like symptoms, skin rashes, drug fever, joint pain, lymphadenopathy
 Rare: Stevens-Johnson syndrome (danger with long-acting sulfonamides: can’t reverse)

 Higher rate in patients with AIDS (nobody knows why)

 Mechanism of idiosyncratic toxicity

o Sulfonamides can be broken down by two pathways
1. N-acetyl transferase (yields non-toxic metabolite)
2. Cytochrome P450 (yields reactive metabolite)
 Reactive metabolite can be detoxified or bind proteins (becomes hapten; generates
immunologic response & cytotoxicity)
o Slow acetylators might be at a higher risk for side effects

Toxicity in premature infants

 Premature rupture of membranes = ↑ risk infections
 Trying to find abx to treat empirically: sulfisoxazole & penicillin lead
to high mortality
 Hyperbilirubinemia
o Physiologic in all newborns (physiologic jaundice) – peaks @ Normal bilirubin: mostly bound to albumin
7-10d, then falls
o Bilirubin lower in sulfonamide treated pts
o But kernicterus present (yellow staining of basal ganglia from
bilirubin)
 Normal situation: bilirubin mostly bound to albumin, etc. – only
unbound crosses membranes
 Sulfonamide bumps bilirubin off of albumin: higher free bilirubin, so
more can cross into the cells (e.g. brain) Kernicterus in newborn: bilirubin bumped off
o Explains findings: [bilirubin]blood ↓, [bilirubin]cells ↑ albumin by sulfonamide; accumulates in cells
Moral of the story: don’t give sulfonamides to a nursing mother or her child

Structural analogues of sulfonamides

For mycobacterial infections
 DDS (Dapsone, 4,4’-diaminodiphenylsulfone): M. leprae (leprosy)
o Usually with Rifamipicin; ineffective vs. other mycobacteriae (unique dihydropteroate synthase)
 PAS (p-aminosalicylic acid): M. tuberculosis (TB)
o Inactive against most other bacteria; remarkably specific for M. tuberculosis
o Other sulfonamides ineffective against TB
For non-infectious diseases: antithyroid, antihyperglycemic, blocker of penicillin secretion & stimulate uric acid
secretion for gout (probenecid), diuretics, others.

Trimethoprim
Diaminopyrimidines (e.g. methotrexate, folic acid, etc.) – two amino groups on a pyrimidine moiety

Trimethoprim: a diaminopyrimidine
 Blocks dihydrofolate reductase (inhibits FH2  THF & limits TMP pool for DNA synthesis)
 Selective toxicity: doesn’t fit into human dihydrofolate reductase enzyme
12
  Huge difference: IC50 300,000:5 (humans:E. coli)
 Resistance:
1. Mutation in dihydrofolate reductase (so trimethoprim inhibits less)
2. ↑ dihydrofolate reductase expression (constant % effect)
 Toxicity
 Rare: rash, nausea +/- vomiting (3-5%)
 Folate deficiency in pregnant, malnourished, alcoholic patients (who are already low in folate)
 Result: neutropenia, thrombocytopenia, megaloblastic anemia

Cotrimoxazole
 Trimethoprim + Sulfamethoxazole (“Bactrim”, “Septa”)
 Sulfamethoxazole inhibits DHP synthase; Trimethoprim inhibits DHFR (later step in same pathway)
 Advantages: synergism, broader spectrum, ↓ resistance, ↓ dosage = ↓ toxicity
o ‘Cidal instead of ‘Static (complicated reasons)
 Half-lives well matched (11-10 hrs)

Similar combo: Fansidar

 Pyrmethamine (diaminopyramidine DHFR blocker like TMP); sulfadoxine (like SMX)
 For malaria

13
 Ribosomal Inhibitors
Basics of Bacterial Ribosome
 70S ribosome
o 50S subunit (peptide exit tunnel, peptidyl
transferase cavity, etc.)
o 30S subunit (A - acceptor, P - protein, E – exit sites)
 Process of elongation: A to P to E; tRNA/mRNA moves,
polypeptide stays still
o Movement to hybrid states is spontaneous, 30S
subunit movement requires energy

Ribosomal inhibitors
 Site specific; work on different subunits. Only
aminoglycosides are ‘cidal in all situations
 See slide for good summary

Aminoglycosides
Structure: 3 hexose sugars, O-glycosidic linkage, 1+ amino
group/sugar

Gentamicin, tobramycin, amikacin

Pharmacokinetics:
 Poor oral bioavailability (IV)
 Distribution: good into interstitial,
poor into cells (except PCT & ear),
poor into CSF (give intrathecal if
needed)
 Not metabolized
 Glomerular filtration; PCT
accumulation
 2-3h half-life but dose once daily (PAE
& concentration-dep killing)

Once-daily dosing
 Get high peak ([]-dep killing)
 Drug-free interval
o Reverse adaptive post-exposure resistance by bacteria (not genetic; will revert & bacteria become more
susceptible)
o Minimize toxicity (need 3-5h drug-free)
 Rationale: []-dep killing, PAE, saturation of PCT & inner ear cells at low [], adaptive post-exposure resistance
 Meta-analysis: reduces / delays nephrotoxicity, no change in clinical efficacy, no change in ototoxicity

Therapeutic drug monitoring: further reduces nephrotoxicity (give dose, wait 30m, draw level, adjust dose)
 Wide PK variability; Cmax related to efficacy, trough related to nephrotoxicity: important to hit targets
 Easy, rapid AG assays exist; can improve outcome
 Hit targets quicker, higher peaks & lower troughs, less nephrotoxicity & costs
14
Which AG to use:
 Check local pattern of resistance first
o Gentamicin: standard (cheap)
o Tobramycin: more expensive but not worth the difference; JHH: a little better vs pseudomonas
o Amikacin: much more expensive but much more expensive (save for when you need it!)
o Streptomycin for TB; Neomycin for topical; Neomycin or kanamycin for oral in hepatic coma
 Ototoxicity similar for all

gentamicin Mechanism of Action: Aminoglycoside antimicrobial agents. Bind 30S ribosomal A site rRNA
Effects: Inhibit protein synthesis, misreading, freezing initiation complex. Actively imported into bacteria via
tobramycin polyamine transporter (inhibited by chloramphenicol, calcium, anaerobic or acidic environment, mutations).
Causes lysis & death of bacteria
amikacin
Selective Toxicity: human 80S ribosomes don't bind aminoglycosides well (exception: cells with megalin
membrane transporter: PCT, inner ear, pigmented retina epithelia; mitochondrial rRNA)
Indications: Gram negative rods (good against E. coli, Klebsiella, proteus, even some "bad" gram negatives.
Gentamicin not great against Pseudomonas or Acinetobacter - TOB or AMI better. TOB not worth the cost).
Use for severe gram(-) infections & for synergy (S. aureus, enterococci, PCN-resistant S. pneumoniae!) with
PCNs.

Administration: IV, once-daily dosing (high peak for concentration-dep killing, drug-free interval to reverse
adaptive post-exposure resistance by bacteria & minimize toxicity). Takes advantage of PAE. Therapeutic
drug monitoring useful too

Toxicity: Nephrotoxicity (10-20%, PCT changes in all, glomerular changes in few, rarely severe, reversible).
Ototoxicity (uncommon, cochlear & vestibular 3-15%ish, irreversible); Neuromuscular paralysis (exceedingly
rare, increased with fast infusion, myasthenia, succinyl choline anesthesia). Ethacrynic acid (loop diuretic)
potentiates nephro/ototoxicity!

Resistance: very slow development of resistance (ribosomal & transport mutations rare). Enzymatic
modifications most common (acetylation, phosphorylation, adenylation). One enzyme may inactivate all
AGs; most that inactivate GEN also inactivate TOB. Very few mutations inactivate AMI

Other: Synergistic with beta-lactams. Antagonistic with chloramphenicol. Has activity against GPC but not
used clinically except in synergistic combinations. PAE against Gram (-) and (+)

streptomycin Like other AGs but used for TB

neomycin Used topically (triple antibiotic cream, etc.)

Toxicity in depth:
 cells with megaline membrane transporters: PCT, inner ear, pigmented retina epithelia

Nephrotoxicity:
 binds brush border phospholipid (MMT) in PCT between microvillus projections; accumulates in renal cortex
15
  gets endocytosed; toxicity from lysozome processing products

Risk factors for nephrotoxicity: Pros & Cons of Aminoglycosides

 Increasing age (PK issue only?)
 Volume depletion (concentrating effect)
 Normal renal function (can’t cause toxicity if
can’t get to PCT!)
 Hepatic dysfunction
 Duration > 72hrs (3-7d on average for toxicity) –
can use eperically
 Concomitant medications:
o loop diuretics, especially ethacrynic acid (1 dose does it!)
o Antibiotics (vancomycin, ampho B, clindamycin, cephalosporins)

Ototoxicity: perilymph concentration sustained over time; total destruction of hair cells
Clinical features of ototoxicity
 High frequency lost first; clinically notable rarely; tinnitus; high low frequency hearing loss
 Imbalance, vertigo, nausea/vomiting if vestibular involvement
 50% irreversible; cumulative (don’t give AG at all if history of ototoxicity); progresses after cessation of drug

Risk factors for ototoxicity:

 ↑age, underlying renal dz, previous AG tx or auditory damage, duration of treatment
 Ethacrynic acid (loop diuretic)
 Genetic mutation (1555AG in mitochondrial rRNA; G mutation binds AGs to mito rRNA!)

Tetracyclines
Tetracycline, doxycycline, minocycline: 4-rings

Allow binding in 30S A site but not transition step;

transported into bacteria; passive absorption to eukaryotes
(doesn’t accumulate)

Originally: broad spectrum; lots of resistance now

(mutations in bacterial active transport system; confers
resistance to all tetracyclines). Good for treatment of atypicals (Chlamydia, borrelia, H. pylori)

Pharmacokinetics: orally bioavailable formulations (doxycycline ~100%)

 Advantages of doxy, minocycline:
o Available IV;
o Can be dosed 1-2x daily; (tetracycline 3-4x daily): longer half-lives and better bioavailability
 Adverse effects: chelated with calcium & deposited in teeth, bones
o Sunlight: darkened bands appear on teeth (important from last few days of pregnancy  6 yo)
o Don’t give with antacids, milk (Ca), Maalox (Mg)
 Doxycycline: least GI side effects

16
 tetracycline Mechanism of Action: Ribosomal inhibitor, antimicrobial agent. Inhibits bacterial ribosomal 30S subunit
at A site
doxycycline Effects: Blocks A/T > A/A alignment (aminoacyl-tRNA can't "stand up")
Selective Toxicity: Will inhibit eukaryotic protein synthesis, but actively transported into bacteria &
minocycline accumulates. Doesn't accumulate in eukaryotic cells

Indications: Atypicals: Chlamydial infections (e.g. Chlamydia pneumonia, most common young adult
CAP, STIs, PID, etc.). Borrelia burgdorferi (Lyme dz). H. pylori (along with other abx & bismuth
subsalicylate).

Administration: q3-4h (less half-life, bioavailability than doxy or mino). Can't administer with antacids,
Maalox, milk (Ca & Mg, see below)
Toxicity: Chelates with calcium (teeth/bones; darkened bands on teeth with sunlight exposure,
important from few days before birth to 6yo)

Resistance: Genetically altered active transport system (shared by all tetracyclines)

Other: Originally broad spectrum, now lots of resistance

“Glycylcycline” class: tigecycline

tigecycline Mechanism of Action: Ribosomal inhibitor, antimicrobial agent. Inhibits bacterial ribosomal 30S subunit
at A site. New "class"- glycylcycline - minocycline with a large sterically limiting side chain
Effects: Blocks A/T > A/A alignment (aminoacyl-tRNA can't "stand up") Overcomes 2 resistance
mechanisms: (1) active efflux from bacteria; (2) protection of ribosomes

Spectrum: broad, ‘Static

 GPC (incl. MRSA & VRE!)
 GNR (incl. Acinetobacter, NOT pseudomonas),
 AnO2 (incl. Bacteroides)

Good efficacy: intra-abdominal, skin/skinstructure, pneumonia

Good tissue penetration, 36h half life! no drug-drug interactions or food effect

Chloramphenicol
From here on out, talking about the 50S subunit (here, peptidyl
transferase cavity adjacent to A & P sites)
 Common / overlapping binding sites for linezolid,
chloramphenicol, clindamycin, macrolides

Chloramphenicol: inhibits peptidyl transferase step; forms a

number of H-bonds with the molecules in the site. Does bind our
mitochondrial ribosome (like AGs a bit)

17
Cool things about chloramphenicol:
 can start IV, finish po or do a whole course of a powerful antimicrobial PO in developing countries!
 Great CSF penetration! Up to 50% plasma concentrations!

chloramphenicol Mechanism of Action: Ribosomal inhibitor, antimicrobial agent. Inhibits bacterial ribosomal 50S
peptidyl transferase at A site.
Effects: Blocks peptide elongation by blocking peptidyl transferase step
Selective Toxicity: Doesn't bind human large ribosomal subunit, does bind mitochondrial peptidyl
transferase
Indications: 'Cidal against S. pneumoniae, N. meningitidis, H. influenzae. 'Static against many Gram
(-) & anaerobes. Used for CNS infections of these.
Administration: insoluble. palmitate ester used for PO (children syrup, hydrolyzed by gut).
succinate ester used for IV (hydrolyzed by liver).

Toxicity:
 Bone marrow suppression: transient, reversible (dose-related, plasma-level related,
marrow vacuolated; dec. reticulocytes, serum iron incr. with RBC decrease, from inhibition
of mito protein synth).
 Aplastic anemia: irreversible > 50% (not dose/plasma/time related; often fatal, 1:40,000,
just takes 1 dose).
 Gray baby syndrome: don't glucuronidate well, blood levels > 50mcg/mL, e- transport
inhibited (ashen gray color, vomiting, refusal to suck, rapid/irreg breathing, abd distension,
cyanosis, diarrhea, flacidity, hypothermia, death).

Resistance: Enzymatic modification (acetylation)

Other: Metabolism: glucuronidated by liver; mostly glucuronidated product cleared by kidney.
Distribution: wide, intracellular, excellent CSF penetration (>50% plasma concentrations). Not often
used in US (afraid of aplastic anemia) although risk ~ PCNs, <NSAID/yr.

Clindamycin
Inhibits 50S peptidyl transferase @ A&P site (peptidyl transferase cavity)

clindamycin Mechanism of Action: Ribosomal inhibitor, antimicrobial agent. Inhibits bacterial ribosomal 50S peptidyl
transferase (A & P site)
Effects: Peptide bond formation blocked
Selective Toxicity: Doesn't bind human ribosomal subunit or inhibit eukaryotic peptidyl transferase
Indications: GPC (S. pneumoniae, Group A Strep, Staph aureus), most anaerobes (important)
Administration: q6-8h, orally absorbed
Toxicity: Pseudomembranous colitis (alters gut flora, C. diff, nursing homes, etc. Use metronidazole (and
vancomycin if failure) for C.diff tx. Associated with clindamycin most commonly but also other broad
abx)
Resistance: Seldom a clinical problem

18
 Linezolid
Blocks movement of fMet-tRNA into 50S P site (inhibits formation of 70S initiation complex) - doesn't block peptidyl
transferase step like clinda, chloramphenicol

Activity for clindamycin, linezolid, chloramphenicol is additive although their binding sites overlap.

linezolid Mechanism of Action: Ribosomal inhibitor, antimicrobial agent. Blocks formation of 70S initiation
complex (blocks movement of fMet-tRNA into bacterial ribosomal 50S P site)
Effects: No formation of 70S ribosome, no protein synthesis in bacteria
Selective Toxicity: Doesn't bind human 80S ribosomal subunit
Indications: WORST OF THE WORST (VRE, MRSA, PCN-resistant S. pneumoniae). 'Static except against S.
pneumoniae.
Other: PAE of 1-2 hrs; time-dependent killing

Macrolides
14-15 member ring with 2 monosaccharide moieties
Erythromycin, azithromycin, clarithromycin (old new)
 Erythromycin used in military recruits to eradicate strep pharyngeal carriage: PCN allergy will pop up in huge
population of recruits.
 Common strategy: start with cheapest (erythromycin); move up if it doesn’t work.
 AZI, clarithromycin q24h: more convenient & better adherence; erythromycin: cheap but GI side effects

erythromycin Mechanism of Action: Ribosomal inhibitor, antimicrobial agent. Binds in bacterial ribosomal peptidyl
transferase cavity (50S), blocks peptide exit tunnel via H-bonding.
azithromycin Effects: Occupies only exit tunnel; allows up to 6-8 peptide bond formation, then termination
Selective Toxicity: Don't bind to human larger subunit; don't inhibit human protein synthesis
clarithromycin Indications: Atypical organisms/pneumonias (Mycoplasma pneumoniae, Chlamydia pneumoniae,
Legionella pneumophila). Can use instead of PCN if allergic (S. pneumoniae, Group A Streptococcus)
Administration: q6h (ERY), q24h (AZI + clarithromycin)
Toxicity: Safest of all antimicrobials, some nausea & vomiting (more ERY)
Resistance: Becoming a problem (very frequently used)
Other: Great cellular uptake (AZI > ERY for macrophage penetration)

19
Ribosomal Inhibitors: Mechanisms of Action

20
 Drugs for Mycobacterial Infections
Special features of Mycobacteria
Cell walls:
 Unique, highly lipophilic with mycolic acid  confers acid-fastness; target for selective chemotherapy
 Many of these drugs are only active against mycobacteria for this reason

Metabolic features:
 Can replicate intracellularly or extracellularly
 Can undergo prolonged periods of metabolic inactivity / dormancy
o Dormant = less susceptible to killing by bactericidal agents
o Need prolonged therapy (months) to completely eradicate infections

Drug resistance:
1. Primary resistance: spontaneous acquisition of resistance
a. 1 out of every 106-8 M. tuberculosis organisms are resistant
to at least one of the standard anti-TB drugs (based on
mutation rate; point-mutations)
b. Not consequential for small, non-cavitary lesions (e.g.
asymptomatic PPD converters) who have less than 1 million
organisms (104-5 organisms means ~0 are resistant)
c. TB pneumonia; TB meningitis: huge organism load, very
likely resistant to 1-2 drugs. (109-11 organisms means 103-
105 are resistant)
d. Single drug (isoniazid) is therefore adequate to treat a recent PPD converter
e. Multiple drugs must be used to treat an individual with clinically apparent disease

2. Secondary resistance: acquisition of resistance during treatment

a. Pts. asymptomatic before all organisms eradicated
i. Slow mycobacterial growth/metabolism, especially in
caseating / cavitary lesions
b. Noncompliance is common with prolonged treatment, esp.
after pt. starts to feel better (only take some pills, skip doses, etc.)
i. Provides selective pressure for the emergence of drug-resistant organisms
ii. Directly-observed therapy (DOT) is how this is handled in USA (Baltimore: down to ~7 cases/yr)
1. Expensive: other countries can’t afford it!

3. MDR & XDR TB

a. MDR TB (multi-drug resistant): resistance to isoniazid & rifampin (two mainstays of bactericidal tx)
within a single organism
i. Can develop MDR TB via secondary resistance, or can acquire as primary infection
b. XDR TB (exceptionally drug-resistant): combined resistance to all first line drugs
i. Most dangerous bacterial infection on planet: lethal, highly communicable, incurable
ii. Treat with 5 drugs, all second-line, not fun!

Molecular mechanisms of resistance:

 Always through chromosomal mutaitons (M. TB not permissive for plasmids or transposable elements)
 MDR resistance is therefore a staged process facilitated by noncompliance
o Can’t get an “MDR plasmid” or something like that; doesn’t occur precipitously

21
 Drugs for Tuberculosis
General principles:
 Slow growth, characteristics of ‘cidal drugs = intermitant therapy (2-3x/week)
o Makes directly observed therapy (DOT) possible
 Duration of tx: reduced from 126 months (4,3 month tx under investigation; 1mo would be best)

Isoniazid (INH):
 Developed as isonicotinic acid hydrazine (INH): nicatinomide analog; nervous system agent; isopropyl
metabolite was more potent than isoniazide but more toxic (lead to MAOI development though)
 Mycobacteria specific

isoniazid (INH) Mechanism of Action: antituberculosis agent; inhibits synthesis of mycolic acids
Effects: 'Cidal. Blocks cell wall component (mycolic acid) production; accumulates inside mycobacteria &
forms oxygen free radicals, killing the cell.
Selective Toxicity: just passes in and out of human cells (doesn't accumulate, no free radicals)
Indications: tuberculosis (as single therapy for PPD converters or part of multi-drug scheme for active
disease). Can be used for post-exposure prophylaxis in pts under 35 (>35yo = risk of hepatotoxicity
outweighs benefit)
Administration: if normal TB: 4 drugs x 2 months, then 2 active drugs x 4 months. Coadminister with
vitamin B6 to prevent neurotoxicity
Toxicity:
 hepatitis (old age, slow acetylators, esp. in combo with rifampin; need to monitor monthly and
stop drug as soon as hepatic transaminases increase significantly).
 neurotoxicity (peripheral neuropathy; INH competes with nicatinomide & leads to relative
vitamin B6 deficiency; coadminister vitamin B6 to prevent)
Resistance:
 katG: catalase-peroxidase enzyme that probably "activates" drug through oxygen free radical
formation; mutation in katG means the drug doesn't accumulate inside the cell and INH isn't toxic.
 inhA: encodes mycolic acid synthesis enzyme; contains binding pocket for nicotinamide, confers
cross-resistance to ethionamide (INH analog), probably INH target; mutation is less common cause
of resistance that katG.
 MDR-TB is by definition resistant to rifampin and isoniazid; XDR resistant to all 1st line agents.
Other: metabolized by hepatic N-acetyltransferase (classic example of variable halflife because of gene
polymorphisms). Slow acetylators (83% egyptians, 50% caucasian americans) half-life = 6hrs, fast
acetylators half-life = 1 hr

22
Rifampin
 Unlike INH, is a broad-spectrum antibiotic.
 Also active against Gram (+) & some Gram (-) bacteria (Neisseria, H. influenzae, S. aureus).
rifampin Mechanism of Action: antituberculosis agent. Macrocyclic antibiotic, broad-spectrum inhibitor of bacterial
DNA-dependent RNApol
Effects: 'Cidal
Indications: 1st line anti-TB agent, part of multi-drug scheme for active disease.
Administration: if normal TB: 4 drugs x 2 months, then 2 active drugs x 4 months.
Toxicity:
 Orange discoloration (urine, sweat, tears, soft contact lenses).
 Hepatitis (can be more common in children; opposite of INH hepatitis).
 Hypersensitivity reactions (flu-like syndrome; more common in healthy patients).
 Light-chain proteinuria in > 50% pts ("unexplained" proteinuria in labs).
 Note: pharmacokinetics are non-linear! drug can accumulate if high doses (saturating clearance
mechanisms).
 Potent inducer of cyt P450s, including CYP3A4 (oral contraceptives, cyclosporin, coumarin, etc!)
Resistance: Via RNApol gene mutations. Emerges quickly if used as single agent. MDR-TB is by definition
resistant to rifampin and isoniazid; XDR resistant to all 1st line agents.
Other:
 Also highly bactericidal against most Gram (+) and some Gram (-) bacteria (H. influenzae, S. aureus)
 Neisseria - commonly used as PEP for N. meningitidis exposure or to eradicate nasal carriage.
 Metabolized by deacetylation (biliary excretion, enterohepatic recirculation, makes elimination half-
life longer than would be expected & unpredictable).

pyrazinamide Mechanism of Action: antituberculosis agent.

Effects: 'Cidal. Structural analog of nicatinomide, like INH
Indications: Tuberculosis
Toxicity:
 Hepatotoxicity (now rare; common with previous higher doses).
 Hyperuricemia (gout-like Sx possible);
 Photosensitivity dermatitis (rare, give at night to prevent).
Other: active at acidic pH; may be especially useful for killing intracellular mycobacteria. Not effective
against dormant organisms. Metabolized to pyrazinoic acid (renally excreted); half-life 12-24 hrs.

ethambutol Mechanism of Action: antituberculosis agent; mechanism of action unknown

Effects: inhibits both RNA synthesis & mycolic acid metabolism
Indications: Tuberculosis
Toxicity: Affects optic nerve: peripheral neuropathy (esp. retrobulbar optic neuritis) with color blindness &
eventual loss of peripheral vision. PERMANENT! Need to screen at baseline / every few months via
opthalmologist; stop as soon as color blindness occurs (esp important in children)
Aminoglycosides; quinolones can also be used against TB
 AGs:Streptomycin: less nephrotoxic, more vestibulotoxic than other AGs
o Others (e.g. amikacin) are active & have been tested; not widely used (toxicities & costs)
 Fluoroquinolones (esp. moxifloxacin) highly active & increasingly used (MDR/XDR-TB)

23
 Dapsone (Leprosy)
dapsone Mechanism of Action: Anti-leprosy agent (sulfone; sulfonilamide analog); inhibits folate synthesis
Effects: Inhibits folate synthesis; bacteria can't produce nucleotides for DNA synthesis
Indications: Leprosy
Toxicity:
 Hemolytic anemia (esp. pts with severe G6PD deficiency - southern Mediterranean);
 Methemoglobinemia and subclinical hemolysis common;
 Hypersensitivity reactions (rash/fever) like sulfonamides;
 Agranulosis & fatal infectious mononucleosis-like syndrome (rarely);
 Reversal reactions and erythema nodosum leprosum can occur during initiation of therapy (kills bacteria
so fast that all bacteria lyse & cause reaction: severe fevers, big thick skin lesions, etc.).
Resistance: Increasingly common (previous extensive use as "monotherapy for life" for leprosy)
Other:
 Also active against Pneumocystis carinii/jiroveci (used as prophy in HIV pts); broad spectrum activity.
 Pharmacokinetics:n-acetylation (like INH, slow & fast acetylators genetic polymorphism).Half life 10-50h

Historically: Dapsone monotherapy for life

Now: 2-3 drugs for ≤ 6 months
Pauci-bacillary (PB) Leprosy
(1-5 skin lesions)
2 drug regimen:
Rifampin + Dapsone x 6 months
Multi-bacillary (MB) Leprosy
(>5 skin lesions)
3-drug regimen:
Rifampin + Clofazimine + Dapsone x 12 months

Drugs for other mycobacterial infections:

 Rifabutin
rifabutin Similar to rifampin; more potent in vitro & longer half-life

Mechanism of Action: antituberculosis agent. macrocyclic antibiotic, broad-spectrum inhibitor of bacterial

DNA-dependent RNApol
Effects: 'Cidal
Indications:
 prophylaxis of MAI in AIDS patients with CD4 < 100 (only FDA use);
 also used for M. avium treatment and active against M. TB (but more expensive)
Toxicity:
 Orange discoloration (urine, sweat, tears, soft contact lenses).
 Uveitis (inflammation of anterior chamber of eye: dose-dependent; rare with regular doses, more
common if pts. on Rx slowing hepatic clearance - clarithromycin, fluconazole, etc.)
 Rare: granulocytopenia, rash.
 Potent inducer of cyt P450s, including CYP3A4 (oral contraceptives, cyclosporin, coumarin, etc!)
Resistance: Via RNApol gene mutations. Cross-resistance with rifampin.
 Macrolides (clarithromycin / azithromycin)
 Fluoroquinolones
Future directions for antimycobacterial therapy
New targets: ATP synthase; FA synthetases; 5-10 new drugs by 2020 but challenging under current pharma model

24
 Quinolones

Gram (-):
First Generation  Nalidixic Acid UTIs only
Tissues
 Norfloxacin  Ofloxacin Gram (-)
“Fluoroquinolones” Second Generation some (+)
 Ciprofloxacin  Levofloxacin
 
Gram (+)
Third Generation  Gatifloxacin

AnO2
Fourth Generation
 Moxifloxacin  Besifloxacin
 Gemifloxacin

(First gen: concentrated in urine; only place that they reach therapeutic levels)

Discovery: chloroquine synthesis; thousands of analogs, rely on fluroquinolone pharmacophore for activity. 9 on
market; 4 “generations” based on activity/coverage, F introduced at C6 = “fluoro”quinolone

Mechanism of action: Inhibit prokaryotic type II topoisomerases (DNA Gyrase & Topoisomerase IV)

DNA topoisomerase review: ENZYME DRUG

Type I (single-strand break)
 Used to relieve supercoiling & get DNA in correct
IA prokaryotes None
topology for all aspects of its metabolism (RNA synth,
IB eukaryotes Camptothecins
DNA synth, recombination, higher order structure). Type II (double-strand break)
 Gyrase: introduces negative supercoils (relieves positive II prokaryotes (gyrase, topo IV) Quinolones
supercoils); operates ahead of the replication fork II eukaryotes Etoposide
 Topo IV: segregates replicating chromosomes
 Both are A2B2 tetramers; (2 DNA-binding and 2 ATPase subunits (also contact DNA)

DNA topo catalytic reaction (ATP dependent)

1. Tetrameric enzyme binds circular DNA chromosome
2. DNA cleaved
a. A “four base stagger” is introduced (see picture): four unpaired bases on
each cleaved side of the strand
b. Two tyrosines on the enzyme bind the 5’ phosphate on each cleaved strand piece, preventing DSB
c. This is a transient covalent intermediate
3. Strand passage through the cleaved strand
4. DNA ligated back together

Mechanism of action
 Form tetramers and base-pair with 4-base stagger + enzyme
 Stabilize DNA-topoisomerase catalytic intermediate (the “cleavable complex”).
o Enzyme can’t ligate DNA substrate; gets stuck in catalytic cycle
o This itself would be reversible (‘STATIC): if [drug] falls, FQ dissociates & enzyme can proceed
 Cleavable complex  irreversible DNA breaks (‘CIDAL)
o Replication fork collision  DNA strand breakage  SOS repair response

25
Target:
 Gram (-): Gyrase is primary target
 Gram (+): Topo IV is primary target

Selective toxicity:
 FQs bind selectively to DNA-gyrase / DNA-topo IV complexes,
not their human equivalents (topo II / gyrase)

Resistance:
 Mutations in gyrase/topo IV most common
1. DNA-binding subunit (first)
2. Secondary mutations: any other subunit
3. Gram (-): gyrase mutates first, Gram (+): Topo IV first
 Can also have mutations in membrane protein transporters (less common)
 Plasmid-mediated resistance is rare (encodes a protein mimic of DNA substrate; FQ binds this, won’t bind
enzyme complex instead)
 Increasing resistance = big worry! (up over 80% in some countries)

Spectrum of activity: 1st gen = gram (-), UTI only; more recent  gram (+), even anaerobes

Pharmacokinetics:
 Absorption: rapid & complete, great bioavailability (>85%)
o Magnesium/aluminum (antacids!) or iron reduces absorption!
 Distribution: wide; intracellular (up to 24x those of serum)
o CSF: 10-25% serum distribution (without inflammation)
 Metabolism:
o Ciprofloxacin: ~15% metabolized, mostly Phase I enzymes (oxidation); interferes with theophyline metabolism
 Mostly renal elimination
o Moxifloxacin: ~35% metabolized, mostly Phase II enzymes (conjugation / glucuronidation)
 1/3 renal; 2/3 biliary (conjugation) elimination
 Elimination: predominantly renal; some biliary/transintestinal
o In RENAL FAILURE, adjust for all EXCEPT moxifloxacin
o NO adjustment for hepatic failure (phase II enzymes sufficiently active even in advanced hep failure)

Toxicities
Class adverse effects
 Gastrointestinal (2-11%): nausea, vomiting, diarrhea
 CNS (1-7%): headache, dizziness, fatigue, sleep disorder; <0.5%: hallucinations, depression, seizures!
 Skin: up to 20% phototoxicity; 0.4-2% hypersensitivity (rash, pruritis)
 Arthropathy in juvenile animals  not FDA approved for children < 18yrs
 Tendon rupture: bizarre & rare but FQs are used a lot! > 200 cases reported; black box warning

Idiosyncratic / rare side effects: illustrate the importance of postmarketing surveillance for practicing docs
 Temafloxacin withdrawn because 1/3500 developed HUS; 2 deaths
 Grepafloxacin withdrawn: small number  torsade de oints
 Trovafloxicin withdrawn: serious liver toxicity, 1/25000

Future: looking to develop a “wundafloxacin”: this is a class that is broad spectrum, safe, excellent bioavailability, good
tissue penetration, ongoing subject of research; growing bacterial resistance & expense are downsides!

26
 Antibiotic Resistance
Antibiotic drug resistance model: "every infection is a mini-epidemic"
 Assumption: microorganisms must reproduce in a manner that maintains or increases the body burden of the
microbe (otherwise it'll become extinct)
 Reproductive number (R): ratio new infectious organisms / original number (or infected cells produced) after
some arbitrary time period during which the organism's replicating.
o E.g. 1 organism --> 5 organisms, R=5
o R < 1: organism continues to grow & reproduce; R > 1: organism becomes extinct
 Effective antibiotic therapy: R < 1 in presence of antimicrobial drug
 Drug resistant organism: R > 1 in presence of antimicrobial drug

How do antibiotics promote drug resistance?

 Genetic mutations occurring continually in bacteria; use of abx reveals resistant organisms (selective pressure;
doesn't facilitate resistance-conferring mutations)

 Primary drug resistance: pre-dates drug therapy.

o When patient acquires the infection, the organism already has R > 1 for the drug.
o Exists because of improper use / overuse of antibiotics.
o Need to treat with drug that is known to be sensitive or combination, where R < 1 for at least one of
drugs. e.g. HA-MRSA.

 Secondary drug resistance: occurs during drug therapy.

o If therapy is effective, R < 1 & secondary resistance not likely to occur.
o If effective therapy taken incorrectly or irregularly, drug concentrations decrease & resistant organisms
can begin to survive & replicate.
o Selective pressure still applied by inadequate doses, so resistant organisms emerge (R>1)
o Non-adherence to prescribed drug regimen is cause of most infections exhibiting secondary resistance

Mechanisms of resistance:
1. Inactivation of antibiotic
o Beta-lactamase & beta lactams,
o aminoglycosides (acetylation, adenylation, p-ation), chloramphelicol (actylation)
2. Modification of antibiotic target
o D-ala-D-ala to D-ala-D-lac & vancomycin,
o alteration of PBPs & beta-lactams, methylation of rRNA to block macrolides, point mutations (RNApol:
rifampin, DNA gyrase: quinolones)
3. Efflux of antibiotic from cell
o Resistance to tetracyclines: inducible expression of efflux pump in response to tetracycline presence
o similar for macrolides, quinolones

Where do these come from?

 Pathogens' resistance mechanisms: similar to self-resistance mechanisms in organisms that produce antibiotics
(prevent self from destruction as they're killing their neighbors to compete for niche)
o Inactivation of oleandomycin via glycosylation, then efflux of inactive antibiotic (S. antibioticus)
o Modification of rRNA (erythromycin target) by methylation in S. erythraeus, which produces it

 Resistance determinants: clustered with biosynthetic genes to produce antibiotics in organism. Can be
transferred horizontally or acquired by neighboring microbes in several ways:
1. Transduction: transfer of DNA inside bacteriophage
2. Transformation: uptake of free DNA from environment, usually post-cell-lysis.

27
  Haemophilus, Neisseria, S. pneumonia are most common
3. Conjugation: Transfer of DNA that occurs during contact between bacterial cells (sex pili, etc).
 Most efficient than transduction/transformation
 Both plasmid and chromosome transfer can occur.
 Most common mechanism.

Practical implications & antibiotic use: bacteria are good at this, so abx resistance will always be around
1. Modification of existing scaffolds: might not work for much longer
2. Combination therapy: combine abx with different modes of action; lower chance that dual-resistance-
conferring organisms can emerge
3. Selective removal or restriction of antibiotic classes to reduce likelihood of resistance to particular classes of
antibiotics (don't prescribe it if you don't really need it)

New directions:
 New targets: unique/conserved in bacteria & essential for viability. DNA replication, metabolism, cell walls, etc.
 New molecules: keep screening (new places: ocean, etc.); combinatorial methods, traditional methods

28
 Viruses

RNA DNA
(all listed are linear genomes)

SS (-) DS
DS Parvovirus (B19) Circular Linear
Rotavirus
(a reovirus)
Segmented Hepatitis B
SS Herpesviruses
 HSV 1,2 (oral/gen lesions,
keratoconjunctivitis, viral
(+) (-) Papillomavirus encephalitis)
 VSV
(chickenpox/shingles/zoster)

Picornaviruses Hepatitis E  EBV (mono, Burkitt’s, etc)

(PERCH) Influenza  CMV (immunosuppressed /
(an orthomyxovirus) transplant; congenital defects)
 Poliovirus Norovirus Segmented  HHV-6 (roseola/exanthema
 Echovirus (a calcivirus) subitum)
 Rhinovirus  HHV-8 (Kaposi’s sarcoma)
 Coxsackievirus Paramyxoviruses
 Hep A virus Flaviviruses (PaRaMMyxo)
 HCV  Parainfluenza Adenovirus
 Yellow fever  RSV  Febrile pharyngitis (sore throat)
 Pneumonia
 Dengue  Measles (rubeola)
Togaviruses  Conjunctivitis (pink eye)
 St. Louis Encephalitis  Mumps
 Rubella
 West Nile
 Eastern / Western
Equine Enceph.
Rabies
Coronaviruses (a rhabdovirus)
 Common cold
Retroviruses  SARS
 HIV HDV
(a deltavirus)
 Pathology: ID & Micro (Viruses)
Pathology of Viral Infection .................................................................................................................................................... 2
Negative Strand Viruses .......................................................................................................................................................... 5
The Herpesviruses ................................................................................................................................................................. 10

1
 Pathology of Viral Infection
Pathogenesis: how viruses cause disease in the host VIRAL STRATEGIES HOST DEFENSES
 Viruses: too small to examine with a light microscope like  Rapid replication  Barriers to viral entry
bacteria. Have to look for patterns in path.  Mutation  Innate immunity
 Virulence genes  Adaptive immunity
Viruses are obligate intracellular parasites
 Genome: RNA or DNA
 Must enter intact host cell; use host to synthesize components
 Progeny virus = virions are assembled in cell, can spread to another cell
 Each class of virus has specific host cells (species and often tissue specific)

Many similarities in viruses that have similar classification; similar symptoms Taxonomy:
even across species (good for animal models) 1. nucleic acid (DNA/RNA; +/-, ds/ss)
2. capsid (symmetry of protein shell:
Typical life cycle: entrygenome exposure  genome replicationmRNA icosahedral/helical)
synthesis  protein synthesis  assembly (viral proteins/virions) release 3. envelope (lipid membrane,
infection of new cell naked/enveloped)
4. dimensions of virion / capsid
Budding: enveloped viruses take part of the host cell membrane with ‘em.

Patterns of disease: vast majority of infections are subclinical. See chart (dark sections = viremia; can detect in blood )
 Acute (rhino, rota, influenza)
 Persistent (lymphocytic choriomeningitis v.)
 Latent/reactivating (herpes)
 Slow (HIV, measles)

Virulence: ability to cause disease (=pathogenicity)

 Polygenic control: different genes control
binding/entry/replication/effects on cells
 How does it enter/spread? Why in certain
cells/tissues? How does it cause damage?
How does immune system cause indirect
damage? How does it go to a new host?
 Can measure as: mean time to death (animal
models), viral load, T-cell counts, other
measures specific to pathogen.
Virulence classification
 Virulent: causes disease;
 Attenuated: no/reduced disease
 Avirulent: no disease

Types of viral virulence genes: studied with tissue culture & animal models + mutations
1. Viral replication: herpesviruses’ DNApol brain only; poliovirus 5’ NCR mutated so not in brain
2. Defeat host defense:
o virokines (viral equivalent of chemokines, subvert immune response),
o viroceptors (tie up host chemo/cytokines)
o not required for growth in vitro but help out in vivo
3. Promote virus spread within/among hosts: gD protein in HSV1 recognizes cell receptors; pt mutation blocks CNS spread
4. Toxic gene products: cause cell injury directly (virotoxins), cause Cl secretion (osmotic diarrhea), etc.

2
Tropism: virus has to enter the cell (susceptibility) and then replicate inside it (permissivity)
 Neurotropism, Pneumotropism, Enterotropism: or all (pantropism)

Viral receptors: required for viral entry; determines tropism (host & tissue), some also need co-receptor, active process
 E.g. HIV-1: two tropic strains depending on co-receptors
o T-cell-line-tropic strain (CD4 + CXCr4 co-receptor)
o Macrophage tropic strain (CD4 + CCr5 co-receptor)
 Receptors can be integrins, Ig-like molecules, GAGs, CHOs
 target for treatment & protection (e.g. CCR5 antagonists in HIV Rx)

Spread: direction of release determines infection pattern (superficial or down deep?)

 local replication (influenza through respiratory epithelium; papilloma through skin)
 systemic spread (must cross basement membrane, etc.)

Viremia: viruses can be carried to blood & disseminated

 often within cells: monocytes (measles, HIV, CMV); lymphocytes (HIV, EBV, HHV), neutrophils (influenza) or free in
plasma (poliovirus, HBV). In cells is a good way to circumvent BBB
 Can disseminate through lymphatics too

TRANSMISSION HOST DEFENSES EXAMPLES

Hand-shaking Mucociliary apparatus URT: Rhinovirus, coronavirus,
RESPIRATORY parainfluenza virus, RSV, influenza
Coughing Alveolar Mφ LRT: adenovirus, parainfluenza, RSV,
SYSTEM
Sneezing Adaptive immune response influenza virus
Eating Stomach pH, Digestive enzymes
Rotavirus, reovirus, measles,
GI TRACT Drinking Flow of ingesta poliovirus, adenovirus
Poor hygiene Adaptive immune response
Urine flow
Sexual activity Thick epithelial layer HIV, HSV (lifelong persistent/latent)
UROGENITAL TRACT HPV: cervical cancer
Fecal contamination Acid pH
Adaptive immune response
Conjunctiva Tears
EYES Abrasions Thick epithelial layer HSV: lifelong persistent/latent
Direct inoculation Adaptive immune response
Cuts, abrasions Poxviruses, papillomaviruses, rabies,
Epidermis Insects: togaviruses/alphavirues
SKIN Insect bites Emerge from below: systemic
Skin oils
Needles infection: measles, chicken pox
Cuts, animal bites; Inhalation
Rabies, herpes simplex, HIV,
NERVOUS SYSTEM Cell trafficking (retrograde transport Blood-brain barrier measles, alphaviruses
up axons to DRG/CNS)

Types of Viral Damage to Tissues

Cytopathic effects (cyto=cell, pathic = abnormal): can be in vivo or in vitro; NOTE: not all viruses produce CPE
1. Cell swelling: bloating of cells
2. Necrosis:
a. ballooning degeneration from membrane injury Cytopathic effects
b. host protein/nucleic acid synthesis shuts down 1. Cell swelling
c. Cell death (pyknosis, hypereosinophilia) 2. Necrosis
i. Single cell necrosis 3. Apoptosis
ii. more widespread (depending on virulence of pathogen) 4. Inclusion bodies
d. Lysis / detachment allows virion release 5. Syncitia/multinucleated
e. Tissue architecture disrupted (caseous or coagulation) giant cells
f. Vesicles can form (necrotic cells, fluid-filled space under epithelium) 6. Cellular hyperplasia /
proliferation 3
 g. Can cause malformations during fetal development
3. Apoptosis:
a. Some viral genes promote apoptosis (aid in virus dissemination)
b. Some inhibit apoptosis (longer replication, establish latency)
c. Some do both (HIV’s “Tat”) depending on context.
4. Inclusion bodies: arrays/aggregates of viral/cellular products
a. Often present only very early in infection
b. Intranuclear and/or intracytoplasmic
c. Can be eosinophilic, basophilic, or amphophilic
d. Usually > ½ diameter of cell
e. Can see peripheralization of chromatin in big inclusions; some look like owl’s eyes
f. Not pathognomonic but a signature microscopic finding, good for aiding in Dx
i. Not all viral: e.g. bismuth inclusions in liver
5. Syncitia/multinucleated giant cells
a. Viral fusion proteins expressed on cell surface  cells fuse together (in vivo/vitro)
b. Allows virus transmission without exposure to host defenses
c. Differentiate from: foreign body giant cells, osteoclasts, megakaryocytes
6. Cellular hyperplasia/proliferation
a. Self-limited & transient usually but may be PRE-NEOPLASTIC
b. May be due to atypical differentiation or accumulation of viral products
c. E.g. molluscum contagiosum, pox virus, EBV burkitt’s lymphoma, HPV cervical carcinoma

Alteration of host cell functions leads to the visible cytopathic effects – can also alter other functions (cytoskeletal
depolymerization, for instance)

Host Responses

Classic: MONONUCLEAR CELL INFILTRATES (LYMPHOCYTES, lymphocytes, lymphocytes… and macrophages)

 Exception: arbovirus can produce PMN response

HIV encephalitis (somewhat general features of viral incephalitis)

 Microglial nodules (collection of macrophages)
 Perivascular cuff of lymphocytes & macrophages
 Multinucleated giant cells (macrophages fuse; full of virions)

Virus-induced immunopathology: can be CD8 or CD4 (Th1 or TH2) T-cell mediated, antibody mediated, etc.
 Can result in immune deposits in glomeruli & cause pathology there

Host susceptibility can vary:

1. Genetic:
o MHC class I diversity: different ability to present peptides;
o Chemokine receptor tropism (HIV elite suppressors); other genetic polymorphisms for different viruses
2. Non-genetic:
o Age (infants/elderly usually)
o Gender (males, pregnant women more susceptible)
o Malnutrition (measles: protein deficiency)
o Other: corticosteroids, cig smoking, stress, etc.

Why study this stuff? Viruses are constantly emerging and re-emerging; classes tend to cause similar diseases, so if we
study something we’ve seen before, we might be better prepared when something new emerges.

4
 Negative Strand Viruses
Positive vs Negative strand viruses
 Negative strand: antisense genome, polymerase included with
incoming virion; first step is to make a + strand (full length
antigenome)
 Postive strand: sense genome, no polymerase included with
incoming virion; polymerase synthesized as first step via
genomic RNA translation
Influenza Viruses
Key features of Negative Strand Viruses
 RNA is not infectious
 Virion contains RNA-dep-RNApol
 Encapsidation: Genomic RNA
packaged in protein (“nucleocapsid”)
 Nucleocapsids have helical structure
 Enveloped virions
 Entry: virion fusion or cell-cell fusion

3 types: A, B, C
 A/B antigentically distinct, structurally similar
 Both cause dz in adults and children
 A more prevalent than B
 Influenza A: ducks, chickens, horses, swine
o Birds = largest reservoir

Transmission:
 Birds  pigs, other non-humans (rarely humans
with some exceptions)
 Pigs  Humans is most common

Virion: structural features

 Major genes: HA, NA, M2
 Segmented genomes (1-3 genes/segment; HA & transcription complex on separate segments)
 Lipid envelope with viral glycoproteins (HA/NA)
o Envelope fuses with host lysosome membrane to allow genome to enter cell

Reassortment: Antigenic shift: possible mechanism

1. 2 strains infect same cell (e.g. two swine strains in a pig cell) 1. chicken strain / human strain
2. All genome segments replicate infect a pig,
3. When virus assembles, mixing of segments happens  reassortant 2. reassortant virus results with:
progeny viruses a. chicken strain antigens
(evades human defense) and
b.human strain machinery
(replicates in humans)
Hemagglutinin
3. pandemic strain can result
 16 antigenic types (flu A, H1-14); trimer with globular head on stalk
 Functions:
o binds sialic acid
o binds and agglutinates RBCs (have sialic acid)
o mediates fusion of viral envelope with cell membrane
 Targeted by neutralizing antibodies: keep virus from binding to host cells
 Minor mutations result in antigenic drift: year/year variation, causes seasonal epidemics
 Replacement with gene from alternate hosts results in antigenic shift (causes pandemics)

Mechanism of entry:
1. virus binding (HA/sialic acid)  endocytosed 
2. low pH induces conformational change in HA in endosome  hydrophobic AAs in HA exposed 
3. fusion of envelope with endosome membrane  release genomes into cytoplasm
5
HA – needs cleavage for activity:
 synthesized in pro-form; needs cleavage for conformational change/activation of fusion function
 cleaved by tryptase Clara, serine protease secreted by nonciliated Clara cells in bronchial/bronchiolar
epithelium (lumen of respiratory tract; may account for restricted location of virus replication)
 happens at defined site (R/K); both HA fragments remain bound together (dipeptide linkage)

Neuraminidase
 Tetramer; 9 recognized subtypes in influenza A (N1-9)
 Cleaves sialic acid residues on cell surface during virus exit; if mutated, can’t exit cell surface

Nomenclature: Type / # of isolate / year of first isolation / HA&NA subtypes

 Example: A/Hong Kong/156/97
 H1N1, H3N2 currently circulating (usually 1-2 for seasonal epidemics)

M2 protein
 Tetramer, spans viral envelope, activated via acidity of endosome
 Pumps protons into virion: loosens protein-protein contacts, facilitates virus uncoating
 Target of amantadine

Replication
 Genome replication happens in nucleus
o No mRNA capping/methylating enzymes, so steals caps (+10-13nts) to prime mRNA synthesis
 Viral mRNAs translated on sER & rER
 HA/NA transported through Golgi to cell membrane,
 Glycoproteins (HA/NA) aggregate on surface of cell membrane, viral proteins & genomes aggregate underneath,
and the virus buds off, coated in an envelope

Location: ciliated columnar epithelial cells in respiratory tract; causes tracheobronchitis

 Lots of virions  shed into respiratory tract (better transmission)
 Virus-induced apoptosis of infected cells, damages respiratory tract
o Protective mucus layer disrupted
o Respiratory epithelium denuded
o Transudates / exudates (inflammatory cells, dead epithelial cells)

Clinical features: Respiratory, seasonal (winter) transmission

 1-4d post-infection: H/A, fever, myalgias, non-productive cough, sore throat, no rinorrhea (3-7d)
o Sx: local production of IFN & IL-1 (localized cell destruction b/c of immune response)

Immunity
 Innate resistance: mucus barrier, clearance by cilia, alveolar Mφ
o Impairment in any of these: ↑ risk infection (elderly, smokers, COPD, immunocomp, pregnant)
 Adaptive immunity:
o Protection: IgA (mucosal), IgG (serum)
o Clearance: IgG + complement, CTL

Complications:
 Primary virus infection: Interstitial pneumonitis
o Cardiovascular dz; pregnancy predispose
o Progression from classical 3d sx  bilateral findings, no consolidation

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 o CXR: bilateral infiltrates
o Non-bacterial: normal flora in sputum, no Abx response (high mortality)
 Secondary bacterial pneumonia:
o from damage to innate immune system, destruction of ciliated epithelial cells, abnormal Mφ function
o Age > 65yo, pulmonary dz predispose
o Improve, then worsen; consolidation
o CXR: consolidation
o Bacterial: sputum shows S. pneumo, S. aureus, H. flu, Abx response (low mortality)

Immunization
1. Killed/inactivated vaccine (mostly HA/NA)
a. Reformulated annually (WHO isolate/IDs viruses, reports strains to reference lab, panel makes rec)
b. Health care workers, populations at high risk of morbidity & mortality
c. Partial protection: incidence ↓ 30-70%, morbidity/mortality ↓ 60-90%
2. Live attenuated intranasal (FluMist)
a. Replication restricted to nasopharynx: cold-adapted (grows best @ intranasal temp); restricted
replication at 37C)
b. Reformulated annually; approved for use in healthy people 5-49yo

Diagnosis
 Direct detection (stain NP aspirates with flu-specific mAb), culture

Paramyxoviruses
General characteristics:
 No epidemiologically important antigenic change Paramyxoviruses: medically important
 No natural reservoir: constant person-person spread 1. Parainfluenza 1-4
2. Respiratory Syncitial Virus
 Spread: respiratory route
3. Human metapneumovirus
 Various proteins: H (receptor binding), F (fusion), M (assembly),
4. Measles
others too.
5. Mumps
 Genome nonsegmented, mRNA generated by polymerase
reinitiation at different promoter regions.

Surface glycoproteins: CHO attached during ER/Golgi transit; usually 2 proteins

1. Cell attachment: binds cellular receptor, elicits neutralizing Ab
2. Fusion protein (F): must be cleaved to F1/F2 by intracellular proteases to be active; required for virion
infectivity (happens only at neutral pH)

Replication cycle:
1. fuse @ neutral pH  intracellular replication (all RNA in cytoplasm, H/F  ER/Golgi  PM)
2. exit: nucleocapsids assemble underneath H/F; virion assembly mediated by matrix protein
a. Virion budding from cell membrane
b. Fusion with adjacent cell (surface proteins fusogenic @ neutral pH)
i. Leads to GIANT CELLS & syncitia formation

Respiratory Syncytial Virus (RSV)

 Outbreaks of respiratory disease in winter
 Transmission: direct contact with respiratory secretions (not aerosolized)
Clinical presentation:
 Otitis media, bronchitis, bronchiolitis, croup (inspiratory stridor), pneumonia
o Most severe in young infants; partial immunity after primary infection (less severe disease)
 Can progress: cough, wheezing, dyspnea, ↑ RR, hypoxemia
7
  1% infants require hosp, 1% of those die
Diagnosis:direct staining of NPAs with fluoro mAB, culture
Vaccine: under development

Human Metapneumovirus
ID’d Netherlands 2001 from respiratory specimens from 20+ yrs; cytopathic effect similar to RSV (syncytia),
 Most infections: childhood (<5yr)
 Causes 7-40% ped resp infections
 Parallels to RSV:
o seasonal (winter), initial exposure in childhood, severe dz in infants/elderly
o range of clinical sx: mild respiratory symptoms to severe cough, bronchiolitis, pneumonia
o repeated infections occur but less severe dz (URI only)
Dx: RT-PCR, Ab for direct-detect

Parainfluenza
 Common cause of URIs
 Most common cause of croup (laryngotracheo-bronchitis) in young children
 Most children: infected by 5 yo, can be re-infected by less severe
 Diagnosis: culture; vaccine not yet available

Measles
 Worldwide distribution; incidence varies with vaccination rates
o Epidemic if high vaccine coverage; Endemic if low
 Age: changed with countries with high vax rate
 Transmission: Respiratory & Aerosol
o Attack rate: 99.9% (only 1:1000 escapes infection if exposed!)
o Mortality rate: developing countries, 30% in infants 6-9mos

Pathogenesis: Systemic replication

1. Respiratory epithelium  local lymph nodes  dissemination via infected monocytes from resp LNs
a. Primary viremia (LOW) from this first dissemination
2. Epithelial / endothelial cells infected throughout body, release virus into blood
a. Secondary viremia (HIGH) from this second dissemination

Clinical Symptoms: happen during viremia

 Prodrome: fever, cough, coryza (sx of head cold), conjunctivitis, Koplik spots (in oral mucosa: red dot & white
clearing around it, virtually pathognomonic)
 Maculopapular rash with immune response (virtually diagnostic): cellular response
o Immune responses: CD4 help, CD8 clearance, IgM, neutralizing IgG

Measles-induced immune deficiency

 Generalized immunosuppression; increased susceptibility to secondary infections
 Multiple mechanisms:
o Early: lymphopenia (activation-induced cell death, apoptosis of infected cells)
o Middle: delayed DTH, decreased lymphoproliferation
o Late: thymus effects?
Diagnosis: clinical picture, direct mAb stain of resp secretions, culture, serology (IgM)
Prevention: live attenuated vaccine (infants 2-15mo)
 has changed age distribution (now very young infants and older children/young adults 10-22yo)

8
 Mumps
Infection of glandular epithelial cells
 Parotitis & orchitis most commonly recognized (big swollen jowls or testicles; mumps gives ya bumps)
 Pancreatitis/ovarian infection occur but infrequently recognized
 Meningitis 10% all cases
Diagnosis: Culture (saliva, urine, CSF); serology, molecular methods now
Prevention: live attenuated vaccine

Rhabdoviruses
Rabies is only important human pathogen
 Incidence: depends on control of domestic animals (better in US than developing world)
 Endemic in wildlife: bats, raccoons, skunks, coyotes, foxes
 < 10 cases / yr in US; mostly imported or contact with rabid bats

Pathogenesis:
1. in saliva of bite of infected animal  limited replication in muscle, subepithelial tissue
2. uptake by sensory/motor neurons; retrograde transport to cell body & major replication there
3. trans-synaptic transmission: early avoidance of immune reponse

Prodrome: fever, malaise, parasthesias at bite site

Later (in CNS now): anxiety, aggressive behavior, seizures, hypertonia, paralysis

Diagnosis: clinical Hx of exposure, biopsy, immunohistochemical staining, PCR

Prevention: inactivated vaccine
 Long incubation period allows for post-exposure use
 Pre-exposure if in vocation with high risk of exposure: vet, wildlife managers, etc.

9
 The Herpesviruses
Note that these are in the same family as EBV, HHV8, etc. which cause cancer (previous lecture)

Common features: similar morphology, ubiquitous, asymptomatic infection, common modes of replication / life cycles
 ALL establish LATENT infections ≪ notorious feature of herpesviruses; Reactivation can produce disease
 Seroprevalence: extremely high in young adults (latent & lifelong)
o HHV8 is the only rare one

Physical characteristics:
 Enveloped, have nucleocapsid with genome woven into protein coat
 Gargantuan genome (>100k, 50+ genes)
1. Enzymes & structural genes
2. Non-structural genes too: modulate host cell gene expression, host immune responses

Infection: 2 “modes”
1. Productive (“lytic”) infection: release of progeny virions
2. Latent infection: no virions produced, reservoir for recurrent disease
a. Recurrent disease results from:
renewed replication or induced cell proliferation (tumor-inducing γ-herpesviruses only)
Lytic infection:
1. Viral entry (envelope fusion  nucleocapsid transported to nucleus 
2. Gene tx, genome rep, progeny nucleocapsid assembly in nucleus 
3. Nucleocapsids bud from nucleus – viral envelope is formed from nuclear membrane (unusual)! 
4. Release via exocytosis
TEMPORAL CASCADE OF LYTIC INFECTION GENE EXPRESSION
Genes Functions
Although latent infection has restricted cell tropism (see
α (immediate early) regulators of viral gene expression
comparison table), knowing where the virus “hides out”
β (early) proteins for genome replication
during latency is important (see slide on right)
γ (late) viral structural proteins
Transmission:
LYTIC INFECTION LATENT INFECTION
Natural modes: “mixing & matching of skin & mucous
membranes” Lots, temporal
 skin, genital tract: HSV-1/2 GENE EXPRESSION cascade (see Restricted
 oral secretions: HSV-1/2, CMV, HHV-6, EBV table)
INFECTED CELL TYPES
 respiratory tract: VSV (weird) Many (≥2) Few (1-2)
(TROPISM)
Iatrogenic modes
VIRION PRODUCED? Yep Nope
 transfusion (e.g. CMV, hiding in monocytes)
 transplants

Disease manifestations:
 Low severity: Recurrent infections, immune competent
 High severity: Primary infections, immune impairment
o Populations with severe infections:
immunodeficient (HIV, etc.),
immunosuppressed (transplant pts, cancer pts),
fetuses/newborns, malnourished pts, burn
victums
o Use prophylactic antibiotics when indicated; high index of suspicion to dx/treat

10
 Herpes Simplex Virus Diseases
Most common presentations: herpes labialis & genital herpes

Pathogenesis
1. Transmission: skin/skin or mucous
membrane/mucous membrane contact
2. Primary infection: epithelial cells (productive)
3. Retrograde transport up axon
4. Secondary infection: sensory neuron cell body
(latent)
a. Orolabial: trigeminal ganglia
b. Genital: sacral ganglia
5. Reactivated(stress, illness, UV light)
6. Anterograde transport down axon
7. Recurrent infection: epithelial cells (productive)

Genital herpes infections: mostly HSV-2 (20-50% HSV-1)

Oral herpes infections: mostly HSV-1 (5-20% HSV-2)
(Note that it’s not “1 above the waist, 2 below” like people think)

Reactivation can be symptomatic or asymptomatic (1-5% Asx in orolabial, 3% Asx in genital)

 Still shedding during Asx reactivation! Good way to spread

Clinical presentations (non-genital herpes)

1. Primary gingivostomatitis (lesions on gums, oral cavity, lips)

2. Herpes Whitlow (from sucking thumb – lesion on end of finger)

3. HSV keratitis: #1 cause of infectious blindness in developing world; dendritic ulcers in eye
2 mechanisms of pathogenesis
o Autoinoculation (orolabial, spread to eye)
o Trigeminal nerve ophthalmic root infection (after ganglion reactivation)

4. Neonatal herpes: 1/3500-5000 deliveries, Neonatal Herpes: 3 syndromes

o transmission through infected birth canal (rarely placental) 1. Skin, eye, mouth (SEM): 40%.
o Most women asymptomatic during labor Usually not fatal but recurs;
o Presentation: first 1-2 wks life; 3 syndromes (see box) 30% w/ neuro sequelae
o Vesicles: can’t use to rule in/out (SEM>CNS>disseminated) 2. Encephalitis:35%
3. Disseminated: 25%
5. Herpes encephalitis:
o most common acute, sporadic encephalitis (10-20% cases)
o Primarily HSV-1
o Classic presentation: fever + focal neuro defects (temporal lobe: memory, mental status)

Genital Herpes
TRANSMISSION IS COMMONLY UNRECOGNIZED
 Asymptomatic shedding is common Epidemiology of genital herpes
(70% acquired from asymptomatic partner)  500K cases/yr in US; 40-60M prevalence
 Primary infections are often asymptomatic  Correlated to number of sexual partners
(80-90% infections unrecognized!)  Women > Men for susceptibility
 Factors unknown (shedding rates don’t impact transmission!) (unknown why, 8% vs 2% /yr)
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Recurrence
 Recurrence w/ Sx can occur after years of “silent” infection; don’t assume infidelity!
 Symptoms less severe than primary (shorter shedding duration, fewer lesions)
 Frequency: 90% have >1 recurrence / yr, 40% >6, 20% >10
Acyclovir & Genital Herpes
 Factors that affect recurrence:
 Reduces recurrences
o time since acquisition (shedding declines 70% over 10 yrs) (w/Sx by 75%, Asx too)
o virus type (HSV-2: more, more severe recurrences than HSV-1)  Reduces transmission
o immune status (immunocompromised = more frequent (50%)
recurrence)

Varicella-zoster Virus (VSV)

Primary infection: Varicella (chicken pox) Recurrent infection: Herpes zoster (shingles)
“dew drop on rose petal” lesions Reactivation in sensory ganglion
(glistening vesicle, red base) Lesions localize to innervated dermatome

Causes severe disease in: Immunocompromised pts:

1. Teens/adults  can disseminate (bad) & spread epidermally
o At risk for varicella pneumonia  ≥ 2 dermatomes
2. Immunocompromised/newborns  Across midline
o life-threatening pneumonia
o encephalitis Disseminated zoster infection: everywhere
o progressive/disseminated varicella

Cytomegalovirus
Usually asymptomatic but can cause disease:
CMV Mononucleosis 80-20 rule (wards)
 20% of mono (EBV = 80%) If common: say 80%
 Frequent manifestation of primary CMV infection in young adults If uncommon: say 20%
 Fever, lymphadenopathy, lymphocytosis without exudative pharyngitis
o EBV = sore throat, CMV = usually not
 HETEROPHIL ANTIBODY NEGATIVE: monospot test will come up negative! (unlike EBV)

Congenital infection
 Most common congenital viral infection
 Severity depends on maternal serostatus in pregnancy
o Primary maternal infection: severe symptoms ~25% births
 Jaundice, hepatosplenomegaly, petichial rash, cerebral calcifications, chorioretinitis, motor disability
 20%: late onset hearing loss
o Reactivation during pregnancy: usually asymptomatic at birth
 but 15% with late onset hearing loss!

Special populations (solid-organ/bone marrow transplants; leukemia/lymphoma pts, AIDs pts with low CD4)
 HIV: reactivation/disease when CD4 < 50 (uncommon with HAART)
o Retinitis, encephalitis, colitis with ulcers
 Bone marrow transplant: commonly pneumonia (prophy with ganciclovir)
 SOLID ORGAN TRANSPLANT: huge problem!
o Usually manifests as disease in allograft
 liver = CMV hepatitis, lung = CMV pneumonitis (renal ≠ nephritis though)
o Highest risk: CMV seronegative recipient and seropositive donor

12
 HHV-6 and -7
Roseola infantum (exanthum subitum): rash-like illness in young kids & transplant patients
 Can see febrile seizures, other sx possible, may contribute to HIV disease progression & exacerbate other viral dz
 Erythematous rash

Herpesvirus diagnostics
 Viral culture (HSV from all sites except CSF, makes it hard to culture for HSV meningitis!)
 Rapid antigen detection from lesions
 PCR for nucleic acids (including CSF)
 Antibody detection: limited utility except mono & to identify high risk pts for transplants

13
 Pathophysiology: ID & Micro (Viruses)
Introduction to Virology.......................................................................................................................................................... 2
(+) RNA Viruses ....................................................................................................................................................................... 5
HIV (and retroviruses) ............................................................................................................................................................. 8
Small DNA Viruses: Parvoviruses & Papillomaviruses .......................................................................................................... 12
Influenza: Epidemics, Pandemics, and Prevention Strategies .............................................................................................. 15
Viral gastroenteritis............................................................................................................................................................... 18
Gammaherpesviruses: EBV / KSHV ....................................................................................................................................... 20
Viral Hepatitis........................................................................................................................................................................ 23

1
 Introduction to Virology
History: “filterable agent” (not like bacteria); nucleic acid infectious, no binary 3 basic types of virus
fission, requires host, first described in 19th century (agriculture (TMV)  1. Bacteriophage
animals (foot/mouth) humans (yellow fever) 2. Animal/plant (DNA or RNA)
3. Retrovirius (RNADNARNA)
Virion: virus particle (viral nucleic acid + structural proteins)
 Structural proteins = payload vehicle to deliver nucleic acids Properties of viruses
 Example: alphavirus is enveloped, icosahedral
 Small, infectious, obligate
Structural proteins: encoded by viral genome; packaged into virion (protective intracellular parasite
coat for nucleic acid)  Genome: DNA or RNA
 Protein capsid ± lipoprotein envelope (cell membrane of host cell)  In host cell: genome
replicated, synthesis of other
Nonstructural proteins: encoded by viral genome, not packaged into virion virion components via host
 Enzymes (polymerases, helicases, etc) or transcription factors systems, progeny assembled
 Needed for viral replication in cell

Usually nonstructural proteins encoded 1st on genome (5’ end) because they’re needed for translation/transcription

Basic structures: icosahedral / helical; enveloped or non-enveloped Taxonomy:

 Example: picornavirus (common cold). Icosahedral (20 triangular faces, 1. nucleic acid (DNA/RNA; +/-, ds/ss)
12 verteces). 2. capsid (symmetry of protein shell:
 Common motif for icosahedral: 8-stranded antiparallel β-barrel icosahedral/helical)
3. envelope (lipid membrane,
Basic viral genome structures naked/enveloped)
4. dimensions of virion / capsid
(+) strand (sense) Non-segmented
Single stranded Non-segmented
RNA

(-) strand (antisense)

Segmented
Double stranded Segmented
Single stranded
DNA

Linear
Double stranded
Circular

Viruses evolve rapidly; produce large #s progeny; RNApol has no proofreading function (population = “quasispecies”)
 Mutation
 Recombination (two viruses in same cell, recombine)
 Reassortment (2 viruses with segmented genomes in same cell, e.g. flu)

One step growth curves: takes a day or two, then kicks into gear. Many fold higher # organisms than bacteria

Viral replication cycle: attachment, penetration, uncoating, transcription of early mRNA/translation early proteins,
replication of viral DNA, transcription of late mRNA, translation of late proteins, assembly, release.

Cell surface molecules for virus attachment:

 CHOs: linked to proteins/lipids (sialic acid, GAGs)
 Lipids (glycolipids, proteolipids)
 Proteins (immunoglobulin superfamily, C’ –regulatory proteins, integrins, TNF receptor superfamily)

Receptor binding sites: can be depressions (picornavirus “canyons”) or projections (rotavirus “fibers”)
2
  Neutralizing antibodies can bind to these receptor sites; block ability to interact with receptor (e.g. bind to
rhinovirus canyon)

Viral genome: all viruses need a strategy to make RNA

 (+) strand RNA viruses: make (-) strand as template to copy, or can undergo direct translation
 (-) strand RNA: need to make (+) strand to copy (have polymerase)
 DNA viruses: need to get into host nucleus for transcription; then mRNA translated in cytoplasm

 Early mRNA: products used to help with transcription, etc.

 Late mRNA: products for structural organization, assembly, etc.

Problems for viruses to overcome

1. Package info for replication into small genome
o Big variety of sizes of genomes
o Strategies: overlapping reading frames, code from both strands, splice RNA, frame-shift, RNA editing

2. Maintain in population without dying out

o Transmission
 Humans: respiratory/salivary, fecal-oral, or sexual contact
 Animals: vector (arthropod), vertebrate reservoir, vector+vertebrate reservoir
o Types of infection: acute, persistent, latent, relapsing
o Persistence: can’t kill host, kill cells in which virus replicates, or be eliminated by immune response

3. Need both stability (transmission) and instability (infection)

o Entry & uncoating strategies
 Endocytosis: both enveloped/non-enveloped,use clathrin-coated pits, enter cytoplasm; fuse
with endosome with acidification (often needed for viral protein conf. changes)
 Fusion: enveloped only, fuse directly with cell
Cytopathic effects:
membrane, discharge virus into cytoplasm
o Outcomes of infection  Rounding / swelling
1. Lysis  lysis
2. Transformation (e.g. pre-neoplastic)  syncytia formation (fusion, esp.
3. No pathological effects enveloped viruses)
 Chronic dysfunction can still result  hemadsorption (absorption on RBC)

Pathogenesis of viral infection

Disease : can be at site of entry (e.g. HSV) or at distant target organs(Coxsackie virus, enters via GI tract  myocarditis)
Time course of symptoms: due to local & systemic infection
 Local: earlier onset of Sx, due to infection of body surface (e.g. cold)
 Systemic: later onset of Sx, from immune response (e.g. measles)
 Rabies, hepatitis can be weeks, others are pretty short

Immune response
 Interferon:
1. dsRNA intermediate presence triggers Mϕ to synthesize & release IFN
2. IFN signals other cells via JAK-STAT pathway to induce antiviral protein genes (inhibit viral release /
products; ↑ MHC CLASS I EXPRESSION
3. Actually appears to control spread of virus before acquired immune response (acquired mops up,
allows for long-lasting immunity)
 Antiviral Antibodies:

3
 1. Serological tests: Dx (ELISA, radioimmunoassay, Westerns)
2. Biological activity: function of Ab?
 Neutralizing (can’t cause productive infection). Effective immune response
1. Eliminate virus from blood/other
Can block attachment, endocytosis, uncoating.
 C’ fixation (causes cell death) fluids (prevent further spread)
 Hemagglutination inhibition (binds viruses 2. Eliminate virus-infected cells
together; can’t productively infect) from tissues (“cure infection”)
3. Roles of antibodies: protect against reinfection, clear 3. Immunity to re-infection
virus from fluids, downregulate intracellular virus replication (not completely understood)
 MHC Class I:
1. Mouse experiment: cytotoxic t-cells only kill MHC-I matched virus-infected target cells
 Cell-mediated immunity: focus immune response (target), clear infected cells, recruit other effector cells,
activate Mϕ , provide help for production of Ab by B cells

Basic immune response scheme:

1. Virus enters
2. Mϕ are 1st responders, pick it up
3. If dsRNA: IFN made
a. T-helpers activated to recruit B cells, Ab made against Mϕ and other infected cells
b. ↑ Mϕ activation (more MHC class I, etc.)
4. Infection cleared
a. T-suppressor cells help tone down immune response
b. Memory B-cells produced (longer-lasting immunity)

4
 (+) RNA Viruses
Picornaviruses
Picornaviruses: Pico (small) RNA Viruses
 Icosahedral Human picornaviruses
 Receptor binds into canyon; neutralizing antibodies bind canyon too  Rhinoviruses
 Entry: endocytosis uncoating  conformational change in acidified  “Enteroviruses”
endosome  extrusion of RNA into cytoplasm (injected) o Polioviruses
 Plus-strand viruses: produce (-) strand intermediate in cytoplasm of cell o ECHO viruses
 Replication: (+) RNA translated as single polyprotein; viral proteases o Enteroviruses 68-71
cleave into individual proteins o Coxsackie viruses A&B
 Translation: have internal ribosomal entry site (IRES) in 5’UTR of RNA  Hepatitis A virus
o IRES: RNA can bind directly to ribosome w/o 5’ 7-methyl cap or
cap-binding protein

Clinical presentation
 Rhinoviruses: cause local upper respiratory disease (stay in resp. tract)
o Generally pediatric problem and nuisance
o Exception: asthma patients
 Enteroviruses: systemic infection
o Fecal-oral transmission  GI tract  viremia (in blood)
o Can go to
o Skin (hand-foot-mouth disease): Rash: pustules on skin
o Muscle (echovirus, coxsackie A/B): myocarditis, pericarditis
o CNS: Brain (polio, coxsackie A&B), meninges (echo, polio, coxsackie)
 Example: paralytic sequelae of poliovirus: limb atrophy

Poliovirus
Transmission: fecal-oral (land runoff, sewage, solid waste landfills)

Pathogenesis: infects throat, feces, blood, CNS (major disease effects

 Replicates in motor neurons of spinal cord
 Poliomyelitis: inflammation, death of motor neurons
o Phrenic nerve involvement especially bad: needed iron lung to support respiration

 Can shut off host protein synthesis

o IRES allows viral mRNA to bind / assemble
o 2A is a viral protease that cleaves elements of cap-binding protein assembly (initiation factor)
o Cellular RNA production stops but viral mRNA is fine!
o Cell death results (very little replication of own proteins)
Clinical manifestations of
Epidemiology: poliovirus infection
 summertime (virus not good in the cold! Seasonality: NE > south, etc.)  90-95% asymptomatic
 age dependence: was early in developing countries, late in industrialized  4-8% flu-like symptoms
countries  1-2% major disease
History: Unclear why some people get
 epidemics started early 20 c. (more leisure time, more time in common
th severe dz, others asx: virus/host
factors?
swimming pools, etc.)
 early attempts to control: quarantine  vaccines

5
Vaccines:
 Sabin’s live virus vaccine helped reduce polio SALK VACCINE SABIN VACCINE
incidence big-time; wild polio eradicated (inactivated) (live virus)
o Advantages: spread immunity via shedding, Use Currently in US Not used in US
mucosal immunity, etc. Revertants to wt? No Yes (rare)
 Problem: tendency to revert to virulence (rapid Administration Injected Sugar cube
emergence of mutations) Mucosal immunity? No Yes
o Vaccine-associated paralytic polio: couldn’t completely get rid of polio as a disease with Sabin’s vaccine
(all new polio cases due to live virus vaccine)
 Switched to Salk’s inactivated virus vaccine (no more revertants)

Current problems:
1. importation of polio from endemic to polio-free areas
2. circulation of virulent vaccine-derived/recombinant viruses
3. prolonged excretion of vaccine viruses by immunodeficient individuals (e.g. AIDS pts)

Togavirus (rubella & alphaviruses)

 enveloped, (+)-strand RNA, icosahedral virus
o 2 types: rubella virus & alphaviruses
 Genome: RNA
o Genome is mRNA for nonstructural proteins (needed to synthesize RNA)
o Second subgenomic RNA is synthesized from part of genome for translation of structural proteins

Rubella
Respiratory transmission, worldwide distribution

Clinical presentation:
 Children / adults: mild maculopapular rash
 Congenital rubella syndrome (CRS):
o requires: maternal exposure, maternal blood invasion, placental Features of CRS:
infection, entry to baby’s blood, fetal infection 1. mental retardation
 lack of any of these means the baby will be healthy. 2. heart defects
o Don’t see CRS if mom gets rubella after 17-18 wks gestation 3. cataracts

Arbovirus encephalitis (caused by alphaviruses & flaviviruses)

Examples: alphaviruses, eastern equine encephalitis, western equine encephalitis

Remember: encephalitis occurs in a minority of cases (most flu-like if even have Sx)

Flaviviruses
 Mosquito-borne viruses (yellow fever, dengue, Japanese encephalitis, West Nile)
 Tick-borne viruses
 Hepatitis C too!

Transmission: birds are animal reservoir; humans infected incidentally via mosquito
West nile virus: spread really fast
 appeared in 1999, across USA over 5 years, caused lots of human disease
 now seems like more American birds have acquired immunity, human cases more sporadic

6
 Coronaviruses
 (+)-strand RNA virus, transcribed and then translated
o Uses subgenomic RNA (along with genomic RNA) as mRNA, like togaviruses
 Morphology: looks like a crown
 Cause common cold and severe acute respiratory syndrome (SARS), which has pretty much disappeared

Summary of (+)-strand RNA viruses

Transmission Presentation
Picornaviruses Human (resp, fecal/oral) Variety: colds, polio, rashes
Togaviruses Human (resp) for rubella Rash, CRS
Mosquitos for alphaviruses encephalitis
Flaviviruses Mosquitos/ticks Fever, encephalitis
Coronaviruses Humans, ?animal for SARS Colds, SARS

7
 HIV (and retroviruses)
History
AIDS: originally described as opportunistic infections in young adults: PCP pneumonia / oral candidiasis (1981)
Thought to be transmissible (epidemiology, hemophiliacs, epidemic in NYC & SF); HIV-1 discovered in 1983
 HIV-1: 3 groups, from SIV (simian), cross-species transmission responsible (SIV doesn’t often cause disease in
natural hosts but does in humans  animal model, use Asian macaques, which aren’t usual host  causes dz)
o M group causing AIDS epidemic currently
o (33M+ living with AIDS, 2.7M new each year, 2.0M deaths each year)
 HIV-2: SIV from West Africa, more slowly progressive, not as widespread as HIV-1

Found RNA-containing virus with reverse transcriptase activity; retrovirus morphology by EM

 immunologically distinct from human T-cell leukemia virus, only other significant retrovirus in humans
 much more like lentivirus (slow disease)
 Can’t really fulfill Koch’s postulates (hemophiliacs kind of?)  can’t put back into humans

Retroviruses
Enveloped, small genome (10kb), (+) ssRNA
 ssRNA capped, polyadenylated like host mRNA Retrovirus genes:
 Has reverse transcriptase & can integrate into host cell genome  gag: structural proteins
 RNA virus benefit: high mutation rate; DNA virus benefit: latent form in  pol: enzymes (protease,
host genome RT, integrase)
 env: coat protein
Complex viruses (also have accessory genes – regulatory gene expression)

HIV Structure
 gp120: surface glycoprotein, trimers, mediates interaction between virus & cell receptor
o Target of neutralizing & cytotoxic AB
 gp41: transmembrane glycoprotein: causes fusion of cell membrane, anchors gp120
 Core:
o 2 copies of viral RNA (needed for the RT step
o Protease, integrase, reverse transcriptase already packaged inside
Cell targets of HIV
CD4+ lymphocytes are targeted and killed by HIV
 Lose CD4+ lymphocytes in: peripheral blood, lymphoid/gut-associated lymphoid tissues
o (normal: 46%, decreased to 3%, etc). CD8 stays the same, so CD8/CD4 ratio increases
 CD4 < 200 is AIDS-defining (normal > 1000); blood level gives good indication of whole compartment
o Onset of opportunistic infections
 Normal jobs: Central in immune response (all arms)
o Mature in thymus into blood
o Recognize antigenic peptides (MHC class II), activate Mϕ, activate B-cells to produce antibodies

HIV also infects CD4+ monocytes/macrophages

 CD4+ monocytes in blood, bone-marrow-derived, migrate into tissues and take virus with them (brain, etc)
o Spread all over body in first few weeks of infection
 Normal jobs: antigen presentation, host defense, repair  differentiate into Mϕ
 Express MHC Class II molecules; chemokine receptors (CCR5/CCR2)

Natural History
 Initial viremia (virus up, CD4 down)
8
  Innate, adaptive immune can control at first, CD4 rebounds but not to normal
 Virus keeps replicating (lymphoid tissues, dumped into blood), goes to set point (for longer period of time)
o The lower the set point, the better the prognosis
(immune system doing better)
o Therapy: keep viral load low

HIV Life cycle

Note: targets for antiretrovirals (except gene expression)
1. Attachment-fusion
a. CD4 (host) and gp120 (virus) interact; CD4 gp120
conf change
b. gp120 (virus) can then interact with CCR5 or CXCR4
chemokine receptor (host) (CD4 not sufficient)
i. CCR5-tropic HIV: on Mϕ (and T-cells
too)(primary infection, most infection)
ii. CXCR4-tropic HIV: T-cells only express
iii. Tropism can shift (R4 is much more pathogenic & cytolytic)
c. Conformational change of gp41 after chemokine
receptor/gp120 interaction Summary of HIV Life Cycle
d. gp41 mediates fusion of membranes & viral entry (core: 1. Attachment-fusion
RT, genome, etc) 2. Reverse transcription (RNA  DNA)
i. some viral particles still left on cell 3. Integration of viral DNA
4. Virus gene expression
2. Reverse transcription (RNA  DNA) 5. Assembly & budding
a. Very complex process 6. Maturation
b. Primer (tRNA from cell) bind primer binding site of viral
RNA in virion (near 5’ end)
c. RT uses primer to start making (-) DNA from RNA (RNADNA)
d. Rapidly runs out of RNA: goes to 5’ end of RNA, then jumps to either 3’ end of RNA or to the second
copy of RNA
e. Duplication results in DNA copy with LTRs (long-terminal repeats) on each end:
i. Allows you to transcribe another RNA without loss of genetic material
f. RNase H chews up the RNA as you go along (no editing capacity)
i. Higher mutation rate than in normal DNA replication

3. Integration of viral DNA

a. Random cut into non-histone coated DNA (endonucleolytic, sticky ends)
b. Insert viral genome
c. Host proteins repair the cuts: looks the same!
d. Until cell dies, can’t clear! – can sit here latently, carry to other parts of body, etc. (e.g. monocytes)
e. Latent virus is a reservoir

4. Virus gene expression

a. Activation state of cell determines either latency or productive replication (e.g. activated T-cell,
maturation of monocyte to Mϕ, etc. triggers replication)
b. Cellular transcription factors; cellular RNA pol II complex used to transcribe HIV DNA
i. Note switch to cellular machinery now (before was viral RT) – not drug targets!
ii. Cellular transcription factors, RNA pol II and HIV’s Tat assemble to achieve high levels of HIV
DNA transcription
iii. TAT also turns on some genes that are toxic to cell (would be good target)
c. Long terminal repeat is a cellular promoter region
d. Full length mRNA produced (whole viral genome), spliced (host cell proteins)
9
 e. Translated to make structural proteins (full length mRNAGag polyprotein) and a longer protein (via
read-through of Gag’s stop protein to make Gag-pro-pol polyprotein, encoding protease/enzymatic
activity)
f. Cleaved via protease (viral)

5. Assembly & budding

a. Structural proteins (gag, gag-pol) myristolated (targeted for cell membrane), RNA targeted to nuclear
capsid & associates, then budding of the whole complex happens
b. This forms an immature virion which is non-infectious

6. Maturation
a. Protease gets bundled along; cleaves itself out of Gag-pol precursor protein
b. After budding: cleaves gag & gag-pol to form mature virion (infectious)
c. Maturation is essential to be infectious  PROTEASE INHIBITOR TARGET

Pathogenesis
Not that virus itself kills all CD4 cells: 2 accepted theories
 Immune activation: so much activation of immune system  exhausted (high level of activation)
 Bystander killing: activated T-cells more prone to apoptosis (more dying)

Transmission
Not a tough virus: fragile (not on surfaces, aerosol, etc)
 Sexual transmission (incl oral)
 Contaminated needles (IV drug use mainly; P=0.3% for needle stick, use antiretroviral PEP, call 5-STIX)
 Mother-child (in utero, at delivery, breastfeeding: all preventable with antiretroviral Rx)
 Probability of transmission depends on viral load (highest in acute infection & during AIDS)

Genetic polymorphisms: CCR5

 CCR5 is primary tropism for HIV transmitted sexually
 Some have 32 base pair deletions (Δ32/ Δ32) in CCR5 and are resistant to infection (1% Caucasians)

Spread:
1. Transmission  dendritic cells / infected Mϕ 
2. local LN  CD4 lymphocytes, Mϕ  viremia in blood 
3. spread to tissues  viremia in CSF (brain infected)
4. Long-lived reservoirs: resting lymphocytes (blood, tissues), Mϕ (tissues)

1st sign of infection: local LN involvement (make tons of viruses; viremia)

Stages of infection
1. Primary (acute) HIV infection: rapid replication (first few weeks),
a. Ab tests initially negative, viral load varies (104-106/mL), CD4 depletion (esp. GALT).
b. Acute retroviral syndrome: fever, lymphadenopathy, pharyngitis, rash
c. Viremia falls: innate, adaptive (CTL) immune response develops
d. Levels off to set point (different in different pts; prognostic)
e. LN full of virus; dendritic cells trapping virus inside LN, adaptive immune response clears
f. Viral load lowers, CD4 counts rebound

2. Asymptomatic (8-10 yrs usually, 20+ in long-term progressors)

a. Persistent infection, rise in viral load, decrease in CD4
b. Current guidelines: start Rx at CD4 > 350 (now being reconsidered)
10
 i. Sooner is better for prognosis! Getting immune response the whole time (continual activation
of immune system, damage being done the whole time)
3. AIDS
a. CD4 < 200
b. Opportunistic infections (fungal, bacterial, parasitic, CNS, lungs, etc.)
c. Use prophylactic Rx to prevent opportunists

Treatment
Multiple drugs: mutation rate high (1 error/genome per 3 replication cycles)
 No editing function (single strand)
 “every base pair mutates every day”
 Partial suppression: rapid production of mutant viruses
 “Do it right or don’t do it”  sequential monotherapy = develop resistance to all!
o Never treat with one drug
o Never add 1 drug to a failing regimen
 3 drugs: likelihood of getting resistance to 3 drugs on same viral genome is low!

Latency & HAART

 Eradication was predicted (1st, 2nd phases showed you’d get done) – but latency was 3rd phase
 Latency: reversibly non-productive state of infection
o Resting CD4 T-cells & Mϕ in sites like CNS
o Normal T-cells: some activated T-cells return to resting state (1 in million) for ready response to future
infections, re-activate when activated
o Stable reservoir of latent cells throughout HAART (would need ~73 yrs to eliminate)

Vaccine?
 6 yr trial in Thailand: guarded possibility of vaccine? 30% reduction in those who receive vaccine; no reduction in
HIV load in vaccinees with HIV (?)
 Why so hard? All current viral vaccines prevent development of disease, don’t stop infection; HIV vaccine would
need to induce “sterilizing immunity” to prevent infection/latency; HIV infection doesn’t induce natural
immune response to prevent progression; would need vaccine against many variable clades of HIV-1/2, diverse
antigenicity among HIV in population

Tests for HIV

Serology: remember: HIV antibodies take 2-4wks to develop (can’t use right away!)
1. ELISA used as first test
ELISA + WESTERN PCR
o Pt. serum + HIV proteins in well; look for binding of
 Inexpensive  Expensive
pt. antibodies
 Rapid  Requires sample prep
o False-positive: 0.4%
2. Western Blot: Blood test (1985)  Requires Ab against  Detect early infection
o Used after ELISA to confirm (combined false- virus (2-4wks post- (3d post infection)
positive 0.005%) infection)  Can quantify viral load
o Purified virions lysed, run on SDS-PAGE Almost no difference in sensitivity
o Western-blot with patient sera to look for anti-HIV ab
RT-PCR
 Amplify RNA in virus (detects infection earlier: 1st week!)
 Gives you viral load: how much virus do you actually have in blood?
 CD4 and viral levels are most important clinical measures

Viral load, CD4 count (via flow cytometry) are the two best prognostic indicators
11
 Small DNA Viruses: Parvoviruses & Papillomaviruses
DNA viruses: unlike RNA viruses, can use host cell nuclear enzymes to transcribe DNARNA & replicate DNADNA
Must either:
1. infect a dividing cell (parvoviruses)
2. induce host cell DNA synthesis (papillomaviruses, polyomaviruses, adenoviruses)

Parvoviruses
 Among smallest of DNA viruses; icosahedral virion (3 proteins + linear ssDNA, ~5000nt)
 Replicate in host cell nucleus
 Don’t have enough room to code for DNA synthesis enzymes: can only replicate in:
1. dividing cells that have necessary DNA synthesis enzymes
 autonomous parvoviruses can replicate alone
2. cells co-infected with a “helper” virus (that provides the enzymes)
 dependoviruses need a helper virus like adeno/herpes

PARVOVIRUSES THAT CAUSE HUMAN INFECTION: QUICK LOOK

Parvovirus B19 Autonomous Erythema infectiosum (“fifth disease”, childhood rash dz)
Acute/recurrent arthritis (adults)
Aplastic anemia/crisis (pts with chronic hemolytic anemia)
Chronic anemia (immunocomp / hydrops fetalis)
Bocavirus Autonomous Respiratory disease (infants)
Adeno-associated virus (AAV) Dependovirus No dz: gene vector (integrates into cellular DNA)

Virions: non-enveloped, icosahedral, linear + or – sense ssDNA, no enzymes, very resistant to inactivation

Genome: 2 reading frames

1. structural coat proteins (overlapping in-frame sequences) Parvoviruses
2. nonstructural proteins for transcription/DNA replication 1. Respiratory transmission 
2. Respiratory epithelium
Replication: nucleus 3. Viremia
1. cellular DNApol makes dsDNA  4. Skin, bone marrow
2. cellular RNApol makes mRNA (erythroblasts), fetus, GI tract
3. If autonomous: need host cell in S phase
a. (can’t stimulate S phase like papilloma viruses)
b. Predilection for bone marrow, GI tract, developing fetus (dividing cells!)

Parvovirus B19
Pathogenesis:
 B19 cellular receptor = globoside (P antigen), found
primarily on erythroid cells
 Virus replicates primarily in erythroid precursor cells
 Cytopathic effect: giant pronormoblasts with nuclear
inclusions, cytoplasmic vacuolization in bone marrow
 Toxicity: express B19 nonstructural protein (NSP) 
apoptosis induction
o Megakaryocytes: nonproductively infected
(no transcription of mRNA for structural
proteins) but NSP compromises & kills

Normal child/adult
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 0. 5-6d incubation
1. Viremic phase (108-1014/mL): fever, malaise, myalgias
2. “slapped face” rash (erythematous, strikingly flushed) afterwards ( immune response )
a. extends to extremities (lacy, evanescent, maculopapular)
b. Adults: develop arthritis during immune response

Destruction of erythroid precursors during acute phase  absence of reticulocytes in blood (transient mild anemia)
 Not clinically important usually, unless:

1. If patient has chronic hemolytic anemia (sickle cell, thalassemia, hereditary spherocytosis)
 More virus made & released (more bone marrow cells being produced & turned over more quickly)
 Already have shortened life for circulating erythrocytes, add on more anemia
 Result: APLASTIC CRISIS (“Transient Aplastic Crisis = TAC”, life threatening!)

2. If patient is immunodeficient:
 Can’t clear virus  chronic anemia (“pure red cell aplasia”)

3. If fetus
 Can cause severe anemia  hydrops fetalis (abnormal fluid in at least 2 compartments), infant death
 Greatest risk: first 2 trimesters,
 Treat: transfuse in utero, but baby might become tolerant to virus & have persistent infection / red cell aplasia

Epidemiology:
 Humans only (esp. school age kids & parents), respiratory transmission (also possible by transfusion)
 Dx: serology later, PCR during acute phase
 If immunocompetent: clear w/o tx, immunity is life-long
 Tx for immunocompromised: immune globulins; no vaccine

Papillomaviruses
HPVs: human papillomaviruses
 Icosahedral, covalently closed supercoiled circular dsDNA molecule, 8kb with histones (“minichromosome”)
 Cause warts & squamous carcinomas (e.g. cervical carcinoma)
 Culture: difficulty; typed via PCR usually

Replication: nucleus of squamous epithelial cells

 2 phases (overlapping reading frames on single strand)
o Early (E) genes: regulatory proteins for replication, transcription, transformation. E2,E6,E7 important
o Late (L) genes: capsid structural proteins (L1, L2)
o Long control region: origin of replication, control elements for transcription/replication

Disease/pathogenesis: species-specific, restricted tissue tropism

1. Cutaneous types: warts
o Virus enters skin via abrasion  basal layer of epidermis  express early genes
 E7: induces DNA synthesis
 Cellular proliferation (hyperplasia)  wart forms eventually
o As infected cells differentiate to keratinocytes, late genes expressed (L1/2), producing infectious virions
o Incubation period: months/years, crops of warts clear at same time (immune mechanism?)
2. Mucosal types: genital/oral/respiratory mucosa
o Worldwide issue
o Women: target proliferating cells at border of squamous/columnar epithelium of cervix
 Several months later: flat condyloma (asymptomatic)
13
  Clearance of virus: 1-2 years, longer if HIV infected (↑ risk)
 Associated with ↑ cytologic abnormality in Pap smear
HPV & Cervical Carcinoma
Essentially all cervical carcinoma worldwide is initiated by HPV infection
 HPV-16, HPV-18 = MOST ONCOGENIC (70%)
 MORE RISK with longer persistent infection (e.g. HIV pts)

Oncogenicity: function of E6/E7 oncoproteins (both required for immortalization of keratinocytes)

 E7: induces DNA synthesis in resting cells (want basal cells to proliferate more)
o Binds retinoblastoma tumor suppressor pRB
 normally regulates growth by binding E2F, keeping G1/S checkpoint in check
 If RB bound by E7: E2F can go do its thing & release G1/S checkpoint (progress to S)
 E6: activates telomerase in epithelial cells; can complex with p53 in high-risk HPVs
o Targets p53 for ubiquitin-mediated degradation (no checkpoint control)
 E2: usually controls E6/7 expression
o HPV usually exists as unintegrated autonomously-replicating episome in nucleus
o In malignant cells: viral genome integrated in a way that disrupts E2 (cut circular genome in middle of
E2 to insert)  no control of E6/E7

Epidemiology:
 Common worldwide in men & women; also linked to penile squamous carcinoma, some head/neck tumors
 Most infected women are asymptomatic, clear infection, and do NOT develop malignant disease
 If developing disease
o Histopathologic progression: cervical intraepithelial neoplasia (CIN)  invasive disease
o Papanicolau smear: screening device; detects cellular changes
o PCR can be used to detect type
o Tx: removal of involved tissue

Immunization:
 Virus-like particles (VLPs) from L1 capsid protein (antigenically different between strains)
o Immunogenic: assemble into empty aggregate
 VLPs for HPVs 16, 18 (high-risk) & 6 ,8 (low risk, cause condyloma, prevent warts = good for marketing) in
current vaccine: prevents against both cancer & genital warts
 Possible therapeutic vaccine: E6/E7; for HPV-induced tumors

14
 Influenza: Epidemics, Pandemics, and Prevention Strategies
Influenza quick review:
 wild waterfowl = natural reservoir; many strains circulate in birds
 influenza A & B = major cause of human disease (A is vast majority)
 Subtypes: classified by Hemagglutinin (H x 16), Neuraminidiase (N x 9)
o H1N1, H1N2, H3N2, novel (Swine) H1N1 circulating recently
 Mutations: antigenic drift (variations within same H&N classes) vs antigenic shift (complete H/N change)
o Shift: H, N, or both H & N: e.g. bird strain & human strain re-assort
 pigs are good facilitators (resp epithelium have both human-like & bird-like receptors)
 high association of shift with pandemics
 Pandemics of 20th c: 1918-19 (Spanish, H1N1, 20M dead Steps to cause an epidemic
worldwide), 1957-8 (asian, H2N2), 1968-9 (“hong kong”) 1. Susceptible population
2. Animalhuman transmission
Novel H1N1 3. Human  human transmission
 Very rapid progression, in viral spread & response (says good 4. Sustained humanhuman
things about current collaborative epidemiological efforts)
 Several steps removed phylogenetically from seasonal flu
 Now counting deaths instead of cases, expect combinations of infections with seasonal flu in winter
 Unusual features:
o Summer outbreak (seasonal=winter)
o High mortality in young adults without comorbidities (seasonal = elderly, infants, comorbidities)
 Symptoms = usually the same, just in young, healthy people too! 5-24yo unusually affected
 Asthma, COPD, CVD, diabetes, immunosuppresed seem to be important comorbidities

Seasonal influenza
 Annual epidemic spread like clockwork: late fall, winter, early spring (peak = Jan, Feb).
 All ages affected, highest rates among children, most serious in >65 and <2 years old + high risk conditions
 Annually 36k deaths, 226k hospitalizations in US; most deaths in >65yo
 50% peds deaths: no underlying high risk condition (secondary bacterial pneumonia is #1 cause)

Signs/symptoms: malaise, myalgias, headache, fever, non-productive cough, rhinitis, sore throat, otitis (peds)
 Normally a non-specific viral constellation; together = influenza-like illness (ILI)
 Uncomplicated: resolves in 3-7d with cough/malaise up to 2 wks (self-limited)

Complications
 Primary viral pneumonia
 Can exacerbate underlying medical diseases
 Secondary bacterial pneumonia / sinusitis / otitis
 Co-infection with viral/bacterial pathogens
 Uncommon: encephalopathy, transverse myelitis, myocarditis, pericarditis, Reye’s syndrome

Dx: difficult clinically to distinguish from other resp viruses; absence of ILI Sx doesn’t rule out flu
 Need lab Dx + high level of suspicion
 Lab dx:
o Nasopharyngeal aspirate: suction catheter, mucous trap, aspirate from posterior nasopharynx, add to
transport media, process < 1 hr
o Nasopharyngeal swab: have to get back to NP, better because won’t aerosolize (esp H1N1)
o After you get the sample: viral culture, immunofluorescente DFA antibody, RT-PCR, Serology

15
Transmission of influenza
 Person-Person via large particle respiratory droplets, coughs/sneezes, 3 foot radius – can use surgical mask
 Close contact, contaminated surfaces
 Some evidence of airborne spread (small particle residue evaporated/suspended like TB – would indicate more
than just a surgical mask!)
 Observational studies in healthcare settings: contact/droplet are primary means; anecdotal airborne spread
 Incubation: 1-4d
o Adults: infectious from 1d prior to Sx through 5d post sx
o Children: infectious from several days prior to 10+d post sx
o Immunocompromised: can shed virus for months
o Shedding prior to Sx: more transmission (less precautions taken)

Vaccines
 Most effective way to prevent infection/complications
 Annually (antigenic drift)
 Two types
o Trivalent inactivate vaccine (TIV)
 Injected, grown in eggs, 3 strains (A/H3N2, A/H1N1, B)
 Inactivated/killed; subunit/subvirion/purified surface protein
 Cannot cause influenza (killed!) ACIP Recommendations
o Live, attenuated influenza vaccine (LAIV) for seasonal flu vaccine
 Intra—nasal administration; grown in eggs, 3 strains
 Children (6mo-19yr)
(A/H3N2, A/H1N1, B)
 Pregnant women
 Live attenuated virus; can cause mild signs / sx of
 >50yo
attenuated influenza
 Chronic med conditions
o Cold-adapted, LAIV (FluMist)
 2-50yo (FDA) and also 50-64; efficacy comparable to  Nursing homes / long-term
injected (85% healthy adults) care
 Well tolerated (rhinorrhea, nasal congestion)  Live with / care for high risk
 Don’t give to pregnant/immunosuppressed for complications
 Safe in healthcare setting (shedding short duration,  Healthcare personnel
less than dose to vaccinate, doesn’t replicate well at  Household contacts of
37F, genotypically stable, etc.) persons of high risk for
 Efficacy: prevention of illness among vaccinated subjects in complications; out of home
controlled trials caregivers of children < 6mo
 Effectiveness: prevelance of illness among vaccinated populations
o Depends on age, immunocompetence, match between ACIP Recommendations
vaccine/strains, outcome measured (death, hosp., etc) for H1N1 flu vaccine
o Good (80-87% kids, 77-90% working adults, less in elderly in  Pregnant women
community / long-term-care)  Household contacts of
persons of high risk for
Medical conditions with ↑ risk of complications complications; out of home
 COPD + asthma caregivers of children < 6mo
 CVD (not HTN)  Healthcare / EMS
 Renal, hepatic, hematological, metabolic disorders (incl. DM)  6mo – 24yo (ALL)
 Immunosuppresion (meds/disease like HIV)  25-64 with higher risk
 Cognitive/neuro dysfunction that compromises resp function or conditions
increases risk of aspiration
*note: no prioritization of
elderly!
Hard to make vaccine: WHO decides in feb which strains to include; 6-8 mo

16
of production, 10s of millions of hand-picked 11-day-old chicken eggs to inject with strain, incubate for several days,
extract/purify egg white: LABORIOUS
Vaccination “season”: people stop getting vaccinated after Thanksgiving although most influenza is in Jan/Feb
 Need to keep up vaccination efforts!

Influenza in health care workers: common (23%, most can’t remember flu or resp symptoms)
 Vaccinate: ↓ patient mortality, ↓ lost hours, ↑ normal function of institution in flu season
 Doesn’t make you sick (large double-blind placebo study)

Antiviral meds: adjunct to vaccination, not substitute

 Adamantanes (amantadine, rimantadine)
o Single point mutation confers resistance; was common in H3N2 circulating strains, was recommended
against for a while, now active against H1N1?
 Neurominidase inhibitors (oseltamivir, zanamivir)
o Resistance mostly in seasonal influenza, increasing over last few seasons
o Active against flu A & B; 83-4% active for prevention, bad in pregnancy?
o Can use for chemoprophylaxis
 NOT vaccine substitute; adjunct
 ~85% effective in household exposure, use in institutional settings (prevent spread in
outbreak), protect high risk when flu circulating (vaccine takes 2 wks to make Abs), protect
immunocompromised, protect those with contraindication for vccine
 Can use for therapy or prophylaxis, both have similar effects in decreasing length of illness

Other prevention
 Hand-washing, respiratory etiquette, community mitigation (close schools, avoid mass gatherings wear masks)
 Respiratory etiquette:
o Cover nose/mouth, use tissues, use hand-hygiene after resp secretions / contaminated objects,
healthcare facilities need to make tissues / hand sanitizer available in waiting rooms!
o Provide no-touch receptacles, tissues; dispensers of alcohol, use masking/separation if resp. symptoms
o Droplet precautions: use mask if sx of resp infection, esp in setting of fever

17
 Viral gastroenteritis
Some viruses replicate in GI tract but don’t cause GI disease: (Enteroviruses: polio, coxsackie, echo, HAV, reoviruses, adenoviruses)

To infect GI tract: need resistance to low pH, detergents (bile), proteases (small intestine)
 Some viruses even co-opt these features as part of life cycle!
Review: anatomy of small intestine
Some viruses replicate in GI tract and cause gastroenteritis  Crypt cells (dividing, secretory)
 Norovirus: (+) RNA no envelope  Villus cells (tip = mature, non-dividing, absorptive)
 Rotavirus: segmented dsRNA no envelope  M-cells (Peyer’s patches, like LNs)

Pathogenesis of viral gastroenteritis: Different viruses infect different sites in small intestine
ingestion  mucosal infection  diarrhea  more transmission

Rotavirus
Rotavirus diarrhea: most common cause of severe dehydrating diarrhea in young children

Rotavirus: segmented, dsRNA (1 segment = 1 protein), no envelope

 In Reovirus family
 RNA alone not infectious
 Different segments = different viruses; can distinvirionguish rotaviruses based on electrophoresis
o Can reassort during dual infection of cells
Structure
 Outer capsid: VP4, VP7 (role: attachment & entry; neutralization / protective immunity target)
o VP7: viral surface glycoprotein, major part of virion
o VP4: much smaller component
 Trypsins from small intestine: cleave VP4  VP8* + VP5*
 Required for infectivity: once cleaved, can exposes fusion domain & allows fusion/entry
 VP5* selectively permeabilizes membranes
 Core:dsRNA genome woven into capsule structure on inside

Steps in infection:
1. Ingest virion  to small intestine  trypsin cleaves VP4  entry mediated
2. Intermediate sub-viral particle formed (ISVP)  enters lysosome, cytoplasm, etc.
 STAYS as ISVP (intact) – doesn’t fully uncoat like other viruses to show genome
3. ISVP has its own VIRAL RNApol – makes (+)-strand RNA & extrudes into cell
4. New RNA can be used as mRNA to make proteins, assemble virus, etc.

Cypopathic effects:
 see blunted, vacuolated villi
 MATURE enterocytes infected, not dividing cells at base of crypts
o In one week: everything restored (more being made at base, infected cells turned over)

Pathogenesis:
 If you have neutralizing antibodies (anti-VP4/7), halts infection (VACCINE target)
 Rotavirus infects mature absorptive enterocytes in small intestine; produce & release NSP4
o Cellular disruption leads to ↑Ca+2  malabsorption & osmotic diarrhea
 Productive infection  production of NSP4: viral enterotoxin
 NSP4:
1. Stimulates Cl- secretion from crypt cells (causes osmotic diarrhea)

18
 2. May also stimulate enteric nervous system (more diarrhea)
Diarrhea: good for virus: more transmission Rotavirus Dx
 Often hard to
Clinical features: (vs other virus causes): high prevalence of vomiting & dehydration culture viruses
 Esp. important in infants – can’t tolerate huge volume depletion  Use antigen-
specific enzyme
Epidemiology: immunoassay
 younger kids (6mo-1yr) get more rotavirus gastroenteritis, diarrhea (stool specimen)
 Biggest single cause of infant diarrhea in both developing & developed countries
o (US: million cases/yr, 150 deaths, $350M in costs; developing countries: 150M cases, 900K deaths/yr)
 Seasonality: more in winter (opposite of enteroviruses)

Vaccine: made by reassortants (rhesus monkey/bovine + human – less virulent but still antigenic)
 One was pulled (linked to intussusception – one part of bowel slides into another like telescope – in infants) in
1999 (rare cases)
 Two live, oral, attenuated vaccines are FDA approved now (bovine reassortment, no intussusception risk)
o Now routine in US

Norovirus
Outbreak of gastroenteritis (1972, Norwalk, OH) – “winter vomiting disease” but no true seasonality
Found viral source: related to small rounded structure viruses; all termed Calciviruses

Norovirus:
 (+) ssRNA, no envelope
 Cup-shaped indentations on surface (β-parallel sheets)
 Only infects some people: depends on receptor status in host & blood type
o FUT2 encodes a carbohydrate that’s part of receptor
o If receptor present: “secretor” (secretor ≫ non-secretor for susceptibility)
o O > A/B for susceptibility (blood types)

Clinical features: high level of variability (some vomit w/o diarrhea, others vice-versa, some both)
 Delayed gastric emptying might be involved (asx infected = no delay)

Epidemiology: all ages, all groups, across the board

 (% with serum Ab increases with age, esp. post 6yrs, depends on country)
 Acute gastroenteritis outbreaks (e.g. banquets,day care, cruise ships, nursing homes, etc.)
o Most common etiology of foodborne illness outbreaks (& foodborne illness overall!)
o Easy to spread (hand-hand, surfaces, etc.)
o Also: wells, water supply, nursing
homes/hospitals, etc. SUMMARY OF GASTROENTERITIS VIRUSES

Infectivity: stool, vomit are infectious Rotavirus

 Many strains with little durable immunity  dsRNA virus that synthesizes RNA inside a
transcriptionally active particle
Dx: no routine tests (usually just for investigations)  Most common cause of dehydrating diarrhea in
Rx: supportive (usually self-limiting 2-3d) children <2yo worldwide

Calicivirus (e.g. Norovirus)

 (+) ssRNA virus with genome similar to
picornaviruses
 Outbreaks of gastroenteritis in all ages
 Most common cause of infectious GI illness
(food-borne, cruise ships, water-related, etc).
19
 Gammaherpesviruses: EBV / KSHV
Epstein-Barr Virus (EBV)
 dsDNA, large genome
 Immortalized B-cells: after infection with EBV: enter cell cycle, proliferate, grow indefinitely in tissue culture,
tumorigenic in mouse models

Epidemiology:
 Everybody, everywhere (>95% adults worldwide)
 Primary infection: transmitted in saliva
o Asymptomatic if infected as a kid (most exposed in early childhood)
o Infectious mononucleosis if infected later in life (25-70% of adults infected develop Sx)
 Most important diseases are associated with latency (tumors) – very uncommon

Virology:
 Has a lytic and a latent phase of infection (Burkitt’s cells are slightly different because they have less protein
expression and are therefore less immunogenic)
o Lytic phase: spread via infectious virions like normal virus
o Latent phase: hangs out in epitopes
Lytic infection of B-cells Latent infection of B-cells Burkitt’s B-cells
(“immortalized”)
Genome Linear Circular epitopes
Viral (acyclovir susceptible), Host (not acyclovir susceptible)
DNApol used
Viral enzymes expressed Viral enzymes not expressed
Lots of proteins expressed Lots (antigenic) Only one (invisible to CD8+
Gene expression T-cells because of lack of
MHC-1 presentation)
Immune response Big response Big T-cell response No T-cell response
Infectious virions Host cellular proliferation; no virions made
Spread
(epitopes partitioneddaughter cells when replicating)

Keeping virus under control:

 T and NK Cell response (atypical lymphocytosis)
o Kills many infected B-cells
o > 1% T cells in most seropositive healthy people target EBV (huge response, surveillance)
o T cells rapidly kill off immortalized B-cells, not Burkitt’s cells

Infectious Mononucleosis
 Especially prevalent if primary EBV infection occurs as adult
Pathogenesis
1. Transmission: Saliva (“kissing disease”)
2. Immortalization of lymphocytes in vivo
3. T cell response, most immortalized B-cells are killed
4. A small number of EBV-infected resting B-cells have minimal antigen expression (like Burkitt’s cells)  escape
5. Reactivation of these infected, resting B-cells occurs sporadically (unknown why)
6. Intermittent in everyone (reactivation): Production of virus, shedding in saliva, infectivity
Clinical features
 Sore throat, fever, generalized lymphadenopathy (esp. cervical)
 Atypical lymphocytosis (activated T & NK cells): “ mononucleosis” is really a lymphocytosis
Diagnosis
 (+) heterophilic monophile test
20
 o Turns out that Abs generated during infectious mononucleosis will agglutinate horse RBCs (weird &
accidental cross-rxn)
o “ Monospot” test used currently based on this
o Disappears with resolution of acute illness
 Serology: IgM to viral capsid antigen (VCA) for current infection; IgG for post-infection

Burkitt’s Lymphoma
 Young males, maxillary / periorbital tumor
EBV Tumor associations
 Equitorial Africa only (malarial distribution): not high
Lymphomas Other
altitudes or deserts
Endemic Burkitt’s Nasopharyngeal carcinoma
 Escape immune detection (makes few viral proteins) B-cell in immunodeficient Gastric carcinoma
 Exact EBV – BL relationship unknown Hodgkin’s disease

B-cell lymphoma (immunodeficient pts)

Basic idea:
 T-cells suppressed, pretty much everybody has EBV B-cells
 can’t keep them in check anymore and end up with B-cell lymphoma (uncontrolled growth)

Patients:
 Transplant patients on cyclosporine, etc – if stop suppression, tumor regresses
 Severe combined immunodeficiency (SCID), X-linked immunodeficiency: often die of EBV B-cell lymphoma
 AIDS lymphoma: 50% increased risk
 (X-linked agammaglobulinemia, XLA): no risk (no B-cells = no EBV, no B-cell lymphoma)

Hodgkin’s lymphoma
 EBV in tumor cells in 30% of cases (associated)
o Find EBV DNA/RNA/Ag at each tumor site, during presentation & during relapse

Nasopharyngeal carcinoma
 Especially prevalent in Southern China (genetic & environmental)
 Virtually ALWAYS EBV-associated (not well understood)

Kaposi’s Sarcoma Herpesvirus (KSHV)

KSHV
 Unlike EBV, doesn’t infect most people (rare except in HIV, MSM, special pops)
 Found via PCR in B-cells of seropositive individuals, DOESN’T IMMORTALIZE like EBV
 Several genes closely mimic human genes (e.g. viral IL-6)
 Transmission: early childhood in endemic regions (saliva?), ? sexual trans in MSM? Rare in transfusion, IV

Kaposi’s sarcoma
 KHSV infection is required
 Geographic: Children in Africa (hands/legs); old men in Mediterranean (Italy, Greece, etc.),
 Immunosuppresion:
o Organ transplant recipients (regress with withdrawal of immunosuppresion
o AIDS patients: especially MSM in North America & Western Europe
 Presentation: tumor, most commonly on skin, may also be GI/lungs
o Neovascular proliferation  purplish color

21
 Primary Effusion Lymphoma
 In AIDS patients, B-cells float in pleural/peritoneal fluid (no solid component)
 Exceedingly rare
 Pts DUALLY INFECTED (EBV+KSHV)

Main Concepts (review)

Latent infection:
 How can a virus establish latency in a dividing cell? How can a virus spread inside a host while latent?
o Need to be able to make DNA that can go into daughter cells
o EBV/KSHV have episomes that are replicated using host machinery & partitioned to daughter cells
 Are viral genes expressed in latency?
o Yes: can be one, a few, many – and virus can take over cell, make it grow out of control
 Can disease processes be associated with latent infections?
o Yes: tumors for example
Lytic infection/reactivation GAMMAHERPESVIRUS TUMOR ASSOCIATIONS
 Is it always harmful to the host? Nasopharyngeal carcinoma
Always EBV associated, regardless
o Not usually – don’t usually want to of geography
measure EBV in blood (diseases aren’t EBV associated in malarial areas of
Burkitt’s lymphoma Africa but not in North
virions but are latent virus)
America/Europe
Tumor associations Hodgkin’s lymphoma Sometimes EBV associated
 What does tumor association mean? Kaposi’s sarcoma Always KHSV associated
o Not just that colon cancer has EBV – Primary effusion lymphoma KSHV and EBV associated
everybody is EBV positive!
o Need to find virus in cancer cells

22
 Viral Hepatitis
Hepatitis = inflammation in the liver
 Nonspecific: alcohol use, acetaminophen, etc. can cause too
 Infectious causes: nonviral (syphilis, TB, histo, etc.) and viral (CMV, EBV, HIV, H[A-C]V, etc.)

Hepatitis viruses: Certain viruses only cause hepatitis clinically

 A to E, really a clinical grouping, not biological (some DNA, some RNA, etc.)

Clinical course of Hepatitis: exposure  incubation (3-4wks)  symptoms (jaundice)  recovery or persistence
 Acute viral hepatitis (USA): A>B>C for frequency
 Chronic viral hepatitis: B & C (A can’t cause chronic hepatitis)

Transmission:
 A (& E) is nonenveloped, not killed by bile, so can be Exposure HAV & HEV HBV & HDV HCV
transmitted fecal-oral (acute) Fecal-oral +4 0 0
 Note that the chronic ones can be transmitted via blood Sexual +1 +4 +1
(makes sense) Blood +1 +4 +4
 Sexual: oral or vaginal Perinatal +1 +4 +2

Clinical features of acute viral hepatitis

 HAV+HEV: provokes a stronger immune response than B/D, C
o Shorter incubation HAV+HEV HBV+HDV HCV
o Higher % with jaundice Incubation (weeks) 2-6 6-24 6-300
o No persistence % Jaundice 30-70 20-40 15-25
 HCV: big one for persistence % Persist 0 5 80

Consequences:
 Liver: largest organ in body, stores vitamins A, B12, D, E, K; metabolizes lipids, makes cholesterol, stores
glycogen
 Fibrosis: scarring (overgrowth of connective tissue), restricts function  bridging (bands of fibrosis)
o Cirrhosis: widespread fibrosis with nodule formation macronodular cirrhosis
 Hepatocellular carcinoma (primary cancer of the liver; one of most common in world, cirrhosis is risk)

Lab Dx:
 Elevated transaminases (ALT, AST > 10x normal): liver-specific enzymes, spilled out in ongoing damage
 Antibodies
o IgM antibodies: markers of recent infection (6 mo)
o IgG: markers of any past infection
o Neutralizing Ab: recovery process under way
 Viral particles(protein/nucleic acid, “antigen”): ongoing infection and infectivity

Prevention: Vaccines (HAV, HBV) or immunoglobulin administration (HAV, HBV)

Treatment: none for acute hepatitis; there are treatments for chronic HBV/HCV

Hepatitis A virus
 Picornavirus, RNA virus
 NO ENVELOPE  bile stable (can be transmitted fecal-oral)
 Capsid proteins elicit a universal neutralizing antibody (one serotype  vaccine possible)

23
 Hepatitis B virus
 S-gene: surface antigen, makes surface antigen in outer envelope;
o first recombinant vaccine (yeast) produced against it (1st anti-cancer vaccine)
 Genome: tiny (3200nt), uses overlapping reading frames
 Replication: entry  uncoating  genome incompletely closed (opened from circle) to be imported to nucleus
o Completly Closed Circular DNA (cccDNA): genome closed & repaired inside nucleus
 Makes a bunch of transcript for viral replication
 Can be INTEGRATED into host genome (stable, reservoir) – hard to eliminate
 Transmission: makes TONS of virus and extra surface antigens (serum packed); environmentally stable (can
hang out on tables, equipment, etc). Very transmissible

Hepatitis D virus
 Has Dependency issues: needs Hepatitis B (either via co-infection or prior chronic infection)
o Uses HBV to put on its capsule (has HbsAg) but has its own RNA

Hepatitis C virus
 Tons of genomic diversity
o Error rate: 1x10-4; turnover is really high (1010-12 per day)
o Mutations: every base, every day, every person (like HIV)
 Forms quasispecies
 Even more genetic diversity than HIV
o Explains failure of vaccine & immune response to clear (some variants can evade & persist)
 Abs don’t neutralize (too much diversity)
 Steady progression of chronic disease, often cirrhosis  end-stage liver disease (ESLD)
 ALT at constant elevated rate; RNA present the whole time
 Clinical correlations of genetic diversity
o 80% persistence, resistance to treatment
o HCV is hard vaccine target, hard target for antiviral drugs
o Reservoir: infections last for decades

Hepatitis E
 40d average incubation; 1-3% CFR
 Pregnancy: often fulminant (15-25% CFR!)
 Higher severity with age; no chronic sequelae

Summary/Review

5 hepatotropic viruses
TRANSMISSION COURSE KEY FEATURE
HAV Fecal/oral Self-limited No envelope = bile stability
HBV Surface antigen in vaccine
HCV Blood/sex/etc Chronic Viral diversity
HDV Needs HBV
HEV Fecal/oral Self-limited Fatal in pregnant women

 Viral particles: ongoing infection

 Anti-viral Abs: IgMs are recent

24
 Pharmacology: ID & Micro (Viruses)
Anti-HIV Drugs......................................................................................................................................................................... 2
Vaccines I ................................................................................................................................................................................ 5
Vaccines II ............................................................................................................................................................................... 7
Antivirals ................................................................................................................................................................................. 9

1
 Anti-HIV Drugs
Goals: how does chronic HIV cause disease? CD4+ T-cell depletion  immune suppression; direct consequence of HIV
replication, so inhibit HIV replication!
 Decrease HIV replication by as much as possible for as long as possible in every patient

HIV dynamics
 HIV replicates very rapidly (can be good: can shut off consequences of infection very quickly)
 Can only suppress chronically, not eradicate (latent reservoir)
 Need to get into brain, LN, genital tract, etc where infection is
 Can develop resistance extremely rapidly (esp. on monotherapy)

Nucleoside analog reverse transcriptase inhibitors

(NRTIs)

Zidovudine (azidothymidine, AZT)

 Also: ddI, ddC, d4T, 3TC, ABC, FTC, TDF
 thymidine analog; 5’ OH replaced with N3
 Synthesized in 1964 as anti-cancer; known
antiretroviral in ‘ 74, anti-HIV in ‘ 85, approved in ‘87
really quickly (single small trial)
 Still one of most potent anti-HIV drugs

zidovudine Mechanism of Action: NRTI, Anti-HIV antiretroviral agent. Thymidine analog. Triphosphate form inhibits
(azidothymidine, HIV reverse transcriptase, acts like chain terminator
AZT) Effects: Incorporated but not substrate for elongation in RNA-dep-DNA-pol activity of HIV RT
Selective Toxicity: poor, also inhibits mitochondrial DNApol
Indications: HIV
Administration: Short plasma half-life (1h) but much longer intracellular AZT-TP half-life (allows more
infrequent dosing, q12h).
Toxicity:
 Bone marrow suppression (common, mostly anemia, less commonly granulocytopenia).
 Rare: Myopathy, lactic acidosis/steatosis
 (steatosis = accumulation of fat in liver cells, fatal and class-wide for NRTIs albeit rare)
Resistance: Need 5+ AA changes. Slow to develop (only 1/3 on monotherapy resistant in 1 year), limited
cross-resistance with other NRTIs
Other:
 Phosphorylated by cellular enzymes to triphosphate (active form). Rapidly converted to AZT-MP,
accumulates in cell (-DP, -TP formation more slow)
 Well absorbed, eliminated by glucuronidation (Phase II).
 Commonly used in other countries (cheap generic) and sometimes for needle-stick prophy here,
although others probably work as well (only one studied)
Tenofovir (TDF) is most common in US now
tenofovir (TDF) NRTI antiretroviral; unlike AZT is a broad-spectrum antiviral (anti-HBV too),
more commonly used than AZT in USA

2
 Non-nucleoside reverse transcriptase inhibitors (NNRTIs)
 Not lots of structural homology in this group (unlike NRTIs) – binding to flexible binding pocket
Nevirapine (NVP)
 Also: delavirdine, etravirine, efavirenz
 Only one that doesn’t inhibit HIV-2, resistance develops rapidly (makes sense)

nevirapine Mechanism of Action: NNRTI Anti-HIV antiretroviral. Non-competitive reverse transcriptase inhibitor
(NVP) Effects: Binds to HIV RT distant from active site, causes conf. change to make RT less efficient
Selective Toxicity: No effect on human DNApols (incl. mitochondrial)
Indications: HIV
Administration: bid but could be qd (long half life)
Toxicity: mostly immune-mediated
 Rash, hypersensitivity (common), hepatitis (rare)
 Stevens-Johnson syndrome (rare, systemic attack of immune system against epithelium: full body
burn, slough off mucosa/epithelium)
 IMPORTANT: CYP450 3A4 INDUCER (drug interactions - like rifampin).
Resistance: FAST (very poor monotherapy) - needs single AA change (1000x resistance), days to weeks,
Cross-resistance to other NNRTIs (exception = etravirine)
Other: no intracellular activation required. Doesn't work against HIV-2 (doesn't bind RT). Well-absorbed,
eliminated by CYP450 3A4

Efavirenz is currently most used in US

efavirenz NNRTI like nevirapine
 Less toxicity, longer half life most common NNRTI in use in USA
 part of Atripla (1 pill qd);

Protease inhibitors (PIs)

HIV Protease: usually cleaves immature surface proteins (immature virion mature core/capsid structure, infectious)\
 Doesn’t prevent virion formation or release
 Inhibits maturation

3
Ritonavir
Ritonavir Mechanism of Action: PI, anti-HIV antiretroviral.
(r)  Competitive inhibitor of HIV protease (mimics transition state)
Effects: Inhibits HIV protease; prevents viral maturation (can make immature virus, but can't make it
infectious). 2-3 log reduction in VL (can't keep replicating + fast turnover of HIV = quick drop!), partially
restores CD4 count even on own
Selective Toxicity: No known human aspartyl proteases inhibited
Indications: HIV: PI but mostly used now as booster (increase concentrations of other HIV drugs)
Administration: bid (3-5h half life)
Toxicity:
 Inhibits CYP450 3A4 (also induces hepatic enzymes but net block). Drug interactions (but also used
for boosting).
 GI intolerance (nausea, vomiting, diarrhea), hyperlipidemia (elevated cholesterol & TGs, reversing
metabolic disturbance created by virus),
 First few weeks: common circumoral & extremity parasthesias (important for adherence)
 Rare: glucose intolerance, hepatic transaminitis (inceased AST/ALT).
Resistance: Weeks to months. Not necessarily in all subjects (unlike NRTIs)
 Primary resistance mutation: 1AA, 3-5x resistance.
 Secondary resistance changes accumulate, resistance keeps increasing, cross-resistance increases.
 If you can keep at high levels (e.g. boosting, drugs with high therapeutic index), 1st mutation will still
be suppressed (dose-response curve).
Other: no intracellular activation required. 99% protein bound. Variable bioavailability (first-pass metabolism,
autoinduction). Eliminated by CYP450 3A4 (oxidative)

Others
 Integrase inhibitors (e.g. raltegravir), inhibit HIV integrase (no chromosomal integration), very non-toxic (like
placebo!)
 Entry inhibitors
o Fusion inhibitors (e.g. enfuvirtide = T-20), interferes with membrane protein bundle formation needed
for fusion, only injectible BID & really expensive (salvage pts only)
o CCR5 antagonists (e.g. maraviroc) – inhibit host cell CCR5! Only effective if CCR5-trophic HIV, approved
for salvage pts only

HAART (highly active antiretroviral therapy)

 Combination therapy ONLY and for EVERY PATIENT
 Potent combinations possible for pretty much everybody
 Popular starting regimens:
o Efavirenz + 2 NRTIs (e.g. Atripla, 1 pill qd, 80% new HIV Rx in US
Atripla 1 pill qd for HIV! efavirenz (NNRTI) + emtricitabine (NRTI) + tenofovir (NRTI)
o Potent PI + 2 NRTIs (usually a boosted PI with ritonavir)

 Rationale: prevent drug resistance (probably need ~3 agents to prevent resistance emergence)
o Probably not synergy (3 NRTIs nearly as active as regimens with 2-3 different targets)
 Trends: less pills, co-formulated drugs, qd regimens, better tolerability, better resistance testing
o Make it easier since it’s for life

4
 Vaccines I
Vaccine: any formulation able to elicit antigen specific protective immunological memory

Classic vaccine principle: vaccine protection based on exposure of host to immunogenic agent followed by the natural
development of immunity (failed in HIV, malaria, cancer, etc)
 Adaptive immune response: only one that has memory, against certain antigens
 Primary response smaller,
 Secondary response faster & bigger to prevent infection
o Can prevent clinical disease!

Main types of vaccines

Live Vaccines Inactive Vaccines
antigens encoded by a genetic material and synthesized in protein/polysaccharide antigen is directly injected into
host (e.g.live attenuated) host (inactivated vaccines, recombinant proteins, purified
polysaccharides, etc)

presented on MHC class I (made inside cells) and MHC II; injected antigens presented on MHC class II (internalized)
make CD8 (cytotoxic) T-cells and helper T-cells too! make mostly helper T-cells

infectious agent, locally deposited, distributed to regional lymphnodes

makes strong innate inflammatory responses, weak, innate inflammatory response
strong induction of all adaptive responses (B and T cells) (requires addition of adjuvant)
longer memory mainly induce antibody responses (weak CD8 responses)

Essential components of vaccine formation

1. Route of administration: Appropriate presentation to immune system (B cells, CD4/CD8 T-cells)
2. Adjuvant(danger signal): immune stimulatory signals
o Start innate immune responses, shape adaptive effector mechanism
o Only really need for inactive vaccines – live vaccines have enough “danger” on their own
3. Active principle: Antigenic epitopes correlated with protection!
o Exact region of molecule & pathogen recognized by T-cell / antibodies

Route of administration (oral, subcutaneous, intradermal, intramuscular)

 Changes how antigen is processed (which cells?), how it modulates immune system
 Want mucosal immunity? Have to expose to mucosa!
 Want B-cell epitope? Polysaccharides (IgM, CD4-independent Ab) or protein (IgG, CD4-dep Ab)
 Want T-cell epitope? CD4: needs class II presentation, CD8: needs to be intracellular, class I presented

5
Adjuvant: Immunology mini-review:
 Live vaccines naturally activate innate immune responses (retain PAMPs,
ability to have C’ fixed, opsonization, etc.) so they don’t need adjuvant T-cells: immune system
 Inactive vaccines: include some stuff that binds to innate immune receptors degrades pathogen protein,
(adjuvant) processes via Class I or Class II
o Aluminum compounds, liposomes, virosomes, viruslike-particles, etc. MHC, presented as small
o Can also conjugate your antigen to an immunogenic protein (older) fragments

Mechanism of vaccine action  T-cells recombine to

1. Activate B-cell response  make Ag-specific antibodies generate molecules;
some can perfectly bind
a. Neutralization: block biological function of antigen
to MHC-epitope
b. Opsonization: faster clearance of antigen combination

2. Activate T-cell response  CD4 helper & CD8 cytotoxic B-cells: antibody’s exact
a. CD4+: cytokine secretion, supports B-cell/CD8+ cytolytic cell conformation is important
activation, proliferation, maturation, memory differentiation (needs to bind actually virus,
b. CD8+: cytolytic (kill infected cells) not virus+MHC)

Vaccines against viruses

 neutralizing antibodies (target surface envelope glycoproteins / proteins)
o Can use plaque reduction neutralization assay (mix virus & ab on culture, if neutralizing no plaques form
in culture cause virus can’t get in; otherwise plaques form where cells infected)
 CD8+ cytotoxic action (target cytoplasmic non-structural proteins)

Vaccines against bacteria (if extracellular)

 Opsonizing antibodies for ↑phagocytosis (target surface polysaccharides, envelope glycoproteins/proteins)
 Antitoxin antibodies (bind & neutralize toxins) – may not even need to kill bacteria to neutralize disease

T-cell independent response (for vaccines against sugars, for instance)

 make mostly IgM because they don’t stimulate CD4+
 Go away relatively quickly – conjugate to protein to induce helper T-cells & get better response!

T-cell dependent response (vaccines against proteins)

 Have antigen and stimulate T-helper cells (make IgG after IgM, differentiate into memory phenotypes)

Vaccines require very high standards

 High safety: Giving to large numbers of healthy people / especially babies!
 High benefit / efficacy:
o High individual protection levels (reduces risk greatly in individual)
o Herd immunity (reduce contagion in community, disease in unvaccinated population)

Herd Immunity

6
 Vaccines II
Lots of vaccine preventable diseases; these are hard to make though! US health care is expensive! Yada yada yada…

Main classes of antigen formation in clinical use

Host attenuated (mutant)
Whole organism
“Live” e.g. BCG; adapt pathogen to non-human host & back into person
(weakened agent)
Recombinant mutant
Purified fraction from organism (part of toxin, antigen, etc)
Sub-unit
“Inactivated” Recombinant antigen
“Whole organism”

Vaccines with live-replicating organisms

 Need to attenuate pathogenicity but preserve immunogenicity
Immune response:
 activate innate immune system, don’t need adjuvant
 presented on MHC I/II, whole shebang: T-cell/CD4-Th/CD8-CTL/B-cells/memory/neutralizing Ab
Can sometimes cause disease if immunocompromised (risk/benefit; depends on disease burden, etc.)

Examples:
1. Attenuated virus: e.g. varicella virus vaccine (varivax)
 Changing hosts can cause virus to adapt in ways that make it less pathogenic to humans
 This vaccine: from child with varicella to human lung cell cx  guinea pig cell cx (gets adapted to different host)  back to
human cell cx (ensure immunogenicity); given sub-q
Oral vaccines:
2. Recombinant/Reassortment virus: e.g. rotavirus vaccine (RotaTeq) can provide mucosal
 Reassorted with different animal strain, using reverse genetics, to immunity (IgA)
attenuate pathogenicity
 Cover multiple strains if there are various pathogenic strains of virus
 This vaccine: human + bovine rotavirus reassorted, covers 5 rotavirus strains, given orally

Vaccines that are inactive/non-replicating

Immune response
 presented on MHC class II (CD4, not CTL CD8s, good memory response)
 often need to give adjuvant to better stimulate innate immune system (often Aluminum)


Examples:
1. Whole organism e.g. hepatitis A vaccine
o Need inactivation of pathogenic properties but preservation of immunogenicity
o Need to give with adjuvant (aluminum)
o This vaccine: given IM; formalin-inactivated whole virus vaccine from attenuated HAV in cell culture (fibroblasts);

2. Subunit: Polysaccharide e.g. meningococcal polysaccharide vaccine (Menomune)

o Need to purify antigen & inactivate toxicity (if applicable); no epitope mapping needed
o Stimulates innate immune system via TLR receptors
o Produces CD4-independent B-cell response (IgMs produced, short-lived)
o This vaccine: sub-q, from several groups of N. meningitides polysaccharides

3. Subunit: Protein-conjugated polysaccharide e.g. conjugated meningococcal polysaccharide vaccine (Menactra)

o Same basic idea as above; still stimulates innate immune system, need to purify / remove toxicity, etc.
o Conjugate polysaccharide to something immunogenic (inactivated diphtheria protein in this case)
7
 o CD4-dependent B-cell response (IgGs, better memory response)

4. Subunit: Recombinant protein e.g. Hepatitis B vaccine

o Express antigen in genetically modified heterologous organism
o Requires adjuvant; produces CD4-dep B-cell response, IgGs, etc. (longer-lived)
o This vaccine: included in childhood to prevent perinatal transmission & cause it’s hard to diagnose

Vaccine uses:
 Active immunity: protection from person’s own immune system after vaccine, long-lasting
 Passive immunity: transferred from another person or animal as antibody; temporary, wanes with time
o Transplacental IgGs passed from mother to child: need to schedule childhood vaccinations accordingly
(or else mom’s IgGs will neutralize the vaccine antigen!)
o Results from: all blood/blood products, homologous pooled human Abs / Igs, antitoxins (pooled serum)

Immunizing during pregnancy

 Protects both mother and infant; transplacental Abs are cheaper & safer than Ig therapy
 Factors that influence Ab transfer in pregnancy
o Time from vax to delivery
o IgG level/subclass (IgM, IgA, IgE: DO NOT CROSS PLACENTA)
o Gestational age: @ 33wks IgGmaternal = IgGfetal, then fetal Abs more prevalent
 Influence on neonatal immunization
o Protect the infant
o Neutralize live attenuated vaccines; influence immunization schedule

Neonates’ Immunological Responses: immunize as early as possible; boost as needed

 Immature lymphoid organs; need 8+ wks post-natal age, adjust for premies
 Limited responses: CD8, innate system
 Immature dendritic cells (less CD4 activation, fewer germinal centers formed)
 Maternal Abs: don’t affect T-cell priming; epitope specific

The Elderly
 Thymus regresses
 Less naïve T-cells, mostly memory population: if you introduce antigen, it might be half-recognized by some cells
that are already around, and a less specific/effective immune response is mounted
 CD4 impaired (TRC/MHC signaling impaired)
 CD8 cells  senescence; Mϕ impaired

Immunocompromised: don’t give most of these vaccines!

 HIV patients can often mount immune responses if CD4+ are OK, check recs for vaccine

8
 Antivirals
Background
Viruses: obligate intracellular parasites.
 Initial thoughts: kill viruses, kill the cell (bad), so develop ways to Need for therapeutic antivirals:
stimulate the immune system (vaccines).  more immunosuppression (chemo, transplants)
 Amantadine: selectively target influenza without killing cells, made  pathological / genetic immunodeficiency (AIDS)
antivirals seem plausible  greater potential for rapid spread of infection
 Current strategies: use basic science discoveries about viruses, (higher population density, greater global
biological screening / high throughput screening, rational drug mobility, emergence of new antivirals)
design
Antivirals against HBV
HBV: 300M+ worldwide, major cause of chronic hepatitis, cirrhosis, hepatocellular carcinoma
 Tiny genome (dsDNA, circular, single-stranded region) copied from RNA template by viral reverse transcriptase
after incorporation into virion

α-IFN Mechanism of Action: Anti-HBV agent. Stimulates Jak/STAT pathways leading to transcription of genes with
"interferon-specific response element (ISRE)"
Effects: ISRE genes interfere with pretty much all aspects of viral life cycle (especially protein synthesis)
Selective Toxicity: IFN is part of normal human antiviral response
Indications: HBV (chronic active HBV)
Administration: Subcutaneous or IM (poor oral bioavailability)
Toxicity: flu-like symptoms and sometimes neuropsychiatric problems
Resistance: tolerance develops in most patients; HBV terminal protein blocks signal transduction
Other: very short-lived effects

lamivudine Mechanism of Action: nucleoside analog (NRTI), inhibits both HIV and HBV reverse transcriptase
(3TC) (similarities in enzymes)
Effects: converted to triphosphate by cellular enzymes; competitive inhibitors / chain terminator of HBV
DNApol (no 3' OH)
Selective Toxicity: humans don't have RT
Indications: HIV, HBV
Administration: po (good oral bioavailability)
Toxicity: negligible
Resistance: mutations in viral RT, some mutants less fit in vitro, others 3TC-dependent. Discontinuing
leads to rebound of viremia.

Antivirals against Influenza (A, B, avian)

Influenza: (-) sense ssRNA genome, segmented, synthesis relies on viral RNA-dep-RNA-pol

M2 inhibitors
amantadine Mechanism of Action: Anti-influenza agent. Inhibits M2 protein
Effects: M2 protein = ion channel used to pump protons into virion compartment & reduce pH, which is
rimantadine required for uncoating.
1. Primary effect: Drug binds inside M2 channel & blocks.
2. Secondary effect: decreases pH in Golgi, causing premature HA conf change, decreasing release.
Selective Toxicity: Humans don't have M2 protein
Indications: Influenza; not used as much anymore
Administration: Oral (rimantadine is methylated deriviative of amantadine, better oral bioavailability)
Toxicity: CNS side effects (rimantadine can't cross BBB as well; less side effects)
Resistance: Rapid (30% in 5 days) via mutations in M2 AA's lining channel. Same mutations overcome
early & late effects. Mutants retain fitness.

9
 Neuraminidase inhibitors
zanamivir Mechanism of Action: Anti-influenza agent. Competitive, reversible inhibitor of viral neuraminindase (NA)
Effects: NA cleaves terminal sialic acids from glycoproteins, glycolipids, proteoglycans, promoting effective
oseltamivir spread of virus throughout respiratory epithelium. Drug is sialic acid analog with larger, positively-charged
(Tamiflu) guanadine to interact more strongly with negative AA in active-site cleft. Oseltamivir also has a
hydrophobic region to bind to enzyme hydrophobic pocket
Selective Toxicity: humans don't have NA
Indications: prophylaxis and treatment of influenza
Administration:
 Zanamivir: poor oral bioavailability (IV or aerosol spray) - CAN'T USE IN PTS WITH RESP PROBS
 Oseltamivir: prodrug, better oral bioavailability, can give PO
Toxicity: Minimal (some nausea)
Resistance: inefficient in vitro; no cross-reactivity between zanamivir/oseltamivir, mutants have reduced
fitness

Antivirals against herpes viruses

Herpes: large, complex virus, linear, dsDNA genome, famous for latent infection
 Tons of interesting targets (tons of proteins) but worst choice - viral DNApol – is most common target

acyclovir Mechanism of Action: Nucleoside analog antiviral agent. Inhibits DNA synthesis
Effects: Chain terminator (no 3' OH) and competitive inhibitor of viral DNApol
valacyclovir Selective Toxicity: Two mechanisms:
1. For initial phosphorylation (ACV to ACV-MP) viral TK >cellular TK in affinity, so drug accumulates
in infected cells. (Next two P-lations via cellular TKs.)
2. ACV-3P inhibits viral DNApol much more than cellular DNApol.
Indications: HSV-1 (facial), half as active against HSV-2 (genital), not useful against CMV or HHV6
Administration:
 Acyclovir: 10-30% orally bioavailable
 Valcyclovir: prodrug with more bioavailability (substrate for intestinal/renal peptide
transporters; rapidly converted to ACV by intestinal/hepatic enzymes after oral administration)
Toxicity: Well tolerated: some nausea, diarrhea, rash, headache; rare renal/neural toxicity
Resistance: Mutation in viral TK (can't P-late ACV); causes cross-resistance to analog. Less frequent:
mutations in viral DNApol (less incorporation)

ganciclovir Similar to ACV but active against CMV

Similarities: converted to monophosphate by viral kinase, then -2P, -3P by cellular enzymes; competitive
inhibitor of viral DNApol
Differences:
 single hydroxymethyl group on sugar side chain
 no viral TK (p-lated by UL97, a protein kinase)
 not an absolute chain terminator (competitive inhibitor)
 accumulates to higher concentrations in CMV-infected cells (although ACV is better viral DNApol
substrate)
Toxicity: SERIOUS. affects bone marrow progenitor cells (low therapeutic index); inhibits lymphocyte
blastogenic responses
Resistance: mostly kinase mutations (like ACV)

10
foscarnet Mechanism of Action: antiviral (anti-herpes) agent. Pyrophosphate analog (inhibits all herpesviruses)
Effects: reversibly blocks pyrophosphate binding site on DNApol, inhibiting cleavage of pyrophosphate from
nucleoside-3P during elongation (pushing reaction backwards)
Selective Toxicity: viral DNApol is 100x more sensitive than cellular DNApol
Indications: only for life-threatening infections with no other treatment available (mechanism of action
different, so often works against ACV/GCV -resistant mutants of HSV/HZV/CMV)
Administration: Oral
Toxicity: SERIOUS. accumulates in bone, causes kidney toxicity
Resistance: Mutations in viral DNApol

fomvirisen Mechanism of Action: anti-CMV agent. Anti-sense RNA complementary to a viral mRNA
Effects: Binds, inhibits translation of a CMV mRNA encoding a protein essential for viral replication
Selective Toxicity: Doesn't bind human mRNAs
Indications: ganciclovir-resistant or -contraindicated CMV retinitis
Administration: injected into eye (completely unstable)
Toxicity: to your wallet
Resistance: has been reported
Other: VERY EXPENSIVE, only FDA-approved antisense drug

11
 Pathology: ID & Micro (Fungi & Parasites)
Characteristics & Concepts of Medically Important Fungi ..................................................................................................... 2
Superficial / Cutaneous Fungal Infections .............................................................................................................................. 5
Opportunistic Mycoses ........................................................................................................................................................... 8
Pathogenic Mycoses ............................................................................................................................................................. 12
Introduction to Parasitology ................................................................................................................................................. 14

1
 Characteristics & Concepts of Medically Important Fungi
 Candida: 3 -4 most common cause of blood
rd th
What is a fungus?
 Eukaryotic (hard to treat; close relationship to other euk) stream infection
 Heterotrophic: feed off of other sources  Aspergillis: most common cause of infectious
pneumonic mortality in BMT recipients
 Polymorphic: different shapes/forms
 PCP/PJP, crytococcus: among most common
 Cell wall: complex, heteropolysaccharides/peptides, target of AIDS-defining infections in HIV pts
antimicrobial therapy
 Cell membrane: contains sterols, commonly ergosterol (target of ampho B)
 Reproduction: all reproduce asexually, 75% have sexual cycle

Fungi contain chitin but not cellulose (plants have both)

Taxonomy based on characteristics of sexual reproduction; 4 classes cause human infections:

 Zygomycetes (mucoralis is order): lower fungi, reproduce sexually
o Rhizopus
 Ascomycetes: reproduce sexually
 Bacidiomycetes: reproduce sexually, basically mushrooms, one exception (Cryptococcus neoformans)
 Deuteromycetes: (deutero = “other”), sexual function has been lost (Candida spp.)

Morphologic Forms
 Yeast: unicellular fungus, reproduces by asexual budding (generation time = hours)
o Budding: create daughter cell, leave mother cell
 Filamentous: fungus whose vegetative form is a mass of individual hyphae (mold)
o Hyphae: characteristics used for dx in laboratory
Branching Septation
 dichotomous = “Y-shaped”  septate, e.g. Apergillus,
 right-angled = “T-shaped”  non-septate, zygomycetes, e.g. rhizopus)
 If NON-SEPTATE, think ZYGOMYCOSIS  AMPHOTERICIN is immediate response
 BRANCHING SEPTATE hyphae in immuncompromised with PNEUMONIA  Aspergillus
 Pseudohyphae: look like hyphae but not filamentous (yeast elongating)
 If HYPHAE, PSEUDOHYPHAE, and YEAST forms present: CANDIDA

Dimorphism: ability of some fungi to exist in two different morphological forms

Classic dimorphism: e.g. Histoplasmosis

 MOLD in ENVIRONMENT (room temp), YEAST in US
(tissue/lab)
 Taken up by Mϕ, cell-mediated immunity critical
Candida: opposite of classic dimorphism
 YEAST in environment, MOLD in us

Structure of a fungus
Encapsulated: only CRYPTOCOCCUS NEOFORMANS!
 Protects against host response
 Cryptococcal antigen: capsular antigen can be detected from LP in CSF via latex agglutination assay or ELISA.
Extremely sensitive test, targets glucuronxylomannan, produced in huge amounts in cryptococcal infections
Cell Wall:
 Rigid, heteropolysaccharide wall, very resistant to hydrolysis, strength & stability

2
  NOT a barrier to environment (cell membrane): like a chain link fence
 Multi-layered: glucans: inner fibrillar/inner matrix of cell wall; glycopeptides: inner/outer layers.
o 90% polysaccharide, 10% peptides
o 1,3-β-glucans: enchinocandins target this specific component of cell wall (Candida, Aspergillus)
o Also mannans, chitin, 1,6-β-glucans
 Can monitor mannans or glucans as markers in detection of invasive fungal infections
 Composition varies between different forms of fungi; target of cell/humoral immune response
 Important receptors for cells, intracellular matrices, and HARDWARE (catheters!)

Septum / septae FUNGUS SEPTAE

 Ingrowth of cell wall; appears to divide hyphae into individual cells; different Zygomycetes Few/none
septae for different organisms Ascomycetes Simple
Basidiomycetes Elaborate
Cell membrane
 Typical bilayer membrane; this is the real barrier between fungal cell/environment
 Sterols incorporated into lipid portion; most common is ergosterol, help maintain fluidity
 TARGET for drugs (ampho B = targets ergosterol in membrane directly, alloamines/azoles target biosynthesis)

Other structural features: ER/ribosomes, unstacked Golgi, simple mitochondria, membrane bound vacuoles,
 most haploid in vegetative form

Reproduction
Sexual reproduction: via fusion of hyphae (see picture on right)
Asexual reproduction:
 asexual spores, germinate  colony with identical genetic composition to parent
strain
 more resistant to organism, better dispersion
 can be infective respiratory inoculum in patients (esp. immunocompromised e.g.
AIDS pt, raking leaves  aspergillosis)
 Sporangiospores: asexual spores, produced in sac-like cell called
sporangium by zygomycetes
 Condida: asexual spores (not sporangium) by all other major
groups (e.g. Aspergillus)

Mycoses & Humans

 Virulence: varies widely between fungi; depends on host status
 Cause wide spectrum of infection ( -osis = disease)
 Transmission: endogenous flora, natural environment; most not
person-person
 Pathogenic morphologic forms can be varied; different than those in vitro

Fungal structure Examples

Budding yeast forms only Crypto, histo, blasto, sporo
Budding yeast + hyphae Candida, tinea versicolor
Hyphae Aspergillosis, zycomycosis, dermatophytosis
Spherule Coccidiomycosis
(Large spherical structure with internal spores)

Virulence factors:
 Cell surface receptors (epithelial cells, endothelial cells, caths, etc.)
3
  Hydrolytic enzymes, host mimicry
 Polysaccharide capsule (Cryptococcus)
 Melanin production: inhibits oxidative response (dampens host response)

Stains:
STAIN FEATURES
H&E Differentiate host response, not sensitive for fungi detection
PAS (periodic acid-Schiff) Stains acid polysaccharide cell wall of fungi
GMS (Gomorri’s methenamine silver) Deposits silver on fungal cell wall, better sensitivity of detection
Mucicarmine / Alcican blue Specific for Cryptococcus capsule
(Fontana Masson) Melanin in cell wall of some fungi

Classification by Host Response / Disease

1. Superficial: no inflammation, cosmetic

 E.g. tinea versicolor: very superficial blanching, “spaghetti & meatballs” (hyphae & clusters of yeast)

2. Mucocutaneous: inflammation occurs but no invasion of deeply viable tissue

 E.g. dermatophytosis: tinea corporis, ringed, papulosquamous (silvery, raised) eruption
o Tinea: initially thought was worm (“ringworm”)

3. Subcutaneous: localized infection following trauma

 Chromoblastomycosis (“copper pennies” + sheets of PMNs)
 Mycetoma (highly destructive, muscles/tendons/bones)
 SPOROTRICHOSIS: much more common than the other two
o Traumatic inoculation  single lesion  lymphocutaneous propogation (up lymphatic)
o Working with hay, prick from ROSE PETAL

4. Deep mycoses: life-threatening

TYPE OF FUNGI HOST IMMUNE STATUS MAJOR IMMUNE RESPONSE EXAMPLES
OPPORTUNISTIC Common fungi Compromised PMN Candida, aspergilla,
zygomycetes
PATHOGENIC More virulent fungi Can be CMI (cell-mediated Histoplasmosis, other
immunocompetent immunity) endemic mycoses

IMPORTANT TO REMEMBER:
Diagnosis: key features of certain organisms
FEATURE ORGANISM
Zygomycosis / Rhizopus
Non-septate hyphae
(give ampho B)
Branching septate hyphae
Aspergillus
(pneumonia in immunocomp pt)
Hyphae + pseudohyphae + yeast form Candida
Capsule Cryptococcus

4
 Superficial / Cutaneous Fungal Infections
1. Dermatophytosis
2. Onchomycosis (nail infection)
3. Tinea versicolor (superficial, variable color, nape of shoulder  across chest)

Superficial mycosis Cutaneous mycosis

Layer affected Superficial straum corneum Epidermis/dermis
Host response No host response Inflammatory response
Example Tinea versicolor Dermatophytoses

Cutaneous fungal infections

Dermatophytes cause most cutaneous fungal infections Dermatophytes

Infections often named by region of body that they inhabit (see table)  Microsporum spp
 Tinea capitis: only children (adults- change in cebaceous glands  stop  Epidermophyton floccosum
getting tinea capitis infections)  Trichophyton spp
 Tinea = “ringworm” (not actually worm) – NOT name of species! Tinea… Dermatophyte
infection of…
Also classified by environmental reservoir Pedis Foot
 Anthropophilic(humans) – e.g. T. tonsurans Capitis Head
 Zoophilic (animals) – e.g. M. canis Corporis Body
 Geophilic (soil) – e.g. M. gypseum Barbae Beard
Cruris Groin
What causes what? Unguium Nail
 Trichophyton (most in US): EVERYTHING (more or less) Manuum hand
o capitis, barbae, corporis, cruris, pedis, unguium
 Microsporum (more common worldwide): capidtis, corporis, cruris, pedis,
o NOT UNGUIUM (no nails)
 Epidermophyton floccosum (only spp of this genus): TINEA CRURIS (groin)

Pathogenesis / Host Defense

 Dermatophytes use keratin as nutrient source
 Inflammatory host responses responsible for involvement of surrounding tissues
 Cellular immunity is key factor in host defense (iron metabolism too)

Hair invasion (arthrocondia = asexual spores)

Type of invasion Athrocondia form… Cuticle Clinically Examples
M. canis
More inflammation
Ectothrix Outside of hair shaft Destroyed M. gypseum
More likely to grow back
T. equinum
Can pull out hair with bulb, without pain.
Endothrix Within hair shaft Intact T. tonsurans
Less likely to grow back

Infections: if possible, can use skin scraping + wet mount to dx

1. Tinea pedis:
a. most common (70% adults worldwide); often Trichophyton rubrum
b. 3 clinical forms: interdigital, moccasin, vesiculobullous (can treat topically)
c. Can have 1 hand + 2 feet: tinea pedis et manuum
d. Can have onychomycosis along with tinea pedis (need to treat systemically)
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 2. Tinea corporis:
a. non-glabrous skin (trunk, extremities)
b. “Ringworm” – erythematous, round, scaly patch; red, raised, advancing border +/- papules/pustules
c. Itchy (pruritic)
3. Tinea cruris:
a. Invasion of hair follicles (can confuse with cutaneous candida)
b. Predisposition: tinea pedis/onchyomycosis at same time (transfer?)
4. Tinea capitus:
a. Infants, children, young adolescents, in US mostly urban (AA/Hispanic preschoolers)
b. Can transmit child-child or animals/humans
c. Usually Trichophyton (T. tonsurans especially) in US; Microsporum canis most common worldwide
d. Variety of manifestations (pustles/papules/etc) on scalp
i. Inflammation  scaling, alopecia, erythema/exudate/edema
ii. Ectothrix: “black dot alopecia” (some patches preserved)
iii. Endothrix: total hair loss
iv. Kerion (scalp condition; thickened raised area with set of spongy lesions) forms
1. increased cell-mediated immune response; all Mϕ & mono not PMNs)
2. Severe inflammation, hair loss, cervical lymphadenopathy
e. Need to hit hair follicles: systemic + cutaneous treatment

Lab Dx of Dermatophyte Infections

 KOH of scale scraped from leading edge of lesion (destroys most cellular debris)
 Culture to confirm; special agar (Sabouraud dextrose) for up to 4 weeks
o ANY GROWTH OF DERMATOPHYTES IS SIGNIFICANT (not a contaminant)
 Wood’s light: UV light, M. canis will fluoresce blue-green

Treatment of Dermatophyte Infections:

Tinea Capitis: Topical + Systemic Tx
1. Oral antifungals (griseofulvin, others)
2. Ketaconozale shampoo (reduce fungal shedding)
3. Prevent spread (clean contaminated brushes, pillows; selenium sulfide for other family members)
4. Kid is OK to go to school as soon as he’s on treatment

Tinea pedis, corporis, cruris, manuum: Topical Tx

1. Miconazole, clotrimazole, etc.
2. Oral if extensive/severe/recalcitrant infection

Onchyomycosis
Onchyomycosis: infection of nail plate and/or nail bed that interferes with normal nail function
Epidemiology: mostly dermatophytes (T. rubrum, others)

Presentation: pain, dysfunction, paronychia (skin infection around nails)

 Increased risk: diabetes (bad!), HIV/AIDS, compromised hosts, elderly

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 Clinical classifications: PSO/DSO/WSO
DISTAL SUBUNGUAL (DSO) PROXIMAL SUBUNGUAL (PSO) WHITE SUPERFICIAL (WSO)
Immunocompromised hosts
PREVALENCE Most common (90%) 10%
(early HIV infection indicator)
Distalproximal
Proximaldistal Dorsal surface of nail
(hyphae under nail plate, spread
INVASION (starts at cuticle, spreads to
proximally, digest stratum plate attacked
entire nail bed)
corneum of nail bed & nail plate)
Whole nail involved / Minimal inflammation
PRESENTATION Proximal parts relatively intact
obliterated (not attacking viable tissue)
HOST RESPONSE Cell-mediated immunity
T. rubrum (most common)
SPECIES T. tonsurans, T. mentagrophytes, E. T. rubrum T. mentagrophytes
floccosum)

Diagnosis: KOH + culture of nail

Treatment/prevention: need ORAL THERAPY (get into nail bed, e.g. griseofulvin)

Tinea Versicolor
Superficial mycotic infection
 Young, middle-aged adults
 Upper trunk/neck/arms; often manifests as depigmentation (“ sun spots” because they don’t tan)

Malassezia furfur is causative agent

 Lipophilic yeast (needs olive oil or something in the agar to grow)
 May also cause fungemia with parenteral lipid solutions (e.g. in babies)
 might be involved in other conditions too

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 Opportunistic Mycoses
Candida, Aspergillus, Zygomycetes, Cryptococcus, Pneumocystis

Mycoses: 2 groups based on ability of host’s non-immune cells to phagocytose & kill the challenging fungal spore/yeast
Mucocutaneous candidiasis
Altered T-cell function
Cryptococcus
(e.g. AIDS)
Opportunistic compromised Pneumocystosis
mycoses hosts only Altered phagocytic Invasive candidiasis
activity (quantitative or Aspergillosis
qualitative defects) Zygomycosis
Histoplasmosis (Histoplasma capsulatum)
Blastomycosis (Blastomyces dermatitidis)
Pathogenic,
Coccidiomycosis (Coccidioides immitis)
deep, systemic normal hosts Cellular/T=cell function
Paracoccidiomycosis (Paracoccidoides brazilensis)
mycoses – Latin America, N. Brazil
Penicilliosis (Penicillium marneffei)

Candidiasis
 Opportunist (causes wide range of infection)
 Candida is genus, albicans is most common member
o Albicans is Germ tube POSITIVE, others aren’t
 Hyphae + pseudohyphae + yeast
 Components of normal flora on mucosal surfaces (skin/oral/GI tract/female GU)
 Causes infection only in compromised hosts
Infections
Mucocutaneous Deeply invasive
THINK NORMAL MUCOSAL DISTRIBUTION.  Candidemia: #3-4 for blood infections overall
oropharyngeal (thrush), esophageal  Endocarditis, hepatosplenic candidiasis
Clinical
candidiasis, candida epiglottis (chronic/disseminated),
presentation cutaneous, onchyomycosis, keratitis,  Acute disseminated candidiasis (high burden  septic shock)
vulvovaginal.  Renal candidiasis (filtering out candida sets up shop)
 Altered barriers (vascular/urinary cath, peritoneal dialysis,
 Underlying disease (HIV/diabetes)
trauma, burns, cytotoxic drugs)
 Corticosteroids
Risk factors  Neutropenia, BMT/solid transplants, surgery
 Pregnancy, elderly (↓ immune)
 Broad spectrum Abx
 Antibacterial Abx (kill normal flora)
 Hyperalimentation, hemodialysis
Topical if not serious
 Clotrimazole, etc. Need SYSTEMIC Tx (Fluconazole, etc.)
Treatment
Systemic if serious (e.g. if esophageal) (Ampho B as salvage b/c of toxicity)
IV if needed

Mucocutaneous candidiasis
Smear / scrape:
 Mucosal: mucosal surfaces; white pseudomembranous placque
hyphae + pseudohyphae
 Cutaneous: intertriginous (where 2 areas of skin rub together) areas: scalded
+ budding yeast
lesions, punctuate satellite lesions
o Diaper dermatitis, paronychial/onchyomycosis, moist areas
o Diabetes
 Chronic mucocutaneous candidiasis: genetic inherited disorder, big scarring; disfiguring
o ↓ cellular immunity to Candida + polyendocrinopathies
 (DM I, adrenal insufficiency, hypothyroid/gonad/parathyroid/etc.)
o Intractable candida: mucocutaneous surfaces (oropharynx, face, toes, fingers, intertriginous areas)
o “Autoimmune-polyendocrinopathy-candidosis-ectodermal dystrophy” (APCED)

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 o Tx: fluconazole but worry about resistance in long term use
Invasive candidiasis
 Pathogenesis:
1. Adherence/colonization 
2. Penetration through mucosa  angioinvasion / access to venous caths 
3. Hematogenous dissemination 
4. Replication in tissues (necrosis +/- abscess formation) Dx in Tissues:
 Host response: hyphae + pseudohyphae
1. Immune competent: acute + chronic inflammatory cells + budding yeast
2. Neutropenic: no abscesses form, lots of hyphae
If you suspect invasive candidiasis:
GET A FULL OPHTHALMIC EXAM
Candida Albicans (to check for involvement of vitriol –
 GERM TUBE POSITIVE species (form hyphae; others are negative) candida endophthalmitis)
 Virulence factors:
o surface receptors (epithelial/endothelial cells; extracellular matrices, hardware)
 can act as immunomodulator
 sticky for cardiac valves, caths, etc.
o Hydrolytic enzymes, host mimicry
o dimorphic (yeast in environment  colonizes  sets up shop as hyphae)

Aspergillus spp (Aspergillosis)

 Filamentous; common in environment
 All infections OPPORTUNISTIC
Treatment of aspergillosis
 Voriconizole / ampho B
Clinical presentations
 Need host immune
1. Toxin-mediated:
response: reverse immune
o aflatoxins (extremely carcinogenic; cause hepatocellular carcinoma) suppression!
–on stored grains/peanuts; not elaborated inside a patient
2. Allergic syndromes (atopic pts)
3. Colonizations / saphrophytic
o fungal ball = “aspergilloma” in old TB cavity or impacted paranasal sinuses
4. Infections (deep infections)
o Keratitis (post corneal trauma)
o Invasive disease: pulmonary +/- dissemination

Invasive Aspergillosis
 Risk factor: PMN FUNCTION depression Conidia = asexual spores
o Quantitiative (neutropenia)
o Qualitiative (function: CGD, post-BMT, high dose corticosteroids, HIV)

 Pathogenesis: Invasive Aspergillosis:

1. Inhaled (conidia)  alveoli   “Angular dichotomously
 Normal host: phagocytosis (Mϕ, killing) branching septate hyphae”
 Compromised host: may or may not phagocytose; don’t kill o = Y-shaped with
2. germinate  hyphal invasion of lung parenchyma  septae
3. Angioinvasion (thrombosis, ischemia, infarction)   Angioinvasion, thrombosis
4. Hematogenous dissemination (sometimes)  areas of necrosis

 Role of host defenses

1. Neutropenia: angioinvasion, infarction, dissemination, hemorrhage

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 2. Immunosuppresion: inflammatory necrosis, local invasion

 Radiology: (not specific for aspergillus – anything that invades a large blood vessel - but commonly present)
1. Halo sign (dense nodule = infarction; delicate structure of local ischemia around it)
2. Air crescent sign (e.g. in recovery; infarcted area
where aspergillus was, separated by a crescent of air
from surrounding parenchyma)

Aspergillus fumigates

Pathology: has characteristic structure:

 Culture: condiophores, vesicles, phialides, conidia
o Powdery surface colonization on plate
 Tissue: septate hyphae (filamentous)
o Note: culture is diagnostic form, tissue just
highly suggestive
Virulence factors
 Adherence receptors, hydrolytic enzymes, complement inhibition; etc.
 Toxins: not afalotoxin in vivo but others

Aspergillus niger
 Commonly saprophytic (in fungus balls; lives off of dead tissue)
 Black color; commonly found in environment

Zygomycosis (mucormycosis)
 Opportunistic; caused by several zygomycetous fungi (Rizopus is most
common species)
 Pathology: wide, non-septate hyphae that branch at right angles
o Key: NON-SEPTATE; T-SHAPED
o Invasion of blood vessel walls/nerves; extensive necrosis in
advance of fungus
 Rapid-growing “LID-LIFTERS” (both in lab and in vivo!)
 Sporangiophores have large “sporangia” sacs filled with sporangiospores
(asexual spores)

Disease Description At risk patient

Saphrophytic / Old TB or other lung cavity; no invasion or
Post-TB, bronchiectasis, etc
colonization dissemination.
FAST course – need to diagnose quickly and get biopsy
1. Inhalation (asexual spores from environment) 
Rhinocerebral paranasal sinuses 
Diabetes mellitus + ketoacidosis
Invasive

zygomycosis 2. tissue invasion (nerves, blood vessels)  cranial nerve

palsies, thrombosis, necrosis 
3. invasion of orbit & eye  extension to brain.
Pulmonary +/-
dissemination
Marked by angioinvasion Neutropenia

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 Cryptococcus neoformans
At risk: T-cell-compromised (corticosteroids, transplants, HIV with CD4 < 100)

Pathogenesis:
1. inhale yeast (environment)  lung replication  CD4/CD8 recruited  usually cleared (specific response)
2. If immunocompromised (T-cells)
a. Progressive pulmonary infection
b. Hematogenous dissemination (cross BBB to BRAIN)

Pathology:
 Normal host: chronic inflammation +/- granulomatous response; resolve w/o calcification
 Compromised: mild to non-inflammatory response
 Gelatinous lesion (ENCAPSULATED) Diagnosis of cryptococcus
 Spherical yeast cells with:  Antigen test or direct
o clear area (capsule), obs. in CSF
o narrow/pinched mother-daughter attachment
 Need PAS/GMS (H&E doesn’t really work) Clinically:
 confusion, decreased
Radiography: disseminated infection concentration, headache
(increased ICP)
Virulence factor: CAPSULE
 Glucuronxylomannan with different side chains (different serotypes) Treatment:
o Produced in excess: detectable as ANTIGEN FOR RAPID Dx  AMPHO B + 5FC
 Inhibits phagocytosis; poor in vivo antigen
 Others: phenoloxidase (produces melanin, which inhibits oxygen-dep killing & is stainable)

Pneumocystis carinii/jiroveci
 Opportunistic
o CELL-MEDIATED IMMUNITY is key (not neutropenia) Diagnosis of PCP
 Alveolar-interstitial pneumonia (fever, dyspnea, non-productive cough)  Bronchioalveolar lavage:
o Extrapulmonary dz is uncommon cysts of trophozoites
o Tachypnea + hypoxia  DFA (mAb available)
 Risk factors: immunosuppresion, corticosteroids, HIV infection, elderly  PCR

Radiography Treatment:
 No nodules or infarcts  TMP+SMX
 Interstitial / alveolar involvement, multilobar
 Delicate proteinaceous debris in alveoli, blocks oxygen exchange (alveolar / interstitial disease)
o Trophozoites from cyst damage & create interstitial rxn / debris

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 Pathogenic Mycoses
Histoplasma, Coccidiodes, Blastomyces, Paracoccidiodes

 Can cause infection in normal host; all are endemic dimorphic fungi
o Contact with organism in well-defined ecological niches
Organism Niche Geography
Histoplasma capsulatum Soil, caves (bird/bat feces) Ohio/Mississippi Valley regions
Coccidiodes immitus Desert soil SW USA (Sonora desert)
Blastomyces dermatitidis Water North/Central, SE USA
Paracoccidiodes brasiliensis unknown South America (Venezuela, N. Brazil)

General features:
 Entry = inhalation (asexual spores from environment); NOT PERSON-PERSON (even if mimics TB)
 Asymptomatic or mild in most hosts
 Disseminated progressive infection: 1/1000 infections Dermatophytes are
o More frequent in T-CELL COMPROMISED transmissible, others
 Pathology: chronic inflammation, granuloma formation generally aren’t

Histoplasmosis (Histoplasma capsulatum)

 Range: Asx to life-threatening
 Histoplasma capsulatum: dimorphic fungus Histo radiography
 Mostly soil/caves in Central USA  acute = infiltrate
o Nature/room temp: filamentous;  chronic = cavitary
 makes micro/macroconidia (microconidia = infectious)
o In vivo/37C: yeast

Disease:
 Pulmonary entry
o Acute: (90-95% have asx or mild resp sx; 5%: moderate mild to severe resp dz)
o 1/1000: disseminated infections (more common in T-cell compromised);
 Severity/progression: related to host status
 Disease of the reticuloendothelial system: Mϕ lining lung, spleen, LN, bone marrow

Pathology
 Early / active infection: intracellular budding yeast cells (in Mϕ & monocytes)
 Normal hosts: Granulomas (fibrosis, calcification in old lesions); Few intracellular yeasts
 Immunocompromised (e.g. HIV+): poorly formed granulomas; Many intracellular yeasts
In vivo yeasts
Diagnosis: DNA probes Cell response Location Disease
Histoplasmosis Monocytes Intracellular Lung dz
Culture: SLOW; takes weeks. Molecular Candida glabrata Lymphocytes Extracellular UG / bloodstream opportunist
probes are faster.
 See conversion to yeast at 37C (reverse of candida); macroconidia + hyphae
 Organism is HIGHLY TRANSMISSIBLE in this form (careful! Advise!)

Virulence factors: evades killing by phagocytes; replicates in phagolysosome (neutralize acid environment?)

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 Blastomycosis (Blastomyces dermatitidis)
 Pneumonia + other presentations
 Water in NE/central USA
 Less propensity for reticuloendothelial system than histoplasmosis
 Hyphae (25C)  large yeast, double wall, broad-based budding (in vivo, 37C)

Coccidiomycosis (Coccidiodes immitis)

 Soil of Sonoran desert of SW USA

Characteristic structure
 Hyphal form at room temperature
o Arthrocondia: little boxcar units
 hydrophobic & easily transmitted (room temp)
 Dispersed throughout environment
 Spherules in tissues (very characteristic); invasive

Clinical presentation: infects lungs, usually mild,

 sometimes can disseminate (brain, joints, other organs)
Tx: antifungal drugs (sometimes for life)

Virtual Rounds
PATIENT DIAGNOSIS TREATMENT PLAN
Little boy with itching scalp; hair falling out. Exam: Tinea capitis: High temp cycle for clothes, systemic Tx +
small areas of inflammation/erythema/scratching; pull Trichophyton spp ketoconazole shampoo, selenium sulfide
hair out including bulb. shampoo for other kids
Migratory farm worker, was working with moss. sporotrichosis Azole
Multiple cutaneous lesions, draining.
sICU pt: came back from surgery starting to spike high Candida (if germ tube +, Fluconazole. If liver enzymes elevated,
temperatures, came back as yeast. albicans) can’t use (use echinocandins) Think of
eyes (call ophthalmologist); think of cath
(make sure it’s clean)
Oncology: AML pt in high dose chemo; cough/high Aspergillus Voriconazole; if liver enzymes elevated,
spiking temperature / pleuritic pain. See halo sign on maybe ampho B
radiography. See branching septate hyphae from
bronchioalveolar lavage
14 year old diabetic girl. Acidotic, sinus infiltration that Zygomycosis Ampho B. Debride, correct underlying
shows black, darkened, necrotic nasal turbinate on immune deficit
biopsy. Broad, non-septate hyphae
24 yo IV drug user; minimal access to medical care. Cryptomycosis Ampho + 5 FC. Worried about
Headache. Get LP with antigen test, positive meningitis, increased ICP
Pt with high risk for HIV. Shortness of breath, 85% Pneumocystis (PCP/PJP) TMP+SMX
O2Sat, diffuse interstitial infiltrate with no nodules.

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 Introduction to Parasitology
Parasite: organism living in complete dependency in or on another living organism (host)
 Host shields parasite from outer world; provides food (parasite’s “restaurant”) Major themes of
 Generally protozoa, worms, arthropods parasitology
Host:  Attachment/invasion
 Host cell invasion
 Definitive: host where sexual reproduction of parasite occurs
 Host-parasite
 Intermediate: host for immature parasite stage / asexually-reproducing stage interaction
Vector: disease-causing parasite is conveyed from this host to another host  Obtaining nutrients
 Immune evasion
Parasitism: most common way of life (>50% all spp);  Encystation/eggs
 all living creatures have parasites (tiny viruses to big tapeworms)  Behavioral changes
 Humans: found in variety of tissues/organs
 man-made ecological changes responsible for perpetuating/intensifying most infectious/parasitic diseases

Epidemiology: huge burden; most morbidity from chronic infection; mortality figures high (malaria in Africa > CVD in US)

Attachment/invasion of host
Attatchment: Parasite needs mechanism to interact with host & prevent its expulsion
 Molecular (receptor-ligand)
o e.g. Plasmodium & RBC molecules; falciparum/vivax use different molecules
 Physical interaction:
o e.g. hookworm, attach with sharp teeth/hooklets
o Feces eggs in soilstepped on  footlungaspirate (weird!)  GI tract

Invasion: Obligate intracellular parasites need host cell to survive & replicate Mechanisms of invasion
 Helminths: different modes of invasion 1. receptor/ligand interaction
1. Direct from environment– worms penetrate skin directly, go to 2. subvert host cell transmembrane
blood (shistosomes, hookworm) signaling pathway
2. Along vector bite path – bite  bloodstream (brugia) 3. modify host cytoskeleton
3. Dispersed from vector bite – enter skin, then go all around through tissue (onchocerca)
Host cell invasion
 Apicomplexan invasion (Toxoplasma gondii)
o glides along surface  apical tip (rhoptry neck) invades; forms
moving junction  rest of parasite pulled in behind (like boat in
Panama canal) – see picture to right
o Result: parisotophorous vacuole. Parasite proteins not
expressed in vacuole, but later help it survive

 Attraction of lysosomes (Trypanosoma cruzi / Chagas dz)

o Secretes molecules to attract lysosome in endothelial/cardiac
cells, gets inside (can also enter via parisotophorous vacuole & fuse)
Host-parasite interaction
Host: Dynamic interaction; host tries to reject, can release cytokines (e.g. IL-8)
Parasite:
 can de-differentiate cells to suite needs
o e.g. Trichinella worm; de-differentiates host muscle by shutting off muscle-specific genes – better for parasite,
huge inflammatory response for host)
 can redecorate host cells to suit needs
o e.g. Plasmodium falciparum: inserts protein into RBC PM; bind to host endothelium so they don’t get destroyed by
spleen (sequestered)

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 Obtaining nutrients
By definition, parasites obtain nutrients from their hosts
 E.g. plasmodium digests Hb from RBC; some protozoa (Toxoplasma) can’t synthesize purines on own

Immune evasion
1. Interfere with host immune system to co-exist
 Block Ag processing by inhibiting protease cleavage in APC; induce suppressor Mϕ & Treg cells, induce tolerance,
use superantigens, inhibit T/B activation
Clearing: Ab / CMI can be important, or innate/Mϕ can be important (Depends on parasite; intracellular = more innate)
Worms: EOSINOPHILS & IgE RESPONSE 

2. Some protozoa can multiply within Mϕ (have to escape lysosome digestion)

Activated Mϕ (T-cell help)  kills parasite; fusion of phagosome with lysosome
Toxoplasma gondii
Naïve T-cells  parasite lives in endosome; doesn’t fuse with lysosome
Trypanosoma cruzi Killed or escapes phagosome to divide in cytoplasm
Leishmania Doesn’t care: resists lysosome enzymes; lives in phagosome
3. Antigenic variation: African trypanosomes express hundreds of VSG (surface proteins); can’t make vaccine
 Waves of infection: one VSG type cleared; another takes over; cleared, etc.

Encystation: eggs/cysts
 Environmentally stable forms (good for transitioning between hosts) Good for diagnosis:
o Thick walled cysts (protozoa, esp. intestinal) stool ova & parasite exams
o Eggs (worms) (“stool O&P”)
 Can be signature forms:
o oocysts in cryptosporidium
o Schistosome eggs
 lateral spur = mansoni; end-spur = haematobium, round = hepatica)

Host behavior
Parasites can alter host behavior
 E.g. Toxoplasma gondii: from cat feces; rats eat it, stop being afraid of other animal
scents (makes it easier for cat to catch them!)

Mechanisms of Pathogenesis
1. Direct cellular damage
 Need to balance host cell damage & needs from host cell
 Direct damage from lysing cell during egress; secreting pore-forming How do parasites cause disease?
peptides, secreting proteolytic enzymes 1. Direct cellular damage
 E.g. Toxoplasma lyses cells during egress – necrotic cell death; invades 2. Mechanical
adjacent cells during the process obstruction/compression
3. Host immunological response
2. Mechanical obstruction/compression 4. Other disease mechanisms
 Helminths are prototype: obstruct GI tract or lymphatics
o e.g. Ascaris  intestinal obstruction in kids in developing countries
o e.g. lymphatic filariasis: block LN, backup of lymph  elephantiasis
 Parasite-filled abscesses/cysts compress vital organs
o e.g. pork tapeworm: brainmass effect seizures
o Encephalitis/brain abscesses in HIV  cerebral Toxo

3. Host immune response

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  Eosinophilia (helminths) irritate GI lining, increase bowel permeability, produce more eosinophils
 Granulomas (around destroyed larvae or eggs)  colon/rectum walls, elsewhere (back up fluids, damage)
 Cytokines: IL-8, TNF-α, etc.
 Damage from parasite itself can be minimal; host immune reaction  extreme & harmful
o Schistosomiasis: eggs in bladder  granulomatous rxn  fibrosis  obstruction; carcinoma!

Other
 Anemia, fever, organomegaly, malnutrition, diarrhea, rash, etc.

Intestinal protozoa
 Fecal-oral route; cyst-tryphozite stages (Giardiasis, amebiasis, crytptosporidiois)
o Cyst: resistant wall (infective, found in feces)
o Trophozoite: metabolically active & mobile (non-
infective)
Diarrhea:
 Secretory: small intestine, ↑Cl- secretion from crypt cells
o E.g. giardia (cyst ingested, releases trophozites, differentiates
into cyst again in gut lumen in response to bile  shed in
watery diarrhea  infective).
 Villus blunting, infiltrating lymphocytes, secretory diarrhea
 Invasive / malabsorptive: esp. colon
o Normally need brush border, good epithelium
o Damage to brush border (break junctions/ulcerate)  malabsorption
o Dysentery: diarrhea + blood/mucus in stool
 E.g. Entamoeba histiolytica: protozoa; common cause of dysentery in developing countries;
 Trophozoite / cyst life cycle
 invades host intestinal mucosa; can spread to liver to make abscesses (lung, brain too)
 Can cause colitis (flask-shaped ulcers – spread laterally)

Trypanosoma brucei: African Sleeping Sickness

 Parasitic protozoa; 2 subspecies
T.b. rhodesiense T.b. gambiense
Geography East africa West africa
Chancre: Inflammatory reaction at site Winterbottom’s sign: Enlarged lymph nodes
of tsetse fly bite in neck
Early Sx/ Signs
Rashes with fever if fair-skinned
Kerandel’s sign: press hard on hands; severe pain shortly after release
Cross BBB to CNS Quickly More slowly

 Transmitted by tsetse flies; prefer to bite humans

o disseminate everywhere post infection & multiply wherever blood is
 Epi: 100% FATAL IF UNTREATED; 500k+ infected; thousands permanently disabled from treatment

 Sx: confused with malaria (high, spiking fever)

o CNS involvement:
 Neuro problems: conflicting psych Sx(agitation, indifference, irritability, uncontrolled sex
impulses, violence)  motor system distrubrances (paralysis, tremors, twitching, slurring), pain,
itching (leads to suicide in some!)
 Sleep disturbances (reverse sleep cycle: insomnia + irresistible urge to sleep)
 Seizures, incontinence, total body cachexia (CNS-mediated apoptosis), coma, death

16
 Tx: need early treatment (otherwise could cross BBB  CNS involvement; white matter encephalitis
o Early stage: without CNS involvement
 Suramin (rhodesiense) or Pentamidine (gambiense), good prognosis
o Late stage: CNS involvement
 Melarsoprol – arsenical; HIGH TOXICITY: 4-12% MORTALITY
 Eflornithine – expensive, injections x14d; phase III trials for oral underway (good for preventing
unwanted hair growth in women too!)

17
 Pathophysiology: ID & Micro (Fungi & Parasites)
Malaria .................................................................................................................................................................................... 2
Helminth Parasitism ................................................................................................................................................................ 6
Other Protozoa...................................................................................................................................................................... 10

1
 Malaria
Global Burden
 Was formerly prevalent in US; eradicated via infection controls & social improvement
 1st global push (‘50s) to eradicate based on DDT+chloroquine; success in some areas, partial in others
o No serious attempt in Africa
o Failed: unrealistic expectations, no integration with existing infrastructure
 Chloroquine-resistant P. falciparum & DDT-resistant Anapholes
 Global distribution today: Africa biggest, SE Asia drug resistant, also other parts of world
o Very different distribution in different countries within Africa – some much higher than others

Epidemiology
 Parasitic, mosquitos; 247M cases/yr, 891K deaths, 85% in sub-saharan Africa (YOUNG KIDS & PREGNANT)
o Resurgence: drug resistance, other factors, no vaccine
 Four species of malaria:
o Plasmodium falciparum: 90% infection; almost all death in Africa, MDR, vaccine efforts
o P. vivax: big contributor in SE Asia morbidity (& mortality)
o P. ovale (Africa only), P. malariae too

 Highly variable around world & within countries with different presentation
o Related to intensity of burden, duration of transmission
o Classic definitions: Spleen rate: hypoendemic < meso < hyper < holo
 Acquired immunity:
o Stable malaria: heavy, perennial transmission; endemic
 Generally protected from severe dz after age 5 (except for in pregnancy
o Unstable malaria: less intense transmission; epidemics / outbreaks
 Protective immunity: later age or not at all; all ages vulnerable

Immunity
 Humoral & Cellular; Initially: innate + spleen
 Maternal Ab last 3-6 mo (don’t see severe dz in children < 6mo)

Protection: slow, need prolonged, repeated exposure; protection from infection is not achieved
 Immunity lost if exposure stops: very common to see expat visit old country & get malaria
 Diminished immunity in pregnancy: increased risk of disease & complications, incl. still birth/miscarriage/low birth wt)
 Limited interaction with HIV: co-infection, not opportunist
o Viral load increases in acute phase; lost protection against malaria
o Biggest interactions in HIV+ pregnant women

Innate immunity:
 Malaria hypothesis: red cell polymorphisms distributed geographically because of selective pressure of malaria
o Hb structure, thalassemias (Hb synth), G6P deficiency (RBC enzyme), Duffy negative blood (PM of cell)
o HLA types? May protect against severe malaria
Duffy receptor and vivax malaria
 Chemoine receptor; spans PM, present in endothelial cells, only P. vivax binds for entry to RBC
 Duffy negative: primarily present in Africans (no vivax)

2
 Life Cycle
A. Mosquito bite (female
anopheles mosquito at
night)  Sporozoites
injected; clinically Asx
B. Hepatic stage: multiple
stages, 6d-weeks of
“incubation”, results in
hepatic schizont filled with
merozoites (still Asx)

(P. vivax & P. ovale can

arrest here as hypnozoites in
liver & relapse months to
year after primary infection)

C. Schizont ruptures and

releases merozoites into
blood stream, which infect erythrocytes.
If patient has Sx post-Tx, what’s up?
D. Erythrocytic schizonts filled with merozoites rupture; more red cells
released: periodicity (via asexual reproduction) Recrudesence: P. falciparum & P.
E. Some merozoites differentiate into gametocytes malariae, reappearance of parasites in
F. Gametocytes taken up by female anapholes mosquito; sexual the blood (e.g. after being pushed down
reproduction takes place in her, infects other host below detectable threshold.
Relapse: P. vivax & P. ovale, revival of
Note: SEXUAL forms responsible for transmission
hypnozoites in the liver.
ASEXUAL for periodicity of symptoms
Re-infection: new infection for patient
Invasion of erythrocytes leads to knobs forming (“sticky” RBC)

Species-specific characteristics:

P. falciparum: P. vivax
 ~5.5d incubation in liver  8 day incubation
 48 hr erythrocytic cycle (fever periodicity)  48h periodicity
 Tons of merozoites per schizont  Fewer merozoites /schizont
 Infects ALL KINDS of RBC (HIGH parasitemia)  Invades mostly RETICULOCYTES (LOW parasitemia)
 Need HIGH burden for fever (even more if immune)  Need lower burden for fever
 Can form hypnozoites (dormancy!)
P. malariae: P. ovale:
 72h periodicity  Similar to P. vivax
 Can form hypnozoites (dormancy!)

Clinical presentation & Diagnosis

 Complex; many vital systems involved; Asx in hepatic & sporozoite stages
 Disease from red blood cell stage: stimulates host immune response
 Periodic fever (chillrigorshigh feversweatingrelease), non-specific
o Can also have cough, H/A, body ache, malaise, weakness, diarrhea
o Signs: fever, anemia, jaundice, enlarged spleen/liver

3
LAB FINDINGS KEY: DIAGNOSIS: no
1. low platelets (first) later than 1 hour
2. low WBC, low RBC (second, third) after malaria first
suspected
Take blood when FEVER is present (higher burden of organisms)
TREATMENT: no
Suspect in US if: later than 1 hour
1. Any fever in exposed person (cough, diarrhea don’t rule out; think 7-25d incubation; after smear read
can relapse (vivax/ovale))
Tx based on:
2. Fever of unknown origin in “unexposed” (P. vivax/ovale ~3-5yr relapse; P. malariae
1. speciation
up to 50yr recrudescence!) 2. quantification
3. geography (drug
Clinical spectrum resistance?)
Mostly uncomplicated malaria if dz present in patients 4. assessment of
 See above symptoms severe malaria
 Tx: oral antimalarial drugs; confirm drug susceptibility by region
 Follow decline of parasitemia post-Tx initiation

Severe malaria = complicated malaria; set of overlapping problems. UP TO 50% MORTALTITY WITH TX
 Can lead to profound anemia, seizures, coma, death
 CAN BE VERY RAPID (esp. if non-immune, immunocompromised)
 Tx: IV drugs & intensive care

Types of severe malaria

A. Acidosis: final common pathway
a. Oxygen delivery impaired (lack of RBC)  metabolic acidosis
b. Sequestration of infected cells in brain/kidneys/lungs: can be organ specific
c. Proinflammatory cytokines, nitric oxide involved,
organ dysfunction leads to coma Severe malaria manifestation
B. Cerebral malaria: altered consciousness, seizures, rapid onset depends on endemicity
but rapid recovery if not fatal; immune-mediated Holoendemic Young patients; mostly
cerebral malaria
C. Severe anemia: hemolysis
Hyper/ Young patients; cerebral early
a. destroy uninfected RBC in spleen; malaria suppresses mesoendemic then severe anemia later
bone marrow (erythropoieses ineffective) Hypoendemic All ages; mostly severe anemia
b. Making less & destroying more
c. Associated with secondary bacterial infections;
d. Tx: transfusion if blood supply is safe

Pathological features
P. falciparum: cytoadherence important for sequestration (knobs with receptors for endothelial cells)
 Ring stage: circulates freely
 Schizont stage: generally sequestered in capillaries & venules (see more in other forms of malaria)

Sequestration & rosetting (P. falciparum / malariae)

 Sequestration: binding of infected RBC to capillary endothelium (keep away from spleen!)
 Rosetting: binding of uninfected RBC to infected RBC (responsible for pathophysiology): see “rosette” of healthy
RBC around infected RBC

Placental malaria: cytoadherance to placental endothelium; placental sequestration & exudates

 LOW BIRTHWEIGHT IS THE SINGLE MOST IMPORTANT PREDICTOR OF INFANT MORTALITY

4
If you suspect malaria
 Ideal: Giemsa stain of thick and thin smears;
o Can quantify (determine risk of severe dz, drug susceptibility)
 Based on RBC (thin) or WBC (thick) count
o Thick: more sensitive, hard to read / speciate, use for quick dx
o Thin: helps with speciation to determine Tx
o quick dry some to read fast: delay can be fatal!
P. falciparum: P. vivax P. malariae
 Normal RBC size; preserved  Fewer merozoites in schizont,  Band-form schizonts
morphology RBCs dysfigured
 Fine delicate rings  Large, irregular rings
 Gametocytes: sickle shaped (but rare)  Round gametocytes
 Rare trophozoites & schizonts  Amoeboid trophozoites present

 Also: dipstick antigen (no quantification or speciation but no microscope needed), PCR

Chemotherapy
 Chemoprophylaxis for travelers
 No prophylaxis generally in endemic countries
o Specific indications are exception sometimes: pregnant women, infants, children
 If it fails: think drug resistance, PK failure, fake drug?

Control
 ITN: insecticide-treated nets
 Indoor house spraying, vector control (limited utility), personal barriers
 Integrate with local systems when present; give effective/prompt treatment
o Currently: Tx without definitive Dx in endemic regions (but drug resistance)?
 Monitor drug resistance!
 Vaccine problems: natural protective immunity is present but restricted; immune response contributes to
pathology; antigenic variation + efficient parasite; lack of good outcome measures

Clinical significance review

P. falciparum infection is MEDICAL EMERGENCY: can infect RBC of all ages, severe anemia, high multiplication rate
 sequesters (microvascular obstruction, tissue hypoxia, capillary leakage, end organ failure)
 Almost always cause of severe malaria
o Cerebral: seizures, obtundation, coma
o Severe anemia
o Hyperparasitemia; severe prostration, end organ failure, acidosis, diffuse bleeding, more

P. vivax: Anemia & ruptured spleens

P. malariae: can cause nephrotic syndrome in African kids

5
 Helminth Parasitism
Cause more disability than death; neglected tropical diseases
100+ spp of helminthes (vs 40 protozoa)
Nematodes (roundworms ) Flatworms:
 hookworm, Ascaris, Strongyloides,  trematodes (flukes/Schistososma)
pinworm/whip-worm, filaria  cestodes (tapeworms)

General principles of helminth dz

 Don’t multiply within definitive host (reproduce sexually & produce transmission stage but not more adults)
o Exceptions: Strongyloidiasis / capillariasis
 Low worm burdens (minority has high & is important for severe dz/high transmission)
o High worm burden = high exposure, not that they’re reproducing inside you
 Disease correlates with worm burden
Endemic regions Expatriates
 Heavily parasitized  Big inflammatory response
 High worm burden  Severe disease
 Little disease (little inflammation)  Low worm burden
 No TX = long term infection
o can live for years [nematodes] to decades [river blindness] to host’s lifetime [strongyloides stercoralis]
 Most produce eosinophilia + elevated IgE response
o Mast cell proliferation, too; all T-cell dependent & down-regulated with continued exposure
o Can cause pathology

Helminth pathogenesis
Mechanical attachment/damage
 Block internal organs (Ascaris, tapeworms, flukes, filiaria, schistosomes)
 Pressure atrophy (echinococcus, cysticercus) Deficiency Organism
 Tissue migration (helminthic larvae) Iron Hookworm
Nutritional depletion: see table Vitamin B12 Tapeworm
Metaplastic changes Macronutrients Ascariasis, Strongyloides
 Hepatoma = liver flukes; bladder cancer = schistosomes
Immunopathology
 Anaphylactic response (IgE/histamine)
 Immune complexes (Ag+Ab deposition in brain,kidney, etc)
 Cell-mediated reaction (monos & Mϕ)

Just because this will almost certainly be on the exam:

6
 Intestinal Roundworms

Organism Mug shot Pathology Transmission Life Cycle Clinical presentation Other
Low worm burden is Asx
Think: irritable kid and
Mechanical GI  Lung High worm burden: abd. pain & intestinal obstruction
Ascaris Ingest egg then these come out after
blockage  GI Migrating larvae/adults: Pulmonary eosinophilia syndrome (Loeffler’s
Tx!
syndrome); biliary/liver inflammation, intestinal obstruction

SKIN: Larva Skin 

Hookworms Blood loss Lose lots of blood; ANEMIA Make anticoagulant
penetrate Lung  GI

Whipworms GI (local Mostly Asx

Think: bloody stools &
(Trichuris damage/rectal Ingest egg All in gut Heavy infection in children: GI problems (abd. pain, bloody diarrhea,
rectal prolapse!
trichiura) prolapse) prolapse; growth retardation)

Hyperinfection into tissues in transplant patients

Strongyloi- Local GI SKIN: Larva Skin  Think: Vietnam vet getting
Initial infection  migration to brain, muscle, other organs with gut
diasis damage penetrate Lung  GI a transplant
flora sepsis (after immune suppression)

Pinworm
Perianal Scotch tape test to see
(Enterobious Ingest egg All in gut Itchy butt at night; adults migrate to anus to lay eggs (E.g. kids) st
pruritus eggs! (1 thing in morning)
vermicularis)

7
 Tissue Roundworms: Filaria
Insect vectors
blood = microfilia; tissues = adult worms

Organism Mug shot Pathology Transmission Life Cycle Clinical presentation Other
Spectrum of disease:
Filiarasis Damage Microfiliare circulate at
Mosquito/ 1. Asymptomatic
(Wucheria & lymph vessels Mosquitos night when mosquitos
human 2. Night fevers (when microfiliare circulate)
Brugia spp) (elephantiasis) feed!
3. Chronic: elephantiasis

Migrate to,
Calabar swelling; can migrate to eye!
Loa loa across sclera Flies Fly /human
Doesn’t cause blindness!
of eye

Inflammatory reaction due

Chronic
Oncheo- RIVER BLINDNESS (whole towns sometimes in Africa) to bacterial co-infection
inflammation Flies Fly/human
cerciasis Subcutaneous nodules (LPS) brought in by
of eye
parasite

Flatworms

Organism Mug shot Pathology Transmission Life Cycle Clinical presentation Other
Liver/bladder fibrosis; cancer
Cercariae
Granuloma S. mansoni: GI disease (in portal veins): cirrhosis, etc. Ingest RBC to eat Hb
Schisto- penetrate skin Snail /
reaction to S. haematobium: (in bladder)  ureter obstruction, bladder cancer Eggs have characteristic
somiasis after release human
eggs Can go to CNS, inflame  paralysis! shapes / spines : see slide
from snail
Swimmer’s itch in Great Lakes: from bird schisto (penetrates only)
Nutritional
Pigs or
deprivation; Ingest larvae Taenia solium: pork/pigs
cows / Make & excrete adults
big worm in (via raw meat) Taenia saginata: beef/cows
humans
intestine
Cestodes Cysticercosis (T. solium ONLY) – can go to all kinds of tissues
(Tapeworms) Larval forms Neurocysticercosis is most serious Note EGG not larva
Pigs or
in tissues Ingest egg  3-5y incubation ingested
cows /
(cysticercus in (fecal/oral)  Psychiatric syndromes; epilepsy, cysts, rarely SC involved/eye Make larvae; can go all
humans
brain, etc.) Dx: CT+ELISA or Western around!
Tx: steroids/albendazole +/- surgery

8
 Eosinophilia:
Worms, wheezes & weird diseases Eosinophilia & Helminths
 Asthma, IBD, cancer, rheum stuff, drugs, etc.
 Not caused by protozoa
 Higher in short-term visitors
Helminth eosinophilia: Usually higher in acute infection
 Often highest before eggs form
o Chronic, high eosinophilia – think helminth!
 Infections with eosinophilia often
o Differs among species (often absent or lower in adult forms)
Asx (sx months to years later)
 Ascariasis: often absent with adult worms
 Hookworm can be low too in adult worms  Absence doesn’t exclude helminth
 Malaria, other bacterial infections
can suppress eosinophilia
Life cycle vocabulary for eukaryotic parasites  Chronic: can cause endomycardial
fibrosis
Malaria: ring trophozoite / trophozoite / schizont containe merozoites
Toxoplasma: tachyzoite divides rapidly, infectious; bradyzoite slowly
Cryptosporidium: sporozoites shed infective eggs;
Leishmania: amastigote in reticuloendothelial cells is infective
Trypanosoma: trypomastigote is infective (fly human); amastigote is intracellular
Giardia: trophozoite is active & replicating
Entoamoeba: cyst; no replication for transmission
Trichomonas: trophozoite only

Helminths

Roundworm
 Adult in intestine, eggs shed in feces, larva (freeliving/parasitic) can go to various tissues, encyst, etc.
Filarial roundworm
 Adult in bloodstream, microfilariae cause disease in tissues; are infective for insect
Fluke flatworm
 Adult in portal/bladder veins, shed eggs in bloodstream
Cestode flatworm
 Adult in intestine, release proglottid with eggs, form cysterci / hydatid cysts in mm/brain

GUINEA WORM is almost eradicated (dracunculiasis) , a roundworm

 99% eradicated
 Roll up on stick!
 If you put your foot in water to cool, larvae burst out

DDx of fever in endemic area: Malaria, malaria, malaria – then other parasites/virus/bacteria, other causes of fever
MALARIA DOESN’T HAVE EOSINOPHILIA

N. meningitides & malaria are two infectious diseases that can kill you in 24h

9
 Other Protozoa
Organism Mug shot Pathology Transmission Life Cycle Clinical presentation Other

1. Cutaneous ulcer: worldwide (esp. Middle East, Central Asia, N.

Africa; Argentina  TX); at sandfly bite site. 2wks-years of
incubation. Non- or slow-healing ulcer on exposed skin, heaped up
edges
Leishmania Lives in Mϕ Dogs / Cutaneous: think vet from
and other RES Sandfly bites; 2. Mucosal: (Central/South America); metastatic from skin; extensive
Sandfly / Iraq or tourist from /to
(Leishman- cells IV drug use non-healing ulcers on mucosa (nose, oral cavity, pharynx, larynx)
Humans South/Central America
iasis) (promastigote)
3. Visceral: (Asia, southern Europe, Brazil): disseminates within RES
cells; 3-8mo incubation; EXTENSIVE NONTENDER
HEPATOSPLENOMEGALY, fever, weakness, weight loss, GRAY
DISCOLORATION of EXTREMITIES (kala-azar; “black fever”)

Think: Primary in healthy

1. Immune-competent: primary infection usually subclinical; can
Forms cysts patient = mono
produce mononucleosis-like syndrome with painless lyphadenitis
(latent;
(esp. cervical)
bradyzoites) if HIV patient reactivates &
Toxoplasma Undercooked
immune Cat/rat, gets brain lesions / neuro
beef/pork; 2. Immunocompromised: reactivation of dormant infection
reaction; Cat-feces- problems
(Toxoplasm- eggs in cat (encephalitis, brain lesions, chorioretinitis, myocarditis,
otherswise human
osis) feces pneumonitis)
proliferates in Pregnant woman changes
lots of tissues litterbox for the first time
3. Pregnant: Primary infection  transinfection of fetus  CNS
as tachyzoites (primary) & fetus gets birth
sequelae, chorioretinitis, severe disease.
defects
Leading curable STI in US
Trichomonas
(7.3M new cases/yr)
vaginalis Pear-shaped Human / Women: 50% Asx  PID & severe complications
Sexual
Motile Sex /
intercourse Theoretically survives up to
(Trichomon- Flagella Human Men: 75% Asx  severe infection, epidiymitis / prostatitis
45m on clothes,
iasis)
washcloths, bath water

10
 Diarrheal Protozoa
Organism Mug shot Pathology Transmission Life Cycle Clinical presentation Other
Cyst active
trophozoite in
Developing countries mostly (also immigrants, travelers, MSM in US) Cyst outside host;
Entamoeba GI tract; Human:
Ingest cyst trophozite (active) inside –
histolytica ingestGI
(water, soil, 1. Diarrhea (severe & bloody – dysentery) see pictures
can invade liver /
food) 2. Liver abscesses
(Amebiasis) (flask abcess) brain
3. Brain abscesses Dx: stool o+p (about 50%)
& spread to
liver, brain
Worldwide: epidemic diarrhea (contaminated water)
AIDS pts: severe diarrhea if low CD4 ct
Oocyst Contaminated
Cryptospor- Sporadic: day care, child care, travelers, backpacker/hiker/swimmer Need special stains (Stool
outside / water (shallow GI only
idium O+P with AFB)
troph inside wells, other)
Large volume secretory diarrhea with nausea/cramps/vomiting/wt loss
Self limited (2-3wks; >2mo in AIDS)
#1 fecal parasite for diarrhea in USA
Think: hiker who drank the
Contaminated Day care, travel to endemic areas, ingestion of unfiltered water while water; smelly stool
Giardia Cyst outside water camping; fecal-oral sex contact (esp. MSM), well water on farms
GI only
lamblia Troph inside (mountain Both trophs & cysts shed in
streams) Acute diarrhea, abdominal cramping, bloating, flatulence, stool; only cyst survives
Stools become NASTY SMELLING & GREASY over time (malabsorptive) Dx: Stool O&P; antigen
No blood/pus/mucous

11
 Pharmacology: ID & Micro (Fungi & Parasites)
Antifungal Drugs ..................................................................................................................................................................... 2
Chemotherapy of Parasitic Infections ..................................................................................................................................... 5

1
 Antifungal Drugs
The big picture:
DRUG INFECTION ROUTE MECHANISM CLASS
Amphotericin B
(deoxycholate)
Deep IV Ergosterol binding
Amphotericin B Polyene
(lipid formulation)
Nystatin Derm/yeast PO/topical/vaginal
Ketoconazole Deep/derm PO/topical
Fluconazole
Deep IV/PO
Itraconazole Ergosterol synthesis Azole
Clotrimazole
Derm/yeast Topical/vaginal
Miconazole
Flucytosine Deep PO DNA/protein synthesis Pyrimidine
Caspofungin
Micafungin Deep IV Cell wall synthesis Echinocandin
Anidulafungin
Gresofulvin Derm PO Microtubule formation Griseofulvin
Terbinafine Derm PO/topical Squalene synthesis Allylamine

General principles: need to be highly specific for fungal target without affecting human counterparts (tough because
both are eukaryotes)

Sterol biosynthesis:
 First part (common to both animals & fungi)
1. Squalene  2,3-oxidosqualene (via squalene 2,3-epoxidase)
2.  lanosterol (via 14-α-demethylase)
3.     zymosterol
 Second part
1. Humans: zymosterol  cholesterol
2. Fungi: zymosterol  ergosterol
 Key point: fungi use ergosterol (more hydrophobic & rigid) instead of cholesterol in their cell membranes

Target: ergosterol in cell membrane (polyenes)

 Note: these act directly on ergosterol (others interfere with biosynthesis)
amphotericin B Mechanism of Action: polyene antifungal agent. Big macrolide ring; half hydrophobic, half hydrophilic, forms a
channel or pore in fungal membranes

Effects: forms cylindrical channel (hydrophobic sides outside, against cell membrane) when bound to sterols &
allows leakage of small molecules resulting in fungal death
Selective Toxicity: Binds more avidly to ergosterol (fungi) than cholesterol; selective toxicity not great

Indications: potentially fatal fungal infections(think of toxicity)

1. invasive aspergillosis,
2. disseminated candidiasis Administration: IV
Toxicity: A lot. NEPHROTOXICITY is dose limiting. Fever, chills, hypotension ("shake 'n bake")
Other: deoxycholate is usual form; also lipid formulations available: same efficacy, less toxicity, 30-40x more $$

Nystatin Very similar to amphotericin, but in topical preparation

Indications: treatment of oral, vulvovaginal, cutaneous candidiasis
Administration: Topical

2
 Target: ergosterol biosynthesis
 Note: none of our current drugs target the fungi-specific part of ergosterol biosynthesis!

Azoles (ergosterol biosynthesis)

 imidazole (2 nitrogen atoms) or triazole (3 nitrogen atoms)
Azoles (in general) Mechanism of Action: azole antifungal agent.
 Low doses: inhibits ergestol biosynthesis.
 High doses: may directly damage fungal cell membrane
Effects:
 Low dose: blocks 14-alpha-demethylase, a CYP450 enzyme (lanosterol  ergosterol).
 High dose: direct damage
Selective Toxicity: Binds fungal demethylase more than human (although both have this enzyme)
Toxicity: GI distress, rash, hepatotoxicity, drug interactions (CYP3A4 inhibitor)

DRUG ORAL ABSORPTION METABOLISM EXCRETION INDICATIONS

Alternative to amphotericin B
Ketoconazole Effective Hepatic Urine
(systemic/mucocutaneous fungal infections)
Good; Urine (80% dose No postantifungal effect; fungistatic.
Mostly non-
Fluconazole independent of excreted in urine 1. Maintenance cryptococcal meningitis
hepatic
gastric acidity unchanged) 2. Prophy for Candida (transplant, etc.)
Erratic, better Systemic; fewer side-effects than ketoconazole
Itraconazole Hepatic only Urine + bile
with acid/food (but still hepatotoxic)
80-90%, better on 1. Invasive aspergillosis
Voriconazole Hepatic only Urine + bile
empty stomach 2. Candidemia
Ketaconazole has shortest half-life (~12h); others in 20-50h range

Allylamines (ergosterol biosynthesis)

naftifine Mechanism of Action: Allylamine antifungal drug. Inhibits ergosterol biosynthesis.
Effects: Inhibit squaline-2-3-epoxidase (earlier step in ergosterol biosynthesis than azoles); lead to membrane
terbinafine disruption and leakage of small molecules.
Selective Toxicity: Highly selective for fungal squalene epoxidase over human (no effect in vivo on cholesterol
biosynthesis
Indications: Candida, etc.
Administration: Topical (+oral for terbinafine)
Other: terbinafine is active ingredient in Lamisil®

Target: nucleotide metabolism (pyrimidine analogs)

Flucytosine Mechanism of Action: Pyrimidine analog antifungal agent. Active form interferes with nucleotide metabolism
(5-FC) Effects: Converted to 5-FU in fungi by cytosine deaminase. 5-FU has two roles:
1. metabolized to 5-FUMP, incorporated into fungal mRNA, interferes with protein synthesis
2. 5-FUMP ; 5-dUMP via ribonucleotide reductase; inhibits thymidylate synthase
Selective Toxicity: Human cytosine deaminase can't deaminate 5-FC (note that fungi and GI FLORA can!)

Indications: systemic Candida/Cryptococcus infections

Administration: co-administered with amphotericin B to combat resistance
Toxicity: generally well tolerated but:
 bone marrow depression,
 GI distress (gut flora killed);
 reversible hepatotoxicity
Resistance: MAJOR PROBLEM - develops very quickly with monotherapy

3
 Target: microtubule formation
Griseofulvin Mechanism of Action: Antifungal agent; Interferes with microtubule formation
Effects: actively transported into fungal cells; disrupts microtubules (mitotic & cytoplasmic), cell cycle arrest at
mitosis, formation of multinucleate cells.
Selective Toxicity: Humans don't actively transport into our cells

Indications: Severe infection of hair, nails, palm, soles (concentrates highly in keratin layers)
Administration: Almost complete distribution; goes to keratin layers
Toxicity: Relatively safe (GI distress, temporary headache)

Target: cell wall biosynthesis

Caspofungin Mechanism of Action: Antifungal agent. Inhibits cell wall biosynthesis
Effects: irreversible inhibitor of 1,3-beta-D-glucan synthase (makes glucan polymers for fungal cell wall); fungicidal
Micafungin Selective Toxicity: Humans don't have cell walls; fungi need glucan polymers for structure & viability
Indications:
Anidulafungin  Caspofungin: Salvage therapy for invasive aspergillosis; esophogeal candidiasis, candidemia. Used when
ampho B, others don't work.
 Micafungin: prophylaxis of candidiasis in BMT recipients
 Anidulafungin: Tx of candidemia
Toxicity: Important (limits usage, 14% of recipients). fever, nausea, vomiting, infusion site complications
Resistance: No cross-resistance with other classes

4
 Chemotherapy of Parasitic Infections
1/3 of world’s pop has parasites. 1:5 Americans! NO VACCINES so you have to use drugs for prophylaxis & treatment
Can classify as protozoa or helminths, or (more useful for pharm): Gastrointestinal vs Tissue/blood

Selective toxicity of antiparasitics (4 mechanisms)

1. Parasite location
A good antiparasitic drug:
a. if in the lumen of the bowel only, use a luminal agent that’s not
 Safe
absorbed (won’t hurt host cells!) (widespread use / prophy)
2. Differences in host/parasite metabolic pathways  Orally effective
3. Differences in isofunctional enzymes  Cure in 1 dose
4. Concentration of drug by parasite  Cheap

Mechanisms of actions for antihelminthics (2)

Note: adult worms don’t multiply in humans
 if you can get them to stop moving & hanging on, your body can flush ‘em out
 Worms have complex nervous systems; need active motility to resist expulsion by peristalsis

2 Targets: motility & energy generation

1. Parasite motility
pyrantel Mechanism of Action: Antihelminthic agent. Ach analog; neuromuscular blocking agent & Ach inhibitor
(causes spastic paralysis & constant muscle contraction of worm)
Effects:Worms can't resist bowel peristalsis; get swept out
Selective Toxicity: Luminal agent (poorly absorbed) - only affects parasites

Indications: Ascaris infection (helminths)

Administration: PO

praziquantel Mechanism of Action: Antihelminthic agent. Causes tetanic contraction of schistotomes (alters Ca
transport) & alters membrane integrity
Effects: Worms can't resist bowel peristalsis; get swept out to liver/lungs (portal circulation from gut or
systemic from bladder area). Surface of worm disrupted then, leading to death.
Selective Toxicity: unknown (NOT LUMINAL)

Toxicity: frequent GI/CNS but mild

Indications: Cestodes / trematodes (schistosomiasis & tapeworms - taenia solium, etc.)

2. Parasite energy generation

Enteric helminths live in anaerobic environment, so they have a special, different way to get energy:
 Transport glucose across membrane; different end of glycolysis (malate) & Krebs-cycle type thing
 Uses succinate dehydrogenase in respiratory chain (reverse direction from humans: fumaratesuccinate)
 Both the transporter & the succinate DH enzyme are different isoforms in parasites

5
Benzimidazoles:
albendazole Mechanism of Action: Antihelminthic agent.
 Block glucose transport
mebendazole  inhibit succinate dehydrogenase activity; an enzyme used in parasite's respiratory chain.
 (also disrupt microtubules selectively)
Effects: No energy for parasites; die & get swept out

Selective Toxicity: Helminths have different metabolism because they're anaerobic; parasitic isoforms are
different for these enzymes than humans'.
 Albendazole: Variable absorption (good to get more coverage; bad because of human
interactions - not a luminal agent)
 Mebendazole: Luminal agent (good absorption
Indications:
 Both: Gut organisms (enterobius, ascaris, trichuris, hookworm)
 Albendazole: tissue too (strongyloides, tapeworm which have tissue parts of life cycle)
Toxicity: Potent teratogen in animals. Don't give to pregnant women. Minimal otherwise
Administration: PO

Gut-dwelling Can go to Tissue

Trematode Cestode
Enterobius Trichuris Luminal?
Ascaris Hookworm (Flukes) (Taenia sp.)
(pinworm) (whipworm)
(Strongyloides) (Tapeworm)
Albendazole +/- absorption
Mebendazole Luminal
Pyrantel Luminal
Praziquantel NO

Classes of antimalarial drugs (3)

Malaria: 100+ countries where P. falciparum (most important) is chloroquine resistant
 all through Africa, Asia, S. America
 Important in USA too: 73 cases in MD last year (more than meningococcus!)
Remember life cycle: sporozoites enter; go to liver, can be hypnozoites in vivax or ovale, form schizonts which burst & release
merozoites, which attack RBC, forming erythrocytic schizonts, which burst in a periodic manner, with more merozoites leaving
(periodic fever); some change to gametocytes, which can be transmitted via new mosquito

 Important: ASYMPTOMATIC until RBC START BURSTING

Note that no drugs have Sporozoite Liver  RBC

activity against all 4 phases  Initial Hypnozoite Asexual Gametes
 Chloroquine
Class I: Asexual RBC form ONLY  Mefloquine
 can’t truly prophylax (need  Quinine
infection to RBC stage to  Fansidar
Class I

start killing) (pyrimethamine +

sulfadoxine)
 Need to start before,
 Coartem
continue through, and
(armether +
continue 3wks after lumefantrine)
exposure for prophylaxis  Tetracyclines
(organisms would have to Class II Primaquine
reach RBC stage to be Atovaquone +
killed by drug) Class III
Proguanil

6
Class II: opposite of Class I
 Prophylaxis only: can’t use in symptomatic patient (no effect on RBC stage)
 Can use primaquine to eradicate latent hypnozoites (use if worried about vivax/ovale exposure)

Class III: treatment & prophylaxis (liver stage & asexual stage)

Molecular mechanisms of action: chloroquine, atovaquone/proguanil

4-subsituted quinolones (chloroquine, mefloquine, quinine)

Heme biosynthesis: When Hb is broken down; heme is formed (toxic). Humans & plasmodia (feed on Hb) both have
mechanisms to detoxify
 Humans: break down via heme oxygenase to make bilirubin & excrete
 Plasmodium: no heme oxygenase: form heme polymers (visible as “malaria pigment” or “hemozoin” in
plasmodia).
 Chloroquine blocks this breakdown; heme accumulates; plasmodia die
o Resistance: enhanced efflux mechanisms

chloroquine Mechanism of Action: Antimalarial drug. Inhibits heme detoxification in plasmodia

Effects: Inhibits formation of heme polymers in plasmodia, leading to buildup of toxic heme
Selective Toxicity: Humans use heme deoxygenase to make bilirubin & excrete (different pathway).
Concentrated 100-200fold in infected RBC

Indications: First line for ovale & malariae

Toxicity: Retinopathy (&gt;100g cumulative dose, permanent)
Resistance: Widespread (more common than not: Sub-saharan Africa, South America, SE Asia).
Mutations in transporter proteins (enhance efflux)
Other: Cheap & available

Atovaquone/proguanil: synergistic against malaria parasites in vivo

1. Atovaquone: Binds cytochrome b in P. falciparum; inhibits mitochondrial electron transport
a. Pyrimidine synthesis inhibited
b. Mitochondrial membrane potential collapses
c. Resistance is rapid if monotherapy
2. Proguanil: metabolized to form cycloguanil, which selectively inhibits dihydrofolate reductase
3. Synergy: Not totally known; probably based on collapse of mitochondrial transmembrane potential (not
pyrimidine synth in experiments although that would be logical)

Antimalarial chemotherapeutic regimens

General principles to keep in mind:
Class Drug Use Notes
Cheap, available
I Chloroquine Ovale/malariae malaria
Widespread resistance for falciparum
Prophy against chloroquine-
I Mefloquine CNS toxicity prevents tx of established infection
resistant falciparum
Old; Quinidine is stereoisomer (can use in a pinch)
I Quinine Tx of chloroquine-resistant
IV for serious infection
falciparum malaria
I Coartem Two-drug combo; non-synergistic
Active against liver hypnozoites (only one)
II Primaquine Add for Vivax/ovale
Hemolytic anemia in G6PD-deficient pts!
Atovaquone + Proguanil
III Tx of MDR falciparum More expensive; synergistic
(Malarone)

7
Situation Treatment
Prophylaxis Before, during, 3wks after
 Chloroquine if sensitive; malarone, doxycycline, mefloquine if resistant
 Add primaquine if exposure to vivax/ovale (test for G6PD 1st)
Mild/moderate infection ORAL
 Chlorquine if sensitive
 Malarone [or Coartem or quinine (+doxy/tetra/clinda)] if resistant
 Add primaquine when recovered if exposed to vivax/ovale (test for G6PD 1st)
Severe illness IV
 Quinidine or quinine + (doxy/tetra/clinda)
 Add primaquine when recovered if exposed to vivax/ovale (test for G6PD 1st)
Note: only 15-30% US travelers take malaria prophy, docs usually get it wrong

Other protozoal infections (metronidazole)

Metronidazole:
metronidazole Mechanism of Action: Anti-protozoal & anti-anaerobe antibiotic.
 When two nitro-radical anion forms collide, they create a reactive complex that causes
alkylation & strand breakage of DNA
Selective Toxicity: Only works against anaerobes:
 has aromatic NO2 group that accepts an electron from reductive metabolism process
(production of ferredoxin), generating nitro-radical anion only in anaerobes
Indications: Protozoa + anaerobes.
 Trichomonas vaginalis Entamoeba histolytica, anaerobes; off-label for Giardia & H. pylori.
Toxicity:
 Genetic toxicity (? - controversial).
 GI common (nausea, metallic taste, disulfiram-like rxn with alcohol),
 Neuro (headache, ataxia, peripheral neuropathy, seizures - can be irreversible but rare).
 Avoid in pregnant/lactating women
Other: Prefers organisms with high A/T content in their genomes. Penetrates well into abscess cavities,
CSF, bile, bone, placenta, milk. Excreted by kidneys (modify for renal failure)

Anti-amebics
3 things amoebae can do:
1. Hang out as cysts (infective form)
2. Turn into trophozoites but hang out in lumen (commensal)
3. Invade as trophozoites (flask shaped ulcers, etc.)

Infection Treatment
Asymptomatic (luminal carrier) Luminal agent only Paromycin, diloxanide fuorate
Symptomatic (tissue invasion) Luminal agent + tissue agent Metronidazole, tinidazole

Pentamidine
pentamidine Mechanism of action: Active transport & accumulation in parasites.
 Activity is multifactorial: disorganize mitoDNA, inhibit mito Topo, bind ribosomes, inhibit
phospholipid synth, etc.
Indications: T. brucei, Leishmania, Blastomycosis, Babesia, P. jiroveci.
 Aerosolized form recommended for PCP prophylaxis in HIV patients (second line because of
toxicity for Tx behind TMP+SMX)
Toxicity: severe in 55% AIDS pts with PCP. leukopenia, azotemia, hepatitis, unpredictable hypoglycemia
(insulin similarities), others.
Other: Structural analog of synthalin (synthetic insulin)

8
 Pathophysiology: Skin
The Dermatologic Vocabulary ................................................................................................................................................. 2
Histopathology of the Skin ...................................................................................................................................................... 4
Acne & Rosacea....................................................................................................................................................................... 6
Cutaneous Autoimmune Bullous Diseases: Pemphigus & Bullous Pemphigoid ..................................................................... 9
Psoriasis & Atopic Dermatitis ................................................................................................................................................ 11
Pigmented Lesions & Melanoma .......................................................................................................................................... 14
Non-Melanoma Skin Cancer ................................................................................................................................................. 17
Dermatology of Pigmented Skin ........................................................................................................................................... 19
Birthmarks in Babies ............................................................................................................................................................. 20
Drug Eruptions ...................................................................................................................................................................... 22
Cutaneous Manifestations of Internal Diseases ................................................................................................................... 25
Common Infections of the Skin ............................................................................................................................................. 27

1
 The Dermatologic Vocabulary
Lesion morphology: shape and relative size of the lesion(s)
non-palpable, circumscribed, color change <1 cm; (“macular”
1. MACULE or “patch” are used to describe larger areas of the color junctional nevus
change)
molluscum contagiosum,
2. PAPULE palpable, circumscribed lesion, < 1 cm
intradermal nevus
palpable, circumscribed, relatively flat topped lesion, greater
3. PLAQUE psoriasis, lichen simplex chronicus
in surface area than in thickness, > 1 cm;
melanoma, squamous cell
4. NODULE palpable, circumscribed lesion, ≤ 1 cm and < 2 cm;
carcinoma
squamous cell carcinoma, basal cell
5. TUMOR large nodular lesion,≥ 2 cm
carcinoma
herpes simplex and zoster infections,
6. VESICLE clear fluid –filled lesion (blister), < 0.5 cm
vesicular foot dermatitis
bullous impetigo, toxic epidermal
7. BULLA clear fluid-filled lesion (blister), > 0.5 cm
necrolysis, bullous pemphigoid
8. PUSTULE turbid fluid-filled lesion folliculitis, acne
9. CYST nodule filled with a semisolid or liquid substance epidermal inclusion cyst
transient palpable lesion (hive) caused by an interstitial serous
10. WHEAL
fluid accumulation in the upper dermis
acne comedone, solar elastosis with
11. COMEDONE plugged pilosebaceous opening cysts and comedones (Favre-
Racouchot syndrome)
short, linear, thread-like lesion caused by the scabies mite
12. BURROW
tracking through the stratum corneum

Secondary Changes in lesions are frequently seen and may result from the primary disease process, normal skin
repair, external manipulation, or infection.
1. SCALE accumulation of adherent stratum corneum psoriasis, tinea corporis

accumulation of serous, cellular, squamous, and bacterial impetigo, secondarily infected

2. CRUST
debris over a damaged epidermis eczema

accentuated skin markings due to thickening of the

3. LICHENIFICATION lichen simplex chronicus
epidermis
4. EROSION tissue loss confined to the epidermis candidiasis

5. EXCORIATION erosion clearly caused by external factors neurotic excoriations

venous stasis ulcer, ulcerated basal
6. ULCER tissue loss extending into the dermis
cell carcinoma
7. FISSURE crack in the epidermis extending into the dermis perleche

8. SCAR fibrous tissue replacing usual dermal tissue space scarring alopecia
steroid induced atrophy, lupus
9. ATROPHY loss of substance of the epidermis and/or dermis
erythematosus
hypertrophic actinic keratosis,
10. HYPERKERATOTIC lesion with excessive “heaped-up” scale
squamous cell carcinoma
11. VERRUCCOUS vegetating, wart-like surface verruca vulgaris

2
Further description:
COLOR Primary Lesion
1. ERYTHEMATOUS Reddened skin
1. Macule / patch
2. Papule / plaque / nodule
2. VIOLACEOUS Violet
3. Vesicle / bulla
Related to purpura (small hemorrhage in
3. PURPURIC 4. Pustule
skin)
Hyperpigmented, hypopigmented,
4. PIGMENTATION
depigmented
DEFINITION Well-defined, Poorly defined DEFINITION
SHAPE 1. Well-defined
1. ANNULAR
Shaped like / forming a ring (is there a 2. Ill-defined
difference between edge & center?)
2. ARCUATE Like an arc (annular, but not complete
3. UMBILICATED With a central depression (like umbilicus) OTHER
4. SYMMETRY Symmetric, asymmetric (color, shape,
5. EXOPHYTIC Growing outward distribution, etc.)
6. ENDOPHYTIC Growing inward 1. Scaly? Crusted?
INDURATION Hardness Excoriated?
DESQUAMATION Epidermis peeling off 2. Linear? Annular?
DISTRIBUTION Umbilicated?
1. LINEAR 3. Erythematous?
2. CONFLUENT Lesions merge / run together Hyperpigmented?
Band-like distribution along dermatome Hypopigmented?
3. ZOSTERIFORM
(usually unilateral) Purpuric?
Visible small blood vessels near surface of 4. Atrophic?
TELANGIECTASIA
skin

3
 Histopathology of the Skin
Overview (Superficialdeep)
1. Epidermis
2. Dermis (papillary  rete)
3. Subcutaneous tissue

Epidermis
Layers:
1) Stratum corneum: anucleate; basket weave
appearance, thickness changes with anatomic site
2) Granular cell layer (stratum granulosum): thickness
varies with SC thickness; basophilic keratohyaline
granules present
3) Stratum spinosum (spinous layer): 5-10 layers; flatter
towards the top, connected by desmosomes (site of
blistering problems in some conditions)
4) Basal layer: single layer ovoid cells; perpendicular to
basement membrane zone, more basophilic, variable
amounts of melanin
5) Basement membrane zone: bonds
epidermis/dermis; PAS+; site of blistering disorder
problems (structural abnormalities / inflammatory
disruption)

Cell types:
1) Keratinocytes: most cells; mature as you go up
2) Melanocytes: about 1 out of 10 cells; in basal layer,
synthesize melanin, transfer to keratinocytes via
dendritic processes
3) Langerhan’s cells (dendritic cells, antigen-
presenting, have tennis-racquet-shaped Birbeck
granules)
4) Merkel cells (sensory receptors) SKIN COLOR
Skin color depends NOT on the
Dermis NUMBER of melanocytes you
Papillary dermis (pegs)  Reticular dermis (underneath) have but instead the amount of
Thicknesses depend on anatomical site pigment they produce.
Contains:
 collagen, elastic fibers; GAGs
 vessels/nerves
 Mast cells (inflammation, etc.)
 adnexal structures:
o Hair follicles: note that hair shaft itself is multi-layered
 Terminal anagen hairs: skin scalp (what we think of as hair)
 Vellus hair: nose, forehead (can’t really see). Male pattern baldness = transition from terminal
antigen to vellus hair on scalp
o Smooth muscle (arrector pili  goosebumps)
o Eccrine units: dermal sweat glands, dump into ducts, merocrine secretion (exocytosed)
o Apocrine glands:
 from hair/epidermial germ;
4
  duct enters at infundibulum; similar to eccrine duct but gland has
apocrine secretion (secretion via budding of PM). Acral: extremities of
 Mostly in axilla/anogenital region but also external ear canal peripheral body parts
(ceruminous), eyelids, breast (mamillary): few non-functional on
face, scalp, abdomen; more prominent in acral skin
Anatomic variation
Acral sites:
 hyperkaratotic stratum corneum
 nerve-end organs:
o Pacini corpuscles (onion/shaped; palms/soles + some on nipples/anogenital, sense pressure)
o Meissner’s corpuscles (ventral hands/feet; mediate sense of touch)
 No hair follicles
Mucosal sites: no granular cell layer or stratum corneum
Scalp: increased anagen hair follicles
Nipple/scrotum: increased smooth muscle bundles
Periorbital/perioral/perinasal/neck: skeletal muscle (neck, orbicularis oculi, etc.)
Nail unit: nail bed under nail plate; cuticle. Note that things under cuticle can leave marks as nail grows (diagnostic help)

Dermatopathology
Pathologic conditions affecting skin and mucosal tissue
 benign/malignant tumors, inflammatory conditions, deposition disorders, infections
Diagnosis: clinical history is key! Exam + demographics + history, etc.

Inflammatory skin conditions: Diagnosis

1. Look for epidermal alteration
a. Thickening (acanthosis = diffuse epidermal hyperplasia; rete hyperplasia)
b. Atrophy
c. Spongiosis (fluid): typically due to eczema; white space between keratinocytes, serum in SC
d. Dyskeratosis/lichenoid tissue reaction (being eaten away?)
e. Blistering (separation of layers)
i. Fluid separation within/beneath epidermis
ii. Can be from spongiosis, cytolysis of keratinocytes, acantholysis (loss of cell/cell contact); BMZ
destruction, liquefactive necrosis
iii. Can be tense (subepidermal separation) or flaccid (transepidermic usually)
f. Stratum corneum alteration (hyperkeratosis, neutrophils in cornea)
g. Cellular atypia (lymphoma, leukemia, breast cancer, melanoma, nevi)
2. Look for infiltrates
a. Where is it? Dermal/epidermal junction, around vessels, interstitial, etc.
b. What is it? Lymphocytes +/- eosinophils, granulomatous, etc.
i. Urticaria (hives): PMNs & eosinophils
ii. Arthropod bite: lymphocytes & eosinophils in wedge shape
iii. Drug hypersensivity: spared epidermis; mostly perivascular lymphocytes in dermis
3. Miscellaneous findings
a. Fat alteration (paniculitis)
i. erythema induratum = thickened septae; erythema nodosum: whole lobule + septae involved
b. Amyloid deposition (yellowish, can pinch & produce purpura)
c. Cysts
d. Cancer/precancerous:
i. Actinic keratosis: precancerous, basal layers abnormal
ii. Squamous cell carcinoma (in situ / invasive)  basal cell carcinoma)

5
 Acne & Rosacea
Things in bold, caps, underlined = things she said we should know
Acne Vulgaris: Pathogenesis
Self-limited condition of the pilosebaceous unit (hair follicle + associated
sebaceous gland)

Sebaceous gland: all skin with hair follicles (all but palms/soles)
 Sebocytes mature, accumulating more lipid  secrete by holocrine
(decapitation: cell dies & releases contents)
 Sebum is secreted product
o KEY: SQUALENE AND WAX ESTERS DISTINGUISH SEBUM FROM
LIPID IN INTERNAL ORGANS
 Activity fluctuates with age (and men>women)
o high at birth, quiescent 2-6yo, increases @ 7yo
o peak in 20s, gradual decline with age (decrease per decade:
men < women)
 Androgens explain fluctuation:
o sebum production corresponds to adrenarche,
not puberty
o DHEAS (weak androgen) is locally converted to
testosterone & DHT (stronger) to stimulate
sebum production (DHEAS ↑ in adrenarche
although systemic T & DHT not ↑ til puberty)

Comedogenesis (comedon = acne lesion)

Keratinization pattern altered inside hair follicle

 Normal: loose organization; many lamellar granules, few
keratohyaline granules)
 Changes: ↑density, ↑structure, ↑keratinocyte
turnover & ↓apoptosis
o Etiology unclear: ↓linoleic acid, ↑ IL-1α, ↑androgens?
 Keratin shed, forms whorls, plugs follicle

Resident flora: Proprionibacterium acnes

 P. acnes is GRAM NEGATIVE, NON-MOTILE, MOSTLY
ANAEROBIC
 No formal link between P. acnes & acne
o Probably normal flora, protective role usually
(but ↑↑ in acne pts)

Possible mechanism of pathogenesis:

1. P. acnes has lipases that break down sebum (+
proteases, hyaluronidases too)
2. Production of FFA + other molecules  inflammation 
3. cytokine (IL-1α, TNFα, IL-8 ) release by kera tinocytes & local inflammatory cells 
4. chemotaxis of T-lymphocytes & neutrophils  damage follicular epithelium
5. Hair follicle keeps dilating; sebaceous gland atrophies  scarring

6
 Acne vulgaris
Comedo/comedone = initial lesion
 Closed comedone: slightly elevated, 1-4mm papule, mostly face (“whitehead”)
o Has lamellated/whorled keratin; not inflammatory grossly but infiltrate on path
 Open comedone: similar but communicates with surface of skin
(“blackhead”)
o Color from melanin deposition
Papulopustle: after progression; more inflammatory (erythema +
tenderness + induration)
 Overlying pustule (pus blocks follicle)
Nodulocystic acne: inflammation persists, becomes deeper; keratin
shedding blocked (scarring imminent)

Acne Fulminans (“acute febrile ulcerative acne”)

 Severe form of nodulocystic acne accompanied by systemic symptoms & signs
 Sudden onset, mainly in teenage boys
o massive inflammatory, tender lesions on back + chest; rapidly ulcerate; heal
with scarring
o Febrile, leukocytotic (10-30k WBC/mm3)
o Polyarthralgias, myalgias, other systemic complaints; +/- lytic bone lesions in
tender bones
o Often require hospitalization: can be a derm emergency!

Neonatal acne
 20% newborns; 2-3 mo; spontaneous remission without scarring
 Infection with Malassezia furfur (yeast)
 Presentation: inflamed papules on cheek, across nose/forehead

Infantile acne
 3-6mo, improves by 1yo but can persist for yrs
 Hormonal imbalances are key
o boys: LH/Testosterone; DHEAS in both from immature adrenal gland

Occupational acne
 A.k.a. “chloracne”; from occupational exposure (chlorinated aromatic hydrocarbons)
o Cutting oils, petroleum products, coal tar derivatives, electrical conductors/insulators, insecti/fungi/herbicides, etc
 Classic: big nodules behind ear, on cheek/scrotum
o E.g. Victor Yushchenko post-dioxin poisoning attempt

Drug-induced acne
 Key clue: Monomorphic (all in same phase of evolution)
 TONS of meds can cause it (EGFR inhibitors are newest but also anabolic steroids, lots more)

Endocrine acne
 Cystic acne in association with other signs of hyperandrogenism (hirsutism, irregular menses, infertility, obesity)
 Polycystic ovary syndrome: #1 endocrine abnormality in US (5% women)
o Diagnosis of exclusion (oligomenorrhea + clinical/biochemical hyerandrogenism)
 High glycemic index of western diet might be involved in prevalence of acne in developed countries

7
 Rosacea
 Less well understood
 Cutaneous reaction that initially presents with flushing of skin Epidemiology
o Flares with remissions  Females > Males
 30-50 yo usually
Pathogenesis  N. Europeans > Asians > Others
 Vascular dysfunction (blood flow ↑ vs regular skin, vessels dilated,
blood/inflammatory substances extravasate)
 Microorganisms (maybe?) – Demodex folliculorum (mite)?
 Neurologic dysfunction:
o Parkinson’s patients often develop
o Hot drinks / emotions / alcohol can trigger flares!

Clinical manifestations (subtypes)

Vascular rosacea
 Earliest stage: recurrent blush, start of telangiectasia (nasal ala  cheeks)
 Degree: related to degree of sun damage
 Edema + burning/stinging (when applying products to face, for instance

Inflammatory rosacea
 Small papules/pustules  deep persistent nodules
 Deeper red than acne; no comedones or follicular keratinization defects

Sebaceous hyperplasia & phymatous rosacea

 Overgrowth of sebaceous glands is prominent in some patients
 Rhinophyma = nasal sebaceous hyperplasia
o Swelling/smoothening of nose  enlarging pores / lumpy  fibrosis later (permanent)
o Path: too many sebaceous glands!

Ocular rosacea
 > 50% of rosacea patients: “dryness / tired eyes”
 Edema / tearing / pain / blurry vision / styes / chalazia (other features too, can be pretty severe)
 Possibly due to meibomain impaction (glands that secrete lipids in tears)  ↓lipid in tear film

Steroid-induced rosacea
 Prolonged use of topical steroids on face (or could be systemic)
 Clues: lesions on UPPER LIP, EYELIDS, AROUND NOSE
 Withdrawing steroid  “ANGRY FACE” syndrome (initial flare, then recedes)

8
 Cutaneous Autoimmune Bullous Diseases: Pemphigus & Bullous Pemphigoid

Pemphigus Vulgaris
 Pemphigus (Greek: “Blister”)
 Painful blisters of mucous membranes / skin
o stratified squamous epithelium only (not respiratory
epithelium, etc.)
o Large erosions, weeping, can recur explosively; flaccid vesicles
o Intraepidermal blistering
 Peak: 30-50 yo; natural history = 50% mortality @ 2yrs, 100% @ 5yrs
 Oral lesions at first  skin lesions later

Pathology: no inflammatory cells but tons of antibodies (IgG fluorescence

everywhere)

Genetics: MHC Class II genes

 DR4 (Ashkenazi Jews) or DQ1 (other populations)
 Everybody with pemphigus has the mutation, but only 1:10,000 with the
mutation develop pemphigus

Desmosomes are key

 cell-cell junctions in epidermis, keratin filaments in cell  desmosomal
plaque  desmogleins/desmocollins  hemophilic interactions with next cell
 Auto-antibodies against desmoglein proteins
o Epitope expansion can occur over time (antibodies Presentation Auto-Ab against…
Pemphigus foliaceus Desmoglein 1
against new desmoglein epitopes); corresponds
Pemphigus vulgaris (oral only) Desmoglein 3
with progression of disease
Pemphigus vulgaris (oral + skin) Desmogleins 3 + 1
Dsg 3,1 + plakin
As long as Ab bind, cell detachment happens (see slide: mouse Paraneoplastic pemphigus
proteins + more
models tried to block other points).
 Weird: cell adhesion is complex. Why would blocking just one
component block adhesion? Nobody knows exactly why (complex
cell signaling pathways)

Treatment Implications:
 need drugs that reduce autoantibody synthesis
 doesn’t help just to reduce inflammation
 remission is slow (12-24mo)

Treatment options:
 Apherisis (too invasive)
 IvIG (give lots of Ab, body starts chewing them up – including anti-Dsg autoAb)
 Usually start with prednisone in high doses
 Add purine synth inhibitors (azathioprine; block T/B cell synth), IvIG / Rituximab (anti-CD20 mAb),
cyclophosphamide (alkylating agent), plasmapheresis, etc. as needed

Bullous pemphigoid

 Elderly patients (60-80yo)

 Large, dramatic, pruritic blisters on skin (not painful)
9
 o On base of large inflammatory process
o mucosal lesions uncommon

Hemidesmosome antigen is target of IgG + complement

 Antigen right near cell membrane (extracellular, in lamina lucida)
 Subepidermal blistering (IgGs found in basement membrane zone)

Blocking steps of cascade blocks blister formation (PMNs are critical)

Treatment implications
 Suppress inflammation & wait for remission
 Bigger menu of drugs to choose from

Treatment: Anti-inflammatory
 Topical steroids sometimes; tetracycline / methotrexate/ niacinamide for
mild cases; maybe dapsone for some
 Can use prednisone in lower doses (purine synth / cyclophos / etc rarely,
in lower doses)

PEMPHIGUS VULGARIS BULLOUS PEMPHIGOID

Rare
COMMON FEATURES Antigen targets known
Auto-Ab are pathogenic (not just markers)
AGE OF PATIENT Middle-aged (30-50 yo) Elderly patients (60-80 yo)
Painful Painless but pruritic
BLISTERS: Large erosions, weeping, can recur explosively; flaccid
Large, dramatic blisters on skin
vesicles

MUCOUS MEMBRANES Involved (oral  skin) Involvement uncommon

TARGET Desmosome Hemidesmosome
LEVEL OF SEPARATION Intraepidermal Subepidermal
INFLAMMATORY
None Big
REACTION

PMNs are critical: if you block PMN activity,

BLOCKING STEPS OF Blocking steps of cascade doesn’t help:
cascade stops (Ab binding insufficient by
DETACHMENT CASCADE Ab binding sufficient to cause blistering
itself)
Reduce inflammation; wait for spontaneous
TREATMENT IDEA Block Ab synthesis; slow remission
remission
High doses (immunosuppressive levels); few Lower doses (anti-inflammatory levels), more
THERAPY OPTIONS
drugs available options

10
 Psoriasis & Atopic Dermatitis
Quick immunology review: Helper T-cells
 Th1: key for clearance of intracellular pathogens;
important in pathogenesis of autoimmune diseases
 Th2: key for clearance of parasites & allergic
reactions (IgE); important in pathogenesis of
allergic diseases

Dendritic cell / T-cell Signaling (immunological synapse)

 Dendritic / APC cell presents antigen on MHC
 MHC + antigen binds complementary T-cell
receptor on matching T-cell
 Other costimulatory molecules are key: e.g. ICAM-1 (APC) / LFA-1 (T-cell), LFA-3 (APC) / CD2 (T-cell)
 Combination of signals leads to T-cell activation

Psoriasis
 Chronic disorder; polygenic predisposition + triggering factors
Epidemiology of psoriasis
Pathogenesis:  Males = females
 Th1 cells are key (cytokines: IFNγ, TNFα, IL-2): autoantigen in skin  30% develop dz < age 20
probably triggers Th1 rxn  2% of general pop
 Results:  10-30% pts  psoriatic arthritis
o Epithelial hyperproliferation, vascular proliferation  Certain HLA subtypes
o PMNs recruited + T-cell mediated immune reaction associated (HLA Cw6 = 13x RR)

Type Photo Description Other

Palpable plaques, silvery scale are classic Most common form;

Plaque psoriasis Extensor surfaces (knee / elbow), sacral “Auspitz’s sign”= bleeding
on removal of plaque.

Younger patients (esp

Guttate Well-defined, smaller, discrete papules
several weeks post strep
psoriasis (still with silvery scale)
infection)

Generalized, lakes of coalescing pustles on

Pustular
background of erythema
psoriasis
Palmoplantar surfaces

Onycholysis (distal lifting of nail bed); oil

Nail psoriasis
spots on nail bed, nail pits

Mono / asymmetric arthritis (DIPs mostly) Can present like RA

Psoriatic
Arthritis mutilans  severe disability (symmetric polyarthritis)
arthritis
Spondylitis/sacroilitis possible too too
Other forms: Erythrodermic psoriasis (diffuse, all over the place),
scalp psoriasis, inverse psoriasis (not classic with silvery scales but erythematous plaques instead)

11
Treatment:
1. Address triggers (trauma, infections, drugs that are exacerbating)
2. Topical treatment (corticosteroids are mainstay; vit D/retinoids/tar too)
3. Phototherapy (unless post-sunburn)
4. Systemic immunosuppresives if severe
5. Newer: TNFα antagonists, mABs, others

Atopic dermatitis
Relapsing, pruritic skin disease
AD IS NOT THE SAME AS ECZEMA
 Eczema is a reaction pattern
Pathogenesis:
 Erythematous patches/plaques with
 Th2 cells are key (cytokines: biphasic)
epidermal changes (Scale/crust)
o Acute atopic dermatitis: Th2-mediated (IL-4, IL-5, IL-13)
o Chronic atopic dermatitis: Th2 and Th1 (IFNγ, IL-12)  Can result from many causes
o atopic dermatitis, irritant dermatitis,
o T-cells, eosinophils, monocytes activated; IgE increased allergic contact dermatitis, venous stasis,
 Skin barrier defective: ↑ cutaneous superinfections; fewer etc.)
lipids/FA in AD pts
 Polygenic inheritance pattern (autosomal dominant)
o 81% of kids with 2 AD parents will have AD; 60% adults with AD have kids with AD Atopy: from Gr. atopos,
o Stronger correlation between siblings with AD “Strange or unusual”
(environmental factors too)

Epidemiology of AD
“Atopic march”: associated with other atopic disorders
 Prevalence doubled in last 30
 Food allergy (30% AD pts)
yrs in industrialized countries
 Asthma (30-60%)
o 15-30% children, 2-10% adults
 Allergic rhinitis (60-80%)
 Females < Males (1.3:1)
 Often begins in infancy, 85% before
Diagnostic criteria: 5yo; 70% remit before adolescence;
 Must have: Pruritis + Eczema (typical morphology / age specific patterns, 50% recur in adulthood; can start in
chronic/relapsing) adulthood: late-onset AD
 Most will have: Early age at onset + Atopy (personal/family Hx, IgE
reactivity, xerosis = abnormal dryness of skin / mucous membranes)
 May have other features too
Signs:
 Dennie-Morgan folds under eyes (secondary to edema)
 hyperlinear palms, keratosis pilaris (spiny papules)
 Ichthyosis (plate-like dark scales on skin)
Progression
Location Quality

Skin folds, face, scalp, cheeks

Infancy Erythematous + exudative
Extensor surfaces (not diaper area)

Childhood Flexor surfaces; Often generalized xerosis (dryness)

pityriasis alba (post-inflammatory hypopigmentation)

More ill-defined
Adulthood Hand dermatitis common Lichenification (thickened
epidermis) more common

12
Cutaneous infections are common with AD
 Impetigo (90% AD pts S. aureus colonized)
 Eczema herpeticum (superinfection with HSV) – discrete, punched out ulcers on background of atopic derm
 Eczema vaccinatum (severe widespread eruptin post-smallpox vax or exposure to vaccinated people, 1:25k-30k)

Treatment:
1. Avoid triggers (irritants/allergens/heat/stress/etc): especially food allergies in children, bacteria + environment
2. Moisturize! (ointment>cream>lotion)
3. Mild soaps (Dove)
4. Topical therapy: steroids for flare-up, calcineurin inhibitors
5. Antihistamines: sedating for sleep, nonsedating for day
6. Treat superinfections
7. Phototherapy
8. T-cell suppression (corticosteroids to sequester T-cells, induce apoptosis; macrolides to block early phase of activation,
immunosuppressive agents like methotrexate or purine synth inhibitors if recalcitrant)

Other random conditions (Ddx of AD)

Contact dermatitis: irritant or allergic; sudden onset; linear / geographic (“outside job”), very pruritic
Lichen simplex chronicus: “elephant skin” or “tree-bark-like” with accentuation of normal skin markings; more common in
adults; chronic itch-scratch cycle (can see in AD, contact dermatitis, psoriasis), hard to treat
Nummular eczema: coin-shaped, 1 or several well-demarcated pink plaques, fall/winter, easy to tx
Seborrheic dermatitis: infants: “cradle cap” (scalp + skin folds); adults: pruritis + greasy white-yellow scales + erythema on
scalp/eyebrows/ears/central chest (where sebaceous glands are)
Tinea Corporis: fungal; one or more annular & polycyclic plaques, use scrape + KOH to diagnose

13
 Pigmented Lesions & Melanoma
Melanocytes:
 from neural crest cells; found within basal layer of epidermis (1 melanocyte: 4-10 keratinocytes)
 dendritic processes with clear cytoplasm & small, dark nuclei (use special stain), solitary cells (no desmosomes)
 make melanin in melanosomes (organelles)  keratinocytes via phagocytosis
o makes UV-absorbing “cap” to absorb radiation

Benign pigmented lesions

Description Location Patient Histology Other
direct relation to sun
small clusters of
Sun exposed areas: ↑ pigmenentation; exposure;
Ephelide macules, Common in
nose, cheeks, shoulders, ↑ transfer to keratinocytes (not recur in summer & fade in
(freckle) tan-red to brown, children
dorsal hands, arm increased local # melanocytes) winter
well-circumscribed

Solar lentigo Irregular evenly Sun-damaged skin (face, Common,

Elongate of rete; no increase in # Incidence increases with
(“age spots” / pigmented macules, dorsal aspects of middle-aged
melanocytes age
“liver spots”) tend to coalesce hands/arms) & elderly

Nevocellular Nevi (melanocytic nevus / “mole”): benign melanocytic neoplasms

 Proliferation of melanocytes  cohesive nests & aggregates
o (do see ↑# melanocytes)
 Transformation: lose dendritic processes, become round/oval, nuclei uniform

Acquired nevi:
Clinical features
 Adolescence/early adulthood; enlarge  stable  involute (maximum in 20s, regress/disappear by 70s-80s) of benign acquired nevi
 Progression: normally distributed on BMZ, proliferate on junction, descend to dermis, then lose melanocytes in junction  Symmetrical
1. Junctional nevus (just at dermal/epidermal junction)
 Regular borders
a. symmetric, sharply circumscribed, flat, uniform medium/dark brown color
 Uniform color
b. No melanocytes in dermis, no atypia, regular size/shape/spacing of nests @ tips of rete ridges
2. Compound nevus (junctional & dermal nests)  Small (<5mm)
a. Raised/dome shape (involvement of dermis); uniform light/medium brown color, can be hairy
(Compare to melanoma, which
b. Dermal melanocytes mature with descent (deeper cells smaller/less pigmented/less nested); no atypia inexorably progress)
3. Intradermal nevus (now in dermis)
a. Raised lesions, light brown / flesh colored, can be hairy
b. Dermal melanocytes maturing with descent like above but in nests/cords/sheets, pushing upwards

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 Congenital nevocellular nevi
 Present at birth, big variation in size (few mm “bathing trunk”)
 Varied appearance (can be asymmetrical, geographic borders but with uniform pigmentation, +/- hair growth)
 Increased risk of melanoma in affected areas
 Singular melanocites with dendritic morphology in lower 2/3 dermis

Other acquired melanocytic lesions

1. Dermal melanocytosis (“Mongolian spot”)
o ill-defined patches, blue, Asian infants, birthfade by early childhood
2. Blue nevus
o Well-circumscribed, dome-shaped papules, small (<1cm), gray-blue/blue-black,
o On dorsal hands/feet/face); present @ birth or any age
o Mϕ chewing up melanin on path

Atypical (“dysplasitic”) nevi

 Acquired, pigmented lesion on skin but with different clinical/histological features than nevi
o Usually > 5 mm in diameter, symmetrical, regular but fuzzy borders, variations of pigmentation
o Architecture: disordered (elongated/bridged rete  “east-west” architecture)
o Hyperplasia, cellular atypia (large nuclei, irregular nuclear membrane, etc) but not clonal
 Some overlap with malignant melanoma
o Abnormal ABCDE but clinically stable
o Not necessarily precursor lesion but marker of ↑risk
 50-100 dysplastic nevi = “atypical mole syndrome
 Puberty  can keep developing throughout life
 Management: most don’t progress; follow with photos, biopsy for atypia; re-excise for severe atypia on biopsy

Melanoma
 Malignant growth of melanocytes
Epidemiology
 Location: skin/sun-exposed areas; can happen on mucosal too;  8,400+deaths/yr, 60k cases/yr
can be de novo or from existing nevi  5% skin cancers but >80% skin cancer deaths
 1/75 lifetime risk in US (increasing)
Pathophysiology: genetics, immune system (host); radiation, etc  53yo median age at dx
nd
(environment)  Most common cancer in women 25-29, 2 to
breast cancer in 30-34yo women

Histology: nests don’t mature; still make pigment as they go down; scattered throughout epidermis, diffuse atypia

Risk factors
 Increased episodic exposure of fair skin to sun (especially in childhood)
 PMH or FHx melanoma; > 50 or irregular nevi, immunosuppressed pts too

Familial atypical mole/melanoma syndrome(FAMM)

 Melanoma in 1+ 1st/2nd degree relative, >50 moles, autosomal dominant condition
 Develop melanomas at younger age, lifetime risk approaches 100%

ABCDEs of Melanoma
 Asymmetry: compare one half to another
 Border: is it ragged/notched/blurred/irregular?
 Color: is it uneven? (reflects histology)
 Diameter: is it > 5mm?
 Evolution: is it changing or evolving in size, shape, color,
symptomatology? (use photos)
15
Progression / growth phases
 Growth phases: radial (epidermis only)  vertical (dives down)
 Stratifying by subtype does not improve prognostic information

1. In situ: no potential to metastasize, confined by basement membrane, no access to lymph / vasculature, can
cure with excisional surgery
2. Invasive lesions
Type Frequency Location Growth pattern Other

Superficial Most common Upper back (+ legs in Variable radial phase  Sometimes changes in
spreading (70%) women) vertical phase pre-existing mole

No radial, immediately
Nodular 20% Legs + trunk
vertical & aggressive

5% Sun-exposed skin Cumulative instead of

Long radial phase 
Lentigo maligna older (mean (head/neck) intermittent sun
vertical phase
age = 65 yo) exposure,
Acral sites
Acral Most common subtype
5% (palms/soles/nail
lentinginous in darkly pigmented pts
beds)

Diagnosis/Prognosis
 Biopsy is key for both (depth of invasion, # mitoses, ulceration, vacular invasion, sparse lymphocytic response?)
 Breslow’s tumor thickness: MOST IMPORTANT histologic determinant of prognosis
o top of granular cell layer to base of ulcer @ deepest point of invasion, 90° to epidermis
 Staging: T1-4 by Breslow depth, N by LNs, M by metastasis
o 0: in situ  I: small, N0M0  II: larger, N0M0  III: N ≥ 1  IV: M ≥ 1

Treatment:
 surgery (need to Dx early)
o bigger excision doesn’t mean better survival (current guidelines: about 1cm margin per mm tumor)
 immune system might be key; no single systemic therapy proven to extend life; combo therapy maybe?

16
 Non-Melanoma Skin Cancer
 Basal cell carcinoma and squamous cell carcinoma are most common (also Merkel cell carcinoma, others)

Pathophysiology
Random facts:
 Host: genetics (skin type, mutations in repair pathways, etc), immune system SPF only tells you how
 Environment: solar radiation, viruses, ionizing radiation, chemicals/trauma good a sunscreen is
against UVB radiation
Triggers
 UV light is big one (90% cancers have signature UV mutations; on sun-exposed areas) ABCDE doesn’t help so
 Immunosuppression (100x risk increase for transplant patients); viruses like HPV much with these cancers
(more for melanoma)
 Genetic mutations: p53 in SCC, Sonic Hedgehog pathway in BCC

Basal Cell Carcinoma

Clinical features:
 Waxy, pearly, translucent, persistent
 Friable (bleeds easily), ulcerated, pink scaling plaques

 90% on sun exposed areas (head neck, other areas depending on culture)
 Locally aggressive: usually doesn’t spread/metastasize (instead infiltrates
surrounding area & destroys tissue)

Epidemiology:
 #1 skin cancer (incidence)
High cure rate but 20-40% chance of developing another case o 80% new skin cancer cases
o Annual incidence 0.1-0.5%
Pathophysiology: mutations in SONIC HEDGEHOG PATHWAYS  4:1 BCC:SCC in clinic
 Genes encoding patched homolog (PTCH1), smoothened homolog (SMO)
o Usually hedgehog stimulates patched, which inhibits smoothed, which sends a signal for growth if not inhibited
 Results in unrestrained growth

Squamous Cell Carcinoma

Clinical features
 Keratotic/scaly plaques on erythematous base Epidemiology:
 Ulcerated / crater-like / friable  #2 skin cancer in gen pop
 300k/yr in US
 75% on head / neck / hands  #1 cancer in transplant pts
 Invades more than BCC (LN, lungs, etc): risk of metastasis 0.5-5%

Pathophysiology: mutations in P53

 Often 2 hits: one leads to dysplasia, second leads to
invasiveness

Progression:
1. Actinic keratosis (precursor lesion, can be detected &
cured)
a. Rough scaly spot on red, irritated base; can shed & recur
b. Sandpaper texture (sometimes more easily felt than seen), can have more than 1
c. 90% go away on their own (immune system: transplant patients can’t clear)
2. SCC in situ 
3. Invasive  metastatic SCC
17
 Treatment
BIOPSY BIOPSY BIOPSY BIOPSY BIOPSY BIOPSY BIOPSY BIOPSY…
 Lots of treatment options
 One cool new treatment is Moh’s micrographic surgery: can check 100% of margin while pt waiting & take out more
 Consider: tumor type, age, cosmetic results, #/size lesions, distinctness of borders, 1° vs recurrent, location

18
 Dermatology of Pigmented Skin
 People have different colors of skin. A majority of Baltimore & soon the US will be people with skin of color.
 Non-white ethnic groups tend to have poorer health care outcomes
 Know the answers to these questions below

What determines skin pigmentation? AMOUNT OF MELANIN PRODUCED BY MELANOCYTES (melanosome activity)
 Number of melanocytes generally constant
 Pigmentation differences from melanosome activity (#/size/composition/distribution)
 Melanosomes: dendritic cells; produce/distribute melanin to keratinocytes, functions for photoprotection
o Pheomelanin (red/yellow melanin): light/dark skin, especially red-heads, women>men
 Can become carcinogenic when exposed to UV light
o Eumelanin (brown/black): abundant in dark-skinned people
 Epidermal-melanin unit: melanocyte + its 30-40 keratinocytes

What is the rate-limiting enzyme in melanin biosynthesis? TYROSINASE

 Melanosomes: organelles that contain melanin; exported to surrounding cells. Matrix proteins + enzymes
o 4 stages of development (1=no melanin, type 4 = lots of melanin)
o Different skin types have different predominant melanosomal stages (dark skinned = has more stage IV)
 Tyrosinase is rate-limiting (part of DOPA/etc pathway) – deficient in some albinism pts
 Darker skin: more melanized melanosomes (later stages); bigger, more melanosomes/cell, slower degradation

Differences in epidermal structure: Melanosomes in black skin are larger, individually dispersed in keratinocytes
WHITE BLACK ASIAN
Stratum corneum Thicker, fewer layers Thinner, more layers
Stratum lucidum Swells with sun exposure No change with sun exposure
Water barrier Higher Lower
Lipids in SC Fewer More
Melanosomes Smaller, grouped in KC, more Larger, individually dispersed in Grouped but individually
numberous in SC than basal KC, more numerous in basal dispersed in sun-exposed areas
layer layer
Vitamin D production High Low
Photodamage Big changes Less changes Big changes

Differences in dermal structure: More dilated blood/lymphatic vessels in Black skin (nobody knows why)
 Dermis = collagen + elastic fibers + interfibrillar matrix (GAGs & water)
 Also: less solar elastosis, thicker/more compact than white skin
WHITE BLACK
Dermis Thinner / less compact Thick / compact
Paipillary/reticular layers More distinct Less distinct
Collagen fiber bundles Bigger Smaller, closely stacked
Lymphatic vessels Moderate/dilated Many, dilated, empty
Fibroblasts Fewer, some binucleate cells Many, many binucleated cells
Elastic fibers More, more evidence of solar Less, little evidence of solar elastosis (photodamage)
elastosis
Superficial blood vessels Sparse / moderate More numerous, mostly dilated

Most derm diseases have WORSE PROGNOSES IN BLACK PATIENTS than in white patients
 Vitiligo (depigmented patches)  Keloidosis (more common in AA/Asian pop, can lead
 Sarcoidosis to scarring / disability)
 Pseudofolliculitis barbae (Razor bumps)  Traction alopecia from braids, etc.

19
 Birthmarks in Babies
Neurofibromatosis Type I (BROWN)
Autosomal dominant, 50/50 spontaneous mutations & inherited, multisystem disorder, 1/3500 people, variable expression, nearly
100% penetrance by age 20
Diagnostic Criteria: NEED 2 OF 7
“Color-Coded” Birthmarks
 6+ café au lait macules (>5mm pre-puberty, >15mm post-puberty)
Brown Neurofibromatosis type I
 2+ neurofibromas of any type, or 1+ plexiform neurofibroma
White Tuberous Sclerosis
 Freckling in axillae / groin (Crowe sign)
Red Infantile Hemangiomas
 Optic glioma
Yellow Nevus sebaceus
 2+ Lisch nodules
 Dysplasia of sphenoid; dysplasia or thinning of long bone cortex
 1st degree relative with NF1
Comprehensive screening finds mutations in >95% individuals – only indicated if they’re at risk

Clinical findings
Finding Picture Description Age

Café au lait macules Need 6+ (2 SD from mean) Increase in number throughout childhood

Skin fold freckling Most specific, nearly

90% adults have freckling
( Crowe sign) pathognomonic finding

Hallmark sign; dome-shaped, Onset at puberty

soft, fleshy, skin-colored to slightly
hyperpigmented / firm / nodular;
Increase in size/# throughout adulthood
Neurofibromas
major source of morbidity Grow most in puberty & pregnancy
(not painful though)
Feels like “bag of worms”;
Plexiform disfiguring, can threaten
Usually congenital
neurofibromas function of area, 8-12%
develop malignant tumor

Tuberous Sclerosis (WHITE)

1/6k-10k, autosomal dominant
Can include seizures / multisystem hamartomas / brain/skin/heart/lungs/kidney, along with derm abnormalities

Findings around infancy:

 Cardiac rhabdomyomas (often detected on prenatal U/S)
o 50-70% infants with TS have one; 96% infants with one will have TS! Often have several
o Often Asx; in ventricular wall, can cause complications
 Hypopigmented macules (“ash leaf spots” or more subtle “confetti macules”) at birth

Later findings
 Seizures before age 1 (70-80%)
 Angiofibromas (facial in adults, periungual, fibrous forehead plaques in ~20% kids)
 Retinal (44% pts, call opthamology!) / pulmonary (bad prognosis) hamartomas
20
  Renal angiomyolipomas: 70-90% of adults, spontaneous hemorrhage is #1 complication
o RENAL PROBLEMS ARE #1 CAUSE OF DEATH IN TS

Infantile Hemangiomas (RED)

Vascular tumor, not malformation; COMMON (4-10% white infants) Risk factors: KNOW THESE
 Nearly all double in size in first 2 months, reach 80% size in 3-5  Females (2-3:1)
months, then regress 10%/yr (50% regress @ 5yr, etc)
 White, non-Hispanic
 Can complicate: big size, on face, segmental morphology is bad  Premature
 LOW BIRTH WEIGHT is #1
(40% ↑/ 500g ↓in weight)
PHACE(S) Syndrome: need 2 of these
 Posterior fossa malformation
 Hemangiomas
 Arterial anomalies
 Coarctation of aorta
 Eye anomalies
 (S)ternal clefting +/- supraumbilical raphe

9:1 females:males, 20% of pts with facial segmental hemangioma are PHACE(S)
Means a more complicated presentation: associated with structural brain & CV
anomalies, 50% have neuro sequelae

New therapy for severe hemangiomas: Propranolol (β-blocker) – nobody knows how it works

Nevus Sebaceous (YELLOW)

1/300 newborns;
Definition:
 small immature sebaceous glands with abortive hair follicules
 Raised at birth (mom’s hormones)  less warty with time  flare up again in puberty
 May need surgical intervention (scalp / central face)

Risk of malignant change:

 Formerly thought it was around 31% but most of these were benign growths
 BCC in 0.8%, NO malignant tumors in children, (4 benign tumors)

Nevus sebaceous syndrome: EXCEEDINGLY RARE; large nevus sebaceous + mental

retardation / neuro signs. NOT IN NORMAL NS

21
 Drug Eruptions
Background: 2.2% - 13.6% inpts have drug rash, 75% from antibiotics, 94% exanthematous/morbiliform

Drug-induced Reaction Patterns: think of pattern for diagnosis!

1. Exanthemous / Morbilliform 2. Erythema
 Exanthemous drug eruption  Red man syndrome
 Drug hypersensitivity syndrome 3. Urticarial
 Urticaria
 Serum-sickness-like reaction
4. Blistering 5. Pustular
 Fixed drug reaction  Drug-induced acne
 Drug-induced pemphigus, pemphigoid, linear IgA  AGEP
 Stevens-Johnson
 Toxic epidermal necrolysis

Exanthemous / Morbilliform
PICTURE DESCRIPTION OTHER
 #1 drug eruption (94%)
Exanthemous
 Morbilliform (“maculopapular)  Starts within 1wk of exposure (semi-synthetic PCNs > 1wk)
drug eruption
 Pink / red / salmon  Resolve 1-2wk post cessation
 Macules/papules, can be confluent  Antibiotics are #1 cause (anti-convulsants too)
exanthem:
“bursting out”  Can spread symmetrically (headtrunk)  Management: stop offending agent, antihistamines, topical
corticosteroids +/- systemic steroids as needed
 Occurs after first exposure, 2-6wks afterwards
 DRESS syndrome: Drug Rash with Eosinophilia and Systemic Sx
 1 in 1k-10k taking anticonvulsants, sulfonamide abx
Similar to  Fever/malaise / cervical LAD / eosinophilia
Drug-induced  Allopurinol too
exanthemous drug  Skin eruption (exanthema / exfoliative dermatitis)
hypersensitivity  Mortality ~10%!
eruption + systemic  Internal organ involvement (Liver: hepatitis + jaundice, 50%
 Management: MUST STOP offending agent; +/- corticosteroids,
elevated LFTs, renal, CNS, pulmonary)
topical steroids & antihistamines for Sx

Erythema
PICTURE DESCRIPTION OTHER
 Related to Vancomycin exposure (rapid infusion; don’t see
much anymore), others too
Red Man
 Pruritis  Within 10m initiation or completion of infusion
Syndrome
 Erythema: face, neck torso  Histamine release involved
 Management: antihistamines (incl. pretreatment);
discontinue infusion

22
 Urticarial
PICTURE DESCRIPTION OTHER

nd
2 most common drug eruption (5%)
 Benign, transient
 Red, erythematous, pruritic
Urticaria  Type I / IgE-mediated hypersensitivity (think about anaphylaxis, watch BP if extensive rash)
papules / plaques (wheals) with
 PCN & derivatives #1 cause, also ACE inhibitors
pale halo
 Angioedema: subcutaneous fat / deep dermal tissue rxn
 Management: discontinue drug, ± antihistamines, ± corticosteroids
 Urticaria & angioedema  Serum sickness: injection of “protein” that induces immune response, deposition of immune
 Fever & arthralgias complexes in vessels, etc.
Serum-sickness-
 Serpiginous / erythematous /  SSLR: from non-protein drugs, NOT associated with circulating immune complexes
like reaction
 1-3wks post exposure, after 2 -3 exposure, F>M
nd rd
purpuric eruption at lines of
(SSLR)
transgradiens on hands/feet (where  Cefaclor / buproprion are top 2 drugs
plantar/palmar surfaces meet

Blistering
PICTURE DESCRIPTION OTHER

 Resolves over 2-3wks, post-inflammatory

Fixed drug  Sharply demarcated, round, dusky, erythematous/edematous plaques
hyperpigmentation
eruption (FDE)  Happens at same anatomic site each time exposed (weird!)
 Tetracyclines & sulfonamides often, anticonvulsants
 Genetalia / lips / hands / feet
too

 Mortality 5% - EMERGENCY!
 Fever, cough, malaise  Histology: full thickness epidermial necrosis &
Stevens-Johnson  Macula exanthema (can blister) blistering, no SC involvement (FAST)
Syndrome  Mucous membrane erosions at 2+ sites  Management(TEN too): ID/stop drug, IVF &
 < 10% body surface area supportive care, get to BURN UNIT

 Think of it like more severe SJS

 Fever, pruritis, conjunctivitis (non-specific)
Toxic epidermal  Mortality 30-50%: BIG EMERGENCY!
 Painful skin (plaques, target lesions, erythema, sheet-like loss of epidermis,
necrolysis (TEN)  Histology, management like SJS – GET TO BURN UNIT
blisters spread with lateral pressure = nikolsky’s sign)
 >30% body surface area

23
 Pustular
PICTURE DESCRIPTION OTHER

Acute
generalized
 Resolves 1-2 wks
exanthematous  Acute pustular eruption but sterile (no bacteria)
 Allopurinol, macrolides + PCN/derivatives (Abx +
pustulosis  Facial edema, fever + leuckocytosis, 100s of sterile pustules
anticonvulsants)
(AGEP)

24
 Cutaneous Manifestations of Internal Diseases

Oncology
PICTURE DESCRIPTION OTHER ASSOCIATED DISEASES

 Firm papules/nodules that are often  10% all metastasis, 75% skin metastasis is first sign of
Cutaneous
bound down (“rubbery & connected”) extranodal spread  Breast / lung / GI
Metastasis
 ± ulceration  Metastasis spreading upwards, invading dermis, chewing / skin cancers
 Side lighting can help up everything, full of atypia

 Localized / diffuse skin infiltration by leukemic cells

 Small (2-5mm) pinkish, non-tender
Leukemia Cutis  Can be sign of leukemic cells in peripheral circulation  Leukemia
papules
 In dermis: epithelial structures /markings still intact

 Overlap with both pemphigus vulgaris & bullous

 Severe mucosal ulceration and
pemphigoid
polymorphic eruptions associated with  CLL/large cell
 Intraepidermal split (like pemphigus)
Paraneoplastic neoplasia lymphoma/NHL,
 Direct/indirect immunofluorescence like pemphigus
Pemphigus  Erythema multifome-type lesions Waldenstrom’s
 immunoprecipitation (+) on transitional epithelium
(PNP)  Friable macroglobuline
of bladder: like bullous pemphigoid)
 Vermillion border involvement mia
 TONS of types of auto-AB – very polymorphic
 very poor prognosis (doesn’t get better)

 Rapidly expanding, very painful,

ulcerative lesions
Bullous  Lymphoreticular
 Pus: sea of PMNs  DEBRIDING BAD (if you traumatize lesion, it grows)
Neutrophilic system
 Looks like bad infection but is aseptic  No antibiotics: want to immunosupress (prednisone, CSA)
Dermatosis malignancies
process (can be superinfected though)
 Violaceous hemorrhagic border

25
 Gastroenterology
PICTURE DESCRIPTION OTHER ASSOCIATED DISEASES
 GI: Hamatomatous
 Early life: hyperpigmented macules (lips, buccal mucosa, polyps (mostly small
 Herditary polyposis (autosomal
Peutz Jeghers palms/soles / periorifical)  bowel, low
dominant, high penetrance)
 Macules fade except on buccal mucosa (stay til adolescence) malignant potential,
mostly recurrent
pain)
 Autosomal recessive
 Infancy: acral dermatitis, alopecia, diarrhea  Can be acquired (dietary Zn
Acrodermatitis  GI: Zinc absorption
 Dry, scaly, eczematous patches/plaques early, then evolve into deficiency, failure of GI absorption,
Enteropathica disorder
vesiculobullous/erosive lesions nephrotic syndrome, bypass surgery)
 Lab: anemia, low serum/urine Zn
Glucagonoma  From excessive
Syndrome  Edge-active skin lesions (blisters, crusting, scales) glucagon production
 Lab: serum glucagon +
(migratory  Periorificial and intertriginous dermatitis / erythema (α-cell tumor of
abdominal CT
necrolytic  Glossitis (red tongue) + angular cheilitis (cracks at corner of mouth) pancreas)
erythema)

Endocrine / Metabolic
PICTURE DESCRIPTION OTHER
Necrobiosis
 Chronic, indolent, relatively
Lipoidica  Well-demarcated, atrophic plaques  2/3 with overt diabetes, rest have
asymptomatic
Diabeticorum  Yellow-brown color abnormal glucose tolerance
 W>M (3:1)
(NLD)  Anterior / lateral surfaces of lower legs

 Indurated (thick & firm) plaques/nodules

Pretibial  Flesh-colored  Hyperthyroidism of Grave’s disease
Myxedema  On pretibial areas of lower legs / recovering from thyroid storm
 Can be tender

5 types
 Hereditary
 Diffuse, velvety thickening & hyperpigmentation  Endocrine (insulin resistance,
Acanthosis
 Axilla, other body folds, dorsum of hand acromegaly, Cushing’s, Addison’s)
Nigricans
 Obesity
 Drug-induced
 Malignancy (usually GI adenocarc)

26
 Common Infections of the Skin
New techniques: instead of growing bacteria (only see what
you grow!) deep sequencing of rRNA with universal primers NORMAL SKIN FLORA
 Flora similar between people, different by site  Cornyeforms (diptheroids) (GM+)
o cornyebacterium, brevibacterium,
propionibacterium spp)
Skin is a defense organ
 Staphylococci (coag neg) (GM+)
 Physical barrier (SC) + constantly shedding
 Micrococci (GM+)
 Chemical (low PH)
 Acinteobacter spp (GM-)
 Immunologic (skin-associated lymphoid tissue)
 Proteus, pseudomonas,enterobacter (GM-)
 Microbiological: normal skin flora occupy niche
 M. furfur (yeast)
 Demodex spp. (mite)

THE BIG PICTURE: SKIN INFECTIONS

 Bacterial: homogeneous, tense red skin, or individual areas + pus (exudates, suppuration),dried pus/serum (crust)
 Viral: can be diffuse immune rxn or localized with discrete areas of cytopathic damage
 Fungal: often has leading edge activity with central clearing; often has scale
Bacterial infections: Strep pyogenes and Staph aureus
Strep pyogenes skin infections (examples)
Streptococcus pyogenes
(group A, β-hemolytic)
 Not part of normal skin flora
 Proteolytic enzymes: RAPID
SPREAD through tissue planes;
greater local invasion,
lymph/vascular spread
 Edema with scarce exudation Impetigo Erysipelas Celulitis
 Impetigo, erysipelas, celulitis Note golden crust Involves upper dermis, Involves deeper dermis
(dried serum) superficial lymphatics and subcutaneous fat

Staph aureus skin infections (examples)

Staphylococcus aureus
(coagulase positive)
 Frequently found transitorily on skin
 Coagulase  abscess formation
 Well-circumscribed, walled-off
 Central fluctuation
 Folliculitis, furuncles, carbuncles
Folliculitis Furuncle (“boil”)
Pilosebaceous unit Tense, pus-filled, tender,
Overlaps with acne drain eventually

Viral infections

DNA Viruses
Papova viruses HPV (warts / cancers)
Poxviridae Molluscum contagiosum
Herpes viruses HSV, VSV (note herpes zoster is VSV)

27
HPV infection HSV Epidemiology
 WARTS (STI & otherwise)  75% population 15-49yo
 Make sure to test for HIV & other STIs after Dx  Subclinical infection:
 100+ types, 30 infect anogenital mucosa, 12+ oncogenic 15% gen pop, 23% HIV- MSM,
o HPV-16 ≫ HPV-18,31,45 for oncogenicity 93% HIV+ MSM

 Cervical (+ anal, oropharyngeal, penile) cancers  Most infections: Asx and

undiagnosed
 Vaccine: gardasil (3 shots x 6 mo, 11-12 yo females)
Genital warts are just the
tip of the iceberg

Herpes simplex HSV infections

 2nd most common STD in US
(after HPV)
 HSV-1 > HSV-2
 Most asymptomatic
 Primary infection & recurrences
(orolabial / genital)
o can reactivate with stress,
UV light, etc Generic HSV Orolabial Herpes Genital Herpes
 GROUPED ULCERS ON Grouped ulcers on “cold sore” HSV-2 > 1
ERYTHEMATOUS BACKGROUND erythematous background HSV-1 > 2

Varicella Zoster Virus: Herpes Zoster (and chicken pox too)

 latency in sensory dorsal root ganglion

 outbreak with immunosuppression or age
 PAINFUL erythematous papules and plaques in a dermatomal distribution
 Vesicular / bullous within hours, neuralgia can persist for months

Molluscum contagiosum
 Pox-virus
 Patients:
1. Children (most common)
2. Sexually active adults
3. Immunosuppressed (HIV)
4. Atopic dermatitis
 Smooth-surfaced, dome-shaped papules with characteristic umbilication
 Custered around site of inoculation

Fungal infections
 Superficial infections: dermatophytoses (tinea corporis, cruris; onychmycosis, etc.) & candidiases
 Deep fungal infections too
 Use KOH prep for diagnosis

28
 Lesions: edge-active, scale, Fungal infections
central sparing

Tinea Corporis Tinea Cruris Tinea Capitis

Microsporum canis, Mostly men, inner/upper Mostly schoolchildren
Trichophyton rubrum thighs, “jock itch” T. rubrum, M. canis mostly (US)

Tinea Pedis / Manus

Athlete’s foot: most common Onchyomycosis Tinea versicolor
T. rubrum mostly DSO, WSO, PSO M. furfur
“sandal” distribution common

Other answers to “test-type questions”

Name the infection

Tinea Versicolor Tinea Capitis

Intertrigo HPV Mostly schoolchildren
T. rubrum, M. canis mostly (US)

Molluscum Basal Cell Carcinoma

Tinea Perleche

 Which isn’t a common strep pyogenes infection?: (erysipelas, cellulitis, intertrigo, necrotizing fasciitis, impetigo)
 Pox virus are DNA viruses

Infection Bug
Tinea versicolor Pityrosporum ovale (& M. furfur)
Thrush Candida Albicans
Superficial onychomycosis Trichophyton metagphraphes
Distal subungual onchyomycosis Trychophyton rubrum

29
 Pharmacology: Skin
Retinoids in Dermatology ....................................................................................................................................................... 2
Principles of Topical Therapy .................................................................................................................................................. 3
 Retinoids in Dermatology
 Sun exposure makes you wrinkled later in life; retinoids can help
 Current definition: any molecule that binds to / activates retinoic acid receptors & activates transcription of
retinoic-acid-responsive genes to result in specific biological processes

Nomenclature
 Β-carotene is basically two vitamin A molecules (all-trans retinol)
hooked together; processed to yield all-trans retinol in vivo

Oxidative changes:
 all-trans retinol (vitamin A) all-trans retinaldehyde  all-trans
retinoic acid via oxidation

Esterification for storage & transport through blood

 add a fatty acid, e.g. palmityl acid, & esterify in enterocyte to get
retinyl palmitate. Ship it through the blood, store it in the liver,
then oxidize it in target cell to use

Inactivated by CYP450 hydroxylation (adds an –OH on the 4’carbon of all-trans retinoic acid)

Function: Retinoid Receptors

Retinoids originally classified based on structure, biologic activity: now based on binding to retinoid receptors
Retinoid receptors:
 Zinc-finger receptors in nucleus (e.g. RAR, RXR)
o After oxidation from ester form, retinoid binds binding protein, translocated to nucleus, binds receptor
o heterodimerize when ligand (retinoid) bound
o DNA-binding domain can then bind DNA & affect target gene expression of mRNAs  effector function
 Majority of receptors are RXRs (can bind hormones, not just retinoic acid)

Many retinoids now look nothing like RAs but just bind the receptors
 (STILL HAVE THE SAME EFFECT ALTHOUGH STRUCTURE DIFFERENT – if you bind the receptor, effect is same!)
 Reduce wrinkling, etc.

What do retinoids do?

 Dermis is 90% collagen (mostly type I); usually a balance between synthesis & destruction
 Fibroblasts make matrix molecules (e.g. collagen); extracellular enzymatic processing involved
o Collagen assembled thermodynamically, then crosslinked
 In photoaged skin you make less collagen (can see on immunostaining)
o UV light: ↑matrix metalloprotease activity, ↓ procollagen synthesis
 Retinoids help restore collagen production (varies person/person)

Results may vary

 Principles of Topical Therapy
 Think of stratum corneum like a “brick wall” built through a programmed series of events, keeping water & stuff
out, with keratohyaline granules tied together by cell-cell adhesions. How can you get through it?

It’s hard to get drugs through the skin in a reliable manner: Lots of variables
 status of skin (damaged?)  partition coefficient (if molecule likes to stay in its
 location (groin≫eyelids≫chest for absorption) vehicle, it won’t leave)
 concentration  diffusion coefficient (how fast?)
 liphophilicity (more is better)  metabolism
 MW (smaller better)  dermal vascular/lymph flow?

What to order: vehicles

 Lotions (Sprays): alcohol/water solutions, e.g. scalp How much to order?
 Creams: oil in water, good acceptance (feels better) 30g = one application
o Always preferred by pts except when they’re dry/scaly to the whole body
 Ointments: more occlusive but greasy (pts don’t like)
o For dry scaly skin in non-occlusive intertriginous area (greasy: not for hands)

Corticosteroids: Actions Pharmocoeconomics 101

1. Anti-inflammatory (a.k.a. things you already knew)
2. Immunosuppressive  Generic drugs are cheaper
3. Vasoconstrictive  Buying in bulk is cheaper
4. Antiproliferative o if you need a lot, buy a lot

Topical steroids (mild to strong): Hydrocortisone < triamcinalone < fluocinonide < clobetasol
 Balance efficacy with side effects; don’t put on groin or eyelids! Can be expensive!

Occlusion: get better penetration by “hydrating the bricks” & loosening up that “mortar”
 Principle: ↑ hydration + ↑ temp = ↑ absorption
 Can use saran wrap, baggies, cordran tape, vinyl suits, shower caps, whatever
 Can cause problems in topical steroid occlusion so be careful (infections, hot, itchy, etc)

Systemic steroids
 If you’re going to use them, use an adequate dose;
 Give at 7AM & 4PM if itchy, NOT before sleep (interferes with circadian rhythms)
 Taper BID to QD in AM 1st, then to alternate day slowly
 Can consider alternate drugs too
Key Points
1. Everything you put on
Treating an itch
the skin gets absorbed to
 COLD (ice cube, not hot shower – feels good but then bad afterwards)
some degree
 Lotions (evaporate; feels good)
2. Absorption ↑ in
 Dry? Lube it up with Vaseline diseases skin (↓ barrier
 Atarax / sedating antihistamines but don’t use with driving or drinking function)
 other therapies too (UV light – but avoid systemic corticosteroids) 3. As skin gets better from
drug, absorption
Wet dressings: for wet, weeping lesions, cooling/antipruritic/debridement decreases
 Keep moist for 30 min QID, don’t allow to dry
 Continuous wet soaks: good for debridement/cleansing, macerates necrotic tissue
 Can use Kerlex/saran wrap, re-wet q4h with asepto syringe
 Pathology: Hematology
Lab Hematology & White Blood Cells ..................................................................................................................................... 2
Introduction to Hemostasis & Platelet Biology ....................................................................................................................... 4
Blood Transfusion ................................................................................................................................................................... 7
Multiple Myeloma & Plasma Cell Dyscrasias ........................................................................................................................ 13
Leukemia ............................................................................................................................................................................... 18
Lymph Nodes & Hodgkin’s Lymphoma ................................................................................................................................. 22
Non-Hodgkin Lymphoma ...................................................................................................................................................... 26

1
 Lab Hematology & White Blood Cells
Leukocytes: nucleated blood cells
 Granulocytes: neutrophils, eosinophils, basophils
 Lymphocytes: B-cells, T-cells, NK cells

Neutrophils
Development: (morphology mirrors functional develop.)

Myeloblast  promyelocyte  myelocyte  metamyelocyte band  PMN

1. Myeloblast: large, round nucleus; 2+ nucleoli; scant basophilic cytoplasm, no granules
2. Promyeloctes: blue/violet (azurophilic) 1° granules, nucleus eccentric, nucleolus
3. Myelocyte: clumped nuclear chromatin with no nucleolus, cytoplasm has 2° and 1° granules
4. Metamyelocyte: cytoplasm pinker, more 2° granules, nucleus bean-shaped
5. Band: nucleus elongated like sausage; width of nucleus smaller then length of indentation
6. Segmented neutrophil: fine filament separating 2+ lobes

 Phases:
o Bone marrow mitotic phase: blastmyelocyte (7.5d)
o Bone marrow post-mitotic phase: meta  mature gran (16.5d)
o Blood: (6hrs)  tissue (1-2d)
 Note: PMNs spend very little time in circulation
o (only 8% in intravascular space)
o Circulating PMNs equilibrate with marginating PMNs
(50/50 of those 8% in circulation)

Myeloid growth factors

 G-CSF and GM-CSF are primary ones (granulocyte ± macrophage colony stimulating factor)
o Used clinically to increase PMN production (e.g. post chemo)
 Expand committed progenitors; shorten bone marrow transit time  INCREASE OUTPUT
 Enhance function of mature PMNs to inflammatory signals

Neutropenia (ANC < 1800)

 ANC (abs. neutrophil ct) < 1800/μL (Mild 1000-1800, Moderate 500-1000, severe <500)
 ↓PMNs, ↑risk infection
 DDx:
o ↓production (congenital – cyclic, like Kostmann’s Syndrome / acquired – drugs, vitamin B12, leukemia; viral causes)
o ↑destruction (autoimmune/sepsis)
o sequestration / splenomegaly
o pseudoneutropenia (increased marginal pool)

Neutrophilia (ANC > 8000)

 Associated with wide variety of physiologic stresses (inflammation, infection, metabolic disturbances, etc)
 If associated with infection: mainly bacterial; look for toxic granulation, vacuolization, Dohle bodies
o Dohle bodies: mRNA in cytoplasm; indicative of cellular activation
 Also drugs (corticosteroids, more), hematologic disorders (myeloproliferative – see below)

2
 I’ve got too many WBC: Is it CML or Leukemoid reaction (malignant or benign)?

LEUKEMOID CML
WBC > 100K Rare Often
BASOPHILIA Rare Often
CHROMOSOMAL CHANGES None BCR-ABL
SPLENOMEGALY / HEPATOMEGALY Rare Often
CLINICAL COURSE Resolves Progresses
WBC (LEUKOCYTE) ALKALINE PHOSPHATASE High (LAP>100) LAP<10

Neutrophil Defects
Qualitative PMN Defects
 Recurrent infections & abscesses; receptors for opsonins / integrins are frequent targets
 Leukocyte adhesion defects (integrins, selectins) – PMN stay in circulation
 Defective motility (inherited/acquired): cytoskeletal defects  ↓ chemotaxis
 Defective cell killing: e.g. Chronic granulomatous disease
o genetic disorders, defects in generating ROS, can’t kill some organisms (no respiratory burst)
o can ID absence of superoxide production (nitroblue tetrazolium (NBT) dye test)
o granulomas at site of infection instead (bacteria proliferate inside cell, can’t clear infection)

Megaloblastic anemia
Morphologic changes:
 Reduced DNA (but not RNA) synthesis
 MCV > 120 = think megaloblastic anemia
 Cells of any type that have rapid turnover are affected

Rare examples of changes (USMLE, not for exam)

 May-Hegglin anomaly: aut-dom, large dohle bodies, giant platelet, thrombocytopenia
 Pelger-Huet anomaly: aut-dom, bi-lobed/dumbbell-shaped nuclei, normal function
 Alder-Reilly anomaly: large azurophilic granules, seen in Huler’s syndrome & other metabolic disorders, metachromatically-staining
mucopolysaccharide deposits
 Chediak-Higashi syndrome: Aut-recessive, lysosomal trafficking regulator protein messed up, large cytoplasmic lysosomal inclusions,
defects in T/NK cytotoxicity & killing activity of PMNs; occulocutaneous albinism, recurring infections, more

Eosinophils Basophils
 Regulate hypersensitivity reactions  Mystery! Granules have histamine, heparin, PAF but
 Innate defense against helminthes/ticks no known deficiency disorder
 IL-5 is major regulatory growth factor  For both basophils & eosinophils, you can have zero
on WBC + diff and it’s fine
Hypereosinophilia: worms, wheezes, weird diseases Basophilia: chronic infection, cancer, iron deficiency,
 Can cause significant tissue damage, sequelae myeloproliferative disorders

Monocytes
Roles: Phagocytosis, immunomodulation, antigen
presentation

Chronic monocytosis: usually chronic infection or

inflammatory disease

3
 Introduction to Hemostasis & Platelet Biology
Hemostasis: physiologic process that leads to stopping of bleeding
 Platelets & plasma clotting proteins

Primary hemostasis: injury to blood vessel  constriction  aggregation of platelets  platelet plug
Secondary hemostasis: inactive coagulation proteins  active (coagulation cascade; thrombin; fibrinogenfibrin)
 Platelet plug becomes more stable (protein + fibrin backbone)

Platelets: the basics

 Made in bone marrow: multinucleated megakaryocytes stimulated by thrombopoieten (TPO, a growth factor)
o Platelets are not cells: fragments of megakaryocyte cytoplasm
 150-300K /μL is normal, circulate for 10 days (120d for RBC, a few hrs for PMNs)
 Spleen stores 1/3 body platelet mass (like a reserve for trauma)

Histology:
 Canalicular system (CS) lets molecules in/out
 Dense granules (DG): ADP, ATP, serotonin
 Alpha granules (AG): fibrinogen, von Willebrand Factor (vWF),
immunoglobulin
o all taken up from plasma; importance not clear
 Lots of mitochondria (M)
 Microtubules (MT): maintain discoid shape
o Rearrange in activation (discoid  smaller sphere with long
pseudopodia  more SA to contact other platelets

Function

1. Adhesion
Injury  subendothelium exposed  vWF (glycoprotein) binds to
subendothelium
a. vWF released from Weibel Palade Body (large organelle in
endothelial cells, circulates in plasma; binds fast (1-3s
postinjury!)
b. vWF is ligand for platelet glycoprotein Ib-IX (receptor on
platelets)  platelets bind vWF at injury site

2. Platelet Activation
Initial platelets adhere  release ADP & thromboxane (TxA2) 
other platelets activated  more platelets incorporated into
developing plug
a. ADP: adenosine diphosphate, from platelet dense granules,
released  binds ADP receptors on other platelets
b. Thromboxane: made by platelets, causes platelet
activation & vasoconstriction.
i. Two thromboxanes: A2 = active but unstable, 30s
half-life  hydrolyzed to inactive B2
ii. Derived from arachadonic acid; related to
prostaglandin (aspirin inhibits TxA2 production)
c. Platelets change shape too (bigger SA, more clotting proteins deposited, localize to needed areas
4
 d. Clotting cascade being activated by tissue factor (subendothelial Mϕ) at the same time
i. Thrombin activates platelets (cleaves thrombin
receptor on platelets, which undergoes shape
change & signals after cleaveage! Crazy!) Also
cleaves fibrinogen  fibrin to form mesh for plug

3. Aggregation
Platelets adhering to each other = aggregation. Glycoprotein IIb-IIa
(integrin on platelet) undergoes conformational change during
activation; binds fibrinogen
a. Fibrinogen (water soluble)  fibrin (water insoluble
polymer, forms supporting structure for blood clot)
b. Platelet plugs fill in like concrete poured on steel bars

“Bleeding time” is how long it takes for all this to happen (usually 3-7m)
Platelet Dysfunction
Congenital / Inherited disorders: can lead to life-long bleeding.
SIGNS & SX: INHERITED PLATELET FUNCTION DISORDERS
 Tons of etiologies: absent agonist receptors, adhesion  Mucocutaneous bleeding
/ receptor / aggregation / secretion / signaling defects  Hemarthrosis uncommon (bleeding into joints more
with clotting factor disorders)
Acquired dysfunction: more common than inherited  Variability in bleeding
 Renal failure: toxins build up, platelet function ↓  Platelet counts normal
 Medications: aspirin is most common  Prolonged bleeding times
 Platelet aggregation/secretion responses abnormal
Testing for abnormal platelet function
1. Bleeding time: small controlled forearm incision, measure time to clotting
2. Platelet aggregation: add agonist (ADP, collagen, etc.) to stimulate platelets) compare to control, measure
degree of aggregation. Different agonists to test different receptions

What keeps platelets from adhering to endothelium/subendothelium normally?

Passive factors: negative charge on endothelial cell surface

Active processes:
 Prostacycline (PGI2): vasodilator, inhibits platelet
activation by raising cyclic AMP levels
 ADPase destroys ADP (decreases platelet activation)
 Nitric oxide (endothelial-derived releasing factor, EDRF):
inhibits platelet function
 Tissue plasminogen activator: promotes clot lysis
 Thrombomodulin: inhibits thrombin (inactivates clotting cascade; inhibits platelet activation)

Quantitative changes in platelets (low platelets!)

Thrombopoesis: Thrombopoieten (TPO)
1. Functions:
a. Megakaryocyte-stimulating factor (along with cytokines, e.g. IL-6)
b. Also primes platelets to be more sensitive to platelet agonists
c. Can give recombinant form to increase platelets in thrombocytopenic patients
2. Made in liver
3. Thrombopoietin receptor (on platelets & megakaryocytes): receptor binds & internalizes growth factor
a. inverse relationship between TPO levels & platelet / megakaryocyte mass (sucking it out of plasma!)
5
 Thrombocytopenia
Causes: decreased production, increased Platelet Count Presentation
destruction, sequestration. > 100,000 No excessive bleeding (even with major surgery)
50-100,000 Can bleed longer than normal with severe trauma
1. Sequestration: splenic enlargement 20-50,000 Bleed with minor trauma, petichiae, no spontaneous bleeding
can sequester large #s platelets, < 20,000 May have spontaneous bleeding
lowering circulating number

2. Decreased production
 Marrow infiltration  Chemotherapy / toxins  Aplasia (aplastic anemia)
(tumor, leukemia)  Hypoplasia (myelodysplasia)  Thrombopoietin deficiency

3. Increased destruction
 Immune (autoimmune / alloimmune disorders, drug-induced, infectious mono)
i. Autoimmune thrombocytopenia: #1 immune cause
 Auto-Ab to platelet glycoprotein receptors (glycoprotein IIb-IIIa)
 Cause unknown; destruction takes place in spleen/liver after Ab-mediated phagocytosis of RBC
 Severe thrombocytopenia & bleeding
 Ab can also bind megakaryocytes / impair platelet production
 Splenectomy can be tx (stop destruction)

 Non-immune
i. DIC with excessive clotting intravascularly / sepsis
ii. thrombotic thrombocytopenia purpura (TTP) pathologic increase in platelet adhesion

 Bone marrow: adequate / increased # megakaryocytes = normal production, increased destruction

 Peripheral destruction is most common mechanism

Platelet function can be impaired too:

 e.g. absence or markedly reduced platelet aggregation in response to epinephrine

Thrombocytosis
Elevated platelet count
Etiologies: Thrombocytosis: can see
 Bone marrow disorders of essential thrombocytois  Thrombotic complications
 Polycythemia rubra Vera (too many platelets)
(excess RBC + WBC/platelets produced from bone marrow)  Hemorrhagic complications
 Chronic myelogenous leukemia (paradoxical: absorbing out all the vWF, etc.)

6
 Blood Transfusion
Indications for transfusion TRANSFUSION MATH
 Restore blood volume in patient with major blood loss
(saline, etc. also used for volume expansion if possible) Whole Blood Volume
 Restore O2-carrying capacity (anemia from bleeding,  Adult: 7% body weight (70 mg/kg)
hemolysis, inadequate RBC) – usually with Hgb < 7 g/dL  Newborn: 8.5% body weight (85 mg/kg)
 Replace cellular elements / plasma proteins  Premature: 10% body weight (100 mg/kg)

Comes from: healthy altruistic blood donors (volunteers) Plasma volume = (1-Hct) x blood volume

Whole blood: Example: 70 kg adult with 40% Hct has 5 liters of

 Provides: volume expansion, red cell mass, some blood volume (red cell mass 2L, plasma volume 3L)
coagulation factors (but low content of platelets, factor VII)

Components are often preferable (spin down & separate parts: see picture)
 Why? Avoids circulatory overload, ↓harmful metabolic materials,
concentrate required material, ↓risk of dz transmission, maximize
use of donated blood
 General parts:
o Plasma (albumin, IgGs, Factor VII/IX/other coagulants, etc.)
o Buffy coat (platelets, leukocytes)
o RBCs
COMPONENT CONTENTS
Whole blood (1 unit)  Blood (450 mL)
 Preservative (63 mL)
Packed RBC (1 unit) RBC (200 mL)
Fresh Frozen Plasma (1 unit) Plasma (220 mL)
Cryoprecipitate  Factor VIII (100U)
(1 unit = 10-15mL)  Fibrinogen (250 mg)
 vWF (40-70% of what was in 1 U FFP)
11
Platelets 4x10 platelets
(1 pheresis unit = 200mL) (6-8 random donor platelet units)

Preservation
 RBC during storage
o ↓ATP levels, ↓ 2,3-DPG (corrects quickly in vivo)
o ↑metabolites (K accumulation can be a problem in newborns)
 75% @ 24 hrs is acceptable RBC survival (related to ATP levels)
 Storage possible for 5-6 wks with modern preservatives (older = ~3-4 wks)

Red Cells
Different components available:
1. Red blood cells (reduced volume)
2. Leukocyte-depleted RBC(leukocytes removed)
3. Washed RBC (plasma removed; e.g. if patient allergic to plasma protein)
4. Frozen RBC (increase storage period, almost indefinite, use for really rare blood types)

7
 Platelets
 Pooled concentrates (from lots of donors, like a blended whiskey):
give you lower cost and more readily available supply
 Apheresis (from individual donors; the “single-malt”):
gives you lower donor exposure to disease, lower reaction rates but has a
more limited donor pool and costs more $$)

< 100k platelets = ↑bleeding time

<10k = start giving prophylactic transfusions (spontaneous bleeding)
< 5k = ↑GI hemorrhage risk Indications for platelet transfusion
 Thrombocytopenia (bleeding or prophylaxis)
Platelet Alloimmunization o More useful if ↓production of platelets
 Pts. with previous transfusions / pregnancies: refractory o Less useful when ↑ destruction (DIC, ITP)
(don’t respond / response decreases each time)  Dysfunctional platelets (aspirin, etc.)
 HLA Ab destroy incompatible platelets (20-50% pts)
 HLA matching can help, need to prevent refractoriness
o Treat with HLA matching, platelet crossmatching (same efficacy)
o Prevent by limiting donor exposure, leukodepleting platelets

Leukodepleted components
Good for:
 ↓ transfusion reactions, ↓ alloimmunization
 ↓ risk viral transmission (viruses that hang out in RBC: CMV, HTLV-1, etc.)
 ↓ immunomodulation? Some evidence that WBC suppress immune system?

Fresh Frozen Plasma

Frozen within 6 hours of collection
Components: VIII, prothrombin complex (X,IX, VI, V, prothrombin) with concentration the same as in fresh plasma
 Problem: putting lots of volume into the patient

Cryoprecipitate
 Helps fix volume problem of FFP to help with hemostasis (only 10-15 mL per unit; fibrinogen + factor VII + vWF)
 Slowly thaw FFP at 4° C, centrifuge, precipitate resuspended; not used as much anymore

Concentrates
 Mostly recombinant (e.g. coagulation cascade factors); give instead of cryoprecipitate
o After pooled concentrates  HIV (90-95% hemophiliacs infected in 1980s), recombinant much safer)
 Patients (e.g. hemophilia) can give themselves at home instead of having to come in

Irradiated Blood
 Helps eliminate risk of transfusion-associated graft-vs-host dz
o 98% FATAL!
o Donor WBC can attack recipient; normally recipient WBC win the fight but not if immunodeficient!
 Give for pts with congenital immunodeficiency, BMT / solid organ transplant, neonates

8
 Immunohematology
ABO Blood Groups

 Transferases put sugar chains on RBC antigens

o Genotype (which transferases you have determines what
those antigens look like)
 Bacteria have similar polysaccharides, so via natural exposure to
those, body will develop Abs against all the RBC ones that aren’t “self”
o High density of ABO antigens on RBC
o High titer IgMs  intravascular hemolysis
 ABO Groups
o Group A has anti-B, etc.
o O = universal donor, AB = universal recipient
o Prevalence depends a lot on population tested
 ABO typing: mix cells & plasma
o (one from patient, one of known type)
o Agglutinate if plasma has Ab against RBC Ag

Rh Blood Groups
 Rh = “rhesus factor”, types of RBC antigens (Very immunogenic)
 15% US pop Rh-; D>c>E

Problem scenario:
1. Father Rh+ and Mother Rh-
2. If fetus is Rh+, then mother can develop anti-Rh Ab
(usually during exposure to fetal blood at delivery)
3. Subsequent pregnancy: mother’s IgG cross placenta; destroy fetal RBC
 hydrops fetalis (fetal loss)

Solution: if mom is Rh- and dad is Rh +,

 Give Rh IG at 28 wks and delivery (coat fetal RBC in maternal
circulation & prevent maternal immune reaction)

Other Blood Groups

 300+ described; many can be clinically significant (hemolysis +
transfusion reactions); others aren’t
 Give blood if the patient needs it!
(match as best you can, but even if the match isn’t perfect, sometimes a patient needs blood no matter what)

9
 Managing Transfusions: Pretransfusion Testing

1. Verify patient identity: the wrong sticker is the biggest cause
of reactions! (no way for blood bank to test)
a. Need Full Name, History #, Phlebotomist ID all
perfectly correct or request will be REJECTED)
2. Blood compatibility testing
a. Type & Screen: ABO + Rh type of patient (“type”);
“screen” for unexpected Ab in patient’s serum
(indirect Coomb’s)
b. Type & Cross: ABO + Rh and crossmatch (“cross”)
patient serum with donor RBC (indirect Coomb’s)
Indirect Coomb’s (antiglobulin) Test:
1. mix screening RBC & pt’s serum
2. add anti-human-IgG Abs
3. If patient has anti-RBC Abs, the anti-human-
IgGs will link them and the RBC will fall out of
solution (used for type & screen / type & cross)
(Direct Coomb’s (antiglobulin) test:
1. use pt’s RBC & serum
2. add anti-human-IgG Abs
3. If pt has autoantibodies, they’ll fall out of
solution (used for autoimmune hemolytic
anemia, for instance)

Adverse Effects of Transfusion

Acute Hemolytic Transfusion Reaction
 Pt has Ab (especially IgM) against donor RBC 
 immediate reaction (hemolysis)

 IgM  fix C’
o Usually naturally occurring (e.g. ABO), T-cell-indep
o Intravascular hemolysis
 Hb in urine (hemoglobinuria) & plasma

 IgG-coated RBC  phagocytosis via RES

o Usually alloantibodies via preg or transfusion (e.g. Rh system)
o Extravascular hemolysis
 anemia w/o plasma/urine color change

Signs & Sx: Severity depends on:

 fever, chills/rigors, anxiety (sense of impending doom), nausea/vomiting  degree of incompatibility
 dyspnea, flushing, hypotension, pallor  rate of transfusion
 hemoglobinuria/hemoglobinemia, bleeding, DIC, jaundice  amount of transfusion
 Renal failure(40-50%) and Death (10%) can result

Investigation: If you suspect hemolytic transf. reaction:
 STOP TRANSFUSION & RE-CHECK
 Re-check: Obtain blood samples, check for clerical
error, re-do direct coomb’s, check plasma
Treatment: if you know there’s one going on
 STOP TRANSFUSION but leave IV in (need access)
 Start dieresis, start fluids, control BP, watch renal
function, follow coagulation status
 Avoid antigen-positive blood for future transfusions

Delayed Hemolytic Transfusion Reaction

 Alloantibody-mediated, extravascular hemolysis
o Amnestic response (>72h after transfusion or >10d if primary alloantibody response)
 ↓Hct, icterus, fever
 + direct antiglobin test (alloantibodies in pt serum); + antibody screen

10
 Febrile, Non-Hemolytic Reactions
Signs / Sx: Temperature elevation of > 1° C
Etiology: WBC are the problem
 WBC Ab in pt. serum vs donor WBC / platelets
 Cytokines generated by stored WBC
Prevent with leukocyte-depleted or washed blood
Ddx vs: hemolytic / septic reactions
(could grow some bacteria in bag if skin plug gets in)
Allergic Reactions
Most common type of reaction by far
Pathogenesis: Histamine release (immune-mediated)
Management: Antihistamines, steroids/ephinephrine
if severe

Infectious Complications / Transfusion Transmitted Diseases (TTD)

HIV/AIDS: 2% AIDS transfusion related prior to 1985 (hemophiliac epidemic)

 screening today: high risk donor deferral, HIV Ab / Ag testing, nucleic acid testing
 Current risk: < 1: 2 million units
o Residual risk because there’s a small window post-infection where virus is indetectable

Hepatitis Viruses: big problem before HCV discovered in 1989 (NANB hepatitis)
 Current risk: 1:2 million units for HCV (same as HIV), about 1:200k for HBV
 HAV: rarely causes TTD;
 HBV: TTD usually from Asx carriers; reduced by screening / donor testing
 HCV: nucleic acid testing + Ab screening today, causes cirrhosis & HCC

CMV: big problem in immunocompromised patients

 Carried in donor WBC; ubiquitous (75% urban adults)
 problem if donor positive & recipient negative / immunocompromised
 Prevent with donor screening & leukodepletion

Transfusions: General Management

How safe are blood transfusions? About 1 death/yr at Hopkins (pretty safe but not without risk)
 MINIMIZE homologous transfusion and explore ALTERNATIVES

Perioperative RBC Transfusion: 7g/dL is more appropriate (10g/dL not justified);

 Moderate perioperative anemia doesn’t affect morbidity / wound healing

Autologous transfusion: pre-deposit & use own blood
 More usage post AIDS, esp. elective surgery
 Lots of wastage (don’t crossover into general supply b/c
motivation is different, might have high-risk behaviors)
Intraoperative hemodilution:
1. remove whole blood during anesthesia, replace with
crystalloid / colloid (dilute) 
2. store in OR  washed cells returned after surgery
3. (blood lost in surgery is dilute, so less net RBC loss)
Managing risks with a volunteer blood supply:
 Minimize exposure
 Use autologous transfusion (pre-deposit)
 Use hemodilution or intraoperative autologous
transfusion
 Directed donors (when appropriate)
o NOT a good alternative in general
o Family pressure  bad donations
o Volunteer are safer
 EPO & other hematopoietic growth factors

Intraoperative autologous transfusion (in general)

 Used for: CV, orthopedic, neurosurgery (not GI or cancer when contamination would be a problem)
 Only washed cells returned: might have to use component support too

11
Pharmacologic therapies
 ↓ risk TTD
 Stimulate production / release of RBC / proteins (DDAVP for vWF, EPO for RBC); minimize surg. bleeding, etc.

Red cell substitutes

 No really good ones available now – maybe 10 years? (expensive, not licensed)
 Would be good for Jehovah’s witnesses, etc.
 Would need to: have normal in vivo survival, replace all cellular functions, not have antigenicity / dz
transmission / toxicity, be easily prepared & have a long shelf life

12
 Multiple Myeloma & Plasma Cell Dyscrasias
Plasma cell dyscrasias (= immunosecretory disorders = gammopathies, dyscrasia means “bad temperament)
 Group of diseases characterized by uncontrolled proliferation
of plasma cells, synthesizing a homogenous (monoclonal) PC Dyscrasias:
immunoglobulin (rarely immunoglobulins) Key Pathologic Abnormalities
 Excessive Ig secretion in blood/urine
Ig review:  Plasma cell accumulation + Ig
 Ig = Ab, produced by PCs (terminally differentiated B-lymphocytes), deposition in organs / tissues
each B-cell makes one antigenic Ig (BCR on surface & Ab in
circulation), Ig made of heavy + light chains
 5 classes of Ig by heavy chain (IgG, IgA, IgM, IgD, IgE in order of adult serum levels)
o 4 subclasses for IgG, 2 subclasses for IgA
o IgG has longest half-life and is only one that can do placental transfer; IgM is pentamer (biggest)
 5 isotypes of heavy chains (γ, α, μ, δ, ϵ); 2 isotypes of light chain (κ, λ)
o PCs make more light than heavy chains, so free light chains (κ, λ) can be measured in serum/urine

Monoclonal gammopathies:
 MGUS = monoclonal gammopathy of unknown significance; accounts for >50% monoclonal gammopathies
 Multiple Myeloma is next in frequency, then amyloidosis, lymphoma, others

Serum Protein Electrophoresis

On serum protein electrophoresis (PEP),
proteins run in groups / bands (“regions”)
 Albumin is usually biggest peak
 γ region has “gamma-globulins” (Igs)
 narrow peak = monoclonal

Immunofixation Electrophoresis (IFE)

sIFE: like a western blot (run PEP, then use specific Abs to detect Ig isotypes)
sIFE vs PEP
 PEP tells you that there is an M-spike, for instance, but you don’t know what it is!
 PEP also less sensitive (can have normal PEP but detect on sIFE)
 MUST perform an IFE when monoclonal gammopathy suspected.

Multiple Myeloma
Multiple Myeloma: Neoplastic proliferation of a plasma cell clone, resulting in excessive production of a monoclonal Ig
 Can often evolve from MGUS
MM: Clinical Features
Epidemiology:  BONE PAIN (70% pts at Dx)
 VERY COMMON (spine/ribs, worse with movement)
(1% of all cancers, 10% hematologic cancers, 4/100k incidence in US)  Pathologic fractures
 Incidence ↑ with age (69/71 yo median in M/F, <5% are under 40yo,  Weakness/fatigue (anemia)
exceedingly rare in children/adolescents)  Renal insufficiency
 African American > White, M>F a bit (myeloma kidney / hypercalcemia)

13
Classic (symptomatic) MM: MM: Diagnosis
 Single clone of plasma cell making an M-protein  M-protein in serum and/or urine
(monoclonal or myeloma, not IgM)  ↑ clonal plasma cells (>10% in BM)
o Usually IgG (52%), can be IgA (20%) or plasmacytoma
o Free light chain (κ or λ) about 7-9% of the time: Bence-
 Evidence of end organ damage
Jones type, indicates poor prognosis (NEED THIS – without it, it’s just MGUS)
o Rarely others (heavy chain, etc) / biclonal
 Postive monoclonal band on sIFE tells you there’s a plasma cell
dyscrasia; need other info to Dx MM

Urine electrophoresis:
 Normal: usually few proteins, mostly albumin but small peak
o Glomerular disease: big band, but albumin (not filtering)

 MM: a huge band in monoclonal light-chain region

o Overwhelming re-uptake in tubules (tubular proteinuria; IgGs
can’t go through because they’re still filtered @ glomerulus)
o Bence-Jones proteinuria (monoclonal light-chain proteinuria)
o Urine IFE shows a monoclonal light chain band

Bone marrow aspirate: cellular morphology & MM

 try to demonstrate tumor (MM vs other PC dyscrasias)
 look for morphology, PC count, PC markers by IHC

Normal plasma cells:

 big ER (making lots of Ab), low number (3-6%) in BM & RES
 oval shaped, deeply basophilic cytoplasm with perinuclear halo
 eccentric nucleus

Morphology in BM sample:
 mature (look like normal PC)
 immature (large nucleoli, ↑N/C ratio, open/dispersed chromatin)
 anaplastic (prominent immunoblasts / plasmablasts from de-differentiation)

Other features in MM:

 Cytoplasm:
o morula (Mott) cells: multiple, pale, whitish, grapelike accumulations of Ig inclusions
o Russell bodies: round, refractile inclusions
 general response to synthesis of mutant Ig (can’t exit / be degraded)
o Crystalline rods
 Nucleus: Dutcher bodies (invagination of cytoplasmic material into nucleus)

PC Immunophenotype Dutcher & Russel Bodies

Benign PCs Malignant PCs
CD38+ (cell proliferation)
CD138+ (anchor PCs to ECM in BM)
Polyclonal light chains (λ & κ) Monotypic light chains (λ OR κ)
Have B-cell markers Lack B-cell markers (CD19 -)

14
 Bone marrow biopsy: cellular morphology & MM
 MONOTONY; diffuse CD38/138+ staining (all PCs!) is diagnostic
 PCs infiltrate bone marrow in different patterns
o Nodular, interstitial, mixed
o Diffuse infiltration = worst prognosis
 Solid aggregates suggests MM; dispersed / non-aggregated suggests reactive plasmacytosis

End Organ Damage

BIRRIA HA: need at least one of these for Dx!

Bone lesions Recurrent bacterial infections

 osteolytic “punched out” lesions  Neoplastic cells destroy normal BM lineages: lots of Ig but
 osteoporosis with demineralization / compression fractures / monoclonal & useless; other cell types decrease too
vertebral collapse  GNRs & GPC

Increased serum calcium Anemia

 >10mg/dL, secondary to bone destruction, ~40% MM pts
 large disease burden
(lethargy/nausea/vomiting/constipation/polyuria
 Need to measure free serum calcium (some M-proteins bind
calcium!)
Renal insufficiency
 creatinine >2mg/dL, many causative mechanisms
 Myeloma kidney: large, waxy casts in DCT, most often with λ
light chains. precipitates of monoclonal light chains with giant
cells around it  dilation  atrophy of tubule, impairs
nephron
 Hypercalcemia: Calcium deposits w/ IgG in tubles
hypercalciuria  osmotic dieresis (water follows) volume
depletion  kidney failure
 Deposition of light chains (κ) in glomeruli (usually minimal
proteinuria)
 Primary amyloidosis: deposit insoluble light chains in kidney;
present with nephritic syndrome, minimal proteinuria
 Increased serum IL-6, nephrotoxic medicines, etc.
 Normocytic normochromic anemia (like anemia of chronic
disease)
 Growth of PC in BM as well as cytokines released inhibit
erythroid development
 Aggravated by expansion of blood volume, hyperviscosity 
rouleaux formation (pile-of-coins aggregation of RBC
Hyperviscosity Syndrome (HVS)
 Blood flow to tissues/organs impaired due to change in blood
itself
 Viscosity is resistance of blood to flow; ↑ with abnormalities
in RBC (sickle cell, etc) or in serum Igs (waldenstrom MG/MM)
 Uncommon in MM (IgA when it does happen); more common
in Waldenstrom macroglobulinemia
Amyloidosis
 Deposition of insoluble fibrillar proteins; 3% MM pts have
overt amyloidosis, 30% do but Asx; adds to morbidity &
decreases survival
o Ig Light chains (amyloid L, AL)
o Serum amyloid A – an acute-phase reactant (amyloid A, AA)
 Manifestations: carpal tunnel syndrome (flatten thenar
eminence), generalized edema (nephritic syndrome)

15
 MGUS
Monoclonal Gammopathy of Unknown Significance
 No single test can tell MGUS from MM: need several
 Common, increases with age (1% 50+yo, 3% 70+ yo) MGUS: Diagnosis of exclusion:
 No evidence of end-organ damage (bone lesions,
Can PROGRESS TO MULTIPLE MYELOMA OR OTHER DISORDERS renal failure, hematopoietic suppression)
(1% per year risk total)  No evidence of other B-cell proliferative disorders
 46x RR for Waldenstrom Macroglobulinemia  Serum M-protein < 3g/dL and stable
 BM clonal plasma cells <10%
 25x RR for MM
 Plasmacytoma, primary amyloidosis, CLL too

Risk factors for progression: high serum M-protein, > 10% PCs in BM, IgM or IgA MGUS are worse

Waldenstrom Macroglobulinemia
He didn’t talk about it, but it sure seems to come up a lot on House

A.k.a. lymphoplasmacytic lymphoma

 Clonal disorder of small lymphocytes that mature to PCs making IgM

Epidemiology
WM: Clinical Picture
 Rarer than MM (1% all heme malignancies)
 Nonspecific (fatigue, weakness, anorexia)
 whites > blacks, older adults (median age 63yo @ Dx)
 LAD + hepatosplenomegaly
 Bence-Jones proteinuria in 40%
Secondary lymphoid organs affected (LN + spleen)  Sx from too many monoclonal IgMs:
 bone marrow too o Hyperviscosity syndrome
o Cryoglobulinemia
Morphology: large heterogeneity in malignant clone morphology o Cold agglutinin hemolytic anemia
Translates to variability in phenotypic markers o Peripheral neuropathy
 All are IgM+, most have B-cell markers (CD19+, CD20+, CD22+)
 25% have CLL makers (CD5, CD23+)

Sx from too many monoclonal IgMs:

 Hyperviscosity syndrome
o IgM is more prone: high MW, all intravascular
o Bleeding (nose/mouth/retina, blured vision, neuro abnormalities)
o Fundoscopic exam is best: see retinal hemorrhage, papilledema, sausage-shape veins

 Cryoglobulinemia
o Igs that precipitate when chilled (20% pts with WM)
o Type 1: precipitate at low temperature:
 affects ends of fingers, etc. (see aggregates of Ig on slides)
 Raynaud’s phenomenon, acrocyanosis, skin ulcerations
o Type 2: precipitates at low temp and has rheumatoid factor activity
 IgM binds Fc region of IgG to form immune complex
 Immune complexes precipitate in vessels
 Sx of systemic vasculitis: recurrent purpura of lower extremities

 Cold agglutinin hemolytic anemia

o Ab (usually IgM) against RBC Ags; bind at low temperature, fix C’  intravascular hemolysis
o 25-31 C (skin & distal extremities’ microvascular affected)
o Acute: infectious mononucleosis / M. pneumonia
16
 o Chronic: WM/CLL associated

 Peripheral neuropathy
o Very debilitating
o Chronic, sensorimotor, distal + symmetric
 (chronic with period of relative stability between progressions)
o Monoclonal IgM against CHO on myelin-associated glycoprotein (MAG)
 Can detect MAG Ag with ELISA, in CSF, etc.

17
 Leukemia
Leukemia: malignant, clonal proliferation of white blood cells with resultant accumulation in blood, bone marrow,
sometimes other tissues
 not a single disease (family); different leukemias have different prognoses

Low quality hematopoietic stem cell is

CML
target in leukemic transformation:
CML
 As normal cells mature / AML
differentiate, phenotype changes:
leukemic cells are often caricatures
of those changes

 Different leukemias: degree of

differentiation maintained (acute
vs chronic) & direction (myeloid
vs lymphoid)

Classification of leukemia
 Traditional: phenotypic properties
(morphology, clinical behavior,
expression of lineage features)
CLL
o Acute vs chronic,
o Lymphoid vs myeloid
 Genetic classification increasing in
use

Chronic myelogenous leukemia

A.k.a. chronic myeloid / chronic granulocytic leukemia
 See a range of maturing myeloid cells (whole spectrum – look at CML: FAST FACTS
chart); high WBC (leukocytosis); all granulocytes (granulocytosis:
both PMNs and granulocytes at different stages of maturation  Tumor of adults characterized by marked
granulocytosis with myeloid cells of all
 Megakaryocytes are SMALL (micromegakaryocytes) differentiation stages seen in blood.

Natural History (accelerated / blast crisis are “advanced” phases)  Hypercellular marrow with myeloid
1. Chronic phase: indolent; 5-6 years preponderance and increased
2. Accelerated phase: 6-9mo (micro)megakaryocytes.
3. Blast crisis: 3-6mo median survival  Defined by bcr-abl translocation
a. 90% die w/o Tx (Philadelphia chromosome); can treat
b. Can be either lymphoid or myeloid (stem cell is target!) with imatinib (Gleevec)
 Splenomegaly common, due to
Philadelphia chromosome t(9,22)  bcr-abl tyrosine kinase infiltration of red pulp by neoplastic
 Causative abnormality of CML; constitutively active myeloid cells; other organ involvement
 REQUIRED for CML diagnosis can be seen less often.
 Imatinib is specific inhibitor; 2nd/3rd gen too (standard of care)  Chronic course lasts 4-6 years on
average, followed by accelerated phase
CML is a chronic myeloproliferative neoplasm (6-9mo), then blast crisis (acute
 Stem cell neoplasm but have mature elements predominating leukemia) usually resistant to therapy.
 Often panmeylosis (different types predominate in different dzs)
 Diseases of adults, generally indolent, subclassified in lots of ways, JAK2 kinase mutations are common in most
of them

18
 Chronic Lymphocytic Leukemia

A.k.a. “chronic lymphoid leukemia” CLL: FAST FACTS

Neoplasm of “mature” B-cells but pts display B-cell dysfunction (monoclonal!)
 Mature-appearing lymphocytes in peripheral blood  Commonest of all leukemias (at least in
 NUMBER, NOT CYTOLOGIC APPEARANCE is indication of neoplasia West), seen in older adults (M > F).
 Hypercellular bone marrow biopsy with lots of lymphocytes
 Peripheral blood lymphocytosis, often to
very high levels, with proliferation of
Epidemology: Common, elderly, males
mature lymphocytes in blood, bone
Natural History: Chronic course; transformation to aggressive disease possible
marrow and other lymphoid tissues.
 Spleen & LN involvement is common
Complications:  Tumor is a clonal proliferation of CD5+ B
 Cytopenias (from hypersplenism / sequestration, auto-Ab production & cells (good for Dx)
immune destruction, marrow replacement)  Biologically similar or identical to one
 Infections (from neutropenia / hypogammaglobulinemia) form of non-Hodgkin's lymphoma, so
 Transformation to aggressive lymphoma possible called small lymphocytic lymphoma.

Chronic lymphoproliferative disorder: any indolent proliferation of  Sx in CLL pts from anemia,
morphologically mature lymphocytes; CLL is one specific variety of these. thrombocytopenia and neutropenia; ±
hypogammaglobulinemia and evidence of
autoimmunity.
The Chronic Leukemias: “General Thoughts”
 Easy to tell CML vs CLL: mature lymphocytes vs granulocytes  Disease usually has an indolent course, (
o Easiest way to DDx CML vs CLL? Blood smear! many years), but is incurable with
conventional chemotherapy
 Hard to distinguish from benign conditions (look normal)
o Easiest way to DDx CML vs reactive granulocytosis? PCR!
 Additional studies: FISH, flow cytometry, cytogenetics for Dx

Pathogenesis: proliferation of cells with mature phenotype  diseases of cellular accumulation

 Usually not proliferation advantage but upregulated anti-apoptotic machinery / survival
 Additional genetic changes (more hits)  transformation (more proliferation advantage!)

Acute leukemias
 Proliferation of immature cells (“blasts”) with arrest in maturation: cells aren’t “growing up”
 Lymphoid & myeloid blasts look alike (much harder to tell ALL vs AML with just blood smear)

Pathogenesis: translocation  altered transcription factor (block normal differentiation)

 More mutations  proliferative advantage

Acute Myeloid Leukemia

High WBC with blasts; decrease in mature elements of all lineages
Any organ can be involved (diffuse or tumor mass); Acute Promyelocytic Leukemia
 complications of AML are important in organ pathology  Specific AML subtype
 Kidney: hemorrhage from thrombocytopenia + WBC infiltrating, for
example  Proliferation of immature but differentiated
cells with distinct granules
Subclassification: AML is not a single disease  t(5:17) translocation (PML – retinoic acid
 FAB is traditional; not good for prognosis receptor)  PML-RARα fusion protein
 More recent: better genetic understanding  Responds to retinoic acid Tx

De novo: specific translocations; abnormal transcription factors

19
After myelodysplastic syndrome: WORSE
prognosis
 Bone marrow failure state characterized by
clonal abnormality of stem cell
 Ineffective hematopoiesis: hypercellular
marrow but pancytopenia
 Characteristic cytogenetic abnormalities:
deletions/ losses (chr 5/7), not translocations
like others
Natural history:
rapidly fatal if not treated; remission in 2/3 but
relapses common
 genetic lesions affect prognosis (MDS-related
worse, certain translocations (APL t(15:17))
better
 Death: infections & bleeding
o Cytopenia from therapy too!
Complications of therapy are like complications of disease
AML: FAST FACTS
 Aggressive disease characterized by proliferation of blasts in blood
and marrow with decrease in normal elements
 Patients present with / often die from, complications due to
thrombocytopenia or neutropenia
 Subclassified by type and extent of differentiation using
morphology, enzyme cytochemistry and immunophenotyping
 Cytogenetics and other molecular abnormalities increasingly
important in classification because they can identify prognostic
subgroups and direct therapy in some cases.
 Can occur de novo or following a period of myelodysplasia, and
this distinction is important to treatment and prognosis.
 Some patients may be cured with chemotherapy but the majority
of patients still die of their disease or of treatment complications.

Acute Lymphoid Leukemia

A.k.a. acute lymphoblastic leukemia
ALL: FAST FACTS
 Childhood (80% leukemias);
 Most common neoplasm in
o adults too (20% adult acute leukemias) – worse prognosis
childhood; accounts for 80% of
 Same presenting characteristics as AML; different Tx / prognosis childhood leukemia and 20% of
adult acute leukemia
Subclassification:
 Can be classified into T-, B-
 immunologic properties (B-precursor = 75-85%, T-precursor = 15-25%)
precursor and B-cell phenotypes
 genetics: lots of prognostic importance (esp. children)
 Can be further subclassified
Outlook: remission rates high but relapses common (especially adults) using cytogenetics into
 3/4 children but less than 1/3 adults can be cured prognostically important
subgroups
Prognostic factors in ALL  Clinical disease is similar to AML
 WBC (high is bad) though therapy is different
 Age (adults do poorly; among children <1yr or >10yr do worse)  High cure rate in pediatric ALL
 Cytogenetics: children are also more likely to have good cytogenetics with appropriate therapy,
o Can have Ph chromosome! Bad prognosis although variability in outcome
o Good: hyperdiploidy - t(12:21) among biologically defined
subgroups.

Acute Leukemias: General Thoughts

 Blasts look alike! ALL AML
 Much harder to tell AML Morphology Nothing specific Granules
from ALL than to tell CML Auer rods
from CLL: need special Enzymology TdT Myeloperoxidase
studies (FACS is definitive) Immunology B or T surface markers Myeloid surface markers
 Same-looking, smooth TDT: nuclear enzyme from early lymphoid development; detect with immunofluorescence or flow
cytometry; characteristic but not specific for ALL
chromatin, high N/C ratio

20
 ACUTE LEUKEMIAS CHRONIC LEUKEMIAS
 Immature cells  Mature cells
 Translocations involving transcription factor  Defective apoptosis
leads to maturation arrest leads to survival advantage
 Aggressive course but may respond to Rx  Indolent course but generally incurable
 Treatment depends on classification  May transform to aggressive disease

21
 Lymph Nodes & Hodgkin’s Lymphoma
The normal lymph node

 Small (<1.5cm), round/reniform organ usually in chains/groups; solid/homogenous parenchyma

 Normally non-palpable

Structure
Capsule & invaginating trabeculae; hilum for entry/exit of lymphatics
Parenchyma: 4 compartments
 Cortex: Follicles (B-cells)
1. Mantle zones (small, round lymphocytes, recruiting
ground for germinal centers)
2. Germinal centers: where Ag is presented, rearrangement /
mutation of Ig genes happens; determination of who has best
match of BCR to Ag presented by APC
 centrocytes/centroblasts
 macrophages, dendritic cells
 lots of division (mitotic figures)
 Paracortex: T-cell zone
1. Small, round lymphocytes (complex mix, especially T-cells)
2. Immunoblasts + plasma cells, epitheliod histiocytes, small
blood vessels
 Sinuses: Termination of lymphatics; pale-pink staining
1. Histiocytes (Mϕ) + endothelial lining
 Medullary cords: big mix of cells
1. Small, round lymphocytes, immunoblasts, PCs, Mϕ

Immunophenotypes: Normal LN
FOLLICULAR B-CELLS PARACORTICAL T-CELLS SINUS HISTIOCYTES
All CD45+ (common leukocyteantigen)
CD20+ CD3+, either CD4+ or CD8+ CD68+

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 Reactive Lymphadenopathy (LAD)
Non-neoplastic enlargement (response to variety of Ag stimuli)
 Normal compartments can enlarge & proliferate, usually just 1 of compartments
e.g. lymphoid hyperplasia
 Focal distortion of LN architecture from inflammatory response (acute or chronic) often post-infection
o e.g. lymphadenitis
reactive LNs are tender and usually mobile
malignant LNs are often “fixed”/ stuck to surrounding structures
Lymphoid Hyperplasia
Can be follicular, paracortical, sinus, or mixed hyperplasia (most is mixed, very rarely just medullary)

FOLLICULAR PARACORTICAL SINUS

Picture

Preferential
B-cell compartment (follicles)
stimulation of…
LN enlarges Abnormal proliferation of
because 2° follicles in GCs
Location Confined within LN capsule
 Crowded follicles, vary in
shape/size
 Mantle zones well defined
Histology  GC often polarized
 Polymorphous cytology in
follicles (not homologous
like malignancy)
Non-specific reactive follicular
hyperplasia is #1 (HIV-
associated adenopathy, toxo, RA,
Sjogren’s, 2° syphilis, etc)
Etiology &
DDx MUST DDx from follicular
lymphoma (architecture,
polymorphous cytology instead of
monomorphous, bcl-2 not
expressed unlike FL)
Other CD20+
T-cell compartment (paracortex)
Abnormal expansion of
interfollicular zone
 Expanded interfollicular zone
 Cytology polymorphic (MIX of
cells: small lymphs, immunoblasts,
PCs, grans, dendritic cells)
 Can have vascular proliferation
Non-specific reactive follicular
hyperplasia is #1
 infectious mononucleosis too (or
other viral adenitis)
MUST DDx from T-cell lymphoma
(architecture, polymorphous cytology
instead of monomorphous, TCR gene
rearrangement studies)
CD3+ & either CD4+ or CD8+
Histiocytic compartment (sinuses)
Distention of subcapsular /
intraparencymal sinuses by benign
histiocytes
 Sinuses engorged with
histiocytes (bland, uniform in
size/shape, pale, lots of cytoplasm)
 Phagocytosis of other hematologic
elements / foreign substances
Non-specific reactive follicular
hyperplasia is #1
Usually idiopathic; can see during
malignancies or with prostheses.
MUST DDx from malignancy
(especially those that travel & end up in
sinuses of LNs: metastatic carcinoma /
melanoma, ALCL, Langerhans’ cell
histiocytosis)
Can be associated with non-
hematolymphoid malignancy

Lymphadenitis (focal lesions)

Necrotizing: focal distortion of LN architecture by prominent necrotic inflammation
 +/- suppuration; mostly from bacteria, ddx: SLE adenitis, Kawasaki’s, others
 See pale/pink dead areas (histiocytes, lymphs, etc)
Granulomatous: focal or diffuse distortion of LN architecture by prominent granulomatous inflammation
 +/- suppuration, ddx: cat-scratch, TB, non-caseating sarcoidosis
 Serpiginous formation often; nerotic debris in center

23
 Hodgkin Lymphoma
Malignant lymphoma characterized clinically by dissemination along contiguous LN groups and pathologically by:
1. Presence of Reed-Sternberg (RS) cells and/or RS variants
2. Proper immunoreactive background (abundant eosinophils, PCs, small lymphs)

Note: need both for diagnosis, almost always nodal-based

Only 1% of tumor is tumor cell & rest is reactive

Epidemiology: 30% all lymphomas; bimodal age distribution (15-35yo and >50)
 M:F 60:40, Caucasians 2X incidence vs non-whites

Staging (important for outcome)

I. 1 LN or group
II. 1+ LN/group on same side of diaphragm
III. LN groups on both sides of diaphragm
IV. Extranodular involvement (spleen/liver/BM)
Also A/B & E
 B: has symptom, worse prognosis; A w/o Sx
 E (extralymphatic by direct extension)

Clinical course
1. Non-tender, firm adenopathy
2. Indolent; dramatic improvement with chemo
advances
3. “B” sx = worse outcomes
4. Tumor burden (stage) is most important prognostic variable
a. but generally patients do pretty well no matter what stage
b. 5yr survival: 90% for IA/IIA; 80% even for III/IV

Reed-Sternberg Cells
 Large lymphoid cell, classically binucleated, prominent eosinophilic nucleoli
o “Owl’s Eye”, many other variants as well
 ESSENTIAL for Hodgkin Lymphoma Dx (although only a small % of tumor)
 Ig rearrangements via PCR B-cell origin but only a few are CD20+

Hodgkin Lymphoma: subclassification

Classical Hodgkin Lymphoma Lymphocyte-predominant Hodgkin Lymphoma
% of all HL 95% 5%
Demographics Bimodal age curve 30-50 yo men
Presentation More than ½ with stage I/II dz Vast majority in stage I/II dz
B-symptoms 40% Rare
Other EBV probably plays a role Slow to progress; relapses frequent but remains
responsive to Tx; may be different dz from Hodgkin
lymphoma (cells not quite the same as RS cells
Histiologic Nodular sclerosis No further subtypes; generally nodular growth pattern
subtypes Mixed cellularity but sometimes diffuse
Lymphocyte depleted or rich
Immunophenotype RS cells: CD15+, CD30+ is classic CD15-, CD30-, EBV-
EBV+/-, CD20+/-, CD45- (no CLA!) CD45+, CD20+

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 Histiologic subtypes of Classical Hodgkin Lymphoma
Morphology not as important as staging for prognosis
Nodular Sclerosis:
 Big nodules bound by sclerosis (scar tissue, fibrous bands)
 Bulk of cells are small lymphs with RS too
 Mediastinal involvement; matted group of big LNs
 Most common in young women

Mixed cellularity:
 No sclerotic bands (dx of exclusion); R-S on background of immunoreactive cells
Lymphocyte-depleted:
 Could also be called “tumor-cell abundant” – there are tons of RS cells

Lymphocyte rich:
 Tumor cell poor: few RS cells

The line between LPHL and classic HL can be blurred as well (similar presentations and can sometimes convert)

Comparison: HL vs NHL

HODGKIN LYMPHOMA NON-HODGKIN LYMPHOMA

Spread Contiguous Noncontiguous
Extranodal? Uncommon Common
Waldeyer’s ring and tonsil
Rare Common
involvement
Localized disease (low Common Less common
stage)
Distinct age peaks, Generally older except for
Demographics including young Burkitt and lymphoblastic
adults (pediatric)
Prognosis Excellent Variable
Cell of origin B cell B or T cell

25
 Non-Hodgkin Lymphoma
Lymphoma: malignant clonal proliferation of lymphoid cells in LNs and other lymphoid tissue
 Not a single disease; lots of different entities; difference from leukemia often mostly semantic

Epidemiology of NHL: 55-60k cases/yr

 incidence has increased 50% in last 25 yrs!
 One of fastest growing cancers!
 HIV associated with ↑risk NHL; doesn’t fully explain increase in incidence

Classification: very complex; morphology + molecular pathogenesis

NHL Classification for Dummies:

1. Remember the “ acute” vs “ chronic” classification for leukemias?
The target was always a low-quality HSC but how far it could
differentiate was what determined acute vs chronic.
a. These are all lymphocytic: so not that myeloid side of stuff
(think ALL/CLL in tissues)

2. With lymphoma, there’s an added wrinkle: lymphocytes can mature

& activate even farther
a. e.g. CTLs from T-cell precursor, plasma cells from B-cells, etc.
b. Adds a new area of classification

3. Comparison table:
Diagnosis Predominant cell type Behavior Analogous to ____ leukemia
High grade Immature precursor Aggressive “Acute”
Low grade Mature differentiated Indolent “Chronic”
High grade Activated lymphocytes Aggressive None

Low grade lymphomas

General characteristics:
 derived from mature lymphocytes (usually small, condensed chromatin)
 low proliferation rate; mitoses rare
 “Survival tumor” / “tumor of accumulation”- resistant to apoptosis
 Rare in children; incurable but have prolonged clinical course (treat/remit/relapse)

Follicular lymphoma
Morphology:
 nodules, recapitulation of normal follicles but not confined to cortex
o effacement of normal LN architecture

Clinical features:
 30-40% NHL in adults; most common 40s-50s, almost never in kids
 Usually Asx with generalized LAD
 Common: spleen (small nodules in white pulp) + BM (paratrabecular aggregates) involved
 Indolent course; may respond to chemotherapy but incurable

Immunophenotype: CD20+ (B-cell tumor; B-cells live in follicles!)

26
Grades determined by cytological differences
 (B-cells in GC are differentiating all the time; at what stage does the follicular lymphoma B-cell stop differentiating?)
 Grade 1: Small cleaved cell (earlier stage of lymphocyte; small, irregular cells)
 Grade 2: “Mixed” (mixture of larger cells; differentiate further)
 Both: predominance of certain cell types; don’t see mitosis or high mitotic rate that a normal LN has

Pathogenesis:
 t(14:18): Bcl-2 oncogene (18) behind IgH (heavy chain, chr 14) promoter (obviously a good one for B-cells in GC)
o Can stain for bcl-2: if strong throughout, probably follicular lymphoma!
o Prevents apoptosis (survival advantage); normal B-cells shut-off bcl-2

Small lymphocytic lymphoma (SLL/CLL)

SLL is tissue equivalent of CLL (SLL/CLL is diagnostic term): 2 manifestations of same disease
 Difference entirely semantic / based on differing clinical presentation
 More diffuse replacement of LN

Mantle cell lymphoma MALT lymphomas

 Specific translocation: IgH – cyclin D1 (strong  Lymphoma of mucosa-associated lymphoid tissue
promoter; strong oncogene)  Indolent in nature
 NOT INDOLENT and NOT CURABLE (worst of both
worlds) Indolent T-cell Lymphomas
 REALLY RARE (almost never occur)

High Grade Lymphomas

 Derived from immature / activated lymphocytes
o medium to very large cells

Low Grade
o dispersed/open chromatin, often prominent nucleoli
o Highly proliferative: lots of mitoses
 Occur in all age groups
Survival Curves

 Systemic Sx are common

 Rapidly progressive if untreated but some pts can be cured with chemo
High Grade

Lymphoblastic Lymphoma
Prototype for high grade lymphoma related to precursor cells

Tissue equivalent of ALL

 Lymphomatous more common with precursor T-cells than precursor B-cells

T-cells  thymus  mediastinal mass is common presentation

Epidemiology:
 Relatively common in childhood (less in adults)
 Not a single entity; many but not all have oncogene translocated to TCR gene

Morphology:
 diffuse replacement of LN
 medium cells with dispersed chromatin & lots of mitoses

27
 Diffuse Large B-cell Lymphoma
Prototype for high-grade lymphoma related to activated cells

Epidemiology:
 common, 30-40% adult lymphomas, also occurs in children
 not a single disease entity (family

Morphology:
 diffuse replacement of LN architecture
 large cells with open chromatin, abundant cytoplasm, prominent nucleoli & lots of mitoses
o “vesicular nuclei” – look paler, like little vesicles

Disease: Can occur de novo (better prognosis) or as transformation from underlying INDOLENT B-cell lymphoma
 Localized or disseminated
 Can be extranodal but BM/blood are rare (why there aren’t “large cell leukemias”)
o Solid masses in extranodal sites / spleen
 50% pts can be cured with chemotherapy; prognosis depends on extent (stage) at dx

Burkitt Lymphoma

Another high-grade lymphoma related to activated cells

 Derived from most proliferative GC cell (very active  very active neoplasm!

Epidemiology: children > adults; two forms

 Endemic: Africa, rapidly growing jaw tumor, EBV-associated
 Sporadic: not EBV-associated, often intestinal

Morphology:
 Diffuse replacement of LN; high proliferation rate (lots of mitoses)
 Uniform, medium-sized cells with fine chromatin / nucleoli
 “starry sky” pattern (Mϕ phagocytosing debris – lots of turnover)
 Morphologically similar to lymphoblastic lymphoma (distinguish with
immunophenotyping)

Disease: medical emergency (highly proliferative) but can cure with chemotherapy
 Often leukemic (“burkitt lymphoma/leukemia”)

Pathogenesis:
 t(8:14): myc (powerful oncogene, chr 8) behind Ig promoter (chr 14)
o gives growth advantage
o actually lack bcl-2! High rate of cell death = good for treatment, but worry about tumor lysis syndrome

T-cell lymphomas
 Much less common than B-cell lymphomas
 “peripheral T-cell lymphoma” is generic name (peripheral, not thymic)
 Do worse than B-cell lymphomas (lower cure rates) – tons of different entities

Sample question: lymphoblastic lymphoma is most likely (vs follicular, mantle cell, SLL/CLL) to be cured with chemo

28
 Ancillary studies

Lymphomas are really complex; morphology has a limited roll  use ancillary studies

Immunophenotyping
 Flow cytometry (suspensions) or IHC (tissue specimens)
 Lymphoma: B-cell tumors are clonal  LIGHT CHAIN RESTRICTION
o (only κ or λ on B-cells, not normal mixture of both like you’d see in hyperplasia)
 Ag-expression patterns for subclassifcation of low-grade B-cell lymphomas (see table)

CD20 CD10 CD5 CD23 Other

Follicular lymphoma + bright + -
SLL + dim + + TdT+
Mantle cell lymphoma +bright + - Cyclin D1 +
MALT lymphoma + - -
Molecular biology:
 Can demonstrate clonality via Ig / TCR rearrangement
 Some types (FL, mantle, Burkitt) have specific molecular abnormalities that can be detected at gene / mRNA /
protein level

NHL Summary
• NHL represents a relatively common family of diseases

• As a first approximation, low grade and high grade lymphomas represent two broad groups
– Low grade: “Survival” tumors with indolent course but ultimately incurable
– High grade: “Proliferative” tumors with aggressive course, sometimes curable

• Specific entities among lymphomas have characteristic morphologies, pathogenesis and clinical behavior, and
in some cases require specific therapy
• Diagnosis and classification of lymphomas is based on morphologic examination, supplemented by
immunophenotypic and genetic information

29
 LYMPHOMA MORPHOLOGY PHENOTYPE (CD) GENETICS CLINICAL PRESENTATION OUTCOME
Other 20 5 10 23
 Older adults
 Indolent but present with
SMALL Non-specific,
 Small cells, monotonous Dim progressed disease
LYMPHOCYTIC + + sometimes  Indolent, incurable
(=SLL/CLL)
 Mature chromatin, not invasive + deletions  LAD + peripheral blood
involvement (involving BM)
 Anemia

 Loss of LN architecture  Middle aged / older adults  Indolent

 Monotonous appearance t(14:18)  Asymptomatic (LAD)  Not easily curable
FOLLICULAR
 Angular centrocytes
+ + (IgH-bcl2)  Frequently involves bone  Can transform to large
 Neoplastic follicles marrow B-cell lymphoma

 Not indolent
 Small cells  Adults
Cyclin D1 t(11:14)  Not curable
 Diffuse (more often) or kind of bright  Asymptomatic or anemic
MANTLE CELL + - IgH-Cyclin
NON- HODGKIN’S LYMPHOMA

(although it’s a low-

nodular (but not follicular) in + + D1
(BM involvement)
grade lymphoma)
infiltrate  LAD, can be GI

 Small, outside of mantle zones

 Indolent, good
 Leaves germinal centers & spreads
outcome
away to involve epithelial
MALT + - - Non-specific  Extranodal; GI Sx, in mucosa  Area radiation as Tx
structures (lymphoepithelial
 Can respond to abx (H.
lesions)
pylori)
 Monocytoid

 Large B-cells, open chromatin, lots  Fever, wt loss, night sweats

 Aggressive
DIFFUSE LARGE of mitosis, visible nucleoli  Can have nodal or
+ Non-specific  Needs chemotherapy
B-CELL  Can be destructive (diffuse, extranodal masses (usually
 Potentially curable
spreading ) find on PE / img)
 Intermediate size Non-specific
LYMPHOBLASTIC Pre-T-  Aggressive
 Blasts 3+ 5+ 7+ (TCR  Mediastinal mass +/- blood
(=ALL) cells!  Treatable
 Increased mitoses Translocns)
 Endemic (EBV positive, jaw)
 Very aggressive (tumor
 Increased proliferation vs Western (often intestinal)
B-cell t(8:14) lysis, early danger)
BURKITT’S  “Starry sky” appearance + +  Rapidly spreading
phenotype IgH - myc  Need Tx right away
 Intermediate size (emergency)
 Potentially curable
 Can be leukemic (+/- blood)

30
 Pathophysiology: Hematology
Hematopoesis ......................................................................................................................................................................... 2
Consequences of & Approach to Anemia ............................................................................................................................... 4
Iron Deficiency Anemia ........................................................................................................................................................... 6
Folate & B12: Metabolism & Deficiency .................................................................................................................................. 9
Hemolytic Anemia ................................................................................................................................................................. 12
Hemoglobinopathies ............................................................................................................................................................. 16
Hemostasis ............................................................................................................................................................................ 20
Thrombosis............................................................................................................................................................................ 25

1
 Hematopoesis
Hematopoeisis (Gr. haimato, “blood” + poiesis, “creation”): The formation of blood cells in the living body

Stem cells: can self-renew (proliferate) or differentiate

 Totipotent: can regenerate entire organism (incl. extraembryonic tissues)
 Pluripotent (e.g. embryonic stem cells): can regenerate across germ layers (no extraembryonic tissues)
 Multipotent (e.g. adult stem cells): can regenerate cell types restricted by germ layer
Zen thought of the lecture: Every time a stem cell divides, it’s still a stem cell but a little less so (not stochastic)

HEMATOPOETIC STEM CELLS (2 classes) OTHER PLAYERS (IN STROMA)

Most primitive Myeloid Growth factor/cytokine Stimulates…
(“ high quality”) (“low quality”) Erythropoietin (kidneys) RBC
Precursor to: All lympho-hematopoetic Granulocytes, RBCs, Thrombopoietin (liver) Platelets, HSC
lineages platelets, B-cells(?) Flt-3 Dendritic cells, HSC
Disease Rarely involved Most “stem cell disorders” Stem cell factor Mast cells, HSC
Engraftment Delayed but life-long Rapid but limited G-CSF PMNs
CD34+/-, other markers CD34+, other markers +,
Phenotype
mostly -, smaller larger
Aldehyde DH +++ + (or low)
Note on engraftment: both progenitors & primitive (high quality) stem cells can give rise to all elements; the difference is
in how long they can reproduce (lose graft after initial good result with low-quality stem cells)

Glossary
 Clone: cell population derived from single ancestral cell

 CFU: Colony-forming unit: represents the cell that gives rise to a colony (assayable growth in vivo / in vitro)
o E.g. CFU-S, spleen CFU (mouse low-quality hematopoietic stem cells, give rise to spleen colonies post-BMT-irradiation)
 Colony-forming assay: isolate mononuclear cells from marrow; let ‘em grow (clones)

 CFU-GM: colony—forming unit granulocyte macrophage: most differentiated myeloid progenitor, no self-renewal
o White colonies on assay: makes white blood cells
 BFU-E: burst-forming unit erythroid: RBC progenitor
o Red colonies on assay; making RBCs
 CFU-Mixed / CFU-GEMM: progenitor of both CFU-GM and BFU-E (probably like CFU-S)
o Mixed coloration on assay; making WBC & RBC too

Malignancy
Malignancy: unregulated clonal growth; from 1+ mutations
Pathways to malignancy
Cancer stem cells: (KNOW THESE)
 tumor initiating cell with limitless self-renewal, limited differentiation  increased proliferation
 Treatments often don’t target them  block in apoptosis
(more common)

Leukemic stem cells: mostly at low-quality HSC (myeloid precursor)

2
 Acquired Aplastic Anemia
 Hypocellular bone marrow, severe pancytopenia, often in young patients
 Autoimmune disorder: CTLs target low-quality stem cells
o Reduced CD34 stem cell pool  pancytopenia
Pathways to bone marrow failure
 Treatment: cyclophosphamide,
(KNOW THIS)
o activated in liver, blows away lymphocytes
1. Oncogenesis / mutations
o stops T-cell reaction against low-quality stem cells (leukemia, MDS, dyskeratosis congenita)
o High-quality stem cells are saved (have aldehyde DH, 2. Direct DNA damage
inactivate cyclophosphamide) (radiation, benzene, chemo)
3. Autoimmunity
Chronic myeloid leukemia (aplastic anemia, pure red cell aplasia)
 BCR-ABL fusion protein (t9:22 – Philadelphia chromosome) blocks 4. Viruses
(HIV, parvovirus)
apoptosis
 Called a “myeloproliferative” disorder – is really a “ myelo-accumulative disorder”

Diseases of Hematopoesis & where they come from

Notes about this crazy picture (down = more differentiation)

Top of the pyramid: high quality / primitive hematopoetic SC.

 Few diseases at this level
Next: low quality / myeloid SC.
 MOST DISEASES here.
Third: lineage-committed progenitors (a bit more differentiated; like those colony-forming units).
 Pediatric diseases are in this category; possibly why they do better clinically (more differentiated)
Bottom: mature / differentiated blood cells.
 Autoimmune diseases attack these more differentiated cells; lymphomas come from here

Final random thoughts:

 You can make human universal stem cells by transducing 4 genes into adult skin cells.
 Remember: epigenetics is important too

3
 Consequences of & Approach to Anemia
Metabolic / Physiologic Responses to Anemia

O2 Delivery & Uptake: 𝑉𝑂2 = 1.39 × 𝑄 × 𝐻𝑏 × (𝑆𝑎 𝑂2 − 𝑆𝑣 𝑂2 ) VO2 = oxygen delivery

1.39 = constant (mL O2 that bind to 1 gm Hb)
Ways to increase oxygen delivery Q = blood flow (mL/min)
1. Increase Blood Flow (Q) Hb = hemoglobin (g/dL)
a. ↑ Cardiac output: ↑HR, ↑pulse pressure, murmurs, bruits, SaO2 -SvO2 = A-V % sat difference
hyperdynamic precordium, tinnitus/roaring in ears (ability to unload oxygen)
b. Change tissue perfusion
i. shift from O2-insensitive (skin: pallor, kidney)  O2 sensitive (heart, brain, muscles)

2. Increase Red Cell Mass (Hb)

a. ↑ EPO (kidney)  Reticulocytosis (see ↑ immature RBCs)
i. Usually lose 1% RBC/day so reticulocyte count is 1%;
higher = “reticulocytosis”
ii. Clinical finding: bony pain, expansion of marrow (e.g. on
imaging)
b. Increased hematocrit is good: to a point!
i. Increase too much: viscosity increases; overwhelms
increased ability to transport; oxygen transport actually
decreases!
ii. Hypervolemia helps a bit (increase volume, can fit more
RBC in) but still can be overwhelmed

3. Increase oxygen unloading (SaO2 -SvO2)

a. ↑ 2,3- DPG (decreased affinity: displaces oxygen from hemoglobin)
i. Generated from glycolytic pathways (anaerobic)
ii. RBC have mostly anaerobic metabolism (90%, 10% aerobic)
1. Allows RBC to generate ATP (maintain shape, flexibility, cation/H2O balance)
iii. More in women (better oxygen delivery)
b. General characteristics of oxyhemoglobin dissociation curve
(see below)

Oxyhemoglobin Dissociation Curve

Oxygen affinity (P50): P50 varies inversely with oxygen affinity
 partial pressure of oxygen when Hb 50% saturated
 curve shifted to right: ↑P50, ↓oxygen affinity
 curve shifted to left: ↓P50, ↑oxygen affinity

INCREASED… SHIFTS CURVE TO… OXYGEN AFFINITY… BECAUSE

You’re bumping O2 off to deliver more to tissues (which is
2,3 DPG Right ↓Decreases
why your kidneys are cranking out 2,3 DPG in the first place)
Bohr effect: if carbon dioxide rises in a tissue, you need more
pH Left ↑Increases oxygen. Blood gets more acidic from CO2, pH drops, oxygen
affinity decreases, and more O2 gets dropped off
Oxygen Left ↑Increases You’ve got high O2 – why not hang on to it?
If it’s cold, your metabolism slows down, so you don’t need as
Temperature Right ↓Decreases
much O2

4
Cooperativity:
 when Hb partially saturated, affinity of remaining hemes increases markedly
 2 Hb conformations: Tense (deoxy) & relaxed (oxy)
 Pictures like the one to the right are popular when discussing cooperativity

Classifying Anemia
1. Cause: is there decreased RBC production, increased RBC destruction, or RBC loss (bleeding)
2. RBC Size: microcytic / normocytic / macrocytic
3. Hb: hypochromic (↓Hb/RBC),normochromic (normal Hb/RBC)
4. Morphology: normal / abnormal (anisocytosis = varied morphology)

Clinical Tests & Definitions

QUESTION TEST
Is the patient anemic? CBC, Hb, Hct
RBC production/destruction/loss? Reticulocyte count (usually ~1%)
Micro/macro/normocytic RBC Indices
Hypo/normochromic
Morphology Peripheral blood smear
PCV g Hb
Hct = ; PCV = packed cell volume (packed RBC volume) Hb =
Vblood dL blood

Hct
Mean Corpuscular Volume: MCV = reflects average size / volume of RBC (in fl, femoliters)
RBC Count

Hb
Mean Cell Hemoglobin: MCH = RBC Count reflects weight of Hb in average red cell

Hb
Mean Cell Hemoglobin Concentration: MCHC = indicates concentration of Hb in average red cell (%)
Hct
Reticulocyte = young RBC
Normal morphology: donut shape, center pallor 1/3 of red cell

Common causes for various types of anemia

Hypochromic, microcytic Normocytic, normal morphology
 Iron deficiency  Hemorrhage / blood loss
 Thalassemia syndromes  Unstable hemoglobins
 Sideroblastic anemia, transferring deficiency  Infection / inflammation / chronic dz
Macrocytic Normocytic, abnormal morphology
 Megaloblastic anemias (folic acid / B12 deficiencies)  Hemoglobinopathies (SS, SC, CC)
 Liver disease, reticulocytosis  Hereditary spherocytosis
 Bone marrow failure syndromes, drugs (AZT, etc)  Autoimmune hemolytic anemia; enzymatic deficiencies

5
 Iron Deficiency Anemia
Background: Iron Metabolism
 Distribution: mostly active use (60% Hb, 13% Mb / enzymes)
o also stored (ferritin/hemosederin, 27%); in transport (transferrin 0.1%)
 Intake: 10-25mg from food per day
o Most dietary intake is nonheme iron (spinach, etc) but less bioavailable than heme iron (veal, meat)

From food to blood: lumen mucosal cell blood

(remember that Fe is very oxidative / dangerous & body needs protection from it) Fe Fe
Fe
1. Absorption: brush border of upper small intestine via transport proteins Tf ferritin
sTf
2. Transport: Binds to apotransferrin in mucosal cell  forms transferrin Fe
exported to blood (intracellular apotransferrin recycled)  exported to Apo
blood  bound to soluble transferrin in blood Tf
3. Uptake: cells that need iron have transferrin receptors, ApoTf
di FeTf

e.g. erythroid precursors TfR

4. Storage: mostly in Mϕ of reticuloendithelial system mono FeTf

(liver/spleen/marrow)
o Ferritin: PRINCIPAL IRON STORAGE PROTEIN. Multi-subunit;
form shell around Fe molecules. Serum ferritin is proportional to
intracellular ferritin (lab test). Good for quick mobilization.
o Hemosiderin: insoluble ferritin (packed together until it
precipitates; can see on microscopy. Longer-term storage
Iron cycle:
 Erythroid precursors: uptake via Tf receptors  incorporate
Fe into hemoglobin & package into RBC
 Also used for myoglobin in muscle
 Old RBC destroyed Mϕ pick up iron
o store as ferritin/hemosiderin (recycling)
o release as transferrin into plasma when needed

Pathophysiology of Iron Deficiency

1. Iron stores depleted

2. Fe becomes limiting factor in heme biosynthesis
3. ↓ heme  ↓hemoglobin assembly
4. ↓Hb  ↓ RBC production
5. Small RBC (microcytic / low MCV) & Hb-deficient RBC (hypochromic / low MCH)

Responses to iron deficiency:

1. Increase absorption, transport, uptake of iron (more absorption, more Tf/TfR made)
2. Decrease storage & utilization (less ferritin, microcytosis, hypochromia)

Molecular Mechanisms:
 When plenty of iron is around:
o transferrin mRNA made but unstable (↓Tf protein, ↓transport)
o ferritin provides iron storage; heme synthesis (ALA synthase) uses iron
o Fe bound to IRPs, IRPs inactive (see below)
6
 Iron sufficient state:
 Iron deficiency: Iron response proteins (IRP-1 & 2)
ACONI- Fe+++
o IRP-1, IRP-2 lose their iron atoms (↓iron around); start RNA- TASE-1

binding (bind iron response element: IRE)

IRE
o Bind IRE in transferrin mRNA & stabilize  ↑transferrin TRANSFERRIN mRNA (unstable)
transferrin

production (↑iron transport) IRE

FERRITIN mRNA
ferritin
o Bind IREs in ferritin / ALA synthase mRNAs & block translation IRE heme
start site ALA SYNTHASE mRNA

o IRP-1 is aconitase (cytoplasmic TCA cycle enzyme); loses Iron deficient state:
enzymatic activity if no iron (increasing iron for it’s own use!) ACON-
ITASE-1
enzyme inactive;
becomes IRP
IRP
IRE transferrin
Iron sufficient state Iron deficient state TRANSFERRIN mRNA (stable)
IRP
Aconitase TCA enzyme activity IRP-1 functions IRE
ferritin
FERRITIN mRNA
mRNA unstable IRP stabilizes mRNA
Transferritin IRP
↓ transport ↑ transport IRE
ALA SYNTHASE mRNA
heme
mRNA transcribed IRP blocks transcription
Ferritin
↑ storage ↓storage
mRNA transcribed IRP blocks transcription
ALA synthase
↑ heme synthesis ↓heme synthesis

Iron losses
 Iron closely conserved in humans: NO PHYSIOLOGIC MEANS TO EXCRETE EXCESS IRONS
 Very small amounts lost (urine/bile/sweat, cells shedding from GI/urinary tracts; 0.05% Fe lost/day)
 Higher loss states: menses in post-pubertal females, pregnancy (to fetus), lactation (to breast milk)

Pathogenesis of iron deficiency

 Iron deficiency = deficit in total body iron: requirement > supply (intake+storage)

Causes: General symptoms (all anemias)

 recurrent / chronic / occult blood lost (e.g. GI bleed)  Pallor
 failure to meet physiological requirements (rapid growth, menses /  Fatigability, weakness
pregnancy / lactation)  Dizziness
 Inadequate intake (diet low in heme iron, e.g. strict vegans; GI disease,  Irritability
surgery, excessive milk intake in infants)

ALL SIGNS AND SYMPTOMS DEPEND ON: OCCASIONAL FEATURES OF IRON-DEFICIENCY ANEMIA
pagophagia craving ice
 DEGREE OF ANEMIA
pica craving of nonfood substances
 RATE OF DEVELOPMENT OF ANEMIA (dirt, clay, laundry starch)
glossitis smooth tongue
Lab findings angular stomatitis cracking of corners of mouth
Peripheral smear: koilonychia thin, brittle, spoon-shaped fingernails
 Microcytic & hypochromic blue sclerae
 anisocytosis (variable sizes) & poikilocytosis (variable shapes), ovalocytes / eliptocytes

Serum ferritin: LOW (best general indicator of IDA), remember that this is proportional to ferritin in cells
 Serum iron (iron saturation transferrin): expect low iron, high transferrin; ratio is less reliable
Bone marrow iron stain is gold standard (but only used in difficult cases)

CBC / RBC indexes:

 WBC normal with low Hb, low Hct
 Low MCV (microcytosis), low MCH
 Platelet ct: normal/high, retic % low/normal, occasionally high, abs. retic ct low (others are better indicators)
7
Sequential changes in lab values
Response to therapy
1. Ferritin decreases: stores being depleted
Peak reticulocyte count 7 - 10 days
2. Iron saturation (iron/transferrin) decreases: you’re iron deficient!
Increased Hb and Hct 14 - 21 days
3. MCV, Hb, Hct decrease: anemia! Hb production is limited now Normal Hb and Hct 2 months
Generally, microcytosis develops before significant anemia Normal iron stores 4 - 5 months

Therapy: RBC transfusion if severe; mostly iron salts (ferrous sulfate) po (IV if required).
 Phytates (cereal grains), tannins (tea), antacids can inhibit Fe absorption; vitamin C (ascorbic acid) helps it

Correcting iron deficiency: need to ID & TREAT the UNDERLYING CAUSE

 GI blood loss (ulcer/tumor parasite); excessive menstral loss (tumor / bleeding disorders),
 Rare conditions (pulmonary hemosiderosis, paroxysmal nocturnal hemoglobinuria)

Differential diagnosis of IDA

 Thalassemia trait: imbalance of globin chain reduction. Also microcytic / hypochromic but iron tests normal
 Anemia of chronic disease: decreasing Fe utilization with adequate stores
o Blood tests can look like IDA but usually ferritin / transferrin normal)

Anemia of Inflammation (Anemia of Chronic Disease)

Causes:
 Chronic Infections: osteomyelitis, pneumonia, abscesses, bacterial endocarditis, meningitis,
HIV, fungus, mycobacteria
 Autoimmune disease - lupus, rheumatoid arthritis
 Malignancy - Hodgkin disease, lymphoma, metastatic carcinoma, sarcoma, multiple myeloma
 Other chronic diseases - congestive heart failure, liver disease, inflammatory bowel disease

Pathophysiology: want to hide iron from bacteria!

1. Inflammation  IL-6 release (endothelial/Kupffer cells)
2. IL-6: makes hepatocytes release hepcidin
3. Hepcidin: inhibits intestinal iron absorption & iron release from Mϕ that
have taken up old RBC Iron deficiency vs. Anemia of Inflammation

IDA Inflammation Both

DDx vs IDA can be difficult: Ferritin ?
 ferritin increases in ACD (want to store more iron) Serum Iron
 total iron binding capacity ( transferrin) increases in IDA (transport more) TIBC ?
 Gets even crazier if both present at once sTfR No 

Marrow Iron No 

Iron Overload Syndromes

 Remember: no route for iron excretion
 Heart (cardiomyopathy / CHF / arrhythmias) and exocrine glands (e.g. liver cirrhosis) are main organs affected

Causes:
 Transfusional hemochromatosis: pts. getting frequent blood transfusions (e.g. β-thalassemia major); get large
cumulative load, Rx with iron chelation drugs
 Hereditary hemochromatosis: genetic disorder of excessive iron absorption in gut (enterocyte transporter
mutation); Tx with periodic phlebotomy.

8
 Folate & B12: Metabolism & Deficiency
Megaloblastic anemias: from reduction in rate of DNA synthesis; RNA/protein synth normal.
 Subset of macrocytic anemias (MCV > 100; abnormally large cells)
 Nuclear-cytoplasmic asynchrony (cytoplasm “matures” faster than nucleus)
can have 2 results: DDx: macrocytic anemia
o cell dies (intermedullary hemolysis / ineffective hematopoesis)  Reticulocytosis (e.g.
o terminal division omitted (big macrocyte formed) hemolytic anemia)
 Liver disease, alcoholism
 Unbalanced growth in all rapidly proliferating cells (bone marrow, tongue
 Drugs
epithelium, small intestine, uterus): look for clinical manifestations here.
 Some myelodysplasias

Pernicious Anemia (B12 defiency) DDx: megaloblastosis:

 Macrocytosis (big RBC) + megaloblastosis (lots of RBC precursors) Interference with DNA synthesis
 Chemotherapeutic drugs
Clinical presentation:  Acute leukemia
Key triad:  Rare inherited disorders
1. Diminished gastric secretions / achylia gastric
(B12 or folate deficiency too!)
2. Megaloblastic anemia
3. Neurologic degeneration (posterior/lateral columns)
Wikipedia on DCH:
Hodgkin's scientific mentor
Patient: older, especially Irish / Scandinavian / English Professor John Desmond Bernal
Signs / Sx: often develops slowly, Asx at first (sometimes neuro abnormalities early) greatly influenced her life both
 Most  least frequent: anemia, paresthesias, GI complaints, glossitis (sore scientifically and politically. He
tongue), difficulty walking was a distinguished scientist of
great repute in the scientific world,
Lab: a member of the Communist
 Macroovalocytes of RBC & hypersegmentation of granulocytes; party… She always referred to him
 Hypercellular bone marrow with lots of erythroid precursors as "Sage" and loved and admired
 Hemolysis: ↑LDH, hyperbilirubinemia, ↑ Fe him unreservedly; intermittently,
they were lovers.

Vitamin B12
Early studies: massive liver feedings helped PA; “extrinsic factor” (B12) in liver & “intrinsic factor” missing in pts
B12: Synthesized by microorganisms; dietary from flesh/milk of ruminant animals
 liver, glandular tissue, muscle, eggs, dairy products, seafood
 Normal body stores 2-5mg, > 1mg stored in liver; daily requirement 2-5 μg (0.1%)
 Significance: B12 stores last at least 1,000 days after absorption stops
Structure: Dorothy Crowfoot Hodgkin
 Porphyrin-like ring with cobalt in center (cobalamin)
 pharm forms are substituted at cyano group & converted by metabolism in vivo

Absorption, Transport, etc.

 Bound to protein in food; released by pepsin (need acid pH) in stomach,
binds to R-substance in gastric juice
 Released from R-substance by trypsin in jejunum
 Intrinsic factor (IF) secreted by gastric parietal cells & complexes with B12
 IF-B12 complex is absorbed EXCLUSIVELY BY TERMINAL ILEUM
(only cells that have IF receptors)
 B12  bloodstream  bound to transcobalamins
(TCII is physiologically relevant)
 TCII receptors in tissues  uptake for use in cell division

9
Functions: co-factor for the following reactions
1. Methyl transfer: homocystine + methyl-THF  methionine + THF
o B12 = obligate cofactor for certain folic acid functions
2. Hydrogen transfer: methylmalonyl coA  succinyl coA
o Not involved in folic acid pathway
o High urinary/serum methylmalonyl coA helps distinguish
B12 deficiency from folate deficiency

Clinical findings specific to Vitamin B12 deficiency

1. Low serum B12 levels Schilling test: Pernicious anemia
2. Peripheral / central nervous system disease 1. Phase 1:
a. Classic presentation: “combined system degeneration” a. Give oral radioactive
 dorsal/lat column probs (↓position / vibratory sense), cyanocobalamin + bolus dose
 peripheral neuropathy, unlabeled B12 to block tissue
 cortical abnormalities (“megaloblastic madness”) binding in B12-deficient individuals
3. Methylmalonic acidemia (see above) b. 24h urine collection (need to take
4. Abnormal Schilling test up B12 to get radioactivity into
urine instead of feces).
Causes c. Abnormal (<7% in urine) if IF
Acquired deficiency state: production impaired by Ab (PA),
parietal cells not working (no IF), or
1. Decreased absorption
terminal ileum messed up (no IF-
a. Loss of intrinsic factor receptors)
(gastric atrophy, autoimmune-associated gastric atrophy is #1, also 2. Phase 2: 5 days later
Ab against intrinsic factor / gastrectomy) a. Same process but administer with
b. Terminal ileum disease oral IF; if the defective absorption is
(ileal resection, gluten-induced problems, non-tropical sprue, cancer, corrected, Dx = pernicious anemia
granulomatous lesions, regional enteritis, bacterial overgrowth) (if no history of gastrectomy).
c. Food cobalamin malabsorption
(chronic achlorhydria, proton pump inhibitors, loss of salivary gland function)
2. Inadequate ingestion (vegans / breast-fed infants of vegan moms)

Congenital deficiency state: usually in infancy (failure to thrive, developmental delay, neuro abnormalities, anemia)
 Autosomal-recessive conditions (cobalamin absorption or transport)

Treatment of pernicious anemia: parenteral cyanocobalamin; treat terminal ileum disease or microbes if present

Folic acid
Folate metabolism: we don’t synthesize it; half of body stores are in liver; body stores last about four months
 Most absorbed in proximal jejunum but:
 DIFFUSE DISEASE of INTESTINE is NEEDED for FOLATE MALABSORPTION to occur
 Dietary sources: green leafy veggies, liver, kidney, fruits, mushrooms

Structure / metabolism / function:

 Dietary folate: conjugated with multiple glutamic acids; intestinal deconjugation is needed for absorption
 Needs to be reduced x4 (dihydrofolate reductase) to THF for activity (methotrexate, trimethoprim target)
 Most important function: methyl transfer (e.g. for thymidilate & subsequently DNA synthesis)
 MEGALOBLASTOSIS is from IMPAIRED THYMIDYLATE SYNTHESIS in folate deficiency.

Causes: dietary deficiency is most common (alcoholics, indigents, malnourished)

 ↑ folate requirements with pregnancy / lactation / chronic hemolytic anemia
10
  Impaired deconjugation or diffuse intestinal disease can lead to malabsorption
 Blocked utilization (cancer chemotherapy) too Diagnosis of folate defiency
 ↓ serum folic acid (<3ng/mL)
Treatment: 1 mg folic acid PO qd
 ↓ RBC folate levels (<135 ng/mL)
 If caused by methotrexate, coadminister leucovorin (FH4)
 Responds to physiologic doses of folate

Compare & contrast: B12 vs Folate

B12 FOLATE
Megaloblastic anemia Yes Yes
Combined system degeneration Yes No
Dietary Deficiency Rare Common
Dietary Source Muscle, liver, milk, eggs Liver, leafy greens
Deficiency induces hyperhomocysteinemia Yes Yes
Deficiency induces ↑ methylmalonic acid Yes No
Site of absorption Terminal ileum Small bowel
Intrinsic Factor required Yes No

B12, Folate, DNA replication, Neural Tubes, Vascuar Disease, and Cereal

Vitamin B12 deficiency: might trap folic acid as N5-methyl

FH4,
 predominant dietary form (can’t be converted to N-
5,10-methylene FH4 for thymidilate & DNA synthesis)
 Oral folic acid can mostly correct B12 ANEMIA
(possible explanation for why)

Treatment of B12 deficiency with folic acid DOES NOT

CORRECT NEUROLOGIC DEFECTS
 Dietary folate enters @ “folic acid” on top diagram;
via methionine synthase & with B12 participation can
generate methionine (needed for myelin synthesis)
 Pharmacologic folate doesn’t generate methionine,
formate, or SAM (enters at THF stage)
 Cure anemia (can still bump up DNA production) but
hide worsening B12 problem: MUST DDX B12 VS
FOLIC ACID PROBLEM

Folate deficiency & fetal malformations

 Folate deficiency associated with neural tube defects
 0.8 mg folic acid po qd prevents 1st occurrence, 4 mg
prevents neural tube defects in subsequent dose
 USPHS: women in reproductive years should take 400
μg/day of folate supplements

Hyperhomocysteinemia & vascular disease: associated with increased incidence of atherosclerosis / heart disease; folic
acid supplementation reduces homocysteine levels but doesn’t prevent venous/arterial thrombotic disease;
homocysteine may be marker of vascular disease instead of causative agent

Cereal: FDA mandated in 1998 that all cereals be fortified with folic acid to try to bump up folic acid intake; designed for
100μg / day increase (falls well short of USPHS guidelines) efficacy of program not known.
11
 Hemolytic Anemia
Hemolytic disorder: any condition where survival time of erythrocyte in circulation < 120 days (normal RBC)

Etiologies:
 Primary (usually congenital): membranopathy, enzymopathy, hemoglobinopathy
 Secondary (usually acquired): immunologic, chemical, physical

Physiologic response (independent of etiology): ↑ rate of delivery of new RBC (↑ reticulocytes)

1. Compensated hemolytic disorder: new increased rate can match destruction
2. Hemolytic anemia: when you can’t compensate (more destruction than new delivery)
a. Max increase is usually 6-8x normal
b. So if RBC life < 15-20 days (1/6-1/8 normal), then hemolytic anemia ensues

Lab techniques
Direct techniques: look at RBC survival time
 Ashby test (historical): transfused mismatched RBCs; follow % cells surviving; problem: not looking @ endogenous RBC)
 Radioactive chromium: most common; binds to hemoglobin (labeling pt’s own RBC)
o Problems: chromium elutes 1%/day from Hb, so have to correct; rate of elution varies with different
Hbs (e.g. faster from SC than normal); has higher affinity for retics, can’t tell blood loss vs hemolysis

Indirect techniques: look at RBC production

 Reticulocyte count (1% circulating RBC normally): increased in hemolytic disorder (abs & %)
o Reticulocyte = cell after most mature nucleated red cell precursor in BM loses nucleus
o Hard to tell in peripheral blood smear: use supravital staining (methylene blue) to clump ribosomes / mitochondria
o Flow cytometry mostly used these days
 Peripheral blood smear:
o young RBC are macrocytes
o polychromatophilia (reticulocytes have diffuse basophilia, look blue when released early from BM)
o nucleated red cells (early release from BM)
 Bone marrow: see more erythroid precursors; usually not required.
 Other: Can see medullary expansion (“hair-on-end” appearance) on radiography; maxillary prominence & expansion of
bones (skull, ribs, hands); sometimes hepatosplenomegaly too (extramedullary hematopoesis & increased sequestration)

Bilirubin
Elevation of indirect bilirubin in hemolytic anemia

Bilirubin review:
1. Breakdown of Hbheme, globin + Fe released
2. Heme  biliverdin (via heme oxidase, CO2 released)
3. Biliverdin  bilirubin
4. Bilirubin bound to albumin when it circulates.
(Unconjugated bilirubin a.k.a. indirect bilirubin =
insoluble, so it doesn’t appear in urine; goes to fat
instead e.g. sclerae)
5. Conjugated bilirubin formed in liver (direct bilirubin,
water-soluble & can be seen in urine)
6. Enterohepatic recirculation from GI to liver or
excretion as urobilinogen from kidneys / stercobilin in
feces

12
Hemolysis: ↑ degradation of Hb  ↑ bilirubin; exceed liver conjugation abilities; see INDIRECT BILIRUBIN in blood
 Conjugated / direct bilirubin doesn’t accumulate (liver can still excrete it)
Liver disease: liver can’t excrete conjugated bilirubin, so DIRECT BILIRUBIN increases in blood

Hemolysis: extravascular & intravascular

Extravascular hemolysis:
 RBC trapped in reticuloendothelial system (liver/spleen/bone
marrow)
 Heme breakdown proceeds through bilirubin pathway; see
increased indirect bilirubin in blood, ↑ CO & Fe

Intravascular hemolysis:
 RBCs destroyed within circulation, Hb released directly into
circulation
 In addition to increased indirect bilirubin, CO & Fe, see
hemoglobin in urine (hemoglobinuria).
 Hb also concentrated by renal tubular cells as hemosiderin,
shed into urine (hemosiderinuria)

Lab stuff

Haptoglobin: α2 globin , binds hemoglobin 1:1, made in liver

 Serum levels vary with age (0 in newborn, higher in older
children & adults); also an acute phase reactive protein
(increased in stress)
 Reduced levels when RBC survival < 90 days
 REDUCED SERUM LEVEL in BOTH intra- & extra-vascular
hemolysis

Hemopexin: β globulin, made in liver, binds heme 1:1

 Serum levels vary with age (higher in older children & adults),
not an acute-phase reactive protein
 REDUCED LEVELS in INTRAVASCULAR hemolysis (mostly)

Methemalbumin: when haptoglobin’s binding capacity exhausted, free Hb combines with albumin → methemalbumin
(means that indirect hemolysis has been liberating Hb into bloodstream)

Carboxyhemoglobin: CO liberated in heme degradation

 rate of CO production directly related to rate of heme degradation (directly related to red cell survival)
 BOTH intra & extra-vascular hemolysis can cause increased levels
 Technically difficult, not used routinely, results messed up in smokers or people with other CO exposure

Summary: distinguishing intravascular & extravascular hemolysis

Both intravascular & extravascular hemolysis Intravascular hemolysis only
 Indirect hyperbilirubinemia  Hemoglobinemia
 ↑ urinary / fecal urobilinogen  Methemalbuminemia
 ↓ haptoglobin / hemoplexin  Hemoglobinuria
 ↑ carboxyhemoglobin  Hemosiderinuria

13
 Classification of Hemolytic Disorders: intracorpuscular vs extracorpuscular defects

Intracorpuscular defect: etiologic factor intrinsic to red cell; most often genetic
 Membranopathy: see elliptocytes & spherocytes
 Hemoglobinopathy: e.g. sickle cell trait / dz
 Enzymopathy: e.g. pyruvate kinase deficiency

Extracorpuscular defect: etiologic factor extrinsic to red cell; most often acquired
 Thermal injury, mechanical injury (e.g. Waring blender syndrome from heart valve, etc.), toxic injury,
 Antibodies (autoimmune hemolytic anemia)

Intra & extra-corpuscular defects combined too: drugs, for example

Mophologic abnormalities
Hereditary Spherocytosis: intracorpuscular membranopathy

 Membranopathy: disturbance in protein-protein interaction (within RBC cytoskeleton or links to cell membrane)
 Spectrin abnormality (or spectrin binding proteins): cytoskeletal proteins involved in vertical (cytoskeleton –
PM) and horizontal (cytoskeleton – cytoskeleton) interactions

 Unstable red cell membrane loss of membrane  SA reduced  sphere forms (smallest SA)

o Cells rupture more easily in hypotonic solutions

(osmotic fragility test)

o Direct relationship between degree of spectrin

deficiency and: osmotic fragility, reticulocytosis,
depression of haptoglobin, severity of anemia

Autoimmune Hemolytic Anemia: extracorpuscular defect

 Ab coat RBC; as RES removes Ab, bits of

membrane get removed: reduction of surface
area  sphering
 Detection: Coomb’s test

DIRECT COOMB’S TEST INDIRECT COOMB’S TEST

Detect antibody attached Detect anti-RBC antibody in
to patient’s RBC surface patient’s serum
Use agglutinating Expose control RBCs to patient
antibody or labeled anti- serum; look for Ab binding to
human IgG control RBCs’ surface
 Can be positive in autoimmune
hemolytic anemia - if enough
Ab produced to exceed capacity
Positive for autoimmune of RBC to bind it
hemolytic anemia  Positive if antibodies are made
against foreign RBC antigens
(post-transfusion, feto-maternal
incompatibility)

14
G-6-PD deficiency: combined extra- and intracorpuscular defect

 Cells sensitive to oxidants: either an absence or dysfunction of glucose-6-phosphate dehydrogenase

 Most common form: A- variant; enzyme functions but has a shorter half-life
o younger RBC have a higher level of G6PD
o If you induce oxidative stress (primaquine), anemia, reticulocytosis,
hemoglobinuria all go away
o Reticulocytosis pumps out more young RBC, so G6PD levels on average are
better. See picture (Hb on top, retics on bottom, primaquine given at t=0)

When hemoglobin falls & red cells start to lyse (after an oxidative stress trigger):
 Heinz bodies (intracellular precipitates of hemoglobin)
 Dark urine (hemoglobinuria/methemalbuminuria)
 Jaundice

Pathophysiology of G-6-PD Deficiency

G-6-PD: catalyzes conversion of G6P to 6PG, reducing NADP to NADPH
G-6-PD deficiency: Cells can’t provide enough reduced glutathione following oxidative stress
 (can’t protect cellular elements against oxidation  symptoms)

Details of pathophys / metabolism:

 G6P usually metabolized mainly through glycolysis, small proportion
through pentose phosphate pathway

 Normal patient:
o Oxidative stress situation: increase in conversion of NADP to
NADPH (more G6PD activity, more 6PG produced, more
glucose utilization, and more pentose shunt activity)
o H2O2 & free radicals oxidize GSH, forming mixed disulfides of
Hb and glutathione
o NADPH is used to return glutathione to reduced state & remove peroxides

 G6PD Deficiency: can’t increase flow through PPP when oxidative stress occurs
1. NADPH can’t be generated as in the normal patient
2. Can’t regenerate GSH (glutathione  GSH conversion needs NADPH)
3. Hb starts to precipitate (Heinz bodies); membrane lipids get peroxidated  red cells destroyed

15
 Hemoglobinopathies
Hemoglobin chains & forms
Genes
Chromosome Genes HEMOGLOBIN TYPES: QUICK GUIDE
β-globin cluster 11 Beta(β), Delta (δ), Gamma (γ), Epsilon (ϵ) Hb A (“adult hemoglobin”) α2β2
α-globin cluster 16 Alpha (α), Zeta (ζ) Hb A2 (“minor adult”) α2δ2
Hb F (“fetal hemoglobin”) α2γ2
To make a hemoglobin: pick one from each cluster HbE (“embryonic hemoglobin”) α2ϵ2
Produced only just after conception ζ2ϵ2
Changes through the lifespan:
Erythropoesis happens in different organs throughout embryonic development (sequential):
 yolk sac  liver/spleen  bone marrow

Hb expression
 Just after conception: ζ and ϵ chains expressed
(ζ2ϵ2 predominates)
 Major switch #1: embryonic ζ chains replaced by
adult α chains
(shortly after conception, α2ϵ2 predominates)
o From this point on, it’s all α chains and no more ζ
o Embryonic ϵ replaced by fetal γ shortly thereafter
(α2γ2 predominates)
 Major switch #2: fetal γ chains replaced by adult β
chains (α2β2 predominates)
o This change is INCOMPLETE and REVERSIBLE
(basis for some therapy)
 Adult hemoglobins: 95% Hb A (α2β2), also 2% Hb A2 (α2δ2) and 2% Hb F (α2γ2)

The locus control region (chromosome 11) along with part of the 5’ β-globin complex help modulate this switching
 Transacting factors bind to LCR; LCR loops over & silences globin genes’ promoters (physical DNA rearrangement)
 Mutations can mess up expression patterns; gene therapy (FDA-approved!) and other therapies can take advantage

Hemoglobinopathies: overview

Hemoglobinopathy: mutation of either the alpha or beta globin genes which leads to:
 Varient globin molecule, decreased globin production, or absence of globin production
 Every mutation type you can think of has been described in globin genes, including regulatory / noncoding areas

Five clinical syndromes:

 Sickle syndromes (sickle cell trait, SC disease, etc)  hemolytic anemia, vaso-occlusive events (pain / infarction)
 Unstable hemoglobins  drug induced hemolytic anemia
 Oxygen affinity variations / M hemoglobin  cyanosis / polycythemia
 Thalassemia (α / β types, microcytic anemia + iron load from transfusion dependence, from α / β imbalance)

16
 Sickle Cell Anemia

Hb S: a different type of Hb (like Hb A, F, etc.) where there’s a β6 GLU to VAL mutation

HB C: a different type of Hb too (B6 LYS to VAL); doesn’t form polymers as readily as S (but more readily than A)
Remember that Hb A is normal adult Hb

Genotype Phenotype FEATURES of SICKLE CELL ANEMIA

AA Normal  Hemolytic anemia (shortened red cell survival)
SS Sickle cell disease  Complex pathophysiology  variable severity
AS Sickle cell trait: no sickling in vivo; same survival as AA  “Gene-switching” therapy
SC SC disease (compound heterozygote); less sx than SS

Pathophysiology
Polymer formation: β6 Glu  Val mutation fits into a
hydrophobic pocket in adjacent β chain of another tetramer
 Other interactions are favorable & stabilize too
 Hb in RBC is really concentrated (97-8% protein is
Hb!) → these polymers are big deal!

Polymers & crisis:

1. Polymer formation is concentration
dependent: in normal situations,
polymers are in reversible equilibrium
with monomers
2. After you hit a certain point (“critical
polymer”), growth of the polymer is thermodynamically favorable
3. Polymers  rigidity, changes in cell shape, membrane distortion
(SICKLING!) SC crisis:
 Sudden in onset
4. Classic theory: Rigid RBC  obstruction of blood flow  tissue  Unpredictable (and 80% SS have < 1 crisis/yr)
hypoxia  tissue damage (localized pain + swelling); repeated low  Variable: even among individuals with
grade obstruction  organ damage (spleen, lungs infarct) identical sickle mutations!
 Multifocal
5. More current ideas: COMPLEX, MULTIPLE EVENTS (RBC, WBC, Suggests that classical theory is incomplete
coagulation)
o RBCs block bifurcations in blood vessels, pre-capillary arterioles (why crises manifest in multiple places!)
o Membrane distortion of RBC  expose new proteins  stick to endothelium (along with RBC)
o NITRIC OXIDE: Intravascular hemolysis, arginase leakage,  ↓NO  inflammation & vasoconstriction
(NO levels would explain some of the systemic nature of the crisis)
o Coagulation cascade activated too

6. Genetic modifiers are key too: not simply a single gene

o WBC count, Hb F levels, cytokine production, endothelial surface proteins, even in opiate receptors
(some patients don’t respond as strongly; docs think they’re malingering!)

Hb F and Sickle Cell Disease

 Increased Hb F corresponds to less pain (Hb F doesn’t form polymers)
 Newborns therefore have no symptoms even if SS (enough Hb F around to inhibit Hb S polymerization)
 Hydroxyurea (and two other drugs): can increase Hb F in SS patients (4% 15%, 50% reduction in pain crises,
hospitalizations, mortality).
 Other treatment: transfusions, bone marrow transplant if needed, others
17
 Lab tests for sickle cell
(know how these compliment one another for the exam)

Sickle Prep (Sickledex™, sickle solubility test)

1. Put drop of blood in sodium hydrosulfite solution
2. RBC lyses, releases Hb
o Hb A goes into solution (clear)
o Hb S precipitates (insoluble  cloudy)
3. ALL THREE TYPES (SS, AS, SC) ARE POSITIVE (just screening for presence of Hb S) – CAN’T DISTINGUISH
Sickle Prep Hb electrophoresis
Hb Electrophoresis
Speed Fast Slow
1. Run sample on electrophoresis; measure migration
Can distinguish
2. CAN DISTINGUISH SS vs SC vs AS vs AA Nope Yep
AA/AS/SS/SC

Thalassemia
DISEASE OF GLOBIN CHAIN IMBALANCE
Mediterranean populations (Italians, Greeks, Arabs, Africans) & Southeast Asia α>β Beta thalassemia
β>α Alpha thalassemia
Normal ratio β:alpha = 1.0 (beta thal <1, alpha thal > 1)

Beta thalassemia
 100+ mutations, decrease in β globin production, don’t alter β-globin protein (normal Hb A, just less)
 Excess alpha chains  unstable α4 tetramers  precipitate  RBC damage  hemolysis
o γ chains are still around: make α2γ2 (Hb F) in increased levels
o δ chains are around in adults: make α2δ2 (Hb A2) in increased levels too
o Hb electrophoresis: see increase in Hb F and Hb A2 relative to Hb A

Presentations:
Genotype Name Features
Heterozygote Thalassemia minor, thalassemia trait Small RBCs, minimal anemia
Homozygote Thalassemia major Transfusion-dependent (severe anemia)
(“Cooley’s anemia”) Microcytic / hemolytic anemia

Compound heterozygote Thalassemia intermedia Thal major with 5+ alpha genes = more mild
Thal minor with 4- alpha genes = more severe

Diagnosis:
 microcytic anemia (decreased Hb, low MCV, hypochromic, etc.)
 increased RBC number (marrow trying to compensate  nucleated RBC in periphery)
 Elevated Hb F and Hb A2 relative to Hb A
 Features of chronic anemia (thal major): Hepatosplenomegaly (extramedullary hematopoesis), brittle bones /
enlarged marrow space (hypertrophy of skull/facial bones, hair on end appearance)

Therapy:
 prenatal dx (incidence has declined in countries where risk was high)
 hypertransfusion + iron chelation (would overload otherwise; no excretion mechanism)
 bone marrow transplant if severe; Hb F “switching agents” (e.g. hydroxyurea) might not make enough Hb F to help

18
Alpha thalassemia
 Excess beta chains → unstable β4 tetramers  precipitate  RBC damage  hemolysis
 In newborn: γ chains make γ4 tetramers (no alphas around)  “Hb Bart’s”; can detect it but useless
o δ chains don’t do you any good either, since you’re low on α chains! Nothing to pair it with.
o Hb electrophoresis: Hb F, Hb A2 don’t change relative to Hb A (all need α chains, so all decrease!)

Common in Black, Italian, Greek, Arab, Asian, Indonesian populations

 Tremendous selection factor (See map)

Genotype Phenotype Features

4 alpha genes Normal Normal
3 alpha genes “Silent carrier” No Sx but can pass on gene
2 alpha genes Trait Microcytic anemia (like β thalassemia trait &
mild iron deficiency anemia in severity)
1 alpha gene Hb H Severe hemolytic anemia
0 alpha genes Hydrops fetalis Inconsistent with life (die in utero)

Diagnosis:
 Microcytic RBC ± anemia
 Often confused with iron deficiency
 Hb A2 / Hb F levels normal relative to Hb A so Hb electrophoresis not helpful!
 RDW / MCHC not reliable; family studies may not be helpful
 Rely on clinical history (race of patient); must rule out iron deficiency anemia as microcytic anemia cause
o E.g. put ‘em on Fe and they don’t get better! Think α-thal!

Methemoglobin (Fe3+): a Hb variant

Doesn’t lead to anemia; can cause decreased oxygen transport  (pseudo)cyanosis

 Blood color (Hb color) altered: RED (Fe+2)  BROWN (Fe+3)
 Can confuse with: pulmonary or cardiovascular disease

Causes: genetic or acquired

 Aut-dom: congenital variants in alpha or beta chain that stabilize heme molecule in Fe+3 (ferric) state
 Aut-rec: deficiency of enzymes in RBC that help keep heme molecules in Fe+2 state (Reduced)
 Acquried: oxidant damage of hemoglobin (drugs / toxins – especially nitrates)
o Too much nitric oxide (used to close PDA in infant)
o Diarrhea (nitrates overproduced by bacteria)
o Poisoning (nitrates from fertilizer in well water)
o Other drugs: nitroglycerin, sulfonamides, napthaline, others with nitrates.

19
 Hemostasis
Background: blood under pressure; breaks in vascular continuity  exsanguination (need to seal it off)

 Procoagulants: Platelets & coagulation proteins work together to stop bleeding

1. Vessel walls contract (reduce vascular flow  ↓bleeding)
2. Platelets adhere (vWF, etc.), provide phospholipid-rich environment for coagulation factors
3. Cross-linked fibrin network (via coagulation cascade)

 Anticoagulants: Balanced against procoagulants (

1. Endogenous anti-thrombotic proteins (dampen procoagulant coag cascade)
2. Fibrinolytic system (remodel / dissolve clots)

Hemostasis

General principles: basic goal is to get to formation & cross-linking of fibrin

 Extrinsic pathway more important in initiation

o Requires “extrinsic” tissue factor
o Produces some thrombin (IIa)
o Tissue factor inhibitor shuts it down pretty quickly
(released by intact epithelium’s endothelial cells)

 Intrinsic pathway big in amplification / propogation

o (heats up after thrombin production by extrinsic pathway)

20
 The Coagulation Cascade

XII Intrinsic Extrinsic

Pathway
Surface kallikrein Pathway
HMW kininogen

IX
XIIa TF + VII
XI XIa Ca++
XI Ca++ Phospholipid

X
Ca++
IXa Phospholipid Ca++
IIa TF + VIIa
VIII VIIIa

Xa

V IIa Va
V fibrinogen

II IIa
Ca++
Phospholipid

fibrin monomer

IIa
XIII XIIIa

fibrin clot

THE PLAYERS
Serine proteases XII, XI, X, IX, VII, II (prothrombin), prekallikrein Circulate in blood as zymogens, cleave & activate others
Cofactors  VIII (cofactor for IX) Increase reaction kinetics (1000 fold) by localizing /
 V (cofactor for X) concentrating partners to membrane surfaces (optimize
 HMWK* ( cofactor for XI & prekallikrein) reaction)
 Tissue factor (cofactor for VII)
Glycoprotein Fibrinogen Becomes insoluble (fibrin) after thrombin cleaves it
Transglutaminase XIII  Cross-links fibrin strands covalently
 Links α2-antiplasmin to fibrin |
(inhibits plasmin, part of fibrinolytic system)
 If no XII: clots fall apart
Vitamin-K-  II, VII, IX, X  Need vitamin K for synthesis (warfarin inhibits)
dependent  Proteins C, S  Vit K needed for addition of γ-carboxy glutamic acid side
chains (allow proteins to bind phospholipid-rich
membranes in presence of calcium
 No Vit K  no side chains  no binding, less activity
*HMWK = high-molecular-weight kininogen
21
 Steps of Coagulation Cascade (in more detail)
EXTRINSIC PATHWAY
Requirements Anticoagulant Associated Disease
Step Description
Ca PLs Vit K Target? State?
0 Factor VII normally circulates; small amounts of VIIa also in blood (VII needs vitamin K)
1 Vascular damage  Tissue factor exposed in subendothelium (normally hidden)
2 Factor VIIa forms complex with tissue factor
3 VIIa + TF cleaves X  Xa (X requires vitamin K)
INTRINSIC PATHWAY
Requirements Anticoagulant Associated Disease
Step Description
Ca+2 PLs Vit K Target? State?
Factor XII activated by exposure to highly negatively charged surfaces (e.g. endothelium)
0
Note: Not important in vivo (just for assays)
XIIa activates prekallikrein  kallikrien; high molecular weight kininogen is a cofactor
1
(concentrates prekallikrein on the membrane where XIIa generated)
1.5 Kallikrein activates more XII  XIIa (positive feedback)
2 XIIa also activates Factor XI (HMWK is cofactor, concentrates XI on membrane)
XIa activates Factor IX  IXa Hemophilia B:
3 ++ ATIII (XIa  XIi)
(needs Ca and phospholipids – surface of activated platelets; IXa needs Vit K for synth) Factor IX deficiency
Hemophilia A:
Proteins C/S
3.5 Meanwhile, VIII activated by thrombin (Factor IIa)  VIIIa Factor VIII deficiency
(VIIIaVIIIi)
Von Willebrand Disease
+2
4 VIIIa + IXa form “tenase” complex, assembles on PL-rich platelets using Ca
VIIIa+IXa (tenase) cleaves X  Xa
5 +2 ATIII (IXa  IXi)
(X also requires vit K, binds to PL using Ca using γ-carboxy-glutamic acid side chains)
COMMON PATHWAY
Requirements Anticoagulant Associated Disease
Step Description
Ca+2 PLs Vit K Target? State?
XXa either by VIIa/tissue-factor (extrinsic) or IXa/VIIIa (intrinsic)
0
(X needs vitamin K, happens on platelet surfaces with Ca + PLs)
Factor V Leiden
1 V  Va via thrombin (IIa) activation Prot. C/S (VaVi)
(hypercoaguable)
Va + Xa (prothrombinase complex) cleaves prothrombin (II)  thrombin (IIa) Thrombin deficiency =
2 ATIII (Xa  Xi)
(thrombin needs Vit K for synthesis) embryonic lethal
3 Thrombin (IIa) cleaves fibrinogen  fibrin monomers ATIII (IIa  IIi)
4 Fibrin monomers polymerize (loose fibrin clot, hydrostatic bonds
5 Thrombin activates XIII  XIIIa
4 XIII is a transglutaminase; catalyzes fibrin cross-linking & affixes α2-antiplasmin
22
Observations:
 When thrombin gets cleaved, things really start rolling: more cofactors! VIIIVIIIa (intrinsic), VVa (common)
o Thrombin also activates platelets and protein C (anti-thrombotic protein!)
 When vitamin-K-activated stuff is involved (II, VII, IX, X) the action needs calcium and takes place on
phospholipids of platelet surfaces (that’s where γ-carboxy glutamic acid side chains like to do their thing)

Lab Tests
Basic idea for both PT & APTT:
1. draw blood into sodium citrate sol’n (chelate calcium)
2. centrifuge (keep plasma only)
3. add phospholipids (platelets were removed) and calcium
4. add XII for APTT (intrinsic pathway) or tissue factor for PT (extrinsic pathway)
5. Measure time to clot formation based on light absorption

Prothrombin Time (PT) Activated Partial Thromboplastin Time (APTT, PTT)

Extrinsic Pathway YES (VII) no
Intrinsic Pathway no YES (XII, HMWK, prekallikrein, XI, VII)
Common Pathway YES (X, V, II, fibrinogen)
Factor XIII NEITHER (need test of clot strength; these are just for clot formation)

Mixing test:
 Prolongation of PT or APTT can be from either deficit in coagulation factor or Ab against coagulation factor
 Mix 1:1 patient:normal plasma, re-run prolonged test.
o If it corrects, it was deficiency (50% of factor sufficient to normalize test)
o If it’s still prolonged, abnormality is from antibodies (neutralizing factors in normal plasma too)

Factor levels
 Isolate a specific factor that’s the issue: use factor deficient plasma (all but one factor) and add patient plasma
o Run test (APTT or PT depending on pathway you suspect) – will be dependent on patient’s factor level
o set up standard curve with length of test vs % of factor (controls), determine patient’s level

Diseases
Hemophilia A: congenital factor VIII deficiency
Treatment of hemophilia A:
 X-linked, recessive (1/10k males)
 Recombinant/plasma-derived
 Deep tissue bleeds, hemarthroses (joint bleeds)
factor VIII
 Severity varies with factor VIII level (mild > 5%, moderate 1-5, severe >1%)
 DDAVP (desmopressin) to
release VIII & vWF (mild only)
Hemophilia B: congenital Factor IX deficiency
 X-linked inheritance (1/50k males)
Treatment of hemophilia B:
 Similar manifestations to hemophilia A
 Factor IX concentrates
Von Willebrand disease: congenital vWF deficiency
Treatment of vWD:
 Autosomal, most common inherited bleeding disorder (1 in 1000)
 mild vWD  DDAVP (makes
 less vWF, which is a carrier protein for VIII in the bloodstream (protects
endothelial cells release vWF);
from C/S inactivation); ); less severe than hemophilia A
 severe  factor VIII
 More important: ↓adhesion of platelets to subendothelial collagen
concentrates (have vWF)
 Bleeding from mucosal surfaces rather than deep tissue bleeds (platelets!)
 Tests:
o ELISA (vWF antigen test) used to measure vWF levels
o Ristocetin Cofactor Assay (antibiotic; causes vWF-dependent platelet aggregation, tests vWF function
23
Vitamin K deficiency: MOST COMMON ACQUIRED BLEEDING DISORDER
Etiologies of Vit K deficiency:
 Immature forms of II (prothrombin), VII, IX, X
 broad-spectrum abx
o Also C and S
 surgery
 Half-lives vary: VII has shortest half-life  prolonged PT 1st (extrinsic)
 poor nutrition
o Eventually PT & APTT both abnormal
 excessive biliary drainage
 Treatment: Vitamin K (oral, sub-q, IV)
 warfarin

Liver disease: all coagulation proteins made in the liver

 Severe liver disease only: need ~90% loss of function before PT/APTT slowed; means poor prognosis
 Factor VIII synthesized outside of hepatocyte; not affected
 Treatment: plasma

24
 Thrombosis
Balance between procoagulant & anticoagulant forces; imbalance  hemorrhage or thrombosis

Circulation & Endothelial Cells: Anticoagulants Procoagulant:

Circulation: prevent local accumulation of activated coagulation factors & incidental  platelets
thrombous formation  coagulation factors
Antithrombotic:
Endothelial cells:  circulation
 express thrombomodulin (binds thrombin, activates protein C)  endothelial cells
 don’t express tissue factor  fibrinolytic system
 endogenous anti-
 produce prostacyclin (PGI2): inhibits platelet function
coagulant proteins
 promote fibrinolysis (tissue plasminogen activator: activates plasminogen)

Endogenous anticoagulant proteins

Antithrombin III: inactivates IIa, IXa, Xa, XIa
 1st to be discovered; synthesized in liver
 Serine protease inhibitor: suicide substrate for IIa, IXa, Xa, and XIa
 Inhibitory action increased 1000-fold if heparin is around (used to treat thrombosis)

Proteins C & S: inactivate Factor Va & VIIIa

Both vitamin K-dependent; bind PL-rich surfaces like activated platelets when calcium’s around

Protein C: serine protease; Protein C  activated protein C (APC)

 Activated by thrombin when bound to thrombomodulin (endothelial cells)

Protein S: in plasma; free (60%) and bound to C4b binding protein (40%)
 Need free form to participate as cofactor for protein C
 C4b binding protein increased in pregnancy & estrogens / OCP (bind more protein S, hypercoagulable)

Activity: APC + free protein S make complex; inactivate Factor Va (Xa cofactor) and factor VIIIa (IXa cofactor)

Fibrinolytic system
Purpose: lyse fibrin clots

Plasminogen: major fibinolytic enzyme

 circulates in inactive form in plasma, activated by two different enzymes (plasminogen  plasmin)
o Tissue plasminogen activator: from endothelial cells; mostly activates plasminogen on clot surface
o Urokinase can activate plasminogenplasmin too
o Plasminogen activator inhibitor I opposes this process (inhibits TPA / UK)
 TPA / UK can be given for thrombotic disease (MI, PE) TPA UK

pharmacologically Plasminogen Plasmin

Plasmin: cleaves fibrin into fragments (fibrin degradation products, FDP) Plasminogen activator inhibitor I

 Opposed by α2-antiplasmin (connected to clot surface by Factor

XIIIa); prevents premature clot lysis Fibrin FDP
2-antiplasmin

25
 Disease states

Pathological venous thrombosis: imbalance between prothrombotic/antithrombotic mechanisms; congenital/acquired

 Usually need several risk factors
(risk adds up, then you go over the top & clot) Acquired risk factors for venous thrombosis
 Immobility
(↓ clearance of coagulation factors)
Factor V Leiden: congenital risk factor for venous thromb  Estrogens / OCP
 Mutation (ARG 506 GLU) in the spot where APC (↑ synthesis of clotting factors VIII, vWF, fibrinogen;
cleaves V to inactivate it ↑ c4b binding protein  ↓ free protein S)
 End result: Factor V resistant to APC (↑ clotting)  Surgery/trauma
 Older age (↑ coagulation factor levels)
Epidemiology: 5% US Caucasians, up to 15% Swedish are  Pregnancy (like estrogen therapy)
heterozygous; uncommon in other groups.  Cancer (hypercoagulable; ↑tissue factor production?)
 Heterozygotes: 5x higher risk;
Homozygotes: 50x higher risk of venous thromboembolism
 Risk amplified if other risk factors present (heterozygote + OCP  30X RR of venous thrombosis)
 Does not increase risk of arterial thrombotic events

Lab tests:
 Activated protein C resistance assay (functional test)
time
o Add APC to patient plasma diluted 1:5 in factor V deficient plasma, do APTT, calculate timewithout APC
with APC
o Normal pt: adding APC prolongs APTT by > 2.2 fold
o Factor V Leiden: less of an APC effect (1.6-fold longer for heterozygotes, >1.3-fold for homozygotes)
 PCR-based assay: used to confirm genetically

Treatment: only if symptomatic (use anticoagulants)

Prothrombin 20210: gene mutation, newly acquired risk factor for venous thrombosis
 3’UTR of prothrombin  increased translation efficiency  ↑ prothrombin levels (25% higher)
 Heterozygotes: 2% Caucasians; uncommon in other groups; 2-3x increased risk
 Diagnosis: molecular biology; Treatment only if symptomatic

Deficiency of Antithrombin III: example of a deficiency in an anticoagulant protein, predisposes to venous thromb.
 ATIII inactivates IIa, IXa, Xa, IXa
 Heterozygotes: 1/5k; homozygotes  embryonic death
 20x increased risk of thrombosis! (heterozygotes! One of most potent inherited prothrombic states)
 Can also acquire (liver dz, nephrotic syndrome – don’t make as much or spill it into urine)
 Dx: measure activity in plasma samples

Protein C/S deficiency: another example of a deficiency in an anticoagulant protein, predisposes to venous thromb.
 5-10x risk of venous thrombosis; Diagnosis: measure activity in patient samples

Protein C deficiency: 1/250-500 heterozygotes; lower # with sx

 Homozygous is rare; causes diffuse neonatal thrombosis (purpura fulminans)
 Acquired from vitamin K deficiency / warfarin; liver disease

Protein S deficiency: 1/1000 heterozygotes

 Can be acquired like protein C; also pregnancy/estrogen/OCP (C4b binding protein levels)
26
Defects in fibrinolytic system not identified so far as venous thrombosis risk factor

Antiphospholipid Antibody Syndrome: predisposes to BOTH ARTERIAL AND VENOUS thrombosis

 Ab against phospholipid binding proteins (e.g. beta-2-glycoprotein I; binds to endothelial-bound phospholipids)
 Ab binding triggers tissue factor expression by endothelial cells; C’ activated, endothelial damage
o End result: coagulation via extrinsic pathway  thrombosis

Signs / sx:
 Fetal loss (placental thrombosis)
 Thrombocytopenia (activation/consumption of platelets; immunological destruction

More common in pts with other autoimmune disorders (SLE, RA) but also viral infections (HIV) or cancers

Diagnosis: very important

Important: These pts have higher risk for recurrent thrombotic events; require longer durations of anticoagulant Tx

1. ELISA (phospholipid antigen substrate, add patient sample, detect with anti-human IgG/M/A)

2. Coagulation assays: sensitive to antiphospholipid Ab, which cause prolongation of clotting in vitro
 APTT: use reagents with low phospholipid content, look for slowing
o Mixing studies to follow up (won’t correct; Ab will still neutralize PLs)

 Dilute Russell viper venom time (dRVVT)

o Directly activates factor X in common pathway (DIC after a snake bite!)
o Reaction & subsequent ones are phospholipid dependent; sensitive to anti-PL Abs
o Anything reducing X, V, prothrombin, fibrinogen would also slow test
 Mixing studies to follow up (won’t correct if inhibitor like antiphospholipid Ab present but will if
due to warfarin, vitamin K deficiency, etc. – normal pt plasma will have enough X, V, etc around)
 Add purified phospholipids and repeat dRVVT: will correct (tons of PLs, bind all the antibodies,
still have PLs around for reaction to take place)

Hyperhomocysteinemia
 Skipped over mostly in lecture; importance diminishing in
recent years
 Acquired/congenital cause for both arterial & venous
thrombosis
 Deficiencies of folate / B12 / B5 result in
hyperhomocysteinemia; mutations too
 Risk increased for venous thrombosis and myocardial
infarction
 High homocysteine  tissue factor expression +
endothelial damage; renal failure can result
 need folate / B12 supplementation

Disseminated Intravascular Coagulation (DIC)

 Acquired coagulation disorder DIC: Associated with…
 Trauma
Pathophysiology
 Sepsis
 excessive activation of clotting cascade  widespread microvascular thrombosis
 Snakebites
 consumption of clotting factors, platelets, endogenous anticoagulant
 Tumors
proteins & activation of fibrinolytic system bleeding
 Amniotic fluid emboli
 Common start: release of activators of coagulation (tissue factor / thrombin /
other activated serine proteases)

27
Plasmin working like crazy (fibrinolytic system)
 digests fibrin clots into D-dimers (fragments)
 Can use ELISA to detect D-dimers in plasma (good in diagnosis)

Tx by detecting & correcting cause

DIC: Levels
 ↑D-dimers (plasmin!)
 ↑APTT/PT (used up all your clotting stuff!)
 ↓platelets
 ↓fibrinogen

Hemostasis: the whole big, ugly picture

28
 Pharmacology: Hematology
Heme Pharm I: Platelet Drugs & EPO...................................................................................................................................... 2
Heme Pharm II: Heparins, Coumarins, Thrombolytics, Procoagulants ................................................................................... 5
 Heme Pharm I: Platelet Drugs & EPO

Note that platelet inhibitors are used

PROPHYLACTICALLY ONLY (they have NO
EFFECT on a formed thrombus)

Aspirin (acetyl salicylic acid): the antiplatelet drug supreme! Safe, cheap, effective
aspirin Mechanism of Action: antiplatelet agent (and anti-inflammatory too).
 Covalently inhibits cyclooxygenase (which produces thromboxane A2 in platelets)
Effects:
 inhibits thromboxane-A2-mediated platelet aggregation & vasoconstriction (aspirin --&gt; vasodilation).
 Inhibition is long-lived (platelets don't synthesize new protein; have to wait for new platelets to be made)
Administration:
 Dose to inhibit platelet cyclooxygenase (160mg) is less than dose for anti-inflammatory / antipyretic effects.
 More than 320mg is counterproductive (can block formation of PGI2 / prostacyclin, a natural inhibitor of
platelet aggregation)
Other: Safe, effective, and really cost-effective (cheap!)

Dipyridamole
dipyridamole Mechanism of Action: antiplatelet agent with dual mechanisms, both leading to increased cAMP:
 inhibits cyclic nucleotide phosphodiesterase
 inhibits nucleoside transport/uptake (stimulates adenylate cyclase)
Effects: increased intracellular cAMP inhibits platelet aggregation. (also has vasodilator properties)
Indications: combination treatment for prophylaxis of thrombosis / embolization
Administration: only proven effective in combination (warfarin or aspirin); does not prevent
embolization / thrombus by itself
Toxicity: headache & hypotension (esp. in high doses More than 320mg is counterproductive (can block
formation of PGI2 / prostacyclin, a natural inhibitor of platelet aggregation)
Other: Safe, effective, and really cost-effective (cheap!)
 Platelet Glycoprotein IIb/IIIa antagonists
 GP IIb/IIIa: receptor for fibrinogen; plays role in platelet activation ( platelet aggregation, adherence)
 3 kinds (antibody, small peptide, small molecule; don’t have to memorize names)
 All cause bleeding but DON’T appear to cause increased intercranial bleeding
 VERY EXPENSIVE ($1500-$2000/course) but may actually save money (prevent re-stenosis post-angioplasty,
prevent need for repeat angioplasty / CABG)

mAb: abciximab

mAb Mechanism of Action: antiplatelet agent. Blocks GPIIb/IIIa-mediated platelet aggregation

IIb/IIIa antagonist Indications: only anti-platelet mAB shown to have anti-thrombotic activity in humans
(abciximab) Administration:
 Always given with heparin & aspirin.
 Rapidly cleared (10m half life); give as large bolus then slow infusion (18-24h).
 Half-life of recovery of aggregation is 24h (Fabs remain on platelets & can redistribute to GPIIb/IIIa
on new platelets).
Toxicity:
 bleeding (2x vs heparin+aspirin alone)
 pseudothrombocytopenia (Ab-mediated platelet clumping)
Resistance: anti-murine antibodies (6.5% after 1 dose, very important - avoid giving a second time!)
Other:
 chimeric (mouse variable, human constant regions); only Fab portion used.
 Could use platelet transfusion to reverse side-effects if needed.

small peptide: eptifibatide

small peptide Mechanism of Action: antiplatelet agent. Blocks GPIIb/IIIa-mediated platelet aggregation by blocking
IIb/IIIa antagonist fibrinogen, vWF, vitronectin binding to IIb/IIIa
(eptifibatide) Effects: mimics AA sequences important for GPIIb/IIIa binding: (KGD mediates fibrinogen binding; RGD
mediates vWF binding)
Indications: anti-thrombotic
Administration:
 Given with aspirin + heparin.
 More slowly cleared than abciximab; still given as rapid large bolus + slow infusion for up to 72 hrs.
 Rapidly reversible effects (mediated by drug clearance from plasma).
Toxicity: bleeding (marginally increased vs heparin+aspirin alone), not immunogenic
Other: Elimitated via proteolysis to AA & urinary elimination of unchanged drug

small molecule: tirofiban

small molecule Mechanism of Action: antiplatelet agent.
IIb/IIIa antagonist  Blocks GPIIb/IIIa-mediated platelet aggregation by inhibiting fibrinogen binding to GPIIb/IIIa
(tirofiban) Effects: binds reversibly to IIb/IIIa receptor
Indications: anti-thrombotic
Administration: Give as large bolus then slow infusion (up to 108h).
Toxicity: bleeding (2x vs heparin+aspirin alone)
Other: Renal clearance (2h half-life); effects rapidly reversible (mediated by plasma clearance)
 ADP Antagonists
 Looking for better / more expensive aspirin
 Clopidogrel - “Plavix”, 2nd to market but maybe less toxic?

ticlopidine Mechanism of Action: antiplatelet agents; inhibit ADP-induced platelet aggregation

Effects:
clopidogrel  Bind irreversibly to low-affinity ADP receptors (non-competitive)
 Block ADP-mediated release of platelet alpha granules / dense granules
 Inhibit fibrinogen binding to activated platelets
 indirectly block activation of platelet glycoprotein IIb/IIIa receptor

Indications: Slightly better at preventing stroke in pts with TIAs than aspirin; can help prevent
coronary thrombosis

Administration: long-lived effects (ADP receptor blocked for life span of platelet; need to synthesize
new ones: 7-10d)

Toxicity:
 neutropenia (severe but reversible, ticlopidine 1%, clopidogrel 0.1%)
 bleeding, diarrhea, thrombocytopenia (TTP)

Other:
 CYP450 substrates - activity requires conversion to active metabolite (complicates
treatment, as activity varies from pt to pt);
 inhibit CYP 2C9.
 Clopidogrel = Plavix; thought to be less toxic than ticlopidine.
 Much more expensive than aspirin

Erythropoietin (EPO)

erythropoietin (EPO) Mechanism of Action: promotes erythropoiesis (hormone)

Effects:
1. binds EPO receptor on erythroid precursor cells
2. causes conformational change & activates Jak-STAT pathway (Jak-2 TK p-lates receptor,
recruits STAT-5, which gets p-lated & goes to nucleus as transcription factor)
3. induces red cell maturation gene expression.
4. Actually primarily BLOCKS APOPTOSIS of erythroid precursor cells.
Indications:
 anemia (chronic renal failure, cancer, AIDS)
 perioperatively (reduce transfusion)
 illicit (blood doping by athletes)
Administration: IV/sub-q, usually start at 80-120 U/kg 3x/wk; sustained effect after its
disappearance
Toxicity:
 aggravates hypertension
 potential increase in thrombosis risk
 theoretical neoplasm risk (cell growth factor - now a black box warming)
Other: 193-AA protein, 1st 23 AA cleaved off, then heavily glycosylated (recombinant form used)
 Heme Pharm II: Heparins, Coumarins, Thrombolytics, Procoagulants
Coagulation System Review
Intrinsic Extrinsic
Activated by Phospholipids, particulate matter (kaolin) Tissue Factor, phospholipids (thromboplastin)
– “intrinsic” to plasma – “extrinsic” to vessel lumen
Test Activated partial thromboplastin time (APTT) Prothrombin time (PT)
– used for heparin monitoring – used for warfarin monitoring

Endogenous mechanisms to prevent/control thrombosis

 Prostacyclin(PGI2): inhibits platelet aggregation  Heparan sulfate: endothelial cell surface
 Antithrombin: specific protease inhibitor (like α1 proteoglycan, like heparin  boosts antithrombin
antitrypsin); interferes with various factors (suicide  Protein C: + protein S, VaVi and VIIIa  VIIIi
substrate for serine proteases)

Indications for anticoagulant tx

Prevention:
 Heparins & coumarins prevent thrombus formation in lots of settings
 Antiplatelets for long-term prevention (esp. coronary / cerebral artery disease)

Treatment: Heparin (acute) and coumarin (chronic) therapy

 Prevent further thrombus formation
 Don’t act on already existing thrombi
 Used for: Arterial & venous thrombosis; artificial heart valve
thrombi, thrombi assoc. with atrial fibrillation

Dissolution: Thrombolytics (“clot busters”)

 Actively dissolve pathologic thrombi
 Used for: coronary arteries, peripheral arteries, large veins, venous caths
 Don’t prevent thrombus formation: follow with short-term anticoagulation (heparin, sometimes warfarin)

Heparin
A Hopkins-discovered drug, disputed discovery, abundant in liver.
Heparin = in mast cell secretory granules; heparan is endothelial cell surface molecule

Heparin
Mechanism of Action: Anticoagulant agent. Several mechanisms of action:
 Boosts antithrombin activity
 inhibits intrinsic >>>; extrinsic pathways (APTT primarily prolonged).
 At high concentrations:
o Interfere with platelet aggregation
o Activate heparin cofactor II (antithrombin homolog, thrombin-specific)
heparin
Indications: Prevention & treatment (acute) of thrombosis, but don't dissolve clots (prevent new ones from
forming)
Administration:
 1 unit = amt heparin needed to prevent 1.0 mL plasma from clotting 1 hour after adding calcium chloride
(variable MW/size; only 30% of molecules have antithrombin-binding-site, so dose by activity).
 Continuous / intermittent infusions & sub-q injections
 Toxicity:
 Bleeding (often inadequte therapeutic monitoring, more common in elderly, worry about intercranial
bleeding.
 Thrombocytopenia (mild is common; severe less frequently & 7-14d post tx initiation, always
reversible with discontinuation)
 Paradoxical thrombosis / white clot syndrome (uncommon), reversible alopecia
 OSTEOPOROSIS (very important, lots of elderly pts)
Reversal of toxicity:
 STOP THERAPY
 Can give protamine (positively charged low molecular weight proteins from fish sperm; give equimolar amount
to titrate out heparin, only if life-threatening b/c can induce hypotension/anaphylaxis/hypercoagulation.
Diabetics who take insulin with protamine are more prone to anaphylaxis: may already have anti-protamine Ab)

Pharmacokinetics: complex & unusual.

 Vd: confined to plasma (high MW, neg charge)
 not orally bioavailable
 clearance is NON-LINEAR (dose-dependent), cleared via RES, longer infusions can diminish clearance
 therapeutic monitoring needed to reach target APTT (1.5-2x)

Other: naturally occuring, polymer of D-glucosamine/D-glucoronic acid. Found in mast cell secretory granules
but natural function unknown; sulfation/molecular weight variable; prepared from bovine lung/porcine
intestinal mucosa

LMW Heparin
Low molecular Mechanism of Action: Anticoagulant agent. inhibit Factor Xa but not thrombin.
weight heparins  still bind to antithrombin III
 do not prolong APTT but work as well clinically.
(enoxaparin,
dalteparin, ardeparin) Indications:
 Prevention & treatment (acute) of thrombosis, but don't dissolve clots (prevent new ones forming).
& LMW hepanoid  At least as good as preventing DVT as heparin; probably equivalent in treating DVT
Administration: Dosed in mg instead of units; give sub-q.
(danaproid)
Toxicity: Bleeding (same as heparin); thrombocytopenia (maybe less frequently)
Pharmacokinetics: less frequent dosing than heparin (reduced binding to plasma proteins / platelets /
cells; increased bioavailability, longer half-life, dose-proportional / more normal PK, not non-linear like heparin)
Other: Preparation: depolymerization & size fractionation of HMW heparins; mixed species.
Way more expensive but popular (no therapeutic monitoring, given sub-q, a little easier to manage).

Coumarin Anticoagulants
Discovered in cattle; produced as rotenticide (still used as rat poison) by Wisconsin Alumni Research Foundation (=WARFarin), suicide attempts

ISI
PTpatient
INR = international normalized ratio =
PTreference

Enhanced oral anticoagulant activity

↓ vitamin K absorption
Displacement from plasma proteins
Inhibition of biotransformation
Inhibition of platelet aggregation
Decreased clotting factor production
Antibiotics, mineral oil, cholestyramine
Sailicylates, clofibrate, chloral hydrate
Allopurinal, metronidazole, chloramphenicol
Aspirin, dipyridamole
Quinidine

Depressed oral anticoagulant activity

Metabolizing enzyme induction Barbituates, glutethimide, griseofulvin
Increased clotting factor production Vitamin K, oral contraceptives
 Coumarins Mechanism of Action: Anticoagulant agent. Blocks reduction of Vit K by vitamin K reductases
Effects: Vitamin K required for factor II, VII, IX, X (and proteins C&S) to have gamma-carboxylated
(warfarin sodium / glutamic acid residues, which help bind Ca++ and PLs on platelets to enhance clotting.
coumadin, 1. decreases synthesis of vitamin K-dependent factors (30-50%)
dicumarol, etc.) 2. factors produced only have 10-40% of normal biologic activity

Indications: Prevention & treatment (chronic) of thrombosis, but don't dissolve clots (prevent new
ones from forming)

Administration:
 therapeutic monitoring with PT (1.2-1.5x normal); INR widely used now.
 LONG HALF LIFE + INVOLVEMENT OF CLOTTING FACTORS = LONG TIME TO STEADY STATE. Adjust
dose only q48-72h and escalate conservatively
Resistance: occurs but is rare

Toxicity & Reversal: less toxicity with lower levels of anticoagulation (and equal efficacy).
 Bleeding: reverse with:
o FFP to replace coagulation factors (first line for acute bleeding) or
o Vitamin K in high doses (some reductases can bypass if enough vit K around; takes longer -
24h, have to wait for synthesis of new factors; effect lasts for days so use only if serious,
might have to substitute heparin for 7-10d after high-dose vitamin K)
 Skin necrosis: from Protein C inhibition  necrotic infarction, watch out for protein C-deficient
pts.
 Alopecia
 TERATOGENICITY: esp 1st trimester, nasal hypoplasia / stippled epiphyseal calcifications /
abortion / neonatal hemorrhage. STRICTLY CONTRAINDICATED IN PREGNANCY (heparin safer).

Drug interactions: VERY IMPORTANT. See chart above

Pharmacokinetics:
 Nearly complete absorption,
 99% bound to plasma protein (albumin),
 metabolism to inactive metabolites by hydroxylation (hepatic) is variable in population,
genetically determined; half-life of ~40h.
 Time course of antithrombotic effect is different than plasma concentration (circulating half-
lives of factors, which have to be re-synthesized: II > IX/X > VII for half-life, so VII recovered
first and thrombin last)

Other: Has an asymmetric carbon (racemic mixture, the enantiomers have different potency /
metabolism)

Thrombolytics

Fibrinolytic system: zymogen cascade; breaks down fibrin (remodel/trim thrombus)

 plasmin (activated from plasminogen via plasminogen activator) is key actor
o binds fibrin via amino terminus (high lysine affinity)
o α2-antiplasmin also binds to plasmin at this site; so plasmin bound to fibrin escapes α2AP inhibition

 “lytic state” - Too much plasmin  digests physiologic thrombi; consumes plasma coag factors
o increases hemorrhage risk
o usually prevented by localization of plasminogen activator to endothelial cells & presence of α2AP in circulation

 Tissue plasminogen activator (tPA): released in response to hemodynamic indicators of thrombus formation
o Short half-life (3m); inactivated by circulating inhibitor (plasminogen activator inhibitor-1), preventing lytic state
o Controls can be overwhelmed by large doses of systemic thrombolytic drugs
Streptokinase: from β-hemolytic strep
streptokinase Mechanism of Action: Thrombolytic agent. Not a kinase / protease but binds to plasminogen, induces
conformational change, results in cleavage of arg-val bond & activation of enzyme (plasmin)

Indications: clot buster (helps digest pre-existing thrombi)

Administration: Need large loading dose to absorb pre-existing Abs; used to give intracoronary but probably
not much better. Get it in FAST!

Toxicity: Bleeding, allergic reactions, anaphylaxis, fever. VERY ANTIGENIC (don't give more than q6-12m)
Pharmacokinetics: Half life of about 80m after Abs absorbed
Other: All adults have pre-existing anti-SK antibodies (exposure to strep)

Urokinase
urokinase Mechanism of Action: Thrombolytic agent. Cleaves plasminogen to plasmin directly at arg-val bond (like TPA)
Effects: activity not localized at clot (can cause systemic fibrinolysis)

Indications: clot buster (helps digest pre-existing thrombi)

Toxicity: Bleeding, allergic reactions (less frequent than with streptokinase: skin rash, fever, bronchospasm)

Pharmacokinetics: Metabolized by liver, half life 15m

Other: Kind of like an early version of TPA

Recombinant Tissue Plasminogen Activator

rtPA Mechanism of Action: Thrombolytic agent. Recombinant serine protease;
Effects: Much tighter binding to fibrin-bound plasminogen than circulating free plasminogen (tPA has lysine
binding sites at amino terminus) so more active against bound plasminogen (less systemic activity, more
localized); can overwhelm control mechanism (serum concentrations 30-300x higher than physiologic [tPA])

Indications: clot buster (helps digest pre-existing thrombi)

Administration: IV bolus + short infusion (short half life, bleeding complications)

Toxicity: despite localization, can induce lytic state. Bleeding (more in elderly, intercranial is serious).
 Unique to rtPA:
1. Damages endothelial cell membranes \ increases circulating vWF;
2. mid-moderate thrombocytopenia (10% cases)

Pharmacokinetics: Metabolized by liver, identical halflife to tPA (3m)

Other: Most common thrombolytic agent in clinical use

Comparison of thrombolytics
Efficacy:
 All better than heparin for resolving pathologic thrombi t1/2 (m) Antigenic Cost
 More mature thrombus = less successful thrombolysis SK 80 Yes $200-250
UK 15 No $1,000-$1,500
 USE WITHIN 6h OF ACUTE MI
rtPA 3 No $2,000-$2,500
o rTPA faster onset than SK but outcome equivalent
 UK/rTPA have higher success than SK for thrombi in peripheral veins, arteries, indwelling caths

Toxicity: all have risk of bleeding, rTPA > SK for intercranial hemorrhage, data mixed on UK vs rtPA/SK
Bottom line: very similar, cost is big issue (consider SK 1st for low cost but don’t use repeatedly: antigenic)
 Procoagulant Drugs
 FFP and clotting factor concentrates are most widely used but not discussed here

ϵ-aminocaproic acid
(ϵ)-Aminocaproic acid Mechanism of Action: Procoagulant agent. Competitive inhibitor of plasmin/plasminogen binding
to fibrin
Effects: Interferes with fibrinolysis, maintaines hemostasis
Indications: Hematuria (excreted rapidly w/o change in urine). Has been hard to demonstrate
clear-cut benefit except in some settings (minor surgery in hemophiliacs)
Toxicity:
 Pathogenic thrombi (by inhibiting physiologic thrombolysis)
 rare myopathy & muscle necrosis
Pharmacokinetics: Excreted rapidly & unchanged in urine

Desmopressin
Desmopressin Mechanism of Action: Procoagulant agent.
 Promotes release of endogenous pools of clotting factors (factor VIII, vWF) into circulation
Indications:
 vWD
 mild hemophilia (VIII > 5-10% normal)
 severe hemophiliacs don't respond (not enough endogenous factor VIII)
Toxicity: electrolyte imbalances; fluid overload (ADH-type activity)
Other: analog of vasopressin (ADH)
 Pathology: The Heart
Overview of Cardiac Pathology ............................................................................................................................................... 2
Myocardial Infarction: (pathophysiology & pathology) .......................................................................................................... 5
Pathology of Heart Muscle Disease ...................................................................................................................................... 13
Pathology of Heart Valves ..................................................................................................................................................... 17
Artificial Valves...................................................................................................................................................................... 22

1
 Overview of Cardiac Pathology
Heart: two pumps PARTS OF THE HEART
1. bodyIVC/SVCRAtricuspid valve RV pulm valve  pulm artery  lungs (THAT GET DISEASE)
2. lungs pulm vein LAmitral valveLVaortic valveaortabody
1. coronary arteries*
2. valves
Coronary Arteries 3. conducting system
Normal Physiology 4. myocardium

2 main coronary arteries exit from aorta just above aortic valve (backflow pushes in) * most common
CA Major Branches Supplies
LAD: Left anterior descending LAD¨50% LV
Left main CA 70% LV
LCX: Left circumflex LCX: 20% / posterior LV
Right CA RV & 30% LV

Dominance: whoever gives rise to PDA (posterior descending) and PLA (posterior lateral) is “dominant”
 Right-dominant: RCA (70-80% hearts)
 Left-dominant: LCA (10%)
 Co-dominant: shared (10-20%)

Venous drainage via bunch of veins into great cardiac vein

Coronary Artery Disease

 Most common disease of heart
o 13.7M Americans, M>F, ↑ with older populations

“Atherosclerotic changes in arteries affecting blood flow to myocardium”

TX: SEVERE STENOSIS
 Narrowing of CA = CAD  ↓ oxygen, nutrients  ischemia 1. stents to open up
o Angina & sudden death (massive MI) can result the lumen wider
2. CABG (saphenous
If sudden (thromboembolus trapped in CA or dissection)  MI vein or internal
 ↓Blood flow distal to blockages mammary
 Which CA tells you where infarction happens (& vice versa) arteries) to bring
blood distal to
If gradual narrowing: blockage
 Collateral circulation can develop
 Compensatory Enlargement: vessel gets bigger to keep lumen size the
same (up to 40-50% obstruction!)

Heart Valves
Normal Physiology
 Tricuspid(RA/RV)
 Pulmonic (RV/PA)
 Mitral (LA/LV, 2 leaflets, others 3)
 Aortic (LV/aorta)

Valve  chordae tendinae to papillary mm, etc.

Thin, mobile pieces of tissue

2
Valvular Disease
 Congenital (e.g. bicuspid aortic valve, most common, in 1-2% population) and acquired
 Most significant disease is LEFT SIDE (mitral /aortic)

Stenosis: thickening and calcification of valve

 Calcification/degenerative aortic stenosis most common in elderly (also HTN, smoking, males)
 Mitral stenosis often from rheumatic fever (young people!)

Regurgitation: blood flows in reverse through incompetent valve (aortic root dilation, floppy mitral valve changes)

Endocarditis: non-infectious or infectious (bacterial/fungal); plaques & vegetations can cause 2 problems:
 impact valve function
 risk to embolize (block artery  stroke) & seed infection

Tx by replacement
 mechanical: bileaflet used more often today; last longer but have to use antiplatelet drugs
 bioprosthetic: e.g. part porcine or bovine; don’t last as long but no anticoagulant therapy needed

Conducting System

Normal Physiology

SA Node  AV Node  bundle of His  Purkinje fibers

 SA & AV nodes are specialized myocardium
 Can use artery to SA node as clue to ID on path

Arrythmias (conducting system disease)

 Electrical conductance disturbance in heart
o E.g. Atrial fib, ventricular fib, blocks (blockage of electrical pulse)
 Can be benign or rapidly fatal
Tx:
 Pacemaker: electrical stim; pace the heart
 Automatic implantable cardioverter/defibrillator (AICD): electrical jolt ends arrhythmia; back to normal rhythm

Myocardium
Normal Physiology Dimensions
Heart weight F: 200-300 g
 Myocytes need lots of nutrients M: 230-420 g
 Endocardium: endothelial cells LV thickness 1.0-1.4 cm
RV thickness 0.3-0.5 cm

Myocardial Disease: Cardiomyopathies, Myocarditis, Ischemic Injury

Cardiomyopathies: 5 types, many are familial / genetic

 Dilated CM is most common (wide LV, can’t squeeze it closed
enough, turbulent flow  thrombus possibility)
 Hypertrophic CM: see myocyte disarray on path; often genetic (thick walls, esp. septum)
 Restrictive CM: usually secondary to infiltrative process (amyloid, sarcoidosis), more rare

3
Myocarditis: most often after viral infection (coxsackie B virus);
 can also be parasitic (Chagas dz; not in USA) or idiopathic (Giant
cell; deadly)
 Results in poor contractility (lower ejection fraction)
 Paradoxical outcome: typical myocarditis  often have
sequelae; fulminant myocarditis  often do very well

Myocardial infarctions: result from ischemic injury to he heart

 Often secondary to CA occlusion; more rarely general
hypotension or anemia
 Myocytes die: lack of oxygen & nutrient supply
o Acute: sudden death of myocytes; replaced with yellow
pus / PMNs, then Mϕ  Heals, collagen scar forms, Cardiomyopathies
other side thickens to compensate
 Histology: see contraction bands from post-infusion reperfusion injury; big scar / fibroblasts lay down collagen

Cardiac transplant
Used in treatment of heart failure (secondary to many of these processes)
 If heart can’t pump blood to lungs/body effectively Cardiac Transplant Facts
 Indications: Heart failure with marked
Failure of transplanted hearts: limitations or bed rest (NYHA class III/IV)
 Often from transplant vasculopathy (coronary vessels narrowed)  10-20/yr at JHH
o different from atherosclerotic CA dz: diffuse process / no  50% chance of 10 yr survival
way to do bypass  Most transplant failures due to:
o Rejection (short-term)
o Transplant vasculopathy (long-term)

Remember that all of these processes work together!

 Concurrent CA dz & calcific aortic stenosis (share risk factors)
 Can cause one another secondarily (examples):
o Aortic stenosis  increased LV pressure  2° hypertrophy of ventricular wall
o Recover from MI  thin scar where myocardium was  2° dilation (dilated cardiomyopathy)
o MI  arrhythmia (destroy part of conducting system) + valvular dz (papillary mm injured)

4
 Myocardial Infarction: (pathophysiology & pathology)

ISCHEMIA
 Temporary imbalance: myocardial O2 supply & demands
 Complete reversibility of derangements
o cell metabolism, electrical, contractile
 “stunned myocardium”, full recovery can take weeks
INFARCTION
 Happens when ischemia is severe enough and for long enough time
 Myocyte death
 Irreversible derangements (cellular, electrical, contractile)

TIME IS MUSCLE: the amount of salvageable myocardium ↓ rapidly after occlusion!

Pathophysiology of “acute coronary syndromes”: KNOW THIS

1. Rupture of “vulnerable” atherosclerotic plaque
2. Exposure of subendothelial matrix
3. Platelet adhesion / activation / aggregation
4. Intraluminal thrombus
5. Total or subtotal occlusion

WHAT PREDISPOSES A PLAQUE TO RUPTURE?

INTRINSIC PROPERTIES OF LESION
 Large, soft atheromatous core
 Thin fibrous cap (especially “shoulder”)
 Cap inflammation (activated Mϕ)
 Most often MILD-MODERATE severity/stenosis
EXTRINSIC TRIGGERS
 Circumferential wall stress (HTN)
 Sympathetic surge (↑MI in morning, winter with
shoveling, emotional stress, vigorous exercise)
 Thrombotic risk factors

Approach to the Patient with Ischemic Discomfort

Vast majority of patients with acute coronary syndrome present with chest pressure / pain

Workup: Working Dx  ECG, look for cardiac biomarkers  final Dx

 ST depression:Unstable Angina, Non-ST-elevation MI (NSTEMI)
 ST Elevation MI: most emergent (others urgent too)
o Represents acute total CA occlusion
 Looking at anterior leads (V2-V4)

Anterior ST segment elevation Anterior ST segment depression

Unstable Angina (no biomarkers)
STEMI (biomarkers present)
NSTEMI (biomarkers present)

Etiologies of MI
 Coronary thrombosis: the primary cause of MI
 Coronary artery embolus: most often from heart
 Coronary vasospasm (Prinzmetal’s angina): vasoconstriction, will totally resolve with nitrates to vasodilate!
 Ao Dxn (with coronary artery obstruction)
 Coronary arteritis (inflammation)
 Congenital coronary artery anomalies
 Severe, prolonged hypotension

5
 Pathology of MI
 Yellowish eccentric atherosclerotic plaque; can still have big lumen with no symptoms

Thrombosis:
 Superficial thrombosis with endothelial erosion (turbulence & exposed substrate for
thrombosis; thrombus forms on surface of lumen)
 Deep thrombosis with plaque disruption (rupture of plaque, blood hemorrhages
underneath to find substrate; plaque disrupted & pushes cap out into lumen)
 Some can do both (push up from underneath & thrombus forms on surface as well)

The longitudinal view

 Downstream from plaque is where blockage often occurs
 Thrombus forms after plaque (where turbulence is)
 Cholesterol deposits there too (swept downstream)

Ischemic Heart Disease: Reversible & Irreversible Injury

 If you reperfuse within 15m in animal studies: all reversible

 After that, longer occlusion  less reversal (bigger infarct) METABOLIC EFFECTS OF MYOCARDIAL ISCHEMIA
 ↓ O2 and substrate delivery
Impaired O2 / Substrate Delivery  ↓ removal of endproducts
 Can’t generate ATP via ox-phos  switch to anaerobic glycolysis  Electrolyte imbalances
 Glycogen gets used up
 Creatine phosphate (CP) and ATP fall (ATP used up, then CP gives up its phosphates to ATP)  PPi increases

Decreased Removal of Endproducts This process is really fast

 Lactate accumulation Big changes in first few seconds!
 Decreased intracellular pH: lactic acid ↑  CP drops first; ATP more slowly
(CP replenishes ATP at first)
Functional manifestations of ischemia  Lactate rises over next few hours
 ATP is about 2/3 gone at 15 min
 Rapid loss of contractility
(point of irreversible change – so
 Contractile dysfunction persists during you can lose a lot of ATP and still
reperfusion; slowly reversible (“stunning”) reverse changes)
 If only part of heart is affected: can see a loss of
segment shortening (“shortening” actually goes negative during systole - expansion!)
o Means that that part of heart is bulging out because of the pressure the rest of the heart’s generating
o Gradually restored over next few days (slow)

Electrolyte imbalances: stuff flows down its gradient

 K+ flows out (decreased membrane potential)
 Na+ flows in (↑[Na+]in)
 Ca+2 flows in (↑[Ca+2]in)

Notes on the picture to the right: remember ↓ATP


+2
Can’t sequester Ca in SR: no ATP!
 Can’t maintain Na/K gradients (no ATP for Na/K ATPase)
 Lactic acid building up inside: more H+ inside, so more Na co-
transported in to get rid of the H (further disruption)
 Normally Ca influx triggers release from SR on each beat; this
whole process is now disrupted because of these imbalance

6
  pH↓ with time (lactic acid building up)
 K+↑ (efflux from cells), then plateaus
o then ↑ again (cells starting to die, release more K+)

Cells start to swell:

 Na+ flows in, Cl- comes along, H2O follows
 Tissue osmolality ↑ (catabolism within ischemic cells  ↑ # stuff)

Morphologic changes in myocardial ischemia:

histological changes subtle, not too useful, cell swelling & chromatin margination but not useful or reliable for diagnosis)

Ischemic Heart Disease (reversible  irreversible injury / MI)

Earliest morphologic changes best on electron microscopy

 look for cell death (blebbing of sarcolemma, disruption of plasma membrane)
 Cytoskeletal damage: disruption of attachment complexes between Z-bands and plasma membranes
o PMs lift up off of Z-bands & form vesicles
 Mitochondrial changes: “amorphous matrix densities” (black blobs in mito) & calcium deposits (donut shaped)

Reperfusion: contraction-band necrosis

 At edge of infarcts or where they’ve been reperfused
 Ischemic myocytes that just made transition to irreversible injury
o Hypercontract when re-exposed to oxygen
o Calcium rises, cell contracts but can’t relapse
o Form contraction bands (proteins of lots of sarcomeres
compacted into single bands)

Dx of MI
1. Symptoms:
 “Typical” chest pain (substernal  neck/jaw, etc, worse on
exercise, etc., etc.)
 Also syncope, dyspnea, orthopnea (SOB on laying down), cough

2. EKG changes: ST elevation or depression

3. Release of cardiac-specific proteins

 Creatine kinase (CK, MB is myocardial-specific isotype)
 Troponin I or T (TnI/TnT; depends on hospital)

 TIME COURSE OF CHANGES (important!)

Note that liver enzymes (LDH / AST) can also rise in MI

(nonspecific for MI, but if you see it, don’t assume pt’s liver is bad)

7
  Total CK and CK-MB peak early (first 48 hrs)
o draw multiple times early in hosp to capture

 Troponin takes longer to return to normal

 If you REPERFUSE, enzymes PEAK HIGHER AND EARLIER

Anatomy of Myocardial Infarction

CA INFARCT COMPLICATIONS
 Shock
 Anterior
LAD  BBB
 Septum
 VSD
Posterior papillary
LCX Lateral
muscle rupture  MR
 Posterior papillary
 Inferior
muscle rupture  MR
Right  Right
 AV block
Ventricle
 VSD

BBB=bundle branch block, VSD = ventral septal defect, MR =

mitral regurgitation, LAD = left anterior descending,
LCX = left circumflex

Anatomy & Prognosis

Prognosis is inversely related to infarct size
 Bigger infarct: ↑ arrhythmias, ↑ hemodynamic complications, ↑ short-term mortality
 Cardiogenic shock: associated with > 30% LV infarction

What determines MI Size?

 Duration of coronary occlusion
 Size of territory that CA supplies (LAD = “widowmaker”)
 Presence / absence of collaterals
 Myocardial oxygen demands (↑HR, BP, contractility can make MI larger!)

Collaterals:
 normally not too many / tiny in everybody
o if you have gradual stenosis of CA (e.g. long-term angina) you can develop collaterals (protective!)
o Can have virtually complete occlusion with collateral: but occlude second artery  massive MI
 Collateral flow highest in outer layer of myocardium
o If enough collateral flow: won’t get a transmural infarct regardless of duration!

8
 Morphologic Stages of MI (Inflammatory Response & Repair)

RESPONSE & REPAIR (WITHOUT REPERFUSION)

0-6 hrs No changes (gross/microscopic)
Endocardium on right, then intact myocytes
(oxygen can diffuse in to a limited extent), and
Coagulative necrosis starts then necrotic, hypereosinophilic region of
6-24 hrs  Cytoplasmic eosinophilia myocytes (where the vessels are); karyolitic +
 Nuclear karyolysis (no nuclei!) maybe starting to see some PMNs in blood
vessel

Anucleate myocytes (karyolysis) with tons of

PMNs
acute inflammatory response (+ coagulative necrosis)
1-4 days
 Lots of PMNs  die & disintegrate by 3-4d

5-7 days Mϕ activity: clean up dead myocytes & PMNs

Right side have nuclei (OK); granulation tissue
forming in middle, cells on left side are dead /
Granulation tissue around rim karyolitic. Blood vessels start to form (tons of
7-10 days capillaries in middle granulation area).
(fibroblasts  collagen, PMNs, capillary formation)

1-6 wks Organization of infarct

1-3 mo Collagen deposition (scar)

Aneurysmal Thinning: when a scar forms after a transmural infarct, the previously infracted
area can become very thin: predispose to aneurysm in that area

Reperfusion: speeds things up

 Accelerates disintegration of irreversibly-injured myocytes (contraction-band necrosis)
 Can accentuate hemorrhage into areas of microvascular injury (hemorrhagic infarct)
 May or may not cause lethal reperfusion injury
 Limits size of MI
 Supports slow metabolic and contractile recovery of viable myocytes

Reperfusion Therapy:
1. Thrombolytics
2. Mechanical (Stent and/or balloon angioplasty, usually both) reperfusion

9
Remember: TIME IS MUSCLE with reperfusion therapy
 Wait 0-1 hours: save 35 extra lives per 1000 patients
 Wait 2-3h: save 25
 Wait 13-24h: only save 5 (big drop)

Consequences of Acute Myocardial Infarction

1. L/R ventricular dysfunction
2. Mural thrombosis  systemic embolism Morbidity & Mortality of MI
3. Arrythmias (mess up wiring)  In-hospital mortality: 7%
4. Mechanical complications (rarer but most feared)  One year mortality: 35%
a) Free wall rupture (hemopericardium; burst through wall  Arrythmias = 40-50% deaths
of heart  blood into pericardium)  Pump failure = 40-45% deaths
b) Papillary muscle rupture  mitral regurgitation o Cardiogenic shock
o CHF (20% of pts who survive MI)
c) Septal rupture  VSD

Killip class: can be used to grade (no heart failure = I, cardiogenic shock = IV): worse outcome with ↑ class

Mural thrombus
LV aneuyrism & thrombus: need a large transmural infarct
1. Infarct thins, elongates (expansion)  LV volume ↑, EF↓, heart failure
2. LV remodeling can be prevented (reduce infarction size, restore patency, reduce afterload with ACE inhibitors)
3. Can be nidus for thrombus formation (dilation  stasis)  embolization

Arrhythmias
Arrythmia Characteristics Treatment
Ventricular premature beats (VPBs) Common None
Accelerated idioventricular rhythm (AIVRs) Common with reperfusion None
Ventricular tachycardia / fibrillation (VT/VF) Cause of sudden death Shock
Drugs
Block 1,2,3°, can be permanent or temporary ± Pacer

Mechanical complications
1. Free wall rupture (hemopericardium; burst through wall of heart  blood into pericardium)
a. Usually fatal: hemopericardium + cardiac tamponade
b. Rarely: leads to pseudoaneurysm
i. Rupture contained by adherent pericardium
ii. See narrow neck / wide body aneuyrism on echo / acth
Treatment of Acute MR
iii. Need urgent cadiac surgery
 Aggressive use of diuretics & inotropes
 Vasodilator therapy
2. Papillary muscle rupture  mitral regurgitation  Intraaortic balloon counterpulsation
a. Can occur with either ST or non-ST segment elevation MI (balloon pump)
b. Usually an inferior MI (posteromedial papillary muscle  Emergent cath to
supplied only by RCA; anterolateral has dual supply) o Confirm dx
c. Causes pulmonary congestion ± hypotension; can o Define anatomy
sometimes be heard as MR (systolic murmur at apex)  Repair/replace with immediate surgery

10
 Treatment of VSD (a lot like MR Tx)
3. Septal rupture  VSD, blood flows back into RV instead of aorta  Aggressive use of diuretics & inotropes
a. Anteroseptal or inferior MI  Vasodilator therapy
b. Frequently at first MI (no collaterals)  Intraaortic balloon counterpulsation
c. Causes pulmonary congestion ± hypotension (balloon pump)
d. ± systolic murmur + thrill at L. sternal border)  Emergent cath to
o Confirm dx
o Visualize VSD
o Define anatomy
 Fix with immediate surgery

Balloon pump (intraaortic balloon counterpulsation)

 Insert through femoral artery, snake up aorta.
 Inflate during diastole, relax on systole
o Increases perfusion through CA (push blood out by increasing backpressure against Ao valve)
o Increases blood flow out to other tissues too

11
12
 Pathology of Heart Muscle Disease
Myocarditis
Key feature: Myocarditis Leukocytes Why?
Type of WBC helps you ID the etiology Chagas Dz / T. cruzi T-cell rich mononuclear Intracellular parasite
Coxsackievirus B3 Lymphocitic Virus (or autoimmune after)
Myocarditis: leukocytic infiltration of Rheumatic fever Anitschkow cells Autoimmune post-strep
heart muscle associated with myocyte (weird histiocytes) (won’t see PMNs, etc)
necrosis. (Aschoff bodies too)
Fungal No WBC Seen in immunocompromised pts
(Generally excludes MI-related inflammation) Drugs (cocaine, etc) Eosinophils Hypersensitivity
Various causes: idiopathic, infectious - hypersensitivity
(parasitic, viral, bacterial, fungal),
rheumatic fever (infectious  autoimmune), drugs Clinical features of myocarditis
• Acute presentation:
heart failure, arrhythmia or death
Infectious Myocarditis • ↑ ESR
• Leukocytosis
Chagas’ Disease (trypanosoma cruzi): parasitic • ↓LV function with ↓ EF
 South America: transmitted by reduvid bug
 16-18M infected; 3M have Chagas’ dz of heart Pathologic findings
• Pale, flabby hearts
 See T-cell-rich mononuclear cell infiltrate: parasite • WBC infiltrate + myocyte necrosis
takes over cytoplasm (by definition)
• WBC infiltrate: may be patchy
Coxsackievirus: picornavirus, fecal-oral or resp trans
 Most common cause in USA
 Coxsackievirus B3 is #1
 Biphasic course:
o initially URI / GI illness; sensitization of immune system
o 7-14d later myocarditis (but virus no longer detectable –
IMMUNOLOGIC RESPONSE is to blame)
 Lymphocitic infiltrate + myocyte necrosis

Why does Coxsackie B3 myocarditis happen? Various theories (may all play a role)
1. Immune system overdoes it while trying to kill virally-infected cardiomyocytes
o Lots of proinflammatory cytokines; persistent infiltration (can be detrimental to remote heart areas too)
2. Autoimmune-mediated destruction (molecular mimicry / similar host-viral epitopes)
o May be immune response against self-antigens, or
o maybe virus injures cells, exposing normally hidden antigenic epitopes to immune system (not recognized as “self”)
3. Direct virus-induced cardiomyocyte injury
In any case immune system is key: immunosuppressive therapy can be used to treat viral myocarditis!

Rheumatic Fever:
 Acute, recurrent, multisystem inflammatory disease
 Autoimmune complication: 1-5 wks post-infection with group A strep (pharyngitis)
o (common epitope with cardiac myosin M protein; Ab formed)
o Treat strep pharyngitis to prevent it!
Path features:
 Aschoff bodies (perivascular round / oval foci of fibrinoid necrosis surrounded by lymphocytes and Mϕ)
 Anitschkow cells: weird looking (like little caterpillers) – modified histiocytes

13
Fungal myocarditis
 Rare; generally seen in immunocompromised pts
 Aspergillus and cryptococcal infection (candida too)
 NO WBC (because of patient – immunosuppresed!)

L to R in picture: Aspergillus (branching septate hyphae), Candida (yeast &

hyphae), Cryptococcus (capsule)

Hypersensitivity myocarditis
 Various drugs (incl cocaine, e.g. Len Bias)

 EOSINOPHILS predominante: intense infiltrate of cells with bilobed

nuclei & eosinophilic granulated cytoplasm (L picture)

 Cocaine: 14% Americans >12yo have tried at least once!

o Sudden death, myocarditis
o Contraction band necrosis in isolated cells (diffuse in
reperfusion post-MI) (R picture)
 (maybe via microvascular spasm? Cocaine prevents
NE reuptake)

Giant cell myocarditis

 FULMINANT disease
 Serpiginous (snake-like) areas of necrosis;
 Big, multinucleated giant cells at margins
 Contrast to sarcoid: other organs free of granulomatous
inflammation

Cardiomyopathies
Pathology doesn’t help in determining etiology, but genetics can help with prognostication
Dilated Cardiomyopathy:
Clinical features of DCM
 Big, flabby, hypocontracting hearts • Chronic progressive heart failure with ↓LVEF
 Boxcar nuclei (hypertrophy of myocytes themselves) • Arrhythmia, embolic episodes
• Mitral/ tricuspid regurgitation
Presentations • CXR: cardiac enlargement and pulmonary
vascular congestion
Alcoholic cardiomyopathy:
ETOH & acetaldehyde Pathologic findings of DCM
interfere with calcium • Biventricular hypertrophy & 4-chamber
transport; relationship to dilation
cardiomyopathy unknown • Mural thrombi
• Myocyte hypertrophy
Beer drinkers’ • Interstitial fibrosis
cardiomyopathy (Canadians
put cobalt in beer to stabilize head, toxic to heart)
14
Peripartum cardiomyopathy:
 onset of CHF in 3rd trimester or 1st 6 mo post-partum
 Risks: multiparity, eclampsia, twins, mom > 30yo, poor nutrition, exact etiology unknown, non-specific biopsy
 Outcome: about 50% pts have heart return to normal size within 6 mo

Andriamycin (doxorubicin) cardiomyopathy

 Intercalating chemotherapeutic agent (anthracycline)
 Dose-related injury; degeneration begins before any clinical abnormality
seen; need to FOLLOW PT with biopsy!
 Classic finding: DILATED SMOOTH ENDOPLASMIC RETICULUM
o (only cardiomyopathy where pathology helps determine
etiology)

Inherited cardiomyopathies: need to take a good FHx‼

 Lamin A/C mutations (one example)
o Type IV IF proteins (between inner nuclear membrane & chromatin)
o Regulate nuclear shape / transcriptional regulation
o Inherited Lamin A/C mutations = 5.9% of all cases of dilated cardiomyopathy!
 (esp. pts with conduction system disease)
o Correlate with survival: worse prognosis!

Hypertrophic Cardiomyopathy:
Clinical features of HCM
 Heavy hypercontracting hearts  Exertional angina
 Dyspnea, fatigue, syncope
 Wide septum (top), myocytes in  Sudden death
disarray (bottom)
Pathologic findings of HCM
 Classic: young athletes! • Asymmetric septal hypertrophy
• Catenoidal configuration to the septum
Genetic mutations are important in HCM • Disarray of the myoctyes
(like in DCM) • Systolic anterior motion of the
anterior leaflet of the mitral valve
β -myosin heavy chain gene • Endomyocardial plaque on the
 1/3 of all HCM outflow tract of the left ventricle
 50% families with HCM have (where MV anterior leaflet keeps
identifiable mutation (can make in bumping against it)
all family members)
 Mutations that change charge of altered AA have shorter survival
 Good prognostic indicator: test family members; take precautions or treat before sudden death occurs

Restrictive Cardiomyopathy:
 LV contracts normally but rigid (ventricle filling is impaired)
 Very rare
 Endomyocardial fibrosis in Africa (fibrosis of ventricular endocardium);
 Lofler’s syndrome (myocyte necrosis + eosinophilic infiltrate)
 Note fibrous ring around LV; RV hypertrophy

15
 Infiltrative processes

Amyloid
 Various proteins can be the cause; deposited in tissues & form β-pleated sheets abnormally
 Immunocyte-derived disease (AL): from light chains (from plasma cell disorders!)
 Senile cardiac amyloid: from transthyretin (prealbumin)

Path findings:
 heart is enlarged & firm
 amorphous eosinophilic hyaline deposits in blood vessels / within
interstitium
 stain with Congo red (see picture to right; would see greenish
bands if polarized)

Others:
 hemochromotosis: can get iron deposits in heart
 glycogen storage disease: congenital; myocytes filled with glycogen

Heart transplants
Remember autograft / isograft / allograft / xenograft (diagram)
 Xenograft: risk of transmission of new disease to humans!

Heart transplants: most often performed for CARDIOMYOPATHIES

 ABO match donor / recipient
 5 year survival: > 60%
 Anastamosis of PA, aorta, atria (don’t want to mess with thin
pulmonary veins)
 Immunosuppression afterwards (but can lead to fungal, cryptococcal,
viral infection, etc)

Rejection: by the time it’s clinically apparent, irreversible damage may have
been done to the myocardium – use heart biopsy to detect before Sx start!
 If you see myocarditis starting (e.g. lymphs) – titrate your
immunosuppresion!

Accelerated graft arteriosclerosis is a problem too (after initial complications of rejection, still 50% lose heart by 13yrs)
 diffuse, concentric process, not a localized eccentric plaque like normal atherosclerosis
 Can’t treat with CABG or stent (because it’s not just in one place)

Endomyocardial biopsy
 Allows histologic diagnosis of myocarditis in living patients!
 Serial biopsys  can document natural history of cardiac disease
 Can improve therapy: better response by titrating doses, etc.

16
 Pathology of Heart Valves
Normal Valves

Embryology (gasp!) of valve development

 (pulmonic + aortic) and (mitral / tricuspid) start out together
(outflow tracts & AV valves grouped)
 PV/Ao rotate, then both split
 Who cares? Can see defects sometimes in how they segregate & separate
Most severe disease: LEFT SIDE (Ao & MV)

Semi-lunar valves (aortic & pulmonic) – far right, upper

 Nodule of arantius = part of leaflet above line of closure; not a big deal if it
gets damaged (not involved in closing)
 Coronary orifices behind cusps of aortic valve (fill with backpressure
generated in diastole in aortic root)

Mitral valve: right

 2 leaflets (anterior & posterior), etc.

Tricuspid valve - far right, lower

 Chordae tendinae connecting to papillary
muscle, etc.

Normal histology:
 Bland & unremarkable (No
inflammatory cells or blood
vessels)
 Zona spongiosa, zona fibrosa,
zona ventricularis

Normal valve function: one way door

(blood goes in one way only)

17
 Stenotic Valve Disease
Stenosis: valve becomes rigid, obstructs blood flow
 Results in severe pressure gradient across the valve

Etiologies: see slide (right)

Aortic Stenosis
 Most common valve to be stenotic

Congenital bicuspid aortic valves (1-2% pop)

 Often stenotic @ 50-60 yo
 Have raphe in middle (valve cusps never separated)

Tricuspid Ao valves can calcify too (60-80yo)

 See big calcifications – obstruct opening
 Histology: see calcifications, no acute inflammation

Bicuspid aortic valve (raphe at top) Calcified tricuspid aortic valve

2 2
Normal valve: 3-4cm , critical stenosis at 0.75 cm

Mitral Stenosis
Post-Rheumatic fever almost exclusively (don’t see too much anymore in US)

Acute rheumatic fever

 Group A strep pharyngitis  rheumatic fever 4-6wks later
o Acute pancarditis (murmurs, rubs, long PR interval)
o Vegetations (gross)
o Aschoff bodies on histology 
(granuloma-type structures with multinucleated cells)

Chronic rheumatic valve disease

 Sequelae of ARF 
 mitral & aortic valve stenosis (30-40yrs)
 ↑collagen & calcification with stiffening of valve

Mitral > Mitral & aortic > Aortic (frequency)

 Classic “fishmouth appearance” for mitral valve
2 2 2
o Nml 4-6cm , Sx @ 2cm , <1cm is critical

18
Carcinoid heart disease

From CARCINOID TUMOR of GI TRACT

 Release vasoactive substances
(serotonin, histamine, bradykinin, prostaglandins)

Plaque-like deposits on RIGHT SIDE heart valves

 Tricuspid and pulmonic stenosis
 Lung inactivates vasoactive substances  left side spared

Regurgitant valve disease

 Valve becomes “two way door”
 Blood flows backwards because of valvular insufficiency
1. Valve leaflet dysfunction
2. Root enlargement
3. Leaflet apparatus failure

Aortic Regurgitation

Etiologies: see slide

1. Cusp disease:
normal diameter valve but leaflets have something on them
2. Root enlargement:
enlarged diameter; stretches valve leaflets

Chronic Rheumatic Dz Dilated Aortic Root

Thickening, fusion of 2 leaflets at Very taut cusps; no way this can
bottom right – can’t close close completely

Mitral Regurgitation

Etiologies:
1. Cusp disease
2. Ring abnormalities (dilated or rigid)
3. Chordae Tendineae
(short vs long/broken)
4. Papillary muscle injury (MI, CM)

Note: MV prolapse isn’t uncommon in young women, but only some develop true regurgitation / floppy valves

19
 Floppy Mitral Valve Myxoid Degeneration Rheumatic Mitral Regurgitation
Floppy cusp (top) won’t make Normal zona fibrosa but myxoid Crazy shortened thickened chordae tendininae,
a good seal (lots of mucousy stuff )mixed in definitely won’t let valve close

Calcific Mitral Annulus Fibrosis

(both sides)

Calcification itself is pretty normal,

but valve can get stuck on it (more
rare, causes regurgitation)

Tricuspid Regurgitation
 Pretty rare
 Can get from old rheumatic fever, carcinoid heart disease, bacterial endocarditis, or dilated annulus (from
right-sided CHF; like MV problems in left CHF)

Endocarditis
The “door stopper” – has two main problems
1. Stops leaflets from closing (regurgitation)
2. Thrombus formation (seeds infection; can embolize)

Non-infectious endocarditis

NBTE (non-bacterial thrombotic endocarditis)

 Thrombotic deposits on line of closure on valve leaflets
 Pts with hypercoagulable state (neoplasia, autoimmune disorders too)
 Organize into “Lambl’s excrescences”- hairy whisker appearance
 Not infectious but can become secondarily infected and/or embolize
o In general, need a damaged valve for infection to set up shop

NBTE Histology:
 Fibrin, platelets, fibroblasts, vegetations
(some Mϕ and Fe too)
 No acute inflammatory cells
(PMNs, etc.) or bacteria

20
Libman-Sacks Endocarditis
 4% of patients with lupus (SLE)
 Often doesn’t cause disease

Infectious endocarditis
More common in:
INFECTIOUS CAUSES OF ENDOCARDITIS
 IV drug users (usually RIGHT SIDED)
o shoot up in veins  R heart, hit damaged valve  #1 is STAPH AUREUS
o Others are in left side valves  Viridans group strep, enterococci, coag-
 Pts w/ prosthetic heart valves neg staph, HACEK organisms fungi,
 Pts w/ structural heart disease others (pretty much everything)
 HACEK: common board question, group
Complications: valve dysfunction & thromboemboli of Gram (-)s, grow slowly (watch
culture 2-3 wks)

Gross view: friable (can break off), growing on line of closure (regurgitation)
 Some can actually eat away at valve leaflet (S. aureus)

Histology:
 Large view: see vegetation overlying valve (arrow)
 Ulceration, some normal valve, colonies with acute inflammation
(PMNs, lymphs, etc)

21
 Artificial Valves
Bioprosthetic or Mechanical?
Material? Anticoagulants? Lifespan?
Bioprosthetic Bovine, pig valve in prosthetic strut No anticoagulants Limited life / need replacement
Mechanical Carbon alloys Need warfarin Last 20+ years

Mechanical: cage & ball was loud & drove you crazy, Poe-style  tilting disk (leaked)  bileaflet / St. Jude (used today)
 Earlier designed – more turbulence  more thrombus formation

Bioprosthetic: possible to get

endocarditis, etc.

Valvuloplasty:
• Severe mitral (and rarely tricuspid) regurgitation or stenosis

Stenotic? Balloon valvuloplasty

(inflate a balloon in the valve space to “crack” it open)

Regurgitant? Artificial cord replacement and ring annuloplasty

Review questions
1. Which of the following is a major cause of aortic 3. This picture is an example of? (shows picture of big
valvular stenosis? root with taut leaflets)
a. Carcinoid heart disease a. Aortic regurgitation due to root
b. Marfan enlargement
c. Syphilis
d. Calcified congenital bicuspid valve 4. The most common infectious cause of
endocarditis is?
2. What is the order most frequently noted for a. Staph aureus
affected valves by chronic rheumatic valve disease
a. Mitral > mitral & aortic > aortic

22
 Pathophysiology: The Heart
Atherosclerosis........................................................................................................................................................................ 2
CVD Risk Factors...................................................................................................................................................................... 6
Angina Pectoris ....................................................................................................................................................................... 9
Treatment of Ischemic Heart Disease ................................................................................................................................... 13
Cardiovascular Aging ............................................................................................................................................................. 15
Heart Failure Hemodynamics................................................................................................................................................ 18
Biochemistry & Cell Biology of Heart Failure ........................................................................................................................ 23
Right-sided Heart Failure & Pericardial Disease ................................................................................................................... 28
Genetics of Cardiomyopathy ................................................................................................................................................ 32
Principles of Electrocardiology.............................................................................................................................................. 36
Arrhythmias - Introduction ................................................................................................................................................... 42
Superventricular arrhythmias ............................................................................................................................................... 43
Ventricular Arrhythmias........................................................................................................................................................ 46
Bradyarrhythmias.................................................................................................................................................................. 48
Device Treatment of Arrhythmias......................................................................................................................................... 50
Valve Pathophysiology .......................................................................................................................................................... 54
Congenital Heart Disease ...................................................................................................................................................... 58

1
 Atherosclerosis
Key points from this lecture: endothelial dysfunction & NO; what makes a plaque vulnerable; pathways of atherogenesis

Why understand this? MI or sudden death often initial presentation of CAD (62%M, 46%F)! Recognize it early!
 Incidence has gone down in recent years despite obesity epidemic (better detection?)

Clinical presentations of atherosclerosis:

1. Asymptomatic
Prevalence of CVD
2. Stable or unstable angina:
 USA: 16.8M with angina / MI /
o from supply/demand mismatch of blood to myocardium
coronary heart disease; 11M with CAD,
o leads to ischemia 1.5M/yr have MI
o “Angina pectoris” = “strangulation of the chest”
 37% who experience coronary
3. Acute myocardial infarction
attack in a given year die from it
o acute loss of blood flow to myocardium  cell injury/death
 0.5M /yr die from CAD
o Can lead to fatal arrhythmias / sudden death
4. Stroke: o half of those die suddenly
o loss of blood flow to brain (injury, cell death)
5. Claudication:
o insufficient blood flow to muscles outside the myocardium  pain!
o Often in lower extremities with walking

Typically in order (asx  stable, then unstable angina  MI  complications  death)

 but can JUMP AHEAD to different stages frequently

Epidemiology:
 if you eliminated all major CVD: live expectancy would rise 7 yrs ATHEROSCLEROSIS VS. ARTERIOSCLEROSIS
 Of a child born today, 47% they’ll die from CVD (more than next 4 on list
combined!) Arteriosclerosis: diffuse, age-related
 AGE is strongest risk factor (M>F but F live longer, so more women intimal thickening, loss of elasticity, and
die numerically than men) increase in calcium content of arteries
Atherosclerosis: focal arterial disease
Pathology: the process starts young involving chiefly the aorta, coronary,
 Foam cells (infants/young kids)  fatty streaks (young children)  + cerebral, renal, iliac, and femoral arteries,
fibrous plaques (adolescents)  + thrombosis (adults) with plaque formation

Various theories of atherosclerosis (not mutually exclusive)

Hypothesis Description Pro Con
Increased chol in atherosclerosis; see Lipids alone don’t make a plaque
Lipid / insudation Lipids in plaque from lipid-filled Mϕ
lipids there Why SMC proliferation?
Platelet / Platelets accumulate to initiate; Plaque has platelets; self-sustaining
Lipids enter ECs passively? Weird.
encrustation organizing thrombus  plaque (thrombus is thrombogenic)
Monoclonal / Cells mutate from direct injury / Plaques become monoclonal as they
proliferative infection  proliferative SMC clone mature

Hyperlipidemia definitely involved (Framingham risk score): optimal LDL

<100-160, HDL > 40-50, TG >150-200
Various risk factors (see slide; some modifiable, some not)

Etiology: not just “clogged pipes”: inflammation plays a key role

(SLE/RA/metabolic syndrome; CRP)

Inflammation: serum levels of inflammatory markers = ↑CAD risk

 C-reactive protein (hsCRP) predict MI 6 years into future
2
 (CRP = Marker? Causative?)
 Most associated with acute phase response (systemic, after infection/trauma, causes inflammation/repair)

Pathophysiology

Normal vessel histology review Intima

(single layer of
Endothelial cells: tight junctions; relatively endothelial cells)
impermeable (except fenestration / sinusoids) internal elastic lamina
Media
Endothelial cells regulate stuff: (smooth muscle cells)
external elastic lamina
 Vessel tone
Adventitia
o Vasodilators: NO, prostacyclin (PGI2)
ECM (collagen, elastin);
o Vasoconstrictors: endothelin-1,
cells (SMC, fibroblasts),
platelet-activating-factor
vasa vasorum, nerves
 Thrombosis
 Inflammation

Dysfunctional endothelium: caused by all CVD risk factors (even after 1 fatty meal!)
 Don’t respond with vasodilation after shear stress or Ach like normal
 NO levels decreased (less released)
 Repetitive, transient, chronic decrease in NO levels  atherosclerosis progression
o Early marker of atherosclerosis and mediates progression
o Can improve with treatment of inciting factors

Nitric Oxide
 Free radical; highly reactive, diffuses across membranes
o Neurotransmitter in neurons
o Vasoprotector in endothelial cells (SMC, platelets, endothelial cells affected)
o Cytotoxin in Mϕ (kills pathogens: reactive!)
NO is antiatherosclerotic
 Produced by nitric oxide synthase ↓ oxidation of LDL cholesterol
o vasodilator & anti-thrombotic/anti-inflammatory ↓ platelet aggregation
↓ SMC proliferation
o Relaxation of SMC in blood vessels by increasing cGMP
↓ SMC contraction
↓ expression of adhesion molecules
 cGMP broken down by phosphodiesterase ↓ monocyte / platelet adhesion
o NO dilates corpus cavernosa blood vessels  erection
o Sildenafil (Viagra) inhibits phosphodiesterase  prolonged NO action

 Tonic presence so when it’s eliminated  vasoconstriction (pro-thrombotic/pro-inflammatory)

o Too much causes shock; too little predisposes to atherosclerosis!

Atherogenesis
1. Endothelium injury (LDL / oxidized LDLs when trapped in vessel wall & radicals oxidize it)
a. Also from radicals, shear stress, toxins, etc.

2. Inflammation (toxins like nicotine, infection, others)

a. Chemokines & cytokines attract monocytes (e.g. MCP-1, monocyte chomoattractant protein 1)
i. New intracellular adhesion molecules expressed on endothelial cells / monocytes
b. Monocytes roll, activate, adhere, diapedese into intima, become macrophages, chemotaxis to lesion
c. Start eating oxidized LDL (this isn’t supposed to be in intima!)  foam cells  fatty streaks
3
 d. Oxidized LDL actually activates Mϕ
e. Mϕ pump out more chemokines / cytokines (positive cycle!)
3. Intimal thickening as WBC keep binding & absorbing LDL particles

4. Smooth muscle cells involved too

a. Normally: regulate vessel tone/blood pressure (constrict with epi/angiotensin or
relax with NO); make ECM; don’t proliferate or migrate
b. When Mϕ and endothelial cells are activated, they can release compounds that
activate SMC
i. Proliferate & migrate from media into intima!
ii. Form a fibrous cap over fatty streak – trying to hide the trash

5. Structure of a plaque:
a. Endothelial layer on top (facing lumen)
b. Smooth muscle cap (ECM components)
c. Core of foam cells/cholesterol/necrotic debris (foam cells eventually die; just
lipids & debris left)
What makes a vulnerable plaque

At the plaque shoulder; often can get rupture and exposed ECM (weakest point)

Exposing ECM: substrate for thrombus formation!

 Adherence: GP VI receptor on platelets binds
exposed collagen
o clotting cascade starts too, fibrinogen
laid down; vWF is binding to collagen
too
 Activation: via thromboxane A2, ADP, etc.
 Aggregation: GPIIb/IIIa receptor on platelets
starts binding to fibrin / vWF and other platelets
o Platelet network forms
o can give GPIIb/IIa inhibitor to prevent this aggregation

Histology
Stary classification: I-VIII (less to more severe), often progress in order
 can skip stages too (e.g. thrombus with just 40% obstruction)
 Fatty streaks: no symptoms; don’t obstruct arterial lumen, no impairment of blood flow
o early stages reversible with meds
 Foam cells present in later stages
 VULNERABLE PLAQUE: SOFT CORE, THIN CAP, INFLAMMATION, ENDOTHELIAL EROSION, prominent shoulder
 Complicated atheromas: can be laminated (recurrent plaque rupture, thrombosis, new atheroma formed)

Acellular / calcified atheromas can cause constant angina but don’t usually rupture! (thin lumen but stable)
Presentations
Rupture can be triggerd by:
 shear stress (hypertension) If a vulnerable plaque ruptures:
 sympathetic nervous system (severe stress   Myocardial ischemia (↓oxygen supply)
vasoconstriction)  Thrombus (severe narrowing)
 Inflammation (MMPs, can erode from inside!)  Unstable angina / MI
o Activated Mϕ and SMC destabilize plaque (secrete
MMPs, activate other cells, secrete cytokines)
4
Angina and fibrous plaques:
 Myocardial ischemia (imbalance: supply/demand of O2) PATHOLOGY  SYMPTOMS
 Heart needs increased blood flow, not increased Fatty streak  asymptomatic
oxygen extraction to improve delivery Fibrous plaque  stable angina
 Vasodilation impaired (lack of NO) Plaque rupture + thrombus  unstable angina or MI

Arterial Remodeling
Angiograms: only really seeing severe stenoses (just looking at lumen)
 compensatory enlargement so lumen doesn’t narrow (~40% blockage)
 IVUS: can do ultrasound down CAs to look at it instead!

Treatment
Lifestyle (diet/exercise)
Aspirin
 (COX 1>COX 2 inhibitor; ↓prostaglandin synthesis, ↓platelet aggregation)
 Probably combination of platelet activation inhibition & decreases in inflammation helps in CAD
 Decreases mortality after MI; decreases risk of MI by 44% in subjects with risk factors (↑CRP)
ACE inhibitors: block angiotensin-II
Lipid-lowering: diet/exercise, HMG-coA reductase inhibitors, fibrates, niacin, bile-acid sequesterants, pheresis
 Statins are really pleiotrophic; affect eNOS too, can even see plaque regression

KEY POINTS (last slide of lecture)

 Atherosclerosis begins with inciting factors (risk  Asymptomatic disease can suddenly lead to acute
factors) leading to endothelial dysfunction, injury , coronary syndromes typically with rupture of
inflammation. vulnerable plaque

 Most disease is from traditional risk factors (these are
often undertreated) and disease starts early in life
 eNOS mediates endothelial NO release
 Activated macrophages and smooth muscle cells
contribute to plaque formation
 Atherosclerosis burden can be slowed or even
reversed with aggressive treatments and lifestyle
interventions
 Angiograms only show the lumen not the total plaque
burden due to phenomenon of remodeling.

5
 CVD Risk Factors
Focus on: traditional risk factors for CAD, components of metabolic syndrome, DM is CAD equivalent, FHR score

Risk factor: characteristic or lab measurement associated with ↑risk of disease

 Causal (modification leads to lower risk, e.g. cholesterol) vs marker (associated; e.g. grey hair or homocysteine)
 Modifiable vs non-modifiable

Heart disease is far and away #1 cause of death in US

 Most people think cancer is a bigger cause  heart disease associated with older age (younger people with cancer = more “publicity”)
 Men > women but F>M for overall death (women live longer)

Traditional Risk Factors

 Hypertension  Diabetes Mellitus  Pulse pressure  Kidney Disease
 Family Hx of  Tobacco Use  Sedentary Lifestyle  Inflammation
premature  Age  Obesity  C Reactive Protein
atherosclerosis  Lipids  Alcohol intake

Subclinical atherosclerosis: markers

 Coronary artery calcium (CAC) – measured with multi-detector CT imaging
 Carotid intima/media thickness: use U/S; just interested in intima but have to measure both

Hypertension is multifactorial: ↑ cardiac output + ↑ peripheral resistance is final pathway

 Excess sodium intake, stress, genetic alterations, obesity, hyperinsulinemia, etc. all at work
 Means you can treat it in a lot of ways too

Primary HT: 94%; no single identifiable cause WHEN TO SUSPECT 2° HT

Secondary HT: more uncommon; secondary to another process  Onset < 20yo
 Renal parenchymal disease  BP really high (>180/110)
 Vascular causes  Organ damage (eye, kidney, heart)
o (renovascular; coarctation of aorta  ↓blood to kidneys)  Poor response to appropriate therapy
 Endocrinological causes  Other features: unprovoked hypokalemia,
o (glucocorticoid / mineralocorticoid / hyperthyroid / parathyroid) abdominal bruit, variable pressures with
tachycardia / sweating / tremor, FHx renal dz
 Pharmacological causes (vasoconstrictors, volume expanders)

Left ventricular hypertrophy: potential risk factor for adverse events; increased demand vs supply, thick walls
 Hemodynamic load increased; genetic / other factors contribute
 Leads to myocardial ischemia, poor contractility, poor LV filling, ventricular dysarythmia

Genetic aspects of atherosclerosis: all kinds of studies show that atherosclerosis has genetic component; GWAS shows Chr 9 associated

Metabolic syndrome
 Need at least 3 metabolic abnormalities:
Men Women
Abdominal obesity
>102 cm (>40 in) >88 cm (>35 in)
(waist circumference)
Fasting blood glucose
≥110 mg/dL
(insulin resistance)
Triglycerides ≥150 mg/dL
HDL-C <40 mg/dL <50 mg/dL
≥130/85 mm Hg
BP
(or on antihypertensive medication)

6
Diabetes, dyslipidemia, obesity & CVD
 Pathogenesis:
o diabetes / insulin resistance  ↑adipose tissue, ↓lipolysis, ↑fatty acids to liver, make more vLDL
o ↑LDL / vLDL, ↑HDL
o ↑oxidative state; ↑advanced glycosylation end products, ↑endothelial damage  atherosclerosis
 News flash: There’s an obesity epidemic in the United States and it corresponds to diabetes epidemic.
o (mentally recreate series of maps here)

Diabetes is a CARDIOVASCULAR DISEASE RISK EQUIVALENT

 same risk as someone without diabetes who had a past cardiovascular event!

Smoking
 Nicotine: increases atherosclerosis, thrombosis, coronary artery spasm SMOKING CESSATION
(↑MI), arrhythmias: tons of effects  20 minutes: BP decreases; body temp,
pulse rate returns to normal
 24 hours: Risk of MI decreases
Diet & Exercise  1 year: Excess risk for CHD is half that of
 Balanced eating, calories in = out, consume nutrient-dense foods, a person who smokes
fruits/veggies, whole grains, fat-free/low-fat, limit intake of saturated /  5 years: Stroke risk is reduced to that of
trans-fats, added sugars, salt, alcohol someone who has never smoked
 Physical activity: lowers BP, improves glc tolerance, reduces obesity,  15 years :CHD risk is the same as a
improves lipid profile, better fibrinolysis / endothelial function, better person who has never smoked
parasympathetic autonomic tone

Estrogen
 Women develop CAD 10 years later then men
 Estrogen: cardioprotective? ↑HDL, ↓LDL, better vasoreactivity in observational studies, RCT negative!
o Women’s health initiative: conjugated estrogens, hormone replacement therapy, increased risk
o Maybe observational studies are confounded (healthy people take estrogen therapy)
o Maybe WHI, others focus incorrectly on older pts

Alcohol
 Favorable effects against CVD (1 drink/day for women, 2/day for men)
o other adverse effects (cancer/accidents/violence)
o Too much = obesity, etc

Kidney function: lower kidney function (GFR < 60) = CV risk increases

Screening
C-reactive protein: acute phase reactant; nonspecific inflammation marker
 Cytokine-induced (IL-6), made in liver TRADITIONAL RISK FACTOR SCREENING
 Predicts with good sensitivity: ↑CRP  ↑ MI Risk  Fasting lipid profile
o More benefit to aspirin therapy when high CRP  Fasting glucose
 Resting blood pressure
 Review smoking history
Coronary artery calcium (CAC) with non-contrast EBCT (electron-beam CT)
 Calculate BMI
 Increased calcification correlates with increased risk of death  Measure waist circumference
 Good predictor of 5 yr mortality  Review family history

Carotid Intima-Media Thickness: use U/S to measure thickness Intermediate risk patients: best for
 Interested in intima but have to measure both use of coronary calcium & others:
 Predicts MI / stroke most advantage (tip decisions one
way or another)

7
Framingham risk score:
 Age, HDL-C, total cholesterol, systolic BP  points  CHD 10-year risk

What to do with the score?

10-year Risk % US Adult pop Recommended Interventions
Low risk <10% 35% Lifestyle modification
Intermediate risk 10- 20% 40% Lifestyle modification ± Drug therapy?
High risk >20% 25% Lifestyle modification + Drug therapy

Strategies to Reduce CVD

Can be combined with each other
Lower overall burden of risk factors in population
 (detection/surveillance, public education, preventative measures)
Identify/target high-risk subgroups who benefit most from moderate, cost-effective prevention
 (screening, targeting preventative, treat HT / cholesterol)
Allocate resources to acute/chronic higher-cost treatments
Secondary prevention interventions for those with clinically manifest disease

ABCDEs of Risk Management

Told not to memorize but actually looks like it might be kind of useful in real life

INTERVENTION GOAL
Antiplatelets Treat all high-risk patients with antiplatelet agents
A ACE inhibitors/ARBs Optimize BP especially if CVD, type 2 diabetes, or low EF present
Antianginals Relieve anginal symptoms, allow patient to exercise
BP control Aim for BP <130/85 mm Hg, or <130/80 mm Hg for type 2 diabetes
B β-blockers Post MI, low EF, or angina
LDL-C targets, ATP III guidelines (CHD, CHD risk equivalents)
 <100 mg/dL (< 70 mg/dL optional)
 <2 RF: <130 mg/dL (< 100 mg/dL optional)
Cholesterol management  0-1 RF: <160 mg/dL
C
HDL-C: ≥40 mg/dL (M); ≥50 mg/dL (F)
Triglycerides <150 mg/dL
Cigarette smoking cessation Long-term smoking cessation
Achieve optimal BMI
Dietary / weight counseling
D  saturated fats;  fruits, vegetables, fiber
Diabetes management Achieve HbA1c < 7%
Improve physical fitness
Exercise
E (aim for 30 min/d on most days per week)
Education of patients & families Optimize awareness of CAD risk factors

8
 Angina Pectoris
Definitions
Myocardial ischemia: Relative imbalance between myocardial oxygen demand and supply due to:
 an increase in myocardial oxygen demand with a fixed supply
 reduced oxygen supply Classical or typical angina:
 combination of both  substernal chest pressure, which
 comes on with emotional or physical stress, and
Angina Pectoris: Symptoms resulting from myocardial ischemia.  relieved with rest or sublingual nitroglycerin

Coronary Flow Reserve: maximal increase in coronary blood flow above resting levels due to CA vasodilatation.
 The CFR = CBF during maximal vasodilatation & basal CBF
 Normal CFR is about 5 (can increase CBF 5x above rest values during strenuous exercise

Balance between myocardial oxygen demand & supply

Normally tightly coupled: increased demand (exercise)  more blood flow
SUPPLY DEMAND
 HEART RATE is most important: ↑ with exercise, fever, etc.
 primarily coronary blood flow (vascular resistance)
 Myocardial wall tension: afterload & preload; ↑ with HT, aortic stenosis
 oxygen carrying capacity (anemia) more rare
 Inotropic state (contractility): ↑ with epinephrine
o (even if pressure, HR the same)
Myocardial oxygen supply

Normally:
Large epicardial vessels run along epicardium;
 Very little vascular resistance (R1)
Branch off to arterioles that traverse myocardium
 Major source of vascular resistance (R2)
 Dynamically alter tone to match supply & demand
 Can increase flow 4-6x baseline to meet exercise demand via
arteriolar vasodilation

Flow (Q) = ΔP / R2
 ΔP = pressure across myocardium
= (diastolic blood pressure – LV end diastolic pressure)

Resistance (mostly R2) influenced by extrinsic & intrinsic factors

 Extrinsic: blood flows through CA during diastole
o Extravascular forces squeeze CA shut; when heart relaxes, intravascular coronary pressure higher than
extravascular compressive forces. Blood flows through CA openings as aortic valve open with backpressure
o Subendocardium: greatest systolic shortening (more squeezing)
 so there’s more compression on arterioles
 SUBENDOCARDIUM IS TERRITORY OF LEFT VENTRICLE MOST AT RISK FOR ISCHEMIA
o Subepicardium: still gets some blood flow in systole (less intrinsic compression)

 Intrinsic: variety of intrinsic factors influence arteriolar vasomotor tone

o Adenosine: breakdown product of ATP; powerful CA vasodilator
 MATCHES SUPPLY & DEMAND
 ↑oxygen demand (e.g. exercise)  ↑ATP degradation ↑adenosine diffuses out
↑arteriolar vasodilation, coronary blood flow, rebalance of supply & demand
 Caffeine blocks adenosine receptor; blocks this effect (can’t vasodilate with exercise!)
o Oxygen tension, pH, ATP-sensitive K channels, sympathetic innervations, etc. too

9
 Fixed Stenoses
With coronary artery disease / epicardial narrowing:
 R1 gets much higher (now offers resistance)
 offset by arteriolar vasodilation & R2 decrease
 Maximally dilated at baseline now! Can’t optimally deliver more oxygen
(optimally delivery) in exercise/stress states, etc.

Coronary Flow Reserve:

 Basal flow maintained via vasodilation up to about 60% stenosis
 CFR is impaired, however (can’t lower total resistance enough to
augment blood flow in stress or exercise
o Can lead to ischemia (demand > supply)
o Stenosis > 90% - basal flow decreases, ischemia at rest or minimal activity

Fractional flow reserve: lab test; easier than CFR (would have to do off-line)
 FFR = max blood flow to heart in presence of stenosis / theoretical normal blood flow
 % max flow with max vasodilation that can be achieved despite stenosis (flow beyond stenosis / flow before stenosis)

 In lab: give adenosine to vasodilate; measure as (pressure beyond / pressure before stenosis)
o Normally 1.0; FFR of 0.5 means 50% of max flow can be achieved; 0.9 means 90% (less severe)
o FFR < 0.75 is significant! (even though it might look similar on angiography) – measuring hemodynamics
 Correlates with + stress test, angina, improvement with revascularization

Endothelial Function
Endothelial release of nitric oxide  cGMP production  vasodilation
 Release stimulated by a ton of agonists (including shear stress in exercise)
 Normally: CONTINUAL RELEASE  TONIC reduction of basal tone (CA and microvasculature)

Effects of acetylcholine Vasodilation NO Ach

 intact endothelium: stimulates NO release Endothelial cells
from endothelium vasodilation results
SMC
Muscarinic
 injured / atherosclerotic endothelium: hits receptors
Constriction
Intact endothelium Injured endothelium
myocytes, stimulates muscarinic
receptors paradoxical vasoconstriction

Balance shows up in an individual patient: CVD risk factors & atherosclerosis have reduced / abolished response to Ach
 All patients respond to intracoronary nitroglycerine (directly stimulates smooth muscle vasodilation)

Importance of endothelial dysfunction:

 Exercise / mental stress / others increase oxygen demand, need increase in flow
 At least partially endothelial-dependent; risk factors / atherosclerosis change balance towards constriction
 Normal pt: exercise, shear stress  ↑NO release; ↑adenosine.
o VASODILATION on balance (outweigh catecholamine production)
 Coronary dz: exercise  NO release attenuated. Catecholamines produced on exercise (vasoconstrictors)
o VASOCONSTRICTION on balance

Circadian variation of coronary events

 Basal coronary tone varies; Morning: normally ↑BP, ↑HR because ↑catecholamines (and other factors)
 ↑catecholamines  ↑vasoconstriction if someone with endothelial dysfunction
 More events, acute MI / sudden cardiac death / unstable angina / angina threshold increased on stress test in morning

10
 Angina: Clinical Perspectives

Diagnosis: use history, risk factors, age, gender

Symptoms of typical angina: Grading of Angina (Canadian classification)
1. Provoked by strenuous, rapid, or prolonged exercise
 substernal chest pressure, which
2. Slight limitation of ordinary activity
 comes on with emotional or physical stress, and
3. Marked limitation of ordinary activity
 relieved with rest or sublingual nitroglycerin
4. Inability to carry out any activity without anginal
pain, including angina at rest
Atypical: missing 1 of 3; nonanginal chest pain missing 2 or all 3

Categorize into high, intermediate, low risk

 helps predict presence/absence of obstructive CAD on angiography
 Then decide whether to do a stress test or not

Evaluation:
 exercise stress test
 myocardial perfusion imaging
 echocardiography
 electron beam CT (calcification)
 coronary angiography

Think: can they walk (for stress test)? Is the risk so low you probably would discard a positive as a false positive? Is the
risk so high you’d probably go to angiography anyway despite a negative result?

Want patients of INTERMEDIATE RISK to do a stress test.

In patients with interpretable electrocardiogram who can ambulate: routine EXERCISE TEST is test of choice
 If can’t exercise: other studies (persantine thallium for LBBB, as EKG doesn’t work well, also dobutamine EKG)
 Gold standard: coronary angiogram

(If you can read this and understand it, you’re probably set)
In the normal coronary artery with normal endothelial function: at rest, there is moderate arteriolar vasoconstriction maintaining
the balance between myocardial oxygen demand and flow. During exercise, increase demand, breakdown of ATP, adenosine and
other mediators (NO) cause arteriolar vasodilatation to meet the increase myocardial demand. Likely due to an increase in shear
stress from increase heart rate and blood pressure with exercise, with normal endothelial function, the epicardial vessel will
vasodilate further augmenting coronary blood flow.

In patients with coronary disease, when the patient is

resting there is significant resistance offered by the
epicardial coronary stenosis resulting in a pressure drop
across the stenosis and compensatory arteriolar
vasodilatation to match resting myocardial oxygen
demands. During exercise, due to endothelial dysfunction
there is epicardial vasoconstriction likely due to
catecholamine smooth muscle vasoconstriction outweighing
shear stress vasodilatation. The pressure drop across the
stenosis increases. The microcirculation (arterioles) already
vasodilated at baseline, have limited capacity for addition
dilatation resulting in impaired coronary flow reserve and
development of angina. Coronary flow reserve would be a
measure of maximal blood flow to resting blood flow, about
1.5, very abnormal. Fractional flow reserve in this example
would be 40 / 100 or 0.4 – suggestive of a significant lesion.

11
 Key Points (straight from notes) for review
Myocardial Oxygen Supply & Demand
1. What are the 3 determinants of myocardial oxygen demand?
Wall tension, heart rate, inotropic state.

2. Coronary oxygen supply is determined by:

Coronary blood flow.

3. Which part of the coronary vessel is the primary source of coronary vascular resistance?
Intramyocardial arterioles.

4. What part of the cardiac cycle does most of coronary blood flow occur?
Diastole.

5. Why do patients get ischemic in the subendocardium?

Coronary flow reserve is lowest in this area because under resting conditions, extrinsic compression is greatest here.

6. What myocardial metabolite may contribute to a feedback mechanism to control intrinsic arteriolar vasodilatation?
Adenosine.

Fixed Stenoses
1. Why do most patients complain of exertional angina when coronary stenoses reach a severity of 60-70%?

At this severity of lesion in the epicardial vessel, coronary flow reserve is decreased, such that at maximal oxygen demand, the
coronary vessel is unable to respond with maximal flow and this imbalance results in myocardial ischemia. The symptomatic result of
myocardial ischemia is angina.

2. What catheterization test can be performed to evaluate the severity of a borderline angiographic stenosis?

Fractional Flow Reserve, the ratio of pressure beyond a stenosis (Pd) to the pressure before a stenosis (Pa). Following adenosine, if a
stenosis is significant, distal coronary pressure falls due to impaired augmentation of blood flow and the FFR < 0.75.

Endothelial function & dysfunction

1. How do people with and without coronary artery disease respond to an intracoronary injection of acetylcholine and why?

Patients without coronary disease and few risk factors respond with coronary vasodilatation due to acetylcholine stimulation of
release of endothelial nitric oxide causing coronary vasodilatation.

Patients with coronary disease or with multiple risk factors respond to intracoronary acetylcholine with paradoxical vasoconstriction
due to endothelial dysfunction, the overall balance is for muscarinic stimulation with smooth muscle constriction.

Clinical approach
1. What is the value of performing a diagnostic stress test in a 24 year old woman with atypical chest pain and no risk factors for
coronary artery disease?

Useless. Your pretest probability that this person has CAD is <5%. If a stress test is positive for ECG ischemia, your post-test
probability that this is CAD is still under 10% and you would call the test a false positive.

2. What is the value of performing a diagnostic stress test on a 45 year old male, smoker who comes to your office with substernal
chest pain that occasional occurs with activity and occasionally at rest.

Reasonable. Your pretest probability that this person has CAD is about 40-50%; a negative test decreases this probability while a
positive exercise test for ischemia significantly increases the likelihood that your patient has angina.

12
 Treatment of Ischemic Heart Disease

BASIC IDEA STABLE /CHRONIC CAD ACUTE CORONARY SYNDROME

YES for ALL PTs with STABLE CAD
 Aspirin inhibits COX-1  ↓prostaglandin  Any dose ≥ 75 mg = ↓death / MI
YES for ALL ACS pts
metabolism  ↓thromboxane  Start immediately on admission  23% better (death) or 50% (recurrent MI /
production  ↓platelet aggregation / (162-325 mg/day) stroke) vs placebo
Aspirin activation.
Platelet  Continue FOR REST OF LIFE
activation key in  RBC = anucleate; COX-1 inhibited for life of (81-162 mg/day)
Platelet Inhibitors

ACS: predicts platelet ALL CORONARY DISEASE PATIENTS SHOULD BE GIVEN ASPIRIN
recurrent ischemic & CONTINUED FOR LIFE (unless contraindicated)
events: more
 ADP platelet receptor antagonist
platelet YES for NSTEMI and STEMI pts
hyperreactivity =  ↓platelet aggregation & activation
 ACS = platelets activated
worse 5 yr risk of
 Prodrug: 85% inactivated by gut; 15%
death / recurrent NO  Always + aspirin (dual antiplatelet therapy)
activated by liver
MI)  NSTEMI: 20% reduction vs aspirin alone
Clopidogrel  Response varies with CYP2C19  No improvement vs aspirin alone
polymorphism (25% pop = slow  Increases bleeding risk  STEMI: dual antiplatelets helps prevent stent
metabolizers; shunt more to gut; more thrombosis in cath/stent pts; reduces
inactivated; ↓effect, ↑risk future events) mortality in medically managed pts: use in
both!
 some hosps genotype, use alternative if slow

 Block angiotensin I  II by angiotensin converting enzyme

YES: pts with DIFFUSE CAD NOT
amenable to REVASCULARIZATION YES for HF or LV DYSFUNCTION post-MI
 Reduce LV afterload (less systemic pressure)
 HOPE: 20% decrease vs placebo  Limits LV remodeling
 Also: ↑NO production, ↑endothelial function, ↓oxidized LDL
receptor expression, ↑t-PA production, ↓plasminogen  Afterload reduction, inhibition of activated
ACE-inhibitors NO: STABLE post-PCI pts with
activator inhibitor 1; ↓ LV remodeling post-MI RAS is beneficial
 Post-MI: RAS & sympathetic system activated; salt retention +
single vessel CAD on aspirin+statin
 CONTINUE INDEFINITELY
vasoconstriction + tachycardia worsens LV dysfunction  PEACE: no benefit in pts who you’re  (less CV mortality, HF admissions, reMI)
going to revascularize with PCI & put on
 Use mostly for neurohormonal effects!
aspirin + statin combo
YES for ALL POST-MI PTS
 Block β-adrenergic receptors: ↓catecholamine effects on heart YES
 ↓ myocardial oxygen demand (↓BP, ↓HR, ↓contractility)  Only anti-arrhythmic to decrease sudden
β-blockers  1st line for stable coronary disease cardiac death & mortality POST-MI
 Slow heart rate  ↑diastolic length  ↑filling (reduce angina frequency; can
 Reduce ischemic ventricular arrhythmias (help with angina) exercise longer)  Better benefit with more LV dysfunction
(better in higher risk patients!)

13
 BASIC IDEA STABLE /CHRONIC CAD ACUTE CORONARY SYNDROME
YES (regardless of baseline LDL)
 Lower LDL cholesterol (HMG CoA-reductase inhibitors) YES for ALL POST-MI PTS
 25% event reduction; lower is
 Increased LDL / total chol predicts CV events in Asx people
better; extra-lipid benefits of statins  LDL < 70 mg/dL is generally the target goal
Statins  Linear relationship between LDL lowering & CV events (lower help pts with low baseline LDL too!
LDL is better); very well tolerated
ALL PTS WITH CAD SHOULD BE ON A STATIN; LOWER IS BETTER
 Also ↓inflammation (CRP); ↑NO; ↑endothelial function
LDL-lowering primary benefit; anti-inflammatory effects too!

BASIC IDEA STABLE /CHRONIC CAD ACUTE CORONARY SYNDROME

PCI
 Goals: improve quality
of life (↓angina) &
improve survival
Revascularization
ONLY if FAIL MEDS or 3 VESSEL DZ
or equivalent (RCA + L main)
 NSTEMI: plaque rupture & critical stenosis but persistent flow; PCI reduces
 CABG might prolong life; no evidence that PCI risk reMI / mortality; stabilize 12-24h first
reduces MI / death
 Really trying to improve QOL with
 STEMI: emergent PCI when available: go right away to cath lab! Shoot for

CABG angina relief (patient tells you when

<90 MINUTES door to balloon time; benefit < 12hrs from Sx
it’s time to intervene)
YES for STEMI
 Restore blood flow  Benefit vs. placebo; survival advantage for pts who get Tx.
quickly if emergent PCI  TIME IS MUSCLE: get it in fast!
Thrombolytics not available (e.g. at  Benefit shown <12h from Sx
community hospital)
 Give it in ambulance, community hosp, etc.
 Use emergent PCI when available (better survival / fewer recurrent
ischemic events)
*PCI = percutaneous coronary intervention; often with stent
**CABG = coronary artery bypass grafting
Summary
 Aspirin: effective for all phases of CAD  ACE-I:  Statins: good for all phases of CAD
o not for low-risk CAD
 Dual antiplatelet therapy: beneficial once o use for CAD + LV dysfunction or post-MI  Revascularization:
plaque rupture happens LV dysfunction o stable CAD if meds fail (“they tell us”)
o most ACS pts (“we tell them)
 β-blockers:
o lower symptomatic angina in stable CAD
o SAVE LIVES post-MI

14
 Cardiovascular Aging
Age is #1 risk factor for cardiovascular disease (CHD); US elderly pop is growing
CV PHYSIOLOGY: CHANGES WITH AGE
 Incidence & prevalence of CHD both ↑ with age (50% 50-year-olds, 60%
 ↑ central arterial stiffness
60-year-olds, 70% 70-year-olds)
 Endothelial dysfunction
o Worse outcomes too: 80-90% of those who die of CHD are > 75yo
o #2 cause of morbidity (behind arthritis) & #1 cause of mortality  ↓ß-adrenergic responsiveness
 Why? Longer exposure to risk factors & changes in physiology  ↓ early LV filling rate
o Increased vulnerability, decreased reserve (diastolic function)
o Heterogeneity in aging: changes happen to some degree in all  Conduction system changes
but at very different rates  Changes in hormone levels

Research & aging: how do you do it?

 Cross-sectional: younger & older at one point in time
o Cheaper but problematic: survival bias (if you made it to 75 years old, you’ve survived the big years of cancer /
CVD mortality in your 40s-60s), cohort effects, can’t discern causal relationships
 Longitudinal studies: follow one group over time
o More expensive but the gold standard * can account for confounders; less biases)
 Clinical trials: very few actually include elderly in design (comorbidities, polypharmacy, etc)
o Makes it hard to apply results to your patients; new challenge = capture heterogeneity of older patients with RCTs

Central arterial stiffening

Structural changes:
 ↑ collagen fibrils (↓degradation); cross-linked by advanced These changes work together to put the
glycation endproducts (AGEs) = even less stretchy heart at higher risk of injury: increasing
 Elastin frayed / broken demand (LV hypertrophy) while decreasing
 Results: central arteries have enlarged diameter, ↑ intimal- supply (CA filling help from reflected wave
medial thickness, ↑ Ca+2 deposition isn’t happening); at the same time there’s
extra stress (increased afterload from
o Can’t absorb waveforms from heart (reduced compliance:
increased inertance & faster PWV).
like having an iron pipe instead of a hose)

INCREASED PULSE WAVE VELOCITY (PWV):

 Normal: pulse wave bounces off of iliac bifurcation, returns to aortic
valve in diastole, helps with CA filling
 More rapid (e.g. aging): wave returns in systole, actually INCREASES
AFTERLOAD instead of helping with CA filling
o ↑ LV end-systolic stiffness  LV HYPERTROPHY (so now you have
to perfuse a big hunk of meat: ↑ demand)
o ↑ LV stress too

INCREASED INERTANCE: bigger diameter of aorta, so LV has to push

harder: increases afterload too

BLOOD PRESSURE LABILITY: ↓compliance; ↓control BP

 Become very sensitive to volume changes (e.g. diuretics)

INCREASED PULSE PRESSURE

 Reflected wave superimposed on forward wave:
o pounding on organs (not good)
 Pulse pressure of 60 instead of 40; ↑systolic / same diastolic would be typical

15
 Decreased responsiveness to β-adrenergic stimulation

Both chronotropic & inotropic responses blunted

 Resting HR unchanged with age, however

Max HR & contractile response to catecholamines ↓ with age

 Epi / norepi levels in response to exercise are higher in elderly
 So probably due to alterations in β-adrenergic receptors &
downstream signaling, not deficient production of catechols

β-adrenergic receptors modulate more than chronotropy & inotropy

More reliant on Frank-Starling relationship to control cardiac output

 CO = HR x SV; if ↓max heart rate, SV has to pick up the slack

Delayed Early Left-Ventricular Diastolic Filling

Normally:
 LV fills during diastole via both passive & active relaxation (70% filling happens in this early phase)
 Towards the end of diastole the left atrium kicks in and pushes some extra blood into the LV (~30% of filling)

In aging
 Passive relaxation impaired (stiffening of ventricle by fibrotic tissue, ↑# and AGE-crosslinking of collagen)
 Active relaxation of LV is delayed (alterations in calcium signaling) – predominant change in aging

Atrium has to provide more filling to make up for this poor timing
 Around 50yo, filling pattern starts changing, by 70yo, 30% of filling is in early phase and 70% late (atrial)
 Result: LEFT ATRIAL SIZE INCREASES with age (more intra-atrial pressure)

Endothelial dysfunction
 Associated with atherosclerotic lesion formation (platelet adhesion / aggregation, thrombogenicity, cell prolif)
 With aging: ↓vasodilatory response to Ach (mechanism unclear)
 Exacerbated by HTN, chypercholesterolemia, smoking, HTN; better if you exercise

Conduction system abnormalities

 Fibrotic & fatty infiltration around sinoatrial node; ↓pacemaker cells
Changes in ECG with aging
o Leads to ↑vulnerability to slow / paused electrical rhythms
•  PR and QT intervals
 Slower conduction through AV node, proximal His-Purkinje system
• Leftward QRS axis shift
 ↑Atrial fibrillation (bigger atria, more atrial pressure)
• ST / T waves flatten
•  RBBB frequency
 Hypertension, CAD, amyloid infiltration magnify these other changes
(but LBBB not normal!)

Neurohormonal changes
 ↑ epinephrine, norepinephrin in response to stress with age
 ↓ renin, angiotensin II, aldosterone, vasopressin (ADH) – less able to adapt via kidneys to regulate volume
 This is why diuretics & salt restriction are good for elderly adults to control BP (strong response)
 (Baroreflex sensitivity & autonomic modulation of HR are diminished too, although she didn’t really talk about this)

16
 Cardiac function at rest & at exercise
 Cardiac function at rest is relatively unchanged! Resting HR the same; CO / SV / LVEDV & LVESV all maintained
at rest (other organ systems’ functions decline; depends on pt)

During exercise in elderly pts:

 Max heart rate ↓ (see above), so to ↑CO, have to ↑SV even more. Cardiac Physiology Review:
 SV↑ (LVEDV & LVESV both increased)  SV = LV’s EDV – LV’s ESV
 CO = HR x SV
 Peak EF is decreased: (EDV – ESV)/EDV = EF, so if you shift the whole
PV curve to the right (↑EDV and ↑ESV), you’ll have a smaller EF  VO2Max = CO x (A-V)O2
 EF = (EDV – ESV)/EDV
End results (vs younger person):
 VO2max↓ (marker of exercise capacity), tissue extraction (A-V)O2↓too, but CO stays the same
 CO of an elderly person is only slightly decreased vs a younger person, but SV rather than HR is the big player
 More reliant on Frank-Starling mechanism (SV increases with end-diastolic volume; elderly rely on SV more)
o Functioning higher on F-S curve (higher SV & EDV), so less cardiac reserve (can’t keep raising EDV!)
 Similar to when a younger person exercises with β blocker – mediated by loss of β-adrenergic responsiveness

Geriatric Cardiology Syndromes

 These changes in structure & physiology lead to clinical
syndromes in the elderly: elderly become more vulnerable to
acquire disease, and the disease happens on an altered
substrate.
 Diminished cardiac reserve in both disease & routine stresses
causes clinical signs & symptoms
 Note that isolated systolic hypertension is very different than
atherosclerotic hypertension seen in middle-aged, for
instance.
 Atrial fibrilliation is a big problem in the elderly: remember
they’re really relying on atrial contraction to fill LV (less
worrisome in younger pts)

Summary
• ↑arterial stiffness • ↓β-adrenergic responsiveness
• ↑myocardial stiffness • ↓endothelial function
• ↓sinus node function
• ↓baroreceptor responsiveness
• ↓plasma volume regulation

Net effect: Marked reduction in CV reserve

17
 Heart Failure Hemodynamics
Evolution of HF models: what’s the main problem? How should it be treated?
Edema (digitalis/diuretics) Pump (PA caths, inotropes, vasodilators)  neurohormonal (ACEI, ARB, β-blockers, aldosterone agonists)

Definition of HF: inability of the heart to pump blood at an adequate rate to fulfill
tissue metabolic requirements or the ability to do so only at an elevated filling
pressure. It can be defined clinically as a syndrome of ventricular dysfunction
accompanied by reduced exercise capacity and other characteristic hemodynamic, renal,
neural and hormonal responses. (HF is a clinical syndrome).

The Big Picture:

 HTN & other initiating factors can lead to LV hypertrophy, MI, remodeling
 LVH and coronary artery disease contribute to myocardial infarction .
 MI can lead to systolic dysfunction (contraction problems)
 LVH can lead to diastolic dysfunction (filling problems)
 Both contribute to CHF’s clinical manifestations

After an MI, ventricular remodeling occurs  heart failure

 Goal: keep stress constant
𝑷×𝒓
 LaPlace’s law: stress = 𝟐𝒉 where r = radius, h=thickness
o If r↑ (load increases, dilating ventricle), h↑ (thicker) to try to
keep stress constant

Classification of Heart Failure

 Dilated: ischemic (CAD), viral, hypertensive, peripartum, etc
 Restrictive: amyloid, pericardial constriction, HCM (?), radiation
 High output: hyperthyroid, anemia, AV fistula (e.g. not totally
occluded in someone on dialysis)

Changes in Heart Failure

CARDIAC
 ↓ SV and CO
 ↓ Ejection Fraction
 ↑ End Diastolic Pressure
 Impaired filling
 Dilatation and hypertrophy
VASCULAR
 ↓ Arterial pressure
 ↑ Systemic Vascular Resistance
 ↑ Venous pressure / compliance
MOLECULAR / NEUROHORMONAL
 ↑ Sympathetic activation
+2
(vasoconstriction, proliferative signaling, Ca changes)
 ↑ Renin-Angiotensin-Aldosterone System
(vasoconstriction, fibrosis)
 ↑ ADH (fluid retention)
 ↑ Cytokines (inflammation)
Lots of gene regulation changes too

Why is this stuff happening? Defense of a normal hemodynamic state by the body. Good in short-term, bad in long-term.
MECHANISM SHORT-TERM EFFECTS LONG-TERM EFFECTS
Adrenergic signaling ↑Contractility ↑ Calcium
↑Relaxation ↑ Energy demands
↑Heart rate Necrosis, arrhythmias, sudden death
Vasoconstriction ↑Afterload Cardiac output impaired
Maintain blood pressure Energy demands
Salt and Fluid retention ↑ Preload Edema, anasarca, congestion

18
 Hemodynamics / Physiology Review
What determines vascular performance (CO?)
 CO = HR x SV
 SV↑ with
↑preload,
↑contractility,
↓afterload

Frank-Starling Mechanism

 SV↑ with ↑end diastolic pressure or volume (preload)

 Steepness of curve reflects contractility
(with a more contractile heart, you get more SV increase for given increase
in preload)

Preload
 Sarcomere length just prior
to contraction (or for whole
heart, ventricular wall
tension at end of diastole)
 ↑EDV  ↑SV (width of PV The Cardiac Cycle
loop) (F-S mechanism) (probably useful to review)

Afterload
 Resistance heart must overcome to eject
 Determined by ventricular wall tension
 ↑end systolic pressure  ↓SV (width)

Contractility
 ESPVR: end systolic P-V relationship
 If contractility stays the same, as you change afterload (~end systolic pressure),
the end systolic volume will change along this curve
 Contractility = any change in ejection that is not due to a change in
preload or afterload; means the slope of the ESPVR line will change
 ↑ contractility  ↑SV
 (graphically, the slope of the ESVPR line gets steeper, so the PV loop gets wider)

19
 What happens when there’s dysfunction?

Systolic Dysfunction:
1. ↓ contractility (ESPVR relationship shifts to less steep curve)
2. ↑ end systolic volume: not ejecting as much
3. ↑ end diastolic pressure: fill more in attempt to compensate & maintain SV
4. SV ↓ despite attempts to compensate (↓ ejection fraction)

What can cause it?

 Impaired contractility (MI, myocardial ischemia, valvular dz, idiopathic DCM)
 Increased afterload (systemic HTN, Ao stenosis)

Diastolic dysfunction
1. Stiffer ventricle: harder to fill (new dotted curve)
a. As you fill, there’s more of an increase in pressure as you add volume
2. ↓ EDV, ↑EDP vs normal (more pressure, less volume)
3. ↓ SV & (↓Ejection Fraction)

What can cause it?

 Impaired relaxation (MI, hypertrophy: HCM or systemic hypertension leading to
LVH, restrictive CM)
 Obstruction to filling (mitral stenosis, pericardial disease – constriction or tamponade)

Pathophysiology, Assessment, Treatment of HF

 All roads lead to adverse remodeling

 Therapy: REVERSE THE REMODELING (takes a while)
o ACEI, ARB, β-blocker, etc

Goal of treatment: PREVENT PROGRESSION along clinical course

1. Stage A: Risk (HTN/DM) but no dz / sx
2. Stage B: structural dz but no sx
3. Stage C: structural dz with sx
4. Stage D: end-stage / refractory HF

Assessment: H&P is KEY

History Physical
 Worsening S.O.B.  Elevated JVP
 Orthopnea  Pulmonary rales
 Paroxysms of nocturnal  Tachycardia
dyspnea (PND)  S3
 Weight gain  Edema
 Poor appetite  Cool extremities
 Fatigue

20
Jugular Venous Pulse
 A = atrial contraction
 C = usually indistinguishable
 V = filling (“villing”) of LA
 X-descent, Y-descent
 Carotid is an uptick, JVP is more of a falling off

How to assess hemodynamic status

 Perfusion at rest: “Warm” (good perfusion) vs “cold” (low perfusion)
o Kidneys: increased BUN or Cr b/c poor glomerular perfusion
 Congestion at rest: “Wet” (congested) vs. “dry” (no congestion)

Why this classification? Good for prognosis (best to worst)

 A: Warm & dry: no congestion or perfusion problems at rest
 L: Cold & dry: poor perfusion, no congestive sx
 B: Warm & wet: good perfusion but congestion
 C: Cold & Wet, COMPLEX patient: worst prognosis,
both congestive & perfusion problems

Diagnostic testing
 Routine serum chemistries (e.g. BUN/Crt, LFTs –
check for liver or renal problems)
 Plasma BNP (brain naturietic peptide) – indicator of
heart failure
 ECG
 CXR for congestion
 Right heart catheterization

Right heart cath (Swan-Ganz)

 Go in through right jugular vein  SVC  RA  tricuspid valve pulmonary valve  pulmonary artery
 Measure pressure at each part

Wedge Pressure / pulmonary capillary wedge pressure (PCWP)

 Inflate balloon / occlude once in PA, just behind the pressure-measuring tip of the cath
 Gives you an idea of how left side is doing – LA pressure will be the pressure of the cath

21
 Working with Swan-Ganz data
See picture for normal cardiac filling pressures
 Remember that 1cm H2O = 0.74 mm Hg

 CO usually 4-7 L / min

 SVR usually 1200-1500
 PVR usually 100-300

 CI = cardiac index; CO / body surface area (how well is

heart performing for your size?)

Does Swan-Ganz cathing make a difference?

 No change in outcomes in studies.
 NOT FOR USE IN ROUTINE PATIENTS (only in very
challenging pts)

If you’re Then your R. heart cath will show…

PCW CI SVR
“Warm & dry” Normal Normal or low
“Cold and dry”
(not perfusing)
Low / normal ↓(CO impaired – not perfusing) ↑ (trying to keep BP up)
“Warm & Wet”
(congested) ↑(backed up) normal Normal or low

“Cold & wet”

(congested, not perfusing)
↑(backed up) ↓(backed up) ↑ (trying to keep BP up)

Examples
1. Cardiogenic shock: this guy has cold extremities, a high
PCW (so he’s backed up), and a low cardiac output with a
high systemic vascular resistance. He’s cold & wet

2. Septic shock: this woman has a normal PCW, a normal CO,

but a low systemic vascular resistance. She’s warm & dry

3. Pulmonary HTN: This woman has a normal PCW, a normal

CO, and a normal SVR. She’s warm & dry. Notice that her
pulmonary artery pressure is high and she has an elevated
JVP with a normal PCWP – she has pulmonary HTN, and it’s
not just backup from the left side!

22
 Biochemistry & Cell Biology of Heart Failure
Review questions in notes might be good for studying
Hemodynamic view: ↑preload (fluid retention), ↓CO & BP under stress, ↑afterload (arterial resistance), ↓contractility

More than just hemodynamics:

 It’s good to reduce filling pressures & improve CO, but how you do it matters!
 Improving contractility has failed so far
 Vicious cycle: insult  pump function reduced  changes
(neurohormonal, remodeling, constriction, tachycardia) 
molecular/ signaling changes  makes initial insult worse
 Changes pump into a new kind of pump
 Genetics at center of change (fetal genes re-emerge)
Take Home Message #1
• Acute neurohormonal stimulation is good
(doesn’t damage heart; augments cardiac
function)
• Sustained neurohormonal stimulation is bad
(alters signaling, causes changes in myocardial
structure, worsens heart failure)

Adrenergic & RAS stimulation

Good Bad
 Volume redistribution (peripheral veins  circulating blood volume)   Myocyte damage & fibrosis
increases preload  Cell hypertrophy & molecular
 ↑ HR & ↑contractility (diminished pump function) changes (diminish function)
 ↑ cardiac growth (compensate for larger chamber size / wall stress)  ↓systolic & diastolic function of heart
 Systemic vasoconstriction (maintain BP)

Catecholamine hyperstimulation
 ↑Sympathetic nervous system  ↑contraction, ↑filling (venoconstriction), ↑arterial resistance, ↑HR
 Higher sympathetic stimulation  less survival
 Higher catecholamine levels in CHF pts (cardiac reserve limited)

Review of sympathetic stimulation

 NE from post-ganglionic nerves (↑contractility); epi from
adrenal medulla after pre-ganglionic stimulation
 α & β receptors both play a role
 Primary receptor: β1 coupled to regulatory G-proteins;
mediated by Gs subunit  adenylate cyclase
o β2 might be protective, Gi linked
 ↑cAMP  ↑PKA phosphorylates lots of stuff

What it does What happens when p-lated by PKA

L-type voltage-gated Calcium channel Increases calcium entry into cell
sarcolemmal Ca+2 channel
+2
Phospholamban regulates Ca uptake into SR p-lated: enhances Ca+2 uptakemore calcium release 
non-P-lated: inhibits SR-ATPase more contractile response
SERCA2a
Troponin I regulatory thin-filament protein; Reduces myofilament calcium sensitivity
modifies interaction of (less force developed for any given level of calcium –
myofilaments with TnC (calcium- enhances muscle relaxation)
binding molecule)
What influences the basic signaling cascade?
 β-adrenergic receptor kinase: phosphorylates receptor, β-arrestin recruited, receptor internalized & ubiquinated
(reduces stimulation response)
 PP-1: protein phosphatase 1, regulates phospholamban phosphorylation (reduces it, so less contractile response)
 I-1: inhibitior of PP-1
23
What happens with chronic sympathetic stimulation in heart failure?
 ↑ Chronic catecholamine toxicity: (apoptosis/necrosis, oxidative stress, hypertrophy)
 ↓ β1 receptor density – depressed signaling
 ↑ Gi – coupled signaling Take Home Message #2
 ↑ GRK-1 (Beta-Adrenergic Receptor Kinase) • Sustained adrenergic stimulation ultimately results in
 ↓ Adenylate cyclase activity myocardial tissue damage, and depressed receptor and
post-receptor signaling.
Therapy: should we try to ramp up this response more? • This contributes to reduced systolic function & reserve.
 It would increase contractile response but WORSENS
• There are ways to enhance this signaling which may be
PROGNOSIS (INCREASES MORTALITY)
beneficial even when direct receptor stimulation is
o especially chronically; seems to work fine short- clearly not.
term in acute use but still bad long-term effects
o E.g. PDE3 (phosphodiesterase) – used for years to augment contractility but worsens mortality!
 These changes also affect cardiac relaxation (need to sequester into SR; phospholamban reduced, so calcium
transient falls more slowly, ventricular relaxation delayed, meaning LV pressure increased during initial filling,
elevated diastolic pressures  pulmonary edema

How about blocking it?

 Can REVERSE the downregulation of adrenergic cascade; reverse remodeling
 Use β-blockers to reverse the regulatory changes that chronic sympathetic stimulation causes
o Acutely: reduce inotropic state & HR (counterintuitive)
o Chronically: lead to ↑systolic function, ↓HR (resting), ↓mortality, ↑exercise capacity
 New approaches: gene therapy to upregulate SERCA2a, suppress βARK, enhance specific AC forms
o Calcium sensitizers: trying to get myofilaments to be more sensitive to calcium(more “bang for your buck”)

Similar to replacing heart with Left Ventricular Assist Device:

 unload the left heart; after time, you see an improved response to sympathetic stimulation

Renin-Angiotensin Stimulation
 Vasodilators initially tried to work with fluid homeostasis
 Not all vasodilators worked as well although systemic pressure
decreases were the same

Angiotensin II and endothelin  stimulate Gαq and Gα11 G-proteins

 Angiotensin II – from systemic circulation & within
myocardium itself

Normal Pathway
1. ↓ renal blood flow  ↑renin from juxtaglomerular cells (also
released from sympathetic & β-adrenergic
stimulation) Take Home Message #3
2. Renin: converts angiotensinigin  angiotensin 1 • Sustained activation of the renin/angiotensin system
3. Angiotensin-1  angiotensin II via ACE (also within plays a key role in maladaptive cardiac remodeling and
heart itself) dysfunction.
4. Receptor: Gaq  subunits, activates phospholipase • It stimulates calcium-dependent signaling pathways
C  DAG & IP3  ↑Ca+ • Mitogen activated kinases
• Calcium/calmodulin dependent kinase/
phosphatases
• Triggers reactive oxygen species generation
• Major contributor to pathologic remodeling – e.g.:
dilation, hypertrophy and fibrosis.
24
RAS In Heart Failure
 ACE upregulated
 Increased calcium  kinases / phosphatases
o cardiac remodeling & dysfunction, oxidative stress, myocardial fibrosis, growth
 ATII stimulation:
o Vasoconstriction (increased SVR in CHF)
o Stimulation of thirst (why heart failure patients are always thirsty – last thing a CHF patient needs!)
o Release of aldosterone (more water retention via Na+ reabsorption)
o Cardiac hypertrophy & oxidant stress signaling
o ↑ collagen synthesis by fibroblasts
o ↓endothelial function (less NO effectiveness)

Treatment implications: use ACE INHIBITORS – not just because they reduce afterload, but because they inhibit ATII!

Natriuretic Peptides, cGMP, Protein Kinase G

 Heart is an endocrine organ! Makes ANP / BNP (atrial & brain natriuretic peptides)
 Opposite effects of RAS! cGMP instead of cAMP

Normal Pathway:
 Stimulated by stretch of intracardiac chambers  pre-formed
pro-peptide released, cleaved in circulation to generate active
peptide  ANP / BNP receptor  guanylate cyclase cGMP 
protein kinase G activated
 Effects: “stress response brake”
o ↑ GFR, ↓sodium re-absorption
o Reduces arterial/venous tone; antiproliferative
o Reduces fibrosis and hypertrophy in heart
o Antagonizes sympathetic tone
o Effector of vagal tone
Take Home Message #4
o Reduces renin and aldosterone release • Enhancing cGMP/PKG signaling is a useful strategy to
enhance vasodilator responses and depress maladaptive
In heart failure: cardiac remodeling.
 ANP and BNP are REALLY HIGH (receptor • Whether we can improve intrinsic responses to NPs, or
dysfunction: effects blunted (desensitization) provide a more effective oral treatment (PDE5a inhibitors,
new artificial NP-derivatives) remains to be tested.
Treatment implications: get cGMP up (VIAGRA!)
 NO  cGMP too; Viagra (sildenafil) blocks phosphodiesterase activity

Electrophysiologic abnormalities
 Death in CHF: either pump function fails or arrhythmiasudden
death (1/3 all CHF deaths!)

Normally:
1. Initial depolarization: inward sodium current
2. Early outward potassium current (transient outward Ito) that can have
a potent impact on duration of AP
3. Plateau: largely from inward calcium (L-type channels)
4. Repolarization: postassium channels (inward / delayed rectifiers)

25
In heart failure:
 Ito is markedly reduced
 SR calcium uptake reduced, more reliance on Na/Ca exchanger to get calcium out of cell (slower)
 Repolarizing K currents often depressed
 NET EFFECT: ACTION POTENTIAL DURATION (APD) IS PROLONGED
o Contributes to electrical instability, especially if change isn’t uniform
o Can provoke a secondary triggered excitation: early afterdepolarization (EAD)
 More APDs  more EADs  more chance of arrhythmia & sudden death

Calcium Homoestasis
Normally:
1. small amount of calcium enters with AP (voltaged gated L-type channels)
2. Triggers SR Ca release (much larger) via ryanodine-sensitive channels (RyR)
3. Calcilum interacts with Troponin-C (TnC)
a. reduces TnI effect (TnI is inhibitory; removal lets actin-myosin interaction to proceed)
4. Then have to remove calcium from myofilaments & returned to SR internal store
a. Mostly via sodium/calcium exchanger (NCX) inot SR
b. Also via extrusion into cytoplasm by ATP-requiring channel

In heart failure:
• Reduced expression of SR Calcium ATPase
• Reduced phosphorylation of phospholamban
• Leaky ryanodine Ca release channel
• Reduced and delayed calcium transients
• Increased role of sodium/calcium exchanger
• Increase mitochondrial calcium – damage and oxidant stress

What does that mean?

 Calcium transients slower (slower mechanical transient)
 Action potential plateau lengthened Take Home Message #5
 Systolic response to increased HR is reduced • Heart failure is associated with marked
 Contractility depressed downregulation of repolarizing potassium
 Relaxation prolonged (increases diastolic pressures) currents, and abnormal decay of calcium
transients.
Treatment implications: Drugs don’t really handle it, implantable • The result is prolonged action potentials,
defibrillators work better for these arrhythmias and propensity to arrythmia.

Systemic Vascular Abnormalities

This isn’t just heart failure: the peripheral vascular system gets messed up too
 Remember the 1 vs 2 leg experiment; if just the heart were affected, you’d only be able to do ½ the exercise with two legs

Endothelial dysfunction:
 no normal response to vasodilating stimuli (shear stress, bradykinin, muscarinic receptor agonists)
 abnormal NO synthesis is major contributor
elevated neurohormones (like ATII)  activation of vascular oxidases (NADPH oxidase  superoxide)
o Superoxide + NO  compounds that blunt net dilation response
 Classic expt: endothelial dysfunction in CHF
o if you give a muscarinic agonist, CHF response depressed
o if you expose directly to NO (nitroprusside), bypass endothelium, see normal reaction in CHF

26
Skeletal muscle metabolic capacity impaired
 Like patients on long bedrest
 Reduced oxygen uptake efficiency in muscles (more lack of appropriate vasodilator response)
 Vascular remodeling – inadequate capillary density; can’t support flow adequately

Peripheral neuroeffector systems

 Baroreceptor responses abnormal; resetting of reflexes (sustained sympathetic & vagal withdrawal)
 Less cGMP synthesis, less vasodilation

Summary: what goes wrong in heart failure?

• Complex interaction of cardiac and vascular
pathophysiology.
• Sustained neurohumoral activation results in
myocardial toxicity, downregulated adrenergic
signaling, matrix remodeling and chamber dilation.
• Genotype includes reactivation of fetal genes and
changes in many other genes coding structural,
energetic, EC coupling, and other proteins.
• Abnormal calcium handling depresses function and
reserve.
• Altered ion channel expression/function stimulates
arrhythmia.
• Endothelial dysfunction results in loss of normal
arterial dilator reserve, limiting exercise capacity and
contributing to dyspnea.

27
 Right-sided Heart Failure & Pericardial Disease
Right ventricle: thin walled; more sensitive to pressure & afterload
 (steeper dropoff in stroke volume with increased afterload)
Left ventricle: if you elevate BP, LV still does its job (big & thick muscled)

If you block a toilet, it overflows

 Fluid accumulates behind the affected structure
 If you block anywhere from LV on back, ↑afterload on RV

If you understand plumbing, you know the etiologies of right heart failure

The most common cause of right heart failure is LEFT HEART FAILURE
 Ischemia, HTN, cardiomyopathy, aortic stenosis or regurgitation, congenital heart disease, infiltrative/constrictive processes

Working backwards from the LV to the RV

Mitral valve problems:
 stenosis (less common, rheumatic fever) : see thickened mitral leaflets, very small opening.
o Diastolic dysfunction: LV / LA pressures mismatched (higher
in LA than LV); small LV with big LA
 regurgitation (more common) – can’t close the whole way

Left atrial myxoma (growth / tumor, occludes LA flow)

Pulmonary vein problems: stenosis or veno-occlusive disease (very

uncommon, just include in your DDx of RHF)

Pulmonary disease: close second to LHF as big cause of RHF

 Emphysema (COPD), pulmonary fibrosis, cystic fibrosis
 Chronic lung disease  ↓ pulmonary vascular bed  pulmonary
HTN  RV hypertrophy, dilatation  RV failure

Pulmonary artery problems

 Idiopathic pulmonary HTN
 Occlusion (embolism), stenosis

Pulmonary valve problems: stenosis or regurgitation (usually congenital)

RV dysfunction (primary RV failure) – systolic or diastolic

 Infarction, cardiomyopathy, congenital, restrictive / infiltrative, constrictive
 Restrictive / infiltrative cardiomyopathy: characterized by diastolic dysfunction (stiff ventricles) & normal
systolic ventricular function (amyloidosis, hemochromatosis, sarcoidosis, etc.)

Tricuspid valve: stenosis or regurgitation

28
 If you know the plumbing, you understand the signs & symptoms
Memorizing isn’t nearly as good as actually understanding what’s going on. Now here is a list of things to memorize:

Signs Symptoms
Left heart failure  Rales  Orthopnea
 S3, S4 gallops  Paroxysmal nocturnal dyspnea (PND)
 Mitral regurgitation  Dyspnea on exertion (DOE)
 Pleural effusion  Dyspnea at rest
Right heart failure  Jugular venous distention  RUQ abdominal fullness
 Hepatomegaly  Anorexia, nausea, early satiety
 Ascites  Abdominal swelling
 Edema  Pedal edema
 Right-sided S3, S4 gallops
 Tricuspid regurgitation
Low output state  Tachycardia  Dyspnea
 Hypotension  Fatigue and weakness
 Pallor
 Cool, clammy skin

“Nutmeg Liver” – engorgement of the hepatic venules (chronic liver congestion)

The Pericardium & Pericardial Disease

Normally:
 Decreases friction (heart / other organs); barrier against infection
 Fixes heart anatomically (reduces excessive motion with changes in body position)
 Visceral pericardium is inner serous membrane (single layer of mesothelium)
 Parietal pericardium is outer fibrous layer
 Pericardial fluid is between them – not much, about 50 cc PERICARDIAL DISEASE
 Acute pericarditis (hours-days)
Pericarditis is a lot like arthritis  Pericardial effusion (subacute / chronic)
 Inflammation! & tamponade (generally acute)
 Inflamed surfaces hurt (CHEST PAIN!)  Constrictive pericarditis (chronic)
 Inflamed surfaces make noise if they rub together (crepitus in RA,
PERICARDIAL FRICTION RUB)
 Inflamed surfaces can “weep” (PERICARDIAL EFFUSION)
 Over time, inflamed surfaces can scar

Acute Pericarditis
DDX: ischemic from pericardial pain
Ischemic Pericarditis NEED 2 OF 3 FEATURES
Location Retrosternal Precordial, interxscapular  Chest pain – usually pleuritic
Quality Pressure Sharp (sharp, worse on inspiration)
Worsened Exertion Inspiration / supine position  Pericardial friction rub
Improved Rest Sitting up  Widespread ST segment elevation
on ECG
Duration Minutes Hours / days
± pericardial fluid
Response to NTG Improved None

29
ECG changes:
 ST segment elevation
o Concave UP like smiley face (MI = down)
 PR segment depression

Etiologies:
• Idiopathic, Infection (usually viral), Invasive tumor
• Irradiation, Infarction/Injury (acute MI, Dressler syndrome)
• Connective tissue diseases ,Uremia, Medications

Pericardial Effusion & Tamponade

CXR Changes
 Mediastinum is usually < ½ thorax width
 “Water-bottle” enlargement with pericardial effusion

ECG Changes
 Voltage lowered across the board
 Electrical Alterans: can see alteration of QRS from beat to beat

Echo: see huge circumferential PE

Concept: Heart fills if pressure inside is greater than the pressure outside
 Otherwise it won’t fill!

Transmural distending pressure: different between intracardiac &

intrapericardial pressures
 With pleural effusion, the intrapericardial pressure increases so the
transmural distending pressure decreases
 Heart won’t fill as much, stroke volume decreases
o (lower filling pressure – F-S curve)

The NORMAL PERICARDIUM IS STIFF: resists distension (pressure ↑ quickly

after small amount of fluid accumulates)

CARDIAC TAMPONADE: if pericardial pressure exceeds the pressure in the cardiac chambers, FILLING CANNOT OCCUR
 The heart won’t fill!
 Transmural distending pressure approaches zero (equalization of intrapericardial pressure & RA/RV pressure)
 Cardiac compression occurs:
o SV↓ (close to zero), BP↑, tachycardia, low output state

Pericardial effusion doesn’t usually lead to cardiac tamponade, but it can… depending on:
1. Absolute volume (need enough fluid volume)
2. Rate of accumulation of fluid (faster makes it more likely)
3. Distensibility of pericardium (stiffer means more pressure increase for a given amount of fluid
30
Pulsus paradoxus
 Exaggeration of normal inspiratory fall of systolic BP (not paradox!)
 R & L sides of heart are competing for limiting space PERICARDIAL TAMPONADE:
SIGNS (YOU CAN SEE IT!)
• Decreased BP
• Narrowed pulse pressure
• Tachycardia
• Elevated JVP
• Cool and clammy
• Tachypnea
• Distant heart sounds
• Pulsus paradoxus

NORMAL INSPIRATION PULSUS PARADOXUS

•  venous return •  venous return
• small  in RV size • small  in RV size
• RV free wall expands into pericardial space • RV cannot expand into pericardial space
• very small  in LV size as interventricular septum shifts to left • Significant  in LV size because septal shift is exaggerated
• Very small  in cardiac output and blood pressure during • Larger  in cardiac output and blood pressure during
inspiration (< 10 mm Hg) inspiration (> 10 mm Hg)

Constrictive Pericarditis
Changes:
ETIOLOGY OF CONSTRICTIVE PERICARDITIS
 Pericardium thickened & pericardium • Acute viral pericarditis
 JVP elevated (systemic venous congestion) • Tuberculosis
 RHF Sx: edema, ascites, pleural effusion • Remote bacterial, fungal, parasitic pericarditis
 Early diastolic sound (“pericardial knock” – limit to how much • Connective tissue disease (RA, SLE, scleroderma)
ventricles can fill, makes a noise when it reaches the limit) • Irradiation
 Kussmaul’s sign: inspiratory rise in JVP; absence of JVP fall • Malignancy (pericardial involvement)
• Previous cardiac surgery
 Pericardial thickening on CT or MRI
• Idiopathic
Pathophysiology: “heart in a box”
 Thickened pericardium
 Heart fills rapidly; can only fill to a certain extent & then stops
 “Square root sign” in ventricular pressure recordings: plateau
 When limits of filling met, pressure in diastole is equal in all chambers

31
 Genetics of Cardiomyopathy
Family history is never “noncontributory” – especially in cardiomyopathy
 (Even if it’s just for documentation of pertinent negatives – no FHx of sudden Take home messages:
cardiac death < 55 yo, etc.) Among all types of cardiomyopathy,
genetic forms are common.
“Idiopathic” CM is often undiagnosed familial CM • The family history is always
 Lots of other causes too (ischemia = #1, “idiopathic” = #2) “contributory.”
 Familial forms are frequently missed: Features that co-segregate with
o incomplete pedigrees, de novo mutations, age-dependent phenotype, cardiomyopathies:
incomplete penetrance hurt detection • Muscular dystrophy (DCM)
 Screening family members should be performed for “idiopathic” CM • Hearing loss (DCM – Txn factor)
(DCM, HCM, RCM) – can identify pre-symptomatic cases • Cardiac arrhythmias (DCM –
o Use echo, EKG, or both ion channels)

Patterns of inheritance review

Autosomal dominant: each descendant of affected individual has 50% chance (but
doesn’t mean 50% of a generation will necessarily be affected)

Autosomal recessive: incidence depends on carrier frequency, need 2 copies, consanguinity

increases chance but not required

X-linked: Males with one mutant X have disease (XY), sons of females with mutant X have
50% chance of inheriting, heterozygous female characters can develop dz too (skewed X-inactivation
 Male-male transmission RULES OUT X-linked traits (males only pass on Y to sons)

Mitochondrial (matrilinear): all offspring of affected woman inherit (but can have
heteroplasmy – genetic heterogeneity within mito population – which influences phenotypes)
 Male transmission of any kind RULES OUT mitochondrial inheritance

Hypertrophic cardiomyopathy
 1:500, M=F, some racial factors but present in all ethnicities
HCM: clinical presentation
 Familial = common (other causes too)
AUTOSOMAL DOMINANT is most common mode of transmission • Sx: Exertional dyspnea chest pain,
lightheadedness, and syncope.
Features: • Age @ onset Sx varies according to
 ↑ Wall thickness (>1.3-6cm, nml 0.8-1.2)without increased external load specific mutation & within families
 2/3 have affected 1st degree relative known with the same mutation.
o Sporadic cases: probably de novo, incomplete family • Physical exam: characteristic murmur
screening, or recessive inheritance. and abnormal carotid pulses
o DO FAMILY SCREENING EVEN IF SPORADIC (“bisferiens” = “double tap”).
Morphology can vary (see left diagram)

LV outflow tract obstruction (right): blocking outflow

because of hypertrophy (especially subaortic) –
increased gradient
 Worse with dehydration, exercise, systemic
vasodilation (alcohol), anterior mitral valve leaflet
contacts wall

32
 HCM: DISORDER OF THE SARCOMERE
Can be mutation in any of the sarcomere genes

MYH7 (β-myosin heavy chain) = representative sarcomeric gene

 Present in approximately 1/3 of cases
 associated with worse outcomes (doesn’t translate to clinical practice)

Inheritance can be complex and have modifiers

 E.g. inherit MHY7 from one parent, a different sarcomere gene from another parent  more complicated
disease

NONSARCOMERIC MUTATIONS & HCM

 Nonsarcomeric mutations also possible: often associated with glycogen storage SIGNS & SX OF FABRY DZ
 HCM
Fabry Disease: GLA encoding α-galactosidase A = representative nonsarcomeric gene  Angiokeratomas
 X-linked, 1:40k males (female carriers can have manifestations)  corneal dystrophy
(cloudy corneas)
 associated with aberrant AV conduction
 neuropathy, proteinuria
 Fabry disease: deficiency of α-galactosidase A
o GLA mutation results in globotriaosylceramide (GB3) deposition
o Diagnosis: enzyme activity (α-galactosidase) blood test
 Takes average of 18 years from onset of sx to diagnosis!
o Treatment: enzyme replacement therapy available!

Genetic testing for HCM

 Don’t just do it for curiosity!
o confirm Dx, anticipate manifestations, Pre-sx testing / focused screening in a family, prenatal family planning
 Need proper counseling: cardiac safety is determined by PHENOTYPIC ASSESSMENT
o SNPs can be different from mutation, penetrance can be incomplete
o Personal genotyping becoming more prominent & affordable CURRENT THERAPY FOR HCM
(worrisome when outside medical establishment)  β blockers (control HR/BP)
o Genetic nondiscrimination act: can’t discriminate in employment or health  cath / surgery to reduce
insurance based on genetics subaortic hypertrophy
Who cares? Maybe we could improve therapy?  arrhythmia protection (ICD)

Nonischemic Dilated CM
 Common: 36.5:100k, at least 1/3 familial, in aut-dom forms no racial /
gender factors influence prevalence DCM: clinical presentation
• Sx: Exertional dyspnea chest pain,
Diagnosis: often underdiagnosed
lightheadedness, and syncope, like
 dilation with low ejection fraction & normal LV wall thickness HCM, but also SKELETAL MUSCLE
 Familial: 2+ affected individuals or one 1st degree relative with unexplained WEAKNESS is more common
sudden death <35 yo
 Exclude: HTN, CA stenosis, chronic excess alcohol ingestion, supraventricular arrhythmias,
• Age @ onset Sx varies according
pericardial/congenital heart disease to specific mutation & within
families with the same mutation
Familial DCM genes (like HCM)
• FDCM tends to have more
1. Dystrophin-glycoprotein complex insidious presentation than
2. Sarcomere components acquired CM, but can present with
3. Nuclear envelope components fatal arrythmia
4. Ion channels
5. Cardiac transcription factors
33
 DYSTROPHIN MUTATIONS & DCM
Duchenne muscular dystrophy: mutations in dystrophin (nonsense or deletions)
Becker muscular dystrophy: in-frame deletions or missense mutations (mutant protein) – milder form

 Dystrophin: cytoskeletal protein

o binds actin at amino terminus and DAG (dystrophin-associated glycoprotein) complex at carboxy
terminus
 Other mutations in dystrophin-sarcoglycan complex  FDCM too

SARCOMERE MUTATIONS & DCM

Sarcomere mutations can also cause DCM (not just HCM!)

 Genotype-phenotype correlation: if a parent has DCM and passes sarcomeric
mutation to kid, the kid won’t get HCM
 domains specific to sarcomere-cytoskeletal interface might be
important in causing DCM

NUCLEAR ENVELOPE MUTATIONS & DCM

Several nuclear envelope genes associated with DCM

 Emerin: associated with Emery-Dreifuss muscular dystrophy
 LMNA – encodes Lamin A/C: several disease associations (including pure DCM)
o Nuclear envelope components; Lamin A & C come from same gene with alternate splicing
o Mechanism to cause disease is unknown, also associated with:
 Lipodistrophy, Charcot-Marie-Tooth neuropathy, premature aging (progeria)

ION CHANNEL MUTATIONS & DCM
Normally cardiac ion channel mutations 
arrhythmias (e.g. long QT syndrome)
 2 mutations have been associated with FDCM cases
too (a KATP channel & a Na channel)
CARDIAC TRANSCRIPTION FACTORS & DCM
Hearing loss + DCM co-segregating in one family
 Analysis found a mutation in a cardiac transcription
factor mutation (weird)

Restrictive Cardiomyopathy
Odd, rare form of CM: LV wall thickness & EF are NORMAL
 Severe stiffness  low CO, atrial dilation, CHF
 Familial RCM well described, many cases “idiopathic” – probably RECESSIVE
 Age of onset: neonatal to late adulthood, often late recognition (hard to recognize: not thick or weak)
o ± skeletal myopathy

Genetics:
 SARCOMERE GENES (troponins, MHY7 / β-myosin HC, etc.)
 NON-SARCOMERE GENES
o Nuclear envelope (LMNA: Lamin A/C)
o Cytoskeleton (DES – desmin)
o Familial Amyloid (TTR – transthyretin)

Familial amyloidosis
 Amyloid deposited in heart, nerves, kidneys, lungs
 Caused by mutations in TTR, which encodes transthyretin
o carrier of thyroxin & retinol, aka pre-albumin, tetrameric but can misfold & accumulate if mutated

34
  4% of African Americans in US have allele associated with late-onset cardiac amyloidosis

Arrythmogenic Right Ventricular Dysplasia (ARVD)

 Fibrofatty replacement of myocytes, especially right ventricle
 Prominent ventricular arrhythmia (patchy ventricular scar), can present wi th sudden cardiac death

GENETICS: DESMOSOMAL CELL JUNCTIONS

 Genetic heterogeneity
o Naxos syndrome: recessive form on island of Naxos, skin thickening
(plakoglobin mutation)
o Homozygous mutations in desmoplakin: similar phenotype + wooly hair
 Any of the components of cardiac desmosome can be mutation target

Management of ARVD:
 Frequent clinical screening for family members
 Focused screening for family post-genetic testing
 Lifestyle modifications (decreased athletic activity) to delay / prevent manifestations

Overall Summary (from notes)

• HCM is usually caused by mutation in elements of the sarcomere.
• FDCM may be caused by alteration in cytoskeleton, sarcomere, ion channels, nuclear envelope, or transcription factors.
• RCM may be infiltrative (like amyloid).
• As we improve our understanding of the pathogenesis of cardiomyopathies, better rational therapies should improve
outcomes for these disorders.

FAMILIAL… DESCRIPTION TARGETS MUTATIONS OTHER

Thick wall with no MYH7 (β-myosin heavy
Sarcomere
extra external load; chain) in 1/3 cases
HCM Prevalent, mostly Non-sarcomeric (often Fabry Disease: GLA encoding
autosomal dominant Enzyme replacement therapy
glycogen storage) α-galactosidase A
Dystrophin (Duchenne,
Dystrophin-glycoprotein Cosegregation with muscular
Becker muscular dystrophy),
complex dystrophy
also DAG complex
Similar to HCM but location Genotype-phenotype
Sarcomere components
Dilation, normal wall different? correlation
thickness, lowered Emerin (Emery-Dreifuss LMNA mutations: lipodistrophy,
DCM EF; skeletal muscle Sx
Nuclear envelope
muscular dystrophy) Charcot-Marie-Tooth neuropathy,
more common components premature aging (progeria)
LMNA (Lamin A/C proteins)
Also associated with
Ion channels
arrhythmias
Co-segregation with hearing
Cardiac transcription factors
loss
Rare, LV wall Sarcomere genes Various
thickness & EF are 4% African-Americans have
NORMAL, severe Familial Amyloid TTR – transthyretin allele associated with late-
RCM stiffness  low CO, onset cardiac amyloidosis
atrial dilation, CHF, ± Non-sarcomere genes Nuclear envelope (LMNA),
skeletal myopathy (others) cytoskeleton,

35
 Principles of Electrocardiology

Conductivity Review
Action Potentials:
 All heart muscle cells can have APs; characteristics (speed, duration, upstroke, etc.) of the AP depend on the
distribution of ion channels (Na / K / Ca)

Ion channels & stuff: quick review of the “rhythmic opening & closing of channels”
 Remember the Nernst equation: ions flow to until their
electrostatic & chemical potentials are at equilibrium
 Gradients set up by use of ATP’s energy (Na/K pump, for example)
 Membrane potential:
measurement of voltage of inside vs outside of cell
o Na+, Ca+ are high outside, K+ high inside
o so if Na channel opens, for example, Na flows in, + charge
accumulates inside, and membrane potential is positive

AP review
 Key point: it’s this rhythmic oscillation of channels opening &
closing that makes an action potential
 Resting  activated  DEPOLARIZES (positive Vm) 
REPOLARIZES (negative Vm)

Description (fyi):
1. At rest, K predominates (negative potential)
2. Depolarization: incoming AP triggers Na channel opening; increase in voltage
closes K channels, magnifying effect; upstroke is result (shoots towards E Na)
3. Plateau: Voltage-gated Ca channels open more slowly, maintain potential around
zero, close gradually. Not many channels open here, so susceptible to perturbation in this stage
4. Repolarization: Ca channels close, K channels open, shoot
down towards K’s negative potential

Conduction:
 SA node (pacemaker) through atria
 AV node (rest of the connection between atria
& ventricles is fibrous; the AV node conducts
slowly - delay) 
 His –Purkinje system (rapid) via bundle
branches, then purkinje fibers 
 Arrives pretty much simultaneously on inner
surface of ventricles; propogates outward
through ventricles

Characteristics of a few special APs

 Purkinje: rapid upstroke, TONS of Na channels
 Sinus node: slower rise (fewer Na channels)
o Has automaticity (leaking in positive charge – funny current – during resting phase)
o Other parts of heart have it too; sinus node is normal propagator though

The width of the AP determines refractoriness: a prolonged plateau means it’ll take longer to be able to fire again
 Sodium channels need to be “re-set”

36
 ECG Basic Principles

 Interface between depolarized (positive potential inside) and re-polarized (negative potential
inside) cells is key (not just the existence of a depolarized & re-polarized part of the heart

 Depol/Repol interface makes a battery: the EXTRACELLULAR current is propagated throughout

the body and sensed by the ECG leads

 If the “measurement vector” of your leads (- +) matches up with the “battery” vector from
the heart, you get a positive deflection (negative if it’s reversed, no deflection if perpendicular, etc)
Walking through a normal contraction on ECG

P-wave: Atrial QRS Complex: Septal depolarization from LR (↑in III, ↓ in I/II, note ST: everything T-wave: last cells to depolarize
Depolarization: that Q is first downstroke and R is first upstroke with S following – weird), is depolarized, (epicardium) are first to repolarize,
SA to AV node, then Apical depolarization (septum cancels, pointing towards apex); L no interface, because they have shorter APs
corresponds to ventricular depolarization is last because the big thick wall of the LV should be (although it’s close, since others
contraction of takes a while to depolarize) isoelectric started their APs early – can be
atria perturbed). Should be in same
direction as QRS complex.
Delay at AV node (pretty slow) – return to baseline
(active interface is tiny!)

37
 ECG math

Paper goes at 25mm/sec

1 little box = 40 ms
1 big box = 200 ms

Normal Values
Start of atrial contraction to
P-R Interval 120-200 ms
start of ventricular contraction
QRS Interval < 120ms Ventricular contraction
(80 nml)
< ½ of Ventricular contraction &
QT Interval
cardiac cycle repolarization

Calculating HR:
 Measure R-R in big boxes
 HR = 300 / # big boxes
 Or: count number of boxes and use the chart to the
right (300, 150, 100, 75, 60, 50, 43, 37)

Augmented Leads
 Calculated from the other leads (not actually physically placed)
via some sort of mathemagic
 aVR, aVL, aVF
 See diagram for where they’re pointing
 Complement I, II, II

QRS Axis Determination

Draw a figure like in the example below if needed. (0° is lead 1, bottom of circle is positive)
The QRS axis is wherever the QRS is most positive, but that’s hard to eyeball

1. Find most isoelectric lead out of the frontal plane leads (QRS up = down)
2. Figure out what’s perpendicular to that lead, since that’s where the axis will be
3. Look at a lead pointing in that direction.
a. If it’s positive, that’s where your axis is
b. if it’s negative, the axis is in the opposite direction
4. Figure out if it’s
a. normal (-30° to +100°
b. left axis deviation (> -30°)
c. right axis deviation (> +100°)
d. extreme axis deviation (between -180 and -90)

Example (+90° mean QRS axis; lead I is isoelectric and lead aVF (right) is positive

38
 Precordial (chest) leads

V1 on right, V6 under axilla

All use a combination of I, II, III

as the negative electrode:
PUTS IT RIGHT IN THE CENTER
OF THE HEART

The 12-Lead ECG

Note that there’s no break in time across the 3 lines: just

changing views

 (can go between I and aVR and V1 and V4 to calculate

heart rate, for instance)

LV Hypertrophy
 Wide QRS:
ventricular phase takes longer
(more muscle mass)
 LARGE QRS voltage
tons of muscle mass = more interface
 Abnormally leftward axis deviation
spending more time pointing towards left side of
heart
 T-wave inversion
sign of problems with depolarization – means
that the depolarization phase takes too long
(e.g. too much muscle mass, so the outside-in
depolarization is reversed (inside-out)

39
 Right Bundle Branch Block (RBBB)
 Wide QRS:
takes longer because the impulse has to go
from the left ventricle to the right ventricle,
not using His-Purkinje system
 Rightward directionality at end of QRS
spreading from LV to RV – NEGATIVE in lead I
 T-wave inversion (vs changed QRS)

Left Bundle Branch Block (LBBB)

 Wide QRS:
takes longer because the impulse has to go from
the RV to the LV – not using the His-Purkinje
 Left axis shift
depolarization proceeds more totally towards LV,
spreading from RV
 Often confused with LV hypertrophy (but LV
hypertrophy has higher voltage)

See right for a comparison of normal, LVBB, RBBB

in V1 (right side of chest) and V6 (left side of chest)

40
 What happens in MI
THINGS TAKE LONGER IN INJURED TISSUE

In systole, the depolarization wave is spreading towards the

infarcted tissue, but the infarcted area takes longer to depolarize
o it’s “repolarized” vs the depolarized tissue around it, and it stays
“repolarized” even when it’s supposed to have been
depolarized (during the ST segment, when the whole ventricle’s
supposed to be depolarized and therefore isoelectric).
o This means that this part of the ECG (the ST segment) will be
elevated in leads that are pointing towards the infarcted area –
it’s like a fake continued wave of depolarization heading
towards it

In diastole, the infarcted tissue (on the outside) is supposed to

depolarize first, but it takes longer instead
 It’s depolarized even as tissue inside it starts to repolarize.
 This means that this part of the ECG (diastole & P wave) will be
depressed in leads pointing towards the infarcted area – it’s
like a depolarization wave heading inwards from the infarcted
tissue

 The ECG re-sets the baseline for this new depressed

level, making the ST seem even higher

ST Elevation: in leads overlying the MI territory

41
 Arrhythmias - Introduction
Arrhythmia: abnormality in the timing or sequence of cardiac depolarization
 tachyarhythmias: HR > 100bpm
o Automaticity: normal or abnormal
o Triggered activity
o Reentry
 bradyarrhythmias: hr < 60 bpm
o Abnormal impulse formation or conduction
 Sx: asx, palpitations, SOB, syncope, sudden death

Tachycardia
1. Normal automaticity
Normally, slow depolarization during phase 4 in certain cells  hit threshold  fire AP
Sinus node has most rapid phase 4 depolarization (60-80bpm, like resting HR)
 usually predominates & controls HR, responds to catecholamines, etc
 other pacemakers present too! Backup for SA node
o AV Node (for instance) has slower (~50bpm) automaticity (His bundle too)
o Purkinje fibers: slower (~30-40 bpm)
P-R interval: caused by delay at AV node Classification of Cardiac Arrhythmias
Chamber in which they arise
Normal automaticity causes SINUS TACHYCARDIA  Ventricular - confined to the ventricles
 Exercise, catecholamines, etc. – stimulate faster HR  Supraventricular - involve the atrium
 Phase 4 depolarization @ SA node enhanced
Mechanism of the arrhythmia
(faster depol – faster firing)
 Automaticity
 Peak HR = 220 – age  Triggered Activity
 Reentry
2. Triggered Activity
ECG Characteristics
Early afterdepolarization: happens during phase 3 of initiating beat
 Rate
 ↑ Ca influx  Morphology of the P wave or R wave
 Associated with conditions that prolong AP
(antiarrhythmic drugs, Long QT syndrome) Duration:
Late afterdepolarization: happens after you’ve returned to baseline  Sustained (> 30s)
 Associated with conditions that increase intracellular Ca (digoxin  Nonsustained (<30s)
poisoning)
3. Reentry
 Most important & most common
 Looping around of pulses
Requires:
1. A circuit (either anatomical or functional)
2. Slow conduction in one direction
3. Differing refractory periods which cause
unidirectional block
a. The fast pathway is refractory for longer than the slow
b. If a premature impulse (PAC for example) hits the two
pathways, the fast one will be still be refractory while the
slow one will conduct (has a shorter refractory period).
c. By the time the impulse goes through the slow pathway, the fast pathway is ready to go, and a loop starts.

Bradyarrhythmias
 Can be from either abnormal impulse formation or abnormal impulse conduction

42
 Superventricular arrhythmias

Sinus Tachycardia (an automatic SVT)

 From sinus node (increased symp tone, e.g.
exercise)
 Atrial rate = 100-180 bpm
 220-age = expected max heart rate
 P-wave morphology normal

Doesn’t mean it’s benign: e.g. bit GI bleed, crazy

catecholamine release, etc.

ECG: just looks normal but firing more quickly

Multifocal Atrial Tachycardia (a triggered SVT)

 Multiple foci in atria give rise to contractile responses (not just the SA node like
normal)
ECG:
 See multiple P-wave morphologies
(different foci at work)

Atrial Flutter (a reentrant SVT)

 One big reentrant circuit usually in the RIGHT ATRIUM
o Treat via cath ablation (cavotricuspid isthmus)
 In structural heart disease or idiopathic
 ↑ risk stroke (stasis: not contracting atria well)

ECG:
 Atrial rate (250-350) > ventricular rate (often 150)
– multiple Ps for every QRS
o Can have 2:1, 3:1, etc. block: every other or
every third pass by the looping RA current makes
it through the AV node; others are blocked (AV
refractory)
 Regular SAW-TOOTH flutter waves (p-waves)

Atrial Fibrillation (a reentrant atrial arrhythmia)

Trigger: rapid firing from PULMONARY VEINS 
multiple reentrant wavelets in atria (functional re-entry)
 More than just single loop of atrial flutter
Epidemiology:
 Men > women (2:1), more common in increased age (>50),
 Structural heart disease, ethanol (e.g. after New Year’s), hyperthyroidism
(check thyroid levels!) too

43
Symptoms: palpitations, dyspnea, fatigue, HF from rate-related cardiomyopathy, asx
 5x risk of stroke, increased with CHADS score (HF, HTN, >75yo, DM, prior stroke) – give coumadin

ECG:
 Atrial rate (350-600) > ventricular rate (note:
faster than atrial flutter)
 P-waves may be indiscernible (quivering)
 IRREGULARLY IRREGULAR ventricular
contraction (no pattern even in irregularity)

AV Nodal Reentrant Tachycardia(AVNRT) (a reentrant SVT)

 Circuit develops in region of AV node
 Abrupt onset & termination

Epidemiology: young people & mid-life (50s) – bimodal distribution

 Most common cause of paroxysmal supraventricular tachycardia (PVST): regular,
rapid, starts & stops suddenly

Atria & ventricles firing at same time

(see pulsation in neck from atria contracting against a closed mitral/tricuspid valve)

Tx: cath ablation of slow pathway

ECG:
 Atrial rate = ventricular rate (130-220 bpm)
 P-wave usually not visible (atria & ventricles firing at same time)
although picture to right shows it in ST segment

Atrioventricular Reciprocating Tachycardia (AVRT) (a reentrant SVT)

 Re-entrant circuit in atrium, AV node, ventricles (as per name) and accessory pathway
 Accessory pathway: runs between atria & ventricles (alternate, faster way for conduction to go rather than the
slow AV nodes). Like a mispl
 Impulse: can go forwards, backwards, or both

Epidemiology: Young people

 Most common cause of paroxysmal supraventricular tachycardia (PVST) in CHILDREN > 5 yo (regular, rapid,
starts & stops suddenly)

Wolff-Parkinson-White syndrome (pre-excitation of ventricles via accessory pathway): increased risk of sudden death
 AVRT in WPW can more easily degenerate into ventricular fibrillation (AV node’s “filtering” effect removed by
presence of accessory pathway – just conduct those atrial impulses right on through to ventricles)

ECG:
 atrial rate = ventricular rate (140-240 bpm)
 Specific manifestation depends on what’s going on

44
 1. Pre-excitation (WPW syndrome) via accessory pathway: not tachycardia yet
a. Normal SA node impulse  atria  to ventricles via AV node (slow) and
accessory pathway (faster)

b. Results in characteristic UP-SLOPING P-R

i. Called a delta (δ ) wave

2. Concealed accessory pathway: if there’s only retrograde conduction, not a big deal (as long as
the atria are still refractory

3. ARVT: in setting of WPW syndrome

a. Premature atrial complex

fires, blocked in the
accessory pathway (still
refractory from previous
beat) but conducts through
AV node.
PAC in WPW  AVRT: accessory As AV-transmitted impulse spreads through
b. Impulse travels down pathway still refractory from previous ventricle, accessory pathway is ready to conduct:
through ventricle and back beat; AV node conducts it retrograde conduction & circuit established.
up to atria via accessory
pathway (got impulses moving retrograde through the accessory pathway now)

c. Circuit now formed: atria  AV node  ventricle  atria via accessory pathway

d. ECG: see PAC (early P-wave) and inverted P-wave in

inferior leads (conduction upwards through atria instead of
downwards from SA node)

4. Atrial fibrillation with rapid ventricular response can result

a. High risk of sudden cardiac death for patients with WPW
b. AVRT  Atrial flutter / atrial
fibrillation  VENTRICULAR
FIBRILLATION
i. (via accessory pathway,
whereas AV node filters
beats in most people)

Treatment for WPW: Cath ablation of accessory pathway

 See disappearance of pre-excitation delta wave in QRS during catheterization

45
 Ventricular Arrhythmias

Idiopathic Ventricular Tachycardia (an automatic VT)

 From right ventricle outflow tract (*) – a “runaway

pacemaker” there

 Happens with ↑symp tone (exercise) in patients with

normal ventricular function

 Good prognosis
o Note that you can have a benign v-tach with a
normal heart

Treatment: drugs or catheter ablation

 (Tx for quality, not quantity, of life)

ECG:
 Ventricular rate ≥ atrial rate
 Wide QRS but regular
o (only get narrow QRS if
going through His-
Purkinje)

Monomorphic Ventricular Tachycardia (a reentrant VT)

 From ventricle (esp. prior MI): re-entry around scar
o Most common in pts with structural heart disease
o HIGH RISK OF SUDDEN DEATH

ECG:
 HR 100-250
 Ventricular rate ≥ atrial rate
 Regular, wide QRS morphology
 Pretty much looks like idiopathic VT but a
little more complex? Patient is key.

Ventricular Fibrillation (a reentrant arrhythmia)

 From multiple reentrant wavelets in ventricle (functional reentry)

o “bag of snakes” – ventricles just quivering
 Most common cause of sudden death
o Esp. occurs in setting of structural heart disease (ischemic dz > CMs, 1°
electrical disease like long QT)
o 80% have CAD, 15% CM, 5% are structurally normal

Treatment
 Lethal if not treated with cardioversion
 ICD for high risk patients (detect & prevent)

For V-fib to start, you need overlap:

46
  cardiac abnormality(CAD / CM / ARVD / valvular / congenital / electrical)
 initiating event (drugs / electrolytes / ischemia / stress / exercise)

ECG
 Ventricular rate (350-600 bpm) > atrial rate
 Irregularly irregular QRS complexes

Torsade de Pointes (a triggered ventricular arrhythmia)

 Must happen in setting of INCREASED QT INTERVAL

o Drugs (antiarrhythmics) or LQT syndrome (congenital)
 Arises from ventricle
 HIGH RISK OF SUDDEN DEATH

ECG:
 Setting of long QT interval
 “twisting of the points”
(undulating QRS amplitude)
 Rate > 200bpm

47
 Bradyarrhythmias

Sinus Bradycardia (abnormal impulse formation)

 HR < 60 BPM
 From decreased firing of sinus node
 Can be physiologic, e.g. in athletes, or during sleep

Sick sinus syndrome: gradual scarring & loss of cells from SA node

ECG: normal P-wave morphology

(unless junctional escape mechanism; then you’d see inversion in inferior leads maybe?)

First Degree AV Block (abnormal impulse conduction)

 Slowing of conduction from atrium to ventricle
 Usually within AV node (more rarely in R/L bundles)

Causes:
 High vagal tone
 Drugs (calcium blockers)
 AV node / conduction system degeneration

ECG:
 Prolongation of PR interval (>200ms) by def’n
(takes longer to get through AV, so P and R separated )
 1:1 AV (P/R) relationship: every beat gets through

Second Degree AV Block (abnormal impulse conduction)

 Intermittent block of conduction from atrium to ventricle

o E.g. 2:1 block, 3:1 block, etc.
 Either a block in AV node or both bundle branches

Causes: same as 1st degree AV block

 High vagal tone, Drugs (calcium blockers), AV node / conduction system degeneration

ECG:
 2:1, 3:1, etc AV relationship: some beats getting through
 Multiple Ps for every R

Third Degree AV Block (abnormal impulse conduction)

 Complete block of conduction from atrium to ventricle

Causes: usually structural heart disease

Treatment: PERMANENT PACEMAKER
48
ECG: atria and ventricle doing their own things, separately
 No AV relationship
o Atria: P-waves marching along as per sinus node (e.g. 75bpm)
o Ventricles: QRS complexes at their own rhythm (depends on block location)
If block is… high (“junctional escape”) low
Pacemaker for ventricle AV node Purkinje, other ventricular cells
QRS complex Narrow (using His-Purkinje) Wide (coming from lower down)
Ventricular rate 40-50 bpm 30 bpm

Junctional escape shown in ECG to right

Diagnosing cardiac arrhythmias

 Clinical history
 ECG
 Event monitors: can wear ‘em around, they record stuff, look at it later, some implantable
 Electrophysiology studies (e.g. cath, use computers, big fancy stuff)

A random aside: neutrally mediated hypotension (= vasovagal syncope = fainting)

Causes: emotional or standing / venous pooling

 Alcohol can play a role too
 About 1/3 population has genetic tendency
Symptoms: Feel warm, sweaty, nauseated, like you should sit down, visual fields constrict
Treatment: hydration, salt, fluid, education
Testing: tilt table (muscles don’t contract, pool more blood in legs)

How’s it happen?
 Low venous return (LV volume down)
 Baroreceptors  increase sympathetic tone
 HR increases, but your ventricle is empty
 Mechanoreceptors increase vagal tone, decrease
sympathetic to settle heart down
 Bradycardia & vasodilation result  syncope

49
 Device Treatment of Arrhythmias
Diagnosis comes first
Tools: can use ECG, monitors, electrophysiology studies
SYMPTOMS OF ARRHYTHMIA
Treatment principles  Palpitations (an awareness of one’s heartbeat;
 Treat inciting factor usually rapid & irregular)
 Devices  Chest discomfort (“pressure / tightness”)
 Drugs (often as adjuvant)  Dyspnea
 Mechanical disruption (catheter or surgery)  Lightheadedness, dizziness, syncope
(transient loss of consciousness & postural tone)
 Heart failure & sudden death

Treatment of Bradycardias
Sinus node dysfunction
 TACHY-BRADY SYNDROME (periods of tachycardia & periods of bradycardia)
 AV block, heart block

Treatment:
 Reversible causes (drugs, endocrine disorders (hypothyroidism), lyme dz, inferior MI)
o Fix the cause!
 Irreversible causes (degenerative dz, HTN, diabetes, cardiomyopathy)
o More common to have irreversible causes (especially in elderly)
o PERMANENT PACEMAKER

Pacemakers
 Initially developed for bradycardia
 Standard Tx for most symptomatic bradycardia
 Now implanted in 1 hr in fluoroscopy room, generators can last 6-10 yrs, leads >20yrs

Basic idea: generate a pulse, electrons flow from cathode (tip) to anode (ring)
 “capture” (depolarize) adjacent myocardium & impulse spreads

Single-chamber: single ventricular lead, paces & senses ventricle only

 Implanted on left side of body @ heart apex

 VOO (“asynchronous” ventricular pacing): single

timer (if rate is 60 bpm, fires every second)

 VVI (“demand” ventricular pacing): Sense & pace ventricle

o Timing cycle has a lower rate limit (say 60 bpm)
 Timer starts; if no event sensed in 1 s, fires
 If event sensed, doesn’t fire, timer reset
o Pacemaker syndrome: No coordination between atrium and
ventricle, could feel pulsations in neck (atrial pulse wave hits closed tricuspid valves, shoots back up IVC)

Dual chamber: Atrial & ventricular leads; DDD = dual chamber pacing / sensing
 Implanted on right side of body (pectoral placement)
 Majority of pacers in US for pts in sinus rhythm

50
  Preserves AV
coordination
 One lead in atrium,
another in ventricle; use
series of timers / intervals
to preserve coordination

Biventricular pacing
 Coordinate contraction of ventricles (one lead in each ventricle & one in
atrium)
 A.k.a. “cardiac resynchronization therapy” (CRT)
 Used for DCM & conditions with asynchronous ventricular contractions

Treatment of Tachycardias

Re-entry tachycardia: cut the circuit!

Radiofrequency ablation
 Used to do surgery with scalpel, open heart

 Now cath & use low energy localized burn from radiofrequency tip on end of catheter

 Resistive heating & cauterization result with minimal tissue

disruption
o Initial inflammatory response  fibrosis (2-4 wks)
o Can’t conduct through fibrosed area!

Syndrome Circuit
WPW syndrome Accessory pathway  pre-excitation (rising delta wave in PR)
AVRT Retrograde through Accessory pathway  tachycardia after APC in WPW
AVNRT (AV-nodal reentry) 2 pathways around AV node area (slow/fast) – makes loop
Atrial flutter Around tricuspid valve

WPW: treat with

 Drugs (block AV node, antiarrhythmics – slow conduction in AV node and bypass tract)
o Only 30-50% rendered Asx, no idea if risk of death reduced
 Catheter ablation – cut the circuit and see immediate delta wave removal
 90-95% successful (w/o recurrence)

AVNRT:
 Similar response to drugs as WPW
 Ablate that sucker (>95% success w/o recurrence)

Atrial flutter: ablate it! connect tricuspid valve & IVC with a series of lesions
 95% successful

51
Atrial fibrillation: technically a reentrant arrhythmia but crazy patterns (not just ring)
 Source: pulmonary veins as triggers / drivers, chaotic

Treatment of A-fib:
1. Anticoagulants! Warfarin to prevent stroke (thrombus formation with stasis!)
o 90% from LA; can embolize to brain, intestine, leg, CA
o Risk 3-5% / yr, reduce 65% with warfarin

2. Control ventricular rate (AV nodal blockers) – ventricular rate depends on AV node in AF!

3. Electrical cardioversion in symptomatic patients to restore sinus rhythm

o Follow with antiarrhythmic drugs or surgical / catheter ablation to maintain sinus rhythm
 Can suppress triggers (beta blockers, Ic AAD)
 Can prolong refractoriness (III AAD)
 Limited efficacy (only 30-60% stay in sinus rhythm

4. Long-term control: surgical or cath ablation

o Surgical: the “Maze operation” – divide atria into compartments to isolate recurrent wavelengths,
isolate pulmonary vein triggers
o Cath ablation: reproduce some of surgical Maze operation but with cath ablation
o Want to ELECTRICALLY ISOLATE focal pulmonary vein trigers

Electrical (DC) Cardioversion

Apply high energy DC current across precordium
Terminate all cardiac electrical activity, allows sinus rhythm to resume
 Terminates nearly all tachycardias,
 but doesn’t mean they’ll stay in sinus rhythm

Focal arrhythmias

Atrial tachycardia: non-reentrant, focal (automatic)

 results in distinct P-waves on ECG
(multiple foci)
 can happen anywhere in RA or LA

Treatment:
 Map conduction via crazy lab techniques & 3d models
 Suppress the focal source
o Medication that suppresses automaticity can help:
 β-blockers (metoprolol, atenolol)
 Ca channel blockers (diltiazem, verapamil)
 Type Ic AAD (Na – flecainide)
 type III AAD (K - sotalol, amidarone)
o Ablation with catheter of focal source

52
 Ventricular Fibrillation
 Mechanism similar to AF but not well understood

ACUTE TREATMENT: SHOCK IT (immediate external defibrillation)

Subacute treatment:
 Look for underlying cause (acute MI, electrolyte imbalance, drug/med intoxication)
 Suppress with IV meds, esp. if recurrent: amiodarone (III), β-blockers (II), lidocaine (Ib)

Long-term treatment: Implantable Cardioverter-Defibrillator (ICD)

 Delivers DC current between can & coils
 Can perform all pacemaker functions
 Detects VF (2-4s), capacitors charge (2-10s), re-checks, delivers 10-36J
 Stores pre-shock ECG to look at later!

FOR:
 SURVIVORS OF VF/VT better than amiodarone for VF/VT pts
 PRIMARY PREVENTION of VF/VT (most are now preventative)

Ventricular Tachycardia
 Usually re-entrant, especially in ventricular scar tissue
 Treatment: like VF (defib to sinus rhythm, use drugs short-term , ICD for long-term protection)
o Sometimes can use surgery (depends on VT)

Summary

Bradycardia: Pacemaker Fibrillation

Reentry: Cut the circle AF: Complex, evolving management

• Medication to slow/block conduction • Anticoagulation to prevent stroke
• Catheter ablation at critical point • Control of ventricular rate
• Rhythm control in selected patients
Focal: Suppress the focal source
• Medication or catheter ablation VF (and most VT)
• External defibrillation
• ICD long-term

53
 Valve Pathophysiology
 Valve lesions cause heart murmurs
o If there isn’t a murmur, you’ve pretty much ruled out valvular disease Regurgitant lesions
 Symptoms of valvular disease reflect what has happened to ventricles and lungs demand a diagnosis
 Prognosis: depends on acuteness and etiology  Can be sx of something
o Prognosis has significant effect on treatment decision-making more serious
 Severity: assessed more than pulses, etc. than by the murmur itself
o Venous pulses, arterial pulses, etc. let you predict what you’re going to hear Stenotic lesions ‘are
what they are’
Aortic Stenosis  mechanical obstruction
is the problem, replace
Hemodynamics
when symptoms
Basic idea: demand it
1. Baroreceptors trying to maintain arterial pressure: note that femoral artery
tracing is normal!
2. Means you have to generate a really high LV systolic
pressure to get that arterial pressure up.

Results:
• ‘Gradient’ between LV and aorta during systole
• High LV systolic pressure
• Left ventricular hypertrophy
• Arrhythmia & sudden death can result (kind of like HCM)
• Diastolic dysfunction - LV ‘failure’
• Slow / poor LV filling from hypertrophy
• Coronary blood flow compromised (angina) – subendocardium more compressed, less blood flow getting through,
more meat to perfuse, etc.

\Magnitude of gradient depends on stroke volume

 If heart valve weakens, the stroke volume decreases (LV pressure decreases)
 Means the gradient can fall if patient not doing well – you can be fooled!
 Looks like a small gradient but can be big stenosis; heart just isn’t generating enough pressure to create the gradient.
 Can calculate valve area (not common in clinical practice) from looking at pressure difference,
etc. – will still be small valve area even if the heart is failing and pressure gradient is falling.

Etiologies
• Congenital - bicuspid or otherwise deformed valve
– presents younger, with signs of a mobile obstructed valve
– Can still move the valve
• Senile calcific
– presents older, signs of a ‘rock-pile’
– Tends to be more immobile

On Exam
Bicuspid aortic valve
 PCG (phonocardiogram):
o Ejection sound:
 Bicuspid aortic valve  makes sound on opening (x is opening noise, before it is MV closing)
o Systolic ejection murmur (crescendo – decrescendo: “SM”)
 Generated in outflow tract , aortic stenosis is classic cause. Finishes before 2nd heart sound
 Carotid pulse: upstroke has vibration & is slower

54
Senile calcific
 Don’t hear ejection sound
 Second heart sound is inaudible
o soft aortic closure – reduced movement of valve with severe stenosis
 Late-peaking systolic ejection murmur
o can be mistaken for pansystolic murmur

Severity of aortic stenosis

1. Slow-rising carotid pulses
• (parvus et tardus – slow & late)
2. Murmur - late-peaking is more severe
• intensity no guide – if you have Ao stenosis with a low pressure gradient,
e.g. in HF, you’ll have a less intense murmur!
3. S2 (aortic closure) may be soft
4. ECG: LVH findings (increased QRS amplitude, esp. precordial leads, increased QRS width, etc.)
5. Echocardiography

Prognosis:
 Usually doing fine for most of life
 When severe symptoms start up (LVH angina, syncope, HF, etc),
it’s time to intervene with surgery
 Can follow pressure gradient and intervene with surgery before
this kind of stuff starts up

Chronic Aortic Regurgitation

Hemodynamics: “Volume regurgitation”
 Low diastolic arterial pressure Etiologies
o Ao valve incompetent, blood flows back in, diastolic pressure ↓ Valve leaflet lesions
 Large stroke volume • bicuspid valve
• myxomatous valve
o Trying to push out a lot to keep arterial pressure up
• endocarditis
 Dilated hypertrophied LV • rheumatic
o Can tolerate well as long as your ventricle can pump out enough Aorta diseases
blood to keep up the arterial pressure • Marfan’s and other
 Wide pulse pressure connective tissue diseases
• Arteritis - giant cell, syphilis
On exam Mixed
• Low diastolic blood pressure • Ankylosing spondylitis
• Bounding pulses: “can see them across the room” – wide pulse pressure • Reiters
– Quincke’s sign: wide pulse pressure – press on nail, see pulsation of “pinkness”
– Corrigan pulses: bounding carotid pulse
– De Musset’s sign: rhythmic nodding or bobbing of head with heart beats

• Duroziez’ sign: for lots of aortic regurgitation

– press on artery, hear diastolic murmur if you put stethoscope upstream of where you’re pressing (blood flowing
backwards in artery because of the regurgitation!)
• Hill’s sign: big difference between popliteal & brachial systolic cuff pressures (higher in legs than arms)

• Displaced PMI (heart is bigger)

• Diastolic murmur: early diastolic murmur (starts synchronously with S2)
– Intensity doesn’t really help with severity (length can help – longer = more severe)

55
 Acute aortic regurgitation
Etiologies:
• Endocarditis
• Aortic dissection

Hemodynamics: not a “volume regurgitation” but a “pressure regurgitation”

 Very different from chronic Ao regurgitation:
1. Diastolic pressure in ventricle transmitted into aorta
2. Don’t have the big ventricle to help compensate
3. Diastolic pressure high (aortic pressure transmitted back into LV)
4. Forces MV closed during diastole (not filling!)
 Normal LV chamber size & stiffness (acute process; no time for LVH)
 Diastolic pressure not low: not flowing back into big LV (LV pressure high!)

On Exam:
 Normal diastolic pressure
 Pulses small volume
(not big bounding pulses)
 Inconspicuous murmur
 Austin Flint murmur: especially in acute
or rapidly worsening AR
 Low frequency rumbling late in diastole heart at apex (MV area)
 Rise in LV diastolic pressure (from regurgitation)  closes MV prematurely  forward flow from LA shut off 
vibration of leaflets of MV cause rumbling
 See picture: early diastolic murmur (arrowhead) + A-F murmur (arrow)

Mitral Stenosis

Etiology: almost always rheumatic

 See less in USA now (antibiotics for S. pyogenes)
 Disease of young women often (if rheumatic origin)

Hemodynamics:
• Affects mitral orifice and inflow tract
• Slow left ventricular filling
• Inflow tract & orifice damaged
• Sub-valve apparatus damaged (interior of ventricle damaged;
inflow tract loses flexibility) – can have bad filling even
without big-time orifice narrowing
• Diastolic gradient between LA and LV (stenosed)
• See PCW (LA) vs LV tracing
• High pulmonary venous pressure, pulmonary hypertension (backup from LA)
• Atrial fibrillation (increase in LV size  more prone to Afib)
• (LV dysfunction too)

Special problems
 Atrial fibrillation: need atria to push blood through orifice! Really bad for those patients (need to go fix it)
 Pregnancy: in young women often, bad combination (increased CO / HR in pregnancy & volume retention – like
a big AV fistula in the pelvis, low diastolic filling time because HR increases)
o Tx: diuresis – get fluid out of lungs, transfusion to help resolve anemia  reduce CO, beta blockers to
get HR down (tachycardic in pregnancy, lengthen filling time)
56
 “Volume” Mitral Regurgitation (more chronic)

Etiologies:
• ‘Floppy’ (myxomatous) valve
• Chordal rupture: usually not acute (break one, then others over a few days)
• Previous endocarditis

• ‘Functional’
• MR from dilated mitral annulus & LV (DCM, post-infarct of that area).
• Angulation of chordae changes too (not pulling in right direction)

• Ischemic papillary muscle dysfunction: post-MI

• Rheumatic disease
• Rarities - lupus, Phen-fen, congenital, non-infectious endocarditis, etc.

Hemodynamics:
 Dilated LV with high stroke volume

 Large LA, with a v-wave higher in venous pulse

o A-wave: atrial contraction (atrial pressure increases)
o V-wave: atrial pressure increases through systole (filling);
when ventricular pressure drops & meets atrial pressure,
MV opens and atrial blood flows into ventricle)
o Here: higher v-wave (flowing back from LV into LA)

 Pan-systolic murmur
o Leak starts at mitral closure and lasts until just before aortic closure
o (actually includes S2 – can still hear S2 if murmur is soft enough)

 Third heart sound (S3): “bounce” on filling of ventricle (high stroke volume in MR, atria full)

“Acute” Mitral Regurgitation

Similar to previous discussion but happens fast
Pressure is key!

Hemodynamics: Normal LV and LA chamber sizes, so:

• Tachycardia and shock
• Very high v-wave
• (see picture – almost as high as BP!)
• Normal sized LA – doesn’t have room for backwards flow
• Severe pulmonary venous hypertension
• Acute pulmonary edema

On exam:
 Truncated murmur:
o LA doesn’t hold enough for the regurgitation to last until S2!
o Pressure between LA and LV equalizes sooner!
 S3
 Rumble: reverse flow during diastole

Prognosis: still need to replace when dilation of heart becomes significant but
 a little easier on the heart than aortic stenosis (can “tough it out” for longer)
57
 Congenital Heart Disease
Presentation: Generally either cyanosis or heart failure
 Per 1000 newborns, 8 have congenital heart disease; 2-3 really serious heart disease (requires intervention)
 VSD is most common, others too.

Cardiac development
Heart forms at 3-8wks gestation
 Primitive cardiac tube loops & divides into bulbis cordis, primitive ventricle, R/L atria
o Bulbis cordis towards the top, ventricle, atria towards the bottom
o Tube rotates & folds, atria get pushed up to the top
 Important point: series of rotations & folds from common tube, if process goes wrong then defects can result

Fetus Neonate
Trucus arteriosus semilunar valves
Conus cordis infundibular septum (wall between
aorta & pulmonary artery)
Bulbus cordus right ventricle
Primitive ventricle left ventricle
Atria right and left atria

Neonatal circulation:
1. LV  aorta
2. Ascending aorta  brain  SVC  RA
3. Descending aorta  joined by blood from RV via ductus arteriosus
(blood can’t go through lungs because they’re not expanded)  lower
body  supplies everything and goes through placenta  oxygenated
4. Oxygenated blood: part goes through liver, part goes through ductus
venosis to IVC  RA
5. Deoxygenated blood from brain  RA  PA ductus arteriosus IVC
6. Oxygenated blood from IVC / RA shoots through foramen ovale to LA,
then up via LV to brain

 Take home points Prenatal circuit Postnatal circuit

o RV does more work than LV Oxygenator placenta lungs
o Lower body gets more deoxygenated blood PVR high low
o Brain gets more oxygenated blood PBF low full CO
Intracardiac shunts DA, FO None
Systemic O2 sat 60-65% 95-100%
At birth:
 Lungs expand, PVR falls, pulmonary flow increases
 Placental circulation interrupted (clamp cord) so SVR rises PROSTAGLANDINS
 Maintain DA open
 Foramen ovale closes: mechanical/pressure effect (RA↓, LA↑)
 No Aspirin or ibuprofen in pregnancy
 Ductus arteriosus closes (prostaglandins↓ muscle contracts) (↓prostaglandins  risk of DA closing in utero)
 Give prostaglandin E for ductal-dependent dz
Result: Two circulations in series (e.g. coarcatation, etc)
 Systemic O2 levels↑

Oxygen predominantly carried by Hb in blood (small amount dissolved in plasma)

 Oxygen content: amt oxygen carried in blood (both Hb and dissolved)
 O2 Saturation: % of Hb binding sites carrying oxygen.
a. 100% if each gram of Hb is carrying maximum (oxygen-carrying capacity)

Hb dissociation curve: Better unloading with shifts to the right (acidosis, ↑blood temp, ↑2,3-DPG)

58
 Cyanosis
Cyanosis: bluish discoloration of skin
Peripheral cyanosis Central cyanosis (what we’re talking about here)
 e.g. go out & get cold blue fingertips  due to > 5g/dL of unoxygenated Hb in arterial blood
 due to sluggish flow in extremities, but normal O2 level)  Related to O2 sat and Hb level
 DDx: Pulmonary, Cardiac, Other
Cardiac cyanosis: too little “blue blood” going to & returning oxygenated from the lungs
(decreased effective pulmonary blood flow)

Transposition: LV connects to pulmonary artery, RV connects to aorta

 Two circuits in parallel, don’t connect: but you get severe cyanosis

Stabilize: open the detours

 Cath up IVC, tear a hole in atrial septum (foramen ovale)
 Prostaglandin E to open ductus arteriosus

Surgery:
 Mustard procedure: “atrial switch”
o PV blood (oxygenated) to RV, systemic blood (deoxygenated) to LV
o Problem: RV hypertrophies (pumping to the whole body

 Arterial switch now (initially unsuccessful but now better technique)

o Switch great vessels to appropriate positions, change CA to new aorta
o 2% mortality, can have various post-op problems (5-10%) – good outcomes!

 OK as fetus: oxygenated blood coming back via IVC from placenta

TETRALOGY OF FALLOT TRANSPOSITION OF GREAT ARTERIES

Tetralogy of Fallot Total pulmonary blood flow decreased Total pulmonary blood flow increased
1. VSD Both have decreased effective pulmonary blood flow
2. Pulmonary stenosis
3. Overriding aorta (aorta arises above VSD)
4. RV hypertrophy

Cyanosis depends on degree of pulmonary stenosis

 If severe, shunt from RV  LV and cyanotic
 If not, shunt from LV  RV, not cyanotic
Typical Presentation:
 Does fine in utero
 1 day old: murmur & mild cyanosis; Dx = TOF
(wait 2 months for surgery to decrease mortality)
 3 mo: hypercyanotic TOF spell, emergent operation

Acute TOF spell: obstruction can acutely change in severity (over course of minute) – cyanosis!
 Can cause stroke or death (uncommon in US b/c early surgery)
 Patient often instinctively squats: increases systemic resistance, increase LV side pressure

Surgery: cut out obstruction!

 Generally subvalvar & valvar obstruction too
 Blalock – Taussig shunt: disconnect right subclavian to pulmonary artery (no longer in use)
o (deoxygenated blood in right subclavian  back to pulmonary artery to get more O2 from lungs)

59
 Heart Failure in children

Volume overload (e.g. VSD) CAUSES OF HF

Causes of volume overload Volume overload
 LR shunt (VSD)  LR shunt (VSD)
 Valvular dysfunction  Valvular dysfunction
 High output states  High output states

Blood flows downhill (path of least resistance) Pressure overload

 VSD will shunt L R because it’s easier to go to lungs  Coarctation of aorta
o (not because pressure’s higher in LV) Cardiomyopathy
 Large VSD with PVR ≪ SVR = CHF  Metabolic disorders
o (blood flows into pulmonary circ, flood lungs, causes tachypnea)  Congenital coronary
 Small VSD with PVR ≪ SVR = asymptomatic abnormalities
o (hole is really tiny; not much blood goes through)  Idiopathic

Natural history of VSD Rhythm disturbance (rare)

 At birth: pulmonary vascular resistance high (until circulation switch completed)
o Even large VSD = little shunting (pulmonary / systemic resistances equal)
 Fall in PVR as transitional circulation finishes  shunting (L to R)
o Symptoms of CHF (lung water, CHF – tachypnea, tachycardia, excessive diaphoresis, FTT)
o Correct with surgery here  PA pressure returns to normal
 No surgical correction: PVR ↑ (damage from constant pounding on pulmonary vascular)
o Eisenmenger’s syndrome: PA hypertension can persist even with surgery
o Baby does better (less CHF) but eventually cyanosis
o Go from excessive pulmonary blood flow to decreased pulmonary blood flow!
o Can lead to early death

Pressure overload (e.g. Coarcation of the Aorta) COARCTATION SX

Coarcation of aorta (a narrowing of descending aorta) Pulmonary venous congestion

 CHF Sx (tachypnea, etc)
Presentation: a few days after birth
 After ductus arteriosis closes (PDA can supply descending aorta, bypassing Lower body perfusion↓
obstruction)  Metabolic acidosis
 Inefficient pumping to lower body  severe metabolic acidosis  Oliguria / anuria
 LV Fails (pumping against arch obstruction)  Diminished hepatic function
o LV filling pressures increase  BP: upper > lower body
o Pulmonary venous congestion

Treatment: Prostaglandin E to reopen DA, improve CO

Surgery: resect coarcatation, use end-end anastamosis or L subclavian (enlarge area)
 10% risk of recoarcatation post-op (fix with balloon cath)

Hypoplastic Left Heart Syndrome

 Tiny LV & aorta, essentially like single ventricle
o babies get metabolic acidosis like coarctation
 Norwood procedure (temporary palliation)
o PA goes up & becomes aorta; allows blood to go out of aorta
o Balock Taussig shunt to restore pulmonary blood flow
 Fontan operation: sew IVC and SVC directly into pulmonary arteries (doesn’t go into heart!)
o Single ventricle basically, just pumping to the rest of the circulation

60
 Pharmacology: The Heart
Pharmacological Control of Serum Lipids & Lipoproteins ...................................................................................................... 2
Nitrates and Calcium Channel Blockers .................................................................................................................................. 5
Sympathetic Inhibitors ............................................................................................................................................................ 8
Inotropic agents .................................................................................................................................................................... 11
ACE Inhibitors & Angiotensin Receptor Blockers .................................................................................................................. 12
Antiarrhythmic Drugs ............................................................................................................................................................ 15

1
 Pharmacological Control of Serum Lipids & Lipoproteins
Treatment goals: LIPOPROTEIN MAJOR COMPONENT CHD RISK
 Lower total cholesterol, LDL, and TGs VLDL TGs ↑Increased
 Raise HDL LDL Cholesterol ↑Increased
HDL Protein ↓Decreased
Use when: diet/exercise/wt control fail (non-compliance or not enough effect)

5 classes of lipid-lowering drugs

Class Mechanism of action

1 Statins Inhibit cholesterol synthesis
2 Bile acid sequestrants Inhibit bile acid re-absorption
3 Ezetimibe Inhibit cholesterol absorption 4
4 Niacin Inhibits vLDL synthesis 5 3
5 Fibrates Faster vLDLLDL conversion 1

2
Lowering LDL Cholesterol

 Liver makes vLDL  out to circulation

 Lipoprotein lipase converts vLDL (apoE protein)  vLDL
remnants (IDL) LDL (apoB100 protein)
 LDL can be oxidized, get eaten by Mϕ in arterial wall
 Reuptake of IDL / LDL into liver can happen via apoE or
apoB receptors

Unesterified liver cholesterol is key to controlling blood cholesterol

Sources:
 De novo synthesis (statins block)
 Uptake of dietary cholesterol from chylomicrons (ezetemibe blocks)
 Uptake of cholesterol from circulating LDL (and HDL)
Regulatory systems:
↓ cholesterol in liver:
Ways to get rid of unesterified liver cholesterol
 ↑ HMG CoA reductase synthesis (bad)
1. Excrete it into the bile
 ↑receptor synthesis (good)
2. Make bile acids
↑ cholesterol (e.g. after meal) has reverse
3. Secrete VLDL effects: take more up & stop making it!
4. Convert cholesterol  cholesterol esters
Mechanism: Sterol receptor cleaved on if sterols
Cholesterol Math not around; N-terminal part (SREBP) goes to
nucleus, binds sterol regulatory element (SRE),
on DNA, activate transcription of HMG CoA
 Non-HDL cholesterol= Total cholesterol - HDL cholesterol reductase & LDL receptor
 Non-HDL target = LDL cholesterol + 30 mg/dL

RISK LDL-CH GOAL

0-1 RFs < 160
2+ RFs <130
High
<100
(CHD / CHD equivalent)
Very high (CHD+) <100

2
 Statins RELATIVE POTENCY OF STATINS
 Reduce MI, Angioplasty / bypass, stroke rosuvastatin Crestor®
o all-cause mortality in those with known CHD! pitavastatin
atorvastatin Lipitor®
 Lower risk groups have better success in reaching target LDLs
simvastatin* Zocor®
pravastatin*
lovastatin*
fluvastatin*

statins Mechanism of Action: HMG-CoA reductase inhibitor (competitive); inhibits cholesterol synthesis.
Effects:
 Lowers LDL cholesterol up to 60%; reduces MI/angioplasty/bypass/stroke/all-cause mortality in CHD pts
 Also raises HDL (8-10%), lowers TGs (10-30%).
 Also decrease thrombosis, have anti-inflammatory effects, and improve endothelial function.
Indications: Lowering cholesterol. All patients with CAD should be on a statin
Toxicity: Contraindicated in liver disease but pretty well tolerated. No side effects vs placebo in trials
but yes in clinic:
 muscle pain, reversible liver enzyme abnormalities
 myositis (can lead to rhabdomyolysis, myoglobin released after muscle cells lysed, can cause renal
failure, rare but serious, can happen when other drugs block CYP3A4 metabolism).
 No cancer risk increase
Other: CYP3A4 metabolism. Rosuvastatin = Crestor, atorvastatin = Lipitor, simvistatin = Zocor.

Ezetimibe
ezetimibe Mechanism of Action: inhibits absorption of cholesterol.
 Blocks the Niemann Pick C-1-like-1 protein (NPC1L1 protein), needed to absorb chol from intestine.
Indications: adjunct to dietary measures: hypercholesterolemia
Resistance: Genetic differences in NPC1L1 protein: genetic difference in response to drug

Bile acid sequestrants

cholestyramine, Mechanism of Action: bile acid sequestrants. Bind bile acids so that they can't be re-absorbed
cholestipol, Effects: Long-chain positively-charged polymer, binds anything that's negatively charged (including
cholesevelam bile acids but also negatively charged drugs)
Administration: cholesevelam (*) is pill, others powder
Indications:
 lowers LDL cholesterol (10-25%), also raises HDL a little (1-3%)
 no change in TGs (can actually increase!)
Toxicity:
 GI sx (including constipation)
 decreased absorption of some drugs
 elevated liver transaminases (rare)
Other: Don't use with elevated TGs

Combination cholesterol therapy (statin + BA sequesterant or ezetimibe)

Key point: hit at several different spots on the pathway for cholesterol to get to the liver
 Statins: lower LDL by increasing LDL receptors; also enhance HMG CoA reductase synthesis
 Bile acid sequestrants increase conversion to bile acids (less unesterified in liver)
 Ezetimibe: reduces unesterified liver cholesterol by decreasing how much dietary chol enters
 Example: use a resin, HMGCoA reductase increases to compensate, use a statin too

3
 TG-lowering medications
Fibrates
If TG are really high (>500)
 use fibrate to bring TG down right away Drugs that lower TGs
 (prevent acute pancreatitis)  Fibrates (gemfibrozil, fenofibrate)
 Nicotinic acid
If TG are moderately high,  Statins
 lower LDL with statin first  Lovasa / omacor (purified fish oils)
 then use fibrate to bring down TG if needed Also progestational agents in women,
 (prevent LDL-related coronary event) anabolic steroids in men (incidental)

fenofibrate, Mechanism of Action: Act on PPAR alpha to inhibit synthesis of apo C-III, which inhibits lipoprotein lipase
gemfibrozil Effects: Increases lipoprotein lipase activity, speeding removal of TGs from VLDL
Indications:
 Lower TGs (20-60%)
 Also raise HDL-ch (8-10%), may raise LDL cholesterol (BAD!)
 Both fenofibrate & gemfibrozil have equal effectiveness.
Toxicity:
 GI Sx, elevated liver transaminases.
 For gemfibrozil (not fenofibrate) myositis (and rhabdmyolysis) when given with statins

Lovasa
Lovasa Mechanism of Action: Purified fish oils (omega 3 FAs)
 Lowers TGs by inhibiting diglyceride to triglyceride conversion in liver & intestine
Indications: Very effective at lowering TGs (up to 60% reduction), doesn't affect LDL/HDL
Other: Purified ethyl esters of omega-3 FAs (active), 4x more potent than OTC fish oil pills

Drugs that raise HDL cholesterol (Niacin)

Note: fibrates / statins also raise HDL cholesterol (8-10%), estrogens after menopause do too
No real proof that ↑HDL or ↓TG prevent coronary disease: just with LDL
Niacin Mechanism of Action: Raises HDL cholesterol. Blocks release of fatty acids from adipose tissue
Effects:
 Activates GPCR that inhibits cAMP formation,
 cAMP normally activates hormone-sensitive lipase in adipose tissue (breaks down TGs to release FA
to bloodstream). So niacin blocks this release.
Indications: Across-the-board activity.
 Lower LDL-cholesterol(10-25%)
 Raise HDL-cholesterol (15-35%)
 Lower TGs (20-30%)
Administration: Crystalline, extended release is most common (1 pill every night); sustained/slow release
gives liver damage!
Toxicity: PROBLEMATIC
 Flushing, upper GI sx, hepatotoxicity, increased uric acid / gout, mild hyperglycemia
Other: A vitamin! Need 1000x vitamin levels to increase HDL though. Nicatinomides ("no flush" niacins) are
big on the internet, but they don't work
Things that lower HDL: anabolic steroids, progesins, thiazide diruetics, β-blockers
Summary
DRUG LDL-CHOLESTEROL TGS HDL-CHOLESTEROL
Bile acid sequestrants ↓↓↓ - or ↑ -
Niacin ↓↓ ↓↓ ↑↑↑
Statins ↓↓↓↓ ↓ ↑
Fibrates ↓ ↓↓↓↓ ↑
Ezetimibe ↓↓↓ - -

4
 Nitrates and Calcium Channel Blockers

Background

Nitrates
 Working to deliver NO to vascular tissue (vasodilator)
 Rapid onset / offset; easy to adjust dose to response

Inorganic nitrates: e.g. nitroprusside

sodium Mechanism of Action: Inorganic nitrate; causes vascular smooth muscle relaxation NO donor (NO formed via local
nitroprusside reduction @ vascular smooth muscle: different pathway than NTG).
Effects: Smooth muscle relaxation / vasodilation
Indications:
 Hypertensive crisis
 Acute heart failure with severe HTN
 precise BP reduction ( e.g.vascular & neurosurgery)
 aortic dissection
 Ergot poisoning
Administration: IV only
Toxicity:
 Thiocyanate toxicity: cyanide is part of molecule; released with local metabolism, converted to thiocyanate in
liver & excreted by kidney; can have adverse effects of CN poisoning (e.g. seizures) if pt has renal dysfunction &
CN builds up.
 Hypotension too.
Tolerance:NO TOLERANCE with prolonged exposure

Organic nitrates: e.g. nitroglycerin (also isosorbide dinatrate, isosorbide 5-mononitrate, erythityl tetranitrate, amyl nitrate)
nitroglycerin Mechanism of Action: Organic nitrate; causes vascular smooth muscle relaxation Two mechanisms.
 High doses: direct NO donor (local formation of NO from NTG maybe via a CYP450, activates guanlylyl cyclase
by binding to ferrous Fe in hemeprotine; cGMP activates protein kinases / ion channels, leading to smooth
muscle relaxation).
 Low doses: bioactivated by mitochondrial aldehyde dehydrogenase (ALDH-2), forming bioactive NOx
intermediate, activating guanlylyl cyclase as well).

Effects: Smooth muscle relaxation. Graded hemodynamic effects:

 venous dilation at lower doses than arteriolar (decreased preload / RA/LA pressure; coronary vessels dilated;
redistribution of blood to ischemic areas of heart in CAD pts).
 Higher doses: arteriolar dilation too (decrease afterload / systemic vascular resistance)

Indications:
 Prevent / relieve MI & associated pain
 Prevent / relieve CHF Sx & hemodynamic disturbances
5
  CN poisoning
 biliary/esophageal pain

Administration: Intermittent dosing (during the day, not at night) to desensitize / avoid tolerance). Various forms
(sublingual, oral, topical, IV, etc). Dose to effect (wide therapeutic index)

Toxicity: Extension of benefits. Headache, hypotension, facial flushing, reflex tachycardia, tolerance/withdrawal,
methemoglobinemia

Tolerance:
 Early tolerance ("pseudotolerance") from baroreceptor reflex to vasodilatory effects; also NO is oxidant, causes
some endothelilal dysfunction.
 Late tolerance (iatrogenic; hours/days) from inactivation of ALDH-2 from circulating NOx; can get withdrawal sx
(coronary/peripheral arterial spasm - vasoconstriction!)

Calcium Channel Blockers

 Ca+2 is the key effector of cardiac / vascular smooth muscle contraction
 [Ca]outside >>>> [Ca]inside cell

Voltage-gated, receptor linked channels control influx/efflux

 L-type channel is the potential-dependent calcium channel
o Regulated by α and β-adrenergic responses, angiotensin II, endothelin-1, NO, arachadonic acid metabolites
 T-type channels are on arterial smooth muscle & SA node; if you could block them you could achieve arteriolar dilation,
decrease in heart rate without depressing myocardial contractility (but no agents available yet)

Calcium channel Mechanism of Action: Calcium channel blocker: directly blinds extracellular domains of alpha subunit of L-
blockers type calcium channel
 Blocks smooth muscle contraction (vascular relaxation).
verapamil  Negative inotropic effects & slowing of AV-node conduction for some (verapamil ≫ diltiazem,
(phenylalkylamines) nefedipine has none)

nefedipine, Effects: Blocks ability of L-type Ca channel to transport extracellular Ca to intracellular space, blocking
nimodipine, cascade of intracellular-Ca-induced Ca release from SR & blocking smooth muscle contraction.
amlodipine  Effects localized to vascular / visceral smooth muscle, cardiac muscle, SA/AV nodes (where L-type Ca
(dihydropyridines) channels found). At AV node (not nefedipine), prolongs refractory period (slower conduction)

diltiazem Indications:
(benzothiazepines)  Hypertension
 myocardial ischemic syndromes (but not acute MI / unstable angina!)
o drugs of choice for variant (prinzmetal) angina (coronary spasm)
o also used for stable angina (Beta blockers are first choice).
 Also used in hypertrophic cardiomyopathy, Raynaud's phenomenon.
 Verapamil only: migraine prophylaxis (decreases frequence / severity)
 Verapamil & diltiazem: Supraventricular arrhythmias ( block av node)
 Nimodipine: subarachnoid hemmorhage

Administration:Original formulations rapidly metabolized; newer agents have longer half-lives

Toxicity:
 Heart block / heart failure, especially with beta blockers, pts with conduction system disease
(verapamil ≫ diltiazem > nefedipine).
 Aggrevate gastroesophageal reflux (confound chest pain assesment!).
 Urinary frequency / incontinence.
 Verapamil & diltiazem are moderate inhibitors of CYP3A4.

6
  Verapamil only: Constipation
 Dihydropyridines: Tachycardia, edema

Metabolism: Inactivated by CYP3A4 metabolism

Other: Three classes of Ca channel blockers bind to different parts of L-subunit & don't compete with each
other. Verapamil-type drugs have greater ionotropic effect & more marked SA/AV node inhibition (verapamil
≫ diltiazem; nefedipine has none)

Distinguishing features: Comparison of Ca Channel Blockers

Phenylalkylamines Dihydropyridines Benzothiazepines

Verapamil Amlodipine Nifedipine Nimodipine Diltiazem
Subarachnoid
Special uses Migraine Prophylaxis
hemorrhage
Longer half-
Administration
life
Arterial Dilation ++ +++ +
Negative inotrope &
AV-block
++++ - - ++
Use for PSVT* &
Yep No No Yep
atrial fib / flutter?
Heart Block / Failure ++++ + ++
Toxicities

Tachycardia Yes (tachycardia – all dihydropyridines)

Edema Yes (edema – all dihydropyridines)
CYP3A4 inhibition Yep Nope Yep
Constipation Yep
*PVST = Paroxysmal supraventricular tachycardia (PSVT), an occasional rapid heart rate.

7
 Sympathetic Inhibitors
Very basic review of SNS from a CV point of view:
Receptor Type Mechanism Effects Location
α1 receptors Post-synaptic, Gq linked Vasoconstriction
Alpha Pre-synaptic, inhibit Vasodilation
receptors α2 receptors central sympathetic ↓HR
outflow! ↓contractility
Myocardium: ↑rate, ↑contractility
↑HR SA node: ↑ firing rate
β1 receptors
G-protein linked ↑contractility AV node: ↑conduction velocity
Beta JGA: ↑ renin secretion
↑adenylyl cyclase
receptors
↑Intracellular cAMP ↓vascular tone Arterioles: dilate
β2 receptors
(vasodilation) Bronchial smooth muscle - dilate
β3 receptors ↑lipolysis (not important in CV)
Dopamine ↑adenylyl cyclase
DA1 Renal, mesenteric, coronary arteries
receptors (DA5 too)
DA2-4 Inhibit AC Neuro functions (not CV) Basal ganglia

Desensitization happens after long exposure: β-receptor density

decreased amplitude of agonist response, Decreased (DOWN-REGULATED) Increased (UP-REGULATED)
drug tolerance • Hypothyroidism • Hyperthyroidism
 P-lation, sequestration (early), genetic • Congestive heart failure • Acute ethanol withdrawal
expression changes too, etc. • Chronic beta-agonist therapy • Chronic beta blocker therapy

Central α2 agonists
Mechanism of Action: alpha-2 adrenergic receptor agonist
Effects:
 Decreases sympathetic outflow pre-synaptically
(takes advantage of feedback mechanism to inhibit AC).
 Decreases SVR, venous return, and CO

Indications:
clonidine  Class-wide: Hypertension.
 Clonidine-specific: analgesia with cancer pain, suppresion of opiod/opiate withdrawal
alpha  Methyldopa-specific: pregnancy-associated hypertension (safe)
methyldopa
Administration: Oral, predictable onset & duration but multiple daily doses needed.
Also topical patch (1 wk duration) for clonidine

Toxicity:
 Class-wide: sedation, orthostatic hypotension, erectile dysfunction.
 Clonidine-specific: bradycardia, can get rebound hypertension on abupt discontinuation
 Methyldopa-specific: chronic hepatitis (cirrhosis), positive Coomb's test (rare hemolysis)

8
 Ganglionic blockade
 Trimethaphan is prototype
 Formerly used for HTN (especially emergent – very potent), now mostly historical & mechanical interest
 Adverse effects limit use (postural hypotension, constipation, urinary retention, serious impairment of sexual function, lots more)

Presynaptic catecholamine depletion

 Riserpine is prototype
 Still available for HTN but not widely used (side effects)
 Adverse effects limit use (severe depression, especially at higher doses, sedation, nasal stuffiness)
 Might see some elderly patients on it who have used for years with no side effects (conflict – take them off?)

Postsynaptic α1 and α2 adrenergic blockade

Mechanism of Action: postsynaptic inhibitor of alpha1- and alpha2- adrenergic receptors
 Phenoxybenzamine = irreversible (binds covalently)
phenoxybenzamine
 Phentolamine, tolzazine = reversible
Indications: Hypertension in pheochromocytoma
phentolamine,
Toxicity: Postural hypertension, sexual dysfunction
tolazine
Other: Pheochromocytoma: huge sympathetic overflow; can't use beta-blockers or others (won't
affect outflow issues, BP could actually go UP!)

Postsynaptic α1 adrenergic blockade

Mechanism of Action: Selective post-synaptic inhibitor of alpha-1 adrenergic receptors
Effects:
 blocks smooth muscle constriction (relaxes ureters);
 arterial & venous dilation (can help with hypertension)
Indications:
prazosin (terazosin,  Hypertension (but questionable mortality benefit in ALL-HAT!)
doxazosin)  especially with BPH-induced urinary obstruction (especially terazosin) - helps relax
ureters (kill two birds with one stone).
 Also decreases LDL & total cholesterol.
Administration: terazosin, doxazosin have longer duration of action than prazosin
Toxicity: Postural hypotension & syncope (especially with first dose!); nasal congestion,
impotence

9
 β-blockers (postsynaptic β-adrenergic blockade)
“Selectivity” for β-1 vs β-2: e.g. metoprolol
 target cardiac effects (β-1 block = decrease HR, contractility, renin) without bronchial effects (β-2 block =
bronchoconstriction)
 At pharmacological doses this selectivity is mainly lost! So metroprolol (supposedly β-1 specific) behaves a lot
like propranolol (both β-1 and β-2)

Lipophilicity is generally just a marketing strategy

Two of these agents (pindolol & acebutolol) have intrinsic sympathomimetic activity (look like partial agonists)

Mechanism of Action: beta-blocker (blocks β adrenergic receptors post-synaptically; reversible)

 Propranolol, nadolol: non-selective (β-1, β-2)
 Metoprolol: “selective” (β-1 > β-2), but selectivity ↓ with ↑ dose

Effects:
 decreased cardiac output (decrease heart rate, contractility, automaticity, AV conduction,
myocardial oxygen demand)
 bronchial smooth mm constriction via β-2 (don't use in asthma)
propranolol,
nadolol
Indications: Class-wide: hypertension, ischemic heart syndromes (MI/angina), heart failure, arrythmias,
tremor (reduce neuromuscular excitability), migraine prophylaxis.
metoprolol
 Special: timolol (similar agent) treats open angle glaucoma
Adverse effects: Heart failure, heart block, asthma, depression / sleep disturbance, hypoglycemia,
claudication (exacerbates Raynaud's phenomenon), erectile dysfunction, ischemic syndromes on
withdrawal.

Other:
 First-pass effects (oral and parenteral doses are very different).
 Genetic polymorphisms affect responsiveness.

Mechanism of action: beta and alpha blocker (alpha-1, beta-1, beta-2)

Used in:
carevediolol
 carevediolol: Congestive Heart Failure
labetalol
 labetalol: hypertension
Adverse effects: hyptension, bradycardia, heart block, heart failure, asthma

Post-synaptic dopaminergic agonism

Mechanism of Action:post-synaptic dopamine receptor agonist (selective DA1 peripheral agonist)

Effects:Binds DA1 receptors on renal, splanchnic arterioles; results in vasodilation & dieresis
fenoldopam
Indications: hypertensive emergencies, esp. with renal insufficiency & post-op settings

Toxicity: can increase intraocular pressure

10
 Inotropic agents
Cardiac Glycosides (Digoxin)
Mechanism of Action: cardiac glycoside inotropic agent. Inhibits Na/K ATPase
Effects:
 less Na extrusion, less Ca extrusion (needs gradient), more Ca sequestration in SR, more available for
next contraction.
 Also vagal stimulation & decrease in sympathetic activity
Indications:
 ADJUNCT for treatment of CHF & sinus cardiac rhythm, can control ventricular HR in A-fib
digoxin
Administration: VERY NARROW THERAPEUTIC INDEX (must monitor levels)
Toxicity:
 Complete heart block, any other arrhythmia
 nausea/vomiting
 visual disturbance (classic: yellow vision)

Other: also digitoxin, ouabain (not used as much).

 PROTOTYPE FOR MIXED CLEARANCE (60-70% renal, 30-40% non-renal)

β-adrenergic agonists
Mechanism of Action: beta-adrenergic agonist (beta-1, beta-2, also alpha-1 partial agonist)

Effects: enhance cardiac output

 Dobutamine: increased contractility, little change in SVR
 Isoproteronol: increased heart rate, drop in SVR
dobutamine
Indications:short-term tx of cardiac decompensation

Toxicity: tachycardia, hypotension, ventricular ectopic activity.

 Dobutamine-specific: hypertension too

Dopamine
Mechanism of Action: Dopamine agonist: three drugs in one.
 Low dose: agonist at DA1 receptor, renal vasodilation (increased renal blood flow, diuresis).
 Intermediate dose: stimulates beta-1 receptor; increases HR & contractility.
 Higher doses: stimulates alpha-1 receptor; vasoconstriction

Indications:
dopamine
 Low dose: Refractory edema with low renal blood flow (want renal vasodilatory effects).
 Intermediate dose: Low CO & shock (want HR & contractility increased).
 High dose: Shock (want vasoconstriction)

Toxicity:
 ventricular arrhythmia angina, hypertension, impairment of blood perfusion (high doses)

Phosphodiesterase inhibitors
Mechanism of Action: Phosphodiesterase inhibitor. increase cGMP, increasing inhibition of
cGMP-inhibited cAMP phosphodiesterase, resulting in rise in cAMP
milrone  stimulates contractility, accelerates diastolic relaxation, dilation(arterial & venous)
Tried to use in CHF but MORTALITY WORSE
Adverse effects: arrhythmia, hypotension

11
 ACE Inhibitors & Angiotensin Receptor Blockers
Background: the RAAS
(ARBs) Angiotensin type-1
receptor (AT-1) effects
Angiotensinogen

JGA:
Bradykinin Renin ↓glomerular
(Substance P, perfusion
Enkephalins) (ACE INHIBITORS)
Angiotensin I

ACE ACE
Angiotensin II
Chymase
(tissue protease;
Inactive alternate pathway for
Fragments Pulmonary & AT III conversion)
Renal Epithelium
 circulation

Angiotensin type-2
receptor (AT-2)
?? effects

Notes:
 AT III conversion in absence of ACE! Chymase can do it too! ANGIOTENSIN II + AT-1 RECEPTOR: A MOLECULAR LOOK
 Physiological effects of ACE Inhibitors: 1. Activates Phospholipase C  IP3, DAG
o Angiotensin II effects decrease 2. L-type calcium channels open:
o Bradykinin effects increase (cough!) vascular smooth muscle contracts

 RAAS components have characteristic sites of production (shown above) – the “circulating endocrine system”
 They’re also made in many tissues (including CV system) – “local tissue paracrine/autocrine system”
o Relative roles of the two systems aren’t well understood

Early effects: see picture above too.

 Mainly INCREASED VASCULAR RESISTANCE
 Direct effects on catecholamine release (central & peripheral sympathetic stimulation)
o ↑ NE release (peripheral sympathetic neurons & adrenal medulla)
o ↓ NE uptake

Later effects:
 POTENT MITOGEN: stimulates smooth muscle hyperplasia, hypertrophy, migration (↑ECM, ↑growth factors)
 Kidney
o ↑ Proximal tubule Na reabsorption
o ↑Aldosterone: ↑Na absorption, ↑ K excretion
 if you impair aldosterone secretion (with ACEIs) K can build up (not exchanging K for Na+ in tubules)
o direct vasoconstriction,  renal sympathetic tone, enhanced renal noradrenergic transmission

12
What do ACE inhibitors do? HOW DOES THIS TRANSLATE TO HEART FAILURE?
 [Angiotensin II]  Angiotensin II
•  Arteriolar + venous constriction •  Resistance (↓afterload)
•  Myocardial remodeling •  Cardiac remodeling
•  Plasma aldosterone
 Aldosterone
•  Intraglomerular pressure
•  Sodium retention (↓preload)
In Hypertension: Net Effect
 ↓Na retention, ↑K retention, ↓vasoconstriction •  Cardiac output
 Drops BP (good!) •  Filling pressures

In Heart Failure: doesn’t really drop BP (weird)

enalapril Mechanism of Action: ACE Inhibitors: reversibly inhibit angiotensin converting enzyme (ACE) by binding
Zn moiety.
(also  ACE catalyzes the conversion of angiotensin-I to angiotensin-II; AT-II acts on the angiotensin
captopril, type 1 receptor (AT-1) via PLC, IP3, and DAG to produce a variety of effects.
lisinopril,  ACE also catalyzes the breakdown of bradykinin.
and the
Effects: ACE-I effects come from inhibition of AT-II effects and an increase in bradykinin effects.
other -prils)
 AT-II's effects: increase aldosterone (more Na/H2O reabsorption & K secretion), acts directly on
tubules to increase Na reabsorption, triggers L-type calcium channels for vascular smooth muscle
contraction, stimulates central & peipheral sympathetic responses by increasing catecholamine
relase, and acts as a mitogen (smooth muscle hyperplasia, hypertrophy, and migration -
remodeling).
 ACE-inhibitors therefore reduce vasoconstriction (A&V), reduce myocardial remodeling, reduce
plasma aldosterone, and reduce intraglomerular pressure.

Indications:
 Hypertension (decrease Na/H2O retention and increase K reabsorption, decrease vasoconstriction,
dropping blood pressure).
 Heart failure (block AT-II so drop resistance / afterload, decrease cardiac remodeling; also reduce
preload by decreasing sodium retention via aldosterone, resulting in increased cardiac output and
reduced filling pressures).
 Also asymptomatic LV dysfunction & diabetic nephropathy (decreases intraglomerular pressure)

Toxicity:
 Cough (10-15%, non-productive, often nocturnal / post-URI, not related to cardiopulmonary
problems, reversible in 1wk, probably related to bradykinin effects).
 Angioedema (abrupt non-pitting swelling of a specific area; often one side of face / extremity/etc,
resolves in 6-24 hrs).
 Also dysguesia (loss of taste), hypotension (via volume depletion in setting of low EF),
hyperkalemia (increasing K reabsorption).
Note: not much different between these except for duration & whether or not they’re prodrugs

13
 Angiotensin Receptor Blockers (ARBs)

Bind with high affinity to the AT-1 receptor (don’t bind AT-2)
 Inhibit known effects of AT-II (like ACEIs)
 Not associated with cough (probably bradykinin mediated; ACE still doing its thing with bradykinin here)

Blocking AT-1 leads to increase in circulating angiotensin II (upregulation)

 AT-2 receptor is being exposed to more angiotensin II (difference from ACE-Is) – but significance unknown
 Really just a marketing ploy

losartan Mechanism of Action: Angiotensin receptor blockers: bind to AT-1 receptor (not AT-2), inhibiting the known
physiological effects of angiotensin II (all AT-1 mediated).
(and the
other Effects: ACE-I effects come from inhibition of AT-II effects at AT-1 receptor.
 Bradykinin is unaffected
-sartans)
 circulating AT-II actually increases (upregulated via feedback from unstimulated AT-1 receptors).
 Similar effects to ACE-I: inhibit AT-II's effects (vascular smooth mm contraction, aldosterone
secretion, release of adrenal catecholamines, increased sympathetic tone, change in renal function,
cellular hypertrophy/hyperplasia)

Indications: Hypertension, hypertension with LV dysfunction, diabetic nephropathy

Toxicity:
 NO Cough (not changing bradykinin breakdown).
 Angioedema is more rare.
 Still see renal failure / hyperkalemia in some cases.

14
 Antiarrhythmic Drugs
Ion channels are important. Antiarrhythmic drugs (AAD) work on them.
 Mostly cations go through them so AAD are basic (block channel with + charge)
o AADs may block multiple ion channels (with different IC50s)
 Evolution: from primitive twin-pore K channel, the site where AADs bind has been preserved in evolution
 Lots of ion channels are involved in action potentials. The picture belois a good summary

Vaughn-Williams Classification
Class I Na channel ↑QRS interval
blockers
Class II Antagonize beta ↓HR, ↑PR interval
adrenergic
receptor
Class III K channel blockers Prolong action potential
Longer refractory period
↑QT interval
Class IV L-type Ca channel ↓HR, ↑PR interval
blockers

Class I: Na channel blockers

 Local anesthetic
 Increases QRS interval (harder to trigger that phase 0 upstroke)
 Voltage- and use-dependent block
o more effectively block & reduce conduction velocity at rapid heart rates and in depolarized tissues
 Raise DFTs (defib thresholds) – need to give more juice

Subclasses:
Moderate potency
Quinidine, procainamide,
Class Ia Intermediate kinetics
disopyramide
Prominent AP prolonging-action (↑QT interval)
Low potency
Class Ib Lidocaine, tocainide, mexiletine
Rapid kinetics
Most potent
Class Ic Flecainide, propafenone
Slowest kinetics

Class II: beta adrenergic receptor blocker

Propranolol, metroprolol (see other section on beta blockers too)
 Improve survival post-MI; need to titrate up dose in HF
 AAD effects:
o Slow sinus node discharge (phase IV)
o Slow AV conduction
o Depress adrenergic-dependent LV function

Class III: K channel blockers

Amiodarone, sotalol (others too)
 Prolong APD & repolarization
 IKf is typical target (rarely specific, can modulate other channels too, agents being developed to target others)
15
 o IKF is mutated in some long QT syndrome pts
 Ibultilide both blocks K channels and prevents Na channels from closing! Extra long AP

 Reverse use-dependence
o more effectively block & reduce conduction velocity at slow heart rates and in polarized tissues
 Lower DFTs (defib thresholds) – need to give less juice
o Amiodarone is exception – actually raises DFTs

Mechanism of Action: Class III antiarrythmic drug but has ALL FOUR V-W classes of action.

Effects:
 Prolongs QT interval, decreases HR, increases PR.
 Also alpha-adrenergic-receptor and muscarinic receptor blockade

Administration: VERY LONG HALF LIFE (20-60d) and very large volume of distribution (>50L/kg)

amiodarone Toxicity: LOTS ("dirty drug for a dirty job").

 Contains lots of iodine and looks like thyroxine so it induces thyroid hormone resistance state.
 Also pulmonary fibrosis, ARDS, hepatitis, neuropathy, thyroid abnormalities, skin discoloration,
photosensitivity, drug-drug interactions.
 CYP3A4 AND CYP2C9 INHIBITOR (metabolized by 3A4).
 Raises DFTs (have to give more juice to defibrillate)

Other: Others being developed (non iodinated) but don't work nearly as well.
 Class III = reverse use dependence (more effective at slow HR).

Class IV: L-type Calcium Channel Blockers

Phenalkylamines (verapamil) and benzothiazepines (diltiazam) – see Ca channel blocker lecture

 Inhibit SA node automaticity; slow AV nodal conduction, depress LV function
 Limited utility in treatment of most ventricular arrhythmias
 Can use in AFib to control ventricular contractions

Note that the V-W Classification is Incomplete

 All have various actions (see chart)
 Some don’t fit into categories but
are still used for arrhythmia (digitalis,
adenosine)

Mechanism of Action: cardiac glycoside inotropic agent. Inhibits Na/K ATPase

Effects:
 less Na extrusion, less Ca extrusion (needs gradient), more Ca sequestration in SR, more available for next
contraction.
 Also vagal stimulation & decrease in sympathetic activity
 AAD effects: increase sodium inside; parasympathomimetic, little effect on conduction / used in rate control
digoxin
Indications:
 ADJUNCT for treatment of CHF & sinus cardiac rhythm; can control ventricular HR in A-fib.

Administration:VERY NARROW THERAPEUTIC INDEX (must monitor levels)

Toxicity:
 Complete heart block, any other arrhythmia

16
  nausea/vomiting, visual disturbance (classic: yellow vision: Van Gough xanthopsia - yellow paintings).
 In high doses: intracellular calcium overload, SNS activation.

Other: also digitoxin, ouabain (not used as much). PROTOTYPE FOR MIXED CLEARANCE (60-70% renal, 30-40%
non-renal)
 Digitalis: Almost all eliminated by P-glycoprotein (potential for drug-drug interactions)

Mechanism of Action: antiarrythmic agent.

 Activates GCPR, opens a K channel (direct effect) and inhibits adenylyl cyclase (indirect effect)
adenosine Effects: Hyperpolarizes atrial myocytes (shortens APD)
Indications: Rapid termination of SVT
Administration: Short half-life (seconds/minutes)

Proarrhythmia
Many of these drugs can be proarrhythmogenic: cause new arrhythmias or aggravate preexisting ones
 This is why these are usually just adjuncts to other therapy (e.g. devices)

Mechanisms: CLASSIFICATION OF PROARRHYTHMIA

Alter nodal cells’ automaticity
(change phase 4 slope) – e.g. beta
blockers, epinephrine, etc.
Ventricular proarrhythmia: can alter:
 impulse conduction
(unmask pre-existing circuit)
 repolarization (abnormal
impulse conduction or
abnormal / triggered
automaticity)
Aggravation or provocation of:
Bradycardias  Sinus bradycardia
 AV block
 AT with block
SVT
 Nonparoxysmal AV junctional tachycardia
Tachycardias  Torsade de Pointes (Class III drugs)
VT  Monomorphic VT (class I drugs)
 PMVT, bidirectional tachycardia
 ↑(class I and amiodarone) or ↓ (class III)
defibrillation thresholds (ICD needs to give more of
Device interactions a shock, for instance)
 Altered tachycardia characteristics

Torsades de Pointes
Related to CLASS III DRUGS (prolong QT)

ECG
 In setting of WIDE QT and Premature
Ventricular Contraction
 “twisting of the points” appearance-
undulating QRS amplitude

What’s going on?

 Spatial & temporal dispersion of repolarization  functional re-entry
 Basically, you’re blocking K channels but not homogenously
 heterogeneity of AP duration (more spatial/regional variation in APD)
o Early afterdepolarization can be seen & play a role too
 means some parts are polarized, some parts depolarized re-entry without structural changes!

17
Treatment:
Risk Factors for drug-induced TdP
 WITHDRAW offending agent  Hypokalemia
 Correct hypokalemia  Hypomagnesemia
 GIVE MAGNESIUM (independent of patient’s Mg level)  female gender
 Correct bradycardia (isoprotereonl, pacing)  underlying heart disease
 slow heart rate
 atrial fibrillation
 long QT before treatment
 genetic predisposition (?)

Afterdepolarizations
 Triggered automaticity (e.g. pushing a part of the heart to increase its automaticity, by giving drugs for instance)
is linked to afterdepolarizations
 Afterdepolarizations: membrane voltage oscillations that occur during (EAD) or following (DAD) an AP

 Delayed afterdepolarization (DAD):

o Increased calcium (e.g. inhibit Na/K ATPase – digitalis – limits NCX function, also
catecholamines & ischemia)
 Early afterdepolarization (EAD):
o Don’t depend on Ca, ? mechanism, small changes in conduction (plateau =
few channels open)

Other random things (drug interactions)

 Interactions can be pharmacokinetic (serum level changes) or pharmacodynamic (no serum level change)
 Drug interactions are more likely if a drug is eliminated by a single pathway
 Polymorphisms in enzyme pathways can alter PK interactions
 Cytochrome P450 (various, amiodarone blocks) and P-glycoprotein (digitalis) are important in AAD metabolism

18
 Pathology: Renal
Diseases of the Tubulo-Interstitium........................................................................................................................................ 2
Nephrotic Syndrome ............................................................................................................................................................... 9
Glomerulonephritis ............................................................................................................................................................... 14
Renal Manifestations of Systemic Diseases .......................................................................................................................... 19
Tumors of Bladder & Kidney ................................................................................................................................................. 28
Pediatric Renal and Bladder Tumors..................................................................................................................................... 33
Pathology of Hypertensive Nephrosclerosis ......................................................................................................................... 36

1
 Diseases of the Tubulo-Interstitium
Some basic points:
 Diseases affecting tubulointerstitium = commonest causes of
acute renal failure
 Tubules & interstitium closely related
 Diseases of arteries, arterioles, glomeruli can affect downstream
tubulointerstitium

What determines what part of nephron will be injured?

Function
 Proximal tubule: lots of uptake, most susceptible to nephrotoxins
 Distal tubule: injured by lithium (unknown why)
Location in renal parenchyma
 Parts in outer medulla more susceptible to hypoxic injury
(less blood flow)
 Ascending infections: renal pelvis  tubules in medulla  cortex
(works its way up)

Consequences of tubulointerstitial disease CAUSES OF TUBULAR

 Abnormal reabsorption INJURY / DYSFUNCTION
(fluid/electrolyte loss, Fanconi’s syndrome – can’t reabsorb anything!) Primary
 Electrolyte / acid-base abnormalities  Ischemia
 GFR failure (fluid overload, hyperkalemia, toxins build up)  Nephrotoxins
 Immunologic
Sublethal Injury Secondary
 With glomerular / vascular injury
Morphologic changes (subtle)
 With interstitial nephritis
(from changes in cell calcium, cytoskeleton, adhesion molecules, cell polarity)
 Apical brush border lost
 Blebbing of apical cytoplasm
 Cell swelling / vacuolization
 Cell exfoliation (individual cells slough off, leave gaps on epithelium) – can show up in urine
Can see changes on EM but also on light microscope

Normal: interconnected Osmotic Injury: very Flattened cells, gaps in EM: Loss of brush border &
epithelium, PAS + brush swollen but still have PAS + epithelium (arrowhead), blebbing in lumen
border & more brush border, some lacking apical blebbing of cytoplasm
mitochondria in PT (vs DT) mitochondria into lumen

2
 Intracellular Events in Acute Tubular Injury
Generally just what happens when cells get injured:
 Oxidative metabolism messed up, ATP depleted

+
Intracellular [Ca ] ↑  phospholipases / proteases activated
 Free radicals generated (direct toxicity, esp in reflow post-ischemia)
 Cell membranes injured, cytoskeleton disrupted
 Cell adhesion & polarization messed up
o Lose the normal zona adherens (tight
junctions & adhesion molecules that keep
apical & basolateral sides separate)
o Can’t generate gradients & now more
permeable (leak stuff out into urine)

Note from picture:

big vacuoles, less mitochondria, ultrastructural derangement

Lethal Injury
Cellular Subcellular
 Coagulative necrosis  Major disruptions in Ca / electrolytes / ATP
 Apoptosis  Proteins / organelles disrupted / dysfunctional
 Cell detachment  Cell membrane disrupted
o Can see dead cells in tubules (drifted down  Nuclear breakdown (karyorrhexis)
from upstream site of injury) and in urine

Normal: interconnected Necrotic cells inside a Necrotic tubules: lots of Apoptotic figures in two
epithelium, PAS + brush relatively intact tubule: dead tubule cells, disruption tubular cells
border & more drifted down from & clogging of tubules
mitochondria in PT (vs DT) upstream

Regeneration / Repair
Epithelial cells transdifferentiate & assume a more mesenchyemal pattern: transition
back & forth along spectrum
 Trying to regenerate & proliferate from this more primitive cell type
Not good: worse cell junctions, simplified surfaces without brush border, bad
polarization, pro-fibrotic

Cellular manifestations: flatter cells, heterogeneous cells / nuclei (↑N/C ratio, almost Arrowhead: flatter cells,
spread out, mesenchymal
like neoplasia) , mitotic figures with apoptosis

Subcellularly: new genes expressed & new proteins

formed (different markers)

3
Inflammation plays a role too: marker of ischemic injury Endothelial dysfunction too:
 See RBC & WBC in vasa recta  Edema from lack of endothelial integrity; NO
 Probably attracted by chemotactic substances lost, so less vasodilation
released from injured tubule cells & capillary  Capillary “sludging” (RBC & WBC stuck in
endothelium capillary b/c ↑adhesion molecules &
 Creates congestion & low flow (ischemia can ↑constriction)
result) o Procoagulant state (loss of protective
surface factors too) ischemia  etc
How does this cause renal dysfunction?
Hemodynamic abnormalities
 Vasoconstriction – tubuloglomerular feedback (& maybe RAAS,
etc)  afferent arteriole constriction
o Not absorbing & secreting normally  shut down glomerulus of
affected nephron!
Back-leak of filtrate into blood with disruption of tubule integrity
 No net filtration! Putting it right back into capillaries
Obstruction of tubule
 ↑tubular pressure  ↑ Bowman’s space pressure  GFR
compromised

Nephrotoxic Acute Renal Failure

 Clinically the above stuff (for ischemic injury) applies too
Small path differences NEPHROTOXIC AGENTS
 Maybe bigger structural injury, more frank necrosis  Antibiotics (gentamicin, ampho B)
 Can be generalized or segment-specific (e.g. PT only)  Radiographic contrast
 Some path agents have distinctive lesions (see below)  Chemotherapy (cisplatin)
 Lithium, mushrooms, insecticides
Effects from interference with oxidative metabolism
 ↑ free radicals  cell damage

Calcineurin Inhibitors: Aminoglycosides: Indinivar:

Isometric vacuolization Myeloid bodies Crystalization
(small, equal-sized (see these things on EM) (big crystal here – check out
vacuoles) tubule size in comparison)
4
 Outcomes of Acute Tubular Injury
 Whole range: from recovery without dialysis to recovery with dialysis or even patient death (MOF)
 Can be partial or complete (severity, duration, patient factors like age/illness, etc)
 Can have chronic sequelae

FAST FACTS - TUBULAR INJURY

1. Most common causes are ischemia/hypoperfusion and toxins, including drugs
2. Morphologic changes are often subtle - while necrosis and apoptosis occur,
sublethal injury and reactive/regenerative changes may predominate
3. Typical cell injury cascade, with altered cytoskeleton, polarization, adhesion
4. Renal failure ensues due to arteriolar vasconstriction, tubular back leak, obstruction
5. Some evidence for an inflammatory component – PMN, T and B cells, adhesion molecules
6. New focus on endothelium in ischemia, improving reflow

Interstitial Disease
Interstitial nephritis: an inflammatory infiltrate in interstitium CAUSES OF INTERSTITIAL NEPHRITIS / FIBROSIS
 Responsible for 15% acute RF, 25% chronic RF  Infection
o Direct (incl. pyelonephritis)
 Can be 1° (± 2° tubule injury), or 2° to tubule injury – hard to tell o Indirect (systemic inflammatory reaction – to
which came first if you see them both drugs, parasites, viruses, etc.)
 Drugs
o If huge inflammatory infiltrate (or if PMNs, eos,  Immune-mediated (Ab or cell-mediated)
granulomas present) probably interstitial first  Obstruction / reflux
 Secondary (to glomerulonephritis or vasculitis)

Direct bacterial infection of the kidney

1. Ascending: “pyelonephritis” – transits urethra, bladder, has to pass through
uretral valves into ureter, etc.
o Papillae  cortex (coming in via ureters from renal pelvis!)

2. Hematogenous: with big time bacteremia, can enter via glomerular capillaries
o Glomerularcentric (coming in through glomerulus!)

Types of bacteria: usually from feces

 E. coli is #1, (also Klebsiella, Proteus, Enterobacter, Pseudomonas, Serratia)

Risk Factors:
 Instrumentation (catheters, etc.)
 Renal calculi (kidney stones, place for bacteria to hang out)
 Virulence factors (capsular Ag  ↓phagocytosis & C’, fimbriae to keep from being
swept away in urine)
 Females (anatomy) & pregnancy
 Vesiculouretral reflux (see below)

Histology: fibrosis separates chronic from acute

 Acute: interstitial edema with inflammatory infiltrate
(often mononuclear with PMNs around / in tubules, can form casts because of ↑adhesion molecules)
 Chronic: interstitial fibrosis with inflammatory infiltrate (can see germinal centers)
 Can see mixed acute + chronic too
5
Bacterial infection of the kidney

Gross: cortical abscesses Bigger cortical abscess PMNs in a cast inside of a Cast with WBC and bacteria
(pyelonephritis) & tubule, also in wall & (in urine, seen here on EM)
streaking (pus in tubules), interstitium (bacterial – can help with Dx
some hemorrhage too infection)

Note that viruses can cause kidney infection too (big mononuclear infiltrate,)

Drug-induced Primary Acute Interstitial Nephritis

Allergic / immunologic reaction to drug
 Example mechanism: drug binds to interstitial / peritubular Offending drugs:
protein  new complex presented to T-cells  response
 Abx (PCNs,
Amplification via cytokine release sulfonamides)
 (from inflammatory & tubulointerstitial cells)  Thiazide diuretics
 NSAIDs
Sx: may have fever/rash/eos in blood  Herbal meds
 days/weeks post-exposure  Others (lots!)
 Eos especially if hypersensitivity (look out for drug rxn!)

Immune-mediated AIN
Anti-basement membrane antibodies:
 LINEAR deposits on IF
 Ab against structural Ag that’s uniformly expressed on TBM (tubular BM)
 Goodpasture’s syndrome (also glomerular BM), renal allografts, membranous nephropathy

Immune complex deposition:

 GRANULAR deposits on IF
 Ab to irregularly distributed (“planted”) Ag
 Granules are aggregates of Ag-Ab complexes
 Some drug rxns, systemic lupus erythematosus, membranous & IgA GN

Cell-mediated
 Sarcoidosis, some drug rxns, TB infection, allograft rejection
 T-cell mediated injury

Renal Dysfunction in AIN

 Tubular dysfunction  altered distal fluid delivery  TG feedback mechanisms
 Vasoconstriction (TGF, reflex, etc); tubular obstruction, Injury / compression / loss of peritubular capillaries,
cytokines / enzymes released  RENAL FAILURE
 Can result in concentrating defects (polyuria / nocturia), renal tubular acidosis, salt-losing nephropathies too

6
 FAST FACTS - INTERSTITIAL NEPHRITIS
1. Causes: infection (direct, indirect), hypersensitivity reactions to drugs, immune-mediated processes (immune
complexes, anti-TBM antibodies, cell-mediated).
2. Histologic hallmarks are edema and inflammation, often lymphocytic/monocytic;
3. The presence of neutrophils suggests infection; eosinophils suggest hypersensitivity reaction; granulomas may be
seen with certain infections and drug reactions;
4. Causes renal failure by damaging tubules, interfering with blood supply - cytokines may play a role.

Chronic interstitial nephritis

Interstitial FIBROSIS is key finding
 from fibrogenic cytokine release: AT II & TGF β  ECM
synthesis, obliteration of capillaries
 Tubular atrophy, mononuclear infiltrate seen too

Tubules shrink  more mesenchymal differentiation 

secrete more collagen  more fibrosis  cycle!

Causes: chronic stage of AIN, chronic ischemia

(atherosclerosis, obstruction, etc.), drug rxn (lithium)
Shrunken tubules,
mononuclear cell infiltrate,
Results: chronic renal failure, concentrating defects, fluid /
zoom: would see fibrosis
electrolyte imbalances (pink in interstitium)
Big, thick basement
membrane(PAS+) with
some epithelial -
mesenchymal transition

Obstructive Nephropathy
 Alterations to kidney / collecting system from obstruction
o usually chronic obstruction  fibrosis
 Can be unilateral or bilateral (how low is obstruction?)
 Can be component of infection or not (increases infection risk)
 MANY causes (uretropelvic: extrinsic, intrinsic, congenital, or vesicourethral: prostate
enlargement, spinal cord probs, etc.)

Hydronephrosis: dilation of collecting system (depends on site of obstruction)

 Can see on imaging with parenchymal thinning & fibrosis
 Calyceal dilation (calyxes dilated) is common – can go away with relief of obstruction
 Pictures to right: R sided obstruction with dilation (top), big dilated calyces (bottom)

Caliculi can form (from increased stasis)

7
 Vesicouretral Reflux (VUR)
Retrograde propulsion of bladder urine into ureters
 Most often from abnormal implantation of ureters into bladder
o more perpendicular angle between bladder wall & ureter
o orifice doesn’t close right during micturition – usually squeezed shut on contraction
 Renal injury can happen early (need to recognize) but present as adult
o NEED EARLY REPAIR (or damage / scarring can result)
 Unilateral or bilateral

Causes of Damage Pathology:

 Infection  Dilation (pelvis / calyces)
o Complement activation  Thinning of parenchyma
o Edema, Ischemia/Reperfusion  Papillae flattened, cortical
o Free radical release tubules atrophy
 Elevated pressure  Interstitial fibrosis
o Tubular damage, ischemia  CLASSIC FINDING: Coarse
(capillary compression) segmental scars over
 Hyperperfusion/Hyperfiltration in remaining dilated calyces at POLES
nephrons  more sclerosis  ± inflammation

Can see reflux (little jets) with increased pressure (images to right)

Why scarring at poles?

 Simple papillae (not at poles) close duct orifices with increased backpressure
 Compound papillae (poles) open duct orifices with increased backpressure (reflux results!)

simple compound

FAST FACTS: CHRONIC INTERSTITIAL NEPHRITIS / SCARRING

1) Caused by prolonged interstitial inflammation, chronic ischemia, reflux, obstruction with back pressure from
collecting system, (also, secondary to vascular, glomerular diseases).
2) Characterized morphologically by fibrosis, inflammation (mononuclear) in tubulointerstitum; glomeruli often
spared until late in course.
3) Is the “pivotal lesion in nephrology,” correlating with prognosis in all renal diseases.
4) Occurs in discrete stages with potential for arrest or even reversal if the process is detected early.

8
 Nephrotic Syndrome
Normal glomerulus
(review: fenestrated endothelium, podocyte feet, etc.)

Remember the podocyte:

 Regulates permselectivity
 Structural support for glomerulus, remodels GBM, endycytoses filterd proteins, counteracts pressure, etc.
 COMPLICATED: mutations in various proteins of filtration slit can lead to hereditary proteinuria

Basement Membrane:
 has lamina densa (dark on EM, middle zone; blocks based on size) & 2
x lamina rara (interna & externa, heparin sulfate, blocks by charge)

Right: EM of the glomerular filter

with labels (fenestrated
endothelium on bottom, foot
processes of podocytes & filtration
slits above)

The Nephrotic Syndrome (general points)

Nomenclature The Nephrotic Syndrome

Diffuse vs • Proteinuria > 3.5 gm/24 hrs
% of glomeruli involved
Focal • Hypoalbuminemia
Global vs Extent of involvement of an individual glomerular tuft • Edema (from ↓oncotic pressure)
Segmental  only part or the whole thing? • Increased serum lipids*
Sclerosing / “Hard” (increase in matrix in the tuft) • (Doubly refractile fat bodies in
sclerosis  proteinuria ± heme urine - from ↑ serum lipids)
Increase in intrinsic glomerular and/or inflammatory cells
Proliferative / *(liver cranking out more of everything to
 hematuria ± proteinuria
hypercellular try to make more albumin)
 (Glomerular hematuria = GBM abnormality / injury)

Nephrosis vs Nephritis
Urine Inflammation & proliferation in glomeruli In general
Proteinuria, not hematuria,
-osis / -otic Cellular casts
Nope Nephrosis is COOL
Hematuria ± renal failure Yes – inflammation / complement cause capillary injury
-itis / -itic Cellular casts with blood, cells getting across GBM
Nephritis is HOT

 Proteinuria: loss of >150mg in 24h (much more in nephrotic syndr.)

o > 3.5g = “nephrotic range proteinuria”

9
 What’s going on in the Nephrotic Syndrome?
A few main points:
Glomerulus is leaky & you’re losing proteins:
 Hormones, vitamins, minerals  deficiencies
 Coagulation factor balances altered 
thromboembolism
 Proteins as nutrients  malnutrition
(kwashiorkor)
 Igs  infections (turnover too fast)

Tubule has to try to reabsorb 

damage & dysfunction

Too little albumin:

 Edema (reduced [protein] in blood)
 Liver starts cranking up synthesis of
everything while trying to make more albumin
(not the brightest organ around)  more
coagulation factors,
more lipoproteins, etc. MAIN CAUSES OF NEPHROTIC SYNDROME:
(more problems like
1. Minimal Change Disease
CVD)
2. Focal & Segmental Glomerulosclerosis
(with hyalinosis)
Major problem is podocyte 3. Glomerulonephritis
injury (can see hypertrophy, 4. Generalized systemic diseases
de-differentiation, or just loss (diabetes, amyloid, SLE)
of charge – but function is lost
so filter messed up!) Prevalence varies with race and age

Minimal Change Disease

Patient: mostly children (2-6yo)
Urine: selective proteinuria (albuminuria ≫ other proteins)
Course: relapsing / remitting
Treatment: steroids (good response; give empirically to a kid with proteinuria)
Prognosis: favorable

Pathology
LM: normal! No glomerular changes!
EM: effacement of foot processes with
loss of negative charge
 Need EM to make diagnosis
(see pic –arrows)
 Smooth instead of nice foot
processes

Pathogenesis:
 negatively charged surface proteoglycans altered
 lymphokines & T-cells may play a role; cationic factor neutralizes negative charge,
 thromboxane  hemodynamic changes?
 can be secondary to drugs (NSAIDs), lymphoma, venom/toxins, viral infection

10
 Focal Segmental Glomerulosclerosis
 Name tells you what it is: focal(<50% glomeruli involved), segmental (only part of glomerulus), -sclerosis = hard

Patient: both children & adults, more common in African Americans

Urine: proteinuria poorly selective (not albuminuria like MCD)
Course: can recur in allografts, hematuria & HTN more frequent
Treatment: poor response to steroids; plasmapheresis post-transplant to avoid (remove unknown circulating factor)
ACEI may help too post-transplant (reduce glomerular capillary pressure)
Prognosis: worse than MGD

Pathogenesis: Variety of possibilities. Probably multiple diseases  one pathological syndrome

 Primary (idiopathic FSGS) – generalized podocyte injury, cause unknown
o Recurs in 40% transplanted kidneys; plasmaphereis post-transplant helps avoid
 Secondary: (“post-adaptive”) – many related to reduced # nephrons & increased filtration
 Localized podocyte loss may be key; TGFβ & AT II  more ECM
o Adaptation to: reflux nephropathy, renal dysplasia, morbid obesity, SCD, primary glomerular dz
 Also: 2° to hereditary nephropathies; heroin-associated FSGS (CONTAMINATED HEROIN), can be HIV-associated

Morphology: different variants. All possible in primary, * = can be seen in secondary / post-adaptive FSGS
Early / recurrent: EM changes only
(podocytes)
Collapsing glomerulopathy: Left: Arrow: giant
 Capillaries collapse & large podocyte!
hypertrophic podocytes seen
(dedifferentiating?) Right: note big
space on EM
between
 Podocyte loses its grip: detach from
damaged
capillary loops; no structural support
podocyte & GBM
 Esp in HIV pts; parvovirus B19 / viral
involvement?

“Tip” lesions
 Foam cells & solidification in segment
of capillary tuft opposite the hilum
 May be more benign

Capillaries no longer patent, adhering to Bowman’s capsule. Hyalinosis (silver stain)

* Segmental sclerosis (often with
hyalinosis & foam cells; peri-hilar)

 Hyalinosis: collections of eosiophilic

material (represent plasma proteins)
o inside  filling capillary lumen

 Can see capillaries adhering to

Bowman’s capsule

* Segmental sclerosis (non-specific)

IF: can see IgM & C3 in sclerotic portions of affected glomeruli (where lesion is!)

11
 Membranous Glomerulopathy

Patient: Adults (peak = middle age, M>F a bit)

Urine: proteinuria poorly selective
Course: Sudden presentation, usually only trace hematuria.
Treatment: poor response to steroids; no good evidence supporting one therapy over another
Prognosis: More variable. Worse with HTN or >10g/day proteinuria

Pathogenesis: Deposition of immune complexes

 Primary / idiopathic: autoimmune
(Ag is probably podocyte glycoprotein M-type phospholipase A-2 receptor)
o Complexes can form in situ (glomerular Ag) or from preformed complexes
that get filtered
 Secondary to: chronic infection, drugs, autoimmune disease, malignancy.
o Anything that causes chronic low levels of circulating immune complexes
can start the process

Pathology:
think SUBEPITHELIAL IMMUNE COMPLEX DEPOSITS

LM: thick capillary walls

(immune complexes thicken them up)
 Silver stain: may see spikes (basement membrane
extending out from / perpendicular to GBM in
reaction to deposits) and domes (same reaction,
when it surrounds deposit)

EM: subepithelial deposits

(between podocyte & BM)

IF: granular IgG & C3 along capillary walls

(immune complexes = granular)

Diabetic Nephropathy
Patient: Diabetics (40% of patients!), associated with poor glucose control
Remember: type I = no insulin, type II = insulin resistance, CHO / fat / protein metabolism messed up
Urine: Microalbuminemia at first  gradual increase to nephrotic range proteinuria
Course: Five clinical stages (see box: hyperfiltration  ERSD). HTN can complicate

Pathogenesis:
Diabetic Nephropathy
 Hemodynamic alterations (increased glomerular
Stage I Early Increased GFR
pressures, hyperfiltration  damage)
Stage II Latent Asymptomatic
 Glycosylated collagen (↓degradation  ↑ECM, Stage III Incipient Microalbuminuria
↓heparan sulfate  ↑anion loss) Stage IV Overt Proteinuria, decreasing GFR
 Genetic predisposition Stage V End stage Fibrosis, Sclerosis

12
Pathology of Diabetic Nephropathy:
 Can have nodular sclerosis ± hyalinosis
o Increased amounts of matrix /
membrane form nodules called
Kimmelstiel-Wilson lesions

 Diffuse mesangial matrix increase

 Arteriolar hyalinosis is KEY (almost

always can see hyalinosis in arterioles!)

 Thickened glomerular capillary walls

 Thick basement membranes on EM

 May have superimposed ischemic injury

(via arteriosclerosis from DM)

 Capsular drops: blobs of hyaline in

Bowman’s capsule

IF: may see linear IgG & albumin along glomerular

capillary loops
 No immune-type deposits! This are just
nonspecific plasma proteins building up

Therapy for Proteinuric Glomerular Diseases

Treatment Strategies
 Treat or remove inciting diseases/factors (drug, neoplasm, autoimmune dz, infection)
 Rx with steroids, other immunosuppressive drugs
 prevent glomerular HTN / hyperperfusion - ACEI, ARB
 Important to reduce proteinuria - will lead to tubular atrophy, fibrosis in time

A really basic summary table (from our small group; not exhaustive but main points)
Minimal Change Focal Segmental Glomerular Sclerosis Membranous
Age Kids Adults Adults
Nephrotic
Presentation Nephrotic Nephrotic
Foamy urine
 Autoimmune Dz
 Lung / colon cancer
 Obesity
Associations Post-infection  Infection (esp. HBV, HCV, malaria)
 Heroin, HIV, Sickle Cell
 Drugs (NSAIDs)
 Cancer (esp. lung / colon)
LM Nothing Focal, segmental, sclerosis Thick capillary loops
Nothing
IF Nothing IgG & C3
(+/- secondary protein deposits)
“Fusion” – simplification  Thick basement membrane
EM
– of foot processes  Subepithelial deposits
Excellent response to
Treatment Most no response to steroids
steroids

13
 Glomerulonephritis
Terminology: diffuse vs focal, segmental vs global; also:
THE NEPHRITIC SYNDROME:
 Exudative: GN where PMNs are significant  Hematuria (can have RBC casts)
proportion of glomerulus  Decreased renal function
(↑BUN & ↑serum creatinine)
 Crescentic: extracapillary cell / matrix  Proteinuria (variable, <3.5g/day)
proliferation (crescents)  Edema
 Hypertension
RBC casts: recapitulate inside of tubule (see on U/A)  Decreased urine output

FORMS OF GLOMERULONEPHRITIS
Immune complex-related Pauci-immune Anti-GBM
 Post-infectious Associated with ANCA:
 IgA nephropathy anti-neutrophil cytoplasmic antibody
 Renal-limited
 Membranoproliferative  Renal-limited  Goodpasture’s Syndrome
(e.g. cryoglobulinemia) (“idiopathic” crescentic GN) (pulmonary involvement too)
 Lupus nephritis  Systemic vasculitis
 Other uncommon forms (Wegener’s, microscopic polyangitis)

Post-Infectious Glomerulonephritis
Clinical presentation:
 Group A, β-hemolytic STREP infection is #1
o Present 1-2wk after recovery from pharyngitis
o Gross hematuria (dark urine) common, low serum C3

Prognosis: excellent for complete recovery in children (small % adults  ERSD)

LM IF EM
Diffuse proliferative & Granular IgG & C3 Subepithelial HUMPS
exudative GN (in capillary loops, characteristic (with
mesangium) abnormal podocytes
± Crescents surrounding them)
(poor prognosis if many) C3 lasts longer
Subendothelial &
mesangial deposits too

14
 IgA Nephropathy

Patient: Most common GN in world but uncommon in African-Americans

Presentation:
 Microscopic hematuria ± proteinuria on routine exam or
 Gross hematuria post-URI

Course: 40-50%  ESRD over 20 yrs

Prognosis: proteinuria > 1g/day & hypertension are bad
Treatment: ACEi/ARB, lots of others but not good evidence
Other: unknown etiology, probably related to henoch-schonlein purpura

LM IF EM
Focal, mesangial proliferative GN Granular IgA & C3 Mesangial deposits
(in capillary loops, mesangium)
Diffuse / crescentic: worse prognosis (Subendothelial too in ~25%)
IgG/M possible but ≪ IgA
Normal-looking: good prognosis
No C1q (lupus)

Membranoproliferative Glomerulonephritis
Epidemiology: Uncommon, 3 types but forms other than type I very rare
Presentation: Mixed nephrotic / nephritic, low C3

Course: Progression to ESRD is common

HIGH recurrence in renal transplants

Other: Subset of patients have mixed cryoglobulinemia (HCV +)

Etiology: Can be idiopathic (primary) or secondary to:

 Bacterial infection
 Viral infection (HCV / HBV)
 Neoplasia

LM IF EM
Diffuse, proliferative GN & hyperlobular glomeruli Granular IgG & C3 (± IgM, C1q) Subendothelial & mesangial
(in capillary loops, mesangium) deposits
Double contours / TRAM TRACKS (PAS / silver)
Cryoglobulin coagula: IgG/IgM “duplication” of GBM
Cryoglobulinemia: Intracapillary pseudothrombi (separated because of deposits!)

15
 MPGN: pathology

Crescents
NOT specific for a given disease: indication of SEVERE GLOMERULAR INJURY

Acute: cellular crescents

 Proliferated parietal epithelial cells, Mϕ, fibrin
 Adhere to Bowman’s capsule
 Can form shape of crescent or extend around entire circumference

Chronic: fibrocellular  fibrous crescents

 Crescents scar over time

Can see interstitial inflammation, disruption of GBM

16
 DDx of Crescentic GN
1. Immune-complex mediated
a. lupus, MPGN, post-infectious GN, IgA nephropathy
b. Crescents = bad prognosis
c. Dx: show immune-complex deposits (IF or EM)

2. Pauci-immune
a. Don’t see deposits on IF or EM
b. Triggering of pathogenesis: PMNS activated  azurophilic granules
exposed  Ab bind  PMNs start degranulating  vasculitis (see
picture to right – can see acute lesions of small vessels)
c. 90% are ANCA positive (anti-neutrophil cytoplasmic antibodies)
Ab against PMN Staining Diseases

Microscopic polyangitis (MPA)

P-ANCA Myeloperoxidase Perinuclear (more often; rarely C-ANCA)
Pauci-immune crescentic GN

Wegener’s Granulomatosis
C-ANCA Pr3 Cytoplasmic
(more often, rarely P-ANCA)

3. Anti-GBM Nephritis
a. Least common of 3 causes of crescentic GN
b. Auto-Ab to portion of type IV collagen α3 chain (“Goodpasture antigen)
c. Dx: need LINEAR IgG in GLOMERULAR CAPILLARIES by IF
i. Confirm: ELISA (pt serum vs Goodpasture Ag)
ii. No deposits by EM
iii. 20-30% also ANCA positive
d. Ab can cross-react with pulmonary alveolar BM
(GOODPASTURE’S DISEASE)

Two examples of GBM IgG deposits: Linear vs Granular

Linear (left): nice and smooth (along the whole GBM)
Granular (right): concentrated where immune complex Ag are
17
A few tables:
Proliferative Glomerulonephropathies (summary from small group)
Acute( post-infectious)
Crescentic Membranoproliferative
glomerulonephritis
antiGBM Immune complex Pauci-immune
Type I Type II
(type I) (type II) (type III)
Nephritic Nephritic > nephritic Nephritic
Nephritic
 ANCA (anti- Nephrotic > nephritic  C3NcF (C3 nephritic  Post-strep (GAS)
Clinical  Goodpasture’s Nephritic
neutrophil factor – Ab that pharyngitis or
syndrome
cytoplasmic Ab) stabilizes C3 convertase) impetigo
Membranoproliferative Proliferative
LM Crescents
Tram-tracking PMNs in capillary loops
Granular
LINEAR Granular Granular Granular
IF Nothing IgG & C3, C4, C1q, etc
IgG & C3 IgG & C3 C3 mainly IgG & C3
(+/- IgM)
Ruptured GBM
Subepithelial Subendothelial Intramembranous Subepithelial and
EM (other crescentic Not much
deposits deposits deposits subendothelial deposits
forms too)

Nephrotic Vs. Nephritic (from lecture notes)

Nephrotic Nephritic
Proteinuria 3.5 grams/day present, but typically <3.5 grams/day
Urine Sediment +/- RBCs, no RBC casts many RBCs, often RBC casts
Edema present often present
Hypertension often absent (but may be present (especially in FSGS)) often present
Serum creatinine typically normal (but may be elevated (especially in FSGS)) usually elevated
Pathologic Features
Glomerular Histology normal cellularity hypercellular
Specific diseases Glomerulonephritis. including:
Non-inflammatory glomerulopathies. including:
 post-infectious GN
 Membranous
 IgA nephropathy
 Minimal change
 membranoproliferative GN
 FSGS
 lupus nephritis (diffuse/focal proliferative)
 Diabetic nephropathy
 ANCA-associated (pauci-immune) GN
 Amyloid
 anti-GBM nephritis

18
 Renal Manifestations of Systemic Diseases
Remember that other systemic diseases with kidney manifestations are in other lectures:
Wegner’s, microscopic polyangiitis, Henoch-Schonlein purpura, HIV, diabetes, etc.

Systemic Lupus Erythematosus

Autoimmune disease involving multiple organ systems (esp. skin, joints,
bone/blood marrow, kidney, CNS) American Rheumatism Association
SLE Diagnostic Criteria
 Not rare, women ≫ men, AA > Caucasians
1. Malar rash
 Young adults most commonly (can see at any age) 2. Discoid rash- erythematous raised
patches with keratotic scaling
Circulating antibodies, especially ANA (ANTI-NUCLEAR ANTIBODIES) – 3. Photosensitivity – skin rash as a
directed against nuclear antigens reaction to sunlight
 dsDNA, histones, nucleolar RNA, non-histone proteins, etc. 4. Oral nasopharyngeal ulcers
 Just about all SLE pts have ANA but 5. Arthritis – involving ≥2 peripheral joints
POSITIVE ANA TITER NOT SPECIFIC FOR / DIAGNOSTIC OF SLE 6. Pleuritis or pericarditis
7. Renal disease – proteinuria >0.5
 Clinical diagnosis (see box) – need ≥ 4, serially or simultaneously
grams/day or 4+ by dipstick, or RBC
 Renal failure and infection are top 2 causes of death casts
8. Neurologic disorder – otherwise
unexplained seizures or psychosis
Lupus Nephritis 9. Hematologic disorder – hemolytic
anemia, leukopenia, or
 70% of pts with SLE  renal involvement (lupus nephritis) thrombocytopenia
10. Antibody to DNA, Smith antigen
General features of lupus nephritis (anti-Sm), or phospholipid
11. Positive ANA titer – in absence of drugs
IF: “FULL HOUSE” staining (IgG/A/M + C3, C1q), esp. in class III/IV known to be associated with this (e.g.,
 C1q is almost always present hydralazine)
 Tubular basement membrane deposits Need ≥ 4, serially or sequentially

Electron microscopy: tubulo-reticular inclusions (endothelial cell cytoplasm)

 Not specific, but most often in lupus nephritis + HIV; from exposure to IFN-α

Classification of Lupus Nephritis (subclasses too for II and IV)

Class Name Description
I Minimal mesangial lupus nephritis Normal glomeruli (LM), mesangial deposits (IF)
II Mesangial proliferative lupus nephritis Pure mesangial hypercellularity and/or mesangial matrix expansion
III Focal lupus nephritis < 50% glomeruli
IV Diffuse lupus nephritis > 50% glomeruli
V Membranous lupus nephritis ± mesangial changes; can be in combination with III/IV
VI Advanced sclerosing lupus nephritis ≥90% globally sclerosed glomeruli

Key idea: Lupus can present in a LOT of different ways in the kidney. Path pics on next few pages.

19
 ↑ Lupus Nephritis TYPE II: mesangial proliferative ↑

↑ Lupus Nephritis TYPE III (focal) / IV (diffuse) ↑

Can also have crescents in either kind; note full house staining in capillary walls & mesangium

20
 ↑ Lupus Nephritis TYPE V (membranous)↑
Note that this looks like “Membranous Glomerulopathy” (page 12) from the nephrotic syndrome lecture

Summary table

Class II Class III Class IV Class V

Description mesangial focal proliferative diffuse proliferative membranous
Frequency (- class I) 15% 20% 50% 15%
hematuria,
hematuria and nephritic or
Clinical pres non-nephrotic nephrotic
proteinuria nephritic/nephrotic
proteinuria
mesangial cell & endocapillary GN in endocapillary GN in capillary loop
LM
matrix increase <50% glomeruli > 50% glomeruli thickening
subENDOthelial, subENDOthelial, subEPIthelial,
EM Deposits mesangial
mesangial mesangial usu. mesangial

Transformations: the different classes can transform from one to another

Indices for prognosis of lupus

Activity: how active is the disease Chronicity: how chronic is the disease?
Each scored 0-3 Each scored 0-3
 Glomerular cell proliferation  Wire loops, hyaline thrombi  Glomerular sclerosis
 Cellular crescents x2 (bad)  Glomerular WBC infiltration  Fibrous crescents
 Fibrinoid necrosis / karyorrhexis x 3  Interstitial mononuclear cell  Interstitial fibrosis
(really bad) infiltrate  Tubular atrophy

 Activity > 9 = ↑ renal failure; chronicity >4 = worse progression (more eventual renal failure)
 Helps you decide how aggressive to be in treatment

21
 Light Chain Cast Nephropathy “myeloma kidney”
 Most common renal manifestation of light chain disease
o Can be 1st presenting symptom of myeloma or monoclonal gammopathy
 Usually presents as acute renal failure
 Light chains (EITHER κ OR λ) + acidic urine + Tamm-Horsfall glycoprotein  large CASTS
o Casts obstruct tubules
o Casts have FRACTURED appearance (artifact of fixing) – if you hear “fractured cast,” think light chain cast
o Cast often surrounded by cells in tubule, including multinucleated giant cells
 IF: either κ OR λ (light chain restriction)

Fractured casts (note how they’re IF: κ positive IF: λ negative

broken up, arrowhead) with cell
reaction (maybe a multinucleated
giant cell in tubule with arrow?)

22
 Amyloid
Two major types
AL (“primary”) amyloid AA (“secondary”) amyloid
Light chains, λ > κ Plasma protein SAA
Amyloid protein derived from…
(L is for “light”) (Type AA is SAA)
Conditions that overproduce light chains
Chronic inflammatory conditions
85-90% monoclonal production
In setting of… (e.g. rheumatoid arthritis, TB,
47% have myeloma
osteomyelitis, Sub-Q-injection drug users)
Most common > 50yo

 Can only distinguish AL from AA by IF or IHC

 Renal amyloidosis: proteinuria (often nephrotic syndrome)
o HTN & hematuria uncommon

LM findings EM findings
Mesangial expansion by :
Extracellular, randomly-oriented,
 Eosinophilic, CONGO RED POSITIVE, acellular material
thin, non-branching FIBRILS
Blood vessels also frequently involved

Amyloid (arrow): fluffy, pink, Left: Congo red positive IF: positive for lambda light
acellular. Glomerulus looks Right: Congo-red-stained amyloid turns green chain (primary / AL amyloid)
hypocellular under polarized light (both AL & AA, only amyloid
has this birefringence)

Left: amyloid Right:EM of amyloid

deposits eventually deposit with fine,
destroying entire randomly oriented
structure here, fibrils
pushing up &
narrowing capillary
lumen, replacing
mesangium

23
 Light Chain Deposition Disease
 Least common of 3 renal manifestations
o 60% pts have multiple myeloma Clinical presentation & course
 Renal insufficiency & proteinuria
 κ > λ (opposite of AL-amyloid)  Poor renal survival (35% @ 5yrs)

LM findings Silver Stain EM findings

 light chain deposits in tubular &  60%: nodular granulosclerosis (like diabetic  finely granular
glomerular BASEMENT nephropathy, but silver-stain negative deposits
MEMBRANES deposits in LCDD)

Left: Nodular glomerular appearance. Need to ddx from diabetic nodular granulosclerosis using silver stain
(center: material is silver NEGATIVE in LCDD, right: silver positive in diabetic glomerulopathy)

Far left: IF
positive for κ-
light chain in
TUBULAR
BASEMENT Right: EM:
MEMBRANE continuous,
granular, dense
near left: deposits in
negative for λ- SUBENDOTHELIAL
light chain GBM

24
 Thrombotic Microangiopathy
Not a specific disease but a type of lesion
 Endothelial cell injury in capillaries, arterioles, and/or small arteries
o Swelling of endothelial cells with detachment from BM
 Subendothelial accumulation: fluid, fibrin cell debris
 Intraluminal fibrin/platelet thrombi
 Trauma to circulating RBCs – microangiopathic hemolytic anemia
o fragmented and distorted RBCs (“schistocytes”) – see picture

DDx of thrombotic microangiopathy involving kidney

Glomeruli / Arterioles > arteries Arteries / Arterioles > glomeruli
 Hemolytic-uremic syndrome (HUS)
 Thrombotic thrombocytopenic purpura (TTP)  Scleroderma
 Anti-phospholipid syndrome (± SLE)  Malignant hypertension
 Certain drugs (cyclosporine, etc.)
 Post-partum ARF (post-partum HUS)

Thrombotic microangiopathy: Hemolytic-uremic syndrome (HUS)

D+ (diarrhea positive) – “classic” / “epidemic” D- (diarrhea negative) – “atypical” /“sporadic”
 Majority of cases, mainly in kids
 Some epidemics: infected meat (e.g. hamburgers)  Adults & children
 E. coli O157:H7 - shiga-like (vero-) toxin producing  Etiology unclear
o Toxin binds to receptors on endothelial cells  Often arterioles / small arteries involved – worse
 Renal disease follows several days of diarrhea prognosis
 Mainly glomerular involvement – good prognosis

Symptoms of HUS
 One of main causes of ARF in children  microangiopathic hemolytic anemia
 See box for symptoms  thrombocytopenia
 renal failure
 occasional CNS involvement
(cause of mortality in childhood HUS)

Thrombotic microangiopathy: Thrombotic Thrombocytopenic Purpura (TTP)

 Most often adults < 40 yo, women > men “Classic” TTP clinical syndrome
 Classic syndrome: see text box  Fever
 Significant renal insufficiency: only 50% pts  Microangiopathic hemolytic anemia
 Pathogenesis: vWF cleavage implicated  Thrombocytopenic purpura
 80% survival of acute dz with plasma exchange  Neurologic manifestations
(formerly uniformly fatal)  Renal failure

25
 Pathology of TTP & HUS
 Fibrin/platelet thrombi in glomerular capillaries / arterioles (> arteries)
 Glomeruli: RBC fragments, RBC stasis, or “bloodless” (due to endothelial swelling )
 Separation of endothelial cell from GBM and production of new GBM – “Double contours”
 Loss of mesangial cells and matrix (“mesangiolysis”)
 RBC and RBC fragments within arterioles; may show focal fibrinoid necrosis
 Best prognosis: glomerular involvement only (involvement of arteries = poor prognosis)

HUS glomerulus: Lots of red Congestion in glomerulus: fibrin thrombi &

(fragmented RBC in capillaries), fragmented RBC in capillary loops (all stuffed up)
lumen lost (endothelial swelling)

Glomerulus: diffusely simplified tuft Focal loss of foot processes; EM: widened subendothelial space with
with fragmented RBC swollen endothelial cells with electrolucent material (double arrow),
subendothelial deposits RBC (arrow)

26
 Scleroderma (systemic sclerosis)
Characterized by excessive collagen deposition at multiple sites
 Skin, GI tract, kidney, blood vessels, musculoskeletal involvement common
 Limited & more indolent forms exist

Etiology: unknown (abnormal T-cell activation, cytokine release, 1° injury to endothelium unknown)
Lab findings: ANA positive usually; <50% have anti-DNA-topo-I Ab (specific if present)
Major problem: SEVERE HTN with ARF (“SCLERODERMA RENAL CRISIS”)

Kidney involvement: up to 70% cases (not always renal crisis)

Small arteries: major findings here Arterioles: commonly involved Glomeruli: variable involvement
 Mucoid intimal hyperplasia  Endothelial swelling  Ischemia-related changes (e.g.
(concentric proliferation of cells in  Focal fibrinoid necrosis capillary collapse)
intima  “onionskin lesion”)  Luminal thrombi  Can have HUS-like changes (capillary
 Intima often has fibrin / RBC  RBC/RBC fragments in vessel wall thrombi, fragmented RBCs)
fragments too
VASCULAR CHANGES LOOK LIKE MALIGNANT HTN – but can happen in absence of HTN

Note huge space between endothelial cells (very

center) & internal elastic lamina (blue ring on outside) Fibrinoid necrosis (arrows):
– filled with smooth muscle cells from media! note both small arteries & arterioles are involved)

Left:

Ischemic glomerulus with capillary

collapse (arrow): wrinkled capillary
loop with ↓ # open capillaries

onion-skin lesion (arrowhead):

concentric narrowing in small artery

27
 Tumors of Bladder & Kidney
Urothelial (transitional cell) Cancer of the Bladder
Epidemiology: 70k cases, 14k deaths in 2008 (USA)
 Male > Female (3:1) – esp. older males like most GU tumors
o Majority present in localized stages (early stage  good tx options)
 Big health care cost burden – starts superficially, keep recurring, progress  more aggressive
o We don’t know who’s going to progress – keep monitoring!  $$$ ($4B/yr)
o Most expensive cancer per patient
Risk factors
 Carcinogen exposure: carcinogens in urine, not via bloodstream
o Smoking: up to 2/3 M bladder ca, pack-years is big risk, slow acetylators ↑ smoking related risk (40%)
o Occupational exposure: up to 25% UrCa (aromatic amines, rubber, petroleum, paint, textile dye, etc)
o Iatrogenic cancers: chemo, phenacetin, X-ray Rx, cyclophos
o Arsenic in chlorinated water (China, Chile)
 Familial: only 8% (not as much as some other cancers). Muir-Torre syndrome is one example
 Schistosomes in Egypt

Clinical Presentation & Evaluation

 Gross / microscopic hematuria (70%)
 Irritation (10%): dysuria, urgency, frequency (esp CIS)
 Cytoscopy & transurethral tesection (TUR) biopsy: gold standard of Dx
o Understaging: 15-50% muscularis propria sampling
o Overstaging: muscularis propria vs muscularis mucosa – need to discern where you are in bladder

Two groups of urothelial tumors (start in urothelium, can become invasive)

Superficial (non-muscle invasive) urinary carcinoma
 Majority (70-80%)
 only 5-10% progress to invasive
 (but 50% recur as non-invasive)
 Can be flat or papillary
Muscle invasive urinary carcinoma
 Minority (20-30%)
 15% have prior superficial urinary carcinoma
 80-90% are “primary” muscle invasive UrCa
 Practically all are high grade
o Only 20-50% overall survival

“Recurrent urothelial tumor” – different from other tumors

 Recurrence in other organs: incomplete resection  regrowth of tumor
 Urothelial tumor: may be shed tumor cells from initial tumor  implant & grow in other areas of bladder
 May be multifocal new tumors (from field effect of chemical carcinogens in urine)

Bladder cancer: Carcinoma In-Situ (CIS)

• Flat morphology • Dyscohesive – positive cytology
• Cytologically malignant cells in any quantity • By definition – High grade
• Increased mitotic figures (risk for deeper muscle invasive disease)

28
 CIS: enlarged cells with ↑ N/C ratio,
CIS in bladder – dark spots Dyscohesion: structure falling apart
no maturation, ↓ organization,
(flat lesions)
arrows = mitotic figures

Prognosis:
 40-83% progress to muscle invasion with resection only
 Variable course (protracted  rapid invasion)
 With tx (BCG): 80% initial response, 50% 4-yr response, 30% dz-free @ 10yrs
 If refractory: 30% have muscle invasion @ cystectomy

Bladder cancer: Papillary Urothelial Carcinoma

Classification
• Papilloma – Mostly cured with excision
• Papillary urothelial neoplasm of low malignant potential – May recur yet otherwise no morbidity
• Low grade papillary urothelial carcinoma – May recur and rarely lead to significant morbidity and death
• High grade papillary urothelial carcinoma – Frequently recur with significant morbidity and occasional mortality

Papillary structure: finger-like Lower-grade lesion: cytology Higher-grade: still have fibrovascular core; some ugly
projections somewhat more regular; epithelial nuclei, ↑ N/C ratio, abnormal hyperchromatic
on outside; fibrovascular core chromatin

Papillary vs CIS: Non-invasive Urothelial Carcinomas

Prognosis: generally better than CIS
(only 3% papillary  invade) CIS Papillary
Risk of “recurrence” 82% 50%
Risk of invasion into muscle 75% 3%
29
 Muscle Invasive Urothelial Carcinomas

Primary (most, present @ advanced stage) or secondary to non-invasive UrCa

 Worse prognosis: only 20-40% @ 5 yrs

Lots of yellowy necrosis here Bundles of smooth muscle with invading urothelial
(invading muscle layers) carcinoma cells pushing into this deep muscular layer

Two phenotypes, two genetic pathways

Superficial & muscle-invasive urothelial (transitional cell) carcinomas have different genetic lesions!
Superficial TCC Muscle invasive TCC
Clinical phenotype Generally more limited 50% pts die in 5-10 yrs with tx
15% can progress to muscle invasive Distal metastasis kills you
Molecular pathway Tyrosine RK (H-RAS/FGFR3) P53 / RB

Treatment of urothelial carcinomas

Small, unifocal, non-invasive or
Transurethral resection (TUR) only
superficially invasive papillary
 TUR
Larger, multifocal, recurrent,
 Intravesical immunotherapy with BCG
high-grade non-invasive,
(attenuated M. bovis to ↑ local immune response & inflammatory reaction)
superficially invasive, or
 Radical cystectomy (refractory to BCG or invasive into bladder muscularis propria)
CIS
o Men: take out the prostate too!

Renal Cell Carcinoma

Epidemiology Peak: 50s, 2:1 M:F

Risk factors Clinical features

• Tobacco  Symptom triad: PAIN, HEMATURIA, ABDOMINAL MASS
• Obesity: BMI >29 have double the risk?  Paraneoplastic syndromes:PTH, EPO, PG, ACTH
• Acquired and hereditary polycystic diseases  Changing presentation: more imaging so seeing smaller
• Familial RCC Syndromes masses now

30
 RCC: types
Type % all RCC Picture Prognosis Other
Cell mutations interfere with H1F1α
(oxygen sensor in cell) – fools cell
into thinking that it’s hypoxic!
Clear cell Intermediate
60-80%
carcinoma (stage dependent) Sends out all kinds of vascular
proliferation factors (VEGF, etc) 
very vascular tumor
Yellow fat – clear cells filled with fat & glucagon

Very good
Papillary RCC 10-18%
(resect!)

Papillary (see cross-sections of the projections)

Excellent!
Chromophobe 2-6% Cure if confined to
kidney

Perinuclear halo, plant-like, thick cell membranes

Collecting duct Aggressive
Medullary Rare Dismal
Sarcomatoid Can see with any of above morphologies Agrgressive

31
 RCC: Prognosis & Treatment
Prognosis:
 Age & gender of patient
 Anatomy: pTNM staging (where is it?)
 Histology: type (table above) & Furhman grade (cytology)

5 year survival
 Localized: 70-90%
 Regional: 40-50%
 Distant metastasis: < 5%
o Most often to lung & bones
o but predilection for unusual sites
o Can metastasize many years post-resection

Treatment:
Local disease Advanced disease
 Radical or partial nephrectomy  Immunotherapy
 Wedge resection  Anti-angiogenic agents
 In-vivo ablation  Tyrosine kinase inhibitors

32
 Pediatric Renal and Bladder Tumors
 Carcinomas ↓ in kids (don’t have chronic exposure of adults)
 Most common pediatric cancers: lymphoma,
Most common pediatric…
leukemia, brain, sarcomas, neuroblastomas, etc.
Kidney tumor: WILMS’ TUMOR (nephroblastoma)
o Kidneys: 6% of pediatric cancers
Bladder tumor: RHABDOMYOSARCOMA

Wilms’ Tumor

Most common pediatric renal tumor: WILMS’ TUMOR (84%)

 Can be favorable histology (80%) or anaplastic (4%)
 Others: congenital mesoblastic nephroma (5%), clear cell sarcoma of kidney (4%), rhabdoid tumor of kidney (2%)

Embryonal tumors: microscopic appearance recapitulates the normal developmental histology of their organ
 “-blastomas” – neuroblastoma, retinoblastoma, hepatoblastoma, etc.
 Nephroblastoma = Wilms’ tumor

Quick embryology review

4th wk Metanephric duct (ureteric bud)
penetrates lateral mesoderm, induces it
to condense into the metanephric
blastema
th
4-8 Ureteric bud branches, dilates renal
wks pelvis, collecting ducts formed
th
8-36 Ureteric bud’s collecting ducts signal
wks metanephric blastema to form
glomeruli.

12 generations of glomeruli formed here

– this is the stage that Wilms’ tumor
recapitulates

Patient: YOUNG KIDS (median age 3.5yo, 90% ≤ 6yo)

Presentation: abdominal mass
 5% bilateral: think of associated syndromes (WAGR, Denys-Drash, Beckwith-Wiedemann)
o Or if you have a pt with one of these, check their kidneys via imaging often!
 Spread: LN, liver, lungs

Prognosis: very good for classic Wilm’s (95% overall survival)

33
 Wilms’ tumor: morphology
Classic Wilms’ tumor is TRIPHASIC
Tumor Element Recapitulates… Looks like…
Blastema Metanephric blastema Deep blue nuclei, scant cytoplasm
Like they’re trying to form structures but not quite getting there
Epithelium Glomerular / tubular epithelium Glomeruli & tubules
Stroma Surrounding renal mesenchyme Spindle cells, bunches, few nuclei
 Can also differentiate  other tissues (blastema = primitive cell line!)
o Skeletal muscle, cartilage, squamous / mucous differentiation, etc.

Other Pediatric Renal Tumors

Prognosis: need to know stage & histopathology
Tumor % Prognosis Picture Other
Classic Wilm’s 80% See above
 Looks aggressive but isn’t
 Lots of mitoses, spindle-
Congenital
Good looking cells, ↑ N/C ratio
mesoblastic 5%
 Has good prognosis even
nephroma
without chemo!
 Just resect!

 Looks like Renal CCC

Clear cell sarcoma  No epithelial features
4% Intermediate
of the kidney  Better prognosis these days
(adriamycin)

34
 Tumor % Prognosis Picture Other

 Markedly enlarged nuclei

with numerous mitotic
Anaplastic Wilm’s figures
4%
Tumor  Poor response to chemo
 p53 mutations
(unlike classic Wilm’s)

Poor
Sheets of cells with pink
cytoplasm & eccentric nuclei

Rhabdoid tumor Lots of mitotic figures

2%
of the kidney
Bad & Sad: Very aggressive
with poor prognosis & 90%
<2 yrs old

Rhabdomyosarcoma (#1 pediatric bladder cancer)

Malignant tumor of primitive skeletal muscle cells
 Q: Doesn’t make sense- bladder has smooth muscle around it?
 A: Arises from primitive mesenchymal cell (differentiates skeletally in the tumor)
Prognosis: based on stage & histopathology type
 Alveolar rhabdomyosarcoma – round cells
 Embryonal rhabdomyosarcoma – spindled cells

Botryoid embryonal rhabdomyosarcoma is most common peds bladder cancer

 Botryoid = “grape-like” (see pictures) – projects into bladder lumen like a bundle of grapes

Grape-like projections into bladder lumen Projections into lumen, Arrows: rhabdomyoblasts
on gross pathology actual location of tumor is (can even see some
more interior (arrow) striations sometimes)

35
 Pathology of Hypertensive Nephrosclerosis
Primary / Essential HTN (no one specific cause) Secondary HTN: results from specific abnormality
 Renal parenchymal dz (Glomerulonephritis, FSGS)
 Genetic & environmental factors  Renal artery stenosis
 Most adult HTN is essential HTN  Tumors (pheochromocytoma, adrenal cortical adenoma)
 AA > Caucasians for incidence  Pregnancy-related (e.g. pre-eclampsia)
 Drugs (e.g. oral contraceptives)

Hypertensive Nephrosclerosis: changes in the kidney as a result of HTN (1° or 2°)

 Benign nephrosclerosis: renal changes resulting from chronic, mild, or moderate HTN
o maybe not so benign (can and does cause ESRD)
 Malignant nephrosclerosis: renal changes resulting from malignant HTN (see description below)
Remember: changes in other organs too! (atherosclerosis / vascular dz / hemorrhagic stroke / LVH in heart)

Benign Nephrosclerosis
Gross Path Arteries Arterioles
 ↓ kidney size  intimal thickening
 cortical narrowing  narrowing of lumen
 Hyaline arteriolosclerosis
 granular surface (untreated  scars)  duplication of internal elastic lamina
 sometimes small cortical cysts  (± mild medial hypertrophy)
Glomeruli Tubules & Interstitium
 ↑ # globally sclerotic glomeruli (esp. subcapsular cortex)
 Tubular atrophy
 periglomerular fibrosis
 Interstitial fibrosis
 sometimes mild ↑ mesangial matrix

Above: Globally sclerotic glomeruli (left Above: Mesangial proliferation (like DM, but w/o
center), replaced by collagen; tubules & thickened BM), hyaline replacing wall in arteriole
interstitium OK in some places (lower L) (arrow), would be very PAS positive
shrunken / absent in others (lower R)

Above: L: HTN nephrosclerosis, R:

normal. Note shrinkage of kidney,
fine pitting pattern externally;
very thin cortex (arrow)
Right: Original internal elastic
lamina (arrowhead) & fibrotic
thickening of intima (arrow) with
incomplete loops & coils of elastica Above: special stain for elastic, see thickend intima with
(trying to protect self from ↑ extra layers of elastic (response to ↑ luminal pressure)
pressure). Also another hyaline
small vessel (diamond)

36
 Malignant Hypertension
Pathophysiology: poorly understood (probably RAAS is important)
Malignant (accelerated) HTN:
 ↑ renin (ischemic kidney produces), prominent JGA in ischemic kidney  DBP ≥ 130-140 mm Hg
 Return to normal BP after unclipping (surgery)  Associated retinal hemorrhages,
exudates, papilledema
Earliest renal sx: proteinuria ± hematuria  Can be 1° or 2
Systemic symptoms:  Can be ± previous HTN Hx
 Visual disturbances  Yearly incidence: 1-2/100k
 Headaches
 Nausea/vomiting
 Transient loss of consciousness

Can cause rapid & irreversible renal damage  ESRD (if not treated)
POTENTIALLY FATAL (prior to antiHTN Rx, majority died within months; much more uncommon today)

Gross Path Arteries & Arterioles

 Normal/swollen size, smooth surface (if no underlying benign nephrosclerosis)
 Fibrinoid necrosis of vessel walls
 Shrunken / granular surface (if underlying benign neprhosclerosis)
 “ONION SKINNING”: Mucoid
 Small hemorrhages with areas of pallor (from ischemia)
intimal hyperplasia
 Occasionally small cortical infarcts (central pallor, hemorrhagic borders)
Glomeruli Tubules & Interstitium
Acutely:
 Focal ischemic ATN (acute tubular necrosis)
 Collapsed / wrinked capillary loops
(ischemia / poor perfusion)
with mild interstitial edema
 Segmental necrosis (from preglom. arteriole)
Over time:
 Same changes as benign nephrosclerosis if underlying
 Tubular atrophy & interstitial fibrosis
(can also be from underlying benign nephrosclerosis)

37
 Malignant Nephrosclerosis: Pathology

Lots of small hemorrhages (dark areas) on surface Would want to treat this patient to ↓ edema 
open lumen before damage becomes permanent

Thrombi / fibrin on damaged wall of small vessel (arrow), More onion skinning
ONION SKINNING (arrowhead)

Left: hypertrophied JGA (trying to

improve perfusion by ↑ renin but can’t
because of renal stenosis, for example)

38
 Pathophysiology: Renal
The Glomerulus ....................................................................................................................................................................... 2
The Tubules ............................................................................................................................................................................. 7
Sodium Balance ..................................................................................................................................................................... 11
Osmolality & Disorders of Sodium Concentration ................................................................................................................ 15
Disorders of Potassium Balance ............................................................................................................................................ 23
Acute Renal Failure ............................................................................................................................................................... 28
Metabolic Acidosis ................................................................................................................................................................ 33
Nephrolithiasis ...................................................................................................................................................................... 39
Metabolic Alkalosis ............................................................................................................................................................... 42
Chronic Kidney Disease ......................................................................................................................................................... 47
Pathogenesis of Hypertension .............................................................................................................................................. 52
Non-pharmacologic Treatment of Hypertension.................................................................................................................. 56
Management of End Stage Renal Disease ............................................................................................................................ 60
Genetic Renal Disease ........................................................................................................................................................... 62

1
 The Glomerulus
The Nephron (review)
1. Glomerular capillary network (capillary tuft)  By the numbers: the kidney
 625-700 mL/min plasma in to kidney
2. Bowman’s space 
 ≥ 90 ml/min fluid filtered (GFR)
3. PCT (proximal convoluted tubule) 
 180 L of glomerular ultrafiltrate made /day
4. Loop of Henle 
 1-1.5 million nephrons / kidney
5. DCT (distal convoluted tubule) 
 25-30 minutes: time it takes for the whole
6. Collecting duct plasma volume to be filtered at the glomeruli

The Glomerulus
Basic Idea: blood comes in via afferent arterioles; fluid filters out of capillaries, across epithelial
cells & filtration barrier, into Bowman’s space, which is part of the proximal tubule, and flows
down the PCT
 Filtrate just like plasma minus macromolecules

Afferent arterioles  glomerular capillaries  efferent arterioles

 Afferent / efferent can constrict / dilate to modulate glomerular function / GFR

Efferent arteriole  breaks up into peritublular capillaries

 Surround proximal tubule / distal tubule of same nephrons & surrounding nephrons
 Loops of Henle of juxtaglomerular nephrons (important in urinary concentration)
supplied by vasa recta

Glomerular Filtration Barrier

Fluid from the glomerular capillaries needs to pass through these layers to reach Bowman’s space en route to the PCT
1. Endothelial cells of glomerular capillaries
a. fenestrated; cells can’t pass but macromolecules can

2. Glomerular basement membrane

a. collagen, blocks large plasma proteins & slows small ones

3. Podocytes (glomerular epithelial cells)

a. with foot processes & filtration slits
b. Finest & final barrier; filters all but small proteins
c. Important for maintaining a relatively protein-free ultrafiltrate

Glomerular Filtration Rate (GFR)

Rate of filtration of plasma  initiate urine formation
 Measures kidney function
 Normal: ≥ 90 mL / min

Depends on Starling forces

 Hydraulic pressure (ΔP) is pushing fluid
out of capillary into Bowman’s Space
 Oncotic pressure (Δπ) is working against
it (more protein in capillaries)

2
Equation: 𝐺𝐹𝑅 = 𝐾𝑓 Δ𝑃 − 𝑠Δ𝜋 = 𝐾𝑓 [ 𝑃𝑔𝑐 − 𝑃𝑏𝑠 − 𝑠 𝜋𝑔𝑐 − 𝜋𝑏𝑠 ]
 where P is pressure, gc = glomerular capillary, bs = Bowman’s space.
 Kf is a filtration constant
(reflects surface area & permeability for fluid movement)
 s is a “reflection coefficient” of proteins across the capillary wall
(0=permeable, 1=impermeable)

Normally, the filtrate is essentially protein free: so πbs = 0 and s = 1

 𝑮𝑭𝑹simplified = 𝑲𝒇 𝑷𝒈𝒄 − 𝑷𝒃𝒔 − 𝝅𝒈𝒄

Puf: can combine terms

(think about GFR in terms of one net driving force / net filtration pressure)
 𝑮𝑭𝑹 = 𝑲𝒇 𝑷𝒖𝒇

As you travel along the capillary, ↓Puf (driving force decreases)

 ↑oncotic force driving fluid back into capillary (fluid left but not proteins)
 ↓hydrostatic force (fluid’s already left for bowman’s capsule)

Regulation of GFR
You can change either the driving force (Puf) or the filtration constant (Kf)

Changing glomerular hydrostatic pressure (Pgc) is most common way to alter GFR via Puf
 Regulate by constricting or dilation of afferent / efferent renal arterioles

aortic pressure− renal venous pressure

Renal plasma flow: 𝑅𝑃𝐹 = renal vascular resistance
 Basically: how much plasma’s flowing through the kidneys?
 Note that this is different from GFR (how much filtrate is being produced?)
 Renal vascular resistance is mostly determined by resistance at afferent / efferent arterioles
Constrict afferent arteriole:
 fluid can’t get through
 less hydrostatic pressure in glomerular capillary
 ↓Puf and ↓GFR
Constrict efferent arteriole:
 fluid backs up
 more hydrostatic pressure in glomerular capillary
 ↑Puf and ↑GFR
In both cases: ↓RBF
 You’re constricting something, so resistance in the kidney increases 
 flow decreases (blood’s being shunted away from it)

What affects this tone?

 Autoregulation mechanisms: Angiotensin II, Intrinsic myogenic control, tubuloglomerular feedback (TGF) – see below
 Norepinephrine: constrict both (afferent > efferent) so GFR↓
o Get blood to important organs!
 Prostaglandins: counteract NE to preserve GFR
o Dilate afferent > efferent

Kuf – the filtration coefficient - can be altered too (physiologically or in disease)

 Contraction of mesangial cells  close some capillaries  less surface area
 Inflammation / sclerosis: damage filtration barrier, ↓Kuf
3
 Autoregulation

Kidney can maintain RBF and GFR pretty well over a range of BP MECHANISMS OF AUTOREGULATION
1. Renin – angiotensin – aldosterone system
I. RAAS system 2. Myogenic mechanism
1. BP falls (e.g. you’re bleeding out) 3. Tubuloglomerular feedback
2. Volume sensors activated  ↑ renin release from juxtaglomerular
cells in macula densa
3. Renin cleaves angiotensingen → angiotensin I
4. AT I  AT II via ACE (lung, vascular endothelial cells, glomerulus)
5. AT II:
a. ↑ systemic vasoconstriction
b. ↑ aldosterone (along with AT II itself)  ↑ renal tubular Na reabsorption
i. Net effect: help restore extracellular fluid volume
c. KEY:ANGIOTENSIN II constricts EFFERENT > AFFERENT arteriole at glomerulus
i. increases Pgc to maintain GFR

II. Myogenic Mechanism

 If you stretch vascular smooth muscle, it contracts reflexively
 If ↑arterial pressure  would lead to ↑GFR / RBF (want to maintain!)
o But: ↑pressure  ↑stretch  contract afferent arteriole  increase resistance
o Brings RBF / GFR back down

III. Tubuloglomerular Feedback Mechanism adenosine

 If renal blood flow increases too much, you overwhelm Na reabsorption
mechanisms
 ↑NaCl at the juxtaglomerular (JG) apparatus –
where the thick ascending limb (TAL) meets the glomerulus
o TAL contacts afferent / efferent arterioles here
o TAL cells facing glomerulus = specialized (macula densa)
o Granular cells of arterioles (afferent & efferent) produce renin
 JGA says “whoa, we’re wasting NaCl: slow down!” to arterioles
by releasing adenosine
 Adenosine  constriction of afferent arteriole (of same nephron as TAL!)
o ↓GFR back towards normal
 Opposite happens if ↓blood pressure  ↓GFR  ↓NaCl

Why autoregulation? If GFR increased proportionally to arterial BP changes:

 Short-term: too much sodium would be
excreted  ↓ECV, many problems
 Long-term: really high Pgc is bad for the
glomerulus (damage capillaries)
Clinical example: Pt on ACEI & NSAID
 ↓AT II and ↓prostaglandins (from NSAID)
 If they get volume depleted:
o can’t increase AT II (no efferent > afferent constriction)
o can’t increase prostaglandin (no dilation of efferent arteriole)
 Net result: GFR drops severely (can’t autoregulate!)

Evaluating GFR
Need a substance: present in plasma, filtered freely at glomerulus, not reabsorbed / secreted / produced / metabolized by tubules

Inulin: polysaccharide, satisfies all above criteria: everything filtered shows up in urine
 Filtered inulin = excreted inulin
 𝑷inulin × 𝑮𝑭𝑹 = 𝑼inulin × 𝑽

4
 o where P = plasma inulin, GFR = glomerular filtration rate, U = urine inulin, V = urine flow rate
𝑼
 𝑮𝑭𝑹 = 𝑷inulin × 𝑽 = the ratio of urine to plasma inulin times the urine flow rate (mL / min)
inulin
𝑼
 More generally, the clearance of any substance is 𝑷 × 𝑽

Creatinine: used in clinical practice to estimate GFR

 Why? Inulin isn’t made endogenously, need to give IV (creatinine is normally around)
 From muscle breakdown of skeletal muscle creatine (endogenous)
Limitations:
 Secreted in proximal tubules (limitation for estimating GFR – makes GFR look 10-20% higher than it is)
o If GFR↓, secretion ↑ (not good – makes GFR look better than it is because more ends up in urine!)
 In plasma, there are some things that are falsely measured as creatinine (make GFR look 10-20% lower)
 (So we say the numerator & denominator errors mostly cancel each other out)

Calculating Creatinine Clearance (THIS IS IMPORTANT – KNOW HOW TO DO THIS)

1. Collect 24h urine & plasma sample
𝑼
2. Creatinine clearance = 𝑷 × 𝑽
a. Example: 1mg/dl plasma creatinine, 100mg/dL urine creatinine, 1440mL/ day 24h urine volume:
𝑼 100mg/dL 1440mL 1day mL
×𝑽= × × = 𝟏𝟎𝟎
𝑷 1mg/dL day 1440min min

Can also calculate from age, lean body weight, and plasma creatinine (Cockcroft-Gault equation)
140−age × lean body weight (kg)
 𝐶𝐶𝑟 = 𝑃𝐶𝑟 ×72
(don’t memorize this)
 (multiply by 0.85 if woman (lower muscle mass as % body mass)
 Note the factors at play: muscle mass decreases with age, bigger people have more muscle, etc.
 This is different for different people: bigger / more muscle will have bigger creatinine clearances

The relationship between plasma creatinine and GFR is EXPONENTIAL

 a little change in plasma CR can be a big change in GFR
 limitation of using plasma creatinine

BUN: Blood urea nitrogen

 made by liver; routinely measured in lab tests
 generally varies inversely with GFR but also ↑ with ↑protein intake, ↑tissue
breakdown, volume depletion; ↓ with liver disease
 marker of waste product accumulation from low GFR

More complicated ways to measure too (e.g. 4 variable MDRD formula – takes ethnicity, gender, age, serum Cr into account)

Glomerular Permeability & Permselectivity

 Size & charge are key
 Remember 3 layers: endothelium, GBM, podocytes(epithelium)
o Tons of molecules involved in slit diaphragm; mutations in any of
them can give hereditary protein wasting syndrome

Electrical charge:
 All 3 layers: glycoproteins with sialic acid moieties (negative charge)
 Positively charged molecules filter more freely
 Negatively charged molecules are blocked (e.g. albumin)
 Minimal change disease: decrease in charge; see albuminuria
5
Size:
 Big stuff doesn’t get through
 Albumin: big (small % gets through) but so much albumin & so much plasma
that about 7g/day filtered
 40 Å is about the cutoff

Shape plays a role too but isn’t talked about as much

Proteinuria
 Generally >2g/day suggests glomerular disease; tubular dz has less proteinuria

Glomerular proteinuria
 Lose protein into urine (200mg  >20g/day) via glomeruli

 Selective proteinuria: usually predominantly albumin (e.g.

minimal change disease: loss of – charge)
o Urine electrophoresis: see big albumin peak only

 Nonselective proteinuria: all plasma proteins appear in filtrate

(same proportion as plasma)
o Urine electrophoresis: see same distribution as in plasma

Tubular proteinuria
 Disease of proximal tubules
Non-selective
(usually reabsorb small filtered proteins + some albumin)

 Urine electrophoresis: see small proteins > albumin Selective

Overproduction proteinuria
 Making too much of a protein
(e.g. multiple myeloma  light chains into urine)

 DIPSTICK ONLY DETECTS ALBUMIN: don’t be fooled!

o If you need to see others, use sulfosalicylic acid (SSA) test

6
 The Tubules
What they do: reabsorb & secrete
 180 L ultrafiltrate; >25K mEq sodium / day: and about 99% of ultrafiltrate reabsorbed

The Basic Setup

 Directional transport is key: need polarity of cell

o what’s in apical membrane ≠ what’s in basolateral membrane

 Passive (channels) or active (transporters; coupling/ATP use)

ion movement

 ATP is generally ultimate energy source

Blood
Lumen
 Na/K ATPase provides gradients that fuel a lot of transport

The Tubule: Big Picture

Most reabsorption: in EARLY PARTS of tubule (PROXIMAL TUBULE and Loop of Henle)

7
 The Tubule

SECTION REABSORBS / SECRETES REGULATION OTHER PICTURE

Reabsorbs most
filtered:
 Sodium
 Water
If proximal tubule is
 Potassium Angiotensin II: broken, you can urinate
PROXIMAL TUBULE  Chloride ↑ sodium reabsorption out too much base (can
 Bicarbonate lead to acidosis)
(actually  ↑Na / H exchanger
+ +

“reclamation” since  Triggered when volume Using INTRACELLULAR

-
HCO3 is broken depleted SODIUM GRADIENT
down & re- (Na/K ATPase) for
assembled on other sodium reabsorption
side)
 Glucose
 Amino acids

Also plays a role in

urinary dilution &
concentration (macula
LOOP OF HENLE densa here, etc) – see
Reabsorbs: below.
 Sodium
 Chloride Using Na gradient to
 Potassium transport in K / Cl-

Some diuretics work

here (block Na
reabsorption)

8
 Aldosterone: By this point, Na
 ↑Na absorb/ K secretion in/out might be close
Reabsorbs:  (↑Na/K ATPase activity, to 1: can’t use

Principal Cells
 Sodium K+ channel opened too) concentration gradient
 Water (if ADH) to bring in Na
ADH (antidiuretic hormone,
Excretes: a.k.a. vasopressin: 3Na/2K ATPase makes
 Potassium  ↑aquaporin insertion inside a little negative;
into membrane facing charge is driving force
urine side for Na absorption

H+ ATPase on urinary
COLLECTING side is predominant
DUCT way acid excreted
Secretes:
H+/K+ ATPase
 Acid
Type A

Aldosterone: ↑ acid activated by

secretion hypokalemia; can
Can reabsorb K if
reabsorb K from
hypokalemic
Intercalated Cells

urinary space when

needed

“A” secretes ACID

Use Cl / HCO3
exchanger on apical
Type B

Secretes: membrane to secrete

 Base (if in excess) when needed

“B” secretes BASE

9
Remember the countercurrent exchange in the Loop of Henle (that it exists, not how it works)
 Sets up a salt gradient (more concentrated at bottom)

Descending Limb of LH: permeable to H2O, not Na+ Ascending Limb of LH: permeable to NaCl, not H2O
 Water flows out but not sodium  Recover salt (flows from high salt concentration
(high salt concentration in interstitium) in lumen to lower in interstitium)

Urinary Dilution
High water load  excrete by diluting urine!

Without ADH:
 Sodium reabsorbed in ascending Loop
of Henle, distal tubule, leading to
dilute urine but…

 Water can’t escape (no aquaporins)

 End result: dilute urine excreted

o (↓↓ urine osmolality)

Urinary Concentration
Water deprivation  conserve by concentrating urine

 Collecting duct passes through

hypertonic medulla (from
gradient generated by
countercurrent multiplier)

 ADH: insert aquaporins

 Water can now follow the
sodium gradient & flow out into
interstitium

 End result: concentrated urine excreted

o (↑↑ urine osmolality)

Summary
Tubular Functions:
 Reabsorption of most of ultrafiltrate
o >99% with bulk early, fine tuning later
 Secretion of solutes
o K+, H+
 Regulation of above processes (Angiotensin, aldosterone, ADH)
10
 Sodium Balance
Distribution of total body water (60% weight)
 1/3 extracellular fluid (ECF)
 2/3 intracellular fluid (ICF)
 Vascular space & ECF generally equilibrate with regard to electrolytes

Whatever sodium you eat generally gets into your body

 Na/K pumps on basolateral surface of gut epithelium provide driving force
 Osmolality increases, brain sends signals, get thirsty & drink water to
return sodium to appropriate concentration

Compartments
If you add isotonic sodium, it stays in extracellular space (vasculature, etc)
If you add sodium only, decrease ICF and increase ECF
 (sodium stays outside of cells, draws water out)
If you add water only it distributes to ICF and ECF equally

Sodium quantity is reflected by ECF volume changes

Serum sodium concentration reflects osmolarity of the whole body
 Abnormal water balance = changes in serum Na

Sodium Intake vs. Excretion

Intake: 0.2 to >12g/day
Excretion: varies with intake
 Body tries to maintain excretion = intake
 Balance maintained unless large changes in intake

NA EXCRETION almost entirely via the KIDNEY

 Na+ reabsorption happens at various points along the
nephron – see diagram
 Proximal tubule: Majority (65%) of Na reabsorption
 Principal cells (collecting duct): fine tuning
o Only 3% of reabsorption, but a lot of sodium passes
through the kidney so 3% can be a big deal
 Blocking Na+ reabsorption  excretion

Fast changes: output lags behind intake

 Eat a ton of salt – takes longer to get output up to speed
o Gain body mass by H2O retention in the meantime
 Same is true for opposite situation: stop eating salt, takes a bit to get
your output back down to normal

Result: steady state ECF volume is determined by Na+ intake

 ↑Na+ intake  ↑ECF volume

Corollary: ↑ ECF volume  ↑ Na+ excretion

o Get rid of Na to get rid of volume!

11
 Edema
 Too much sodium  too much ECF  edema! (too little
sodium = low ECF = low intravascular volume too)

 Note that when you have CHF, you’re starting at a higher ECF
level with reduced ability to get rid of sodium (hang on to all
that you can)
o Smaller increases in Na intake can push you over
the line to edema
 The threshold for Na excretion is greater in edematous
states – e.g. start getting rid of Na at higher ECF volumes

Sodium Balance: How’s it Happen?

 Important to maintain ECF  vascular volume  blood pressure (for cardiac function)
o Sodium deficit ECF ↓  intravascular volume ↓ (not cool)
o Sodium excess  ECF ↑  edema

Basic idea:
 ECF reflects Na+
 To maintain balance, just sense volume & adjust Na accordingly
(@ kidney since it’s the main way Na+ can leave)

1. Effective circulating volume

a. The part of ECF that’s in the arterial system and effectively
perfusing tissues (doesn’t count edema fluid, etc)
b. This is what the sensors use to detect body sodium

2. Sensors
a. In both arterial & venous circulation
b. Sense stretch (direct relation to pressure)
c. Want ‘em close to brain (the important place; detect problems
before they arise)
d. Want redundancy (cause the brain is important)

Carotid Sinus, Great Vessels of the Chest, Atria

 Sympathetic stimulation:
+
o ↓stretch  ↑symp ↑Na retention & ↑vasoconstriction
+
o ↑stretch  ↓symp ↓Na retention & ↓vasoconstriction
o If you’re not stretching, volume is low:
+
try to get more Na and vasoconstrict to keep BP up

 ADH (vasopressin) released with volume depletion too

o (mostly osmotic regulation though – ADH responds more sensitively to isovolemic osmotic increases)

Renal afferent arteriole:

 Stretch receptors in afferent arteriole
 ↓ pressure  renin released  angiotensin II formed
 Opposite for high pressure and increase stretch (less renin)
(Hepatic sensors too but not as important)

12
3. Effectors: Two main mechanisms of regulation:
A. Systemic hemodynamics (cardiovascular)
 Sympathetics & angiotensin II:
vasoconstrict & shunt blood towards brain
o Clinically: cold extremities, etc.
B. Renal Na+ excretion / retention
 Sympathetics, angiotensin II, and
aldosterone
 Also GFR & atrial natriuretic peptide, but these
aren’t as important

EFFECTORS & WHAT THEY DO

Sympathetic System Atrial Natriuretic Peptide
 Vasoconstriction
(veins: more venous return, arteries: ↑BP)  L. atrial distention increases release
 ↑ contractility  Inhibits Na reabsorption in collecting duct
 ↑ renin  ↑(AT IAT II)
 ↑ tubular Na+ absorption (direct effect)
Aldosterone Angiotensin II
 Regulates Na reabsorption  Vasoconstriction too
+

 Principal cell of cortical  ↑ proximal sodium reabsorption

collecting duct is primary  ↑ renin  ↑(AT IAT II)
target  ↑ GFR
↑GFR
 ↑ Na/K exchange (constricts eff > aff arteriole)
 ↑Na channels in CCD & DT
Note: constrict both afferent & efferent arteriole  help maintain GFR but shunting blood away from kidney too (to brain, etc)

Tubuloglomerular Feedback
Happens at the single nephron level: another mechanism to control sodium balance

1. ↑ NaCl at macula densa (tubule cells - part of thick ascending limb) – there’s too much
NaCl getting through, so you need to slow down!
2. Macula densa feeds back on afferent arteriole by secreting adenosine (constrict: ↓GFR!)

The Big Picture

If ECV drops, ↓venous return  ↓CO  ↓BP drops

Restoration of blood pressure is goal(two ways)

 Volume: Hang on to Na (restore circulating volume)
 Hemodynamics: Pump more volume, faster,
harder against more resistance

Note from diagram:

 Sympathetics : direct effect on ↑tubular Na reabsorption
 Angiotensin II works on hemodynamic (vasoconstriction)
& volume (reabsorption of Na) mechanisms
 Increasing venous return, contractility, heart rate, &
resistance all help keep BP up
 Na is the key to increasing effective circulating volume

Manifestations: cold extremities (shunt blood to vital

organs), tachycardia, etc.

13
 Edema: When Sodium Balance Goes Bad

Edema is the manifestation of excess extracellular volume Common causes of Edema

 Effective circulating volume actually DECREASES  1. Congestive Heart Failure
 ↑ sympathetics, ↑angiotensin II, ↑ADH 2. Cirrhosis
3. Nephrotic Syndrome
Even if excess total volume, the kidneys can’t tell (just see effective circ. vol)
 Vicious cycle results because the volume is useless (not in circ)
The mechanisms are the same as before, just driven by different causes than bleeding out

Congestive Heart Failure

 Low CO  ↓baroreceptors  ↑Na & H2O retention, etc.
 Pulmonary & peripheral edema can result

Cirrhosis
 Portal hypertension (blood backs up in portal circulation)
 Also shunted from arterial to venous circulation
 ↓ECV  ↑ Na retention, etc.
↓ albumin
 Ascites (backup to splanchnic ↓oncotic pressure
circ) & peripheral edema result
Venous pooling Cirrhosis
Nephrotic syndrome Nephrotic
CHF
 Protein lost in urine Syndrome
 ↓albumin  ↓oncotic pressure
Can’t keep blood in circulation
 goes to interstitial space
 ↓ECV  ↓Na retention, etc.

 Peripheral edema (and even

ansarca: edema over whole
body) can result

Take Home Points

 Sodium is the primary determinant of ECF

 Sodium balance is achieved through responses to changes in effective circulating volume
 Responses require sensors and effectors
 The final common pathway = salt retention or excretion by the kidney
 Dysregulation of the system can result in volume overload with edema as an important feature

14
 Osmolality & Disorders of Sodium Concentration
Osmoles & Osmolality
Osmole: # moles of a substance dissolved in solution: a quantity
 (e.g. 1mmole glucose  1 mOsmole; 1mmol NaCl  2 mOsm)

Osmolality: osm / kg (temperature independent)

Osmolality: osm/L (temperature dependent – can freeze)

Osmotic pressure: hydrostatic pressure exerted by particles in solution

on opposite sides of semipermeable membrane

Tonicity
Tonicity: measure of effective osmolality
 Ineffective osmole: if the membrane is permeable, equilibrates & no gradient left
o Urea, glucose
 Effective osmoles: restricted to one compartment
o Only effective osmoles contribute to tonicity
o Na is major extracellular osmole; largest determinant of tonicity in humans (2Na ~osmolality b/c NaCl)

BUN glucose
Estimated osmolality = 𝟐 × [Na] + + (KNOW THIS EQUATION)
𝟐.𝟖 𝟏𝟖

Osmolal gap (OG)

OG = Measured – estimated osmolality (usually ≤10 mOsm/kg)
 >10 indicates presence of osmotically active particle – there’s something else in there!
 Need to think about poisoning (ethanol, methanol, ethylene glycol,isopropyl alcohol, mannitol)

Regulation of body fluid compartments

Remember these fractions:

 TBW (total body water) = 0.6* x wt (0.5 in women)
 ICF = 2/3 x TBW
 ECF = 1/3 x TBW
 Plasma ≈ 1/4 x ECF

If you change tonicity, water movement goes from

low osmolality  high

15
 Regulation of Osmolality
Osmolality is primarily regulated by gain or loss of WATER
 If you have too much Na or too little, the main mechanism is NOT gain / loss of Na
 Plasma osmolality ~ 280 -285 mOsm / kg
o Sodium = 140 mOsm (2xNa ~280)
↑release of ADH ↓release of ADH
ADH is primary driver • 1% rise in tonicity • Fall in tonicity
(made in hypothalamus, stored in posterior pituitary & released)
• Pain • Ethanol
 Increased osmolality from increased Na (relative lack of
• Nausea
water)  triggers osmolality receptors
• ≥10% decrease in ECV
o Stimulates thirst (drink more)

 Also released when >10% decrease in effective circulating volume

o Hypoperfusion (dehydration, heart failure, hypotension) will release ADH
o NON-Osmotic release – last-ditch method in rare circumstance to use ADH to conserve volume
 Serum [Na] will fall!
o Why not use ADH for volume regulation? Water is a poor volume expander – would shift to ICF!

ADH:
1) binds V2 receptors on basolateral surfaces of medullary
collecting duct cells  ↑ cAMP  ↑aquaporin-2
insertion into luminal side  allows water reabsorption

2) Conivaptan, tolvaptan inhibit V2 receptor: aquaresis

(serum Na will RISE but only because water is lost)

Normal kidney: can concentrate a lot!

 50 mOsm/kg (no ADH)1200 mOsm/kg (max ADH)
 14L max to 580 mL min of urine
 Big range: but what if you ate only 300 mOsm & drank 8L
water? You’d become hyponatremic
(can’t make it that dilute!)

OSMOREGULATION and
BLOOD PRESSURE / VOLUME REGULATION
are DIFFERENT!

OSMOLARITY IS CONTROLLED BY WATER

BALANCE! BLOOD PRESSURE IS CONTROLLED BY NA
BALANCE!

OSMOLARITY IS CONTROLLED BY WATER BALANCE!

BLOOD PRESSURE IS CONTROLLED BY NA BALANCE!

OSMOLARITY IS CONTROLLED BY WATER BALANCE!

BLOOD PRESSURE IS CONTROLLED BY NA BALANCE!

OSMOLARITY IS CONTROLLED BY WATER BALANCE!

BLOOD PRESSURE IS CONTROLLED BY NA BALANCE!
16
 Hyponatremia (<135 mEq / L): General points
General Approach
1. Hx / clinical status of pt
 Fall in Na often but not always implies fall in tonicity
2. Determine osmolality
 Clinical symptoms of hyponatremia:
3. Evaluate volume status
o Need fall in TONICITY
4. Evaluate urine osmolality
 (isoosmolar hypoNa is asymptomatic!)
& electrolytes (if needed)
o MOVEMENT OF WATER (not Na) dictates symptoms
5. Treat
[Na] Symptoms
Mild 125-135 Nonspecific: anorexia, apathy, restlessness, nausea, lethargy, muscle cramps
Moderate 120-125 Neuro sx start: agitation, disorientation, headache
Severe <120 BAD: seizures, coma, areflexia, Cheyne-Stokes breathing, incontinence, death

What happens to the brain?

1) Acute: brain swells
(water rushes in because *Na+ is ↓ outside)
2) Chronic: brain adapts (electrolytes shift from
inout; brain returns to normal size)

Clinical approach: Summary

First, assess osmolality:

 Isosmotic? Rare; could be lab
error or isotonic infusion. Some
other osmole must be taking
Na’s place
 Hyperosmotic? Hyperglycemia
(more glucose around) or
hypertonic infusions could do it

If hyposmotic (vast majority),

check volume:

 Hypovolemic? You’re losing

water & sodium, but more
sodium (hyponatremic). Give
isotonic saline

 Isovolemic? You’ve got too

much water, either because
you’re drinking too much
(polydipsia) or you’re holding on
to too much (ADH messed up,
like in SIADH). Water restrict.

 Hypervolemic? You’re gaining

water & sodium, but more
water (RAAS + non-osmotic ADH
release in CHF, for example).
Water restrict ± diuretics.
Isosmolar hyponatremia
17
  Fall in Na without change in tonicity: must have some other osmole to account for difference
 No water shift  no symptoms
Etiologies:
 Isotonic infusions (e.g. use isoosmotic glycine in prostate surgery; gets absorbed; isoosmotic but no Na )
o *Na+↓ (water added) but no fluid shifts (tonicity unchanged
 Pseudohyponatremia: lab artifact of flame photometer in pts with hyperlipidemia / hyperproteinemia (rare today)

Treatment: often doesn’t require intervention

Hyperosmolar hyponatremia
 Addition of non-Na osmoles at concentration greater than plasma osmolality
 Osmolality ↑ but Na ↓
o (volume added and/or water shifts from ICF to ECF due to ↑ extracellular osmolality, but no Na added)
Etiologies:
 Hyperglycemia: e.g. diabetic ketoacidosis
o Normally, glucose put into ECF equilibrates with ICF (via insulin)
o Diabetes: ↓insulin, so glucose becomes effective osmole (more volume sucked out of cell)
o [Na] falls 1.6 mEq/L for every 100 mg/dL rise in glucose above 100
 E.g. if you have a pt with Na = 130 and glc = 500, you can expect Na = 136.4 when you control glc to 100
 Hypertonic infusions: e.g. give mannitol

Treatment: treat underlying condition

Hypoosmolar hyponatremia: general points

Most common disorder of sodium concentration
 Need to make sure: check osmolality! (most hyponatremia pts will be hypoosmolar but some aren’t! see above!)
 Now that we’ve checked hyperosmolar & isoosmolar hyponatremias off of the list, nail down what kind of hypoosmolar
hyponatremia this is by using volume status

Key features of hypoosmolar hyponatremia:

 Plasma osm < 280 mOsm/kg
 Need to determine volume status for etiology (BP / osmolality regulated independently)
o Hypovolemic, euvolemic, hypervolemic: check clinically!
o Skin turgor, edema, rales, capillary refill, low BP, tachycardic, etc.to look for low volume
 Patient has too much water relative to sodium
o although absolute amounts of TBW & sodium can be high, nl, or low

Hypovolemic hypoosmolar hyponatremia

Dehydrated & hypovolemic
 loss of sodium > water but have lost both
o pt drinks water but doesn’t replace Na deficit
 ↓ECV  non-osmotic ADH release (trying to conserve volume)
o dilutes Na even more
o Body trying to maintain perfusion at expense of tonicity!
 Urine osm > plasma osm
o (concentrating: using ADH to try to conserve volume, so
concentrated urine!)

18
Etiologies: Urine Na Why?
Renal Loss (diuretics, obstruction, RTA, etc.) > 20 mEq / L Can’t conserve Na via kidney mechanisms, so spill to urine
Non-renal Loss (GI: vomit/diarrhea, etc) < 10 mEq / L RAAS activated, so hang on to sodium

Treatment: give isotonic saline (replace Na & water, shut off non-osmotic ADH release)

Hypervolemic hypoosmolar hyponatremia

Volume overloaded: ↑total volume sodium & water, but more water than sodium (hypoNa)
 Gain of water > sodium
o Intense stimulation of RAAS: retain Na & H2O (CHF / cirrhosis)
 CHF: AT II, ADH, impaired renal perfusion
(so can’t excrete excess Na & water) all contributing
o Can’t excrete Na/H2O (renal failure)
o Both lead to volume overload
 DECREASED ECV (not effectively perfusing)  non-osmotic ADH release (ongoing retention despite hypoNa)
 Urine osm > plasma osm
(concentrating: using ADH to conserve water, so concentrated urine)

Etiologies: Urine Na Why?

Renal Failure > 20 mEq / L Can’t fully excrete water load, losing some sodium
RAAS activated big time - hang on to Na
CHF, Cirrhosis < 10 mEq / L
(hypoperfusing; trying to ↑ECV)

Treatment:
 Fluid restriction
 Treat underlying condition (CHF, etc.)
 Sodium / water removal: diuretics / aquaretics (V2 blockers, antagonize ADH) /
dialysis

Note: in both hyper- and hypo-volemic disorders, urine osm > plasma; ADH increased in both
 need to assess VOLUME status!
 Treatment is very different! Isotonic saline for hypovolemic, fluid restriction for hypervolemic!

Euvolemic hypoosmolar hyponatremia

 No clinical evidence of volume overload or hypovolemia (no edema, pulm edema, HF Sx, etc)
 Fairly normal sodium balance but DO have EXCESS WATER
o Impaired free WATER EXCRETION but normal ECV
o ADH can be high, normal, low

Etiologies: Urine Na Why?

Increased ADH Release
Reabsorbing water but normal ECV: concentrating too much
 Adrenal insufficiency, nausea,
> 20 mEq / L “reset osmostat”- decreased threshold for ADH secretion
hypothyroidism, medications, pain
SIADH is diagnosis of exclusion
 SIADH (see below)
Drinking too much water (e.g. psych problems) – dilute urine, ADH
Primary Polydipsia < 10 mEq / L
suppressed (hyponatremia with appropriately low urine osm)
19
Treatment
 Fluid restriction
 High solute diet (help excrete more)
 water removal (aquaretics: V2 blockers, block ADH function e.g. in SIADH)

Syndrome of Inappropriate ADH (SIADH) secretion

 Clinically euvolemic

 Serum osm < 270 mOsm / kg

 Urine osm >100 mOsm/kg (> serum osm)
o Net retention of water: you see a really
low serum osmolarity, so your urine
osmolarity should be really low (should be
trying to get rid of water with dilute urine
by shutting off ADH) – but you’re not
diluting enough (keep inserting some
aquaporins because ADH turn off)
 Normal dietary intake with UNa > 20
 No alternative diagnosis (thyroid, adrenal
problems) – diagnosis of exclusion
Causes of SIADH
 Idiopathic
 Pulmonary disease
 Postoperative
 Severe nausea / vomiting
 Drugs (SSRI, narcotics, cyclophos, others)
 Exctasy ingestion (aggravated by big fluid intake)
 Ectopic ADH production (e.g. small cell carcinoma of lung)
 Marathon runners / extreme endurance sports
 Also: infections, vascular problems, psychosis, HIV, oxytocin,
waldenstrom’s, head trauma, delirium tremens, others!

Treatment of Hyponatremia
Remember: severe hyponatremia  brain swells → seizures, other bad sx
 If you give a more hypertonic solution (3% is max), you’ll raise Na levels very quickly

Emergent therapy: for bad symptomatic hyponatremia

 GET Na UP! Raise until seizing stops or Na = 115/120 mEq/L
 ACUTE, SYMPTOMATIC HYPONATREMIA with CNS SX REQUIRES 3% NaCl (1-2 mg/kg/hr)
o Overwhelms ability of kidney to excrete Na

Routine therapy:
 Raise slowly (no more than 8-12 mEq/L in 24h: 0.5 mEq/L/hr)
 Once stable, can try aquaretic if too much ADH is problem (antagonize)
 3% NaCl is for emergent therapy only!

Central Pontine Myelinolysis: what happens if you correct hypoNa too quickly?
 ECF [Na] rises suddenly, water rushes out of cells & brain shrinks
 Osmotic demyelination can occur (especially in pons)
 Neuro sx: paraperesis, quadriparesis, dysarthria, dysphagia, coma, seizures
 Dx: CT/ MRI, may take 2-4 wks for lesions to develop
o More risk if post-partum, malnourished, alcoholics

Managing SIADH
 [Na]↓ with normal saline (0.9%)the Na will be excreted (RAAS working OK) but water will be retained (ectopic ADH).
 Salt tablets don’t work either (same reasoning)
 Aquaretics (conivaptan, tolvaptan): block V2 receptor for ADH in collecting duct (sodium excretion unchanged)
o Free water excretion (aquaresis, not diuresis)
o Don’t use if hypovolemic hypoosmolar hyponatremia: would lose volume!.
20
 Hypernatremia
Lack of water relative to Na
 Pts usually volume contracted; plasma osmolality always increased

 Water  out of brain down Na gradient (cerebral atrophy)

o Rapid correction bad: cerebral edema

(suddenly water flows back into brain
cells, expansion  poor results)

Causes:
Loss / inadequate water intake (water loss > Na loss)
 Hypernatremia makes you REALLY THIRSTY: have to ask “why wasn’t this person getting the water they need”?
o Sweating, diuretics, impaired thirst
o Lack of free access to fluid (elderly, nursing home, paralyzed)
o Urinary concentrating defect (DIABETES INSIPIDUS)
 usually OK with just drinking a lot of water (but can become hypernatremic if access cut off)

Administration of hypertonic saline (inpatients, will be hypervolemic)

Treatment: e.g. hypernatremic & hypotensive pt

 Best way to expand plasma volume without inducing cerebral dehydration? Normal saline
o Minimal [Na] change so very little osmotic shift happens
o large proportion remains in vasculature so BP increases & perfusion better

 Lower [Na] the most? D5W (5% dextrose in water)

o Can’t just give pure water IV: RBC will lyse
o 5% dextrose: temporary osmotic gradient (moves into cells slowly with insulin secretion)
o Like giving free water but safe & slow (gives cells time to adjust)

 Correct slowly (0.5 mEq/hr decrease in [Na], 8-12 mEq/L/day to avoid edema)

21
 Diabetes Insipidus
ADH system is messed up: DI is the opposite of SIADH in a lot of ways!

Central DI Nephrogenic DI

not making enough ADH (hypothal / pituitary)
 Pituitary tumors (do visual field tests),
 Pituitary apoplexy (infarction post-partum)
 Infections, idiopathic too
kidneys not responding to ADH (ADH production OK)
Can be complete or partial (more common)
 Drugs (lithium, others)
 Electrolytes (hypercalcemia, hypokalemia)
 Congenital mutations (e.g. V2 receptor)
 Disease (SCD, amyloid, sjogren’s, renal lymphoma, others)

How does lithium cause DI?

 Enters distal nephron via epithelial Na channel (blocked by K+ - sparing diuretics – good for treatment)
 Interferes with ADH-induced AQP2 upregulation
 Can stop Li to prevent more damage, but DI may persist

Treatment of DI:
Central Nephrogenic

 Give exogenous ADH (ddAVP)  Treat cause when possible

 Treat cause  K+-sparing diuretics (amiloride) if lithium use ongoing
(block Na channel that Li uses)
 Thiazide diuretics / low solute diet to decrease polyuria

DDx: pt with polyuria & drinking 5L fluid/ day: has ↑ plasma *Na+, ↑ Posm = 300, Uosm = 70, glc = nl
 Primary polydipsia: [Na] & urine osm are low in polydipsia (large water ingestion so [Na] drops; shut off ADH so
dilute urine) – here plasma [Na] is high
 Diuretics: not DM (glc normal), would think high Uosm (more salt excreted)
 Renal concentrating defect is cause here: insufficient fluid intake to account for losses (so [Na] is high in plasma)

22
 Disorders of Potassium Balance
Potassium:
 Major intracellular cation (98% in cells)
 3Na / 2K ATPase maintains gradients

Major physiologic functions of potassium:

1) Cell metabolism (regulates protein / glycogen synthesis)
2) Determines resting potential against cell membranes
a. Nernst formula, etc: ~-88mV

Membrane potential (Em) is proportional to [K]in /[K]out

 Hyper- and hypo-kalemia can result in muscle paralysis & arrhythmias

Normal K+ homeostasis
Excess potassium needs to be dealt with (can’t have it hanging out in ECF – would disrupt potential):
1) Distribute excess K+ into cells (quick, right after ingestion – maintain ratio)
2) Excrete excess K+ into urine (need to eliminate what you “hid” in the cells)

What influences ICF / ECF K+ ratio?

PHYSIOLOGIC STUFF
Na out, K in. Catechols, insulin, thyroid hormone, state of K+ balance all regulate activity.
Na/K ATPase
 Digitalis inhibits (can lead to fatal hyperkalemia)

α-2 receptors inhibit, β-2 receptors promote K+ entry

 β-2 receptor: stimulates at least partly by activating Na/K ATPase
Catecholamines (basal catecholamine levels permissive)

+
Give β-blocker: more increase in plasma K after ingest a bunch (can’t take up into ICF)
 Release of epinephrine during stress: acute ↓ of plasma K
+

Promotes K+ entry (skeletal mm, liver) via ↑Na/K ATPase

Insulin

+ +
Independent of glucose transport; physiologic role in K regulation (basal levels allow K entry)

By itself can promote K+ entry into cells (passive mechanisms?)

Plasma [K+]
 Block symp & insulin deficient: can still get K+ entry (but impaired)
Exercise too
PATHOLOGIC STUFF
Chronic disease
Metabolic acidosis has big effect (resp. acidosis has minor effect)
 More pronounced when not due to accumulation of organic acids (lactic/keto-acidosis)
 Excess H+ enters cell to be buffered  Cl- enters poorly, so electroneutrality
Extracellular pH maintained by kicking out K+ (and Na+) into ECF
 Plasma K+ ↑0.2-1.7 mEq / L for every 0.1↓ in pH
Net effect: depends on severity of acidemia & K+ balance
Water diffuses out of cells down gradient; K+ moves too (solvent drag through H2O channels)
Hyperosmolality
Increased K+ inside  gradient for passive exit via K+ channels
Cells release K+ when broken down (trauma, crush injury) so K+ ↑ in plasma
Rate of cell breakdown
Cells need K+ if rapidly proliferating (correction of megaloblastic anemia, etc): ↓ K+ in plasma

23
 Renal potassium excretion
KIDNEYS play major role in K+ balance
 Small amounts lost in stool/sweat (can maybe see changes in fecal excretion with mineralocorticoid level shifts, K +
balance changes, rates of stool excretion)

1) Proximal tubule reabsorbs 70-80% of

filtered K (passive, follows Na/H2O)

2) Thick ascending limb reabsorbs 15-

20% (Na/K/2Cl cotransporter)

3) By the early distal tubule: only 10%

left, so rate of K+ excretion depends
on K+ secretion (principal cells in
cortical collecting tubule & outer
medullary collecting tubule)

K+ Secretion (principal cell of CT)

 Na/K ATPase in basolateral side:
pumps K+ in using ATP (need to have K+ inside to get rid of it)

 K+ secreted passively via K+ channels in apical side: uses

favorable electrochemical gradient
+
o Lumen-negative gradient generated by Na
+
reabsorption (through Na channels)
+
o Tubule flow constantly washes away secreted K

 ALDOSTERONE regulates all these steps

REGULATION OF K+ SECRETION
Sodium Transepithelial
Aldosterone Plasma [K+] Distal flow rate
Reabsorption potential difference
 ↑ # Na channels in apical Wash away
membrane  more negative secreted K+ (if
+
lumen  more K secretion
+
↓flow, K builds up More Na+ If lots of poorly
in lumenless reabsorbed reabsorable anion
 Enhances basolateral Na/K Same changes as
secretion) ↑Na/K ATPase (HCO3-), lumen more
ATPase (↑ *K+]in so bigger aldosterone
(independently!) activity  more K+ negative
gradient) More flow  more inside  better
 ↑ # open K channels in apical
+ Na+ delivered  gradient to secrete (so more K+ secreted)
membrane (↑ K+ permeability) see Sodium
Reabsorption

24
 Hyperkalemia (serum K+> 5.5 mEq/L): Causes
1. Increased K+ Intake
a. Need accompanying defect in K+ excretion to be a problem
b. Body good at preventing K+ accumulation (taken into cells / excreted) MAJOR CATEGORIES
OF HYPERKALEMIA
2. Pseudohyperkalemia: lab artifact  ↑ Intake
a. Take blood sample  mechanical trauma during venipuncture  Pseudohyperkalemia
b. RBCs damaged, release K+ in tube  Shift from inout of cells
c. Can see ↑ K in serum samples (RBC removed from serum samples by  ↓ renal excretion
clotting, release some K when they clot)
i. See even more if WBC > 100k or plt > 400k (more clotting)
ii. Can use green top tube (has heparin so no clotting) to measure K in plasma to avoid

3. Shift out of cells

a. Catecholamines & insulin  ↑ Na/K ATPase as per above; deficiency in either leads to ↑ Kplasma
b. Normal pt: glucose load  insulin released  glucose into cells (& mild hypokalemia)

c. Type I Diabetics: glucose load  no insulin released  glucose stays outside; water rushes out because glc
is osmole now  K follows  hyperkalemia
i. Treat with insulin: K+ goes back into cells (and glucose too – double effect)
ii. Total body K ↓ (high glucose  osmotic diuresis, renal K+ loss)

d. Β-adrenergic blockade (using β-blockers)

i. Can interfere with K+ entry – usually OK unless renal failure or big K+ load superimposed
e. Digoxin: blocks Na/K ATPase; tends to ↑ K levels (insignificant @ therapeutic levels)
f. Tissue breakdown: trauma (e.g. crush injury), rhabdomyolysis, tumor lysis  ↑ K release

4. Decreased Renal Excretion

a. Renal failure
i. K+ OK if adequate urine output (compensates by ↑ K+ excretion @ each functioning nephron)
ii. Mediated by aldosterone & ↑ Na/K ATPase activity
iii. Oliguria: ↓ K+ excretion (↓ flow to distal secretory site)
b. ↓ Effective circulating volume
i. Fluid loss, heart failure, cirrhosis
ii. ↓ GFR, ↑ Na/H2O reabsorption proximally 
↓ distal flow & Na delivery  ↓ K secretion
iii. Happens despite 2° hypoaldosteronism
c. Hypoaldosteronism
i. Either ↓ effect or ↓ production of aldosterone
1. ± other forms of Na wasting, metabolic acidosis
ii. Major stimuli for aldosterone secretion:
↑ plasma K and angiotensin II
1. Defects anywhere along the pathway can cause problems (see picture)
iii. #1 cause of hyperkalemia in adults: HYPORENINIMIC HYPOALDOSTERONISM (type IV RTA)
1. Mild-moderate renal insufficiency; 50% with diabetes, 85% with ↓ renin
2. Typically Asx hyperK
iv. Cyclosporin, NSAIDs, ACEI can cause similar problems (interfere with aldosterone)
v. K-sparing diuretics (spironolactone: directly antagonizes all aspects of aldosterone, amiloride &
+
trimamterene block luminal Na channel) also impair excretion
vi. ↓ Adrenal Synthesis too (primary adrenal insufficiency, enzyme deficiencies, heparin may ↓ aldo)
25
 Hyperkalemia: Symptoms, Treatment
Symptoms:
 Muscle weakness
 Abnormalities in cardiac conduction ( cardiac arrest)
 EKG:
o Peaked T-waves (see picture, ↑ with ↑ K) are key finding

o Widened QRS, loss of P wave

 sine wave pattern  Vfib /
no activity!

o Variable levels of onset

between patients: must
monitor EKG!

Treatment
1) Stabilize membrane with calcium gluconate: short-acting – restores membrane potential / excitability
2) Shift K+ into cells by giving insulin & glucose: insulin  drives K into cells (glc prevents hypoglycemia)
a. Sodium bicarbonate helps too (bicarb helps with acidosis)
3) Remove extra K+ (shifting is only temporary – need to get that potassium out of the body!)
a. Cation exchange resins (sodium polystyrene sulfonate = Kayexelate®) – takes up K in exchange for Na in gut
b. Dialysis if diabetic / available / etc (but invasive)
c. Diuretics to help excretion (with diuresis)

Hypokalemia: K+ < 3.5 mEq/L

Low K is almost never spurious (only if something like ↑WBC in

leukemia, really metabolically active, take up K in tube)

Need to determine: ↓ total body K or just K shifted into cells?

Transcellular potassium shifts: shift K into cells!

 Metabolic alkalosis (K+ and H+ lost in diuretics / vomiting)
o Modest effect only
 Insulin & β-adrenergic receptors  K+ entry

Decreased total body potassium: really lost it!

 ↓ oral intake is rarely cause
o Principal cells good at downregulating K+ secretion
o Intercalated cells can reabsorb K+ if K+ depleted
+ + +
 ↑ # H / K ATPase pumps with ↓ K

26
Decreased total body potassium, continued…
 Potassium loss: hypokalemia usually from renal or GI loss
 diarrhea (incl. laxative abuse)
GI loss

 intestinal fistulas, other drainage

 (vomiting is mostly renal loss!)
↓ Na reabsorption in loop of henle (loop diuretics) or distal tubule (thiazides) 
Diuretics
↑ Na delivered to distal nephron ↑K secretion
NOT GI loss
 ↑ bicarb (vomitus has H+)
Vomiting
 Overwhelm reabsorption  bicarb delivered to distal nephron  ↑ K secretion (charge)
 Transient (↑ Na, HCO3 reabsorption because hypovolemic)  limit bicarb delivery
-
Renal / urinary loss

 Esp aldosterone  renal K loss

 May have co-existent metabolic alkalosis, mild volume expansion, HTN (aldo effects)
Mineralicorticoid  Think adrenal adenomas / carcinomas / hyperplasia (↑ mineralicorticoids)
excess  Cushing’s: ectopic ACTH produced  ↑↑ cortisol  overwhelms normal conversion to cortisone (can’t bind),
cortisol can still bind mineralicorticoid receptor  effects
 Hyperreninism too
Bartter’s & Gitelman’s syndromes (rare inherited disorders)
Nonabsorbable  More K+ secreted in distal tubule (more negative lumen)
Anions  HCO3- is most common, can see others too
Ampho B  Increased membrane permeability
Hypomagnesimia too

Symptoms
 Impaired neuromuscular function (weakness  paralysis, intestinal dilation, ileus)

 EKG findings: primarily delayed ventricular repolarization

o S-T segment depression
o Flattened T-waves
o ↑ U-waves
o Can see PR prolongation/ wide QRS too
o Predisposes to cardiac arrhythmias
(esp with digitalis or Hx of coronary
ischemia)

 Renal dysfunction
o poor response to ADH, polydipsia & polyuria
o Urinary acidification (K+ exchanged for H+  intracellular acidosis  H+ loss by kidney)
o Chronic K+ depletion  vacuolar lesions in PT/DT epithelial cells
 can see interstitial fibrosis & tubular dilatation (can be irreversible!)

 Rhabdomyolysis if severe K depletion (can’t regulate muscle blood flow)

Treatment
 K+ replacement
o Give as KCl oral or IV (oral is faster, can be dangerous IV)
o Prefer KCl to KHCO3 because Cl helps take care of metabolic acidosis that often comes with hypoK
 Also, bicarb is non-reabsorbable (could promote more K loss!)
27
 Acute Renal Failure
Routine lab panel (right): BUN & Cr are circled

ARF: Abrupt (<48hrs) decline in GFR

 serum creatinine ↑ ≥ 0.3 mg/dL from baseline, or
 serum creatinine ↑ ≥ 50%, or
 oliguria (↓ urine output) < 0.5 mL/kg/hr for > 6hrs
a.k.a “acute kidney injury” (AKI)

Creatinine ≥ 1.3mg/dL often used but has pitfalls ARF: PROBLEMS!

 relies on muscle mass (bigger more normal in big people)  Accumulation of toxins
 can be falsely elevated by meds that interfere with tubular Cr  Azotemia: ↑ BUN
secretion ↑ nitrogenous end products of protein /
 Doubling of creatinine = 50% ↓ GFR AA metabolism in blood
 Uremia: signs & sx with azotemia
Urine output in ARF (sleepy, confused, asterixis, pericarditis,
 Can be normal too! etc)
 Oliguria: ↓ urine production (<500mL/day)  Fluid management problems
 Anuria: absence of urine (<50mL/day)  Electrolyte abnormalities
 Acid/base disorders
 Medication dosing (if renally cleared!)
End result: ↑ morbidity & ↑mortality  Temp / long-term dialysis?
 6x risk mortality with hosp-acquired ARF  Recovery is common (± sequelae)
 40-60% mortality for oliguric, 15-20% for nonoliguric

Important & common (1-4% general med-surg admissions, 10-30% ICU admissions)

Classification: by anatomic site

For every patient with ↑ SCr, think:

 Is it prerenal (↓perfusion)?
 Is it postrenal (obstructive)?
 Is it renal (intrinsic)?

 If renal, think through the kidney: renal

vascular, glomerular, interstitial, tubular
(ischemic or toxic)?

Helps categorize the DDx and think of where to look

Prerenal ARF
Pathophysiology: need to get blood to glomerulus to form urine!
 Autoregulation: hold RBF / GFR constant over perfusion pressure range
o ↓ perfusion  dilate afferent (eicosanoids) & constrict efferent (angiotensin II) arterioles
 If you ↓ renal perfusion below autoregulatory range, can get sudden GFR drop!

28
Picture to right has causes of prerenal failure
In general: not getting blood to kidney!
 ↓ intravascular volume
(ECF loss or sequestration)

 ↓ cardiac output
(myocardial dysfunction)

 Renal vasoconstriction (drugs)

 Renal artery occlusion

(thrombus/embolus/trauma)
Labs
Diagnosis of prerenal ARF
BUN / Cr Great key for prerenal ARF!
> 20:1 Kidney holding on to sodium,
1) History (HPI, PMH of cardiac disorders, ratio
Na/BUN coupled so BUN ↑ vs Cr
bleeding; meds: diuretics, NSAIDs, oliguria) Urine Na < 20 mEq / L
2) PE: volume status (HR/BP, orthostatics), Holding on to sodium!
FENa < 1%
dry mouth, skin tenting, etc.
Uosm > 500 mosm/kg Non-osmotic ADH release!
3) Should return to baseline with fluids
U/A Normal
𝑈 ×𝑃
FENa%: Fractional Excretion of Sodium = 𝑃 𝑁𝑎 ×𝑈 𝐶𝑟
𝑁𝑎 𝐶𝑟
 What % of sodium is being excreted? (adjusts for other variables, not as simplistic as urine Na)
 Low FENa = salt avidity, FENa > 2%: acute tubular necrosis or other kidney disease (can’t reabsorb)
o Need oliguria to suggest prerenal disease, can’t interpret if on diuretics

Problems with BUN/Cr ratio

 ↑ urea formation: falsely ↑ (catabolic state: fever, tissue necrosis, corticosteroids, sepsis, GI bleeds)
 ↓ urea formation: falsely ↓ (protein malnutrition, advanced liver dz, hereditary syndromes of urea cycle)

Hepatorenal Syndrome (HRS)

 Pts with advanced chronic liver disease (18% of those with cirrhosis / ascites in 1 yr)
 Vasoconstriction of renal circulation with vasodilation of extrarenal circ  arterial hypotension
 No significant renal abnormalities on path, resolve renal function with liver tx!

Postrenal ARF (“obstructive uropathy”)

Block urine flow at any point along its journey; requires bilateral obstruction for ARF to develop

Pathogenesis: Causes
 Calyces / pelvis of each kidney Children Anatomic abnormalities
generally only has 5-10 mL urine Young Adults Caliculi
 Obstruction  proximal dilatation Prostatic hypertrophy / cancer
of calyces / pelvis  destroy Older adults Retroperitoneal / pelvic cancer
medulla & compress cortex Caliculi

Acute renal failure results:

 pressure atrophy
 intrarenal reflux
 ischemia

29
Clinically:
 hydronephrosis (dilate urinary tract proximal to obstruction)
 ↑ UTI frequency

Diagnosis: early is important!

 Renal U/S to look for obstruction / hydronephrosis
 CT if U/S doesn’t help
 Abdominal Xray for stones
 Intravenous pyelogram (IVP) but requires dye
 Bladder cath

Treatment:
 Address life-threatening issues first (sepsis, severe electrolyte abnormalities)
 Try to preserve renal function (relieve obstruction!)
 Direct therapy to cause of obstruction!

Renal ARF
Think renal after excluding prerenal & postrenal!
Categorization of renal ARF: ANATOMY
Vascular  Intrarenal vascular
Thrombotic micoangiopathies:  Glomerulonephritis
 vascular thrombosis  Interstitial
 2° endothelial cell injury + platelet activation  Tubular*
 Etiologies: malignant hypertension, scleroderma, TTP, HUS,
pregnancy-related (Acute Tubular Necrosis is most common cause of ARF)

Renal vein thrombosis bilateral or in a solitary kidney

Glomerulonephritis
Rapidly Progressive Glomerulonephritis (RPGN): Glomerular injury + extensive crescent formation
 Anti-GBM AB (e.g. Goodpasture’s)
 Immune complex formation / deposition (lupus, post-strep, IgA nephropathy, endocarditis, mixed cryoglobulinemia)
 Pauci-immune (“ANCA-associated GN”: Wegener’s & microscopic polyangitis)

RPGN: What happens?

 Nephritic syndrome with glomerular inflammation
 ↓ GFR, non-nephrotic proteinuria, edema, HTN, hematuria (+ RBC casts)

RPGN: diagnosis
 Renal insufficiency
 U/A: glomerular hematuria, RBC casts, mild proteinuria
 Systemic complaints: fatigue, edema, extrarenal involvement
o Multiorgan associations –
 each has characteristic multi-system manifestations
o Each has its own diagnostic test too
o Don’t have to memorize for this lecture,
but maybe a good chart anyway

30
Interstitial
Acute Interstitial Nephritis (AIN) CLINICAL PRESENTATION OF AIN
 Inflammatory infiltrates in interstitium Renal Extrarenal
 Rare but need to detect (treatable & reversible)  ARF Hypersensitivity!
 Drug rxn most commonly, but can be idiopathic or 2°  Mild proteinuria
(<1g/day,↑ if 2° to NSAIDs)  Low grade fever
to infection, dz, malignancy
 Abnormal U/A: RBC, WBC,  “Maculopapular” rash
o Methicillin & NSAIDs are big offenders, lots
WBC casts (see pic)  Arthralgias
of Abx & common infections, leukemia,
 Eosinophiluria  Eosinophilia
lymphoma, SLE too
 Flank pain
(2° to capsule distension)
Pathophysiology of AIN
 Immunological hypersensitivity rxn to antigen
(usually extrarenal, e.g. drug)
 Cell-mediated immunity key
(T-cell infiltrate, ± granulomas, Ab / immune complexes)

Treatment of AIN:
want to stop before it gets to fibrosis (can be irreversible)!
 Stop agent
 Ccontrol inflammation (corticosteroids, prednisone)

Tubular
Acute tubular necrosis: #1 CAUSE OF ARF in hospitalized patients (should always be #1 on DDx)
 Injury to renal parenchyma following:
o Renal ischemia (sepsis, surgery, bleeding)
o Exposure to nephrotoxins (endogenous or exogenous)

ATN outcomes: high mortality rate (esp with dialysis), up to 80% with MOF in ICU
 Ischemic ATN: from prolonged prerenal state (shock / sepsis)

ISCHEMIC ATN
 Proximal tubule & medullary TALH are most susceptible to ischemic & toxic
injury (don’t get much O2)
o Avid Na+ retention by S3 segment of PT & TALH  ↑O2 demand, ↓PO2
 Poor oxygenation  tubular injury (death or sloughing of normal cells into lumen)
o ↑ intracellular Ca, oxygen free radicals↑, ↓ ATP, apoptosis
 Other factors: C’ activation (alternative pathway), intracellular adhesion molecules involved, inflammatory cells (T-cells),
inflammatory mediators, etc.

TOXIC ATN: Can be either endogenous or exogenous nephrotoxins

1. Endogenous nephrotoxins that cause ATN

 myoglobinuria (rhabdomyolysis), hemoglobinuria
 light chains (myeloma)
 crystals, urate, hypercalcemia

31
Rhabdoymyolysis (endogenous nephrotoxin: myoglobin) Diagnosis of rhabdomyolysis
 Important cause of ATN (10-15% hosp pts with ARF in US)  Suggestive Hx
 Causes: trauma, esp crush injury, cocaine, exercise, statins, many others  Dipstick: heme + but no RBC
(tricking the dipstick: actually seeing Mb!)
Pathogenesis  Serum creatine kinase ↑↑
 Skeletal mm damage  myoglobin released  freely filtered @  Creatine ↑ disproportionate to BUN
glomerulus  PT reabsorption overwhelmed delivered to DT,  HyperK, hyperureicemia, HyperPO4
casts form (esp acid urine)  Metabolic acidosis
 HypoCa
(Ca/phos deposited in injured muscle)
Consequences:
 Intrarenal vasoconstriction (second hit) – scavenging of nitric oxide Tx of rhabdomyolysis
o Third-spacing of fluid in damaged muscle  hypovolemia  more
 Establish high urine flow rate
vasoconstriction
with saline infusion
 Proximal tubule iron toxicity (from Mb)  ± Supportive dialysis (but doesn’t
remove Mb, which is too big)
2. Exogenous nephrotoxins that cause ATN
Agent Effects
 Gent: direct tubular toxin
 Cationic: interacts with lipids in cell membranes
Aminoglycosides  ARF 5-10 days after start of Rx (if right away, not AG’s fault!)
Antimicrobials  Distal injury  polyuria (nonoliguiric ARF)
 Cr takes 3 wks to recover
Ampho B, vancomycin
Chemotherapy Cisplatin, 5-FU, others
Lithium
 Radiocontrast for CT, cardiac cath, etc.
 ATN via direct tubular toxicity
Other
Radioconstrast  Prerenal ARF too! (intense intrarenal vasoconstriction)
 Generally recover; avoid nephrotoxins while recovering
o No specific treatment

Diagnosis & Treatment of ATN

Diagnosis: H&P, often with multiple possible causes Treatment: no specific treatment; try to tx
(bacteremia + hypotension + gent) underlying cause, remove offending agents
 U/A: muddy brown, granular casts; ↑ Urine [Na+]  supportive care until / if renal function recovers
 Uosm > 350 (lose urine concentrating ability)
Finding Prerenal ATN
U/A Normal Muddy brown casts
+
ARF most commonly caused by ATN but prerenal ARF is 2nd! Urine [Na ] <2 >40
FENa < 1% > 2%
See table to right: remember in ATN can’t retain Na or concentrate well!
Uosm > 500 < 350

HIV-associated nephropathy (HIVAN)

 FAST – rapid onset  ESRD
 Mostly African Americans; 3rd leading cause of ESRD in AApts 40-65, most CD4 < 200
 Glomerular lesion (HIV pts also get ARF from infection, HTN, meds, intratubular obstruction from med crystallization, etc.)

Presentation: ARF + heavy proteinuria + bland UA, U/S shows large kidneys
Path: FSGS with collapsed basement membrane
Treatment: antiretrovirals, prednisone, ACEi
32
 Metabolic Acidosis
Acidemia: blood pH < 7.4 Alkalemia: blood pH > 7.4 Normal physiologic pH values*
Acidosis: processes that lower pH Alkalosis: processes that raise pH Extracellular fluids 7.37 – 7.43
3 HCO− Intracellular fluids 6.60 – 7.20
Henderson Hasselbach: 𝑝𝐻 = 6.10 + log(0.03 x PCO )
2 Range of extracellular pH 6.80 – 7.80
(Don’t memorize: (while still being alive)
just know you can calculate pH, bicarb, or PCO2 given the other two) * Biological processes run best at pH optima!

METABOLIC ACIDOSIS
Characteristics Etiology: REDUCTION OF HCO3-
 Fall in plasma HCO3-
 ↑ acid production
 Low arterial pH
 ↓ renal acid excretion
 Compensatory hyperventilation  Loss of HCO3- (stool or kidney)
(blow off CO2  ↓ PCO2)

ACIDS: Two classes

Carbonic acids (carbohydrates & fat) Non-carbonic acids (proteins), a.k.a. “titratable acids”
 Much more around, most important buffer  Less around
 Carbonic anhydrase (CA):  H+ comes during breakdown to glucose + urea
CO2 + H2O (CA) H2CO3  H+ + HCO3-

In general, we produce acid overall (generates an acid load – how do we get rid of it?)
 Extracellular buffer (HCO3-): 600k times higher than H+ concentration
 Intracellular buffers (proteins, CHOs, phosphates in cells/bones)
o Cells/bones eventually buffer about 55-60% of acid loads
o H+ into cells, K+ out of cells

Kidney and Acid/Base

Basic principles
HCO3- is reclaimed Acid is secreted
 removed by secreting H+ from tubule lumen
 filtered bicarb  completely “reabsorbed”/reclaimed
 H+ combines with titratable acids or NH3
 90% proximal, 10% distal tubules
to buffer acid in urine

HCO3- Reclamation

Proximal tubule : 90% of bicarb reclaimed Collecting tubule: 10% bicarb reclaimed distally
 Na/H antiport on apical surface, H combines with  Same idea, just no sodium gradient available now (most
bicarb, CO2 in, bicarb reformed inside, Na/bicarb has been reabsorbed: have to use ATP to get the hydrogen
symport on BM side into lumen & Cl / bicarb antiport to get bicarb into blood)

33
 Acid Secretion

Proximal tubule: Titratable acids Collecting tubule: Titratable acids

 
+
Same Na/H antiport as before Same idea; need ATP to get H out because sodium isn’t
 +
Instead of combining with bicarb, H combines with around; combines with titratable acid & excreted
titratable acid & excreted into urine;

Collecting tubule: AMMONIUM BUFFERING Proximal tubule: another way to form ammonium
 MAIN WAY that acid is excreted!  From glutamine (protein products)
 Ammonium can diffuse through to lumen, combine  See diagram of ammonia recycling below
+
with H , gets trapped (only uncharged things move
through membranes) & excreted

Ammonia recycling:
 Ammonia is freely permeable (NH3)
 Ammonium gets trapped in collecting duct  out in urine
(taking that extra hydrogen with it!  acid secreted!)

Approaching Acid-Base Problems

1) Look at pH (acidotic / alkalotic?)

2) Look at serum [HCO3-] (metabolic or respiratory?)
3) Calculate serum anion gap
4) Determine underlying cause
5) Determine therapy

34
In metabolic acidosis
 ↓ HCO3- is the primary problem
 ↓ PCO2 to compensate
o Tachypnea (try to “blow off CO2”)
o Try to maintain pH (but can’t quite)

 H+ + HCO3-  H2O + CO2

 ↓ HCO3,  LeChatlier shift to left  ↑ H+
 That’s bad, so ↓ CO2 via ↑ RR to balance

Arterial blood gas is how you get this data

 Format: pH / PCO2 / PO2 / HCO3-
 Example: (~ normal values) 7.4 / 40 / 90 / 25

Serum Anion Gap

Measured cation – measured anion = Na+ - (Cl- + HCO3-)

AG Why? Examples
Unmeasured anions:
Normal AG value 5-11 Healthy people
(phosphates, sulfates, proteins)
High anion gap Exogenous acids, poisons
> 11 Extra anions present but not measured!
metabolic acidosis Endogenous ketoacids or lactates
Normal anion gap GI bicarb Loss
5-11 HCO3- out but replaced by Cl- in
metabolic acidosis Renal bicarb loss

High anion gap metabolic acidosis

SLUMPED (MEMORIZE THIS): DDx of High Anion Gap Met Acidosis

How to assess?
Salicylic acid overdose Blood salicylate level
Lactic acidosis (incl. D-lactate) Serum lactate level
Uremia (renal failure) BUN / Cr / phosphate
Methanol poisoning Serum tox screen
Paradehyde poisoning
Ethylene glycol poisoning Serum tox screen, urine oxalate crystals
Diabetic keotacidosis Blood / urine ketones

Lactic acidosis
 Lactic acid: chews up bicarb, leaves behind anion gap
 ↑ lactate production (seizure, shock, hypoxia, sepsis)
o altered redox state  ↑ lactate production
 ↓ lactate utilization (hypoperfusion, liver dz – blocks
gluconeogenesis in liver & shunts pyruvate to lactic acid
formation)

35
Ketoacidosis
 Acetoacetate, β-hydroxybuturate  chew up bicarb, leave
behind anion gap
 Uncontrolled DM (usually type 1) is #1 cause
 alcoholic ketoacidosis - #2 cause (↑ lipolysis, ↓
gluconeogenesis, ↓ calories with alcohol  ↑ ketones)
 fasting (using FA  ketones for fuel)

Aspirin (toxin): converted to salicylic acid (chews up bicarb, etc)

 tinnitus, vertigo, nausea, diarrhea, altered mental state, coma, death
 Respiratory alkalosis at first! Stimulates respiratory centers (↓ PCO2), then high anion gap met acidosis
 Tx: dialysis

Methanol (toxin): wood alcohol

 converted to formaldehyde by alcohol DH formic acid
 Weakness, nausea, headache, ↓ vision, blindness, coma, death
 Lethal dose: 50-100 mL (doesn’t take much)
 Treatment: Fomepizole (inhibits alcohol DH), dialysis,
ethanol (as a competitive inhibitor of alcohol DH)

Ethyene Glycol (toxin): antifreeze, solvents

 Metabolized: glycolic & oxalic acid
o Can see calcium oxalate “envelope” crystals in urine (Dx!)
 Drunkenness, coma, tachypnea, pulmonary edema, flank pain, renal failure
 Tastes sweet & gives you a buzz, but…
 Lethal dose: 100mL (doesn’t take much)
 Treatment: same as methanol (fomepizole, EtOH, dialysis)

Renal Failure: 2 possibilities

 ↓ GFR  ↓ titratable acid excretion  ↑ anion gap, metabolic acidosis
o High anion gap metabolic acidosis!
o Titratable acids building up!
 ↓ tubular function  ↓ ammonia generation  retention of HCl  normal anion gap
o Normal anion gap metabolic acidosis
o Cl retained as bicarb ↓ so anion gap doesn’t change

Normal anion gap metabolic acidosis

 -
Bicarb lost but Cl increases, so anion gap stays the same
 GI loss: Diarrhea (GI loss of bicarb) or uterosigmoidostomy (urinary Cl exchanges with bicarb in gut)
 Renal losses (renal tubular acidosis): types 1,2,4

GI losses
Diarrhea: gastroenteritis, E. coli, cholera, laxative abuse
 Intestinal fluids have 50-70 mEq/L bicarb  lose in diarrhea
 Volume depletion  ↑ NaCl reabsorption in kidney  ↑ Cl
o For every bicarb lost, Cl- is gained  normal anion gap

36
Uretrosigmoidostomy
 Implant ureters into sigmoid colon (old surgery for congenital bladder problems)
 Hyperchloremic metabolic acidosis results
 Urine: high Cl- and NH4+, colon:
o absorbs Cl- in exchange for HCO3-
o absorbs NH4+ with Cl- as anion
 Other (rather predictable) problems: ↑ pyelonephritis, bowel incontinence (leak mixture of urine & stool at night on occasion)

Renal losses: renal tubular acidosis

Plasma + Urine
Type Picture Description HCO3
- K
pH Causes
↓ bicarb reabsorption in proximal
tubule Multiple myeloma
Carbonic anhydrase inhibitors
Can have pH < 5.3 (still have distal Other drugs
tubule working to acidify by secretion), nl
Type II bicarb can be OK (distal compensation), 14-20 or <5.3
(proximal RTA) ↓ Consequences:
Fanconi syndrome: damage to proximal
tubule  can’t reabsorb a lot of stuff rickets or osteomalacia
hypophosphatemia, glucosuria, (from phosphate wasting)
aminoaciduria
Chronic kidney disease #1
↓ net H+ secretion in distal tubules nl Drugs, autoimmune disorders
Type I <10 or >5.3 (Sjogrens, RA)
(distal RTA) No distal nephron to compensate: urine
pH rises, plasma bicarb can fall a lot ↓
Anything that messes up the
distal tubule

No response to aldosterone
Type IV ↓ H+ & K+ secretion in distal tubules 
(hypoaldosteronism) mild metabolic acidosis + hyperK
+ (amiloride, triamterene,
↓ urinary NH4 excretion too
Aldosterone deficiency
(adrenal insufficiency, heparin,
diabetic nephropathy, HIV)
15-17
↑
<5.3
↑ Aldosterone resistance
spironolactone, trimethoprim)

37
 Urine anion gap
UAG = (Na + K) - Cl
 Different from serum AG!
 Urine electrolytes: NaCl, KCl, NH4Cl
o So Na + K + NH4 should equal Cl
 Urine AG therefore a measure of AMMONIUM: should be negative
o Negative UAG: ↑ ↑ NH4Cl
o + or near zero: ↓ ↓ NH4Cl

UAG: Diarrhea, proximal RTA normal (negative) UAG

 Large NH4 in urine (DT works fine) so negative UAG
 Proximal RTA will have normal UAG too (distal NH4 production is fine)
 More ammonia as % of ‘lytes: but each NH4 comes with a Cl so anion gap is still negative!
o Getting an “extra” chloride for each NH4  negative gap

UAG: Type I or Type IV RTA: positive or zero UAG

 Now NH4 production is impaired (either damaged DT or ↓ aldosterone)
 Urine mostly NaCl, KCl: so (Na+K) and Cl will be mostly balanced!
o UAG = zero or positive!

Lab value summary table for RTA

Respiratory Compensation: What should pCO2 be?

 Usually going to hyperventilate so expect ↓ PCO2 with metabolic acidosis: but how much?

 Winters formula: predicted pCO2 = 1.5 (HCO3-) + 8 (± 2)

 If pCO2 < expected: simultaneous respiratory alkalosis (overcompensating: breathing too fast?)
 If pCO2 > expected: simultaneous respiratory acidosis (not compensating enough: breathing too slow?)

 Example: HCO3- = 14, expect pCO2 to be (1.5x14)+8 ± 2 = 29 ± 2

o If your patient had a pCO2 of 27-31, they’re in the expected range

38
 Nephrolithiasis
 Common (13% males, 7% females) and more common (37% ↑ ’80-’94), and expensive ($2B in 2005)
 Can be a phenotypic expression of an underlying metabolic disorder
 Advances in technology: helical CT for Dx, minimally invasive interventions for Tx
Stone classification
INFECTION METABOLIC
Struvite Calcium (classic)
Carbonate apatite - calcium oxalate
- calcium phosphate
Cystine
Uric acid

Infection stones: Struvite

Struvite a.k.a. “staghorn stones”
 Magnesium ammonium phosphate
 Can occur only if ↑urine pH / ammonia

How to make struvite

 Urease-producing organism needed: Proteus, Klebsiella, also ureaplasma,
staphylococcus, providencia, pseudomonas
o E. coli doesn’t make urease (so E. coli UTI doesn’t cause struvite stones)
o Urease: urea  2NH3 + CO2
o NH3 + H2O  NH4+ + OH-, then ammonia can go into Mg NH4 PO4 stones

What’s important about struvite stones?

 Rapid growth & large size (staghorn configuration)
 Associated morbidity (chronic infection, sepsis, lost of renal function)
 Requires surgical removal (pay attention to microbiologic studies too)

Metabolic Stones
Metabolic stones: need abnormal urine physical chemistry as a consequence of renal pathophysiology
Metabolic Stones: Cystinuria
 RARE: <1% all stone formers
 KIDS: median age of onset 12 YEARS
o Aut recessive (hereditary)
 High rate of recurrence but can ↓ recurrence with tx

Mechanism:
 Impaired PT transporter
o reduces reabsorption of dibasic amino acids (cys, ornithine, lys, arg)
 Results in increased urinary cystine excretion
 Cystine insoluble @ physiologic urinary pH)
o Push urine pH ↑, can increase solubility of cysteine: can prevent
formation & eventually dissolve stones

39
 Metabolic Stones: Uric acid
 5-10% all stones
o Gout = ↑ risk, but most pts don’t have gout (but do have “purine gluttony”- lots of steaks)
o Also associated with: chronic diarrheal states, diabetes + metabolic syndrome
 RADIOLUCENT on PLAIN X-RAY (visible on CT)
o No calcium – so if a patient has pain & xray clear, could still have uric acid stones

Pathogenesis:
 ↑ urinary uric acid helpful but not mandatory
 Acid urine pH required
o H+ + Urate-  Uric Acid
o Drive soluble urate salt to insoluble uric acid (pKa 5.75)
 Again: alkalinize urine  make UA more soluble!

Metabolic stones: Calcium Oxalate

Idopathic calcium oxalate stone former: the typical kidneystone patient
 About 80% kidneystone patients

Supersaturation: 1° importance for struvite, cystine, uric acid (precipitation, etc.)

Calcium oxalate stone formation: more complex

o Supersaturation necessary
o Other factors may be as / more important
o We’re all supersaturated with calcium oxalate, but only some form stones!
 Balance between supersaturation & inhibitors of stone formation

Randall (JH grad @ Penn): studied cadavers, found papillary

calcification (“plaque”) with stones attached
 Randall’s plaque: White plaques at papillae
 big calcium phosphate plaques where calcium oxalate
stones start forming
 nidus for crystallization

Mechanism of crystallization (not for memorizing)

 initial crystal deposits: BM of loop of henle, crystals
accumulate (interstitial CaP)
 urothelium erodes, CaP exposed to urine, CaOx binds (CaOx
supersaturated in urine), stone can grow

Non-idiopathic calcium oxalate stone formers: Enteric hyperoxaluria

 short gut syndrome (bowel resection, IBD, or bariatric surgery) or
malabsorptive state
 Fat malabsorbed; fat-soluble vitamins & calcium are saponified
o Ca normally binds oxalate in gut
o Saponified Ca can’t bind oxalate
o ↑ oxalate load absorbed, delivered to kidney
o ↑ Urinary oxalate
o Calcium oxalate stones form

40
 Metabolic Stones: Calcium Phosphate

Calcium phosphate crystallization is pH dependent (unlike calcium oxalate)

 Prefers alkaline pH (unlike other stones – can be a consequence of over-treatment with alkali therapy!)

Renal tubular acidosis (Type 1 – distal)

 Inability of distal nephron to acidify urine
 Net acid excretion impaired, ↓ plasma bicarb, urinary pH can’t fall, chronic H+ retention
 Associated with stone formation (multi-factorial)
o Acidosis (↑ calcium phosphate release from bone – buffer to retained acid)
o ↑ pH (more calcium phosphate precipitation)
o ↓ urinary citrate (normally inhibits stone formation)

Primary hyperparathyroidism
 Bones, stones, abdominal moans, psychiatric overtones
 Disease of middle age, W>M
 All consequences from ↑ PTH
o Hypercalcemia (↑ gut absorption, ↑ load to kidney, hypercalciuria b/c of ↑ filtered load)
o ↑ calcium reabsorption by distal tubule (but overwhelmed by Ca load)
o ↑ bone resorption ( osteoporosis / osteopenia)

 Stones in 15-20% cases (calcium oxalate &

calcium phosphate occur most commonly)

 Clinical presentation: nothing distinguishing

about stone disease (serum Ca can be only
mildly elevated)

Idiopathic hypercalciuria: happens despite normal

serum calcium level
 Intestinal overabsorption
 Defective renal tubular Ca reabsorption

Treatment
 Surgery (minimally invasive)
o 1 cm incision, stick mini vacuum cleaner into kidney collecting system, break up stone & suck it out
 Uteroscopy: minimally invasive; grab it with a basket
 Shock wave lithotripsy
o Hit kidney with shock wave to break stones up into tiny little pieces, wash out without symptoms
o Non-invasive!

41
 Metabolic Alkalosis
Compensation is part of metabolic acidosis
Has: generation phase (starts) and maintenance phase (persists)

What is metabolic alkalosis?

1. excess serum HCO3- ≫ 24 mEq/L (pathological process responsible)
2. ↑ plasma pH (≫7.4)
o To make ↑ plasma pH closer to normal: RR↓, PaCO2↑ (compensation)
o PaCO2 ≫ 40 (if 40 or less, something else is going on!)

For every 1 mEq/L rise in bicarb above 24, get a 0.7 mm Hg rise in PaCO2

Approaching acid/base status:

Can’t just tell from serum bicarb

1) Look @ serum pH (> 7.4?)

2) Look @ bicarb (>24?)
3) Determine expected compensation for PaCO2
-
a. 0.7 mm Hg x (Δ *HCO3 ] from 24) = expected change
b. Add expected change to 40 mmHg to see if another
process present as well
-
c. Example: if HCO3 = 31, expect (7x0.7)=4.9 increase in PaCO2

Consequences of metabolic acidosis: What’s the big deal?

Metabolic acidosis can KILL you!

↓ respiration  ↓ O2 delivery to tissues

 O2 dissociation curve of Hb shifts left ↓ O2 release to peripheral tissue

o “Bohr effect” – remember, if acidic (e.g. lactic acid ↑ in muscles), then the body wants to dump off more oxygen.
If alkalotic, will hang on to O2

 Vasoconstriction (↓ perfusion of vital organs)

CEREBRAL METABOLIC CARDIOVASCULAR
↓ cerebral perfusion  ↑ anaerobic glycolysis Vascular constriction
tetany, seizures, lethargy, delirium ↑ organic acid production
↓ coronary perfusion
↓ K+
↑ supraventricular & ventricular arrhythmias
↓ plasma [Ca+]

H+, HCO3-, and the Nephron

Proximal tubule: net HCO3- reclamation

Collecting duct: net H+ secretion

Next page: more detail

42
 Proximal Tubule: Reclaim HCO3-
Net movement: dotted line (reclaim bicarb)
 90% of filtered bicarb reclaimed here!

Proximal acidification linked to proximal HCO3- reclamation

 H+ secreted (Na exchange)  bicarb buffers  CO2 diffuses, etc.
 Weak acids, NH4+ also buffer secreted H+

Collecting duct: type A intercalated cells

Reabsorb last 10% of bicarb
 H+ ATPase pump secretes H+ (no more Na gradient)
+ -
o H comes with a Cl for electroneutrality
-
o To maintain Cl in cell for excretion, exchange Cl and bicarb at
basolateral membrane
o Result: reclamation of bicarb
 Aldosterone: ↑ H+ pump activity

Secrete acid
 H+ ATPase pump secretes H+ (↑ with aldosterone)
 Same thing as before, the H+ just doesn’t combine with bicarb
o H+ buffered in lumen by / excreted as:
 NH4Cl (most secreted this way)
 H2PO4 (titratable acid), HCl
 Note that Cl- still exchanges with bicarb on basolateral surface
o For every H+ secreted, a bicarb gets reabsorbed

In hypoK+
 H+/K+ ATPase (exchanger): second way to secrete H+
o Activated when ↓ K+

 Hypokalemia: ↑ acid excretion in type A cells

o BAD for alkalosis
 (for every H+ you secrete, you absorb a bicarb!)
 Bicarb is the last thing you need! You’re alkalotic!

Collecting duct: type B intercalated cells

Secrete base

 Requires Cl- in urinary space‼ (key)

 Bicarb and chloride exchanged!

43
 Collecting duct: principal cells

Acid secretion
 Generate a negative charge in lumen

 3Na / 2K ATPase (↑ with aldosterone) on basolateral side

o more of a drive for Na to come in from lumen than for K
to go out (3 Na / 2 K)
o slight negative charge generated in lumen

 Negative charge in lumen  easier for H+ to be secreted from

type A intercalated cell (bottom)
o Means more bicarb reabsorbed too!

COLLECTING DUCT IN ACID-BASE: SUMMARY TABLE

 H+ secretion (luminal H+/K+ ATPase)
Type A intercalated
 HCO3- regeneration (basolateral HCO3- / Cl- exchanger)
Type B intercalated  Secrete HCO3- (luminal HCO3- / Cl- exchanger)
Principal  Na+ influx  negative lumen  indirectly ↑ H+ secretion
 ↑ H+-ATPase activity (type A cells)
Aldosterone
 ↑ Na+ into principal cells (↑ lumen negativity  ↑ H+ secretion

Metabolic Alkalosis: Generation Phase

To have metabolic acidosis need
 Generation phase: something to start it up GENERATION PHASE: WHAT STARTS MET ALKALOSIS?
 Maintenance phase: something that keeps it going Loss of acid
 Vomiting
Vomiting:  Diuretics
 Normal: HCl (stomach) neutralized by NaHCO3 (pancreas)  ↑ aldosterone states
 Vomiting: lose HCl  NaHCO3 stays in blood alkalosis!
Hypokalemia: H+ shifts into cells
Diuretics Alkali load
 ↑ NaCl delivery to collecting duct  Citrate from massive blood transfusion
 ↓ volume  ↑ aldosterone (the whole point of diuretics)  NaHCO3 administration
 Milk alkali syndrome (e.g. antacid use)
 Combination: More Na absorption (principal cell) Volume contraction
o more Na in lumen = ↑ gradient to enter cell
o ↑ aldo  ↑ Na/K ATPase in principal cell
o ↑ Na absorption  lumen more negative 
o ↑ H+ secretion from type A intercalated cell met alkalosis

44
 Metabolic Alkalosis: Maintenance Phase
What keeps alkalosis going? Need impaired renal HCO3- excretion
 ↓ GFR: can’t get rid of extra bicarb
 ↑ tubular reabsorption
o Volume depletion, hyperaldosteronism, hypokalemia, chloride depletion
o All these keep kidney from getting rid of extra bicarb
 Target maintenance for treatment!

What happens? Vomiting? Diuretics?

Volume depletion
↓ ECV  ↓ renal perfusion ↑ AT II  ↑ aldosterone (see below)  
↓ ECV  Cl- depletion too (see below) Losing volume Losing volume

↑ aldosterone  ↑ H+ secretion
 ↑ H+ ATPase ( type A cells)
 ↑ Na/K ATPase  ↑ Na+ reabsorption (primary cells) more  
Aldosterone negative lumen Losing volume Losing volume
↑ RAAS ↑ RAAS
Aldosterone: good for fixing ECV but bad for alkalosis! ↑ aldo ↑ aldo
 Last thing you want to do is pee acid: H+ lost  bicarb is retained!

↑ H+/K+ ATPase (type A cells)

 Acid excreted, maintains alkalosis
 Good for fixing hypoK, bad for alkalosis!  
Hypokalemia Losing volume Losing volume
↑ RAAS ↑ RAAS
Why ↓K? Not from direct loss (vomit): in both cases, ↓ volume
↑ aldo ↑ aldo
 ↓ volume  ↑ aldo  ↑ Na/K exchange (principal cell) 
 retain Na (try to maintain volume) but excrete K  hypoK

 Volume depletion  ↑ RAAS,  ↑ Na reabsorption 

+

Cl follows paracellularly
 ↓ Cl- in lumen by the time you get to collecting tubule

Type A intercalated cells export H+ with Cl along

(maintain electroneutrality)  
 Bigger gradient for Cl to flow blood  cell  lumen, easier to drag
-
Chloride depletion Losing volume Losing volume
+
H along to keep electroneutrality ↑ RAAS ↑ RAAS
- -
 ↑ H+ excretion  maintain alkalosis ↓ Cl in urine ↓ Cl in urine

Type B intercalated cells secrete base

 Need luminal Cl- to pump in (exchanger for HCO3 excretion)
 Low urine Cl  can’t exchange for HCO3-  maintain alkalosis

Chloride sensitive vs resistant metabolic alkalosis

+
Normally, use urine Na to assess volume status
In metabolic alkalosis, use urine Cl-: why?
 Early (volume depletion + metabolic acidosis): two competing forces
+
o Want to raise volume  retain Na  urine Na should be low
o Want to dump bicarbonate  fight alkalosis  bicarb secreted proximally as NaHCO3  ↑ urine Na
o Can make urine Na look normal, even if ↓ volume!
 (Later: volume considerations win out, ↓Na)

45
 Cl- “sensitive” (UCl < 25 mEq / L) Cl- “resistant” (UCl > 25 mEq / L)

Mineralocorticoid excess
GI loss Diuretics
Example  1° hyperaldosteronism
(vomiting, NG suction) (late-remote use)
 Cushing’s syndrome

↑ distal Na+ delivery

↓ HCl generates alkalosis ↑ aldosterone  “aldosterone escape” (kidney
 ↑H+ / K+ loss
What senses too much aldosterone  excrete NaCl!)
happens? ↓ ECF, ↑ aldo, hypoK, ↓ Cl
↓ ECF, ↑ aldo, hypoK,
maintain alkalosis Unclear mechanism
↓ Cl maintain alkalosis
Low with remote use
Urine Cl- Low (can be high with current High (both UNa and UCl)
use: losing lots of fluid!)
Apparent mineralocorticoid excess (licorice, 11-β-OH-
Other steroid-DH deficiency, LIddle’s syndrome),
Post-hypercapnia
examples Glucocorticoid-remedial HTN, adrenogenital
syndromes, Bartter’s & Gitelman’s syndromes

IV NaCl + KCl KCl + fix underlying problem

Not NaCl: actually have ↑ total body NaCl (HTN)!
↑ aldo is problem: high aldo w/o ↑ ECV!
Treatment NaCl: restore volume (less Na- retention, ↓ aldosterone, lets
kidney excrete NaHCO3, ↑ Cl delivery to distal nephron)  Fix hypoK – still causes problems
+ + +  Remove adrenal adenoma, use aldo
KCl: replete K deficit (hypokalemia), ↑K  ↓ H secretion
antagonist like spironolactone

More on mineralocorticoid excess & other causes

Primary hyperaldosteronism & Cushing’s syndrome
 HTN, metabolic alkalosis, hypokalemia
 ↑ H+ secretion (directly through type A intercalated cells’ H+ ATPase & via principal cells / negative lumen)
 ↓ K+ and ↑ aldosterone maintain alkalosis

Syndromes of real & apparent mineralocorticoid excess (all of those listed above)
 Normally: cortisol  cortisone (inactive) by 11-β-OH-steroid-DH
o Cortisol can bind mineralocorticoid receptor just as well as aldosterone & provoke same effects
o Just normally inactivated in tissue where it would hit those MRs
 Enzyme deficiency, inhibitors (licorice / chewing tobacco), or just a ton of cortisol (Cushing’s) 
o Cortisol binds MR, aldosterone-like effects

Bartter’s Syndrome: acts like a loop diuretic Gitelman’s syndrome: acts like thiazide diuretic
 Genetic defect of Na+ reabsorption in TALH  Genetic defect of Na+ reabsorption in DCT
Both: ↑ distal Na delivery  H+ & K+ wasting
+

Both: can be exacerbated by volume depletion

Contraciton alkalosis
 E.g. CHF pt treated with diuretic
 Lose NaCl, KCl, HCl in ECF with diuretics
 Don’t lose bicarb: same amt bicarb, less volume  ↑ *HCO3-]

46
 Chronic Kidney Disease
Measuring GFR
 Inulin Clearance: gold standard, don’t really use clinically Definition of CKD
 Serum Creatinine: 1st line (good or bad?)  Kidney damage for ≥ 3 months
 Creatinine Clearance: UV/P & match units o Structural or functional abnormalities of
o Hard to get urine, lots of problems, etc. kidney, ± ↓ GFR
 ↓ GFR for ≥ 3 months
Abbreviated MDRD study equation New staging for CKD: primarily based on kidney function
 Better approximation, easier (no urine collection)
 SCr, age, gender, race – but didn’t include older people in study (does it apply?)
 Given to you on labs (hard to calculate – lab does it)

140−age × lean body weight (in kg)

Cockcroft-Gault equation: 𝐶𝐶𝑟 = × (0.85 𝑓𝑜𝑟 𝑤𝑜𝑚𝑒𝑛)
𝑃𝐶𝑟 ×72
 Easier to calculate, useful, not as accurate as MDRD

CKD: Epidemiology
20M with CKD in US, many more at risk
 Staging: see picture (higher is worse: based on GFR)

Diabetes is #1 cause, HTN #2, Glomerulonephritis #3

What are we looking at? GFR is the total GFR!

 Takes whole kidney into account
 Single nephrons: snGFR

Progression of CRD
Injury to a single nephron (glomerular, tubulessclerosis)
 Initially ↓ GFR
 Then ↑ GFR: residual nephrons start working harder!
o Can even take out a kidney and get GFR recovering
 But ↑ snGFR  ↑ injury to remaining nephrons!
o Downward spiral

What does the kidney do?

• Fluid and Electrolyte Homeostasis
– Sodium and Volume , Water Balance and Tonicity
– Potassium, Calcium/phosphate and Magnesium
• Acid/Base Balance
• Elimination of toxic waste
• Blood Pressure Regulation
• Endocrine (EPO, 1:25-OH-Vit-D)

Sodium in CRD
+
If GFR > 25 cc/min: can increase your FeNa to still get rid of salt (no symptoms!)
If GFR < 5-25 cc/min: start retaining sodium (edema, HTN, pulmonary congestion)

Kidney can keep up – to a point!

47
 Water
Normally: concentrate or dilute urine
 Loop of Henle: generates medullary concentration gradient, reabsorb Na+ to dilute urine
 Countercurrent mechanism is intact, adequate distal delivery of salt & water

CRD:
 Scarring, not a lot of space to do the exchange: all of this messed up
 Limits both concentration & dilution:
o Normal range for urine: 50-1200 mOsm/L
o CKD has an upper range of 600 mOsm/L

Potassium
 If aldosterone production is normal: you can handle potassium until
GFR < 20 mL/min (then you start hyperK)
 Deficient in aldosterone: develop hyperkalemia earlier(with higher GFRs!)
o ↓ aldo: primary adrenal problem, 2° adrenal problem to diabetes, HIV, or ACEi

Acid/Base Balance
Acid load: 1mEq/kg/day
 Sulfuric acid: sulfur-containing amino acids
 Excreted as H+ (titratible acids) & ammonium

In CKD:
 GFR > 40 ml/min: ↑ ammonium excretion per nephron
o (can be 3-4x normal excretion per nephron because they’re
compensating)

 GFR below 40: can’t keep compensating with remaining nephrons

o ↓ Total ammonium excretion (see graph: can’t get rid of it!)

Why is this a problem?

 Body starts using hydroxyapatite as base  bones dissolving  fractures!

Uremia
Multiple functions of kidney deteriorate in parallel  complex symptoms

Kidney needs to eliminate poisons but we don’t know what they are!
 Small water soluble molecules? Urea? But we used to give it as a diuretic! Not convincing
o Inhibits Na/K/2Cl cotransport
o Inhibits NO synth in Mϕ
o Precursor of guanidines: inhibits PMN superoxide production, may induce seizures, etc.
 Protein bound compounds? if you eat less protein, less symptoms of CRD!
o P Cresol: multiple cell functions incl. oxygen uptake, drug protein binding, growth, permeability of cell membranes
 Phenol is end product of protein metabolism
o Indoles: product of liver metabolism, ↑ levels  ↓ endothelial cell prolif / repair
 Middle molecules? (MW > 500 Da)
o These middle weight fractions of dialysis can inhibit various things – but we still don’t know

48
 Blood Pressure Regulation
Increased blood pressure:

 Need less when giving a pressor! Decreased threshold

 In chronic kidney disease:

o Can’t get rid of sodium: ↑ effective arterial blood volume
o ↑ renin, ↑ NE: more vasoconstriction
o Exacerbates HTN, causes more damage, etc.

Endocrine: Anemia
EPO deficiency is primary cause
 ↓ GFR  ↓ EPO so ↑ anemia prevalence (see graph)
Secondary causes too:
 Fe deficiency
 Nutritional deficiencies
 Occult GI bleeds
Anemia from any cause can happen in pts with CKD
 need to do full evaluation first

Endocrine: PTH, Calcium & Phosphorus

Parathyroid hormone is key in control of vitamin D, calcium, and phosphorus balance

Calcium Homeostasis: Get back to set point (10 mg/dL)

 ↓ blood *Ca+2]  ↑ PTH 

o Bones: release Ca+2
o Kidneys: take up more Ca+2 & make more
1,25OHD3
 More active vit D  more uptake in
intestines

 ↑ blood *Ca+2]  ↑ calcitonin (thyroid)

o Bones: deposit Ca+2
o Kidneys: take up less Ca+2

So if kidney is messed up, so is calcium homeostasis!

Phosphorus:
 Proximal tubule reabsorbs (2Na+ / H2PO4 cotransport)
o 15-20% gets through, excreted in urine
 So phosphate would also be out of balance in kidney disease

49
Vitamin D:

Normal synthesis:
1. Make Vitamin D3 by exposure to sun
2. Precursor binds to D-binding protein

3. Hepatic: D3  25(OH)D3
(storage form)

4. Renal: 25(OH)D3  1,25(OH)D3

(active form)

 No kidney  active vitamin D3 ↓

 Most vitamin D deficiency: Middle East (stay out of sun & veils for women)

In chronic renal failure: Bone problems in CKD

 ↓ Ca+2  ↑ PTH  Acidosis  use hydroxyapatite as base to buffer
 But kidneys are messed up:  Calcium homeostasis disturbed
o can’t reabsorb & o ↓ reabsorption
o can’t make active vitamin D to get from diet! o ↓ active vitamin D  ↓ GI absorption
 Chew up bones in order to maintain calcium homeostasis! o ↑ bone breakdown to release more calcium
 CHRONIC HYPOCALCEMIA

Phosphorus: goes up in long-standing kidney disease (eventually)

Earlier: when GFR > 20, (↑ snGFR) Later: when GFR < 20
 ↓ serum phosphorus  Still have blocked transporter but
 have ↑ phosphorus in tubule vs. to normal  ↑ serum phosphorus
 Block phosphate transporter via PTH  pee it (weird – why aren’t you still peeing it out if you can’t absorb it?)
out  GFR very low: not getting phosphorus excreted  builds up

How long as CKD been going on?

 Check PTH and hemoglobin!
o Very elevated PTH - ↓ GFR (higher stage CKD)
o Low Hb (anemic! ↓ Epo

50
  Can’t rely on calcium or phosphate levels
o as calcium↓, PTH ↑, driving ↓ phosphate and ↓ Ca
o Maintains a pretty constant level of Ca and
phosphate
o but PTH itself is elevated (keeps increasing with ↓
GFR as each new drop in calcium happens)

↑ Calcium and ↑ phosphate also deposit (CaPO4)

 Skin: patients often itch
 Arteries, mitral valve  arterial/valvular calcification
o Basically getting CAD!  ↑ heart disease risk

Parathyroid hyperplasia
 Need to crank up PTH so parathyroid grows
 Eventually develops nodularity  single nodule
 Doesn’t respond to normal feedback
o Making PTH no matter what!
o Even if you correct Ca+2 levels, doesn’t help:
o e.g. transplant, might have to remove parathyroid
(↑↑ PTH persists!)

51
 Pathogenesis of Hypertension
Definition: a persistent elevation of the systolic blood pressure and/or diastolic blood pressure in the systemic arteries
 repeated measurements
 Cutoff point is arbitrary: Classification of BP for adults 18yo or older
o Resting SBP ≥ 140 and/or BP classification SBP (mm Hg) DBP (mm Hg)
o Resting DBP ≥ 90 Normal <120 and <80
Prehypertension 120-139 or 80-89
Stage 1 hypertension 140-159 or 90-99
Epidemiology: major public health problem Stage2 hypertension ≥160 or ≥100
 High prevalence (24% all US adults, ↑ in Blacks)
 ↑ risk CVD (MI & stroke) & ESRD
 Awareness is low (72% pts aware they have ↑ BP)
 Treatment & control are lower (61% get Tx, 35% under control!)

Pathogenesis of Hypertension
BP = CO x PVR (need to keep them balanced)
HTN: ↑ CO and/or ↑ PVR
 ↑ CO: ↑ preload, ↑ contractility, ↑ HR
 ↑ PVR: ↑ arteriolar vasoconstriction, or structural alterations (remodeling)
↑ preload = ↑ECVF (extracellular fluid volume) ↑ contractility or ↑ HR ↑ PVR
↑ ECFV = Na, H2O retention
 Arteriolar vasoconstriction
(alteration in kidney’s ability to regulate Na balance)
 ↑ sympathetics  Vascular structural remodeling
 ↓ Na excretion & ↑total body Na
 ↑ catecholamines o ↓ elasticity, capacity of circulatory
 ↓ Na excretion: from ↓ GFR (CKD) and/or ↑
system to accommodate CO
tubular reabsorption (mineralocorticoids)

Primary / Essential HTN (95% of hypertensives)

 Most patients = no definable cause (“primary” / “essential” HTN)
o Big variety of systems involved: CO, PVR, RAAS, sympathetics;
o Other factors: endothelin, NO, ANP, bradykinin

Most hypertensives: NORMAL CO but ↑ PVR

Cardiac Output
 PVR: determined by small arterioles, which have smooth muscle cells in walls
& PVR
 Prolonged smooth mm constriction  structural changes in vessel walls  irreversible rise in BP

Renin: secreted from JGA cells of aff. arteriole if:

 ↓ glomerular perfusion, ↓ salt intake, symp. stimulation via
o stretch receptors in aff. Arteriole
o symp. nerve endings in JGA cells
o composition of macula densa fluid (TALH))

RAAS  Many HTN pts have LOW RENIN & AT II levels (elderly, AAs)
 See other lectures for full/better summary of RAAS
AT II effects via ATII type I receptor:
 vasoconstriction  ↑ tubular Na reabsorption (direct & via aldo)  ↑ thirst
 ↑ aldo synthesis / release  ↑ vascular cell hyperplasia & hypertrophy

Remember: non-circulating, local RAAS systems too (brain, heart, kidneys, arterial tree); regulate regional blood flow

52
 ↑ SNS  ↑ BP:
 Heart: ↑ CO (↑ contractility & ↑HR)
 Vasculature: ↑ PVR
Sympathetic  Kidneys: ↑ fluid retention
Nervous
System
Contributes to development of HTN but not maintenance of HTN as much
 Can induce vascular changes (smooth muscle hypertrophy)  maintain
HTN although symp activity ↓

Most potent endogenous vasoconstrictor

 Released from endothelial cells  bind ET-A receptors (vascular smooth mm)  vasoconstriction
 Plasma levels normal in HTN subjects (↑ sensitivity in “essential HTN”?)
Endothelin-1
Possible evidence for role in HTN:
 excise endothelin-secreting tumor cure HTN
 Bosentan (ET receptor blocker) has equivalent BP reduction as enalapril (ACEi)
 Endothelin antagonist: ↓ BP, ↓ PVR in normotensive people: maybe tonic role in BP?

Potent vasodilator
 Short-lived, highly permeable gas, released by endothelial cells in response to…
o BP changes, shear stress, pulsatile stretch
Nitric Oxide  Also: ↓ platelet adhesion / aggregation, ↓ migration/proliferation of vascular smooth mm cells

Tonic role? Animal models: NO inhibitors  sustained HTN

 NO -mediated relaxation diminished in HTN pts, but don’t know if this is cause or consequence of HTN

Multiple genes, may account for ≈ 30% variation in population BP

 HTN 2x as common if one or both parents have HTN

Inherited HTN component: primarily in the KIDNEY(abnormal Na HANDLING)

Genetic  Transplanted kidney from donor with HTN  ↑ BP, ↑ need for antihypertensive Rx
 Donor without HTN: no ↑ BP in recipient
Factors
Specific mutations can cause HTN too
 Liddle’s : HTN (mutation  activate ENaC in DCT, low plasma renin / aldosterone, responds to amiloride)
 Congenital adrenal hyperplasia: 11-β-OHase deficiency, ↓ cortisol  ↑ ACTH  HTN (↑ secretion of
11-deoxycorticosterone)

Low birth weight is the big one (poor fetal nutrition)

Intrauterine  ↓ birth weigh  ↓ # nephrons  HTN
differences
Also ↑ with ↓ social status of father

53
 Many factors: SALT INTAKE, obesity, occupation, alcohol intake, family size, crowding

Salt intake: strong association

 “salt sensitivity” – may be interaction between genetic predisposition & environmental exposure
Environmental  ↑ Systolic BP with ↑ Na excretion (measuring Na intake) and ↓ potassium excretion
Factors
The western diet:
 ↑ Na intake  ↓ renal adaptation  ↑ Na retention & ↓ K retention
 ↑ Na/K ATPase activity  ↑ cellular sodium ; ↓ cellular potassium
 Vascular smooth mm constriction, ↑ PVR, HTN

Secondary Causes of Hypertension

Can be renal, endocrine, cardiovascular, neurologic, other (drugs, genetics, etc.)

Renal causes Cardiovascular causes

 Renal parenchymal disease  Congenital coarctaion of the aorta
(glomerulonephrits, chornic pyelonephritis, PKD) (just distal to L. subclavian a.)
 Renal vascular disease  Polyarteritis nodosa
(renal artery stenosis from atherosclerosis or or other vasculitis that affects kidneys
fibromuscular dysplasia)
 Renin-secreting tumors (really rare) Neurological causes
 ↑ intra-cranial pressure
Endocrine causes:  Sleep apnea
 Adrenal gland:
adrenal cortical hyperfunction (Cushing’s, Conn’s, CAH) Others:
 Pituitary gland:  Pheochromocytoma
acromegaly, basophilic adenoma (↑ ACTH)  Drug-induced or related
 Thyroid gland (thyrotoxicosis)  Genetic: Little’s

A few specific examples:

Renal artery stenosis

 ↓ renal perfusion  ↑ RAAS  HTN

 Can be caused by atherosclerosis, or

fibromuscular dysplasia

Pheochromocytoma
 See IVC displaced anteriorly on sagittal MRI (finding for adrenal tumors)
 CATECHOLAMINE-SECRETING (unregulated & excessive)
o ↑ CO, ↑ PVR  HTN

Primary hyperaldosteronism
 Adrenal enlargement on T1-weighted MRI
 Unregulated, excessive tumor production of aldosterone
o ↑ mineralocorticoid effect  ↑ Na reabsorption in DT
o Na retention  volume expansion  HTN
o Renin: chronically suppressed

54
 Risk factors for HTN
• Genetic predisposition or family history • Excessive alcohol intake
• Black race • Low socioeconomic status
• Diagnosis of prehypertension • Sleep apnea
• Increasing age • Use of certain illegal drugs or over the counter
• Obesity medications
• High sodium – low potassium intake

Resistant HTN
If you see a patient with HTN and can’t control despite multiple Rx’s (resistant), think of this list

 Improper BP measurement  Associated conditions:

 Non-adherence o Obesity
 Inadequate doses o Excess alcohol intake
 Inappropriate combinations
 Drug-induced:
o Illicit drugs: cocaine, amphetamines, …
 Volume overload:
o Sympathomimetics: decongestants, …
o Excess sodium intake
o Oral contraceptives
o Kidney disease
o Steroids
o Inadequate diuretic therapy
o Cyclosporine, tacrolimus
o Erythropoietin
o Licorice

Hypercoagulability and Hypertension: a mystery wrapped in a riddle

The thrombotic paradox of hypertension, a.k.a. the Birmingham paradox

 Blood vessels exposed to HIGH PRESSURE in HTN
 But the main complications of HTN are THROMBOTIC (stroke & MI) rather than HEMORRHAGIC

55
 Non-pharmacologic Treatment of Hypertension
BP measurement history Benefits of “lifestyle” therapies
 Harvey (1616): circulation ↓ BP
 Hales (18th c): cannulated artery (horse) Non-hypertensives Prevent HTN
Prevent age-related rise in BP
Kortokoff: observed sounds made by constriction of artery at certain Always initial therapy
points in inflation / deflation of cuff that correspond to SBP & DBP Hypertensives Adjunct to drug therapy
Substitute for meds

Accurate BP measurement in office

 Properly calibrated & validated instrument
 Seated measurement (5 minutes in chair with feet on floor, legs not crossed, arm supported at heart level)
 Cuff: right size (should cover at least 80% of arm)

Inflate cuff  occlude blood flow 

1st Kortokoff sound @ SBP
5th Kortokoff sound @ DBP

Waveform: maximum amplitude of pulse in

cuff (used in oscillometric)

Ascultory: listen to BP
Aneroid (dial measures pressure)
 Less accurate than mercury
 Mercury banned now though

Oscillometric (machine)
 Less accurate
 Measure amplitude of pulse waveform at
maximum, algorithm  estimate SBP &
DBP
 Underestimate higher BPs, overestimate lower BPs

Who cares about blood pressure?

 SBP ↑ with age (target in elderly)

 DBP ↑ with age until about 60
 ↑ Pulse Pressure with age

↑ HTN with ↑ BMI

Hypertension is #1 for burden of disease / death in developed world!
↑ risk of stroke (at all ages)

56
 Blood pressure classification (JNC VII)

“pre-hypertension” – have 90% risk of developing HTN Category Systolic BP Diastolic BP

 Try to motivate to change lifestyle! Normal < 120 and <80
Pre-hypertension 120-139 or 80-89
Prevalence: most people are abnormal Hypertension
HTN: 27%, PreHTN: 31%, HTN: 42% Stage 1 140-159 or 90-99
Stage 2 ≥ 160 or ≥100
Pretty much everybody develops HTN if you live to be 85
 But some studies: less in farmers than city dwellers in China
 Lifestyle could make a difference!

Treatment
Always encourage lifestyle: even if they’re normal; add drugs depending on stage (HTN stage 1 or 2)

LIFESTYLE THERAPIES TO ↓ BP
 Weight loss (among those who are overweight or obese)
 ↓ salt (sodium chloride) intake
 ↑ potassium intake
 Certain dietary patterns
o DASH diet
o Vegetarian diets
 Increased physical activity
 Moderation of alcohol intake (among those who drink)

Don’t see: smoking (doesn’t ↑ risk HTN on its own), trans-fats, saturated fat, cholesterol etc!
 Hypertensives should still reduce these things (CVD/stroke risk!)

Calcium & Mg supplements, fish oil, fiber don’t seem to work in isolation
Studies in isolation: see table for ↓ SBP/DBP

1) Choose & prepare foods with Little or No Salt

a. ↑ NaCl  ↑ BP, we eat way more than basic needs (150
mmol vs 10 mmol)
b. DASH DIET: lowers blood pressure (10mm – like taking a pill)
1. bigger effect if your diet was high sodium before
2. Difference maintained throughout day & night
3. Bigger effect in AA vs non-AA pts
c. BP response to change in salt intake is heterogeneous: AA & older pts are more “salt sensitive”
1. Issues: no clinical test for salt sensitivity, use groups
d. Where does salt come from? Processed foods (not much at the table)
e. Goal: < 1,500 mg/day (65mmol)
1. interim target (<2,300 mg / 100 mmol/day) –hard to hit real goal with current food supply

2) Increase your intake of foods rich in potassium

a. Diet rich in potassium  lower BP
b. Hard to take KCl pills (really big)  diet is the best way to go
1. ↓ BP, reduces “salt sensitivity”
c. Food: preferred (usually KCitrate, a bicarb precursor: also helps with ↓ bone turnover, ↓ risk kidney stones)

57
 1. fruits (bananas, oranges, orange juice)
2. vegetables (broccoli, tomatoes/tomato juice, potatoes)
3. others (beans, yogurt, dairy)
d. At least 4,700 mg per day (should be lower if impaired K excretion)
e. Impaired excretion:
1. Drugs: ACEi, ARB, K+-sparing diuretics
2. Medical conditions: diabetes with kidney damage, CKD, HF

3) Consume the DASH Diet

a. This is the recommended diet – not Atkins, etc.
1. Was tested with outpatients, fed them everything, isocaloric (wt constant) & Na similar in all diets
2. Tested vs. typical American, DASH, typical American with more fruits & vegetables

b. What is it?
1. Emphasizes: fruits, vegetables, low-fat dairy products
2. Includes: whole grains, nuts, poultry, fish
3. Reduced: sat fat, total fat, cholesterol, red
meat, sweets, and sugar-containing beverages

c. What does it do?

1. Fast & significant BP lowering (10 mm Hg)
2. Effective in broad segments of pop
3. Especially effective in:
1. Hypertensives
2. African-Americans
4. Also: ↓ LDL, meets all major nutrient / food recommendations, consistent with US dietary guidelines

4) Maintain a healthy body weight

a. BMI↑, HTN↑
b. BMI↑, also other ↑ CVD risk (HTN, DM type 2, cholesterol)
c. Weight loss  ↓ risk factors (BP, etc.)
Weight (lbs)×703
d. 𝐵𝑀𝐼 =
height (in2 )
e. To lose weight: cut calories: ↓ intake, ↑ exercise
1. 500 cal/day  4 lb / month
2. Hard – people tend to go back to weight

5) Be physically active
a. As you exercise, ↑ BP; with training, less increase in BP with exercise (good!)
1. Sedentary lifestyle: ↑ BP, ↑ BMI, ↑ CVD risk
2. Moderate activity: can lower BP (brisk walking, swimming) - recommended
3. Vigorous activity: also lowers BP but ↑ risk orthopedic problems
b. Shoot for: 30 min most days in a week

6) Moderation of Alcohol Intake (among those who drink)

a. Drink  ↓ BP; rebound ↑ BP after binge
b. J-shaped relationship: moderate drinking = ↓ risk of dying
1. Above 2 alcohol drinks / day, BP↑ with ↑ alcohol
c. Recommend: for those who drink, do so moderately
1. (≤2 drinks/day for M, ≤1 for women)
58
 2. (↑ HDL, so don’t start if you don’t drink)
7) Macronutrients also affect BP
a. Reduce carbs, increase protein, increase good fats
b. 16 mm reduction (especially high protein) – DASH-like diets are good

How can docs help?

Public health approach: a 5mm reduction in SBP would lead to 15% less coronary heart disease, 27% less stroke
 Individual level – hard to maintain over time

Exercise advice:
 43% pts reported getting advice to ↑ exercise; 75% of those reported exercising
 42%: got advice to ↓ fatty foods, 88% reported trying

If you focus on sodium reduction, you can lower by 50% (confirmed by 24h urine!)
 Great chance for success – be encouraging

59
 Management of End Stage Renal Disease
Stage Findings
GFR < 15 - need to start renal replacement therapy (dialysis or transplant)
Urinary abnormalities
I
GFR > 90 mL / min
Scope of the problem
II GFR 60-89
 600K pts with ESRD, 100k/yr and growing, $28B/yr
III GFR 30-59
 Minorities over-represented: AA, Hispanics, Native Americans
IV GFR 25-39
V (ERSD) GFR < 15
Leading causes: DM, HTN, chronic glomerulonephritis, HIV-associated
nephropathy (HIVAN), hereditary dz (polycystic kidney or alport's)

Treatment options: (often switch modalities)

Hemodialysis Peritoneal dialysis Renal transplantation
(in center or home)  Continuous ambulatory peritoneal dialysis (CAPD)  Deceased donor
 Continuous cycling peritoneal dialysis (CCPD)  Living donor (related or unrelated)

Hemodialysis
Dialysis = "to separate": separating crystalloid from colloid by a semi-permeable membrane
 Dialyzer: biocompatible membrane with parallel hollow fibrils
o blood flows inside fibrils, rapid blood flow rate (450mL/min)
 Dialysate: bathes blood with countercurrent flow
o solute drawn off by diffusion, fluid drawn off by convection
o Fast flow replenishes gradient
Inadequate dialysis:
 Delay: pan-serositis can result (pericarditis especially common if severe fluid load, advanced uremia)
 Inadequate: recurrent uremic symptoms & poor surival
 Access failure is life-limiting problem (if you keep clotting, can run out of access sites)

Requirements for hemodialysis

 Access to blood stream
o Large central venous cath (not good - invasive, endocarditis, etc)
o A-V fistula or graft for access, can cause HF problems if too large
 Fistula preferable to graft: use own blood vessels, "matures" in 8-16 wks
 Graft: more tendency to clot / infection
Facility placement, transport 3x/wk
o 3-4hrs per treatment + 1 hr pre-post preparation
o Fixed schedule - MWF or TThSa
 Compliance with diet, medication
Advantages Disadvantages
 Access complications (infection, clotting, thromboses,
high-output HF because of A/V fistula)
 Rapid, performed by staff
 Accelerated atherosclerosis (more AGEs, not cleared)
 Nutritionally safe (not losing protein)
 Hyperparathyroidism
 Can give IV meds (procrit, iron, VitD, Abx)
 Depression & suicide (passive, via withdrawal of Tx mostly)
 Easy to monitor
 Inflexible schedule
 Social interaction, supportive environment
 Rapid fluid shifts (hypotension, cramping weakness)
 "Sawtooth" labs & BP shifts

60
 Peritoneal dialysis
 Uses peritoneal membrane as "dialyzer" membrane
 Slower blood rate than hemodialysis, do it every day
 Dialysate in via catheter with perforated tip in lower abd
 CCPD: continuous cycling PD (4-6 exchanges at night)
 CAPD: continuous ambulatory PD (4-6 exchanges in 24h)

Cath-related peritonitis: 0.5 episodes per pt/yr (fever, abd pain, nausea)
 Signs: abd tenderness +/- rebound, cloudy dialysate, elevated peritoneal WBC with PMNs
 50% gram + (coag - Staph, Staph aureus, VRE, Group B strep) - think skin organisms
 15% gram - (pseudomonas), 5% polymicrobial, <2% fungal

PD vs hemodialysis
PD advantages PD disadvantages
 Personal freedom  Personal responsibility / time committment
 Better BP control  Protein wasting - big complication!
 Higher Hgb/Hct (less blood loss)  K wasting
 No a/v access problems (clotting, infection)  Potential for cath-related bacterial peritonitis
 Smoother uremic control (avoid saw-tooth  4-6wk lead time (surgical visit, cath placement, cath maturation, education)
chemistries, big volume  "cycler claustrophobia" - have to be hooked up toa machine at night
expansion/contraction)  Need: space for supplies, visual acuity +/- helper

Transplantation
 Dialysis is management, transplant is cure
 Transplant: remember that kidney does more than fluid / electrolyte balance
o Mineral balance, EPO secretion, drug metabollism all taken care of with transplant but not dialysis
o Can reverse all signs & symptoms of uremia
Types :
 Cadaveric: brain-dead donor
 Living
o related donor
o unrelated donor
 Cross-match negative (unrelated donor better than cadaveric as long as they're blood type compatible)
 Cross-match positive (will do higher risk transplants in some exceptional situations)

"Most perfect" renal replacement therapy

 Rejection / chronic allograft nephropathy: limit long-term survival
o 10-20 yrs graft survival can occur
 Complications of immunosuppression therapy are big
Pre-transplant preparation needed:plasma exchange & immunosuppression

Advantages Disadvantages
• Perioperative risks (morbidity & mortality)
• Freedom from dialysis • Lifelong need for immunosuppression
• Avoids accelerated CV syndrome with dialysis • Risk of rejection
• Better overall survival • Risk of allograft nephropathy
• Side effects of therapy

Side effects of therapy:

• HTN, infection, malignancy (skin, lymphoma, other), steroid toxicity (cataracts, bones, joints, diabetes)

61
 Genetic Renal Disease
Glomerular disorders Tubular disorders
Salt wasting Tubular structure
Alport Syndrome (hereditary nephritis)
Bartters syndrome
Congenital Nephrotic Syndrome Autosomal dominant polycystic kidney disease
Liddle syndrome

Alport syndrome (hereditary nephritis): a GBM disorder

X-linked and autosomal forms
Autosomal forms
X-linked form
Recessive Dominant
85% of Alport’s 15%
Epidemiology Rare
Males more severely affected Severity: M=F
• Glomerular hematuria (from birth) • Hearing loss
• Proteinuria (develops in childhood) common Overlap
Signs & • Hearing loss (55%) – progressive, sensorineural • Hematuria with familial
symptoms • Anterior lenticonus: cone-like lens deformation (in 15-30%, pathognomonic) (common in benign
• Variable presentation in females (random X-inactivation) heterozygous hematuria?
o Intermittent microscopic hematuria, no significant proteinuria, ↓↓ESRD “carriers”)
• ESRD common in males ESRD early
Course
(most young adulthood < 30, subset later) (teens-20s)
Mutations α5 subunit of type IV collagen (+α6 for subset with leiomyomatosis) α3 + α4 α3 + α4

Pathology
Bright-field: non-diagnostic (benign early  sclerotic glomeruli later)
IF: loss of Goodpasture epitope in GBM (males/AR forms)
• (can see staining / non-staining alteration in females)
• Can be diagnostic
EM:
• Early: GBM thinning (non-diagnostic)
• Late: basket-weave pattern (pathognomonic) (areas of thinning and
thickening, breaks in GBM on close-up, looks moth-eaten, holey, patchy)

What’s Wrong?
Type IV Collagens
• α1-α6 subunits, 3 combine  protamer
o 2 classes: (α1,3,5 | α2,4,6)
• α1-2 / α3-4 / α5-6 paired up on different
chromosomes (head-to-head)
• Goodpasture epitope is in globular domain of α3 subunit
• X-linked: α5 mutation, Autosomal: α3 + α4 mutation
Skin biopsy: can use for Dx
• α3,4,5 normally in GBM
• α5 is in skin too: see if it
stains! (near right)
• X-linked: no staining (males)
alternating stain (females)
IF of glomerulus:
• see all 3 (α3/4/5) are missing
• If you disrupt one, the whole collagen trimeric protamer can’t assemble
• Picture: far right
• This is why Goodpasture epitope (α3) lost in X-linked pt with α5 mutation

62
 Congenital Nephrotic Syndrome (NPHS1): a podocyte disorder

Epidemiology Clinical Presentation

• Rare (Finland: 1/8000; Lancaster County, PA (Groffdale  Early fetal presentation (Heavy proteinuria)
Mennonites): 1/500) – founder effects  Premature birth
• Autosomal recessive  Proteinuria (± RBC/WBC)
 Often die in first years of life (complications
of nephrotic syndrome, 1° infection)
Pathology:
• Grossly enlarged kidneys with ↑# nephrons
• LM: non-diagnostic (normal glomeruli)
• EM: GBM ok, FOOT PROCESS FUSION of podocytes (see EM)

What’s wrong?
Mutation: Autosomal recessive (19q13.1,29) – NPHS1
 Expressed in kidney (fetal & adult), encodes adhesive protein
 Nephrin: the gene product, localized to slit diaphragm
o Slit diaphragm messed up, ↑ permeability  proteinuria

Bartter’s syndrome: a salt-wasing tubular disorder

Autosomal recessive, present at:
Presentation: like a LOOP DIURETIC OD
 birth/infancy (dehydration, severe salt wasting
 Hypokalemic metabolic alkalosis
 early childhood (failure to thrive)
 ↑ urine Cl excretion
 ↑ plasma renin & aldosterone activity
What’s wrong?  HypoNa (volume contraction ↑ ADH)
Rule out: 1° hyperaldo (no HTN), 2° hyperaldo (extrarenal NaCl losses  HyperCa  nephrocalcinosis
unlikely because so much Cl being secreted)

Various mutations: in the end, affecting TALH NaCl transport (like loop diuretic – Na/K/2Cl cotransporter)

Mutation Target Why is Na transport messed up?

NKCC2 Na/K/2Cl transporter Inactivates, so no NaCl absorption
ROMK ATP-sensitive K channel ROMK is backleak K channel: K is usually
low outside of cells, so to have 1:1:2
Na:K:Cl stoichiometry in cotransporter,
need to let K leak out into lumen
ClC-Kb Basolateral Cl channel Need to get rid of Cl to keep Na/K/2Cl
transport going

Barttin: another mutation, but causes hearing loss too!

 β-subunit for ClC-Ka and ClC-Kb chloride channels, required for membrane localization
 In cochlea, there are both ClC-Ka and ClC-Kb chloride channels (kidney: -Kb only)
o Knock out ClC-Kb, get: Bartter’s without hearing loss (cochlea still has Ka channel)
o Knock out barttin, get: Bartter’s + hearing loss (can’t localize Kb or Ka channels)

Why hypokalemia? ↑ distal flow to collecting duct  ↑ Na reabsorption (aldosterone)  ↑ negative lumen  ↑ K secretion
Why metabolic alkalosis?

+ +
HypoK  ↑ NH3 synth in PT; ↑ H /K ATPase in intercalated CD cells
 Negative lumen effect like above
Why hypercalciuria? Less positive lumen, so less force driving paracellular reabsorption of Ca & Mg out of lumen
Why not hypomagnesemia? More salt wasting, hypoaldo  ↑ Mg reabsorption in DCT

63
 Liddle Syndrome: a salt-wasting tubular disorder

Autosomal dominant Clincal Presentation

 Childhood / early adulthood presentation
Rx: amiloride/triamterine (sodium channel blockers) in early stages (with HYPERTENSION)
 Transplantation cures HTN in early stage, may have  “Pseudohyperaldosteronism”
irreversible vessel changes in later stages o HTN, HypoK, Metabolic alkalosis
o ↓renin / aldo! (not hyperaldo!)
What’s wrong?

Mutations: ACTIVATING ENaC

 β or γ subunits or C-terminus of ENaC (sodium channel) in DCT
 ↑ cell surface expression or ↑ open channel probability
o Remember: ↓ volume  ↑ renin  ↑ AT II  ↑ aldo  ↑ ENaC
insertion into apical membrane in DCT  ↑ Na reabsorption (along with
↑ Na/K ATPase activity)

 ENaC constitutively on: as if aldosterone were working all the time!

(pseudohyperaldosteronism)

Polycystic Kidney Disease - disorder of tubular morphology

Tubules must be properly patterned (appropriate luminal diameter to match work)
 Too wide: inefficient processing; Too narrow: ↓ flow rate; Correct polarity needed too

PKD: group of disorders with altered tubular morphology

 Renal tubules don’t form properly or “forget” correct diameter

Autosomal dominant PKD:

 Common (1/500-1/1000), responsible for 4-5% ERSD in USA!
Systemic disorder
 GI cysts: hepatic in 80%; pancreatic in 10%
 Vascular abnormalities: intercranial aneuyrisms in 7%, aortic aneyurisms too
 Other complications: HTN (70-80%), cardiac valve abnormalities, kidney stones
(20-25%), UTI, hernias, diverticuli

HUGE KIDNEYS (see picture)

Genetics: PKD1 (85%) or PKD2 (15%), all probably membrane proteins / channels
 Two hit model (cysts are focal) – a germline mutation, then a somatic one

Possibilities for what PKD proteins do:

 Maybe related to cilia dysfunction? (non-motile, sensory cilia, role unknown in regulation)
 Maybe related to planar orientation? (for the cell: who’s in front of me or behind me? How should I be arranged)
 PKD inactivated: ↑ cAMP in cystic tissue, ↑ cAMP growth response – who knows?
o V-2 receptor blockers (aquaretics): ↓ cAMP signaling, some good response in mouse models?

ESRD in African Americans

 ↑↑ risk ESRD (except PKD) for AA pts (7x higher!), clearly multifactorial cause for discrepancy, but…
 Maybe a genetic factor? AA kidney dz pts have ↑↑ African heritage in chromosome 22
 May be related to dystrophin-type complex, regulating podocyte structure (hold together GBM)?

64
 Forensic Pathology
Note: these are only topics that were mentioned as possible exam material. Boxes = highly emphasized material.
Her notes are pretty concise for the other (pretty interesting) stuff

Cause vs. Mechanism vs. Manner of Death

Cause of Death: that disease process or injury that brings about the cessation of life (immediate cause)
 ( i.e. multiple gunshot wounds, multiple injuries, hanging, narcotic intoxication, pulmonary embolism, etc.)

The proximate or original, initiating cause of death:

 underlying medical condition or injury that initiates the lethal chain of events culminating in death.
o (write on part 23 of the death certificate)

For example, a person might die of sepsis, but the initiating cause could be a stab wound of the chest. Therefore, part 23a would be:
Sepsis (immediate cause of death) and part 23b would be: Stab wound of the chest (proximate cause of death).

Mechanism of Death is the physiologic process that results from the cause of death
 i.e. cardiopulmonary arrest, asystole, respiratory arrest, etc.
 NEVER PUT A MECHANISM OF DEATH ON A DEATH CERTIFICATE!!

Manner of Death is the circumstance under which the cause of death occurs
 i.e. Homicide, Suicide, Accident, Natural, or Undetermined
 Only medical examiners can certify non-natural deaths.
 Another physician can fill out and sign a death certificate with approval of the medical examiner’s office. A medical examiner will
have to co-sign the death certificate. The funeral home usually brings the death certificate to our office for co-signature.
Remember if there is any type of trauma or injury listed in the Cause of death or Other significant condition sections and a
physician fills in a manner of natural, vital records will reject the death certificate and the case will be investigated by our office,
hopefully before the body is embalmed!!

Pulmonary embolism can be any manner of death (what if you were shot  broken leg  etc. – homicide!)
Quadriplegia too (if you tried to jump off a bridge, died years later – still suicide!)

Suicide / Homicide vs. Murder

Suicide: the act of taking one’s own life (no intent needed)
Homicide: a death caused by the act of another or the omission of an act (no intent needed)
Murder: a legal definition that implies INTENT

Laceration vs. Cut

Incisions or cuts are caused by sharp objects. They can be straight or jagged.
 There is no peripheral abrasion, tissue bridging, or undermining.
 Stab wounds are sharp force injuries that are deeper than they are long.
o The depth of a stab wound can be longer or shorter than the actual knife blade.

Lacerations or tears in the skin are caused by blunt objects.

 They usually have irregular contours, peripheral abrasion, the presence of uncut strands of tissue bridging
between the opposing edges of a linear defect, and often show undermining.
 The BRIDGING TISSUE IN A LACERATION is the most important criteria in distinguishing a cut from a laceration.

1
 Other types of blunt object injuries
Contusion: bruise which is the leakage of blood from torn vessels
Abrasion: scrape with damage to the surface of the skin and is produced by friction or pressure.

Automobile accidents: Blunt and sharp force injuries are common. Sharp force injuries include dicing and slicing.
 DICING INJURIES: small angulated cuts produced by the cube-like fragments of tempered glass
o from the side or rear windows.
 Slicing injuries: delicate, thin, long, straight cuts produced by laminated glass
o from the front windshield.
o Laminated glass consists of a layer of plastic between two layers of glass and in an accident it usually comes off in
one large dented and folded piece

Lividity (liver mortis) / Rigor Mortis / Algor Mortis

Lividity or Livor mortis: the postmortem pooling of blood in dependent areas of the body due to gravitational forces.
 After approximately 8-12 hours, the blood congeals in the capillaries or diffuses into the extravascular tissues and does not
permit blanching or displacement at this point it is determined to be “fixed”.

Rigor mortis: the postmortem stiffening of the muscles due to lack of ATP regeneration and acidity, which results in
the formation of locking chemical bridges between actin and myosin.
 Becomes apparent within 30 minutes to an hour, maximizes at 12 hours, remains for 12 hours, and progressively disappears
within the following 12 hours.

Algor mortis: postmortem cooling of the body.

 Average conditions: body cools at a rate of 1.5°F per hour during the first 12 hrs and 1°F per hour for the next twelve hours.

Close firing range / Stippling / Contact Gun Wounds

Know CONTACT and CLOSE RANGE

Entrance wound has a circumferential marginal abrasion collar and its edges are unopposable.
Exit wound: laceration or tear in the skin; usually larger than the entrance wound and the edges can be opposed.

Range of fire:
Soot: burnt particles of gunpowder which can be wiped from the skin around an entrance wound.
Gunpowder stippling are punctate abrasions on the skin caused by unburnt particles of gunpowder striking and
scraping the skin around an entrance wound. STIPPLING = CLOSE RANGE (18 inches)

Contact GSW – soot and gunpowder are within the wound track and there could be a muzzle imprint on the skin
surrounding the entrance wound.
 If on scalp, the scalp closely overlying the bone has a tendency to tear due to the loss of kinetic energy of the bullet.
o Star shaped tear; entrance beveled inward, exit beveled outward

Near or Loose contact – soot and gunpowder are within and partially around the entrance wound.
Close range – searing of the skin (w/in 2 to 3 in), soot deposition (w/in 6 in), and gunpowder stippling (w/in 18 inches)
Distant – no soot or gunpowder stippling is present on the skin surrounding the entrance wound.

2
 Definition of decomposition
Decomposition includes:
 autolysis, which is the enzymatic digestion of the body
 putrefaction, which is the action of bacteria on the body.

24-36 hrs: Early decomposition

 green discoloration of the skin
 gaseous bloating
 dark purple to green discoloration of the skin of the face
 purging of bloody decomposition fluid from the nose and mouth.

36-48 hrs: A marbling pattern

 from decomposition of blood; formation of sulfhemoglobin and hematin w/in dilated subQ blood vessels.

After 72 hrs: Vesicle formation with skin slippage and marked bloating of the entire body

If the body decomposes in a dry environment, mummification of the skin can occurs at about 4 days.
Skeletonization is dependent on environmental conditions
 in a hot, dry climate if may take 6 to 9 months
 hot, humid climate with marked insect activity: a week to ten days.

These postmortem changes are extremely variable.

They are basically chemical reactions; heat accelerates them and cold slows them down.

3
 Pharmacology: Renal
Drugs and the Kidney .............................................................................................................................................................. 2
Diuretics .................................................................................................................................................................................. 5
Drug Treatment of Essential Hypertension............................................................................................................................. 9

1
 Drugs and the Kidney
The kidney’s effect on drugs
Elimination, Metabolism, Distribution, and Absorption

Elimination
Filtration (glomerular)
 Aminoglycosides (big issue: toxin hits from tubular size)
 Digoxin (high toxicity potential)
 most β-lactam antibiotics: not a big problem usually (high therapeutic index)
 fluoroquinolones, vancomycin (rarely an issue)

Remember: Plasma creatinine has a non-linear relationship to GFR

Cockcroft-Gault Formula: MEMORIZE THIS

140 − age × lean body weight (in kg)
𝐶𝐶𝑟 = × (0.85 𝑓𝑜𝑟 𝑤𝑜𝑚𝑒𝑛)
𝑃𝐶𝑟 × 72

Aminoglycoside dosing: need to be careful if diminished renal function

1. Loading dose : get up there quick
a. Hit target concentration immediately
b. Depends on Vd, NOT clearance (not renal function)
c. “Once daily dosing”: 5-7 mg/kg for loading dose
i. “Traditional” q8h dosing: 2mg/kg (3-4 mg/kg in ICU for sepsis)
2. Maintenance dosing
a. “Once daily” 5-7 mg/kg, “traditional”q8h 5-7 mg/kg
b. GFR-adjusted based on serum creatinine & calculated creatinine clearance
c. Use CCr from formula above to calculate clearance, adjust
d. (if 50% renal function, give 50% dose – because it’s almost all renally cleared)
3. Target concentration
a. Peak “once daily” not established
b. Peak “traditional” 7-10 μg / mL or peak / MIC ratio
4. All this applies to gent & tobra, amikacin doses/targets are 4x higher

Meperidine (Demerol): morphine-like agent

 If you’re renally impaired, you can’t excrete nor-meperidine
o neuro-toxic metabolite formed after oral / high-dose parenteral
administration
 Accumulates more rapidly if renal glomerular impairment

Secretion (tubular)

Probenecid: blocks renal secretion of all penicillins and cephalosporins

 also zidovudine & cidofovir (reduces toxicity of cidofovir)
 Not used with penicillin anymore (originally used to conserve penicillin during war: could use less PCN)
 Uricosuric agent:
o uric acid filtered & then reabsorbed
o reabsorption blocked by probenecid, makes you pee out uric acid (good for gout)

2
Reabsorption (tubular)

Aspirin (acetyl-salicylic acid)  rapidly de-acetylated to salicylic acid (SA)

 SA is both metabolized by liver & eliminated by kidney in a pH-dependent fashion
 In overdose setting: hepatic SA metabolism is CAPPED (zero-order kinetics)
o Renal elimination is therefore key to get rid of that SA
o Eliminated by NON-IONIC DIFFUSION

Non-ionic diffusion
 Remember henerson hasselbach
 SA is a weak acid (pKa = 3.4), acids ionize above their pKa
 Only uncharged particles cross lipid barrier
o Alkalinize the urine, you can trap ionized SA in the urine &
excrete it
o Top picture = normal urine pH, bottom = after Urine pH↑
 Give bicarb to treat aspirin overdose
o Rise of 1 in urine pH  10x decrease in reabsorption (or 10x
increase in excretion) of SA

Metabolism
Vitamin D
 In renal impairment: can’t generate Vitamin D active metabolite
 2-step process: Vitamin D hydroxylation
o Hepatic: 25-hydroxylation
o Renal: 1-hydroxylation (active 1-25OH Vit D generated)
 Vitamin D deficiency is key component of renal osteodystrophy (bone problems)

Imipenem
 Filtered & secreted from blood to renal cells
 Hydrolyzed to inactive / toxic metabolite by dehydropeptidase (DHP)
 Give with cilastin to block DHP
o ↑ imipenem *urine+, no renal toxicity

Distribution
Think: pH partitioning (salicylate toxicity) - ↑ pH in urine to hasten elimination (See above)

Absorption
Dialysis Dementia: stuttering speech, altered mental status/cognition, seizures, death
 ↑ serum aluminum (high Al in dialysis water sources, Al hyperabsorption in phosphate-binding oral Al salts)
+3 +3

 No longer a problem (don’t use phosphate-binding Al salts, treat water to remove Al)

Renal Toxicity
Even with rational drug design, “toxicity is always a crapshoot” – see table to right for partial list of nephrotoxic drugs

Factitious Toxicity: ↑ SCr or BUN but not really causing toxicity

 Assay interference (ketone bodies, flucytosine, cefoxitin)
 ↓ creatinine secretion (cimetidine, pentamidine)
 ↑ creatinine release (rhabdomyolysis)
 ↑ BUN (corticosteroids, tetracycline)

3
Aminoglycoside nephrotoxicity
 Onset: late in 1st week (5-7 days), can last up to 1 week after d/c drug
 Proximal tubule death & release of enzymes detectable in all patients

 Non-oliguric, no proteinuria (not damaging glomerulus)

 Usually mild (as measured by GFR), rarely severe
o “always” reversible – if you can get them through the ARF
o PT cells can regenerate if you haven’t damaged BM, and AGs don’t – but ototoxicity not reversible

 Gent > tobra > amikacin for toxicity at equimolar doses (so you can give 4x dose ami)
 ↑ risk: total dose, females, elderly, liver disease

How does AG nephrotoxicity happen?

 Bound, incorporated by proximal tubular epithelium (pinocytosis) from lumen (reabsorption)
 Accumulation, long retention by proximal renal tubules
o Labeling studies in mice: accumulates in kidney, esp kidney, only PT!
 ALWAYS proximal tubular damage
 NO damage to basement membrane  tubules can regenerate
Other nephrotoxic drugs
Aspirin / NSAIDs
 Both non-specific & specific cox-2 inhibitors Cisplatin
 Nephrotoxicity: in situations that depend on prostacyclin to  Nephrotoxicity depends on a renal glutathione S-transferase
maintain intraglomerular pressure o (normally a “detoxifying enzyme” but here forms a
o Blocking prostacyclin’s dilation of afferent arteriole toxic metabolite!)
o Block synthesis  can’t maintain IGP
Cidofovir
ACE inhibitors  Transported into renal tubular cell by organic anion
 Same kind of deal: block constriction of efferent arteriole  transporter (HOAT-1)
can’t maintain IGP o Probenecid blocks this transporter  ↓
nephrotoxicity
Amphotericin B
 Nearly inevitable nephrotoxicity (every patient!) Bevcizumab
 Vascular, glomerular, tubular damage  Anti-angiogenesis agent
but mechanisms unclear (anti-VEGF mAb for cancer chemo)
 Lipid formulations  less severe damage (but still not great) o Causes proteinuria in 21-64% treated, HTN in 3-36%
o Renal thrombotic microangiopathy seen in pts
Radiocontrast affected
 Peaks 2 /3 day after exposure
nd rd

 Recovery in 2 wks is the rule, occasionally permanent loss of
function
o Animal models: osmotically-induced endothelin-1 mediated
renal vasoconstriction involved
Radiocontrast: Gadolinium
 New syndrome: nephrogenic systemic fibrosis
o ESRD on dialysis
o Odds ratio (exposed vs unexposed): 20/1 – 46/1
Cyclosporin
 Haven’t been able to separate mechanism of
immunosuppressant activity from nephrotoxic activity
 Seems to be “on target” nephrotoxin (rapamycin may not
share nephrotoxicity?)
 Is nephrotoxicity related to VEGF target?
In other words, can we fix this or not?
o Looks like it’s direct reduction of VEGF target (↓
glomerular VEGF production) that’s at fault –VEGF-A
production needed to maintain integrity of vascular
bed, bevcizumab interferes with cross-talk between
podocytes & glomerulus
Fangchi:
 Chinese herbal nephropathy: progressive interstitial
fibrosis with glomerular sparing, often with urothelial
cancers in Belgian women taking fangchi for weight
reduction
4
 Diuretics
Background
 Some of most commonly prescribed drugs in US
 Increase urine flow (“diuresis”) by inhibiting reabsorption of NaCl (different sites of nephron for different classes)
o Loss of urinary NaCl (“saliuresis”)  water loss
 Treat: HTN (thiazides are #1), edematous states (CHF, cirrhosis, nephrotic syndrome: loop diuretics are #1)

The Four Major Classes

In order of potency (most  least)
Class Acts at
Loop diuretics TALH
Thiazide diuretics Distal tubule & connecting segment
Potassium-sparing diuretics Cortical collecting tubule
(aldosterone-sensitive principal cells)
Carbonic anhydrase inhibitors Proximal tubule

Sodium reabsorption: things to keep in mind

 Huge amount of sodium filtered & reabsorbed every day
o Affecting even ~ 3% of reabsorption (collecting tubule) can have a
significant effect on sodium excretion
 PT is #1 for absorption (microvilli, mitochondria, tons of SA)
 TALH is #2
 Site of action of diuretic affects the “ceiling” – what % of Na
reabsorption can potentially be blocked?

How to measure sodium intake? 24hr sodium excretion!

Step increase or decrease in Na intake  increase or decrease in excretion (after lag) to match
 ↑ Na+ intake  ↑ ECF (levels off when excretion↑ to equal new higher intake)
+
o So steady state volume depends on Na balance (esp. intake)
 ↑ ECF  ↑ Na+ excretion
 Mechanisms involved (see other lectures)
o hemodynamics (arterial pressure  carotid / cardiopulmonary / afferent arteriole sensors  RAAS, symps)
o hormones responsive to ECF (ADH, aldosterone, ANP, etc)
o direct kidney involvement (tubuloglomerular feedback)

Edema
 ↑ ECF volume b/c reduced ability to EXCRETE SODIUM for a given ECF volume
o CHF, renal failure, cirrhosis, nephrotic syndrome
 See graph: ↑ threshold ECF for Na+ excretion
o (takes more ECF to get Na+ excretion > 0)
o Edema at lower sodium intake

Best initial treatment: DIETARY SALT & FLUID RESTRICTION

 Go to diuretics when this doesn’t work

5
 Chronic Adaptation to Diuretics
1) ↑ NaCl excretion initially with diuretic use
+
a. Negative sodium & chloride balance  net Na excretion 
net water loss
b. ↓ECF, edema lessens, etc.
2) Na / H2O loss declines with time: “braking phenomenon”
a. Go back to baseline levels
b. Adaptive processes: ECF is dropping!
c. RAAS, sympathetic, aldosterone, etc. (see above) kick in
d. Good: if you always had a negative balance, ECF would keep
dropping and pt would be dehydrated
3) So what good are diuretics?
a. Reach new steady state with a lower ECF!
b. Diuretic resistance: if adaptation happens
before desired ECF reached (↑ dose if
possible)

Too much diuretic?

 Hypovolemia results (↓ ECV)
 Symptoms: thirst, weaknes, lethargy, lightheadedness
 Signs: postural hypotension, ↑Hct, azotemia (↑BUN)
 Note: can have intravascular volume depletion (↓ ECV) at the same time as ECF overload (edema)!

Where diuretics work

6
 Loop diuretics
Furosemide (Lasix), bumetanide, torsemide, ethacrynic acid
 #1 diuretics for ↓ volume (edema) – high potency
 “High ceiling” diuretics (potent: 25% Na reabsorbed @ TALH)
 Short half life with steep dose-response curve: sometimes hard to hit the sweet spot
o “Lasix” “lasts six” hours (t1/2 = 6h)
 Rebound sodium retention can ↓ efficacy, so give twice daily
o Delivering more Na distally, can ↑ Na reabsorption in DT (↑ aldo)
 Keep in mind that these are working on urine side  drug is secreted in PT

How they work: Block Na/K/2Cl transporter in TALH (apical side) – 25%

Other effects:
+
 ↑ Ca excretion (mainstay Rx for hypercalcemia )
 ↑ venous capacitance
(post-IV administration: Rx for acute pulmonary edema)

Side effects / Toxicity:

 ↑ K+/ H+ loss  HYPOKALEMIC METABOLIC ALKALOSIS
(CONTRACTION ALKALOSIS)
o #1, most important side effect – can be really bad!
+
o ↑ K loss (blocking Na/K/2Cl transporter)
+ +
o ↑ Na delivery ↑ Na absorption distally  ↑ K . H secretion
+ +
o ↑ renin (low volume)  ↑ AT II  ↑ aldo K , H loss
 Hyperuricemia (↓ uric acid clearance)  gout sometimes
 Ototoxicity (inhibits cotransporter isoform in inner ear)
o Especially ethacrynic acid + aminoglycoside (now don’t use EA that much)

Thiazide Diuretics
Hydrochlorothiazide (HCTZ), chlorthalidone, indapamide, metolazone
 #1 diuretics for hypertension (1st line for essential HTN)
 Moderate/low efficacy after 1 dose (“low ceiling”)
 Daily dose: Longer half life than loops, no rebound sodium retention

How they work: block Na / Cl cotransporter in DCT (apical side) – 5-10%

Other effects:
 Anti-HTN independent of diuretic effect!
 ↓ Ca+ excretion with long-term use (opposite of loops!)
+
o Rx for nephrolithiasis (reduce urine Ca ), may help in osteoporosis

Side effects / Toxicity:

 ↑ K+/ H+ loss  HYPOKALEMIC METABOLIC ALKALOSIS (CONTRACTION ALKALOSIS) – same reasons as loops
 Hypokalemia is more common than with “loops” (counterintuitive: loops blocking Na/K/2Cl transporter)
+ +
o Give K supplementation or K -sparing diuretic
 Hyperuricemia (↑ with ↑ dose)  gout
 Hyponatremia
 Hyperglycemia, hyperlipidemia (except indapamide)

7
 K+-sparing Diuretics
Sprinonolactone (aldosterone antagonist)
Amiloride, triamterene (sodium channel blockers)
 All have low efficacy (only 3% filtered at this part of nephron)

How they work: work on principal cell of collecting duct

 Aldosterone antagonists: inhibit aldosterone-sensitive Na/K exchange
(natriuresis & K retention result)
 Sodium channel blockers: block sodium channels (yep)  natriuresis
+ +
o Less negative lumen  less K secretion  K sparing
Other effects:
 Spironolactone: ↓ mortality in CHF pts (with ACEi ± ARB)
o 30% improvement @ 3 years!
 Amiloride: helps in lithium toxicity (Li enters cells via Na channel that amiloride blocks)
 All useful in potassium wasting disorders

Side effects / Toxicity

 HYPERKALEMIA (esp in pts with renal failure)  can be FATAL
o With acidosis (K+ and H+ retention) too
 Spironolactone: gynecomastia, impotence (↓ in newer, more expensive drugs)

Carbonic Anhydrase Inhibitors

Mild potency (distal nephron compensates, and you’re only blocking one of many ways for Na to get into PT)

How they work: inhibit CA, which normally produces H+, which is exchanged for Na+ as part of bicarb system
 Loss of Na+/H+ exchange  Na+ loss (with ↓ reabsorption of bicarb)

Other effects:
 Acute mountain sickness (brain effects, probably a more common use)
 Useful in open-angle glaucoma, Meniere’s disease too
 Used in patients with metabolic alkalosis occasionally (if saline can’t be given)

Side effects / Toxicity

 Hypokalemia
 Acidosis (bicarb loss)
 TERATOGENIC
Other Diuretics
Osmotic diuretics: don’t usually use as diuretics but for other things
 Freely filtered, not reabsorbed so drag water out too
 Use: treatment of cerebral edema (intravascular osmotic agent)

Clinical use
 Loop diuretics for severe edema (CHF, nephrotic syndrome, cirrhosis, renal failure)
o Thiazides added in combo if edema loop diuretic resistant
o (as part of compensation, ↑ % reabsorption in DT after loop diuretic taken: so bigger thiazide effect!)
 Thiazides for mild edema and #1 for HTN
Drug combos
 Loop + thiazide: potent & useful

+
Thiazide + K -sparing: for HTN, help with K-lowering effects of thiazide

+
ACEi + thiazide: ACEi reduces K loss (inhibits RAAS), thiazide synergistic for anti-HTN effects (lisinopril + HCTZ)

8
 Drug Treatment of Essential Hypertension
Epidemiology:
 Prevalence of HTN is high (50% in older age groups)
o Treatment really reduces morbidity/mortality
o Only 30-40% are well controlled
 AA > caucasian (midlife, evens out later in life) Classification of BP for adults 18yo or older
 Females > Males BP classification SBP (mm Hg) DBP (mm Hg)
Normal <120 and <80
Classification: see table (from another lecture) Prehypertension 120-139 or 80-89
Stage 1 hypertension 140-159 or 90-99
Stage2 hypertension ≥160 or ≥100
Complications start at 110/75 (seems low!)
 BP is major risk factor for:
o CVD, CHF, LVH, ischemic stroke, intracerebral hemorrhage, chronic renal insufficiency & ESRD

White coat hypertension: higher with doctors! Some patients have ↑↑ BP when a doctor takes it!

General Points
General efficacy: In essential HTN, aggressive lowering is better!
 AMOUNT BP LOWERED but not drug used is KEY DETERMINANT OF OUTCOME
o (don’t get suckered by big bad pharma)

Monotherapy: if no specific indication, can choose from:

1. Thiazide diuretics
2. Long-acting calcium channel blockers (usually a dihydropyridine)
3. ACEi / ARB

 (NOT β-blocker: ↑ stroke, ↑ risk heart disease)

Combination therapy:
 Start on combo if > 20/10 mm Hg above goal (e.g. 140/100)
 Many patients initially controlled with monotherapy will eventually need combo (30% @ 1yr, 40% @ 5yr)

Blood Pressure goals:

Condition Goal
Uncomplicated combined systolic & diastolic HTN 140/90 mm Hg
Special Circumstances
 Diabetes mellitus
130/80 mm Hg
 Proteinuric chronic kidney disease
 Atherosclerotic CVD
Older individuals with isolated systolic HTN Treat systolic as much as
 Wide pulse pressure! possible but maintain
 SBP > 140 but DBP < 65 = isolated systolic HTN DBP > 65 mm Hg

LOWER BP GRADUALLY if patient doesn’t have end-organ damage / urgency

 Patient needs time for homeostatic mechanisms to adapt to new, lower BP
 Lower too fast  stroke, other cerebrovascular / coronary events
 STROKE, ACUTE MI, other signs of acute end organ damage: do lower emergently!

9
 Resistant Hypertension
Definition: DBP > 95-100 despite 3+ antiHTN meds

Why does it happen?

 Suboptimal therapy  Secondary HTN
 ECV expansion  Office / “white coat” HTN
 Poor compliance (medical ± dietary therapy)  Pseudohypertension

Discontinuing Therapy
Some patients with mild HTN are well controlled on single medication – can consider stopping the meds gradually

If you chose to discontinue therapy: TAPER (discontinue gradually!)

 5-55% pts remain normotensive for 1-2 yrs on no meds
 More do well with less meds or lower doses
 Best success if can use nonpharm techniques (wt loss, sodium restriction)

Abrupt cessation of short-acting β-blocker (e.g. propranolol) or short-acting α-2-agonist (clonidine) CAN BE FATAL
 Withdrawal syndrome! Need to gradually taper, consider switching temporarily to longer-lasting agents

Chronic Kidney Disease

 Aggressive treatment is better (down to 130/80 or less!)

TREATMENT IN CKD:
FIRST THERAPY (↓ progression renal dz via ATII block)
ACEi
 ARB if contraindicated, bad cough, etc.
Should add too! Most patients not controlled on monotherapy
DIURETIC  LOOP if GFR < 20 mL/min (↓ thiazide efficacy)
 can use thiazide + loop if refractory edema

If HTN not resolved with ACEi + diuretic, add another one of these:
Ca channel blockers More effective if pt volume expanded (better result with ↑ salt diet)
(potent vasodilator) – use if refractory HTN
Minoxidil
 Side effects: Na retention, worsening edema, hirsutism

ACEi/ARB: potential complications in CKD pts

↓ GFR (from ↓ glomerular capillary pressure) Hyperkalemia
 Can’t dilate afferent > efferent arteriole to maintain
 Already have ↓ ability to excrete K (kidney messed up)
GFR
 Now, ↓ AT-II  ↓ aldosterone release  ↓ Na/K
 Remember: worse with NSAID (↓prostacyclin)
exchange
 Common to have acute ↑ SCr
 If needed: use loop diuretic (excrete more K!),
 Recommendation: as long as SCr doesn’t increase more
institute low K diet
than 30-35%, keep them on ACEi

Subgroups: AA patients
AA patient: generally respond less well to ACEi than whites for HTN treatment
 In CHRONIC KIDNEY DISEASE the RECOMMENDATIONS ABOVE are THE SAME

10
 Uncomplicated Essential HTN
FIRST LINE: Really doesn’t matter which you use – all work the same (keep it cheap)
 Thiazide-type diuretics
 ACEi/ARB
 Ca-channel blockers

Thiazide diuretics: Β-blockers NOT used for initial therapy

 HCTZ used more commonly & more widely
available, but
 chlorthalidone might be better in trials (longer-
acting) & both really cheap (use it if you can)
except for in specific populations:
 POST-MI PATIENTS
 SYSTOLIC HEART FAILURE (+ ACEi)
 Other patients that are on β-blockers for
another problem (e.g. migraine)

Subgroups with Selective Responses

Subgroup Response:
Younger patients & Caucasians Better ACEi response
Older patients & African Americans Better Ca-channel blocker response

This shouldn’t change initial selection –

 Each agent will normalize BP in 30-50% of pts with mild HTN
 If you switch unresponsive pt to a different class, 50% will respond

Take home: if drug from class #1 doesn’t work, SWITCH to class 2, and then 3, before adding!
 Can often (60-80%) find a monotherapy that works! (or use a combo if it’s still one pill/day, etc.)

Specific antiHTN drugs

DRUGS SPECIAL INSTRUCTIONS

Cardioprotective beyond BP lowering effect! Use if:
 HF, asymptomatic LV dysfunction, systolic dysfunction,
ACEi (& ARB)
 Post-STEMI, post-non-STEMI with anterior infarct
 diabetes, proteinuric CKD
Chlorthalidone is preferred (HCTZ less potent, shorter acting).
Thiazide diuretics
Loop diuretics for volume control if HF or CKD ± nephrotic syndrome
No absolute indications; usually use long-acting dihydropyridines (verapamil, diltiazem)
Ca channel blockers
 Can use for other effects: A-fib or angina control
NOT initial antiHTN therapy, esp in pts > 60yo
 ↑ risk stroke, coronary dz, CV events, maybe mortality!
 Also ↓ glucose tolerance, ↑ risk new onset diabetes
β-blockers Use if:
 Post-acute-MI
 HF or asymptomatic LV dysfunction (start with low doses!)
 Rate control for A-fib, angina control, others
ALLHAT: doxazosin terminated prematurely (↑ risk HF compared to chlorthalidone)
α-blockers
 Can use in older men with prostatism symptoms (esp if not high CV risk)
Pregnant women (just from clinical safely experience)
α-methyl-dopa

nd
β-blocker is acceptable as 2 choice

11
 Pathology: Lung
Interstitial Disease................................................................................................................................................................... 2
COPD ....................................................................................................................................................................................... 7
Pulmonary Vascular Disease ................................................................................................................................................. 12
Pulmonary Neoplasia ............................................................................................................................................................ 16
Lung Infections ...................................................................................................................................................................... 22
Lung Development / Pediatric Lung Disease ........................................................................................................................ 29

1
 Interstitial Disease
Similar findings –combine clinical / path / radiology / etc for Dx
 Open lung biopsy more helpful Diffuse interstitial lung diseases
Interstitium: note that it supports the capillaries! Chronic
 Type II cells make surfactant, type I are large flat squamous cells  Chronic inflammatory infiltrates ± lung
fibrosis (IPF, collagen vascular
diseases)
 Granulomatus disorders
 Dusts (EAA / pneumoconiosis)
Acute
 Diffuse alveolar damage (DAD)
 Acute interstitial pneumonia (idiopathic)

Idiopathic Pulmonary Fibrosis (IPF)

Chronic interstitial pneumonitis: chronic inflammation in pulmonary interstitium; relatively nonspecific lesion (lots of causes)

Idiopathic pulmonary fibrosis: subset of idiopathic interstitial pneumonias

 Chronic inflammatory & fibrotic lesion

o Infiltrate: lymphocytes & plasma cells (± eos & PMNs)
o Fibrotic: ranges from fibroblast foci (acute damage / repair) to well formed collagen scars
 Interalveolar septa most prominently involved
 Lower lobes and subpleural areas most affected

Other characteristic findings

 Patchwork pattern: variability in degree of inflammation & fibrosis from area to area
 Temporal heterogeneity (some acute lesions, some late lesions)
 Fibroblast foci
 Honeycomb change (remodeling)
o Can see in almost any interstitial disorder; can’t make IPF Dx from Bx showing only honeycomb change
o Implies large cystic restructured areas of lung with diffuse fibrosis in between

UIP (usual interstitial pneumonitis): these histologic patterns (path correlate of IPF)
 Can also see in RA & other collagen vascular diseases (same findings; need to separate clinically / lab info / etc)
 Drug reactions can mimic IPF findings too

Pathogenesis of IPF
 Repeated stimuli  sequential lung healing aberrant wound healing  fibrosis
 See temporal heterogenetity in lesions (some young fibroblast foci, others well healed scars)

2
 IPF: Path Findings

L to R: CXR, CT, gross, wedge biopsy. Note small lungs with honeycombing in lower lobes / subpleural areas

Interstitial widening, F: fibroblast foci (recent injury) Remodeling of walls (L)  honeycombing (R) (now have no
chronic inflammation, I: interstitial inflammation (PCs, capillaries), ↓compliance, bronchiolar-type epithelium mucus
fibrosis lymphocytes) production & congestion.

Left:
F: fibroblast foci (more recent)
C: collagen (pinker, older)

Non-specific Interstitial Pneumonitis (NSIP)

 Diffuse & uniform chronic interstitial inflammation ± fibrosis
o Note from right: diffuse pattern without accentuation
o Cellular or fibrotic variants
o No subpleural accentuation; fibroblast foci not required
o no architectural distortion, no honeycomb change

 Commonly associated with:

o Collagen vascular disorders
o Hypersensitivity pneumonitis (e.g. EAA)
o Drug reactions
o Other slowly resolving lung injury

3
 Pneumoconiosis
ILD related to inhaled inorganic dust (asbestos, silica, etc.)
 Specific reactions correspond to certain irritants

Dusts can be fibrogenic (aspestos, silica, etc.) or inert (coal dust, iron – siderosis)
 Inert dusts generally just give you an abnormal CXR but aren’t clinically a problem
 Can also have mixed exposure (modified response, not like any single component)

Silica
 CXR: Large silicotic
nodules
 Dense, hyaline pleural
nodules ± pigmented
dust
Silicosis
Asbestos
 CXR: Calcified pleural plaques & interstitial thickening
 Similar to UIP at large view
 Asbestos fibers (DUMBELL SHAPED ferruginous bodies)
o Characteristic, can be in Mϕ

Siderosis (inhaled iron)

 CXR: Hazy but PFT ok
 Iron in Mϕ, interlobular septae

Asbestosis

Siderosis (iron)

Extrinsic Allergic Alveolitis (EAA)

A.k.a. Hypersensitivity Lung Disease
 Limited to the lung (vs. sarcoidosis)
 Reaction to inhaled organic dusts – many named for exposure (Farmer’s lung, etc)
o Molds, animal antigens, thermophiles, etc.

Granulomas: large & LESS WELL FORMED than sarcoidosis

 See poorly-formed granulomas, think inhaled hypersensitivity

Make sure to do AFB stain & fungal workup if you see granulomas!

4
 Sarcoid
Another ILD with granulomas
Multisystem disease: related to T-lymphocyte dysfunction

Granulomas: MORE WELL FORMED (“hard” or “naked”)

 RANDOMLY DISTRIBUTED (across all parts of lung)
 Primarily formed by histiocytes
 Can be found in wall of small airways (transbronchial Bx useful)
 No caseous necrosis (would think infection)
 Can persist  fibrotic change

CXR: Hilar adenopathy, interstitial lung dz, or both

Sarcoid EAA
Well formed Poorly formed
Granulomas
Randomly distributed Mostly in interalveolar septa
BOOP Rare Frequently present
Upper lobe Pachy infiltrates
CXR
Hilar adenopathy No adenopathy
Disease Systemic Isolated to lung

Diffuse Alveolar Damage (DAD)

Histological correlate of Adult (Acute) Respiratory Distress Syndrome (ARDS)
 Causes: infectious agents (viruses), toxic inhalants, drugs (heroin OD), shock,
radiation, various others

 Pathogenesis: damage to alveolar epithelium / epithelium  acute exudative

stage  edema (interstitial, intra-alveolar) + hyaline membranes + thrombi

 Can resolve or lead to fibroblast ingrowth  organization  fibrosis

Pathological Features & Stages:

Acute exudative Proliferative Organization
 Interstitial
 Endothelial /  Fibroblast
inflammation
epithelial damage proliferation
 Type II pneumocyte
 Interstitial edema (in septa, within
proliferation
 Hyaline membranes alveolar lumen)
 Microthrombi

Can resolve from any

of these stages (but
very rare if organizing)

5
 Hyaline membranes – pink, dead epithelial cells
CXR: Cloudy
(fibrin looks more beady). Interstitial widening too

Proliferative changes: type II

Gross: dense, collapsed lung
pneumocytes (type I dying)

Above: outcomes & events of ARDS

Left: Organization (vascularizing) with areas of fibrosis (F) – leads to an
ineffective epithelium for gas exchange
Acute Interstitial Pneumonia
 Diffuse alveolar damage with no known etiology
 “Hamman-Rich Syndrome”
 Pathophysiology
o Neutrophils (oxidants, proteases)?
o Mϕ (ILs, TNF, etc)?
o Depletion / inactivation of surfactant?
o O2 / mechanical ventilation?

6
 COPD

Normal Airway Review

Bronchi: 30% cartilage (bronchioles don’t have)
Airway structure review:
 15% mucus glands, 5% smooth mm  Bronchi  terminal bronchioles  resp
 Connective matrix (arteries / veins / lymphatics/ nerves) bronchioles
 8-24 divisions to reach alveoli
Picture: normal bronchus  Larger central airways = most resistance
 A: collagen should be loose  Total surface area ↑↑ with < 2mm airways
 B: pseudostratified ciliated columnar epithelium
 C: Cartilage (bronchi only)
 D: Seromucinous glands (mucinous lighter; serous darker pink) –
secrete proteinaceous fluid

Epithelium Types
 Bronchi : ciliated pseudostratified columnar
 Bronchioles: flatter (more cuboidal)
 Alveoli: flat (pneumocytes: type I & II)

Terminal bronchioles:
 Lack cartilage
 Muscle layer about 20% of thickness
 Important in disease processes

Gas exchange: pass through:

endothelium, connective tissue, epithelium

Disorders of Airflow Obstruction (COPD Spectrum) – summary table

Clinical Term Anatomic Site Major Pathologic Changes Etiology Signs/Symptoms
Mucous gland hyperplasia, Tobacco smoke, air Cough, sputum
Chronic bronchitis Bronchus
hypersecretion pollutants production
Persistent or severe Cough, purulent sputum,
Bronchiectasis Bronchus Airway dilation and scarring
infections fever
Smooth muscle hyperplasia, excess Immunologic or Episodic wheezing, cough,
Asthma Bronchus
mucus, inflammation undefined causes dyspnea
Airspace enlargement; wall
Emphysema Acinus Tobacco smoke Dyspnea
destruction
Small airway Tobacco smoke, air
disease/ Bronchiole Inflammatory scarring/obliteration pollutants, Cough, dyspnea
bronchiolitis miscellaneous

7
 Asthma
Pathophysiology
 Extrinsic: type I hypersensitivity
st
o 1 exposure: Sensitization
(Ag recognized by T-cell, etc)
nd
o 2 exposure: mast cells / hypersensitivity
response (mucus secretion, ↑ inflammation, muscle
contraction  bronchoconstriction)
 Intrinsic: non-immune (viral infections, drugs, inhaled
irritants, stress, exercise)
o Mast-cell independent (eos have big role)
o Same kinds of downstream reactions

Path Features:
 Intraluminal secretions:
plasma, inflammatory cells, desquamated epithelial cells.
 Airway epithelial desquamation
 Goblet cell hyperplasia
o Can result in mucus plug
 Airway inflammation: lymphocytes (CD4 mostly) / eosinophils
o Charcot-Leyden crystals: pink; from eos’ products
 “Hyalinized basement membrane: collagen fibrils”.

It would be weird to see this stuff in practice (Bx of asthma? Yeah right.)

Charcot-Leyden Crystals Goblet / Mucus cell

Mucus plug
(may be imaginary) hyperplasia

8
 COPD
Cigarette smoking is the big deal, ↑↑ COPD in females recently
Chronic obstructive pulmonary disease: disease state characterized by presence of:
 chronic bronchitis or emphysema
 with airflow obstruction, which may be accompanied by airway hyperreactivity
 may be partially reversible but is relatively fixed

COPD: Chronic Bronchitis

 Chronic cough & mucus production ± airflow obstruction

BRONCHIAL INFLAMMATION: lymphocytes, mϕ, PMNs

 Hypertrophy of glands; goblet cells
 Thick BM
 Inflammation  remodeling  airflow limitation (?)

Chronic Bronchitis

Left and above:

note bronchial involvement with
gland hypertrophy Bronchial inflammation

Emphysema
Emphysema: Abnormal and permanent enlargement of
 airspaces distal to terminal bronchioles
 accompanied by destruction of their walls
 without obvious fibrosis

Centriacinar emphysema: respiratory bronchiole

Panacinar emphysema: alveolus & duct

Morphologic types
of emphysema
 Centriacinar (centrilobular)
 Panacinar (panlobular)
 Paraseptal (distal acinar)
 Irregular
(very commonly overlap)

9
 Centriacinar Emphysema
Features
 Respiratory bronchiole affected
 Normal alveoli
 Upper lobes ( worst in apical segments)
 Black pigment in wall commonly
 Can involve alveoli if severe
(DDx from panacinar may be impossible)
 Predominantly in smokers (also coal workers)

Subpleural bullae common (can rupture  pneumothorax)

Upper lobes 
anthracotic
pigment
deposited in
scarred
terminal
bronchioles

Center of acinus (respiratory bronchiole)

affected; spared rim around outside
Inflammation around bronchioles

 Bleb: separation of pleural layers

 Bullae: subpleural destruction of lung tissue

Above: subpleural bullae common

(gross on left, big air space on LM on right).

Panacinar Emphysema

 Entire respiratory lobule affected (terminal bronchiole to alveoli)

o See picture: no sparing of rim, bigger spaces than centriacinar
 Lower zone & anterior margins (worst at bases)
 Associated with alpha-1 antitrypsin deficiency

Paraseptal emphysema
 Distal portion of acini affected
 Adjacent to pleura, lobular septae, at margins of lobules
 Also seen adjacent to fibrosis, scarring, atelectasis
 Upper half of lung = more severe
 Multiple confluent airspaces
o See picture: larger, cyst-like spaces
 Most likely frequent cause of spontaneous pneumothorax in young adults
o (usually tall thin males)

10
 Irregular emphysema
 Acinus irregularly involved
 Usually associated with parenchymal scarring
 Very common; often asymptomatic

Pathogenesis of Emphysema
• Alveolar inflammation: ↑↑ PMNS & Mϕ
• Protease/antiprotease imbalance
– Neutrophil: source of elastase
– Macrophage: source of metalloprotease
– Loss of antiproteolytic proteins:
alpha1 antitrypsin deficiency
• Alveolar cell apoptosis
• Oxidative stress: interaction with others

He had a summary table at the end of his notes; there were so many corrections made verbally in lecture that it seemed useless.

11
 Pulmonary Vascular Disease
Pulmonary & Bronchial Arteries: Dual Blood Supply to Lungs
Pulmonary Arteries: carrying deoxygenated blood from heart to lungs
In order from proximal (near hilum) to distal (alveoli):
Type of
Size Description Pictures
artery

6 mm – 500 microns Similar to main pulmonary arteries, aorta

Elastic (Largest)
Left: normal stain; Right: elastic stain (see elastic fibers)

Similar to systemic muscular arteries but:

 double (internal & external) elastic lamina

500-70 microns Only pulmonary vessels that can regulate blood flow
Muscular (Medium) via vasoconstriction

Left: M = muscular media layer.

Right: I = internal elastic lamina, E = external elastic lamina

Medial (muscular) layer thins out / disappears

 (around 70 microns)
Non- <70 microns
(Smallest) Acquire pericyte layer (important endothelial functions)
Muscular
M: muscular medial still present; N: more distally, non-
muscular artery (muscular layer disappears)

Bronchial Arteries: systemic muscular arteries, arise from aorta

 Enter lung either by accompanying airways or coursing over pleural surface (enter peripherally)
 Anastamose with pulmonary arterial system
12
 Pulmonary Hypertension
Defined hemodynamically (not by clinical Sx or pathology): Definition of Pulmonary Hypertension
Mean PPA > 25 mm Hg (rest) or >30 mm Hg (exercise)
Why is it bad?
 Need low perfusion pressure or fluid pushed out into interstitium  Mild-moderate: 25-45 mm Hg
(pulmonary edema)  Severe: > 45 mm Hg (systemic pressures)
 RIGHT HEART FAILURE most common cause of death in pts with severe PAH

Path findings
 Pulmonary vascular remodeling (intima, media, adventitia changed) – depends on severity & size of artery

INTIMAL THICKENING – looks like atherosclerosis

Large  Foamy Mϕ accumulate in intima  calcification
pulmonary arteries  Myofibroblasts surround Mϕ

(>500 microns, elastic) Atherosclerotic lesions:

 correlate with long term severe ↑ PPA but not used to Dx (not very specific)

Either smooth-muscle based or endothelial-cell based M: marked enlargement of muscular

media (should be ≈ 10% diameter)
Smooth-muscle-cell based remodeling
 present irrespective of PPA level, also in normal
individuals or pre-HTN!
Medium  In both mild and severe PAH
pulmonary arteries
Arrow: plexiform lesion (at branch
(500-70 microns, point; can see plexus of little vessels
muscular) – endothelial proliferation causes
Plexiform lesion: a type of endothelial cell growth
this.
 Often at branch points from larger arteries
 In SEVERE PAH ONLY (NEVER NORMAL or mild PAH)
May see vascular dilation or
 PATHOGNOMONIC FOR SEVERE PAH angiomatoid lesions nearby

13
 Classification of Pulmonary HTN
1. Pulmonary Arterial Hypertension
a. Idiopathic (think young women 3:1 vs men) Mild/moderate PAH Severe PAH
b. Familial  COPD  Idiopathic
c. Associated with other diseases (same vascular morphology in the lung as idiopathic PAH:  ILD  Collagen vascular Dz
congenital systemic  pulmonary shunts, HIV, collagen vascular disease, liver disease and others)  Sleep apnea  HIV infection
2. Pulmonary hypertension with left heart disease  Congenital heart
3. Pulmonary hypertension associated with primary lung disease and/or hypoxemia malformation (LR shunt)
4. Pulmonary hypertension due to chronic thrombotic and/or embolic disease  Sarcoidosis
5. Miscellaneous

Other Path Findings (chronic obstructive lung diseases, primary interstitial lung dz like IPF, etc.)
Disease processes Picture
This artery shows both medial
hypertrophy (M) and fibro-intimal
hyperplasia (F) with fibroblasts &
 Muscular hyperplasia myoblasts.
Vascular Anything that ↑ pressures
remodeling (remodeling is response)
 Fibrous intimal thickening Can see both, or just one

Emphysema: lose capillary bed with

destruction of parenchyma
 Emphysema
Capillary bed loss
 Interstitial lung disease

Arteries this far out (<70 microns)

aren’t supposed to have smooth
muscle!

Abnormal muscularization of COPD, Stained with smooth muscle actin

distal pulmonary arteries esp. chronic bronchitis immunostain

14
 Pulmonary Emboli
Epidemiology: about 600k/yr, most from lower leg

PE usually doesn’t cause pulmonary infarction (dual blood supply; would need double infarct) but can if…
 ↓ LV function or CHF (not perfusing bronchial circulation)

Acute: e.g. saddle embolus:

 can dislodge from lower leg / right heart  stick in pulmonary artery branch point
 Complete occlusion  RH dysfunction  arrhythmia, sudden death

Chronic thromboemboli:
 Can lyse, be incorporated into intima, or become recanalized (restore blood flow)
 If multiple pulmonary arteries: superimposed pulmonary HTN  see vascular remodeling as above Saddle embolus wedged in PA branch point
o Need >80% arteries blocked
 Path findings
o Thickening of intima & lumen
o Fibrotic bridges in vascular lumen (organization of previous thrombi)

Emboli that aren’t thromboemboli

 IV drug use: can have emboli of matrix / “filler” used in prescription drugs
o Microcrystalline cellulose, etc.
 Carcinomatous emboli: can (rarely) be numerous enough to produce pulmonary HTN
 Amniotic fluid emboli in pregnancy

Re-canalized emboli: can see that new channels

IV drug use embolus: see foreign body giant cell reaction in muscular pulmonary arteries (left); have formed
with polarized light, see a crystalline reflective substance (filler from drug)

15
 Pulmonary Neoplasia
Notes on terminology: MORPHOLOGICAL VARIANTS OF LUNG CANCER
 Small cell vs non-small-cell-  Squamous cell carcinoma
lung-cancer: previously didn’t  Adenocarcinoma
distinguish between NSCLC  Small cell carcinoma
because treatment was the same;
 (pulmonary carcinoid)
now need to subtype
 Large cell lung cancer: probably Derived from airway epithelial cells
poorly differentiated squamous cell carcinoma or adenocarcinoma

Squamous Cell Carcinoma

Histology: squamous differentiation
 Moderate to poor differentiation MAJOR FEATURES
 Nests of cells, keratization / intracellular bridges  > 95% in smokers
 Large tumors: necrotic centers  Involve LARGE AIRWAYS
o Can use bronchoscopy to visualize & Bx
Cytology:  More centrally located
 Hyperchromatic nuclei
 Variable keratinization (depends on differentiation) in cytoplasm

Around central airways Nests of cells, keratinization, whorls, intracellular bridges

Also see squamous metaplasia in other airways (widespread tobacco smoke injury) 
 Carcinoma can develop from sites of in situ squamous carcinoma / dysplasia

Adenocarcinoma

Glandular carcinoma, more heterogeneous than squamous cell carcinoma

Histology:
 IRREGULAR gland formation
 +/- mucin secretion MAJOR FEATURES
 > 80% in smokers (non-smoker with
Cytology: lung cancer: think adenocarcinoma)
 Round / oval nuclei  Involve SMALLER AIRWAYS
o Use transthoracic needle biopsy
 Prominent nucleoli
 More peripherally located
 Less hyperchromasia than squamous cell

16
 Can’t differentiate grossly

Some have a papillary differentiation (see bottom right)

Glandular appearance

Bronchoalveolar Carcinoma
 “Lepidic” growth pattern – like butterflies on a tree
(malignant cells on alveoli) MAJOR FEATURES
 Can grow extensively through lungs (mimic pneumonia)  Variant of adenocarcinoma,
 If confined to small area/nodular: resect  Uncommon but only 50% in smokers
 Involve peripheral lung
 Can have focal BAC in adenoCa
 Malignant cells grow along alveolar
walls without invasion

Alveolar walls well preserved, less fibrous Malignant cells growing along
stroma / tissue reaction alveolar walls

Atypical Adenomatous Hyperplasia (AAH)

 Most often seen in adenocarcinoma
 Not really hyperplasia (term used incorrectly)
 8mm or less in peripheral lung, often multiple
 Like bronchoalveolar carcinoma but just smaller (size is only difference)

Controversy: is AAH pre-invasive precursor to adenocarcioma?

Yes
 Looks like BAC / BAC-like areas of
adenocarcinoma
 Molecular changes of adenocarcioma
 Seen in pts with adenocarcioma
No
 Frequency of recurrence no higher in
pts with AAH
 Limited follow up  no evidence of
progression to adenocarcinoma

No longitudinal data is convincing at this point

17
 Large Cell Carcinoma
Probably just adenocarcinomas or squamous cell carcinomas that
aren’t differentiated enough to allow histologic classification
MAJOR FEATURES
 Mostly in smokers
 ↓ LCC Dx with ↑ use of IHC
 Airways of all sizes / locations
Can have giant cell (large, bizarre cells) or neuroendocrine differentiation  LARGE, AGGRESSIVE tumors
 Signals poor prognosis if one of these variants

Huge tumors Poorly differentiated, larger cells Highly abnormal nuclei

Non-small-cell lung cancer

Applies to all of the above; use IHC now to subclassify because chemo protocols differ between these types

Small cell carcinoma of the lung

Histology & Cytology:
 Small cells, somewhat look like lymphocytes
MAJOR FEATURES
 ↓ cytoplasm with relatively large hyperchromatic nuclei  >95% in smokers
o “Salt / pepper” finely granulated chromatin  Large, central airways
 ↑ mitotic figures / apoptosis; large tumors  necrosis  Neuroendocrine differentiation
 Little stromal response  HIGHLY AGGRESSIVE

HIGHLY AGGRESSIVE  METASTASIZE WIDELY

 On diagnosis, assume that it’s already metastasized (non-resectable) even if small & no mets recognized

Smaller cells with “salt-pepper” type of chromatin (finely Can have COMBINED small cell / non-small-cell carcinoma
granulated); lots of mitoses (aggressive) Left: SCLC + adenocarcinoma; Right: SCLC + squamous
carcinoma

Small cell carcinoma might be epithelial in origin (combined small cell / NSCLC variants – differentiated differently?)
If combined SCLC / NSCLC: might only get one type on Bx!

18
 Carcinoid Tumors
 Usually central (involve airway)
 Presentation: bronchial obstruction
 NEUROENDOCRINE differentiation
 DOES NOT PROGRESS to small cell lung cancer (although may look similar – neuroendocrine differentiation)


Occluding bronchial lumen Small, round cells without many mitoses (not SCLC)
Organoid pattern: stroma + capillaries between ball-like tumor
cell collections: like in normal neuroendocrine organs (adrenal
medulla, parathyroids, etc.) – also neuroendocrine marker +

Atypical carcinoids: invasion & atypical features

 Can recur locally or metastasize
 Still DOESN’T PROGRESS to SCLC Atypical carcinoid

Patterns of Invasion & Metastasis

Lung cancer metastasizes…

 Directly to adjacent tissues (pleura & mediastium)

 Lymphatics: LN, brain, bone, liver, adrenals

 Hematogenous / aerogenous spread more rare

Staging
Clinical staging: assessment of radiographic studies
Pathological staging: examination of tissue

Important for predicting survival

 VERY POOR (both NSCLC + SCLC)
o Only 60% at 5 yrs for stage 1!
o Stage IV (distant met)  almost nobody at 2 yrs

19
 Molecular Stuff
 p53 mutation common in all variants (more aggressive)

Adenocarcinoma: generally have either EGFR or KRAS (not both)

 Epidermal Growth Factor Receptor (EGFR) mutations EGFR mutations

o inhibition helps shrink tumor (oncogene addiction)  Women, Asian descent, non-smokers
o Especially in adenocarcinomas with bronchoalveolar features
 Almost exclusively adenocarcinomas
o Can also be amplified (mostly squamous diff) but not good
 Response to EGFR inhibitors (Erlotinib)
clinical response to EGFR inhibition
o Erlotinib (EGFR inhibitor): response is good, but doesn’t correlate with improved survival

 KRAS: mutated in subset of adenocarcinomas; exclusive of EGFR mutations

o No response to EGFR inhibitors

Paraneoplastic syndromes in lung cancer

Lung cancer can present first with other systemic sx
 General: fever + cachexia
 Endocrine syndromes:
o SIADH
o ectopic ACTH
o hypercalcemia (PTH-like substances)
 Neurological paraneoplastic syndromes; Dermatomyositis
 CLUBBING (hypertrophic osteoarthropathy) – see picture
o Pathophysiology: not well understood; maybe growth factor related?

Detection
Sx: only in advanced stages of disease (metastasis / paraneoplastic syndromes)
 Primary cancers (cough / hemoptysis) = advanced too
 Means survival is down (worse stage IV vs I, although both are bad)

Early detection: detect it while treatable

 X-ray & sputum cytology: tried it, didn’t improve survival
 High res CT is all the rage now
o One uncontrolled study found good outcomes
o Mayo clinic looked at it vs before high-res CT: ↑ detection,↑ resection, but survival & advanced cases the same!
 Lessons:
o Can’t detect highly aggressive cancer in “window of opportunity” for Tx
o Treating indolent (non-aggressive) lung cancers doesn’t ↑ survival (and more risk from procedure!)
o May be overtreating some indolent cancers!

Diagnosis
Depends on location of tumor; anything you see on radiography needs to be confirmed with histology / cytology
 Sputum cytology Centrally located cancers
 Bronchial brushings (e.g. squamous cell, exfoliates a lot of cancer cells into airways, can get with sputum)
 Bronchial biopsy (if needed) (SCLC central too)
 Trans-thoracic needle biopsy / aspirate Peripherally-located cancers (e.g. adenocarcinoma)
 Open lung biopsy (if needed) that are inaccessible via bronchoscopy

20
 Cigarette Smoking and Lung Cancer
Smoking causes cancer (surgeon general – 1964; first reports in 50s)

Tobacco Master Settlement (1988)

Good Bad
 $246B to states  States rely on tobacco settlement funds
 ↑ warnings (can’t hurt companies too much)
 ↓ advertising  $11B in legal fees

The Changing Cigarette (or, why ↑adenocarcinoma and ↓ squamous cell carcinoma)

Change Supposed to In Reality End Result

↑ stems
↑ nitrates (NNK) – specific for adenocarcinoma in lung ↑ adenocarcinoma (↑ NNK)
and ribs
↓ smoke ↓ PAH (polycyclic aromatic hydrocarbons) from tar but ↓ squamous cell carcinoma (↓ PAH)
Filters (mainstream), smokers cover vent holes, puff more frequently, and ↑ exposure of peripheral lung & more
Trap tar increase puff volume to ↑ nicotine exposure to NNK (breathing deeper, etc)

NOW: ADENOCARCINOMA IS THE MOST COMMON LUNG CANCER IN BOTH SMOKERS AND NON-SMOKERS

Other causes of lung cancer

Etiologic agents Comments
Cause of lung cancer in occupationally exposed individuals; appears to be synergistic with
Asbestos
cigarette smoking
Demonstrated as cause in uranium miners, where it was shown to be synergistic with smoking.
Radiation
The role of low-dose radon exposure in homes is not well established.
Indoor smoke associated with lung cancer in China.
Air pollution
Severe urban air pollution may also increase incidence.
Genetic predispositions Only rare families show linkage that suggests a genetic predisposition
Arsenic/ chromium High exposure limited to few individuals

Mesothelioma
 >80 associated with ASBESTOS EXPOSURE
 Glandular or sarcomatous differentiation
 Pleural lesions (mesothelium) – see picture
 Poor prognosis
 2k pts / yr (vs 200k for conventional lung cancers)

Metastatic Carcinoma
 Lots of other cancers like to metastasize to the lungs
 Frequently MULTIPLE METASTATIC WELL-DEFINED NODULES
o (vs single & invasive for primary lung cancer)
 Pleural lymphatic spread common too

21
 Lung Infections
1/6 of all deaths in US every year! Why?
 Large surface of alveolar space exposed to contaminated air TYPES OF PNEUMONIAS
 Aspiration (nasopharyngeal flora)
 Effects of other disease on immune system Gross Classification (CXR)
 Lobar vs bronchopneumonia
Bacterial Pneumonia Etiological Classification (clinical)
Classification:  Community-acquired (CAP)
 Lobar & bronchopneumonia  Nosocomial (hospital-acq, HAP)
 CAP (community-acquired)  Aspiration pneumonia (bacterial & chemical)
 Pyogenic pneumonia Atypical pneumonia
 (uncommon bacteria & viruses)
Pathogens
Chronic pneumonia
 Strep or pneumococcus pneumoniae
 (fungi, uncommon bacteria – nocardia)
 Also staph, pseudomonas, gram neg bacteria

Clinical picture:
 Abrupt onset of fever, chills, productive mucopurulent cough, pleuritic chest pain.

Diagnosis: blood cultures

Acute Bronchopneumonia
 PMNs are key cells
 Not limited by line of demarcation (fissure)
between two lobes

Lobar pneumonia: limited by fissures Acute Bronchopneumonia

 Similar microscopically to broncopneumonia
4 morphological stages of lobar pneumonia
 vascular congestion and edema
1. Congestion
 heavy lungs, frothy material on compression
2. Red hepatization  exudate formed by polys; fibrin and clotted RBCs in alveolar spaces
(consolidation)  liver-like consistency
 RBCs break down; exudate remains
3. Gray hepatization
 gray-brown dry surface
 consolidated exudate enzymatically digested
4. Resolution
 debris resorbed, ingested, or coughed up; normal structure

Early pneumonia: fibrin Fluid, prominent Advanced organizing pneumonia: lung trying
PMNs, Mϕ cleaning up
exudation into alveolar capillaries, cells into to heal; like granulation tissue. Fibroblast foci
debris now
spaces alveolar spaces (lighter texture, lots of spindle-like fibroblasts)

22
 The Pneumonia Syndromes
 Community Acquired Acute Pneumonia (bacterial)
 Chronic Pneumonias (mycobacteria, granulomatous)
 Community Acquired Atypical Pneumonia (viral)
 Necrotizing Pneumonias & Lung Abscess
 Nosocomial Pneumonias (bacterial)
 Pneumonia in the Immunocompromised Host
 Aspiration Pneumonia (bacterial & chemical)

Complications of bacterial pneumonia

 Abscess
 Empyema (pus / exudate in pleural space)
 Organization of exudate with fibrosis
 Bacteremia with dissemination of organisms to heart valves, brain, etc.
 Pleuritis
 Pleural effusion
Empyema
 Bronchopleural fistula (fibrin, pus exudate:
pleural surface of lung)
Viral / Atypical Pneumonias
A.k.a. Primary Atypical Pneumonia; more accurately interstitial pneumonitis
Clinical Course
Why atypical?  Variable, usually mild
 Lack of consolidation (alveolar exudate)  Fever, headaches, possible dry
cough
 Lack of sputum production
 Significant respiratory distress*
 Predisposes to bacterial infection
Acute febrile respiratory disease with patchy inflammatory changes in lung  Treat empirically
 Largely confined to septae & interstitium  Usually resolves without sequelae

Primary Atypical Pneumonias

Coryza (“cold”) Lots of nasal discharge & pharyngitis (various viruses)
Mycoplasma Most common cause (“walking pneumonia”)
 Children, young adults; epidemics in schools, military camps, prisons, hospitals, etc.
 Bad, persistent cough
Chlamydia #2 cause
Other Influenza A & B, RSV, adenoviruses
More on atypical pneumonias:
 Patients: early childhood, or immunocompromised pts of any age
 Pathogenesis: NO PUS
o Attach to resp epithelium  necrosis of cells / inflame response  interstitial inflammation (if extend to alveoli)
 Course: Resolve spontaneously ± erythromycin if mycoplasma or chlamydia
o Severe (rare): can  ARDS (50% fatal)
o Damaged epithelium  predisposition to 2° bacterial infection‼!
 Sputum: cleargreen/yellow, think bacterial superinfection
 Sx/findings: can present as URI (“common cold”) or more severe LRI
o Headache, fever, cough, patchy infiltrates on CXR
 Rx: mycoplasma & chlamydia w/ erythromycin or other abx
 Histopath: Intersitial pneumonia with mononuclear infiltrate (DAD if very severe)
Atypical Pneumonia: Path

23
 Thickening of alveolar Interstitial pneumonia with RSV: characteristic giant cells
Interstitial Pneumonia.
wall; no PMNs diffuse alveolar damage:
MONOnuclear infiltrate:
HYALINE MEMBRANES form,
Mϕ & lymphocytes in interstitium
↓ gas exchange
(not PMNs)
(ARDS is correlate)

Severe Acute Respiratory Distress: SARS

March 2003, Guangdong province, China

Sx: Dry cough, malaise, myalgias, fever, chills
Course: 1/3 resolve, remainder  severe resp dz; 10% die
Cause: previously undiscovered coronavirus (unique: infects lower resp tract  spreads throughout body)
Transmission: civet  human, now humanhuman via resp secretions
Dx: PCR to detect virus, antibodies

Pathology: DIFFUSE ALVEOLAR DAMAGE with GIANT CELLS (resembles ARDS)

Aspiration Pneumonia
Patient: markedly debilitated (unconscious, stroke victims, alcoholics, repeated vomiting)
 Abnormal swallowing & gag reflex

Mixed chemical + bacterial pneumonia

 Gastric acid, enzymes  lung damage (edema + bleeding)
 Necrotizing: very serious!; Bacteria can grow
 Goes to dependent position (GRAVITY)
o Lower (upright) or Middle (laying down) right lobe
 R bronchus is straighter down
 LUNG ABCESSES common!
 Can see gastric contents or foreign body giant cell rxn (see picture)

Chronic Pneumonia
Think NOCARDIA: #1 for chronic pneumonia!

 Weakly staining Gram + rod-shaped bacteria;

forming partially acid-fast beaded branching filaments

24
 Tuberculosis
M. tuberculosis is causative agent; chronic, communicable dz
 Slender, acid-fast rods (lots of lipids  resist decolorization) Granulomatous Infection DDx:
o Stains: carbol fuschin & decolorize with alcohol;  TB (+ atypical mycobacteria)
fluorescent (auramine-rhodamine) more sensitive  Fungal infections
 Drug resistance is big problem

Epidemiology: 1.7B infected, 1.8M deaths, 6% of all deaths worldwide!

Uncommon in US, 20x↑ in poor countries
↑ infection in costal SC; ↑ in immigrants (Hispanic/Asian countries  40% new cases) ↑ with AIDS (now↓ in US)
Transmission: Inhalation of infected droplets (cough/sneeze) or exposure to resp secretions (reservoir: humans with active Dz)
At-risk: debilitation, immunosuppression, elderly
Geography: poverty / crowding / chronic illness PPD (purified protein derivative)
 Intradermal injection
 Rxn peaks at 48-72 hrs
Course: having “TB” doesn’t mean disease necessarily  Measure size (not redness) of induration
 >5mm = positive
 Primary infection: causes minor reaction
(cell-mediated hypersensitivity to TB Ag in pt)
o Delayed hypersensitivity develops
(detect with PPD 2-4 weeks after infection)
 15M positive in US
(5-10% US pop; 23K new active cases-yr – after
o Well formed granulomas, caseation necrosis, PPD + conversion, 3-4% acquire active TB in 1 yr, <15%
thereafter)
 Reinfection or Reactivation of existing, walled-off infection 
serious disease False Negative PPD: IMMUNOSUPPRESSION
(anything that causes anergy)

Path: Necrotizing granulomatous caseating response (ddx vs fungal)

Miliary TB (multiple Left: Necrotizing caseating granuloma Acid-Fast

caseating granulomas) Right: histiocytes, multinucleated (Langerhan’s) giant cells

TB: Course

Immunity: expose naïve immuncompetent person to TB

 Mediated by T-cells, hypersensitivity and resistance develop in parallel
 Hypersensitivity: allows fast mobilization of rxn but ↑ tissue necrosis
o If hypersensitivity ↓, means resistance has faded
o No necrotizing granulomas in HIV!

First infection: 1° TB
 Inhalation  lung  proliferates in mid-lung subpleural location
 Taken up by pulmonary alveolar Mϕ
25
 o Some Mϕ degrade / present mycobacterium  hypersensitivity
o In others, phagolysosome inhibition  survives & proliferates in Mϕ  regional lymph nodes
 < 3wks: unchecked proliferation in Mϕ & airspaces (bacteremia!)
Ghon lesion:
 3wks post infection: well formed granulomas, caseation necrosis, PPD + initial focus of 1° infection
o Mϕ present to T-cells  TH1  secrete IFN-γ  activate Mϕ  NOS, TNF
 ROS (kill bacteria/ cells)  caseous necrosis, tissue destruction Ghon complex:
 TNFα  monocyte recruitment  diff to Mϕ  granulomas Ghon lesion + lymph node

Implications of 1° TB
 Hypersensitivity, ↑ resistance; can harbor viable bacteria (later reactivation)
 Can progress without interruption (progressive 1° TB)
o Immunocompromised (esp HIV+, certain racial groups)
o Can’t mount cell-mediated response
o Can resemble acute bacterial pneumonia: (consolidation, pleural effusion,
hilar adeopathy)
o Lymphohematogenous dissemination: rare & bad
 TB meningitis, miliary TB, death possible

Reactivation (2° TB)

 From previously sensitized host (5% 1° infection  2°, decades later)
 Can be from reinfection too (↓ immune, ↑ inoculum)
 Location: APEX or APICES of upper lobes (↑ O2 tension)
 Clinical: Cough, malaise, afternoon fever, night sweats, weight loss, anemia, fatigue
o Can cough up organisms, spread disease; 25% mortality if untreated
 Immune system is all jacked up & ready to go: big destruction of tissue

Manifestations & complications of 2° TB

 Tissue necrosis (lots of granulomas ± cavities)
 Miliary TB: erode into bloodstream; granulomas in many organs
 Hemoptysis: erode into airways
 Bronchopleural fistula: subpleural cavity ruptures into pleural space
o Empyema, pneumothorax can result
 Intestinal TB: from swallowing bacilli

Mycobacteria other than TB

M. bovis (unpasteurized milk: oropharyngeal, GI tract infections)
M. avium-intracellularae (MAI), often in AIDS
 Most common atypical mycobacteria
M. leprae, others; M. bovis & M. TB hominis are obligate aerobes

Common features:
 Immunocompromised pts
(AIDS, cancer, BMT)
 Poorly formed granulomas, fibrosis

Poorly formed granulomas MAI overwhelming Mϕ

(immunocompromised pts) 26
 Fungal Pneumonia
 Mostly inhaled  Necrotizing granulomatous inflammation (like TB)
 Cell-mediated immunity  Stain: GMS or D-PAS
Fungal Pathogen Features Pictures
Pt: chronic dz / immunocompromised

Invasive, saphrophytic, allergic

 Saphrophytic: feed off dead stuff
 why they can form fungal balls!
Aspergillus
Cx usually negative (need Bx)

Hemmorhagic infarction with sparse inflammatory infiltrate Aspergillus infection with Aspergillus ball 45° branching septate hyphae
Hyphae: invade blood vessels & alveolar septae infarction

See vegetative forms (hyphae+ pseudohyphae + yeast)

Candida
 means it’s not a contaminant!

Yeast, Hyphae, and Pseudohyphae

Southeast US (caves in Mississippi Valley)

 caseating, necrotizing granulomas
Histoplasma
Tiny organisms multiply in Mϕ (see pic)

Southwest US
Coccidiomycosis
Forms spherules (see pic)

27
 Has a MUCOID CAPSULE
 shows up as empty space on normal stains
 can stain with special stains
Cryptococcus
Important in AIDS pts

Variable sizes

Double-walled appearance
Blastomycosis
+ acute inflammation

Pneumocystis Pneumonia

Pathogenesis:
 Hypoxia, restrictive defect
 Reproduces in association with Type I pneumocytes
 Active disease: lungs only
o trophozoite feeds  enlarges  transforms to cyst form
o Cyst ruptures, new trophozoites released, attached to alveolar lining cells

Pathology: Interstitial pneumonitis with intra-alveolar exudate

 Heavy firm lung (can cause DAD)
 Organisms: look like “CONTACT LENSES” on silver stain

Clinical Presentation:
 Can have minimal symptoms or fever, dyspnea, dry cough
 Can progress to respiratory failure (alveolar filling on CXR)

Dx: BAL, tranbronchial bx, IF, PCR

Formerly a major problem / often fatal in AIDS pts

 Now use prophylactic aerosolized pentamidine to prevent (other cases not so bad)

28
 Lung Development / Pediatric Lung Disease
Lung Development
Lung: foregut derivative
Week Name What happens
th
26 day Lung appears: bud from caudal end of laryngeotracheal sulcus
0-5 Embryonic period Lung buds form lobar bronchi, major segmental branches
5-16 Pseudoglandular period Bronchial branching continues, cartilage develops
20 Surfactant production starts in type II pneumocytes
24-26 Surfactant sufficient to provide lung stability (ABCA3 produced, etc)
25 Thin air-blood barrier formed; theoretically can maintain respiration
26 - term Terminal Sac / “ Alveolar” period Shallow distal airspaces develop

Birth – 4 years Alveoli continue to ↑ in number

4-8 yrs Alveoli ↑ in size as chest wall grows (also ↑ number)

Three Laws of Lung Development

1. The bronchial tree is developed by the 16th week of
intrauterine life
2. Alveoli develop after birth
a. They increase in number until 8yo
b. They increase in size after 8yo until chest wall stops
growing
3. The development of pre-acinar arteries corresponds with
the development of airways

Fetal lung in glandular stage; lobes established already

Left: Glandular structures (arrowhead; will eventually connect to trachea) surrounded by thoracic mesenchyme (arrow).
Center & Right (LM & EM): close up; see all glycogen (arrow) but few organelles in glandular cells = haven’t differentiated yet

th
After 16 week: bronchial tree has developed Later: closer to term. Alveoli have subdivided over &
Couldn’t breathe yet over, connect to airways. Blood vessels from
(airways=arrows, airspaces=arrowheads are separate) mesenchyme have invaded alveolar walls

29
 Surfactant
 Made by type II pneumocytes (produced, stored in lamellar bodies, secreted)
 ABCA3 protein involved in transport of material into LB
 Note that capillaries really wander back and forth across septae (not in middle) – from one side to other

LB secreted (phospholipids,
SEM from inside capillary TEM of alveolar septa; note capillary Lamellar bodies in type II
etc)  ↓ surface tension in
Arrow : type II pneumocyte wandering back and forth between pneumocytes
lung!
Arrowheads: capillaries adjacent alveoli

Why surfactant?
 There’s an air liquid interface (starling forces  leak out liquid), so 
 alveoli want to collapse

LaPlace’s Law
 The smaller an alveolus gets, the smaller it wants to be
 Alveolar stability due to tissue forces (elasticity – tethering) and alveolar lining layer
 Surfactant especially important in newborns
o 2/3 of alveolar stability provided by surfactant in newborns, ↓ in adults

What happens at birth?

Lung isn’t “collapsed” in utero: filled with fluid
 Intrauterine “respirations” keep amniotic / pleural fluid in contact
o (check amniocentisis to see lethicin levels  assess lung maturity!)
 At birth: empty fluid & fill with air
o ↑ RV with subsequent breaths (need surface tension ↓ via surfactant)

Transient tachypnea of newborn

 Retain fluid (don’t expel at birth) – cloudy CXR
 Gone by the enxt day

Respiratory distress in the Newborn

Idiopathic Respiratory Distress Syndrome is #1 for morbidity and mortality
 Also infection, CV/CNS disorders, etc – not just ARDS (bigger DDx)

For: newborn respiratory distress syndrome

Think: premature vs term? (IRDS vs meconium aspiration)

30
 Idiopathic Respiratory Distress Syndrome
A.k.a. “hyaline membrane disease” (older name; infections / other causes of alveolar damage can also produce path findings)

Basic cause: deficiency of effective pulmonary surfactant  lung instability

 Immaturity (failure of production), failure of release, abnormal structure / function of surfactant, or combo
 Not really idiopathic!

Infants at risk for IRDS

 Premature infants  Second born of twins
(appropriate size/wt for gestational age) (maybe not paying attention during delivery?)
 Males > Females  Genetically determined disorders of surfactant system
 Whites > Blacks o Surfactant associated proteins
 History of previously affected premature o ABCA3 mutations / inactivity
 C-section < 38 wks with mother not in labor (transport of material into lamellar bodies – LBs are
 Infants of diabetic mothers weird shapes, etc.)
Lack of stress may be important- stress in mother  ↑ steroids, etc.

Path findings:
 Abnormal pattern of lack of expansion in lung
 Distal airspaces collapsed
 Distal airways dilated & lined with hyaline membranes (eosinophilic)
o Looks like DAD in ARDS! From cellular debris from alveolar lining
 Septal lymphatics dilated ± focal hemorrhage, edema

CXR: Ground glass appearance with air bronchograms

Complications:
 Development of PDA (reopen / fail to close)
 Bronchopulmonary dysplasia
 Interstitial emphysema (pulmonary alveolar air) & sequelae

Treatment of IRDS:
 Artificial surfactant; Give O2 + mechanical ventilation

Lung: all collapsed, looks like liver IRDS: most of lung collapsed with hyaline membranes (like DAD + collapse)

Alveolar ducts are main damage site Genetic surfactant protein deficiency
(rest is collapsed) Lots of proteinaceous material / Mϕ
31
Bronchopulmonary Dysplasia – complication of treatment for IRDS
All you need to know from this part: bronchopulmonary dysplasia is a complication of treatment for IRDS

“Old” BPD: 28-32 wks gestation, complication of RDS & “New” BPD: <28wks, may be complication of RDS treated
treatment (high O2, vigorous +-pressure ventilation) with surfactant (or premature birth)
 Structural damage to airspaces, airways w/ fibrosis  Development / growth abnormalities in lung:
↓ alveoli, simplified alveoli

“old type”BPD with interstitial fibrosis “New type” BPD with collapsed areas, big open
areas, simplified alveoli

Pulmonary Interstitial Air

A.k.a. “pulmonary interstitial emphysema”
E.g.: Infants with IRDS ± BPD
 Air gets out of airspaces into interstitium
 Lung can pop  pneumothorax if air dissects out the whole way to edge of lung
o Pneumothorax: see pic to right

Not every infant with pulmonary interstitial air has IRDS

 Can have cystic congenital defects, etc, or with meconium aspiration syndrome
 pulmonary interstitial air may be more common than recognized but resolves on own
o 15% infants have a small
pneumothorax

Path findings:
 Cystic spaces around
bronchovascular bundles & septae of
lung (see pictures)
o Can misinterpret as “cystic
malformation”

AIR can produce a GIANT CELL REACTION!

 Don’t assume it’s a virus!

32
 Meconium Aspiration Syndrome
Meconium = fetal poop (green  bile formation)

Meconium Aspiration Syndrome

 Stress of childbirth  big respiratory intake burst  babies tend to inhale meconium
 Tends to happen in mature or post-mature (not premature) – more vigorous respiratory intake movements

Findings
 Green stained placenta
 Meconium in larynx
 Patchy infiltration on CXR (like aspiration + pneumonia)
 Mucus & squamous cells in bronchioles & other small
airways, etc. on path
o Mucus is key (squamous cells in any
cause of newborn respiratory death)

Mechanism:
 Mucus blocks bronchioles like ball valve
air trapping 
 Pressure builds up, can dissect out of alveolus,
get pulmonary interstitial air

Perinatal Pneumonia
CLASSIFICATION OF PERINATAL PNEUMONIA
Transplacental  Part of a systemic congenital infection (usually maternal origin)
 Present at birth
Intrauterine  Aspiration pneumonia (infected amniotic fluid)
Aspiration

 From organisms in maternal vagina

 Signs in 1st wk of life
Acquired during birth  Maternal vaginal infection usually (esp poor prenatal care)
 GBS can be rapidly fatal if untreated
 Signs in 1st month of life
Acquired after birth
 Organisms from environment (staph, pseudomonas, serratia)

Group B Strep is a big problem in neonates!

 Check pregnant mothers for colonization

 Toxin causes diffuse alveolar damage!

o See hyaline membranes with

blue color (organisms!) CXR: patchy infiltrate (here like PMNs in alveolar spaces
bronchopneumonia)
o Pleural effusions too (not
common in normal DAD)

Group B Strep: GBS: HYALINE MEMBRANES with GPC (right)

33
see pleural effusion here (GBS in setting of pleural effusion)
 Cystic Fibrosis
Autosomal recessive genetic disorder affecting multiple organ systems with protean manifestations

 CFTR: cystic fibrosis transmembrane conductance regulator (chr 7)

 Abnormal secretions  bacteria  damage, etc. (See chart)

 Mucociliary escalator messed up (abnormally hydrated mucus)

Causes of death: recurrent pulmonary infection, resp failure, cor pulmonale

 Many extrapulmonary features too
Earlier Later
Mucoid, alginate-producing pseudomonas mutants arise (harder to eradicate)
Mucus plugging of tracheobronchial glands
Burkholderia & atypical mycobacteria too
 Obstructs bronchi / bronchioles
 Infection follows  recurrent bronchitis,
Recurring bronchopneumonia  bronchiectasis
bronciolitis, pneumonia
 Parenchymal damage from bronchopneumonia 
scarring  retraction  dilate bronchi
Organisms: eventually can permanently colonize
 S. aureus
Lower resp tract problems:
 H. flu (less now with vax)
 Fibrosis around small airways
 Pseudomonas
 Interstitial chronic inflammation

Young CF pt: bronchopneumonia Older CF pt: accumulations of mucus, Bronchiectasis (B) – airways too big,
scarring, bronchiectasis too far out in lung. F = fibrosis too

Right:
Left: Pseudomonas
more bronchiectasis making a biofilm
in CF patient; clogged in abnormal
with purulent debris secretions (hard
to eradicate)

34
 Pathophysiology: Lung
Formulas to Memorize ............................................................................................................................................................ 2
Lung Mechanics Review .......................................................................................................................................................... 3
Reading a CXR ......................................................................................................................................................................... 5
Pulmonary Function Testing ................................................................................................................................................... 6
Interstitial Lung Disease ........................................................................................................................................................ 10
COPD ..................................................................................................................................................................................... 13
Pathophysiology of Asthma .................................................................................................................................................. 17
Expiratory Flow Limitation .................................................................................................................................................... 21
Pulmonary Vascular Disease ................................................................................................................................................. 24
Obesity & Breathing Disorders.............................................................................................................................................. 27
Ventilatory Failure ................................................................................................................................................................ 30
Acute Respiratory Distress Syndrome (ARDS) ...................................................................................................................... 34
Pneumonia ............................................................................................................................................................................ 37
The Pleural Space .................................................................................................................................................................. 44
Bronchopulmonary Dysplasia ............................................................................................................................................... 48
Cystic Fibrosis ........................................................................................................................................................................ 52
Disorders of the Lower Airways ............................................................................................................................................ 56
Upper Airway Disorders ........................................................................................................................................................ 61

1
 Formulas to Memorize
PAO2 Alveolar O2 tension
𝑷𝒂 𝑪𝑶𝟐
Alveolar gas equation: 𝑷𝑨 𝑶𝟐 = 𝑭𝑰 𝑶𝟐 × 𝑷𝑩 − 𝟒𝟕 − ( 𝟎.𝟖
) FIO2 Fraction inspired O2
PB Barometric pressure
 If on room air: simplify it! 𝑷𝑨 𝑶𝟐 = 𝟏𝟓𝟎 − (
𝑷𝒂 𝑪𝑶𝟐
𝟎.𝟖
) (corrected for water
pressure, - 47)
Use to calculate A-a difference (alveolar – arterial) PaCO2 Arterial CO2
 Normal values: < 20 on room air (20% O2) < 100 on 100% O2
 Increase: suggests venous admixture (poorly oxygenated blood reaching circulation)

Arterial Blood Gases: know normal values

pH 7.35-7.45
PaO2 80-100 mm Hg
PaCO2 35-45 mm Hg

2
 Lung Mechanics Review
Note: there’s probably way more to review than this lecture covered
Transmural pressure = pressure inside – pressure outside
Transpulmonary pressure (PL)= (alveolar pressure) – (pleural pressure) = elastic recoil pressure
Transdiaphragmatic pressure (Pdi) = abdominal pressure = pleural pressure
PBS = body surface pressure, Ppl = pleural pressure, PCW = chest wall pressure
So the pressure across the respiratory system is PL – PCW = (Palv – Ppl) – (Ppl – Pbs) =
 PRS = Palv - Pbs

Compliance: slope of the pressure-volume curve

 Compliance = ΔV / ΔP
 Elastance = 1/compliance
o high compliance = very distensible, high elastance means very stiff
o Compliance is better term
 Graph
o Note that compliance isn’t linear
 changes with volume (less compliant at higher volumes)
o Volume at zero transmural pressure: residual volume
(unstressed volume)

Unstressed volume (relaxation volume) Stressed volume

volume in an elastic structure when transmural pressure = 0 volume above the unstressed volume which distends the surface

Lung Compliance

 Note that RV is the volume that remains in lung at Tm = zero

 Lung is less compliant at higher volumes

Some disease processes make lung:

 more compliant (emphysema)
 less compliant (fibrosis)

What determines lung compliance?

 Tissue properties (elastin,
collagen, etc.)
 Surface tension: wherever an air-
liquid interface exists, there’s a net attractive force that tends to collapse the bubble
o Fill lung with saline: Less pressure needed to inflate (more compliant – no
surface tension)
o Surfactant: reduces surface tension & stabilizes alveoli
o ARDS: loss of surfactant = less compliant lung

Hysteresis: the compliance curve is different on inspiration vs

expiration
 Convention: compliance = expiratory compliance
 Why? Harder to inflate than keep inflated
o surfactant
o lung units close on exhalation & takes extra work to pop them back open
o tissue relaxes after time in stress & loses recoil

3
 Chest Wall Compliance

This curve only applies when chest wall TOTALLY RELAXED

 Don’t measure in pulmonary function lab – can’t totally relax
 Less compliant at lower volumes (rib joints, etc. limiting compression)

Note: chest wall; lung compliances are similar over range of breathing pressures

Note: chest wall wants to spring open; lung wants to collapse

Chest wall compliance disorders:

 E.g. fibrothorax; scarred, thickened pleura;
obesity too (less compliant)

Respiratory System Compliance

Compliances are in series so add reciprocals
 Makes sense: blowing up a balloon inside of another balloon would be harder than blowing up either one
 1/CRS = 1/CL + 1/CCW

How does this relate to FRC, RV, TLC, and all that stuff?
 See graph – just adding the pressures of CW & lung to get RS
 FRC: inward recoil of lungs = outward recoil of relaxed thorax
o Graph: chest wall pressure is same distance from zero as lung pressure
 RV: all airways are closed
 TLC: inward recoil of RS = outward recoil of maximally contracting
inspiratory muscles

Air flow dynamics

Resistance = pressure / flow
 What pressure is needed to generate flow?
 ↑ with turbulence, tube length, and DECREASING RADIUS
 ↓ with ↑ lung volume
 80% of resistance is in LARGE AIRWAYS (bigger than subsegmental)
o Remember, small airways have large total area

Flow patterns
concentric layers of air flow slipping past Resistance:
Laminar each other @ different velocities (faster in independent of gas density
middle)
Resistant: strongly
molecules tumbling around (still with a net
Turbulent vector in flow direction)
dependent on gas density
(↑ with ↑ density)

near bifurcations; areas with eddies

Transitional partially disrupt laminar flow

4
 Reading a CXR
Not on the exam; just a few pictures & concepts that seemed helpful

Assessing quality
 Not too much lung field above clavicle (bending over?)
 Should be able to just make out outlines of vertebrae through mediastinum (exposure good?)
Note: left hemidiaphragm “stops” (mediastinum & abdominal contents are same opacity)

Distribution
Masses (>4cm)?
 Upper or lower? Infiltrates? Effusions?
 Unilateral or bilateral?
Nodules (<4cm)?

Alveolar? Mixed?
Interstitial?
 Water
 Reticular (lines)
 Blood
 Nodular
 Cells
 Combined
 Pus
 Honeycomb
 Protein
 Ground glass
 Calcium

5
 Pulmonary Function Testing
Spirometry:
 Inhale to TLC
 Exhale as rapidly/completely as you can
 Measure exhaled volume vs. time

Results:
 FEV1 : Volume exhaled in 1st second
 FVC: total volume exhaled
 FEV1/FVC: fraction of total volume exhaled in 1st second (FEV1%)
o Normally ~0.8

Interpretation of Spirometry
Ventilatory defect: FVC FEV1/FVC

Restrictive ↓ Normal or ↑

Obstructive Normal or ↓ ↓

Common Causes Of:

Restriction Obstruction
Small / stiff Respiratory ↑ airway Increased airway
Small / stiff lungs ↓ lung recoil
chest wall muscle weakness resistance closure
Pulmonary fibrosis Kyphoscoliosis ALS Chronic bronchitis Emphysema Asthma

Flow-volume curves

Spirograms show expired volume and time; you can also plot
flow per time. Either way lets you calculate FEV1 and FVC

See chart to left

6
Can also have patient inhale as fast as possible
at end of spirometry to generate flow-volume
loop (see right)

Lesion Affects…
Upper airway inspiratory flow >
obstruction expiratory
expiratory flow >
COPD
inspiratory
Fixed obstructions (e.g.
could affect both
tumor around trachea)

Arterial Blood Gases

What can we assess from blood gases?
Oxygenation: hypoxia
Ventilation: hypo or hyper ventilation
Acid/base balance: nephrology
Arterial Oxygenation
Remember the oxyhemoglobin saturation curve
 Most O2 bound to Hb
 Saturation, O2 content change very little above PaO2 = 60mmHg
 Mix of blood with high and low PO2: dominated by low value
o E.g. mix 95% saturated blood ( 100mmHg) with 75% saturated blood (40 mm Hg) –
end up with 87% saturated blood (average) but because curve is sigmoidal, PO2 is
about 55 mm Hg (not an average!)

Clinically significant hypoxemia:

 Arterial Hb saturation of less than 90% (PaO2 60 mm hg)

Alveolar gas equation: memorize this: PAO2 = [FIO2 x (PB-47)] – (PaCO2/0.8) PAO2 Alveolar O2 tension
FIO2 Fraction inspired O2
 If on room air: simplify it! PAO2 = 150 – PaCO2/0.8
PB Barometric pressure
o Room air close to 20% oxygen (corrected for water
 Inspired [O2] changed by water vapor & CO2 pressure, - 47)
PaCO2 Arterial CO2
A-a gradient (i.e. who cares about the alveolar gas equation?)
 Calculate PAO2 (alveolar PO2) and compare it to arterial PO2 – are you getting oxygen from alveoli to arteries?
 Normal values: < 20 on room air (20% O2) < 100 on 100% O2
 Increase: suggests venous admixture (poorly oxygenated blood reaching circulation)

7
 Causes of Hypoxemia
Cause Description A-a Response to
O2
Maldistribution of V relative to Q (ventilation / flow)
V/Q Mismatch  Some areas are overventilated (↑ PaO2) ↑ Corrects
 but doesn’t correct for underventilated areas (↓ PaO2)
Extreme V/Q mismatch

 lots of venous blood gets to L heart

without traversing ventilated alveoli
Shunt ↑ Doesn’t correct
 E.g. collapsed alveoli, septal defect, etc. –
can be intrapulmonary or
extrapulmonary

Alveolar O2 diluted by ↑ PACO2 Good response

Hypoventilation nl can ↑ resp
 PACO2 MUST be ↑
acidosis!
Diffusion Hypoxia with exercise, not at rest ↑ with
impairment  Red cells don’t have time to reach equilibrium on exercise exercise
Decreased FIO2 Altitude, for instance nl

Ventilation: PaCO2 & pH

PaCO2 = K x VCO2 / VA (K=0.86; VA = VTidal – VDead Space)

 VCO2 = CO2 production; VA = alveolar ventilation
 Just K x CO2 production / CO2 removal

PaCO2 VERY tightly controlled (35-54 mmHg)

 >45 =HYPOventilation (VA is ↓: total ventilation ↓ or ↑ dead space)
 <35 = HYPERventilation
 Terms for actual PaCO2 findings: hyper- & hypocapnia

Hyperbolic relationship between VA and PaCO2

 If you’re hypoventilating (low part of curve), can get BIG PaCO2 changes
 Exercise (dotted curve): need more VA to maintain PaCO2

Calculating pH changes due to PaCO2 changes

pH: Acidosis (<7.35) vs Alkalosis (> 7.45)
 Can calculate pH changes for PaCO2 changes A 1 mmHg ↑ in PaCO2 causes
(see table to right) Acute (non-compensated) ↓ 0.008 in pH
Chronic (compensated) ↓ 0.003 in pH
Diffusing Capacity
Fick’s law: gas flux = (membrane diffusion coefficient X pressure gradient) / (thickness X area of membrane)
 Don’t memorize; just know that those are the things that go into flux
 Simplify everything: flux (J) = driving pressure (ΔP) X diffusing capacity (DL)
 𝐉 = 𝚫𝐏 × 𝐃𝐋 𝐃𝐋 = 𝐉/𝚫𝐏

To measure diffusing capacity:

8
  Can’t measure DLO2, although we’d like to – backpressure (dissociates from Hb)
 Use DLCO instead! Doesn’t have backpressure (binds really tightly to Hb)
o Pt inhales 0.3% CO in 10% He (both diluted equally, He is marker), holds breath 10 seconds
o Exhaled mixed alveolar gas sampled, exhaled [CO], [He}]measured,
o Calculate: how much CO was able to diffuse?

Interpreting DCO
 Sensitive, non-specific (something’s wrong, but huge DDx); wide normal range
 ↓ DCO: ↓ alveolar-capillary SA for gas exchange
 ↑ DCO: ↑ pulmonary capillary blood volume

Lung Volumes
How to measure residual volume?
 The rest we can get from spirometry
 Need to use GAS DILUTION (He, nitrogen, Ar, methane)

Gas dilution
 Measures only ventilated lung units
 Breathe in & out to equilibrate
 Calculate measure diluted [He]
 Use known initial volumes & initial / final [He] to figure out how
much lung capacity was around (TLC), then calculate RV by TLC-VC

Plethysmography (body box) is another option

 Uses Boyle’s Law (P1V1=P2V2)
 Measures ALL thoracic gas volume (cysts & bullae too)

INTERPRETING LUNG VOLUMES

↓ TLC Restriction
↑ TLC Hyperinflation
↑ RV Air trapping

Key Points
Patients can be pathophysiologically categorized with use of:
 Spirometry and Flow-volume curves
 ABGs
 DCO
 Lung volumes

Patients can be diagnosed with H&P, PFTs, x-rays….

9
 Interstitial Lung Disease
Pathogenesis of restrictive diseases:
 Stiff lungs (don’t expand) ILD: A restrictive disorder
 Stiff chest wall (or too small)  ↓ TLC (by def’n)
 Respiratory muscle weakness (diaphragm rises  small lungs)  ↓ FVC (almost always)
 Normal FEV1/FVC
Interstitial Lung Disease: STIFF LUNGS (no flow restriction)
 150+ clinical entities can cause ILD  ↓ DLCO (specific to stiff
 “Diffuse parenchymal lung diseases” would be better lung restrictive dz)
o Lung is simple
 tubes (airways: asthma & COPD are Dz)
 blood vessels (pulmonary HTN)
 parenchyma (alveoli) – the stuff that isn’t tubes or vasculature

What is the interstitium?

 Potential space with vascular components; substrate for gas exchange
 Normally should contain nothing (better for gas diffusion)

ILD / Diffuse parenchymal lung diseases (DPLD)

 Inflammation and/or fibrotic process affecting pulmonary interstitium
 Results in scarring of lung
o ↓ lung compliance
o ↓ lung volume (FVC, TLC)
o ↓ diffusion capacity (DLCO) – lets you distinguish from stiff chest wall or resp mm weakness

CLINICAL CLASSIFICATION OF ILD

Occupational/environmental
Connective tissue disorders
Drug / treatment-induced dz
Idiopathic disorders
Hereditary / genetic
“Other” disorders
 Pneumoconiosis (aspestos, silicosis)
 Toxic inhalation (ammonia, sulfur dioxide)
 Hypersensitivity pneumonitis (farmer’s lung, pigeon-breeder’s lung)
Pretty much any autoimmune disease
(scleroderma, RA, SLE, polymyositis-dermatomyositis, etc)
Amiodarone, cancer drugs (bleomycin, methotrexate), radiation therapy
 Idiopathic pulmonary fibrosis
 Sarcoidosis
 Bronchiolitis obliterans organizing pneumonia (BOOP), Eosinophilic granuloma
Various mutations: surfactant proteins B/C, ABCA transporters, telomerase mutations,
Hermansky-Pudlak syndrome (all Hopkins-discovered)
Lymphangitic carcinomatosis, respiratory bronchiolitis, tuberous sclerosis / lymphangiolyomatosis (LAM),
systemic lipoidosis

Now, on to some specific examples

Idiopathic Pulmonary Fibrosis

Epidemiology: 25-30% of all cases of interstitial disease; 8-12/10k and rising, males>females (2:1), mean age 65
 Think older males; significant morbidity & mortality (≈ breast cancer)
 Distinct disease entity: not just waste basket term

Presentation: Progressive dyspnea on exertion for one year or more

10
CXR:
 ↑ interstitial markings
 Fibrosis
 Predominantly LOWER LOBE involvement
& SUBPLEURAL

CT:
 Architectural distortion
o (traction bronchiectasis: bronchi
pulled apart by stiffness)
 Honeycombing is diagnostic (radiographic hallmark of IPF)
o Don’t need biopsy anymore!

Pathogenesis: Initiating event unknown (idiopathic!)

 Inflammatory response, epithelial cell injury, neovascularization,
repair / fibrosis all seen on path
 Genetics (telomerase defects / telomere shortening may be involved;
maybe why ↑ in older people?)

Pneumoconiosis
Accumulation of dust in the lungs; results in tissue reaction
Types of Pneumoconiosis
 Reaction can be collagenous or non-collagenous
 Excludes dust exposure that results in:  Silicosis
o malignancy, asthma, bronchitis, or emphysema  Asbestosis
 Coal workers’ pneumoconiosis
 Talcosis
Silicosis  Berylliosis
 Most prevalent chronic occupational lung dz in the world!  Hard-metal pneumoconiosis
 Inhalation of silica, usually in quartz form o Tungsten carbide
 Settings (esp. if not using appropriate respiratory protection) o Cobalt dust
o Mining (hard rock/ anthracite coal), foundries, brickyards, glass/ceramic
manufacturing, industrial sandblasting

Clinical Presentation:
 Dyspnea & cough (>20yrs low-moderate exposure, 5-10yrs high-level exposure)

CXR:
 Small rounded opacities in upper lung zones
 Conglomerate (>10mm) opacities
o Called progressive massive fibrosis (PMF)
o Looks like tumor
o Small opacities can progress to PMF
PFTs : identical to IPF
 May see airflow obstruction, ↓ FEV1/FVC occasionally

Pathogenesis:
1. Silica particles deposit in alveoli
2. Mϕ gobble them up
3. Mϕ injured / cell death happens
4. Release of intracellular proteolytic enzymes  lung injury / fibrosis
5. Silicotic nodules form!

11
 Diagnosis of Interstitial Lung Disease
 Patient history is crucial!
o Check for exposures, how long have Sx been going on, any Hx autoimmune dz, other sx?
 Chest radiograph useful (& chest CT)
 Fiberoptic bronchoscopy
o Broncheoalveolar lavage: rule out infection, look for eosinophils
o Transbronchial biopsy: e.g. for sarcoidosis
 Thorascopic / open lung biopsy too

Treatment of Interstitial Lung Disease

Note: no FDA approved therapies for IPF: for a disease that affects 1/2M people in US & causes 40k deaths / year!

In general, for ILD: (* = not of benefit for IPF)

 Avoid exposure to causative agent
 Corticosteroids*
 Alternative immunosuppressive agents*
o Cyclophosphamide
o Azathioprine
 Anti-fibrotic drugs*
 Follow pt response to therapy with serial PFTs & pt-reported Sx
o How are they doing? Try something new if not working

12
 COPD
COPD: chronic disease characterized by REDUCED EXPIRATORY AIRFLOW Risk factors for COPD
 CIGARETTE SMOKING
Diseases included in COPD: both COPD: Clinical Course  Older age
caused by cigarette smoking  Progressive ↓ in pulmonary function  Male gender (?)
 Emphysema  Punctuated by acute exacerbations  Airway hyperreactivity
 Chronic bronchitis  Low socioeconomic status
 Eventually: disability & premature death
 Others: asthma /  Alpha-1 anti-trypsin deficiency
asthmatic bronchitis / bronchiectasis / CF technically COPD too, but not in
common parlance

Emphysema Chronic Bronchitis Asthma (for comparison)

Anatomic definition (need Bx to Dx)
Definition:
 Progressive destruction of alveolar
septa & capillaries 
 Airspace enlargement & bullae
development
Destruction of septa 
↓ elastic recoil (↑ compliance)
 ↓ maximum expiratory airflow
 ↑ static lung volumes
Historical definition (Dx via phone!)
Definition:
 chronic mucus hypersecretion
 > 3mo chronic sputum production for 2
consecutive years
↑ airway resistance 
↓maximum expiratory airflow
Episodic cough, wheezing, dyspnea
Often considered pathophysiologically
separate from COPD unless chronic
abnormalities present:
 Lung function
 Cough
 Sputum (“asthmatic bronchitis”)

Natural History of COPD

FEV1 normally ↓ with age; much faster in COPD
COPD:
 Usually clinically recognized in older pt / 50s (Sx)
 Changes start much earlier (can detect with PFTs!)
o Just need spirometry (cheap!) to see FEV1

Only 1 in 7 smokers get COPD

 But in those who are going to get it, these changes start early

If you quit:
 Rate of FEV1 drop goes back to normal! Delay onset of Sx

13
 Pan-Acinar vs Centrilobular Emphysema
Remember: acini / lobules are the functional unit surrounding one respiratory bronchiole

Affects Part of Lung Cause Picture

Alpha-1
Entire Base >
Pan-Acinar antitrypsin
acinus apex
deficiency

Respiratory Apex > Cigarette

Centrilobular
bronchiole base smoking

Protease Imbalance Theory of Emphysema

Basic idea: ↑ proteases & ↓ antiproteases  imbalance  damage
 Mϕ secreting cytokines in middle of everything
 Cytokines  hyperplasia of other cells (e.g. mucus cells)
o Can lead to bronchitis too!

Evidence:
 Alpha-1 antitrypsin (normally inactivates proteases) deficiency leads to
premature emphysema
 Proteases such as elastase causes severe emphysema in lab animals
 Cigarette smoking causes inflammatory cells to secrete proteases (which
accumulate in the terminal airspaces)
 Cigarette smoke inactivates anti-proteases

Pink Puffers & Blue Bloaters (typical COPD pt has elements of both)
Findings Picture

 Emphysematous  Purses lips

 Dyspneic
 Hyperinflated  Shoulders elevated
Pink Puffer  Low PaCO2
 Thin physique  Leans forward
 Worse O2sat w/exercise
 Accessory mm to breathe

 Bronchitic
 High PaCO2
 Less hyperinflated
 Better O2sat w/ exercise
Blue Bloater  Obese physique
 Cyanotic
 Not dyspneic

14
 Pathophysiologic Abnormalities in COPD
Probably good to memorize these lists of 3 things
Major pathophysiologic abnormalities in COPD
Airflow Obstruction: causes 1. Airflow obstruction (Early)
1. ↓ elastic recoil (emphysema) 2. Hypoxemia (Mid-course)
2. ↑ airway resistance (chronic bronchitis) 3. Pulmonary HTN (Late)
3. ↑ airway smooth muscle tone (asthmatic bronchitis)

Hypoxemia: causes
1. V/Q mismatch (because of non-linear Hb dissociation curve)
2. Hypoventilation (late in course; more common in chronic bronchitic)
3. Diffusion impairment (exercise or high altitude;
more common in emphysema)

Flow-volume loop:
 More curvilinear (some areas emptying very slowly – bullae, etc)
 Smaller in general (less volume)

Air trapping & hyperinflation

 Air trapping makes RV↑ (extra volume that can’t be expelled)
 Hyperinflation means TLC↑ (bigger overall volumes)

Operating lung volumes (rest vs. exercise)

 Normally ↑ VT by blowing out more during exercise
 In COPD:
o can’t blow out fast enough
o take another breath before fully exhaled
o ↑ end expiratory volume
o VT ↑ to keep up with metabolic demands
o Reach TLC – need to stop exercise
(can’t ↑ VT any more)

CXR findings (not good for screening vs. spirogram)

 ↑ A-P diameter
 Flat diaphragms (less efficient)
 ↓ vascular markings
 ↑ size of central pulmonary arteries
 ↑ anterior air space
 ↑ sterno-phrenic angle

CT findings with
density masking:
 better for Dx
 Too much air
(↓ density)

Pulmonary Hypertension: due to chronic alveolar hypoxia

 Give O2 to prevent
 Maybe contribution from destruction of pulmonary capillary bed too

15
Gas exchange: problems progress over course of disease

Consequences of pulmonary HTN

 RV dilatation
 ↑ venous pressure (↑ RA pressure too)
o Peripheral edema
o Can’t ↑ CO with exercise or stress
 Decreased survival
 50% 5-year mortality with cor pulmonale (RH failure)

Treatment of COPD
Chronic oxygen improves survival in pts with hypoxemia
 Concentrator or liquid O2 
 deliver with nasal cannula, Venturi mask (control concentration), or transtracheal catheter (high flow) as needed

Smoking cessation slows progression

 ASK ABOUT SMOKING & give forceful encouragement to quit (↑ quit rate 50%)
 Encourage unambiguous quit date
 Follow up progress
 Nicotine replacement (transdermal patch, gum, lozenge, spray)
 Bupropion or varenicline
 Refer to group program
 1-800-QUIT-NOW – have somebody else do the counseling for you!

Long-acting bronchodilators & inhaled corticosteroids

 ↓ exacerbations & ↑ survival

Influenza vaccination & pneumococcal vaccination might have benefit too?

Advanced treatment:
 Lung transplant
 Alpha-1 antitrypsin replacement therapy ($30K/yr, not known if benefit, only for pan-acinar)
 Lung volume reduction surgery
 Long-term mechanical ventilation

Exacerbations in COPD
 Increase in cough, phlegm, dyspnea
 Occur on average 2-3/year
 50-75% caused by bacterial infection
 Treated with antibiotics, steroids Treatment for Acute Respiratory Failure
 Impair quality of life  Non-invasive positive pressure ventilation
 May result in acute respiratory failure  Intubation & mechanical vent if needed
 Can be prevented by inhaled bronchodilators, inhaled steroids

16
 Pathophysiology of Asthma
Definition: Chronic lung disease characterized by Epidemiology
1. Chronic airway inflammation  20M (7%) in US
2. Airway hyperresponsiveness  M>F in kids; F>M in adults
 Most common childhood chronic dz
3. Variability in outflow obstruction
 Prevalence, mortality rate ↑
Cause: UNKNOWN  ↑ mortality in AA pts (big gap!)
 Genetic factors (clusters in families, ↑ in atopic pts - ↑ ability to generate IgE after allergen exposure)
 Environmental exposures (tobacco smoke, occupational agents, air pollutants)
 Respiratory infections? Controversial: exacerbates but no good data for causation

Chronic Airway Inflammation

Triggers: lots!
 Cockroaches, mice, irritants, infections, etc. (more later)
Effectors
 EOSINOPHILS major player
 Mast cells (IgE) too
 Histamine, prostaglandins, etc. released

Leads to:
 Bronchoconstriction
 Airway edema
 Goblet cell hyperplasia (↑ mucus)

Eventually results in ↑ AIRWAY RESISTANCE and AIRFLOW OBSTRUCTION (wheezing, shortness of breath)

Airway Hyperresponsiveness
Exaggerated bronchoconstriction after environmental exposures or response to stimuli
 We all do it; just more in asthma pts
 Allergens (e.g. dust mite), irritants (e.g. tobacco smoke), methacholine (diagnostic)
 Mechanism unclear: airway inflammation? Abnormal neural control of airways? ↓ ability to relax smooth mm?

Methacholine (MCh) challenge

 MCh: cholinergic agonist  bronchoconstriction
 Inhale progressively higher [MCh] & record FEV1 after each dose
o Precipitous drop in asthma pts
 Provocative Dose 20 (PD20): dose needed to provoke 20% fall in FEV1
o PD20 < 8 in asthma
 NOT PREDICTIVE of sx severity
 Sensitive but NOT SPECIFIC: all pts with low PD20 don’t have asthma
o COPD, CF, other resp disorders
o 10-15% normal pts
o Can’t use by itself to Dx asthma

17
 Variability in Airflow Obstruction
Obstructive ventilatory defect present
 LOW FEV1/FVC RATIO (<0.7)

Can at least partially reverse with bronchodilator therapy

 Usually FEV1 ↑ >12%, 200mL

Obstruction VARIES TEMPORALLY: within and between days

 Often worse in early AM
 Symptoms are episodic
o DYSPNEA
o CHEST TIGHTNESS
o WHEEZING
o COUGH (can be only
presenting symptom!)
 Can see fluctuation in FEV1 with time

Obstruction VARIES SPATIALLY as well

 Radiolabeled aerosol deposits: patchy deposition mostly in
large & proximal airways; some airways less obstructed

Asthma Exacerbations
Acute ↑ in airway resistance from: bronchoconstriction, airway edema, mucus / cell debris
 Usually over days-weeks but can be sudden
 60% asthmatics: 1+ severe exacerbation/yr
Triggers
Clinical Presentation
 VIRAL INFECTIONS (most common cause; rhinovirus, influenza)
Hx: ↑ SOB, chest tightness, wheezing, cough
 Inhaled irritants (cig smoke, ozone, particulates)
PE: tachypnea, wheezing, prolonged expiration
 Inhaled allergens (dust mites, animal dander – cats, mice, etc)
Radiology: hyperinflated, flattened diaphragms
 Exercise or cold air (irritates!)
 Occupational exposures
Physiological alterations in exacerbation:
Hyperinflation: Specific to patient (need to test & find out).
Can have delayed symptoms too – exposure, get Sx hours later!
 Diaphragms flattened  mechanical
disadvantage (hard to flatten more to breathe!)
 ↑ work breathing
o abdominal paradox: use less efficient intercostals to breathe, so abdomen goes in instead of out on inspiration
o Can lead to respiratory failure
 Pulmonary HTN: alveolar capillaries compressed (↑ alveolar pressure)

Signs of a severe asthma exacerbation

1. Pulsus paradoxus: > 10 mmHg drop in SBP with inspiration, caused by ↑ pleural pressure swings (↓ LH filling)

2. Respiratory muscle fatigue: from being hyperinflated

o Can’t speak in full sentences
o Accessory mm of respiration (sternocleidomastoid, intracostals) retracting
o Paradoxical abdominal movement (abdomen in instead of out on inspiration)

18
 3. Hypercarbic Respiratory Failure (↑ PaCO2)
o Diaphragm fatigued (↑ work of breathing)  alveolar hypoventilation with ↑ PaCO2
o Normally asthma pts hyperventilate during exacerbation so PaCO2 should be low (<40mmHg)
o A NORMAL PaCO2 is therefore a bad sign in asthma exacerbation

Treatment of Asthma
Patient education: what it is, how to manage, what drugs are, etc.
Avoid triggers: needs to be comprehensive Goals of treatment
 Smoke avoidance, Pet avoidance, Roach control, Mouse control
 Dust mite modifications: 1. Control symptoms
o Allergy proof covers, Wash linens in hot water weekly 2. Prevent exacerbation
o Vacuum/sweep weekly, Carpet/curtain removal, Humidity control 3. Maintain lung function as close to
Asthma management plan normal as possible
 Can have pt measure peak expiratory flow rates at home • Use objective measures: pt
may not realize how bad it is!
 Plan with pt: what actions to take based on peak flow
 Helps with appropriate medication use (not overuse), can have pt call &
4. Avoid adverse effects from
schedule appt or prescription refill if drastic decline, etc. medications
5. Prevent irreversible airway
Pharmacologic treatment: obstruction
• Is asthma predisposition for
1. Bronchodilators: relax bronchial smooth muscle COPD?
a. Short & long-acting β2 agonists, anticholinergic meds 6. Prevent asthma mortality
b. Inhaled
c. Short-acting meds for RESCUE ONLY
2. Inhaled corticosteroids: anti-inflammatory 3. Oral corticosteroids
a. Cornerstone of daily control therapy a. If can’t control with inhaled meds
b. Add if pt needs their bronchodilator b. ↑ side effects
>2x/wk, for instance
4. Others: if refractory to tx
Drug Description
Cromolyn sodium / nedocromil Anti-inflammatory, Mast cell stabilizer (↓ degranulation)
Anti-inflammatory, less effective than corticosteroids
Leukotrine modifiers
(can use if mild asthma or corticosteroids contraindicated)
Theophylline Methylxanthine bronchodilator
Anti-IgE Really expensive; IV; only in very severe cases

Acute Exacerbations:
 ↑ frequency of short-acting bronchodilators with ↑ Sx
 Often needs oral corticosteroids, may need subQ or parenteral β-agonists if severe
 Monitor for respiratory failure

Inhaled drug delivery:

Metered-Dose Inhalers (MDI)
Spacers with MDIs
Dry-powder Inhalers
Nebulized Solutions
 Aerosolized spray with a propellant, currently with hydrofluoroalkane
 Requires slow deep inhalation with 10 sec breathhold to be most effective
 Minimizes oropharyngeal deposition with MDI
 Requires less coordination
 Can deliver drug as effectively as with nebulizer, even during exacerbation
 Rapid inhalation
 Dose lost if exhales into the device
 Expensive
 Depends less on patient coordination

19
 How to use MDIs & Spacers

MDI: don’t put it the whole way into

mouth (just coat back of throat!)

Spacer: discharge before inspiration

(MDI alone – simultaneous)

Step Care
Sx, severity depend on:
 frequency of exacerbations
 frequency of nocturnal symptoms
 variability in lung function (FEV1 / PEFR)

Step up if: frequent need for β-agonist

Step down (remove treatments) if 1-6mo symptom control

Summary (from slides)

1. Asthma is more common in children (↑ mortality in African-Americans)

2. Three cardinal features: airway inflammation, airway hyperresponsiveness, variable airflow obstruction
3. Genetics, respiratory infections, and environmental exposures all likely contribute to developing asthma
4. Asthma Sx: wheeze, dyspnea, cough, chest tightness
5. Bacterial infections rarely trigger asthma exacerbations
6. Airway hyperresponsiveness (positive methacholine challenge) is not specific for asthma
7. Airflow obstruction is due to bronchoconstriction, airway edema, and inflammatory exudates in airway lumen
8. Pulsus paradoxus, a rising PaCO2, and respiratory muscle fatigue indicate a severe asthma exacerbation
9. Treatment should include patient education, environmental control practices, an asthma management plan
and medications based upon symptom severity.

20
 Expiratory Flow Limitation
Expiratory Flow Limitation (defn): PATHOPHYSIOLOGY OF RESPIRATORY FUNCTION: BASIC CATEGORIES
Restrictive ventilatory defects Difficulty getting air into the lungs
↑effort to exhale does NOT cause Obstructive ventilatory defects Difficulty getting air out of the lungs
↑ expiratory flow rate Difficulty with efficient movement of
Gas exchange defects
gases between alveoli & blood

A spirogram (left) is any

graph of exhaled
volume vs time.

The slope is the

expiratory flow
(volume per time); can
be graphed against total
exhaled volume (right)
as expiratory flow –
volume relationship

The pleural pressure generated is analogous to the effort exerted.

 ↑ effort  ↑ expiratory flow: but only to a point.
 The curves all superimpose on their way back down

Isovolume effort-flow relationship:

 At a given volume, there’s a relationship
between % max effort and flow
 ↑ max flow at ↑ volume still in lung (earlier,
before you’ve exhaled the volume) – e.g. A vs B
 Flow restriction: there’s a point of effort at
which ↑effort doesn’t translate to ↑flow
o Normally about 60% max effort is
where flow restriction happens

What Causes Flow Limitation?

For the following, pretend that this is all isovolume (lung volume constant despite expiratory effort & airflow)

Picture What’s going on

 Ppl is about -8 if you hold your breath with glottis open after inspiration
 That makes Pel (elastic recoil) 8 (positive = lung wants to recoil)

21
 Expiratory muscles contract
 Isovolumic so Pel has to be the same (8)
 ↑Ppl (contraction of expiratory muscles), so ↑Palv too (keep Pel same)
 ↑Palv now creates a gradient, and ↑airflow out

At the same time, Ppl pushes in on bronchus, causing it to narrow

 esp. distal bronchus – where pressure is lower (gradient with Patm=0)
 ↑resistance so ↓airflow out

Flow limitation:
 airflow stops increasing at some point (60% max effort in normal)
 resistance from ↑ Ppl cancels out ↑ airflow from ↑ Palv

But if totally occluded, ↑ pressure inside bronchus (>Ppl)

 forces airway open again

Airway opens up again  now the pressure is greater outside (forces closed)

Paradox: if closed, pops open; if open, forced closed

Resolved by either:
 Bronchus fluttering open & closed
 Bronchus doesn’t really close; self-adjusts diameter to maintain it just
open enough to balance opening & closing

What determines max expiratory airflow?

Determinant Contributing factors Picture

1. Airway resistance  Diameter

(bronchi)  Length

Bronchi have cartilage, smooth mm to resist closure, but will

still shut if pressure across them is more than slightly negative
2. Tendency of airway to
 Smooth muscle tone (↑ with asthma so ↑closure)
close (or resist closure)  Mucosal thickness
 Tethering effect of parenchyma

 Lung volume (↑volume  ↑ recoil)

 Elastic properties of lung tissue
3. Elastic recoil of lung
Emphysema: ↓elasticity, ↓ elastic recoil  ↓ flow at any
volume. Opposite for IPF (↑elasticity  ↑elastic recoil  ↑
flow at any volume)

22
 Why is this a problem in chronic obstructive lung disease?

Normally: lots of reserve at rest

 Exhalation happens far underneath maximal envelope

COPD: reserve lost

 ↓ volumes, ↓ maximal expiratory flow
 Even at rest, operating on your maximal envelope
 Try to exert  can’t ↑ expiratory flow

What does this have to do with other systems?

Bladder like lung, urethra like bronchus

 ↑ abdominal pressure to try to force urine out (like ↑ pleural pressure)
 Prostate squeezes urethra like pleural pressure on bronchus
o ↓ flow with prostatic hypertrophy
 Flow limitation happens during micturition – can’t get it out!

Similar Flow Limitation in:

 Expiratory airflow
 Inspiratory airflow
 Vena cava blood flow
 Micturition
 Blood flow during CPR

23
 Pulmonary Vascular Disease
Review from last year: pulmonary circulation
Key points about the pulmonary circulation:
 Entire cardiac output goes through it
 Low pressure drop (25-5)
 Low resistance (low pressure drop!)
P −P
 PVR = PA𝑸 LA
𝒕
o Resistance = pressure gradient over flow.
o Pressure gradient (pulmonary artery to LA) divided by the flow
(cardiac output = venous return)

Passive: Pulmonary circulation not a rigid tube:

 ↓ PVR with ↑ CO (passively!)
 Capillaries are recruitable & distensible
 No active processes needed
 Maintains pressure gradient over CO range

Active: Vascular tone can be modified to adapt to changing Qt (=CO)

 Change along curve = passive adaptations
 Shifting between parallel curves = vasoconstriction or vasodilation

PVR is U-shaped curve (passive mechanisms)

 LOWEST PVR at FRC
o ↑ lung volume: compress alveolar vessels (↑ PVR)
o ↓ lung volume: compress extra-alveolar vessels (↓ PVR)
 Hyperinflation (e.g. asthma): ↑ PVR (above normal FRC)
 ARDS: lowers FRC (↑ PVR too)

Pulmonary Hypertension: Definition

Definition: MEMORIZE THIS
Abnormal elevation of pulmonary artery pressure, the gradient
between pulmonary artery & pulmonary vein, or increase in PVR Mean Ppa > 25 mm Hg
Can be measured non-invasively with electrocardiography

Causes of Pulmonary Hypertension

PPA− PLA
Remember R=ΔP/Q, so PVR = 𝑸𝒕
Rearranging to find things that can affect P PA:

PPA = Cardiac Output × Resistancedownstream + PLA

So ↑ PPA with
1. ↑ left atrial pressure
2. ↑ downstream resistance
3. ↑ cardiac output

24
1. ↑ LA pressure
 LV or mitral valve disease (cardiomyopathy, mitral regurgitation or stenosis, etc)
 ↑ LA pressure  ↑ backpressure so ↑ pulmonary arterial pressure
 Most common cause of pulmonary hypertension (because LH dz very common)
 Treatment: unload left heart (treat underlying condition to ↓ LA pressure)

2. ↑ downstream resistance
 Very uncommon to raise resistance in veins – usually arteriolar or arterial

↑ arteriolar resistance: primarily hypoxic

 Hypoxia causes ACTIVE pulmonary arteriolar vasoconstriction
(↑ resistance)
o Altitude, hypoventilation, etc.
o Why? Hypoxic Pulmonary Vasoconstriction to match V/Q
o shut down blood flow to underventilated lobe; reduce shunt
o Good locally but bad globally (leads to pulmonary HTN)
+ +
o Mechanism: maybe from inhibition of K channels (see K channels shut down
in hypoxic PA cells but not endothelial cells from other areas of the body –
would want to vasodilate there!)

 COPD: both hypoxia & distortion of alveoli & capillaries

 Interstitial disease: sarcoid, IPF, etc
o distorting capillaries mechanically, some dropping out
 ARDS, positive pressure ventilation, others IDIOPATHIC PULMONARY ARTERIAL HYPERTENSION
(PRIMARY PULMONARY HYPERTENSION)
↑ arterial resistance: primarily vascular  Women 20-45 yo
 Looking at more central, larger arteries  Dyspnea >1 yr
 Pulmonary Arterial Hypertension  PPA markedly elevated at dx
o Idiopathic, Familial, or associated with CVD / HIV /
 Median survival = 3 yrs (before Tx)
Liver disease /Drugs
 TGF-β involved in vascular remodeling
(definitely in familial forms, probably in
 Chronic thromboembolic disease sporadic form too)
o Needs to be chronic  No cause or association identifiable
o throwing lots of clots, ↑ resistance over time o Rule out other causes
(occluding vessels downstream)

3. ↑ cardiac output
 ↑ pulmonary blood flow  ↑ PPA
o Anemia, hyperthyroidism (↑ CO); generally not severe; reversible
 Chronic ↑ flow  vascular remodeling  ↑ resistance (more fixed form)
o L-to-R shunt (ASD/VSD), Sickle cell anemia too

25
 Consequences of pulmonary HTN
ACUTE (e.g. Acute PE) CHRONIC (e.g. chronic lung dz, PAH)
 RV not hypertrophied; fails quickly  RH has time to hypertrophy
(pushing against ↑ resistance) o See BIG RV and RA
 RA pressure ↑ as RV fails  RA pressure ↑ over time (can’t eject everything) 
 ↑ catecholamines to ↑ mean systemic pressure, ↑ HR pulmonary hypertension
 ↓ Venous return / CO  shock, sudden death  Venous return, CO maintained (↑ sympathetics, ↑
 Acute PEs have 10-15% mortality mean systemic pressure to augment return)

Cor pulmonale: RH failure due to pulmonary disease

 These are patients with COPD or CHRONIC HYPOXIA, for instance
 RH has to keep pushing against diseased lung, eventually fails
 Findings: Edema, ↑JVP, loud P2, right S3, RV heave, tricuspid regurg, hepatic congestion, big pulmonary arteries, ↓DLCO
 Dx with echocardiogram or right heart cath

Prognosis:
 Correlates with mean pulmonary arterial pressure!
o See graph: ↑ PPA = ↑ mortality
 Similarly:
o ↑ RA pressure (RH failing!) = 3 mo median survival
o ↓ CO (failing) = bad prognosis
o Hyponatremia (compensatory mechanisms failing) = bad prognosis

Treatment of pulmonary HTN

Goals of treatment:
 UNLOAD the RV
o Vasodilation
 Reverse hypoxia & active vasoconstriction
 O2 is a vasodilator!
 Reverse remodeling
 Avoid in situ thrombosis & embolism from deep veins (anticoagulants)

Prostaglandin I2 (prostacyclin)
 Vasodilation & inhibition of remodeling
 Requires chronic perfusion but
improvement in survival (50% at 5yrs
vs 20% w/o Tx)
VASCULAR MODIFIERS
Endothelin receptor antagonists PDE5 inhibition
(e.g. Bosentan) (e.g. sildenafil / Viagra®)
 Endothelin usually leads to
 ↑ cGMP  vasodilation, inhibition of
vasoconstriction, proliferation,
remodeling
migration of smooth mm (reverse!)
 Can give orally, again good functional
 Can give orally; good functional data
data but not good data for survival
(six minute walk) but not good data
for survival (should correlate?)

Lung transplant: cures PAH but has significant problems in its own right
 5yr survival is ~50% (worst of transplants)

Summary:
 Pulmonary hypertension can arise via various physiologic or pathophysiologic mechanisms (most still unclear)
 Harder to diagnose than systemic HTN / often presents late
 Major clinical importance of pulmonary HTN: effect on the RV (acute vs. chronic)
 Strategies to decrease PVR and unload the RV have beneficial effects on patients with pulmonary hypertension
26
 Obesity & Breathing Disorders
Obesity: BMI kg/m2; >25 overwt, >30 obese. Growing problem (ha!).
More obesity in Missisippi. Obstructive
 (mentally recreate obesity epidemic maps) ↓ Sleep Apnea↓

Obesity can cause a range of breathing disorders

 Some while awake, some while asleep
 Various clinical significances

Sleep apnea
Clinical Features
Upper Airway Obstruction Alterations during sleep
 Snoring  Excessive movements
 Choking, gasping  Insomnia
Cardiopulmonary dysfunction
Alterations in daytime function
 Hypertension
 Excessive hypersomnolence
 Glucose Intolerance
 Intellectual deterioration
 MI / Heart Failure / Arrhythmias
 Fatigue
 Cor Pulmonale

What do you see on overnight sleep study?

1. Periods of no ventilation
2. ↓ O2sat as a result
3. ↑ esophageal pressure variations 4
(trying to inspire: asphyxic response)
2
4. Microarousals: waking up from sleep (although not 1
the whole way – patient doesn’t fully awaken)

Interruptions in sleep Daytime hypersomnolence, etc.

3

Epidemiology: measure apnea / hypopnea index (AHI)

 # of episodes per hour (<5/night is normal)
 <10% in general pop, but ↑↑ in obese men, snorers

Sleep Apnea: Pharyngeal Obstruction

Pharyngeal obstruction is key component (critical pressure)
 Normally, negative pharyngeal pressure keeps airway open
 Apneic patient: throat closes! Positive critical pressure

Spectrum of critical pressures: more negative keeps things open

 Snoring, obstructive hypopnea can result even at - pressures (more closed)
 Positive critical pressure: sleep apnea (totally obstructing)

27
Neuromuscular activity:
 Normally, when upright, genioglossus contracts
(to pull tongue forward on inspiration to open airway)
 Normally, when supine, have more genioglossus activity
(tonic activity too to keep tongue out of the way)
 Apneic patients have ↓ / absent genioglossal nerve firing

In adults: combination of
 structural problems and
 this neuromuscular dysfunction

Obesity:
 More common in upper body obesity (“apples” – mostly males)
o Fat encroaching on neck / pharyngeal tissues  ↑ collapsibility
o Fat  ↑ load on resp system / impedes gas exchange
o Fat  cytokines / humoral factors that ↓ CNS reflexes to keep things open

Therapy for Obstructive Sleep Apnea

Change either the nasal or critical pressure

↑ Nasal Pressure: CPAP

↓ Critical pressure:
 weight loss
 structural approaches
 ↑ neuromuscular activity

CPAP: change nasal pressure

 continuous positive airway pressure
 How it works: wear mask, force air in through nose, inflates throat,
push airway open
 Mainstay of treatment
 Sleep study: AE = ↑ CPAP pressures
o smaller esophageal pressure swings (not trying to breathe
as hard); no obstruction, airflow normal
o Arrows: inspiratory airflow limitation (snoring)
 Partial obstruction so limit flow at a point

 Linear relationship between airway pressure & flow

o Below Pcrit, still obstructed
o Find point where flow is normal & prescribe CPAP at / above that pressure

Changing Critical Pressure

1. Weight loss (good way, even small reductions help)
2. Structural approach
a. Body positioning
b. Uvulopalatopharyngoplasty (surgical – open things up)
c. Hyoid / mandibular repositioning (not done much anymore)
3. Increase neuromuscular activity
a. protriptyline (not great results) or direct electrical hypoglossal stimulation (experimental)
4. Bypass obstruction (tracheostomy) if really severe

28
 Daytime Respiratory Complications of Severe Obesity
Hypoxemia & hypercapnia  cor pulmonale

Hypoxemia: from mechanical alterations

 ↓ TLC & ↓ FRC (↓ chest wall compliance)

 ↓ FRC  ↓ oxygenation (breathing at lower lung volume)

o Below closing volume (where airway closure starts):
 some of your airways are going to be closed
o Microatelectasis too (small areas of collapse; worsens shunt)
o V/Q mismatch & hypoxemia can result
o

Hypercapnia:
 ↑ metabolic demand (more CO2 produced) if obese
 Should ↑ alveolar ventilation (VA) to compensate
o Blow off extra CO2
 If ventilatory drive depressed, ↑↑PaCO2
(not getting rid of the extra you’re producing)

Why hypoventilation? (see hypercapnia above)

 Won’t breathe (CNS problems)
o Impaired ventilatory drive, metabolic alkalosis,
CNS-depressing meds
 Can’t breathe (mechanical problems)
o Neuromuscular disorders, restrictive chest abnormalities (OBESITY),
parenchymal lung dz, upper airway obstruction

In obesity: alterations in drive to breathe

 Blunted ventilatory response to CO2 challenge
 Leptin deficiency blunts response in mice in and of
itself (ob/ob mice) – restored with giving leptin

Therapy for Hypoventilation in Obesity

Treat Hypoxemia!

 ↓ PaCO2
o ↑ VA (alveolar ventilation): blow off more CO2
 Stimulant (progesterone)  ↑ VA (the same way ↑ metabolic demands dealt with in pregnancy)
 Mechanical ventilation / CPAP to ↑ VA if needed
o ↓ VCO2 (produce less carbon dioxide!)
 WEIGHT LOSS (even moderate loss ~ 5% helps!)

 Maintain oxygenation
o ↑ PIO2 (supplemental oxygen)
o Treat sleep apnea (repeated ↓ in oxygen sat)

29
 Ventilatory Failure
Lung failure Pump failure
Primary feature Hypoxia Hypercarbia
Pneumonia, Asthma, COPD,
Clinical syndromes interstitial lung disease, myopathies, neuropathies,
PE, ARDS spinal cord lesions
Note: hypercarbia is LATE in pump failure: don’t miss stuff that comes before!

Muscles of Respiration: Review

Fiber types & fatigue
 Tendency to fatigue related to oxidative capacity
Type Oxidative capacity Fatigue Strength
I Slow (S) High Slowly Low
IIa Fast-fatigue-resistant (FR) Medium Moderate Medium
IIb Fast-fatigable (FF) Glycolic Quickly High

Diaphragm: usually mostly slow & fatigue resistant

 As ↑ ventilatory demand: recruits more strong fast-fatigable fibers

The Diaphragm: “C-3/4/5 keeps the diaphragm alive!”

 Vertical fibers (contract = pull down)
o Curvature is mostly the central tendon
o Costal and pleural attachments
 Actions:
o Piston-like: pull down, ↓ pleural pressure (upper ribs sucked in)
o Appositional: ↑ abdominal pressure (lower ribs pushed out)
 What passes through diaphragm where?
o “I ate ten eggs at twelve” = I 8 (IVC @ C8) 10 Egs (esophagus @ C 10) AT 12 (azygous & thoracic duct @C12)

Intercostal muscles & scalene

 Really active with every breath (not just accessory muscles)
 External = inspiration; Internal = expiration (backwards)

Accessory muscles:
 Inactive in relaxed breathing; active during exercise or disease
 Sternocleidomastoid is big one
 Pectoralis major / minor, trapezius, serratus anterior too

Expiratory muscles
 Remember that TIDAL EXPIRATION is PASSIVE
o Use active expiration during exercise, obstruction, dyspnea, pulmonary function testing
 Abdominal muscles & internal intercostals
 Essential for STRONG COUGH (clear mucus!)

30
 Mechanisms of Respiratory Muscle Failure
IMBALANCE between DEMAND and CAPACITY
↑ demand, ↓ capacity, or both

RM demand: how much are you breathing and how hard is it to breathe?
↑ demand with … Because…
↑ CO2 production Need to get rid of CO2 (e.g. obesity)
Alveolar ventilation is needed to get rid of CO2:
Minute ventilation ↑ Dead space
↑ total ventilation if ↑ dead space to preserve VA
↑ respiratory drive By definition
↓ lung compliance
Harder to breathe if stiffer
Respiratory system mechanics ↓ chest wall compliance
↑ airway resistance Pushing against more

RM Capacity: what determines it?

 Intrinsic muscle function
 Neural function FRC
 Lung volume
o Remember: muscles have maximum in the tension-length relationship
o At point of ideal actin/myosin overlap (length), can get most force
generated (tension)
o FRC: muscles are at length to generate maximum tension
 Metabolic substrate: Oxygen supply & blood supply to resp mm

When things go wrong: Hyerinflation

Hyperinflation:
 Diaphragm “piston” descended, fibers oriented more medially
o flattened so away from maximum on length-tension curve
 ↓ zone of apposition (less effectively turning ribs outward)
 Ribs more horizontal (intercostals, scalene less effective)
 ↓ outward recoil of chest wall (harder to inspire)

Results of hyperinflation: ↑ work of breathing

 Compliance ↓: at a higher volume so lung is less compliant
o For the same VT, you now need to generate a bigger ΔPPL
 Intrinsic (auto) PEEP: need to isovolumetrically contract t o get
pressure down to zero before next breath!

When things go wrong: COPD

RM demand ↑↑ (RM pressure output ↑↑ 3x normal)
 Hyperinflated, ↑ resistance, ↑ resting ventilation (↑ dead space)
 In COPD, O2 consumption shoots up with ↑ ventilation much faster than in normal subjects

RM capacity ↓↓
 Hyperinflation (worse with exercise)
 Malnutrition (esp. protein)  ↓ diaphragm mass END RESULT IN COPD
 Steroids (COPD Tx)  chronic myopathy ↑ demand + ↓ capacity = failure
 Myopathy  ↓ oxidative capacity
31
 When things go wrong: Critical Illness

Cardiogenic or septic shock: ↓ cardiac output

 Hypoxia (because ↓ CO)
o ↓ delivery & ↑ demand (↑ ventilation because hypoxic!)
 People in shock die when they STOP BREATHING (hypoxia  arrhythmias)

Faster progression to lactic acidosis if have to use muscles to breathe

 Expt: dogs with blood loss on vent or breathing on own
 Use mechanical ventilation if patient in shock even if nothing wrong with lungs

Recovery phase (problems after critical illness)

Critical illness polyneuropathy Critical illness myopathy
 MOF after sepsis
 After corticosteroids or neuromuscular blockade
 Demylenation or axonal degeneration
Occur in up to 25% of patients on mechanical vent > 1 wk
Usually but not always recover; often prolongs period of time on ventilation

When things go wrong: Neuromuscular Disorders

Many conditions cause ↓ capacity (stroke, spinal cord injury, ALS, phrenic nerve injury, Guillan-barre, myasthenia gravis, MD)

Spinal cord injury: C-3-4-5…

Site of cervical cord injury Muscles affected Results
Accessory / expiratory muscles
Lower Weak cough  pneumonia
Diaphragm spared
Higher Diaphragm affected (+others) Need long-term ventilation

Diaphragmatic Paralysis
Causes
Cardiac surgery, trauma,
Unilateral
tumor, stroke, herpes zoster
Neuropathies, herpes zoster,
Bilateral
vasculitis, Lyme dz
Features
 Relatively Asx (DOE)
 ↓ max voluntary vent (25%)
 Severe dyspnea & ORTHOPNEA (really bad)
 ↓ VC and max voluntary vent (50%)
 Diagnose by Pdi (transdiaphragmatic pressure – balloon in esophagus vs stomach)

↓ respiratory drive: either won’t breathe or can’t breathe

 Drug OD or CNS disorders of central drive can cause

When things go wrong: Obesity

What’s wrong? Why’s it bad?

 RM oxygen consumption ↑↑ (can reach 15% total) Makes you less tolerant:
o ↑ work of breathing, have to move all that extra mass  Of any lung disease
 RM force ↓ (especially supine – same as above)  Of low respiratory drive
 RM endurance ↓

32
 Assessment of RM Function
Simple clinical observation: “TAP”
 Tachypnea
 Accessory muscle use
 Paradoxical breathing
o Put one hand on abdomen, other on chest: should rise & fall together. If diaphragm can’t contract, not raising
abdominal pressure. Accessory muscles contract, suck abdominal contents in  abdomen falls
o Respiratory alternans: periods of alternating paradoxical & normal breathing
 Diaphragm works for a while, takes a break & lets accessory muscles work, etc.

Blood gases: hypercarbia (but a LATE sign! Very ominous if rising – some pts can have chronic hypercarbia)

Maximum inspiratory / expiratory pressure (MIP/MEP)

 Measurement of global inspiratory or expiratory strength
 Inhale / exhale against occluded airway
 Varies with lung volume
o Max MIP at RV (the whole way down, easiest to inhale)
o Max MEP at TLC (totally expanded, easiest to exhale)

Transdiaphragmatic Pressure (Pdi)

 MIP/MEP measure all muscles together
 Pdi is specific for diaphragm
Treatment of RM failure

Muscle training (exercise) – works for skeletal muscle but NOT for resp muscle Treatment strategies
 Works in normals (↑ strength / endurance) but not patients  Exercise
 Problem: already exercising resp MM all the time (e.g. COPD)  Rest
 Medications
Rest (mechanical ventilation)  Pacing
 Allow respiratory muscles to recover from constant load  Surgery
 Mechanical ventilation
o Non-invasive (nasal / facial mask with positive pressure), invasive (if intubated)
o Temporary (endotracheal tube) or permanent (tracheostomy)

Medications: don’t really have any good ones! Respiratory muscle surgery : Lung volume reduction
 Bronchodilators (dilate airways, ↓  Used infrequently these days
hyperinflation)  Severe emphysema:
 Theophylline (↑ strength, ↑ resistance to ↑RM strength by ↓ hyperinflation
fatigue)  ↑ lung fxn, sx, survival in some pts, but
 Androgenic steroids (mixed results) unpredictable outcomes

Diaphragmatic pacing: rarely useful

 Traumatic or resp. center injury, NOT for fatigue
 Need intact phrenic nerves

Key Points (from slides)

 RM failure manifested by hypercarbia
 Diaphragm is main inspiratory muscle
 Inspiration is impaired by hyperinflation
 RM failure due to demand/capacity imbalance
 Treated by restoring balance
o ↓ workload or rest muscles with ventilator
33
 Acute Respiratory Distress Syndrome (ARDS)
Biopsy: Diffuse Alveolar Damage (thickened alveolar/capillary septae, hyaline membranes)
CLINICAL DEFINITION OF ARDS
What is ARDS?
 Acute lung injury of the alveolar-capillary membrane, 1. Acute respiratory distress.
characterized by: 2. Diffuse alveolar infiltrates on CXR
o Permeability pulmonary edema
o Acute respiratory failure 3. Severe hypoxemia (PaO2/FIO2 ≤ 200 mmHg)
Example: PaO2 of 200 mm Hg on FIO2 = 1.0
 A syndrome (see box to right) 4. Absence of left heart failure
(pulmonary capillary wedge pressure < 18 mmHg)

Routes of Injury
Inhalation Blood-borne Direct injury to lung
 Sepsis
 Aspiration of gastric contents  Trauma
 Pneumonia (diffuse bilateral)  Drug overdose (narcotics, ASA)  Lung contusion
 Smoke inhalation  Multiple transfusions  Radiation
 Near-drowning  Pancreatitis
 Venous air embolism

Predisposing factors
Other risk factors for ARDS
SEPSIS IS #1
 SEPSIS / trauma /gastric acid
 40% pts with sepsis develop ARDS; 40% ARDS pts had sepsis as factor aspiration
 Sepsis / trauma / gastric acid aspiration = 75% of cases  Older age
 Severity of associated illness
Multiple factors multiply risk of ARDS development  Cig smoking / chronic lung dz
 Chronic alcohol abuse

Clinical Course of ARDS

Variable onset of signs / symptoms
 Direct lung injury (gastric aspiration, etc): explosive course (resp distress over min-hrs)
 Blood-borne causes (sepsis, trauma, drug OD): gradual onset (hrs to days)

Risk factor exposure  90% develop sx, on vent within 3 days

 If you’re exposed to risk and don’t get sx within 3 days, you’re probably ok

Mortality: currently 30-40%; Most deaths within 2-3 wks (90%)

 Early (<3 days): underlying illness
 Late (>3 days): multi-system organ failure / nosocomial sepsis
 few (15%) from failure to oxygenate / ventilate (good at management)

Survivors: mostly NOT severely impaired

 Pulmonary function: spirometry & lung volume nl by 6mo; DLCO stays at 70% by 12mo
 Functional recovery is slower (peripheral muscle weakness common @ 12mo)

34
 Pathphysiology of ARDS
1. Injury to capillary endothelium (activated PMNs, Mϕ)  cytokines, oxygen radicals, etc.)
2. Pulmonary Edema
o Protein rich (both water & protein leaking)
o Sensitive to small increases in capillary pressure
o Insensitive to changes in blood oncotic pressure

Normally:
 fluid drains out (depends on Kf = conductance constant & driving pressure,
combination of hydrostatic pushing out minus oncotic sucking into capillary)
 Lymph channels drain lung, keep the alveolus dry

ARDS: damaged capillary endothelium

 ↑ Kf (leaky)
 ↓ σ (oncotic pressure keeps fluid in capillary less because proteins are leaking through )
 ↑ fluid filtration (Qf) as a result (Starling equation)  edema

Pulmonary edema: leads to hypoxemia & ↓ lung compliance (CL)

 Hypoxemia: Right to left intrapulmonary shunt

o Refractory to oxygen; caused by alveolar flooding & collapse
 Airway resistance ↑ (extra weight pushing on them, less tension pulling airways open)  regional hypoventilation
 Alveolar instability: abnormal surface tension forces?
o V/Q mismatch too (same mechanisms as above, just not complete) – in transition zone
o NOT contributing: diffusion impairment or hypoventilation

 ↓ Lung compliance: lung is smaller & stiffer

o Why?
 ↓ ventilated lung volume (alveoli compressed / closed)
 ↑ surface forces (surface tension ↑)
 ↑interstitial edema (heavier weight of lung itself)
 Fibrosis (later)
o All this means respiratory muscles have to work harder

Findings: CXR, CT, biopsy

 tons of Area of compression

interstitial (shunt – no ventilation) with
edema on CXR transition zone above (V/Q
mismatch)

 Diffuse alveolar damage on biopsy

 Thickened alveolar/capillary membranes
 Hyaline membranes
 Diffuse inflammatory infiltrate

35
 Management of ARDS: Oxygen Therapy
Oxygen Therapy: main strategy for ARDS treatment
GOALS OF O2 THERAPY FOR ARDS
PEEP: essentially raising FRC  Arterial O2sat = 90%
 Keep positive airway pressure at end expiration o (too high is toxic!)
 Recruits more lung: stents open compressed airways & alveoli w/ +pressure  Keep FIO2 ≤ 0.60
o ↑ FRC, ↓ shunt fraction, ↑ compliance  Maintain cardiac output

Risks of PEEP: METHODS

 ↓ venous return  ↓ cardiac output (↑ FRC  ↑ resistance)  Mechanical ventilation
 Barotrauma (volutrauma) – overinflate lung (pneumothorax!)  PEEP (positive end-expiratory pressure)
 ↑ dead space (ventilated but not perfused)
o squeezing shut alveolar capillaries; same reason why ↓ venous return)

Mechanical ventilation
 Study: reducing tidal volume in mechanical vent lead to ↓ mortality, ↑ vent-free days, ↓ organ failure
 Can cause more damage with overstretching!

Overall Therapy of ARDS: Summary

 No direct anti-ARDS treatment
 Treat underlying problem (if possible)
 Maintain O2 delivery and systemic organ fxn

 Avoid complications:
o Oxygen toxicity (keep FIO2 ≤ 0.60)
o Ventilator-induced injury (keep tidal vol ≤ 6 ml/kg)
o Nosocomial infections pneumonia, catheters

36
 Pneumonia
Significance
th
7 leading cause of death in US Generally, patients with pneumonia do well
 Leading cause among nosocomial infections  (only 25% CAP hospitalized; 12% of those die)
 M. tb is most deadly bacteria in world  Need to recognize, assess risk, Dx, Tx
 Pandemic influenza major geopolitical death

Pathogenesis
Pneumonia: infection of the lung parenchyma
 Not one disease, but many common ones that share a common anatomic location
 Some non-infectious processes also are called “pneumonia” – e.g. eosinophilic pneumonia

Route of Infection
 Many people think it’s inhaled respiratory transmission – but not most common way!
 Most: colonization (oropharynx / endotrach tube)  establish there  aspirated into lung!

Route of transmission Organisms

Inhalation M. TB, Legionella, endemic fungi, viruses (e.g. flu), anthrax
Micro-aspiration S. pneumo, H. flu, GNB, S. aureus
Anaerobes (esp. those found in mouth) – not as pathogenic (need more!)
Aspiration
Macro-aspiration  People with seizure disorders, drug users, alcoholics, neuromuscular disorders, etc. –
need big aspiration!
Mucosal spread Respiratory viruses
Hematogenous S. aureus (from R-sided endocarditis)

Pathogens need to overcome host defenses

 Angle of airways can change airflow  problems!

 Mucociliary escalator: sweep mucus upwards, cleared
 Cough reflex (prevents aspiratory pneumonia)
 Lots of stuff secreted; cellular components

 If this gets messed up, you have ↑ susceptibility

↓ Host & ↑ Microbe: the “arms race”

Lowered host defenses Microbial virulence
 Impaired consciousness
 Antigenic drift / shift (Influenza virus)
 Endotracheal intubation
 Capsule (resist phagocytosis) (S. pneumo, Cryptococcus)
 Viral infection & smoking (knocks out mucociliary escalator)
 Evasion of phagolysosome killing (M. TB, Legionella)
 Immunodeficiency

Clinical Presentation
Symptoms: Signs:
 Fevers, chills, rigors (shaking) – cytokines, etc.  Infiltration  crackles
 Cough, sputum production, dyspnea, pleuritic  Consolidation  dull to percussion,
pain (sharp with inspiration / coughing) – when tubular breath sounds
more established  Pleurisy (friction rub – scratchy sound on insp.)

CXR: INFILTRATE (diagnostic!)

37
Pneumonia vs Acute bronchitis: important for treatment
Pneumonia Bronchitis
Sx Cough & Fever Cough + Fever
Normal VS
VS: P >100,RR >24, BP
PE Rhonchi, wheezes
Crackles, consolidation
(except flu)
X-ray Infiltrate Negative
Etiology BACTERIAL VIRAL
Antibiotics? YES NO Infiltrate: hallmark of pneumonia

Diagnosis: CXR Patterns

 Lobar = restricted by fissure

 Air bronchogram: outline of bronchi stand

Consolidation
out against fluid-filled alveoli

Lobar  No normal airflow: alveoli filled w/ fluid

pneumonia
 Pneumococcal; other bacterial
pneumonias especially

 Spotty, patchy infiltrate around central

airways
Broncho-
pneumonia  Not a homogenous lobular pattern

 Viral / atypical pneumonias especially

 Linear, reticular patterns (“web like”)

 Less dense, fluffier infiltrates

 Inflammation in interstitium
Interstitial
(fluid, not pus)
pneumonia
 No air bronchograms

 Viral / atypical pneumonias especially

 Necrosis  debris discharged via

connection to airway (leaves cavity)

Lung  Air-fluid levels (if still some pus around) –

abscess or means pyogenic bacteria (S. aureus,
cavity Klebsiella, oral anaerobes)

 limited Ddx:
GNR, S. aureus, M. TB, fungi

38
 Diagnosis: Sputum & Culture
Quality of Squamous
Polys Grossly From
sputum: epithelial cells
Good: Lots Few Thick mucus Lower resp tract
Bad: Few Lots Saliva Upper resp tract

Can be mixed too: believe type III, consider type II, throw out type I
 Graded by lab
 Picture: left is good (thick sputum with polys); right is bad (saliva with epithelial)

Is what you isolated the cause?

Probable Cause Definitive Cause
 Likely pathogen isolated from normally sterile site
Likely pathogen isolated from resp secretion that… (blood, pleural fluid)
OR
 Is screened to distinguish sputum with saliva  Definite pathogen isolated from resp secretion –
 Gram stain: predominant pathogen c/w culture result these guys are never incidental!
 Culture: Moderate to heavy growth o Bacteria: Legionella, mycoplasma, M. TB, B. anthracis
 Can’t call it definitive if it could be there for other reasons! o Viruses: Influenza, paraflu, RSV, SARS
o Fungi: Pneumocystis, endemic fungi

Other rapid ID techniques:

 Antigen detection / IF (urine, resp. secretions, blood), Nucleic acid amplification (resp secretions), Ab detection (blood)

Clasisfying Pneumonia
Acute vs Chronic
Acute evolves over hours / days (S. pneumo, H. flu, Legionella – fast growers)
Sub-acute / Chronic evolves over weeks-months (M. TB, fungi, anaerobic abscesses, PCP – slow growers)

Community acquired vs Nosocomial (hospital-acquired) – for acute pneumonias

Community-acquired no significant exposure to healthcare system S. pneumo, mycoplasma, chlamydia, H. flu
Hospital-acquired Onset >48h after admission S. aureus, Pseudomonas/GNRs, Enterobacteriaceae

Community-acquired pneumonia

Causes: Common Less common

 Bacterial (80%) > Viral (15-20%) ≫
Fungal (1-2%) > parasites ( < 1%)  Strep pneumoniae
 H. flu
 See chart:  Legionella *
* = not commonly isolated from sputum / blood  Mycoplasma pneumoniae*
 Chlamydia pneumoniae*
Treatment: often EMPIRIC (and successful)  Viruses*
 Staphylococcus aureus
 Moraxella catarrhalis
 Gram-negative bacilli
 Anaerobic bacteria*
 Respiratory syncytial virus*
 Parainfluenza*
 Adenovirus*
 Metapneumovirus*
 SARS coronavirus*

39
 Classification of CAP: typical vs. atypical
“Typical” pneumonia “Atypical” pneumonia
Onset Acute Subacute
Nonspecific, systemic, more viral:
Symptoms Fever / chills / Rigors
Headache, pharyngitis, myalgias
Cough Productive of purulent sputum Non-productive cough
Lung exam findings Consolidation Few findings
CXR Dense infiltrate Patchy / interstitial infiltrate
Leukocytosis YES (WBC > 15k) Modest (WBC < 15k)
Etiology Strep pneumoniae, H. flu M. pneumoniae, Legionella sp., Chlamydia sp, viruses

Mycoplasma & Chlamydia Sp

 Symptoms relatively mild (“walking pneumonia”); mortality basically nil
 Won’t ID agents with routine studies
 Mycoplasma: can cause extrapulmonary dz (hemolytic anemia, neuro sequelae)
 NOT RESPONSIVE to β-LACTAMS: cover with tetracycline, macrolide, fluoroquinolone

Legionellosis
 Epidemiology: 2-5% of CAP, sporadic in general pop, epidemics (hotels, hospitals)
 At-risk: age > 40, COPD, immunosuppressed (old, smoking / drinking too much – like a Legionnaire)
 Dx: urinary antigen detects 80% (doesn’t grow well)
 Treatment: macrolide or fluoroquinolone
 MORTALITY: 10-20% !

Influenza
 Epidemiology: common (seasonal), also pandemic (drift/shift)
 Mortality: 36k/yr, esp. elderly elderly
 Sx: high fever, myalgia, headache, cough
 Dx: clinical Dx > Ag test > culture
 Rx: amantadine / neuraminidase inhibitors (give w/in 36hrs)
 Prevention: vaccine (70-90% efficacy, ↓ severity), antiviral px, respiratory isolation, good resp precautions

Influenza can lead to bacterial superinfection (bacterial pneumonia 2° to influenza)

1° influenza pneumonia Bacterial superinfection
Course Progressive Transient recovery from influenza, then relapse
Sputum High titers of virus S. pneumo, H. flu, S. aureus, GAS
Rx Antivirals, supportive care Pathogen-directed Abx

Aspiration Pneumonia
Frequency: ≈ 10% CAP, common cause of HAP
At-risk: Macro-aspiration (alcoholism, drug abuse, seizure disorder, neuromuscular disorder)
Sx / signs: Cough, fever, infiltrate in dependent segment (GRAVITY)

Dx: usually clinical:

 at-risk host +  compatible CXR +
 subacute course +  no other pathogens ID’d
 putrid sputum (anaerobes) +

Treatment: Clindamycin, β-lactam + metronidazole, β-lactam / β-lactamase

40
Where’s it coming from? Gingival crevice!
 Anaerobes, etc.
 See polymicrobial flora on gram stain but nothing grows on Cx (anaerobes!)

Chemical pneumonia involved too (acid!)

 Organisms in aspiration pneumonia take a while to establish themselves
 Acid burn of gastric contents  rapidly develop pneumonitis
o If no bacterial involvement: transient, no Abx needed

Aspiration pneumonia:
if bacterial agents get involved, ends up in dependent locations (GRAVITY)
 Lower lobe if standing up
 Right middle lobe if laying down / on back
 Often lead to abscesses!

Abscess vs Cavity

Aspiration pneumonia, etc. M. TB, etc. – infectious, need respiratory isolation

Often see air-fluid levels Upper lobe, esp. apical location; No air fluid levels

Nosocomial Pneumonia
Hospital pathogens: Gram (-) bacilli, S. aureus

Hosts are compromised:

 HIV, cancer Rx, neutropenia, elderly
 Mechanical defenses impaired: NG tubes / ventilators
↑ aspiration risk: impaired consciousness (anesthesia), procedures
↑ exposure to other pts: Legionella, RSV, influenza, TB, SARS

Treatment
 Empiric: BROADER spectrum than CAP (more possible causative agents)
 Pathogen directed when you figure out what it is

Prevention
 Proper infection control (↓ transmission)  Avoid unnecessary antacid therapy
 Identify aspiration-prone patients, ↑ HOB (↑ bacterial contents in stomach  ↑ infection if aspirate)
 Limit ventilator time

41
 Immunocompromised pts
Type of defects depend on what kind of immune compromise you have (what usually clears the infection?)
 Table for reference; probably wouldn’t memorize
 Asplenia  ↑ susceptibility to encapsulated organisms

TYPE OF DEFECT EXAMPLE(s) MAJOR PATHOGENS

Humoral agammaglobulinemia S. pneumoniae, H. influenzae (N. meningitidis)
Asplenia Sickle cell disease, traumatic or surgical asplenia S. pneumoniae, H. influenzae (N. meningitidis)
S. aureus, Serratia, Burkholderia, Aspergillus,
Neutrophil dysfunction chronic granulomatous dz
Nocardia
Neutropenia Aplastic anemia, cancer chemotherapy, congenital Gram-negative bacilli, Aspergillus sp.
AIDS, steroids, organ transplant recipients, cancer Pneumocystis, Mycobacteria, Nocardia, Fungi,
Cell-mediated immunity
chemotherapy, lymphoma Legionella sp. Herpesviruses (CMV, HSV)

HIV: CD4 count  what kind of infection you’re susceptible to (table for future reference too)
CD4+ Pathogens
>500 S. pneumoniae, H. flu
200-500 S. pneumoniae, H. flu, M. TB
S. pneumoniae, Pneumocystis jiroveci, H. flu , M. TB,
50-200 Histoplasma, Cryptococcus
S. pneumoniae, P. jiroveci, M. TB, Other mycobacteria,
<50 H. capsulatum, C. neoformans, Aspergillus sp.,
Nocardia sp., Rhodococcus equi, CMV, Kaposi’s sarcoma

Pneumocystis jiroveci (formerly carinii)

 Frequency: up to 90% AIDS-associated pneumonia
 Sx: Cough, dyspnea, fever (x 3+ weeks)
 Dx: Induced sputum, bronchoscopy, open lung Bx
 Rx: TMP/SMX, then HAART
 Mortality: 100% w/o Abx; 17% hosp pts + Abx
 Prevention: Abx px, HAART

CXR in Immunocompromised Patients (another one not to memorize but future reference)
CXR Finding Associated pathogens
Diffuse interstitial infiltrate Pneumocystis, CMV, Kaposi sarcoma, respiratory viruses
Diffuse nodular infiltrate (miliary) Mycobacteria, Histoplasmosis, other fungi, Pneumocystis
Localized infiltrate Typical bacteria, Nocardia, Fungi, Mycobacteria
Large nodular/cavitary infiltrate Staph aureus, Mycobacteria, Nocardia, GNR, Aspergillus, other fungi, anaerobes (aspiration)
Hilar adenopathy Mycobacteria, fungi, Kaposi sarcoma, lymphoma

42
 Etiology by Age
Newborn Children Young adults Middle age** Elderly**
(0-6 wks) (6 wk–18 yrs) (18-40 yrs) (40-65 yrs) (> 65 yrs)
 Group B strep  H. flu  Mycoplasma  S. pneumoniae  S. pneumoniae
 GNR  Mycoplasma  C. pneumoniae  Anaerobes  Anaerobes
 Chlamydia trachomatis  Viral***  S. pneumoniae  H. influenzae  H. influenzae
(4-6 wks)  Pneumocystis  GNR
 carinii (AIDS)  Viral***
Agents are listed in rank order
** Major causes of nosocomial pneumonia: *** Major viral pathogens
 GNR (Klebsiella sp., P. aerug, Enterobacter sp., and E. coli),  RSV, parainfluenza, and adenovirus
 S. aureus, anaerobes  middle-aged adults: only common viral cause is influenza.

Treatment of Pneumonia
Who should I be worried about? (Predictors of BAD OUTCOME)
 Older age  Marked derangements in vital signs
 Co-morbidities (malignancy, cardiopulmonary dz)  Multiple lobe involvement
 Alterations in host defense (don’t use bacteriostatic abx!)  Bacteremia

Treatment
 Often empiric, usually successful
 Narrow spectrum when pathogen-directed
 ↑ need to identify specific pathogens if:
o Severe disease
o Host immunosuppressed
o Unusual features (e.g. cavity)
o Failure to improve

Summary of Important Points

Role: Most important infectious disease!
Agents: Pneumococcus, Legionella, Influenza, mouth flora, M. tuberculosis
Distinctive pathogens: Age, CAP, HAP, Compromised host
Diagnostic evaluation: Poor yield, colonizers in respiratory specimens, few rapid diagnostics
Treatment: Usually empiric abx and usually successful

43
 The Pleural Space
Anatomy Review
 Lined by parietal & visceral pleural (merge @ hilum)
 Pleural cavities separated by mediastinum
 2000 cm2 of surface area, 10-20 μ in diameter (thin)

Villi on mesothelial cells (very metabolically active), stroma too

Visceral pleura: NO SENSORY FIBERS (if patient says “ow”, it doesn’t mean you hit the lung)

Pleural fluid: generally produced on parietal side

 From: Pleural capillaries primarily
o Parietal: intercostals, internal mam. arteries
o Visceral: bronchial & pulmonary arteries
o Some from interstitium too
 Intrathoracic lymphatics important for draining
 Peritoneal cavity: can have peritoneal fluid go up into pleural fluid in some disease states

Normally: slightly negative pleural pressure (lungscollapse, chest expand) – suck fluid in

Starling Equation: what determines movement of liquid into pleural space from capillaries??

 𝑄𝑓 = 𝐿𝑝 × 𝐴[ 𝑃𝑐𝑎𝑝 − 𝑃𝑝𝑙 − 𝜎𝑑 𝜋𝑐𝑎𝑝 − 𝜋𝑝𝑙 ] Qf = liquid movement

Lp = filtration coefficient (H20 conductivity of membrane)
A = surface area of membrane
 Basically: ↑ with ↑ surface area, permeability of
P/π = hydrostatic and oncotic pressures
membrane to H2O, pressure difference between
σd = solute reflection coefficient
capillary & pleural space. ↓ with ↑ oncotic pressure
• ability of membrane to restrict large molecules
difference (& ↑ impermeability of membrane to • capillary permeability (VEGF)
proteins

What causes ↑ pleural fluid?

 Normally produce 0.01 cc/kg/hr
 Lymphatics: can take up ≈ 0.28 cc/ kg/ hr (28x production!)
 So you need either ↓↓ lymphatic flow or another process to get pleural fluid build up

Normally 8 cc pleural fluid per side

 1-2 g protein / 100cc; 1400-4500 cells / μL, mainly Mϕ, monos, lymphs
 Need optimal amount for normal respiration (transpulmonary pressure maintenance, easy sliding)

Pleural effusions
Causes of Pleural Effusions
Increased Production Decreased Clearance
 ↑ intravascular pressure / interstitial fluid
 lymphatic obstruction is #1
o LV / RV failure, PE, pneumonia, SVC syndrome, pericardial effusions
o 28 fold capacity for drainage vs normal
 ↓ pleural pressure
production
o Atelectasis, ↑ elastic recoil pres.
 ↑ systemic vascular pressures
 ↑ pleural fluid protein
o SVC syndrome, RV failure
 ↑ permeability
 ? disruption of aquaporins
o pleural inflammation, VGEF
o 4 types found in the lung;
 ↑ peritoneal fluid
o AQP1 important in peritoneal fluid transport
 Disruption of thoracic duct / intrathoracic vessels
 Iatrogenic

44
Epidemiology:
 CHF (500k), Parapneumonic (300k), Malignant (200k), PE (150k), Viral (100k) are big ones
o Parapneumonic = related to pneumonia!
 Also: Cirrhosis/ascites, post-CABG, GI dz, TB, mesothelioma, asbestos exposure

Clinical features: due to underlying cause of effusion

 DYSPNEA: 57%
o 1° due to large effusion:  alteration in chest wall PV curve
o Like emphysema
 Cough, chest pain (dull in malignant, pleuritic in benign)
 Fever: more in benign disease

Thoracentesis
(taking fluid out of pleural effusion)
Indications Contraindications
Unless you know why it’s there, take it out! Absolute & relative
Especially if:  Bleeding, infection
 Unilateral effusions, particularly L-sided*  pneumothorax (1.3-20%, 2% need chest tube placed)
 Bilateral effusions of unequal size* Also:
 Normal cardiac silhouette on CXR* o vasovagal episodes / arrhythmia,
 Febrile, evidence of pleurisy o tumor seeding of needle tract,
(* = indicates that effusion’s less likely to be transudate) o puncture of other organs,
o re-expansion pulmonary edema
For relief of dyspnea too
o death (rare)

Visualize the effusion

 CXR (can lay down in lateral decubitus to help see level)
 Ultrasound
o good for ICU, small effusions, trauma, teaching
o U/S is really the standard of care these days

Go OVER THE RIB

 Superior side – avoid intercostal vessels / nerve
 Go more laterally (avoid intrathoracics, etc)

Transudates & Exudates

Two types of pleural effusions: transudates / exudates; different clinical significance & etiology
Transudate Exudate
Cause Hydrostatic or colloid pressure imbalance Inflammation / disease of pleura
Pleura Intact Damaged
CHF, PE, cirrhosis Pneumonia, malignancy, PE, GI disease
Major causes
(almost all cases!) (>90% cases are one of these 4)
Nephrosis, peritoneal dialysis, pericardial disease,
Tons (huge DDx)
Other causes hypoalbuminemia, Glomerulonephritis, sarcoid, SVC
syndrome, urinothorax, myxedema CHF:can produce exudative effusion post-diuresis

45
Is it an exudate? Get both peritoneal fluid & serum LDH + protein compare.
 Need one of the following (looking for ↑ leakage into pleural fluid)
o Fluid : Serum protein >0.5
o Fluid : Serum LDH >0.6
o Fluid LDH >200 IU/L or > 0.45 upper limit nl for lab
 If no serum labs: can use pleural fluid protein / LDH levels alone (not as good)
o (protein > 2.9, LDH > 60% upper limit nl, chol > 45 mg/dL)

If you suspect a transudate, check serum – fluid albumin gradient

 Transudate if > 1.2 g (not leaking albumin)

Other things to do:

 Check the appearance of the fluid: serous, serosanguinous, purulent (empyema), etc?
 Closed pleural biopsy is good for TB (stick needle in, try to rip off some pleura)

Parapneumonic Effusions (PPE) & Empyema

Parapneumonic effusion = effusion after pneumonia (40-57% pts with bacterial pneumonia develop PPE)
 No clinical difference but ↑ mortality (3.4-7x), especially with delayed drainage (16x)
 DON’T WAIT to treat – “never let the sun set on a pleural effusion”

PPE  empyema (pus in pleural space) in 10-20% PPE

 Up to 58% overall mortality!

Don’t wait to treat a pleural effusion! These can move quickly (e.g. PPE  air pockets rupture)

Hours later: air pockets develop with After days / weeks: can rupture,
PPE, can treat by draining
gas production, would need surgery requiring thoracotomy (major surgery)

Therapy for PPE

 ABX: based on local prevalence, resistance
 DRAIN IT:
o Chest tube ± fibrinolytics
o Thorascopy, thoracotomy, open drainage

Malignant Effusions
#2 cause of exudative effusions (200k/yr in US), #1 for exudative effusions that need thoracentesis

Lung cancer, breast cancer, lymphoma responsible for 75% 1° tumor Survival
 1° tumor not identified in 6% GI CA 2.3 mo
 BAD SIGN: Die in average of 4 months – PALLIATE by treating effusion Lung CA 3 mo
o Primary tumor is most important predictor; performance status too Breast CA / unknown 5 mo
Mesothelioma 6 mo
Pathogenesis:
 tumor emboli  visceral pleura, 2° seeding of pleural space / parietal pleura (or via diaphragm)
46
Work-up of malignant effusions:
 Thoracentesis (cytology beter than closed pleural Bx)
 Thorascopy (95% sensitivity)
 NOT Bronchoscopy (little value!)
Treatment: for palliation
 Don’t use much sedation – no nerves in visceral pleura
 Go in and remove malignant nodules
 Talc blown in (acts as glue to hold lung to chest wall;
also prevents re-accumulation of fluid)
Paramalignant Effusions
(not all effusions in cancer are malignant effusions)
 related to primary tumor but
 not direct neoplastic involvement of pleura
Etiologies: Post-obstructive pneumonia  PPE, obstruction of thoracic duct
 chylothorax, PE, SVC syndrome, post-obstructive atelectasis  ↓ PPL,
low Ponc from cachexia, pneumonitis/trapped lung, cancer Rx, more

Pneumothorax
Moving from fluid (effusion) to air (pneumothorax) in pleural space

Pneumothorax: AIR in the pleural space Pneumothorax: Physical Exam

 Spontaneous  ↓ breath sounds
o Primary (tall, thin males – paraseptal emphysema?)  ↓ fremitus
o Secondary (HIV, other underlying disease)  Hyperresonance
 Traumatic (stab wound, etc)  Tracheal deviation
 Hypotension
Presentation: depends on size & co-morbidities  Tachycardia

Small pneumothorax Tension pneumothorax

R. tension pneumothorax; lung collapses entirely  filled

R. apical pneumothorax; white line is visceral pleura; more
with air (more radiolucent), mediastinum shifts away from
radiolucent above (no lung features)
air (to left in this case)

Tension pneumothorax:
 Tachycardic: shock  death
 Need needle decompression HR returns to normal immediately!

PTX Treatment: depends on signs, symptoms / 1° vs 2°

 Observation
 100% O2  4-6x ↑ in rate of absorption
 Tube thoracostomy

Take Home Points

 Pleural fluid accumulation results from:
imbalance in hydrostatic / oncotic pressure
 Lymphatics are important for drainage
 Drain effusions EARLY!
Prior to getting a chest CT! Drain ‘em dry!
 Malignant effusion  palliate early!
 Pneumothorax: can be life threatening
47
 Bronchopulmonary Dysplasia
BPD Definition: Premature infants who require oxygen or ventilatory support beyond 36-wks post-conceptional age
 A.k.a. “premature lung disease of infancy”

Relatively new disease (1967), pulmonary disease after resp therapy of IRDS (↑ O2 conc, mechanical vent)
 airway inflammation, fibrosis, smooth muscle hypertrophy
 high mortality rate Common features of BPD
 Abnormal CXR
Premature births in US  Respiratory symptoms
 11% all US births < 37 wks (premature)  Hx of supplemental O2 and/or
 308k with low BW (<2500g), 58k with very low BW (<1500g) mech vent in neonatal period

Complications of prematurity: not just lung problems in these infants!

 BPD  periventricular leukomalacia  retinopathy of prematurity
 intraventricular hemorrhage  necrotizing entercolitis

In US, bronchopulmonary dysplasia is the leading cause of chronic lung disease in infants
 BPD can also occur in up to 20% of mechanically ventilated FULL TERM infants
Pathological Findings
ATELECTASIS, OVER-INFLATION, CYSTIC CHANGES

Hyperinflation, interstitial changes, “Mosaic changes” on CT: Histology: areas of atelectasis, other areas
cystic development dense areas, hyperinflation with alveolar enlargement; fibrosis rxn

Treatment
Has really ↑ survival for very early gestation infants
 Use of bovine surfactant
 Tertiary care centers take care of infants
 Better ventilator techniques (less damage)
 Prudent supplemental O2 use
o (high concentrations  free radicalsimpairs alveolar growth)
o Remember lung keeps growing & developing (until 2 yo)

Exogenous surfactant: made huge change in these infants

 ↓ airway surface tension
 ↓ IRDS incidence in premature infants
 Can work really fast (6 hrs in picture to right!)

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 Surfactant review
Surfactant:

 Formed in lamellar bodies in type II pneumocytes

 Secreted, forms monolayer in air-liquid interface
 ↓ surface tension

Surface tension: directly proportional to pressure needed to open & keep open alveoli
2×tension
 LaPlace’s Law: Pressure =
radius
 If ↑ surface tension, need ↑ pressure to keep open (newborn with RDS: collapse!)

BPD in Extremely Low Birth Weight Infants

Exogenous surfactant: doesn’t ↓ incidence of BPD in extremely low birth weight infants
 BPD extremely common in extremely low birth weight infants (52% 500-750g, ↓ with ↑ wt)

“New BPD”: FEWER & LARGER alveoli (alveolar hypoplasia)

 Secondary to developmental arrest in canalicular stage
(16-24 wks gestation)
 Fewer alveoli, smaller SA of lungs (see picture)  problems
 Extremely premature infants have ↓ surface area

BPD Risk Factors

1. Positive pressure ventilation
a. causes inflammation, problems in lung

2. Infection
a. Immune systems not developed
b. pre/post-natal infections

3. Inhibition of alveolar growth

a. nutrition (malnutrition)
b. steroids / oxygen (double-edged swords)

How to prevent PBD

 Prevent premature delivery
 Avoid mechanical ventilation in preemie infants when possible
o consider high frequency ventilation (smaller volumes) and permissive hypercapnia
 Steroids – double-edged sword
o Prenatal –OK
o Avoid postnatal when possible (esp. first week of life)
 Avoid infections in mother and infant
 Maximize calories in preemie infants to prevent malnutrition

49
 Diagnostic Criteria (severity of BPD)

If born ≤32 wks gestation & got >21% O2 for 28+ days: assess at 36 wks PMA or at time of discharge
Mild BPD Breathing room air
Moderate BPD Need < 30% O2
Severe BPD Need ≥ 30% O2 and/or positive pressure (nasal CPAP / PPV)

↑ need for pulm meds, hospitalization in follow up studies if more severe BPD

Respiratory Syncitial Virus: RSV

 Infection  High morbidity & ↑ mortality, especially in BPD infants
 Out to 2-3 yrs, ↑ RSV hospitalizations in BPD infants

Respiratory Symptoms of BPD

 Fast breathing  Cough with gagging / emesis
 Wheezing (breathing really fast – hard to take bottle)
 Ronchi / crackles  Cyanosis with exertion
 Retractions and/or head bobbing (bad sign)

Medical treatment
Meds
consider if need supplemental O2
Diuretics
 Preterm > 3wks – acute / chronic distal diuretics may improve pulmonary mechanics
Inhaled steroids BPD infants have ↑ airway resistance & inflammation
β-adrenergic bronchodilators use PRN (can develop tolerance)
Anticholinergics can help in respiratory aspiration
(nebulized ipratroprium, etc)  IRDS – kind of like COPD lungs in a mechanistic sense

Supplemental Oxygen
 Hypoxia in BPD infants (formerly thought was ↑ SIDS)
o ↑ number of central apneas
o ↑ central apneas, hypoxia  bradycardias, severe hypoxemia, inability to auto-resuscitate (death)
 Maintain O2 sat: better growth / development, prevent central apneas / oxygen
o ↓ risk of sudden death from acute hypoxia
 Want O2Sat 92% or greater during sleep, with feeds, during activities

Weaning off O2:

 Consider if O2sat > 93%
 Wean off during day first, assess growth over several weeks
 Consider overnight sleep study before discontinuing at night

Nutrition: need 120-150 kcal/day for adequate growth, supplemental tube feeding if needed

Exacerbation of respiratory Sx in BPD

 Aspiration during feeds  Bronchomalacia / tracheomalacia (resolves by 2-3 yrs)
 Gastroesophogeal reflux  Vocal cord dysfunction / subglottic stenosis
 GER + aspiration

Recurrent insults to lungs can worsen underlying BPD & prevent compensatory lung growth
 Growth continues through 2 years – window for catching up!

50
 Pulmonary Outcomes in BPD infants
Respiratory Sx in 25% young adults / adolescents who had BPD:
 Wheezing (↓ small airway flows)  Radiographic abnormalities
 Recurrent pneumonia  ↑ risk of airway obstruction & reactivity
 Chronic need for resp meds (↓ FEV1)
 ↓ exercise tolerance

Course:
 Hospitalizations for resp problems ↓ by 4-5 yo
 ↑ frequency of chronic resp problems (esp. obstruction)
 Wheezing ↑ smaller kids (in BW < 1500g
 ↓ resp reserve, ↑ O2 desaturation with exercise

Non-respiratory issues too!

 1/3 require physical, occupational therapy, technical aids
 One of most costly chronic childhood diseases
 Impact on everyday family function (big problem esp. if ↓ socioeconomic class)
 Severe disabilities (22% @ 6 yrs) – e.g. cerebral palsy, blindness, profound deafness
o Boys > girls
 Cognitive impairment in 41% at 6 yrs

51
 Cystic Fibrosis
Genetics of CFTR
 1:2750 Caucasians, carrier rate 1:25
 ↓ in African Americans (1:17k), ↓↓ in Asians (1:70k)
 CFTR : Single gene mutation
o (chromosome 7, most common mutation is ΔF508)
o cAMP-regulated chloride channel
o Autosomal recessive

Manifestations of CFTR
Systemic!
Lungs Chronic obstructive pulmonary disease Diagnosis by CLINICAL TRIAD:
Pancreas Pancreatic exocrine insufficiency (↓ enzymes to digest fat)  ↑ SWEAT CHLORIDE
GI CFTR channel helps in stool transit
 PANCREATIC INSUFFICIENCY
Repro glands Can’t develop (e.g. vas deferens)
Skin Sweat electrolytes ↑ (sweat test, messed up salt balance)  CHRONIC PULMONARY DISEASE

Respiratory Manifestations
 Chronic cough and bronchitis at first
 Bronchiectasis (no matter how well you treat)
 Recurrent pneumonia (staph aureus,
pseudomonas aeruginosa)
 Chronic sinusitis, nasal polyps
 Hemoptysis, pneumothorax (↑ pressure  cysts  can pop!)
 Chronic airways obstruction, irreversible

CF lung disease starts as endobronchial infection

Max prevalence Other notes
Staph aureus 50% age 5-17 yrs
H. flu 25% age 2-5 now vaccine so ↓ incidence
Pseudomonas aeruginosa peaks age 18 & remains throughout life mucoidy, makes biofilms
Burkholderia cepacia feared, very hard to treat
Progression of lung infections:
Findings in Lung
1. Bacterial endobronchial colonization

2. Intense inflammatory rxn

3. Obstructive lung dz with superimposed

pulmonary exacerbations
o (↑ cough, sputum, dyspnea, ↓ PFTs;
wt loss, fatigue, rarely fever)

Can require intermittent abx

 Oral / IV / inhaled
 Airway clearance, bronchodilators, anti-
inflammatories too

Don’t let it progress – INTERVENE EARLY

Need to be able to clear mucus

(multidimensional treatment approach) Submucosal glands dilated, hypertrophied. Airways are the problem –
mucus plugs, surrounding inflammation in response.
CXR: patchy, white, interstitial inflammation; Lungs: bronchiectasis

52
Complications of CF lung disease

Hemotypsis: bronchiectasis, dilation of brachial arteries

 Control with abx, embolization

Pneumothorax: dilated peripheral airways + mucus plugging / air trapping, rupture of pleura
 Chest tubes, pleural sclerosis involved too
 50% recurrence rate
See these more frequently in adults now: about 1/3 CF pts are adults these days

CF Upper airway disease

Nasal polyposis (shouldn’t see nasal polyps in child) Pan-sinusitis: maldevelopment  opacifiction, erosion
 Nasal polyps + asthma in child: 99% of time it’s CF!  All CF pts; Tx with abx, surgery
 3% CF pts; tx with topical steroids, surgical excision

CF GI disease
GI Sx start early: pancreas blocked, no good in utero production of fat metabolizing enzymes
 Meconium ileus (newborn) ≈ Distal intestinal obstruction syndrome (postnatal) – GI blockage
o Can lead to intussusception (telescoping of bowel into itself, can cause death)
 Meconium peritonitis too
 Pancreatic insufficiency is lifelong (malabsorption)
 Hepatic cirrhosis, portal HTN, neonatal direct hyperbilirubenemia, gall bladder obstruction
 Nutritional aspects (edema, hypoalbuminemia, hypovitaminosis A/K/E) – more rare these days

DIOS: Distinal Intestinal Obstruction Syndrome

 Not secreting chloride  stool accumulates at ileal/cecal junction
o Esp if pt out in heat, gets a little dehydrated
 Can densely adhere to wall intussusception, currant jelly stools, blood
 Tx with pancreatic enzymes, osmotic laxatives, enemas, even surgery

Pancreatic Disease
 ↓ volumes & bicarb content of pancreatic fluid
 15% have milder mutation pancreatic sufficiency (longer life span but ↑ risk pancreatitis!)
 Can lead to CF-related diabetes (3% kids, 14% adults)
o Block islets  ↓ insulin and ↓ glucagon (so ketoacidosis rare)
o Stresses can trigger hyperglycemia: pregnancy, corticosteroids, pulmonary exacerbation

Hepatobiliary Dz
 Eosinophilic concretions in bile ducts  ↑ gall bladder dz, gall stones, microgallbladder
 Cirrhosis in 3%: portal HTN, splenomegaly, esophageal varices

Congenital Absence of Vas Deferens

 Most CF males  absent / atretic vas deferens  azoospermia, infertility
o Even with mildest mutations
 Dx with palpation or U/S

53
 Diagnosis of CF
Sweat Test
 Classic test; still used as primary test

 Pilocarpine to stimulate cholinergic pathway of sweat generation

o collect w/ filter paper, measure salt
 CFTR: reabsorb chloride to protect from dehydration
o So if there’s too much chloride (very salty sweat), CF
o ≥ 60 meq / L chloride is high

 Other causes too! (but usually CF)

Varies with age: up to 80 in some adults, ≥ 30 meq/L suspsicious in young infants

When should I get a sweat test? (these things mostly make sense)
 Meconium ileus, meconium peritonitis  Panopacification of sinuses/pansinusitis in  CBAVD/Azoospermia at any age (but
 Jaundice in infancy childhood becomes more obvious in adults)
 Hypochloremic alkalosis in infancy  Pancreatitis in late childhood/early  Recurrent or persistent pneumonia any age
 Heat prostration Infancy/adulthood (males) adulthood  Staphylococcal pneumonia at any age
 Failure to thrive Infancy/childhood  Unexplained cirrhosis in (especially infants)
 Rectal prolapse in childhood childhood/adolescence  Mucoid Pseudomonas in lung at any age
 Nasal polyposis in Childhood/adulthood  Gallstones in late childhood/early adulthood  Bronchiectasis at anyage
 Family history (sibling, first cousin)
Immunoreactive Trypsin
 Most CF patients develop ↑ immunoreactive trypsin, but 80% false positive rate

Dx by Genotyping
 1000x mutations in CFTR; internet databases; don’t know significance of all
 Commercial genotyping available

CFTR: an ABC Transporter

 ΔF508 is the classic mutation (European)
o 44% homozygous
o 45% heterozygous
o 11% non-ΔF508

Classes of Mutations in CFTR

I-III: more serious
I. Stop codons (no synthesis)
II. ΔF508 (block in processing, both not fully
constructed & doesn’t make to surface)
III. Regulation: can’t open with cAMP
(pancreatic insufficiency CF if 2 serious mutations

IV-V: milder mutations (If one serious, one milder: mild dominantes - milder phenotype)
IV. Altered conductance
V. Reduced synthesis

CFTR has a spectrum of pheonotypes

 Heterozygous, / mild mutation – maybe asthma modifier
 CF Syndrome: maybe mild mutations only  sinusitis alone (atypical CF phenotype)
 Cystic fibrosis: Severe/Severe genotype

54
Organ-Specific Vulnerabilities
 Organs that make lots of protein & secrete slowly through long tortuous passages
 Genotype: predictive of pancreatic sufficiency but not other diseases (meconium ileus, liver dz, diabetes)

Pulmonary Status
 Variable rate of decline (even with identical genotype)
 Complex structure / function, main cause of morbidity / mortality

↑ CFTR carrier frequency in…

 Obstructive azoospermia  Disseminated bronchiectasis  Sinusitis
 Idiopathic pancreatitis  Diffuse bronchiectasis associated with  (Sarcoidosis)
 Allergic bronchopulmonary aspergillosis rheumatoid arthritis

CF Treatments
Aspect of CF
High Sweat Chloride
Thick Airway Mucus
Chronic Lung Infections
Inflammation
Respiratory Failure
Pancreatic Insufficiency
Meconium Ileus
Islet Cell Loss
Male Infertility, CBAVD
Biliary tract insufficiency
Treatment
Dietary Salt (a disease you ↑ salt for!)
Chest Physiotherapy/DNase
Hypertonic Saline
Antibiotics
Anti-Inflammatories
BiPAP
Lung Transplant
Pancreatic Enzymes
PEG, stool softeners
Insulin, Pancreatic Transplants
In Vitro Fertilization
Bile acid salts

Some Data and Stuff

Better survival with more recent birth cohorts

 ↑ with nutrition, vitamins, enzymes, abx, better tx / analaysis of data / use of registries (best practices)

FEV1 ↓ with age but ↑ with BMI

 Try to keep BMI of CF pts up!

Respiratory severity ↑ with age (more normal lung fxn in children)

 Once you lose it, won’t get it back

Bacterial infections vs time

 Pseudomonas: 80% pts from 25-34 yo
 ↑ MRSA these days
 B. cepacia – especially bad

Lung transplant: not a good solution; limited organs available, tons of side effects, risk of death
 Trading one disease for another

Median predicted survival now 38 years (↑ but still – only 50% live to be 38!)

55
 Disorders of the Lower Airways
“When noisy breathing is not asthma”

Clinical Approach
History
Physical Exam of the Chest  Onset
 Inspection: Vital signs (resp rate, SaO2), retractions, contour  Alleviating / exacerbating factors
 Percussion (dullness vs hyperinflation) o Position
o Diaphragmatic domes normally w/in 1-2 finger breadths of scapular tips
o Occurrence: sleep or activity
 Palpation o Response to therapy
 Auscultation is the big one  Other associated symptoms:
o Inspiratory or Expiratory COUGH (never normal in babies!)
o Airway disease = narrowing
(laminar vs turbulent air flow depending on radius)
 Something pushing in from outside!
Position Sound Ins/Exp More detail
Above thoracic output Stridor Inspiratory
High pitched Peripheral (e.g. asthma)
Below thoracic output Wheezing Expiratory
Coarse sound Central (larger airways)

Where do sounds come from? THE AIRWAY!

 Turbulent = loud, laminar = quiet
 Most from trachea, medium sized bronchi
 Peripheral airways: nearly silent; contribute little to total resp resistance
o Unless asthma / narrowing

Describing breath sounds

NORMAL ABNORMAL
 Respiratory phase
 Bronchial (tubular): equal loudness I/E o Inspiration (stridor) or end-inspiration (crackles)
 Vesicular: I>E, soft expiratory phase o Expiration (wheezes)
 Location (e.g., central or peripheral)
 Quality (e.g., monophonic or polyphonic)

Lower Airway Lesions in Newborns & Infants

“Wheezing since birth” – noisy on 1st day of life
 Think congenital lesions (vascular ring, tracheal web, absent pulm valve, congenital lobar emphysema)
o All result in tracheal compression – can see expiratory flow reduction

Congenital Thoracic Malformations:

old nomenclature separated; now lumped together
 Affected lobes remain filled with fluid at birth (radiodense), then later air
 Recurrent infection is common complication, often with abscess formation (periphery)
 Unaffected lobes: usually normal, can be compressed
 Get an electrocardiogram (associated with cardiac abnormalities)

CTM: foregut cysts:

 Not pathogenic in and of themselves but press on other things; can get infected
 Most common cyst in infancy (Sx = compression) but
50% diagnosed >15yo (Sx = chest pain, dysphagia)

56
 o Small incidence of malignancies
 Tx: often lobectomy (no recurrence with complete excision)

CTM: Congenital cystic adenomatoid malformations

 Often solid / fluid filled at birth  air filled with time
o Can see air-fluid level on CXR
 Classification: related to location and potential for malignancy
o Associations with other syndromes & malignancies
 Tx: resection (esp. infection)  most surgeons remove

CTM: Pulmonary sequestration

 Pulmonary tissue separated from functioning lung and
supplied by SYSTEMIC circulation
 Etiology: 2 theories

o Congenital: accessory lung bud;

primitive perfusion from systemic circ
persists

o Acquired: focus of infection/scarring

 develops systemic blood source

 Anatomy of pulmonary sequestration

(w/in parenchyma, Asx until infected (adolescence)
Intralobar 75% usually L posterior basal) (recurrent “pneumonia”, abscess formation, abnormal CXR)
(beneath L. lower lobe; perfused by
Detected in infancy (associated malformations)
Extralobar 25% abnormal artery coming from below
diaphragm) Diaphragmatic lesions, gut anomalies, polyhydramnios
Extralobar extrathoracic Rare
 Treatment: surgical excision

Congenital large hyperlucent lobe

Formerly “Congenital lobar emphysema” (CLE)

Incidence: 1:20k-30k
Etiology:
 Mechanical obstruction in utero(25%) – mucosal flap, lobar twisting on pedicle
 Airway collapse (25%) – bronchial atresia, deficient bronchial cartilage
 No clear etiology (50%)

CXR: over inflated lobe

 compressing trachea
 pushes everything over to right
 Hyperlucent(over inflated) – can get V/Q mismatch
 Upper lobe disease: here LUL, most common, > RUL > RML, LL rare)

Pathology: ↓ # alveoli, ↓ bronchial wall cartilage

Treatment: expectant management (see if improves) – previously more excision
 Some mechanical vent techniques might help (oscillatory vent if ventilated)

57
Tracheoesophageal Fistula
 Incomplete mesodermal separation of primitive foregut
 Esophagus connected to trachea
o See barium swallow to right
 More common: 1st and twin pregnancies; ↑ with ↑ maternal age
 2/3 have other associated abnormalities
 Presents around birth (feeding / breathing abnormalities)

4-5 different kinds:

 H-type fistula: small connection between trachea & esophagus
o Can present later: recurrent pneumonia / wheezing but rare
 Esophageal etresia is most common (esophagus stops as blind pouch, distal esophagus connects to trachea)

Can all be repaired surgically

 Local tracheomalacia & brassy cough common after TEF repair
o Malacia = “softening”
 Esophogeal dysmotility (vagal disruptions)  recurrent aspiration
 TEF can recur after repair (very rare)

Vascular Rings
 Can show up early but often later in life
 Extrinsic obstruction of trachea & esophagus
 Most common: double aortic arch; can see others too
o Wraps around trachea, compresses
o Just sever one of arches (smaller one)  everything OK

CXR: look for right sided arch (sensitive but not specific – common variant)

Pulmonary swing:
 Left PA originates from Right PA, courses posterior to trachea (see CT)
 Results in tracheomalacia

Tracheomalacia / Bronchomalacia

Dynamic collapse of trachea secondary to increased compliance of tracheal rings

 Worse on exparation
 Most common in distal 3rd
 Can get kinking (transition from malacic segment to normal segment)
 Babies: spells of apnea (collapse airway with crying, etc.) - dangerous

Laryngeomalacia Tracheo/ bronchomalacia

stridor, inspiratory, upper airway wheeze, louder on expiration
Many people have combo! Biphasic noise (may indicated fixed narrowing)
Most gets better over time if not repeated injury from aspiration, other probs

Parents often aware of noisy breathing early but often don’t present until 6-12 mo
 Fremitus is uniform, normal lung volumes (obstructing), lack of retractions, poor bronchodilator response
 ALWAYS present if you have a TEF

58
Bronchoscopy:
 Left mainstem bronchus has keyhole appearance
 Right mainstem bronchus has a lip (airway flopping into lumen)

Tracheal Bronchus
If airway not built right (e.g. aberrant RUL bronchus coming off of trachea instead of bronchus)
 Picture: ignore arrow, actually the top bronchus branching off early

 Normal variant, predisposes to chronic RUL atelectasis

o Pigs are all like this, so called “pig bronchus” too

 Don’t need to do anything about it unless causing problems

Foreign body aspiration

 Can occur in any age, frequently toddlers / preschoolers (stick stuff in mouth)
 Choking Hx often negative
 Unilateral / “monophonic” WHEEZE
(same tone throughout)
o Phase delay on differential stethoscope

CXR often doesn’t help: most are radiolucent

 may be difficult in younger pts to get insp/exp films
 L-R decubitis films show absence of deflation

Lack of response to all medical therapy

Chronic Congestion
 CHRONIC WET COUGH IS A RED FLAG – something else is going on! (wheezing + cough)
o Beyond just narrowing of airways
o CF / primary/acquired dyskinesia, passive smoking, humoral immunodeficiency, retained foreign body

Gastroesophageal Reflux Disease

 Recurrent croup is often a sign of GERD (“spasmodic” with no sign of URI)
 Hoarseness
 Can lead to laryngomalacia (acid)
 Poorly controlled asthma

59
 Bronchiolitis
INFLAMMATION of BRONCHIOLES usu. occurring in children UNDER 2 YRS OLD resulting from VIRAL INFECTION
 Disease of WINTER, infectious in nature

Pathophysiology
 Airway obstruction  Ventilation / perfusion mismatching
o Airway wall edema o Hypoxemia
o Mucous plugging
o Bronchospasm  Paradoxical breathing
 Increased airway resistance o Decreased tidal volume
o Air trapping o Decreased minute ventilation
o Decreased compliance
o Increased work of breathing

Path: large mucus plug, fairly loose, some cellularity

Related to CERTAIN INFECTIONS

 RSV: causes lower airway dz in infants (cold in adults)
 Also: influenza A, metapnuemo, paraflu, adenovirus, mycoplasma pneumonia

Clinical manifestations of RSV:

 Rhinorrhea
 Cough
 Low grade fever
 Apnea (CNS-related)
o Early: RSV-specific
o Later: sign of resp failure
 Tachypnea
 Hypoxemia
 Wheezes / Crackles

Therapy:SUPPORTIVE CARE

Remember: not all that wheezes is asthma… but most of it is

60
 Upper Airway Disorders

Anatomy Review
Nasal Cavity Turbinates and sinus ostia (ethmoid, maxillary, frontal)
Nasopharynx Airway posterior to the nasal passages, adjacent to soft palate
Oropharynx Posterior to the tongue
Hypopharynx Superior to and including the vocal cords
Larynx Airway inferior to the vocal cords

Where are potential sites of obstruction?

Upper Airway Development

Birth: large epiglottis

 covers soft palate, forming channel that encourages nasal breathing

 INFANTS are OBLIGATE NASAL BREATHERS

o If you block the nose, hard to breathe!
o Cleaning out the nose (congestion) helps with many problems

 If epiglottis closed, straight shot to esophagus:

o but everything close to each other: easy to aspirate!

Laryngeal Position
 Infants: have high larynx (C3)
o more efficient breathing with nursing
o ↓ aspiration risk

 Adults: larynx drops down (C5)

o Better for speech (longer passage)
o Older, better coordination, can handle aspiration risk

 Neanderthals were somewhere in between (some capacity for speech)

Airway Obstructions: Overview

Nasopharyngeal obstruction Oropharyngeal obstruction Laryngopharyngeal obstruction Infection
 Choanal atresia  Tonsillar hypertrophy  Laryngomalacia  Croup
 Adenoid hypertrophy  Micrognathia  Vocal cord paralysis  Epiglottitis
 Macroglossia  Subglottic stenosis  Diphtheria

Nasopharyngeal Obstruction
Choanal atresia
 Nasal cavities extend poteriorly during development, directed by palatal process’ fusion

st
Membrane separates nasal cavitiy from oral cavity  thins & ruptures (mid 1 trimester)
 Rupture failure = choanal atresia
o Remember infants are nasal breathers: 1° route of breathing obstructed

Epidemiology: most common cause of true nasal obstruction (1:10k)

 2:1 unilateral:bilateral
Associated with other congenital anomalies in 50%, including CHARGE
 Colomba, heart, choanal atresia, retarded growth, genital hypoplasia, ear defects
61
Choanal atresia, cont.

Presentation: can cause cardirespiratory failure on 1st day after birth

 Apnea, cyanosis, respiratory distress – relieved with crying / mouth breathing
o Re-establishing an airflow via mouth!

Dx: try to pass a #8 French catheter through each nostril to see if it’s patent!

Complications:
 Aspiration from dyscoordination (2° to ↑ nasal airway resistance)
 Severe hypoxemia with sleep (trying to breathe through nose  obstructive apnea)

Treatment: INTUBATION is most effective initial treatment

 Surgical excision with stent (4+ wks) to prevent recurrence is definitive

Waldeyer’s Ring
 “adenoids & tonsils”

 Pharyngeal tonsils = adenoids

 Lingual tonsils too
 Palatine tonsils = normal tonsils
 Tubal tonsils – back side

Tonsils have strategic placement

 Where particles should drop out of air
 Lymphoid tissue picks it up

But if they get inflamed, they can cause instruction

Adenoid Hypertrophy
 Long face
 Open mouth breathing (blocked nasal passage)
 “Nasal” voice
 ↓ development of maxilla over time

Maxillary development is dependent on nasal breathing

 Some weird oxygenation effect?
 Chronic obstruction  ↓ maxillary growth

Treatment: adenoidectomy

Oropharyngeal Obstruction
Tonsilar hypertrophy
 “kissing tonsils” – see pictures
 Can be graded but airway obstruction doesn’t correlate directly
o Also depends on airway tone is with sleep!
 Cause airway obstruction

62
Presentation (Tonsilar hypertrophy)
 Snoring is most common
 Muffled voice, drooling, trouble swallowing, choking on solids (more rare)
 Obstructive sleep apnea: no airflow movement during breathing (dx with sleep study)
o mostly between 2-6 years old (tonsils growing, airway smaller)
o or adolescents (heavier  more soft tissue)
Treatment: Tonsillectomy (80-90% successful)

Micrognathia
 often associated with underlying genetic disorders

Pathophysiology: Mandibular hypoplasia of unclear etiology

 often associated with cleft palate
o (small jaw  tongue displaced ↑  palate shelves can’t fuse)

Therapy:
 Mild micrognathia: may improve by school age
 Severe micrognathia: can require intubation / tracheostomy

 Better breathing in prone position (tongue flops forward out of airway)

 Mandibular distraction  mandibular remodeling (pic)

 Labiolingual suturing (“tongue-lip adhesion”)
o prevents tongue from being posteriorly displaced
o temporary (until child grows)

Macroglossia
 Big tongue
Associated with: angioedema, congenital syndromes (e.g. Beckwith-Wiedemann), lymphangioma
Pathophysiology: Tongue displaced into hypopharynx  obstructive apnea
Therapy: prone positioning, tongue debulking (rarely done)

Laryngopharyngeal obstruction
Laryngomalacia
 Most common cause of stridor in infants
o Inspiratory noise, implies extrathoracic obstruction
o (Wheezing = expiratory, intrathoracic – e.g. asthma)

Pathophysiology:
 Dynamic anomaly, cartilage collapses into airway
 Etiology unclear (no tissue anomalies, no differences in muscle bulk – maybe muscle dyscoordination, structural variation)

Presentation:
 Stridor onset since birth, minimal respiratory distress
 Worse in supine position and when agitated / active
 ↓ noise when at rest (↑ flow  ↑ turbulence – kind of like cardiac murmurs)
 Normal voice quality & pitch

Treatment: usually no therapy required (resolves by 12 mo)

63
Vocal Cord Paralysis
 #2 common congenital laryngeal abnormality
Bilateral VCP Unilateral VCP
Etiology  usually idiopathic  usually recurrent laryngeal nerve damage
 can be from CNS lesions (anything pressing on  birth trauma or with cardiac surgery too (e.g. PDA
brainstem ligation)
Presentation  Diagnosed late  Normal phonation & stridor
 Mild stridor, hoarse phonation, occasional aspiration  Occasionally as airway emergency
(if on top of cough, cold, etc)
Treatment Correct CNS lesions, may need tracheostomy Improves (↓ inflammation, other VC compensates)
 Signs of birth trauma: think VCP possibly
 VCP: can be early sign of brain stem / spinal cord compression
 Acquired too: local neck trauma, head trauma, viral compression (more rare in kids)

Subglottic Stenosis
Congenital Acquired
rd
Epidemiology 3 most common laryngeal anomaly Related to airway inflammation
Incomplete recanalization of larynx Inflammatory factors: prolonged intubation, traumatic
Pathophysiology
during gestation intubation, oversized endotracheal tube used, GE reflux
Presentation Recurrent / persistent croup Hx of prior intubation, airway instrumentation
If Severe stenosis: biphasic stridor, dyspnea, labored breathing
 Gets much worse if they have a cough or cold  already obstructed
If you’re having trouble with expected ET tube size, be careful!

Treatment: frequently requires tracheostomy or airway surgery (more than other two)

Laryngopharyngeal Obstructions: Approach

Diagnosis:
 X-rays correlate poorly with actual degree of airway narrowing
 Flexible laryngoscopy for Dx
 Pulmonary function tests  upper airway obstruction (need > 6yo kid)

Laryngoscopy: looking down into the airway

Epiglottis somewhat omega-shaped

Laryngomalacia Can see that it’s dynamic (collapsed on picture
to right)

Unilateral vocal cord paralysis

(lack of bulk on paralyzed side in L picture, doesn’t
Vocal cord
completely close in R picture)
paralysis
Opening: should close completely (aspiration risk)

Subglottic Very narrow opening

stenosis (all subglottic stenosis closing it up)

64
Laryngopharyngeal Obstructions: Complication
Inability to coordinate feeding
 Growth failure, aspiration
 Treatment: occupational therapy or feeding tube (worst-case scenario)

Obstructive apnea (GET A SLEEP STUDY)

 Hypoxemia  growth failure, neurodevelopmental delay, pulmonary HTN & cor pulmonale
o Sleep study for snoring kids!
 Treatment: CPAP / BiPAP (stent open airway), airway surgery and/or tracheostomy

Infections
Viral Croup (Laryngotracheobronchitis)
 Most common infectious cause of upper airway obstruction in pediatrics
o Peak 18-24 mo
o Often post-URTI (coryzal prodrome)

Most common agents (75% cases): parainfluenza viruses (esp. PIV1)

Pathophysiology:
 Edema  narrowing; stridor from turbulence
 Smaller airway, poor cell-mediated immunity  predisposition of airway obstruction
 Cricoid cartilage: complete ring (not C-shaped like lower down in trachea, bronchi)
o Bigger reduction in lumen (so more predisposition to obstruction) (resistance ↑ with r4)

Presentation:
 Barking cough, hoarse voice, inspiratory stridor (exertion / agitation), restlessness
o Drooling / resp distress in severe cases
 Symptoms worse at night
 Hypoxemia / hypercarbia: severe upper airway obstruction
 Hx of recurrent croup suggests underlying abnormality
(more than 3-4x in same kid)

X-ray: STEEPLE SIGN is classic

 Supposed to be open airway but blocked!
 Doesn’t correlate with severity of obstruction

Therapy:
 Nebulized epinephrine (α-adrenergic effects vasoconstriction, ↓ edema)
o beta-agonists don’t help
o Doesn’t affect duration of croup
o REBOUND can occur – keep watching the kid for a while!
 Heliox mixtures  ↓ turbulence but no large studies
 Most studies: no benefit with humidified air
 Corticosteriods: supported by evidence but type, route, dosing regimen debated

65
Epiglottitis

Cellulitis of supraglottic structures

 Typically 2-7 yo in autumn / winter
 Incidence ↓↓ with HiB vax

Pathophysiology of Epiglottitis
 HiB  99% of cases historically
o Other bacteria & some viruses since vaccine
o HiB still in non-immunized, vaccine failure
(trisomy 21, prematurity, malignancy, immunodeficiency)

Presentation
 Rapid for HiB, more gradual for strep
Sore throat / dyspnea  muffled voice, drooling, tripod position, toxic appearance
o Picture: kid tripoding (leaning forward, on hands; retractions too)
 Stridor isn’t prominent but can occur with worsening obstruction

X-ray: THUMB SIGN

 (looks like large thumb on epiglottis - inflammation)
 Getting X-rays before airway secured = controversial

Therapy: MEDICAL EMERGENCY

 Call ENT or anesthesia IMMEDIATELY
 Inhalational induction of anesthesia, intubation:
but be ready to do tracheostomy

 Abx: cover HiB & Strep

 Some evidence for empiric use of steroids

Prognosis: Intubation time: 1.3 days for HiB, 6d for Strep

Diptheria
 Incidence ↓↓↓ with vaccination
 Exudative material clogs / blocks airway (gray films)
 Antitoxin is mainstay of therapy

Important Points
Upper airway obstruction can present as a medical emergency
 Secure the airway first, then worry about diagnoses
 Nasal obstruction can pose significant problems for obligate nasal breathers (infants)
Obtain polysomnography (sleep study) to assess severity of obstructive apnea
 Pulse-oximetry alone is not adequate
 Asymptomatic examination while awake can be misleading
Why we treat:
 Obstructive apnea can lead to growth failure, developmental delays, and right ventricular failure

66
 Pharmacology: Lung
Drugs for Asthma .................................................................................................................................................................... 2
 Drugs for Asthma
Anti-inflammatory Bronchodilators
 Short-acting β2 agonists
Acute therapy
 Systemic steroids  Ipratropium bromide
(quick relief meds: rescue!)
 Theophylline
 Inhaled steroids
 Systemic steroids
Prophylaxis / Maintenance  Long-acting β2 agonists
 Montelukast / Zafirlukast
(long-term meds: prevent Sx!)
 Zileuton
 Neocromil / Cromolyn

β2-agonists
Structurally related to isoproterenol (pure nonselective β-agonist)

Short-acting: for quick relief

Mechanism of Action: Short-acting beta-2 agonists (anti-asthma)
Effects: Relaxes smooth muscle (bronchodilation) by stimulating adenyl cyclase, increasing cAMP.
Other distant effects too (importance less than bronchodilation in asthma): suppresses histamine / leukotrine release from
pulmonary inflammatory cells, enhances mucociliary clearance, decreases microvascular permeability.

Selective Toxicity: Selective for beta-2 over beta-1

Indications: Quick-acting symptom relief for asthma
albuterol
Administration: MDI or neb
metaproterenol
terbutaline Toxicity: due to excessive stimulation of beta receptors.
levalbuterol  CVS (tachycardia, palpitations, exacerbastes CAD, arrhythmias).
isoetharine  CNS (anxiety, apprehension, tremor, anxiety).
 Metabolic (hypoK, hyperglycemia).

Resistance: Tolerance has been documented at high doses with chronic treatment.

Special Members of Class: Levalbuterol: R-isomer of albuterol; 100x more affinity than S-isomer, more expensive
but probably equally effective; occasionally use in kids

Long-acting
Mechanism of Action: Long-acting beta-2 agonists (anti-asthma)
Effects: Like short-acting (see above), but longer duration.
 Also inhibits inflammatory mediator release from lung

Indications: Long-acting maintenance / prevention for asthma.

 12h protection against bronchoconstricting stimuli; esp. nocturnal / exercise-induced asthma

Administration:
salmeterol
 Salmeterol: Does not fully occupy beta-2 receptors so can use short-acting drugs as needed as rescue
formoterol
meds (can still use albuterol).
 Formoterol: Dry powder aerolizer. q12h (10h plasma halflife).
o Faster onset than salmeterol (1-3 min vs 10-20 min)
Metabolism: Formoterol metabolized by multiple CYP enzymes

Toxicity: Black box warning: make sure to counsel on how to use (not for rescue!); o/w like short-acting

Resistance: Tolerance (like short-acting)

 Inhaled Administration: Nebulizers vs Metered-dose inhalers (MDIs)
MDI Nebulizer
 Enhances drug delivery to site of action
 Doesn’t require coordination like MDI
Advantages (droplet size optimized to hit deep airways)
 Delivers more medication
 ↓ systemic absorption, toxicity
 Coordination & understanding required  More expensive than MDI
Disadvantages
 Compliance can be an issue (use too much)  Delivers more medication

Tolerance:
 If you give methecholine challenge & measure FEV1 < 20%, β-2 agonists can raise the level.
 Less effect after time for asthmatic patient: tolerance develops (feedback regulation)
 Take-home: lowest dose for least amount of time to be effective.

Anticholinergic agents
Structural analogs of atropine
Mechanism of Action: anticholinergic agent (for asthma)

Effects:
ipratropium  block muscarinic receptors in airway smooth muscle
o (inhibit resting cholinergic bronchoconstror tone by reducing cGMP levels).
bromide
 Also block vagus reflex bronchoconstriction (block sensory afferent input)
o augments parasympathetics so more bronchodilation.
tiotropium
Indications: short-acting asthma rescue
Administration: more robust response when combined with albuterol
Other: tiotropium's use in asthma is off-label

Methylxanthines (theophylline)
Mechanism of Action: methylxanthine anti-asthma agent. Tons of possible mechanisms of action:
 Inhibit PDE so more cAMP and cGMP, more smooth muscle relaxation.
 Adenosine antagonists so bind to A2 receptors (stimulate membrane bound adenyl cyclase).
 Short-term: may increase catecholamine levels & enhance effect on adrenergic receptors)

Effects: relaxes smooth muscle.

Positive effects & negative effects related; + can be – in some pts!
Good (can be bad too) Bad
↓ drowsiness, clearer flow of thought, less nausea, anxiety, tremor,
CNS
fatigue. Stimulates medullary respiratory center. insomnia, seizures.
↑ cardiac contractility, may ↑ catecholamine ↑ ventricular instability
theophylline CVS
sensitivity. ↓ PVR & venodilates in patients with CHF
Skeletal mm ↓ fatigue.
Renal diuretic effects
GI ↑ secretion of gastric acid & pepsin
Metabolic ↑ BMR and free plasma fatty acids.

Administration: with basic compound to enhance solubility.

 aminophylline = 80% theophylline, 20% ethylene diamine

Toxicity: See above; related to dose (more toxic episodes with increased [serum])
Other: methylxanthine potency: theophylline > caffeine > theobromine.
 Glucocorticosteroids
Mechanism of Action: anti-inflammatory agents.
 Suppress release of leukotrine & prostaglandin mediators from inflammatory cells
 (inhibit phospholipase A2, ? phospholipase C).

Indications: in asthma, prophylaxis only (NOT rescue). MAINSTAY of controller treatment.

inhaled Administration: inhaled
glucocorticosteroids Toxicity:
 Candida infections (mouth/throat).
 Dysphonia (laryngeal myopathy) - less with slow inhalation, using a spacer, gargling.
 systemic side effects possible with large doses (inhibit hypothal-pituitary-adrenal axis).
 bruising & purpura at high doses.
 May inhibit growth in children (but outweighed by benefits)

Mast cell stabilizers

Mechanism of Action: "Mast cell stabilizers" - antiasthma agents

Effects: NOT bronchodilators.
 Inhibit mediator release (histamine, leukotrine, platelet activating factor) from pulm inflammatory cells;
prevent degranulation.
chromoglycate
 Low concentration: suppresses chemotactic factors' effects (on PMNs, eos, monos).
(Cromolyn)
 May prevent bronchoconstriction neurally
o (bradykinin / SO2-mediated bronchoconstriction; maybe C-fiber sensory nerve involved).
neocromil
Indications: prevention of cold- and exercise-induced asthma.
 chromoglycate especially effective against cough.
 can work against both acute & delayed effects (single dose).

Leukotriene antagonists
 Leukotrienes: arachidonate metabolites

o Arachidonate presented to 5-lipoxygenase by FLAP (5-lipoxygenase

activating protein)  LTA4 (unstable intermediate).
o LTA4 can be converted to LTB4 (via LTA4 hydroxylase) or LTC4 (via
LTC4 synthase) depending on cell type
o LTC4LTD4LTE4 via enzymes in tissues / circulation

Mechanism of Action: leukotriene antagonist anti-asthma agents.

Effects: Inhibits cysteinyl-LT (enzyme involved in downstream conversion of leukotrines to effectors).
Indications: Prophy/maintenance of asthma sx. Increases FEV1% and reduces asthma symptoms
 Montelukast at least as effective as zafirlukast
zafirlukast
Metabolism: montelukast:
 Rapid GI absorption; plasma [] peak in 3-4 hrs; half-life 2.75-5.5 hrs. Metabolized by CYP3A4 and 2C9.
montelukast
Toxicity:
 zafirlukast: inhibits CYP450 enzymes (drug interactions with theophylline, warfarin, prednisone
o Churg-Strauss vasculitis & hepatic toxicity too.
 montelukast: doesn’t inhibit CYP450s; less of other side effects too
 Mechanism of Action: leukotrine antagonist antiasthma agent. Inhibits 5-lipoxygenase
Effects: 5-lipoxygenase mediates conversion of arachidonate to LTA4 in the leukotrine metabolite pathway.
Zileuton Indications: Not first line; may use as alternative to corticosteroids if contraindicated.
Administration: 600 mg QID
Metabolism: rapidly absorbed, Tmax = 2hrs, T1/2 = 2.5 hrs. Hepatic glucuronidation.

Anti-IgE mAb
Mechanism of Action: anti-IgE mAB(anti-asthma)
Effects:
 binds free IgE (released from mast cells & basophils in pts with allergic component to asthma);
 down-regulation of IgE receptors results (long-lasting effect: 100-fold reduction in IgE)

omalizumab Indications: > 12 years old with

(Xolair)  moderate/severe persistent asthma &
 reactivity to allergen with symptoms inadequtely controlled by inhaled corticosteroid
 (e.g. tons of hosp visits or severe symptoms)

Administration: IV or SQ q 4 wks
Other: EXPENSIVE (annual cost $6-12k) - cost-effective if preventing many hospital visits in allergic patients.

Summary (from slides)

 The fastest bronchodilator response is provided by
inhaled beta-2 agonists.
 More prolonged bronchodilator response may be
achieved with salmeterol, formoterol or
theophylline. Reducing or preventing
inflammation is an important aspect of asthma
treatment.
 Inhaled corticosteroids are the drugs of choice for
preventing or blunting the inflammatory
response. Zafirlukast or montelukast may offer a
convenient, oral alternative to or adjunct with
inhaled corticosteroids.
 Bronchodilator treatment may augment or, in
selected patients, replace anti-inflammatory
agents.
 Systemic (oral or intravenous) corticosteroids
should be reserved for severe cases in which less
hazardous treatments have failed.
 Omalizumab is a novel treatment for asthma, but
its cost and the uncertainty of long-term safety
suggest that it should be reserved for patients
with severe asthma who are frequently admitted
to the hospital.
 Pathology: Neuro
Intro to Neuropathology ......................................................................................................................................................... 2
Trauma of the Nervous System .............................................................................................................................................. 7
Cerebrovascular Disease ....................................................................................................................................................... 13
CNS Tumors ........................................................................................................................................................................... 20
Peripheral Neuropathy ......................................................................................................................................................... 25
Pathology of Neurodegenerative Disease ............................................................................................................................ 30

1
 Intro to Neuropathology
Cellular Components
Neurons
 1011 in CNS; many different types; big variety of size/shapes
 Have selective vulnerability to hypoxia, neurodegenerative dz, other insults
 Generally lots of cytoplasm & large round nucleus with prominent nucleolus
o Look like “fried egg”
 Nissl substance: lots of RER (very metabolically active; need to sustain lots of cytoplasm)
 Dendrites (lots; tree) & axon (1) project from body (soma)
 Organized in groups (nuclei, ganglia) or layers

Neuronal reactions to injury:

 Acute neuronal injury  red neurons (after
hypoxia/ischemia/toxic/infectious insults)
 Atrophy/degeneration (chronic disease)
 Axonal reactions
 Neuronal inclusions

Glia
 Lots of different functions:
o mostly neuronal support system, react to injury, regulate metabolism
 Most numerous cells in CNS
 Astrocytes, oligodendroglia, ependymal cells, (microglia – not really glia)
 GFAP = IHC stain for glia
 Note: Neuropil = “nerve felt”; mix of neuron/glial cell processes (fluffly pink between cell bodies)

Astrocytes: found throughout neuroaxis

 Protoplasmic astrocytes in grey matter; fibrous in grey & white
 Structure:
o Round / oval nuclei; star-like processes
o Nuclei: round/oval, slightly larger than oligodendrocytes
 End-foot processes with TJs  BBB & CSF-brain barrier
o Abut neurons, vessels, pia, glia limitans
 Functions: metabolic buffers, detoxifiers, suppliers of nutrients, electrical
insulators, physical barriers
o Major cells in damage repair in CNS (fibroblasts of brain)

Oligodendroglia: found in white matter

 Processes wrap around, insulate axons
o Allow saltatory conduction
 1 oligodendroglia : several axons
 Round, regular, lymphocyte-like nuclei
with dense chromatin
o Can have halos around cells

2
Ependyma
 Single layer of cuboidal to columnar cells lining ventricular system
 Cilia / microvilli on apical surface
 Brain / CSF barrier; involved in transport
 Choroid plexus is specialized ependymal structure (CSF-secreting)

Microglia
 NOT GLIA (mesoderm-derived, from bone marrow)
 Act like Mϕ / monocyte system in brain
o Proliferate / migrate in response to infection / injury
o Phagocytic
o Act as APC of CNS
 When activated, retract / thicken
processes & then can migrate to site
of injury/ infection
 Clean up dead neurons
(neuronophagia) – looks like sesame
chicken

Choroid / Meninges
Choroid plexus
 Specialized cells derived from ependyma; secrete CSF
 Papillary fronds of cuboidal epithelium covering vascular cores
 TJs maintain BBB
 20 mL CSF / hr made; normal CSF volume ≈ 140 mL
o (25mL in ventricles, rest in subarachnoid space)

Meninges
 Dura: fibrous; closely attached to periosteum
o Epidural space present in SC
 Leptomeninges = arachnoid, pia
o Made of meningothelial cells & connective tissue
 Arachnoid: thin, translucent, drapes over blain
 Pia: delicate; invests arteries as they penetrate brain, closely attached to cortical surface

CSF: circulates in subarachnoid space (between arachnoid / pia)

 Arachnoid granulations: small aggregates of arachnoid cells
o protrude into dural venous sinuses
o One way valves (CSF drains into dural venous sinuses)
o Blockage (e.g. meningitis)  hydrocephalus

Special Neuropath Stains

Stain For…
The Black Stain (Golgi’s silver) Lets you see single cells (dendrites, axon, etc) – only taken up by some cells
Gold chloride-mercury (Ramon y Cajal) Astrocyte stain, like Golgi’s Black stain
GFAP IHC for glia (glial fibrillary acidic protein)
Synaptophysin & NeuN IHC for neurons
Luxol Fast Blue Myelin
Hirano silver Alzheimer Dz
Methenamine silver (GMS) Fungi
(Note that other IHC stains are available for pretty much everything else too)
3
 Pathology of Neurons
Neuronal Apoptosis
Pathology of Neurons
 Programmed cell death  Apoptotic neuronal cell death
 In normal development: eliminate extra neurons  Hypoxic / ischemic neuronal necrosis
o Can be seen in CNS disease too (e.g. brain tumor)  Neuronal loss (neurodegenerative dz)
 Axonal pathologies
 Clumped, fragmented chromatin o axonal degeneration after neuronal death
o Karyorrhexis o neuronal changes after axonal damage
(DNA fragmentation)  Neuronal inclusions
o Condensation (apoptotic bodies) (esp. infectious / neurodegenerative process)
o Individual cells, dispersed pattern

Necrosis
 Hypoxia, ischemia #1, also heat, toxins, hypoglycemia
 Particularly vulnerable: cortical layers 3/5, hippocampus (CA1), Purkinje cells

If acute: see: RED NEURONS (eosinophilic discoloration w/in 12 hrs)

 If severe: glia die too  Mϕ clean necrotic region afterwards

If chronic (E.g. neurodegenerative)  gradual neuronal loss (no red neurons)

Axonal pathologies

Axonal degeneration after neuronal injury (see pic: CST in ALS)

 Decoloration (myelin stain is negative; CD68+ for Mϕ )

Neuronal cell body reaction after axonal damage

(a.k.a. “axon reaction”)
 Dendrites retracted
 chromatolysis
(rounded shape, eccentric nuclei)
 Nissl substance lost

In PNS: Schwann cells (axons regenerate pretty well)

In CNS, oligos don’t help regenerate axons as well

Neuronal Inclusions (Neurodegenerative Disease)

Cytoplasmic
Alzheimer’s Neurofibrillary tangles
Parkinson’s Lewy bodies
Pick’s Pick body

Nuclear
Huntington’s Ubiquitin (+) inclusion
Generally proteinaceous debris in inclusions

4
Metabolic Disease
 Many inherited metabolic diseases can result in neuronal abnormalities

Inclusions: viral infections

 Can see in both neuronal & glial cells often
 CMV, measles, adenovirus, herpes, VZV, rabies, etc.

Pathology of Glial Cells

Reactive Astrocytosis: non-specific reaction to infection, seizures,

autoimmune dz, infarction, etc.
 Normally: can’t see outline of astrocyte, just nucleus
 If you can see outline: astrocyte is starting to react & change!

Fibrillary gliosis: proliferation of reactive astrocytes

Pliod gliosis: can see around spinal cord cavities & other long standing reactive gliosis in cerebellum, hypothalamus

Genetic . metabolic diseases can involve glia too

 Most commonly leukodystrophies (disrupt myelination)

Progressive Multifocal Leukoencephalopathy ()

 Caused by JC virus glial inclusions
 Oligos infected (mostly in white matter; right)
 Mϕ come in to clean up damage (left)

Overview of basic CNS pathology

Infarction
Hours / days Neurons: eosinophilic, shrunken
PMNs: infiltrate lesion
Days / weeks Neurons gone
Mϕ infiltrate lesion
Reactive astrocytosis around edge
Months / years Cystic cavity

Viral infection

 Acute: tend to involve brain parenchyma (encephalitis)

 Lymphocytic infiltrates around vessels, in neural tissue
 Rod-shaped activated microglia, micoglial nodules
 Chronic: can have varied appearances

Bacterial infection
 Purulent meningitis or brain abscess
 Lots of PMNs

5
Fungal infection
 Can involve either brain or meninges primarily
 Some can cause granulomatous inflammatory responses
 Immunosuppressed patients mostly

Aspergillis (trophic for blood vessels  hemorrhagic necrosis)

Also: blasto, mucor, candida, histo, crypto, coccidiomycosis

Demyelinating disease

 MS: sharply circumscribed plaques

o myelin gone or in foamy Mϕ
o Reactive astrocytes, preserved axons also present

Trauma
 Can cause: superficial contusions, hemorrhage at any site, frank necrosis
 Hemmorhage: epidural, subdural, subarachnoid, intraparenchymal

Diffuse axonal injury

 Microscopic damage to nerves
 Caused by severe acceleration or deceleration of head
 Worse with lateral motion
 Medial structures most affected
 Axonal swellings in white matter

Neoplasia

 Gliomas: most common CNS tumors

o Infiltrate through brain
o can’t fully excise surgically

 All CNS cell types can give rise to tumors

Neurodegenerative diseases
 Affect various populations of cells, have disparate mechanisms
 Characterize by distinctive inclusions and associated neuronal / glial cell loss

6
 Trauma of the Nervous System
Introduction
 Most traumatic brain / SC injuries can be prevented
 Trauma of brain often accompanied by trauma of spinal cord
 Complications of TBI: secondary brain edema, herniations, infarctions, hemorrhages

Brain & SC protected: skull, spine, CSF (shock absorber) Complex pathogenesis:
 But bony structures can become source of injury!  Stress
 Mass effects
 2° vascular perturbations
& edema
Epidemiology
 1.5M / yr with TBI; 50K die, 80k  long-term disabilities
 5.3M in USA living with disability as result of TBI
 Cause: Transportation > falls > firearms, assault, others

Lesions by anatomical location

Scalp injury
abrasions, contusions, lacerations, hematomas (collection of
blood outside vessels)

 Examine scalp  may be able to locate site of impact

 Can have brain injury without scalp lesions (“shaken
babies”, auto accidents)

Skull Fractures
 Falls: non-depressed fractures in calvarium (skullcap) with linear or complex pattern
 Severe trauma: fractures of calvarium extend to base of skull
 Blunt trauma: depressed fractures are more common

Brain contusions / lacerations frequently result from depressed fractures (but linear fractures can cause too!)
 At time of impact: edges of fracture can become depressed for an instant  cause damage  instantly realign

Basal skull fracture: often from severe trauma

 difficult diagnostically (complex radiographic appearance of base
of skull); some signs:
o blood in ear canal
o hemmorhagic discoloration over mastoid (Battle’s sign)
o CSF leak through nose

7
Dura mater & Leptomeninges
Hemorrhages
Type Etiology Characteristics

 Arterial origin  rapid development, life-

Epidural Fx of squamous portion of temporal bone threatening volume in hours (FAST!).
(=extradural) laceration of middle meningial artery  Treat with surgical burr, can have good recovery
 Bulges out away from skull (convex: high pressure)

Venous or capillary origin  slow growth (days)

Esp. in pts with severe brain atrophy: vessels
Common in all types of trauma
bridging dura / brain become stretched, susceptible to
Subdural From cortical contusions or tears of
tears with minor trauma – e.g. old pts in falls
bridging vessels (shearing)
 Can be chronic and calcify
 Can re-bleed with next injury or spontaneously

Variable distribution; prominent over convexity of

Most common path consequence of head
hemispheres (vs aneuyrism  at base of brain)
Subarachnoid trauma, also often from rupture of
aneyurisms (berry aneurysm @ base of brain)  May block normal CSF circulation 
hydrocephalus

Can see contusion on edge of brain if traumatic;

Inside brain parenchyma, e.g. if someone falls
Parenchymal multiple parenchymal hemorrhages  probably
(old person, etc.)
traumatic

MRI appearance of four types of acute, post-traumatic intercranial hemorrhage

 Right: epidural (lens-shaped, convex, doesn’t cross sutures)
 Left: subdural (follows surface of brain, concave, crosses sutures)
 Top: subarachnoid (penetrates down into gyri)
 Top, just below subarachnoid: parenchymal (ball-shaped)

8
Cortical Contusions
Bruising of brain (most frequently cerebral
cortex) from impact against skull
 Most (not all) hemorrhagic
 Can lead to focal neuro
manifestations and/or seizures

Can become cavitated
 Mϕ remove debris, astrocytes
(fibroblasts of brain) respond, see
hemosiderin (brown pigment)
Contusion vs. Concussion
Contusion Concussion
A traumatic lesion characterized by tissue necrosis, damage to Transient impairment of consciousness due to head
small vessels, interstitial bleeding, and edema, without trauma, without a determinable structural lesion of the
disruption of the continuity of the tissues. brain.
 Concussion has a functional connotation

Post-concussive syndrome: for < 6 mo:

 Headache  dizziness / vertigo
 sleep cycle abnormalities  attention / concentration impairment
Lacerations of the brain
Wounds or cuts in parenchyma; result from high mechanical stress / skull fracture

Hemorrhages / hematomas
 Traumatic hemorrhages can be single or multiple
 Cerebral white matter is common site
 Amyloid deposition in cerebral blood vessels (older pts)  ↑ risk of traumatic
hemorrhage

Axonal shearing
White matter injury often from acceleration / deceleration injuries (e.g. automobile accidents)
 Causes cognitive / motor deficits in aftermath of head trauma

Brain edema / swelling

↑ brain volume due to ↑ water content
 Vasogenic (from trauma / tumors) – tight junctions open in BBB
 Cytotoxic (hypoxia / ischemia)

Can be localized (around contusion / laceration) or generalized (diffuse axonal

injury in acceleration / deceleration)

Signs:
 Flattened cortical gyri
 Collapsed ventricular system / aqueduct of sylvius
 Cerebral herniations (if severe)

ICP rises exponentially with volume (>75-100mL excess - ↑↑ ICP rapidly)

9
Herniations
Parenchyma of brain extrudes through openings in skull
Herniation Description
unilateral supratentorial lesion pushes uncus (mesial portion)
of temporal lobe through tentorial notch
Transtentorial / Uncal  Often compress CN III
 can lead to Duret’s hemorrhage
unilateral supratentorial lesion pushes
Cingulate / subfalcial
cingulate gyrus under dural falx

bilateral supratentorial lesion pushes

Central
diencephalon & hypothalamus downwards
posterior fossa lesion pushes
Tonsillar cerebellar tonsils through foramen magnum
 compresses medulla, CV/resp centers  bad

Vascular complications: blood vessels stretched / compressed during herniation

 Duret’s hemorrhage: midline hemorrhage of the pons (blood vessels stretched after transtentorial herniation)
 Occipital lobe ischemic / hemorrhagic infarcts from compression of PCA in uncal herniation

Mechanisms of head injury & patterns of lesion

Note that there’s usually a combination of mechanisms, not just one
Blows to the Head
 Scalp laceration / contusion, skull fracture, underlying contusion / laceration of brain parenchyma
 Can see subarachnoid, epi-, subdural hemorrhage too

Falls (Coup-Contrecoup)
Primary forces are translational (not much rotation)
 Point of impact: scalp contusion or laceration ± skull fracture

 Coup injury directly under point of impact: small

lesions

 Contrecoup injuries on opposite side of skull:

extensive cortical contusions
o Base of brain is rough! Back of brain is
smoother – posterior fossa, etc)

Most survive; can have frontal lobe problems

 Can have behavioral problems
o (plan, drive, impulsivity  prefrontal cortex)
 Occasionally see seizures

Example: fall backwards, hit back of head.

 Point of impact: scalp contusion, subgaleal hematoma, no skull fracture, no
cerebellar / occipital lesions
 Large cortical contusions of frontal / temporal poles, orbitofrontal regions

10
Acceleration / Deceleration (Diffuse Axonal Injury)
Automobile & sports accidents: neuro impairments with “closed head trauma”
 Angular / rotational forces  axonal & microvascular shearing

 Scalp, skull intact; Imaging, external exam of brain unremarkable

(± some edema, subarachnoid hemorrhage)

Path:
Macroscopic: linear hemorrhages
(frontal/temporal white matter, corpus callosum,
periaqueductal region)

Microscopic: extensive axonal shearing

 “Axonal balloons” – axonal swelling
o means that axon has been cut
(can be ischemic too)
 Pallor in myelin-stained sections
“Shaken Baby Syndrome”
 750-3750 / yr in US; 1/3 die, 1/3 permanent injury, 1/3 spared
 Kids with TBI from child abuse usually have other traumatic injuries too (ribs, limbs, etc.)
 See acceleration / deceleration injuries on path
 Retinal hemorrhage can be seen too (but not just in trauma: 25% neonates for 1st 4-6 wks, but goes away)

Sports & TBI

 Concussion is most common brain injury in sports (300k/yr), 90% boxers, 1 in 3.5 football games
 Superficial cortex, neurons & astrocyte problems result; hippocampus / parietal cortex  memory probs
 Chronic traumatic encephalopathy in adults: boxers, football players
o Brain atrophy, hydrocephalus in young people (with tau accumulation!)

Firearm use & TBI

 Firearm use is leading cause of death related to TBI
o (10% of all TBIs, 44% of TBI-related deaths)
 9/10 people with GSW of brain die
Long-term consequences of head trauma
Chronic subdural hematomas, limited to hemosiderin-stained subdural membrane; cortical contusions
 Cause posttraumatic seizures

Hydrocephalus: after subarachnoid hemorrhage impairs flow / reabsorption of CSF

 Variable clinical expression
 can lead to dementia, gait apraxia, incontinence (normal pressure hydrocephalus)

Cranial nerves can be injured: vision (II), ocular motility (III/IV/VI) often

After diffuse axonal injury: Can cause severe motor / sensory / behavioral / cognitive deficits
 brain atrophy  2° loss of myelin in frontal, temporal lobes
 hydrocephalus

Clinical consequences:
 Neuro impairments affecting consciousness, cognitive, sensory, motor domains
 Executive function impairment (cognitive / behavioral) often overlooked
o From frontal lobe lesions, esp. after diffuse axonal injury
11
 Spinal Cord Trauma
Most frequent causes: motor vehicle accidents, falls, gunshot wounds, sports accidents (diving / football)
 Males 15-25 have highest risk
 Often combined with head injuries Traumatic Spinal Cord Injury
 11k/yr in US; 190k living with
Most SC injuries: from compression 2° to paralysis due to SC injury
fractures, dislocations, subluxations of  24 h survival is important: 85% of
vertebrae those who survive 24h after
 Possible to have SC damage without injury still alive 10 yrs later
obvious injury of vertebral column too
 Cervical, lumbar spines most vulnerable (↑ mobility)
 Thoracic less susceptible (rib cage, costal-vertebral ligaments  ↑ stability)

Cervical spine / cord injuries between C4 & C8 are most common nonfatal spinal injury associated with head trauma
 Always damage ligaments  dislocation / subluxation (partial dislocation) of vertebrae
 Hyperextension, hyperflexion, hyperrotation, compression
o Compression: e.g. diving accident, football head-on tackle: one cervical vertebrae compressed, “ burst” fracture,
compresses cord
Lumbar, lower thoracic spine / cord  mostly rotation / flexion (vehicular accidents / falls)

Pathology of spinal cord injury

Acute
segmental softening
variable degrees of necrosis & hemorrhage
 Necrosis most severe centrally (gray & white
matter), tapers off in caudal / cephalic areas
Later: (1+ months post-injury)
necrosis replaced by central cavity
 Degeneration of ascending / descending spinal
pathways on microscopy
 Leads to irreversible axonal injury

Pathogenesis of SC injury (animal models)

 1° injuries (immediate): mechanical disruption of membranes, abnormal electrolytes, ATPase ↓
 2° injuries (1st 24 hrs): ischemia, reperfusion, free-radical generation, Ca-mediated toxicity
o 2° injuries = target for treatment now (steroids, adrenergic blocking agents, endorphin inhibitors, etc)

Clinical Features
Segmental signs at level of injury
 Muscle atrophy / weakness at one or two root levels (LMN involvement)
 Ascending long-tract signs (loss of all sensory modalities below level of lesion)
 Descending long-tract signs (UMN involvement)
o Paralysis, Spasticity, Hyperreflexia, Extensor plantar responses below level of lesion

Above C4  highest risk of fatality (PHRENIC NERVE  diaphragm paralysis, also tetraplegia)

Level, extension of lesion determines:

 Tetraplegia (paralysis of all extremities) vs Paraplegia (paralysis of lower extremities)
 Total or partial paralysis

Cervical, high thoracic injuries: extra problems

 Resp / autonomic control
 Bladder, bowel, sexual functions compromised

12
 Cerebrovascular Disease
Introduction
Brain needs blood! 2% of body wt, but gets 15% of cardiac output & uses 20% body’s oxygen
 Has no glucose stores of its own
 Cerebral blood flow is highly regulated (under normal arterial pressures, no significant change in flow)
o Gray matter > white matter for blood flow
o ↑ PCO2 in interstitial space with ↑ neuronal activity  local vasodilation  ↑ local cerebral blood flow

Stroke: happens when vascular supply is interrupted (infarction or hemorrhage)

 3rd leading cause of death in US
 All ages; ↑ incidence with age

Anatomy review
Internal carotids & vertebral – basilar arteries form dual blood supply to brain
Circle of Willis formed from these – variable sizes of anastamoses

ICAs  “anterior circulation”

 anterior cerebral a. (ACA), middle cerebral a. (MCA), anterior choroidal a., posterior com. a. (P-com)
Vetebral aa.  “posterior circulation”
 posterior cerebral a. (PCA), superior cerebellar a. (SCA), anterior inferior cerebellar a. (AICA), posterior inferior
cerebellar a. (PICA)
13

Artery
Anterior cerebral artery (ACA)
Middle cerebral artery (MCA)
Posterior cerebral artery (PCA)
Path Features:
 blurring of gray/white junction
 petechial hemorrhages in affected areas
Cortical Blood Supply
Territory Deficit of stroke Pictures
 Contralateral legs
Medial walls of:
 Frontal lobe
 Motor + sensory (primary motor,
 Parietal lobe
primary somatosensory cortex)
Lateral walls of:  Face, arms > legs (primary motor,
primary somatosensory cortex)
 Frontal lobe
 Parietal lobe
 Speech centers
 Temporal lobe
(if dominant hemisphere – usu. L)
 Medial and inferior  Visual cortex
surfaces of temporal lobe (or optic radiations)
 Occipital lobe  Contralateral visual field cut
14
 Blood Supply to Deep Nuclei
Basal ganglia, thalamus, hypothalamus: supplied by perforating branches of ACA, MCA, PCA
 ACA: anterior hypothalamus, anterior caudate /
putamen, anterior limb of internal capsule
 MCA: posterior caudate / putamen, most of globus
pallidus, genu / post. Interal capsule, middle
hypothalamus
 PCA / P-com: post. Hypothalamus, subthalalmic
nucleus, dorsal thalamus, choroid plexus

Picture: stroke going right through internal capsule

(pure motor stroke!)

Blood Supply to Brainstem

Midbrain Posterior cerebral a. (PCA); basilar artery
Pons, cerebellum Basilar artery, PCA
Medulla Vertebral arteries
Note that multiple unnamed branches supply medial, lateral portions of brainstem too
Pic: old lateral medulla infarct
 Lateral medullary syndrome: PICA or vertebral artery occluded; takes out lateral medulla
o Lose pain/temp contralateral in body, ipsilateral in face (crossed)
 STT damaged (contralateral body); trigeminal nucleus (ipsilateral face)
 Motor to body spared (CST in pyramids; not affected)
o Also dysphagia, ataxia, slurred speech, facial pain, vertigo, Horner’s syndrome, diplopia

Blood Supply to Spinal cord

Spinal arteries originate from vertebral arteries

Anterior spinal artery (1) Anterior 2/3 of cord

Posterior spinal arteries (2) Dorsal columns

Reinforced by medullary arteries

 enter cord with nerve roots
 artery of Adamkiewicz @ lumbar level is most important

Infarcts usually happen in anterior spinal artery distribution

 Disrupt a. of Adamkiewicz can cause infarction of middle, lower levels of cord (Ao dxn or repair of AO dxn, aneyurism)

Pathogenesis of Infarction
Large Vessel vs. Small Vessel Disease

Large vessel disease Small vessel disease

Named vessels & branches (see above) Basal ganglia, cerebral white matter, pons affected
 Lacunar infarcts
Usually from atherosclerosis, thrombosis, embolism Usually from HTN or DM
Note that HTN is important in both (↑ BP  ↑ risk atherosclerosis, also damages small vessels directly)
Lacunar infarcts
 Small “holes” from occlusion of small vessels
 Affect deep gray nuclei, deep white matter, cerebellum,
base of pons

15
Embolic vs Thrombotic infarcts

Thrombotic infarcts: thrombosis of large vessels

 caused by atherosclerosis in intercranial or neck vessels (e.g. bifurcation of carotid)
 single infarcts (one vessel occluded)
 nonhemorrhagic: generally remains occluded for long period of time; little / no reflow

Embolic infarcts: showers of embolic material travel to many vessels

 usually from carotid, can be from left heart
o particles from atherosclerotic plaques, mural thrombi, vegetations on cardiac valves
 multiple infarcts
 hemorrhagic: fragments break down  reflow

Selective Vulnerability
 Function of cell type (neurons > glia > blood vessels)
o Hippocampus (CA1), large neurons in cortical layers 3 & 5, Purkinje cells especially vulnerable
 Gray matter more vulnerable than white matter (more metabolically active)

Clinical implications: laminar necrosis with transient / lower levels of ischemia

 Cardiac arrest or global hypoxia-ischemia: selective for big neurons / areas listed above

Regional Vulnerability / Watershed Infarcts

 Function of vascular anatomy
 Most cerebral arteries are end-arteries ACA
o so ↓ BP  poor perfusion of distant arterial territories

“Watershed” / “border zone” infarcts develop (at junction between territories) MCA MCA
 Border between ACA / MCA or MCA / PCA
 Can be single, multiple, or continuous
 Often hemorrhagic when flow restored (to necrotic vessels) PCA

Time Course of Pathological Changes

Early changes (hours-days)
Time Path changes
0-4 hours Nothing
4-6 hours Hyperchromasia of neurons (“red neurons”)
 “Red neurons” more prominent
12-24 hours
 Discoloration & softening grossly
Edema (here with big midline shift, looks like ↑
24 hours
white matter size)
 Neuronal hyperchromasia Edema (acute MCA infarcts).
 Glial necrosis Note midline shift in right specimen
1-4 days Neuronal hyperchromasia
 Scattered PMNs (“red neurons”)
 Worse edema
People die from stroke if interference with cardio / resp function occurs

Possible complications:
 Transtentorial Herniation (compress 3rd nerve, with hemorrhage)
 Duret hemorrhage (secondary - push on brainstem, pull on small arteries in
midbrain / pons  stretch  hemorrhage)

16
Later changes (weeks / months)
Time Path changes
5-7 days Mϕ start appearing, cleaning up
 Rest of cells pale
8-14 days  Reactive astrocytes appear Reactive astrocytes (above)
 Pink cyto, full of IFs
 Edema resolves
 Liquefied necrotic tissue removed Organizing infarct (left)
wks / months
 Cyst formation  Well-defined border
 Liquefactive necrosis
Long-term changes (months / years)  Gradual cystic change
 Takes months / years for large infarcts to resolve
completely (slow rate of removal of liquefied necrotic Falling apart; border becomes
more distinct. Remember: no
tissue)
fibroblasts in brain (astrocytes)!
 No fibrosis (no fibroblasts)  CYST results
 Volume of cyst is smaller than original tissue volume
o so ipsilateral dilation of lateral ventricle / midline shift towards lesion can result

Primary intracranial hemorrhages

(Vs. secondary hemorrhages (trauma, Duret hemorrhages))
Other causes (aside from list to right): Major causes
 coagulopathies (esp. in hospitalized pts) – platelet, clotting factor deficiencies of 1° intercranial hemorrhages
 Disorders of blood vessels (amyloid, vasculitis, Aspergillus / Mucor infection)  Hypertension
 Amyloid angiopathy
Hypertensive Hemorrhages  Berry aneuyrisms
 Most common cause of primary intracerebral hemorrhage  Vascular malformations
o (also #1 for occlusive stroke: HTN is common!)
 Blood pushes brain
Base of brain! aside
 Deep gray matter, esp. putamen Putamen  Can often do well if
 (pons, cerebellum too) you survive (not
destructive)

Can:  Rapidly fatal (herniate

 rupture into lateral ventricle (fatal) Pons  compress resp.
 resolve as hemosiderin stained slits centers)

Pathogenesis of hypertensive hemorrhages:

thought to arise from Charcot – Bouchard aneurysms
 microscopic dilatations
 develop at branch points of penetrating blood vessels
 theory: one ruptures  pushes on adjacent ones  they rupture

Arterial tortuosity may play a role too

Diagnosis of hypertensive hemorrhage for intraparenchymal hemorrhage:

 History of hypertension (or HTN path changes on autopsy)
 Location of bleeding (base of brain?)

17
Amyloid angiopathy

Associated with Alzheimer’s disease & aging

 deposition of β-amyloid (abnormal breakdown of APP)
 deposited in media of small vessels (arterioles); Congo red birefringence
 Rare families have inherited forms

Location: usually supratentorial and relatively superficial with lobar distribution

 Think: LOBAR HEMORRHAGE in OLD PATIENT

Berry (saccular) aneurysms

 From arterial branch points in / near the circle of Willis
o Usually anterior circulation
 Small (3-10 mm) saccular dilations
o arise from congenital defects
o may be multiple, sometimes familial (25% have >1)
o may be asymptomatic if small, or rupture

Subarachnoid hemorrhage: if berry aneurysm ruptures

 ↑ risk of rupture with ↑ aneurysm size
o 1/3 ruptures associated with acute ↑ ICP
(straining at stool, lifting heavy objects)

 Early – mid-adulthood (rupture)

o 1st episode may be “sentinel bleed” (warning sign)

 “worst headache of my life” is classic description

o Can produce cranial nerve sx (compression)
o Can extend to brain parenchyma / ventricular system (hydrocephalus)

 Arterial vasospasm: major complication of rupture

o Can lead to extensive cerebral infarction
(↓ blood flow to rest of brain)

Treatment: clips or coils

Arteriovenous Malformations (AVMs)

Tangled masses of markedly abnormal blood vessels in parenchyma, meninges, or both

 Arise from early embryo (when cerebral blood vessels form)

 Include nidus, feeding artery / arteries, and draining veins

o Arteries feed directly into veins  high flow shunt
(drain blood away from parenchyma)

 Produce subarachnoid and/or intraparenchymal hemorrhages

o sometimes focal ischemia too

18
Symptoms
 Early / middle adulthood
 Seizures or headaches (can have focal symptoms too)

Treatment: surgery, endovascular embolization (sacrifice vessels for surrounding veins), radiosurgery (gamma knife)
 Can re-form if abnormal vessels remain

DDx: multiple hemorrhages in unusual sites

Esp in hospitalized patients
 Platelet disorders (leukemia – no platelets!)
 Clotting factor abnormalities
 Vasculopathies (fungal infection: aspergillis)

Sample cases (for practice)

Notes:
 Case #2: swelling tells you it’s a few days ago
 Case #2, flip side: older, because of contraction / shrinking in affected area

19
 CNS Tumors
Classification & Grading
 Classified by how they resemble a normal precursor cell (although origin not actually clear)
 Molecular characterization useful for some (oligodendroglioma, glioblastoma, medulloblastoma)

Grading
 Numerical index: degree of malignancy, biological aggressiveness
 Descriptions below can vary with treatment, type of tumor
o little Tx effect for glioblastoma; ½ cured in Grade IV medulloblastoma
Description Life expectancy (if untreated)
Grade I Well circumscribed, “non-invasive”, slow-growing, little malignant potential
Grade II Often infiltrative; prone to malignant degeneration variable, often ≤ 10 yrs
Grade III Mitotically active, usually infiltrative ≤ 5yrs
Grade IV Overtly malignant (anaplastic) ≤ 2yrs

Benign vs Malignant
 Vary; generally malignant for grade III-IV gliomas; is it really “benign” if grade II kills you in 10 yrs (astrocytoma)?
 Some malignant neoplasms (choroid plexus carcinoma) – cured by excision alone
 “Well-differentiated” vs “anaplastic” is more precise
o but still need to take type, grade, location, Tx available into account

Staging
 Only used rarely in CNS tumors; CNS tumors rarely spread outside of nervous system
Intra/extra-axial
 Meningiomas are usually extraaxial; the others here are usually intraaxial
Clinical expressions
Produced by:
 Bulk of neoplasm itself
Mass effect  Peritumoral edema, hemorrhage
 Obstruction of CSF pathway
 Rare: choroid plexus papillomas – actually secrete CSF
Common presentation in tumors involving cerebral cortex
Seizures
 Temporal lobe is most frequent site of epileptogenic tumors
Varies with location
 Some are very stereotypic
Focal neurological defect
 Mostly need MR, Sx and biopsy to make diagnosis
 but sometimes can use neuro sx + imaging alone

Spinal Cord Lesions

Epi- (extra-) dural Can be bad if it’s invading bone!
Intradural extramedullary Often easier to resolve
Intramedullary: Bad – don’t want to be inside the cord!

Pics:
 meningioma is intradural extramedullary (left)
 astrocytoma: intramedullary, diffusely infiltrating
(right)

20
 Meningioma
Feature Description
Arachnoid meningothelial cells (cranial, spinal meninges)
Origin  can be intraventricular (meningothelial cells in choroid plexus)
Spontaneous mostly, also prior radiotherapy or inherited syndromes (Neurofibromatosis 2)

 ADULTS, slightly F>M

Clinical  ↑ ICP and/or focal neurological deficit (depends on site)
Features  Seizures are less common than intra-axial neoplasms
 Can be discovered incidentally, usually well-circumscribed

Discrete contrast-enhancing lesions

Radiology  Short extensions along dural surface (“DURAL TAILS”)
 Most arise along meninges & compress instead of infiltrating brain (malignant variants can invade)
Most well-differentiated; cells resemble normal leptomininges
Histology  WHORLS and CALCIFIED CONCRETIONS (“PSAMMOMA BODIES”) are classic
Grade I (well diff) > grade II (atypical) > grade III (anaplastic)
Loss of chromosome 22 (in region of NF2 gene; ½ -2/3)
Molecular
Losses on 1p and 14q = tumor progression (↑ in grade II/III)

Simple excision (often truly benign) or just follow

Treatment
 Harder to excise if infiltrate bone or surround critical fessels
Prognosis
 Can recur if less well differentiated (anaplastic)

L: Normal meningothelial cells; Classic whorls & psammoma body Meningioma (lower left); expands &
R: meningioma (very similar) (central calcification of whorl) causes mass effect here

Most are spontaneous; here radiation-induced (L, in path of Common locations (bad if
DURAL TAILS on MRI
beam) and from NF2 (multiple lesions) around ICA, etc)

Left: meningioma invading skull

(rare)

Right: Grade II meningioma

(more mitoses, prominent nucleoli)

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 Gliomas (Glioblastoma Multiforme, GBM)
Note that gliomas include astrocytomas, oligodendrogliomas, ependymomas: here focusing on GBM
Feature Description
Astrocytes (precise origin often obscure)
Origin
Mostly spontaneous (rarely: prior radiotherapy, Turcot’s syndrome – DNA mismatch repair, colon + brain tumors)

Adults mostly (can happen in kids, esp. in pons)

Clinical
 Throughout CNS; most common in cerebral hemispheres
Features
 Recent onset symptoms (fast grower): seizures, headaches, focal neuro defects

Ring or rim of contrast around dark central necrotic area

Radiology
 Broad zone of edema on T2 MRI

Variable (multiforme), composed of malignant glia (generally astrocytes)

 2° features: NECROSIS and VASCULAR PROLIFERATION
 Necrosis with PSEUDOPALISAIDING (rows of cells around it)
Histology  GLOMERULOID VASCULAR PROLIFERATION
o (VEGF released from ischemic cells  pericyte, endothelial cell hyperplasia  looks like glomerulus!)
Malignant: ↑ cellularity, ↑ mitotic rate, ↑ invasion & infiltration
 Often pass through corpus callosum to opposite hemisphere

Primary pathway: more common, no obvious precursor: ↑ EGFR, deletion of p16, PTEN mutations
Molecular Secondary pathway: from better differentiated astrocytoma precursor  develops p53 mutation
Loss of chr 10 common in both; distinguishing feature from grade III anaplastic astrocytoma

Curative surgical excision impossible except in rare cases

Treatment
 Inevitable residual tumor, rapid growth, resistance to other therapies
Prognosis
Rarely survive past 3 years; median survival 15 months

Normal: Astrocytoma: H&E (L, kind of looks Glioblastoma (L, MRI with contrast; R, T2)
O = oligodendrocyte, like astrocytes) & IHC for GFAP Note ring around central area of necrosis
A= astrocyte (R, see astrocytes & processes w/ contrast

More glioblastomas (MRI with contrast) – see ring of No distinguishing path features;
Gross: large necrotic area; here
contrast enhancement around central necrosis here tiny cells but can have tons
producing herniation (mass effect)
Lesion on right is in brainstem of forms

22
 More glioblastomas

Vascular proliferation (left) and Highly invasive: infiltrating corpus callosum

pseudopalisaiding (cells crowding
together & kind of lining up around
area of necrosis)
Glomeruloid vascular proliferation:
(left; myelin stain, see cell bodies); crossing
kind of looks like a glomerulus if you
corpus callosum (right) to contra. hemisphere
squint just right

Medulloblastomas
Feature Description
Mostly unknown / spontaneous
Origin
Some have sonic hedgehog pathway mutations  external granular cell layer mutations

Children mostly (can happen in adults too)

Clinical
 Sx: CSF flow obstruction: headaches, nausea, vomiting
Features
 Cerebellar neuro deficits too

 Discrete, contrast-enhancing masses in vermis or cerebellar hemisphere

Radiology
 CSF pathways can be seeded at presentation

From neuronal precursor

 NEUROBLASTIC (Homer Wright) ROSETTES
 Immunoreactive for synapse-associated protein (synaptophysin)
Histology
If from SHH pathway: nodular architecture (neoplasm & developing CNS tissue)
 Called desmoplastic medulloblastomas
Densely cellular; grade IV by def’n, variation in differentiation; some respond (↓ mitosis) better than others (↑)

Heterogeneous; ¼ have SHH mutations, ¼ have WNT mutations; 17p involved too
Molecular
↑ MYC = bad prognosis, ↑ TRKC = better prognosis

60% cured overall; mostly by total excision of well differentiated tumors

Treatment
 Bad prognosis for anaplastic tumors or disseminated at Dx
Prognosis
 Get radio & chemo-therapy in both cases

B
P

I I

Normally: Left: cells migrate down from external granular cell Medulloblastoma: densely Medulloblastoma with
layer (E) through Bergmann astrocyte layer (B) and Purkinje cell cellular, proliferative, rapid neuroblastic (Homer-Wright)
layer (P) to establish internal granular cell layer (I). progression without treatment rosettes
Right picture: the end result in an adult

23
Nodular / Desmoplastic meduloblastoma What’s going on? Kind of recapitulating the normal development of the EGLIGL.
Most likely to be external granule cell layer Some % is normal, some % is mildly abnormal, some % is very abnormal
(SHH) – derived; area to left is a little more Depends on how many hits each part of cell pop has had
well differentiated (see neuropil)

CSF Seeding: multiple white areas in spinal cord

Some young kids might not actually need

treatment; others will seed down the neuroaxis

This is why Tx of both cerebellum and rest of

neuroaxis is needed (major implications for kid,
but necessary)

Anaplastic medulloblastoma: much Chemo + Rad to neuroaxis too!

poorer prognosis; really bad looking cells

24
 Peripheral Neuropathy

Normal Peripheral Nerves: Pathology & Pathophysiology

The peripheral nerve
 Peripheral nerves are painful when you touch them
 Most common biopsy site: sural nerve behind lateral malleolus
 See trichrome, drawing, schematic below

Epineurium Perineurium Endoneurium

around whole nerve around each fascicle, thick (up to 12 layers thick) inside (pink stains myelin here)
fatty yellow  Not present in root  Green is collagen
 Inside of nerve is immunologically privileged space (gives nerve stretchiness)

Dorsal root (see EM above): paucity of collagen (vs peripheral nerve)

Fiber Speed Other
Large, myelinated axons (Aβ) 120 m/s
Small, myelinated axons (Aδ) 15 m/s “first pain” (immediate after burning hand)
Pale gray circles: unmyelinated axons (C-fibers) 1 m/s “second pain” (later; slower; really hurts)

Node of Ranvier axon narrows as Schwann cell processes interfold

 Where almost all ionic exchange occurs
 saltatory conduction relies on N of R
 diameter of axon ↓ at nodes
 Lots of Na channels (inflow of Na) in node itself

+
K channels ↑ on either side (K out, termination of flow) Node of Ranvier: axon stained (L), myelin stained (R)

C-fiber axons (no myelin)

 Lots of collagen (in peripheral nerve); Schwann cells wrapped around axons
 C-fiber: light gray axoplasm with neurofilaments & MTs
 In unmyelinated state, can have several axons per Schwann cell
o In neuropathy, axons missing! Schwann cells will actually wrap collagen

Left: normal C-fibers, several wrapped by Schwann cell.

Right: Schwann cells wrapping collagen! (neuropathic)

25
 Pathology
Major categories
Wallerian degeneration Axonal degeneration
Demyelination Schwann cell loss
Vasculitis / amyloid Endothelial dysfunction
Immune mediated Mϕ / Abs
Connective tissue disorder fibroblast  collagen
Metabolic disorder Systemic effects

Wallerian Degeneration
 time-delayed, actively-mediated, axonal degradation distal to a nerve injury
o Cut off from soma, so axon degenerates distally

Early phase WD little visible change in nerve

Mid phase WD  neurofilaments and microtubules quickly dissolve
(48-96h post  myelin ovoids form
transection)  responder cells synthesize DNA
 macrophages proliferate and digest myelin
Late phase WD
 Schwann cells proliferate, axons may sprout

MTs, neurofilaments losing structure Myelin ovoids; also ↓ #axons Foamy Mϕ (fat-filled with myelin) at work
(L: normal, R: mid-phase WD) (shouldn’t see individual axons) Also ↑cellularity (more blue) but no axons

Demyelination

Segmental in nature (one or more Schwann cells / internodes may degenerate)

 Schwann cell is target!
 (vs Wallerian degeneration, which occurs everywhere distal to injury)

Acute phase demyelination: immune-targeted Mϕ invade

 begin myelin digestion (foamy Mϕ)
 Acquired demyelination

Subacute phase demyelination: “naked” axons & thinly myelinated axons

 Big axons without myelin are ABNORMAL: myelination should be proportional to axon diameter!
 Acquired or inherited

Repeated demyelination / re-myelination  “onion bulbs”

26
 Mϕ in nerve; some axons normal; Onion bulbs from demyelination /
others being pathologically changed “Naked axons” – shouldn’t see remyelination cycles
big axons without myelin! (visible hypertrophy of nerves on PE!)

Vascular Pathology

Vasculitis: inflammation and occlusion of vessels

 Vasculitic damage is often patchy but may be confluent.
First phase vasculitis Peri-vascular inflammation and ↑ Mϕ inside vessel
Second phase vasculitis Fibrinoid necrosis and invasion of the vessel wall
Third phase vasculitis shows vessel occlusion

Nerve appearance with vasculitis:

Fasicle-fasicle variation and
 Centro-fascicular axon loss and fascicle-to-fascicle variation centrofasicular axonal depletion

Amyloid: deposition of amyloid in vessel wall; distorts vessel wall

 Congo red & apple-green birefringence with polarized light
 Small, myelinated axons depleted, large axons preserved

Immune-mediated disorders
Multiple variants of Guillain-Barre syndrome
AIDP/CIDP/AMAN
 AMAN = motor variant
Sensory>motor
Anti-MAG
 Myelin Associated Glycoprotein
Pure motor block (looks like ALS!)
MMN (multifocal motor neuropathy)
 IgM to GM
Pure sensory
Hu
 paraneoplastic, neuronal Ab

Connective tissue & metabolic

Collagen disorders  nerve injury

Metabolic forms
 Diabetes: multiple forms of PN associated
 Renal: painful burning, cold, numbness
o ↓ with ↑ Epo supplementation in renal failure
o Epo receptors on nerve fibers!

27
 Clinical Approach to Peripheral Neuropathy
Prevalence
 5% medicare patients have it as 1° diagnosis; 8.5% as 1st or 2nd 3 diagnostic questions:
 Most common starting in middle age  Focal or diffuse?
 Diabetes is #1, others important too  Axonal or demyelinating?
 Heritable or acquired?
Patient questions:
 What is neuropathy? A disease of the peripheral nerves (connect legs/arms to SC/brain). Like wiring!
 Is there a treatment? Depends on the cause.
 Will I wind up in a wheelchair? Probably not.

Focal or Diffuse?
 Numbness: legs  arms   forehead (C2 wraps up –
sort of long!)
 Can tell on physical exam

Options:
 Radicular pattern?
 Named nerve?
 Diffuse & symmetrical?

Axonal or Demyelinating?

 Use EMG / nerve conduction study to figure it out!

Axonal Demyelinating Both

 Severe compression  Mild compression  Diabetic
 Toxicity  Autoimmune (GBS, CIDP)  Severe GBS
 Nutritional  Heritable  Nutritional

What’s in the peripheral nerve? Those are the things that could be affected!
 Axons (neuronal processes)
 Schwann cells (myelinating & non-myelinating)
 Mϕ, fibroblasts, mast cells, endothelial cells, etc.

Nerve conduction studies EMG

 Motor / sensory  Extent of denervation
 Demyelinating  Evidence of intrinsic mm disease
 axonal, patchy vs diffuse  Really painful!
 acquired vs. inherited esp. abductor pollicus (carpal tunnel) / biceps

Skin biopsy: small fiber assessment

 Essential for small fiber neuropathies
 Well-tolerated, easily repeated, great clinical marker

Skin biopsy: C-fibers (small fibers)

28
Heritable or Acquired?

Heritable Acquired
 Axonal  Sensory / autonomic  Compression  Toxicity
 Demyelinating  Motor  Autoimmune  Viral

Lab studies:
 Basics: metabolic, TSH  PN extra: autoimmune, ANA, SS-A
 PN special: 2h glucose tolerance test (diabetes)  PN CSF: protein, cells (GBS, etc)

Diagnosis & Treatment

Summary of diagnostic tests:

Test Used for…

NCS/EMG Large fibers
Skin biopsy Small fibers*
Lab studies Disease markers
Nerve biopsy Vessels, inflammation (vasculitis, amyloid, leprosy, sarcoid)
*Note that NCS/EMG DOESN’T tell you anything about small fibers!
nd
* do a muscle biopsy too for vasculitis: don’t want to miss it & subject pt to 2 Bx

Nerve biopsy: generally the last stop for diagnosis

Treatment
 Anti-depressants, narcotics / atypical agents, anticonvulsants, ± topical
 NSAIDS ARE NOT EFFECTIVE for neuropathic pain
o If not responding to ibuprofen, etc – think NEUROPATHIC!

29
 Pathology of Neurodegenerative Disease
Alzheimer Disease (AD)
 Most common neurodegenerative disease, #1 cause of dementia
o Usually elderly, F>M
o 10% have strong FHx

 Slowly progressive course (years)

o Early: memory loss (esp. short-term)
o Loss of other cortical functions:
language, judgment, abstract reasoning, impaired visuospatial skills
o Average survival 5-10 yrs after onset

Gross:
 Diffuse cortical atrophy & hippocampal atrophy
 Narrowed gyri & widened sulci result

Microscopic: Plaques & Tangles

Neuritic plaques: Extracellular Amyloid-β, abnormal neurites (organelles plus tau), reactive microglia
Neurofibrillary tangles Cytoplasmic inclusions made out of tau protein

Plaques
 Neuritic plaques: Amyloid-β peptide+ abnormal neurites
o Most important for AD Dx

o Neurites come from multiple surrounding neurons

 Swollen because tau & abnormal organelles accumulate
o May or may not have dark spot in center seen in pic L: close-up neuritic plaque, R: zoomed out
o Reactive microglia too (inflammatory component)
o ↓ # synapses within plaque

 Diffuse plaques: seen in other situations too

 Amyloid-β can accumulate in blood vessels also

Amyloid-β (Aβ)
 Key component of plaques, can see in vessels too

 From Amyloid precursor protein (AP) via abnormal cleavage (β-, γ- secretases)
o AP is normal transmembrane protein

 Peptides of varying lengths

 smaller > larger oligomers for toxicity

30
Familial AD (autosomal dominant form)
 APP is replicated in Down Syndrome (trisomy 21)  AD in pts with Down’s!

 Presinilin 1 in ≈ 40% of early onset cases, but small % of overall cases

o Presinilin – component of γ-secretase, also involved in NOTCH signalling

 ApoE4 is a risk factor (in late onset forms)

Gene Chromosome Age of Onset % of Early Onset Cases % of All Cases

APP 21 45-66 <1 <0.1
Presenilin 1 14 28-62 40 1-2
Presenilin 2 1 40-85 <1 <0.1
ApoE4 19 >60 (late onset) (risk factor)
What do these genes do? ↑ levels of Aβ42 (pathogenic)

Tangles:
 Start in medial temporal lobe (incl. hippocampus), spread throughout cortex
o Sterotyped spread (unlike diffuse neuritic plaques)
 Primary sensory / motor areas are affected last

Hippocampus:
 Normal circuitry: Neocortex → Entorhinal cortex → Dentate gyrus → CA3 → CA1 → Subiculum
 Hippocampus crucial for short-term memories
 Earliest tangles appear in entorhinal cortex and CA1
o Taking out afferent and efferent circuitry to/from hippocampus!

Tau
 Microtubule-associated protein that’s main component of tangles

 Hyperphosphorylated in AD  dissociates from MTs 

 Self-aggregates into paired helical filaments (PHF)
 Abnormal tau accumulates in cyto as
o neurofibrillary tangles (cell body)
o neuropil threads (neuronal processes/axons)

Tau / amyloid- β relationship is controversial & unclear!

 Mutations in tau itself cause NON-AD degenerative disease!

Parkinson Disease

#2 neurodegenerative disease
 1% of pop > 65 yo  Usual onset 40-70 yo  Slight M>F

Clinical features
 Rigidity, bradykinesia, resting tremor
 Postural instability, mask-like facies, festinating gait
 Some cognitive impairment in late stages

Gross:
 Pallor in substantia nigra of midbrain (lose cells  lose black pigmentation!)
31
  Other brainstem nuclei affected too:
o locus ceruleus (adrenergic to forebrain)
o dorsal nucleus of vagus (parasymps to viscera)

Microscopic:
 Loss of DA neurons in substantia nigra

 LEWY BODIES: α-synuclein (in pigmented DAergic SN neurons)

o Round, cytoplasmic inclusions with clear halos
 LEWY NEURITES: α-synuclein again
o In neuropil around Lewy bodies

α-synuclein: normal presynaptic protein

 Misfolded in Lewy bodies & Lewy neurites
 Protofibrils (not large aggregates) may be toxic

Mutations in familial Parkinson dz (not as common as familial AD

Gene Inheritance Function Lewy Bodies Age of Onset

α-Synuclein Autosomal dominant Synaptic function(?) Yes 30-60
Parkin Autosomal recessive E3 ligase (ubiquitin-proteasome) Rarely ~30
LRRK2 (most common) Autosomal dominant Protein kinase Variable 40-80

 Parkin: early onset Parkinson Dz

 α-synuclein: removed by parkin through Ub-proteosome system
 Nobody really knows how these genes are linked together

Dementia in Parkinson’s Disease

 Most people with PD don’t have dementia

Causes:
 Severe, end-stage PD itself
 Co-existing disorders (Lots of overlap between AD and PD – consider AD in PD pt!)
 Dementia with Lewy bodies (cortical Lewy body disease)

Dementia with Lewy Bodies (DLB)

#2 neurodegenerative dementia Distinguishing Features of DLB

 Age of onset similar to AD; average survival 8 years  Visual hallucination
 Onset of dementia prior to PD or within 2 years  Parkinsonism
 Clinical / pathologic overlap with both AD and PD  Marked fluctuation in symptoms
Pathology:
 Cortical Lewy bodies: limbic & association areas of cortex
o No halos (can’t see in H&E)
 Lewy neurites in hippocampal area CA2

Relationship of dementia with Lewy bodies to PD?

 2 diseases or continuum?
o Continuum: Lewy bodies: medullaponsmidbrainlimbic ares of cortex  association areas
o Different: Most PD pts won’t get cortical Lewy bodies or dementia; pts with DLB generally don’t have full PD

32
 Amyotrophic Lateral Sclerosis (ALS)
 “Motor neuron disease” (most famous: Stephen Hawking, Lou Gehrig)
o Both upper motor neurons and lower motor neurons (spinal cord, medulla)

Clinical Course: Progressive weakness and atrophy, eventually involving respiratory muscles

Epidemiology:
 40-60 years of age  Usual duration 3-5 years  5-10% familial
 male > female  10% > 10 years

Gross findings
 ATROPHY of VENTRAL ROOTS of SPINAL CORD
o Compare size of anterior & posterior roots!
 Rarely: atrophy of motor cortex

Microscopic findings:
 Lose myelinated axons in CST,
ventral roots, motor nerves

 Lose motor neurons

Neuronal inclusions containing ubiquitin, TDP-43

 Ub seen in a bunch of neurodegenerative inclusions
 “Skein inclusions” – have TDP-43 (ALS-specific)

TDP-43: Transactivation response DNA-binding Protein 43

 Normal: found diffusely throughout nucleus
 Sporadic/familial ALS: see cytoplasmic ± nuclear
inclusions in motor neurons

TDP-43, ALS, and frontotemporal dementia (FTLD-U form)

 TDP-43 inclusions also found in most common form of frontotemporal dementia

o FTLD-U = “frontotemporal lobar degeneration with Ub inclusions”

 SPECTRUM: ALS  ALS + dementia  FTLD-U (without ALS!)

o Pathogenic & clinical overlap

Genes in familial ALS

 Superoxide dismutase
o 1st “ALS gene” in familial ALS, 10% familial cases, aut-dom
o no TDP-43 inclusions: maybe not relevant to sporadic ALS?

 TDBP: gene for TDP-43

o but only a few ALS families have been described with mutations in TDBP

 Other mutations associated with TDP-43 deposition in FTLD-U

o but not yet linked to ALS itself

33
 Huntington Disease
Epidemiology
 Age of onset usually 30-50 years, but onset in infancy through old age is well documented
 Duration typically 10-30 years
 Autosomal dominant inheritance (polyglutamine repeat)

Clinical Features
 Chorea; also an akinetic-rigid form
 Personality change, depression and psychosis; progressing to dementia

Gross findings:
 ATROPHY of STRIATUM, esp. CAUDATE NUCLEUS
 Dilation of ventricles results; cortical atrophy later

Microscopic:
 Neuronal loss and reactive astrocytosis
 Loss of 50% of striatal (spiny) neurons: onset Sx

 Intranuclear inclusions: HUNTINGTIN

 Similar inclusions in other polyglutamine diseases

Polyglutamine repeats: Left: control; Middle: HD, ↓ neurons & ↑ astrocytes

 Huntingtin, on chr. 4p Right: Huntingtin inclusion in nucleus (zoomed in)
 Expressed throughout body; function unknown in neurons
# Phenotype
<27 Normal
Repeat expansion numbers are important clinically
27-35 Unstable, prone to expansion /
 Anticipation (esp. paternal) contraction but no disease
 ↑ repeat # in successive generations 36-39 Variable penetrance
>40 Clinical disease (can be much higher)
Repeat length is important too:
 Longer repeat length: earlier onset and more severe disease
 Shorter repeat length: later onset and milder; may present as dementia

Proteins in Neurodegenerative Disease

 Good for study of pathogenesis, good place to start, but don’t know if they’re markers, harmful, protective?
 Mechanisms still not worked out

Summary table
Disease Gross findings Neuronal loss Inclusions / deposits Protein(s) Gene(s)
Hippocampal
Alzheimer Hippocampus Neuritic plaques and Aβ peptide APP, presenilins 1&2,
and cortical
disease and neocortex neurofibrillary tangles tau ApoE4
atrophy
Parkinson
Substantia nigra, α-synuclein
disease / Pallor of Lewy bodies
other brainstem α-synuclein parkin
dementia with substantia nigra Lewy neurites
nuclei LRRK2
Lewy bodies
Ventral horns;
Atrophy of Skeins SOD-1
ALS hypoglossal TDP-43
ventral roots rounded inclusions TDBP
nucleus
Striatal
Huntington
(especially Striatum Nuclear inclusions huntingtin huntingtin
disease
caudate) atrophy
34
35
 Pathophysiology: Neuro
Functional Neuroanatomy ...................................................................................................................................................... 2
Functional Neuroanatomy: Brainstem & Cranial Nerves ........................................................................................................ 6
Localization ........................................................................................................................................................................... 12
Coma, Persistent Vegetative State & Brain Death ................................................................................................................ 17
Cerebrovascular Diseases ..................................................................................................................................................... 21
Pupils & Eye Movements in Cerebrovascular Disease .......................................................................................................... 26
CNS Infections ....................................................................................................................................................................... 30
Multiple Sclerosis / Demyelinating Diseases ........................................................................................................................ 38
Paraneoplastic Neurological Disorders (PND)....................................................................................................................... 42
Headache: Dangerous Secondary Causes ............................................................................................................................. 44
Primary Headaches (Migraine, Cluster, Tension).................................................................................................................. 50
Vertigo and the Pathophysiology of Bedside Vestibular Eye Signs....................................................................................... 55
Gait Disorders & Ataxia ......................................................................................................................................................... 62
Neuromuscular Disorders ..................................................................................................................................................... 64
Muscular Dystrophy .............................................................................................................................................................. 69
Clinical Spectrum of Movement Disorders ........................................................................................................................... 74
Memory Loss and Alzheimer Disease ................................................................................................................................... 83
Clinical Features of Cognitive Disorders ............................................................................................................................... 87
Seizures and Epilepsy ............................................................................................................................................................ 94
TNDs, TIAs, & Neuro-electrical Auras: .................................................................................................................................. 98
Pathogenesis of Episodic Neurologic Symptoms .................................................................................................................. 98
Developmental Disorders in Childhood .............................................................................................................................. 103

1
 Functional Neuroanatomy
Functional anatomic system in the nervous system: population of neurons that serve a specific functional role
 Neurons linked synaptically but not always in straight chain
 Simple: system connects to end organ (CNS  PNS  organ, e.g. 1° motor/sense)
 Complex: no specific end organ (cognition, motor planning, etc)

If a functional system is damaged, the function it serves is lost or disrupted

 Sometimes disease can cause an increase in function (retinal detachment  flashes of light as detachment starts)
 Positive symptoms = gain of function; negative symptoms = loss of function

Categories of functional systems

Input Processing Output
(sensory: 6+ senses) (consciousness / cognition: 2 genres) (motor: 3 classes)
 Voluntary (initiate / move face, head,
 General (touch/sense position, feel  Consciousness (sleep/wake, pay
arms, legs)
pain/temp) attention, enjoy)
 Special (look, chew/swallow/speak,
breathe, coordinate)
 Special (smell, see, taste, hear,  Cognition (communicate, remember,
 Visceral (focus, salivate, urinate,
balance) interpret, plan)
defecate, procreate)

Organization of functional systems (simple = linear, complex = non-linear)

Sensory 3-neuron chain: primary, secondary, tertiary
Simple (linear) Motor 2-neuron chain: upper & lower motor neurons
Autonomic 3 neuron chain: 1st, 2nd, 3rd order
Diffusely projecting One-to-many
Complex (non-linear) Reciprocal circuits Feed-forward & feed-back loops
Distributed networks Many-to-many, often with a hub

Simple systems (linear)

Basic sensory systems
E.g. vision, hearing, touch
 General senses (epicritic = light touch / proprioception, protopathic = pain / temp)
 Special senses (vision, taste, hearing balance)

0. Receptor (specialized end organ)
1. 1° neuron (receptor to relay nucleus*)
2. 2° neuron (relay nucleus* to thalamus)
3. 3° neuron (thalamus to cerebral cortex)
Example (eye)
Transduction apparatus: Cornea / lens
Specialized receptors: Rods / cones
Bipolar cell body (inner nuclear layer of retina) &
axon (inner plexiform layer of retina)
Ganglion cell body (ganglion cell layer of retina), axon (optic nerve / tract)
Geniculate cell body (lateral geniculate nucleus), axon (optic radiations) 
primary visual (striate) cortex cell body

* the relay nucleus has different names in different systems:

 retina (eye), vestibular nucleus (balance), nucleus gracilis / cuneatus (light touch), dorsal horn (pain)

Thalamus: way-station for virtually all sensory information headed to cerebral cortex
 has cell bodies of all third order sensory neurons whose axons terminate on sensation-specific regions of cerebral cortex
 Exception: smell (goes straight back to 1° olfactory cortex  thalamus  other brain regions
o Evolutionarily older, no separate receptor, 2 neurons instead of 3

2
  Each neuron chain attached to only a very small part of receptor (e.g. one cone photoreceptor)
 chains bundled together in groups of different sizes
o Given different names: retina, optic nerve, optic radiations, etc; some packed more tightly or loosely

Nomenclature:
Peripheral nervous system
Spinal cord, brainstem
Cerebral, cerebellar hemispheres
Gray matter (cell bodies)
Ganglia (e.g. dorsal root ganglia)
Horn or nucleus (e.g. dorsal horn, 3rd nucleus)
Cortex, nucleus, or unique names (primary motor cortex, nucl. accumbens, putamen)

White matter (axons)

Peripheral nervous system Root, plexus, nerve (e.g. median nerve)
Central nervous system Tract, fascicle, fibers, radiation, capsule, commissure, or unique names
(corticospinal tract, corpus callosum)

Basic motor systems

E.g. face, limb movement

2-neuron chain
1. Upper motor neuron: Primary motor cortex to
a. Brainstem (cranial nerve nuclei) via corticobulbar tract
b. Spinal cord (ventral horn) via corticospinal tract
2. Lower motor neuron:
a. Cranial nerve nuclei to muscles of head and neck
b. Spinal cord ventral horn to muscles of arm, legs, trunk

Corticobulbar tract: connects primary motor cortex (pre-central gyrus) to brainstem (bulb)
 control voluntary muscles of face, tongue, neck & specialized mm for chewing, swallowing speaking
 2 UMN innervate 1 LMN (different from basic motor paradigm) – redundancy
o Unilateral UMN inactivation doesn’t cause clinical deficit here
 LMN in brainstem cranial nerve nuclei  head and neck
o Cranial nerve fascicles within brainstem
o Cranial nerves (PNS) after exiting brainstem

Corticospinal tract: connects primary motor cortex (pre-central gyrus) to spinal cord (ventral horn)
 Control voluntary muscles of limbs, trunk & special midline muscles for truncal postural control
 Redundant innervation typically here too
o unilateral UMN inactivation doesn’t cause deficit in redundantly innervated muscles
 Spinal cord = CNS, spinal nerves (PNS) once they exit
o PNS names: root, plexus, trunk, division, cord, nerve, branch (depends on surface appearance)
 No synapses between ventral horn and neuromuscular junction
 NMJ: converts electrical signal into one that can be received by muscle
 Motor unit = NMJ & muscle

Basic autonomic systems

E.g. papillary motor control

3-neuron chain (first, second, third-order)

1. 1st order neuron (hypothalamus to brainstem or SC gray matter)
2. 2nd order neuron (brainstem / SC to autonomic ganglion)
3. 3rd order neuron (autonomic ganglion to NMJ  smooth muscle in specialized end organ)
3
3 major visceral motor systems follow this paradigm:
1. Pupillomotor system
2. Exocrine motor system (tears & saliva)
3. Vasomotor system

 bowel, bladder, sexual control are similar but slightly more complex
 solid-organ innervation is less well defined anatomically

Autonomic functions: symps & parasymps (dual innervation, including blood vessels)
 mostly happening at unconscious level
 Simplistic view: HYPOTHALAMUS is the “COMMAND AND CONTROL CENTER” for autonomic nervous system
o Most signals for symps / parasymps begin here

Pupillomotor system is most important clinically

 Unique anatomy  well recognized bedside syndromes
o Pupillary paralysis / anisocoria (= asymmetric pupils)

Pupillomotor system: parasympathetic

1. Hypothalamic cell body (hypothalamus)  axon 
2. Brainstem cell body (Edinger-Westphal nucleus in midbrain)  axon (3rd fascicle / nerve) 
3. Ganglion cell body (ciliary ganglion)  axon (short ciliary nerves) 
4. Iris sphincter muscle (papillary constriction) + ciliary muscle (lens accommodation)

Pupillomotor system: sympathetic

1. Hypothalamic cell body (hypothalamus)  axon (lateral brainstem sympathetic tract) 
2. Spinal cord cell body (cervical cord)  axon (ventral root, rami communicantes, sympathetic chain/trunk) 
3. Ganglion cell body (stellate ganglion)  axon (long / short ciliary nerves)
4. Iris dilator muscle (papillary dilation)

Note the long path over the lung taken by sympathetic system: upper chest lesions can result in dysfunction!

Complex systems (non-linear)

3 types, in order of increasing complexity

Diffusely projecting systems
Reciprocal circuits
Distributed networks
One-to-many, originate from single nucleus
Semi-distributed, reciprocally-innervated
parallel loops
Diffusely interconnected networks with
regional “hubs”
Brainstem reticular activating system,
dopaminergic “reward” pathway
Basal ganglia circuitry, memory circuitry
Language area, prefrontal motor cortex,
parietal association cortex

Diffusely projecting
 “shotgun approach” – system tightly packed at origin but projects widely (diffuse / dispersed system at target)
 Small lesion at origin can cause devastating widespread neuro dysfunction (e.g. coma)
o May also be potential target for therapy (restore simple region?)

4
Reciprocal circuits
E.g. basal ganglia: starting, speed, smoothness, synchrony, stopping of voluntary movements
 Reciprocally-innervated parallel loops with on and off (excitation / inhibition) signals sent
o Diseases that affect different parts of loop can have opposite effects
 Huntington’s chorea (too much movement), Parkinson’s disease (too little)
 Therapy: selectively stimulate / inhibit correct part of circuit (deep brain stim in Parkinson’s)

Distributed Networks
E.g. language, motor planning, sensory integration
 Neurons in many locations but regional specialization into hubs (certain information coalesces)
 Wernicke’s area: major regional hub for language
o Language not stored here but rather in diffuse neural networks
o Wernicke’s area is like a network router; destroy the router and access to network is lost!
 Global aphasia results

The brain (to a first appoximation)

Part of brain: Front Back

General function Output Input
Heteromodal association cortices Frontal Temporal / Parietal
Role of association cortices Plan Interpret
Lesion to this integrative area Apraxia, Abulia Agnosia, Neglect

5
 Functional Neuroanatomy: Brainstem & Cranial Nerves
Basic Structure / Introduction
Midbrain: rostral
 On top: stuff here linked to basal ganglia & thalamus
 Substantia nigra: motor, tone / speed
 Peri-aqueductal gray matter: sensory, pain/pleasure

Pons: middle
 Heavily connected with cerebellum
 Cerebro-ponto-cerebellar circuit: learning (esp motor)

Medulla: caudal
 On bottom: linked to spinal cord / body
 Respiratory / cardiovascular centers, etc.

Cranial nerves: nerves to/from hands/face/neck

 Part of PNS (optic nerve clinicall & anatomically PNS
although immunologically / embryologically CNS)

Cardinal Sections of the Brainstem

(look at an atlas) 

What’s the point of the brainstem?

Conduit (‘long tracts’)

 Motor (out) to body
 Sensory (in) from body
 Autonomic (bowel/bladder)

Cranial (CN 3-12)

 Motor (out) to head
 Sensory (in) from head

Control
 EOM control centers
 Arousal/sleep, mood,
pain/pleasure
 HR, BP, Resps, etc.

Long Tracts (conduit functions)

Major long tracts (learn these & where they go)
Tract Type Description
Corticospinal Motor Voluntary motor to limbs / trunk
Dorsal column – medial lemniscus Sensory (epicritic) Light touch, vibration, proprioception
Spino-thalamic (a.k.a. anterolateral) Sensory (protopathic) Pain, temperature
Other tracts too: (wouldn’t worry about the course of these – but they pass through the brainstem)
 Corticobulbar (voluntary motor to head/neck)
 Cerebro-ponto-cerebellar (descending motor learning circuit)
 Reticulo-, rubro-, tecto-, vestibule-spinal (accessory motor / postural control)
 Autonomic tracts (sympathetic / parasympathetic bladder pathway)
 Spino-cerebellar, dentate-rubro-thalamic tracts (cerebellar in/output)
6
Cranial Nerves / Functions
 Damage: varied symptoms (diplopia, gaze palsy, etc.)
o Damage to spinal nerves generally just produces weakness (motor) and/or numbness/tingling/pain (sensory)
Nerve Function
I. Olfactory Smell
II. Optic Vision
III. Oculomotor Motor (eye movements) & parasympathetic (constrict pupil)
IV. Trochlear Motor (eye: superior oblique)
V1 (ophthalmic) –sensory only (forehead, eye, etc)
V2 (maxillary) – sensory only (middle of face, nasopharynx, etc)
V. Trigeminal
V3 (mandibular) – motor (mm of mastication) &
sensory (lower jaw, floor of mouth, anterior 2/3 tongue)
VI. Abducens Motor (eye: lateral rectus)
Sensory (auricle; taste in ant. 2/3 of tongue)
VII. Facial Motor (muscles of facial expression)
Parasympathetic (secretomotor to nasal mucosa, lacrimal, salivary glands).
VIII. Vestibulocochlear Hearing / Balance
Taste & general sense: post. 1/3 of tongue, pharynx)
IX. Glossopharyngeal
Motor (stylopharyngeus), Parasympathetic (parotid gland)
Motor (larynx, pharynx, palate)
X. Vagus
Parasympathetic (visceral mucosa to left colic flexure)
XI. Accessory Motor (trapezius / sternocleidomastoid mm.)
XII. Hypoglossal Motor (tongue muscles)

Brainstem Control Centers

 Serve semi-autonomous functions: eye movements, extrapyramidal / accessory motor control, “visceral” fxns
Location Centers
 Eye movements: vertical gaze & vergence centers
Midbrain  Visceral: periaqueductal gray (pain, pleasure)
 Motor: substantia nigra (extrapyramidal motor)

 Eye movements: horizontal gaze center

Pons
 Visceral: locus ceruleus, raphe nuclei (arousal, mood)
 Eye movements: horizontal gaze-holding center
Medulla
 Visceral: respiratory & cardiovascular centers

Pain/pleasure sensing structures (lots of opiate receptors) – esp. peri-aqueductal gray of midbrain
 Pain transmission / modulation

Substantia nigra, pars compacta (niagro-striatal): part of basal ganglia circuitry; lose neurons  bradykinesia (Parkinson’s)
Reticular activating system (pons, midbrain)  diffusely protejecting; responsible for arousal (look like net)
Respiratory / CV control in medulla

Brainstem Organization: Front-to-back (ventro-dorsal)

Ventral (front) Middle (“tegmentum”) Dorsal (back: “tectum” or “velum”)

 Long tracts (sensory)
 Long tracts  CSF space – aqueduct, 4th, open subarach space
 Cranial nerve nuclei
(motor)  Tectum – quadrigeminal plate (‘colliculi’=‘hills’)
 Visceral (HR, BP, resps) & special (EOM…) centers

7
MOTOR TRACTS are ANTERIOR (ventral)
 Corticospinal tract: from cortex to spinal cord
o Decussates @ cervico-medullary junction

 Cerebral peduncles  basis pontis  olives & pyramids

(names of surface landmarks)

2/3 of descending motor info is NOT destined for SC / limbs

 Fronto-pontine (1/3), parieto-pontine (1/3) projections destined
for cerebellum (motor cortex  pons  cerebellum  basal
ganglia  motor cortex circuit; importat for learning) – damage
produces very few deficits

CSF SPACES (in back)

 Lateral ventricles (choroid plexus)  (foramen of Monroe) 

 3rd ventricle (diencephalon, sandwiched between 2 halves
of thalamus / hypothalamus)
 Cerebral (Sylvian) aqueduct (midbrain) 
 4th ventricle (pons, cerebellum)  (foramina of Lushka, lateral,
and foramen of Magendie, median) 
 Subarachnoid space  around SC, etc.  reabsorbed via
arachnoid granulations  superior sagittal sinus

TECTUM / VELUM

Tectum: “Roof” over cerebral aqueduct (midbrain only)

 Four colliculi (“quadrigeminal plate”)
o Superior colliculi:
 saccades (fast eye movements)
 turn head to novel/threatening sights
o Inferior colliculi:
 auditory processing (turn head to
novel/threatening sounds)
Velum: medulla; anatomic structure, not of much clinical relevance

TEGMENTUM (middle: the “beef”)

 Everything between CSF space & motor parts up front
 Cranial nerve nuclei & visceral / special centers live here
 Sensory long tracts pass through here

Much has a “reticulated” appearance (mixed white/gray matter)

See next page for more descriptions

8
Tegmentum: Sensory long tracts

Pain / temp (spinothalamic/anterolateral) more lateral

Touch / vibration (dorsal column / medial lemniscus) more medial

Tegmentum CN Nuclei
 See top-bottom organization below (2-2-4-4 rule)
 Recognize that CN nuclei are in tegmentum

Cerebellar Peduncles
 Just think of where they are and figure out where they’re going

Inferior Input to cerebellum From spinal cord

From cerebrum (via cerebral
Middle Input to cerebellum
peduncles & pontine nuclei)
Superior Output to cerebrum (red nucl.  basal ganglia  ctx)

Stuff Around the Top of the Brainstem

Pineal gland: circadian rhythms (melatonin)

 Masses  compress dorsal midbrain (cause upgaze, failure of papillary light reflexes, convergence-retraction
nystagmus, eyelid retraction, potentially life-threatening obstructive hydrocephalus)

Diencephalon = thalamus, mamillary bodies, hypothalamus

Thalamus: major sensory way-station

(almost all sensory input passes through here)
 Lateral geniculate bodies = relay for visual
sensory information, hang down off sides

Mamillary Bodies:
 part of memory circuitry
(w/ hippocampus, medial thalamus)
 right next to 3rd ventricle
 affected by thiamine deficiency
 major site of memory-disturbing pathology in
Wernicke – Korsakoff syndrome (acute confusional +
post-confusional / amnestic)

Hypothalamus:
the “command center” for most autonomic functions

Cell bodies here include:

 Neuroendocrine functions (hypothal-pituitary-adrenal axis; thyroid/other releasing hormones)
 1st order symp neurons (headed for SC  head/body via sympathetic chain)
 Pre-motor neurons (descend to control 1° parasymp neurons in brainstem)
9
 Brainstem Organization: Top-to-bottom (rostro-caudal)

Cranial Nerves: 2-2-4-4 rule

(cerebrum 2, midbrain 2, pons 4, medulla 4)

Cranial Nerves: remember that nuclei all in tegmentum

Cranial Nerves Control centers

(Cerebrum) I, II
Vertical gaze / vergence
Midbrain III, IV
Substantia nigra
Horizontal gaze
Pons V, VI, VII, VIII
Locus ceruleus, raphe nuclei
Medulla IX, X, XI, XII Respiratory / CV

Gaze center locations are logical:

 Vertical gaze:
o CN III, IV are involved; vertical gaze center & CN III/IV nuclei located together in midbrain
 Same with horizontal gaze and CN VI (lateral rectus)
o Signal for horizontal movements needs to get to CN III (nucleus in midbrain; innervates medial rectus)
o Travels up MLF (medial longitudinal fasiculus) to midbrain

Gaze holding: sustaining eye in eccentric position of gaze

(e.g. look to side & hold eyes there)
 Need sustained signal
o (orbital tissues, mm are elastic; tend to
return eyes to center)
 Medulla has gaze-holding center
o does OK job on own but great when
calibrated by inferior cerebellum (nearby)

Medial Longitudinal Fasiculus

 superhighway of axons that connects eye-
movement-related sections

10
 Brainstem Organization: Middle-to-Side (Medio-Lateral)
Medial (Motor) Intermediate (Visceral) Lateral (Sensory)
 Special motor nuclei
 Somatic motor CN nuclei (e.g. for swallowing)  Somatic sensory CN nuclei
 Parasympathetic CN nuclei
 Sympathetic tracts

“Motor” is Medial
 Somatic motor = purely voluntary (arms/legs/eyes/tongue) - medial
 Special motor (“branchiomotor” – moving face / jaw - intermediate

Note that only eye (3/4/6) and tongue (12) CN motor nuclei are medial;
other CN motor nuclei are intermediate

Selective lesions (e.g. strokes) can affect lateral brainstem only (or medial)
 Medulla (Wallenberg syndrome) or pons
How? Vascular supply to lateral brainstem is different from medial brainstem
LATERAL BRAINSTEM STORKE = MOTOR (MEDIAL) SPARED
 Stroke with NO HEMIPARESIS (weakness) /
HEMIPLEGIA (paralysis)
 Corticospinal tract fibers SPARED
 Dx: dizziness, nausea, vomiting, gait unsteadiness:
looks like benign inner ear problems but stroke!

11
 Localization
Functional Segregation
 If function is only segregated in one place along a chain, selective loss of one function means lesion is there
 Corollary: More “abstract” functions lost means lesion is more likely to be near cerebral cortex
Examples:
 Night blindness: selective visual loss, can only happen at photoreceptor / retina (cones = day, rods = night)
 Loss of stereognosis: selective tactile sensory loss – only separated at cerebral cortex
o Loss of 2-point discrimination is the same – has to be at cortex

“Trophic Influences” (UMN vs LMN)

 Identify UMN vs LMN (BOTH present with weakness)
LMN UMN
“keeps the muscle alive” (trophic) “keeps the LMN under control”
Weakness plus… Weakness plus…
 Fasciculation (ACUTE) – irritability of mm fibers  Upgoing toe (Babinski)
 Atrophy (chronic)  No atrophy*
 Aberrant regeneration (chronic)  Spasticity (chronic)
 Normal to low tone  Clonus (chronic)
 Loss of reflexes  Hyperreflexia (chronic)
* mild atrophy can develop in UMN lesions (disuse); more profound in LMN
Note: flaccid weakness occurs in acute UMN lesions!
 Don’t use flaccid weakness to Dx LMN lesion unless atrophy / fasciculation present

Acute Lesions: HARD

 BABINSKI is ONLY reliable sign to indicate ACUTE UMN LESION
 FASICULATIONS are ONLY reliable sign to indicate ACUTE LMN LESION

Chronic lesions: easier

 Spasticity, hyperreflexia, clonus = chronic UMN lesions

Redundancy
 If there’s redundancy, then unilateral UMN (cortical) lesions produce no deficits (brainstem / CN)
o Unilateral LMN lesions will produce deficits (ipsilateral to lesion – LMNs on same side!)
o If there’s partial redundancy (e.g. 7th n), then cortical lesions produce partial deficits!

Due to either: Can only be caused by:

 unilateral BRAINSTEM (LMN) or  unilateral BRAINSTEM (LMN) dz *
 unilateral CEREBRAL (UMN) dz  NOT cerebral lesions (redundancy!)
 unilateral 3rd, 4th, or 6th nerve palsy, CN 3/4/6
 unilateral horizontal gaze palsy CN 3/6  unilateral paralysis of chewing muscles CN 5
 hemi-facial numbness CN 5  unilateral complete facial paralysis CN 7
 hemi-oropharyngeal numbness CN 9  unilateral loss of taste CN 7±9
 unilateral weakness of shoulder shrug CN 11  unilateral hearing loss CN 8
 unilateral tongue deviation CN 12  unilateral paralysis of soft palate or vocal cords CN 10
 unilateral weakness of head turning (SCM) CN 11
*(CNs / end organs could be damaged too, just not cerebral lesions – but think of these as brainstem symptoms / signs

12
Redundancy example: Facial Nerve weakness
 note: most “lower” (5,7,9-11) CN nuclei are redundantly
innervated by both hemispheres
 CN 7: only gets partially redundant innervations

Top part of forehead ONLY is redundantly innervated (red in pic)

Paralysis of left lower face & sparing of left brow movement:

 RIGHT (contralateral) UMN CN 7 lesion!
 Left brow is redundantly innervated (Left CN 7 UMN supplying;
preserves movement
 See right pic 

Bell’s Palsy: LMN CN 7 lesion

 Ipsilateral CN 7 LMN affected (L. Bell’s palsy = L. CN 7 LMN)
 Total hemifacial weakness without brow sparing
 Bell’s phenomenon: pt. attempts to close eyes, affected side doesn’t close,
affected side’s eye rolls up in orbit (means pt is making a good effort at eye closure)

Density
 Small lesions in densely packed bundles produce big deficits (e.g. L. internal capsule  R. hemiparesis)
 If lesion is in loosely-packed “bundle” and produces big deficit, it must be large (e.g. motor cortex)

Mangification
Cortical representations are magnified to importance (lips & hands)
 Think homunculus

 lesions in important areas produce smaller deficits

(in terms of body zone affected)

 lesions in less important areas produce larger deficits

Proximity
 If chains converge / diverge, patterns of loss indicate particular localization
 If chains from different body regions close to each other, can get
discontiguous defects

Example: Visual System

 Monocular = pre-chiasmal lesion
 Binocular = post-chiasmal lesion
 Review the picture to the right & understand it

Example: Cortical stroke  face/hand without arm

 See homunculus above
 Face & hand are next to each other; arm is farther away
 Cortical stroke can produce face/hand deficits
o But SPARE arm (seems weird!)

13
 Orientation (Long Tracts vs Segmental Systems)
 Long tracts: up and down the neuroaxis, rostro-caudally Function Long tract
o Symptoms only localize lesion if they fit a pattern Sensory Spino-thalamo-cortical
Motor Cortico-spinal
 Segmented: in and out of neuroaxis; ventro-dorsally Coordination BG-vestibulo-cerebello-spinal
o Cognitive circuitry, cranial nerves & spinal nerves Autonomic Cortico-hypothalamo-spinal
o Symptoms define narrow level that can be affected

Example: Arm / Leg weakness

 Distal lesion can only cause leg weakness (not arms)
 Proximal lesion can cause either arm + leg weakness or leg weakness only (partial lesion!)
 Key point: if arms affected, lesion must be proximal. If legs only, you can’t tell

Adjacency (what runs near what?)

 Lesions produce dissociated loss of functions when pathways are not adjacent
 Have to know levels of crossing to be able to localize!

Example: Lateral medullary syndrome

 Touch / vibration = dorsal column – medial lemniscus
 Pain/temperature = antero-lateral, a.k.a. spinothalamic

These pathways are far apart in medulla but right next to each other in midbrain
 Lateral medullary syndrome: take out pain/temp but spare touch/vibration (pic)
 Midbrain lesion: really hard to take one out without the other

Example: “crossed” brainstem syndrome

Symptoms:
 ipsilateral face affected
 contralateral body affected

Brainstem lesion: take out one side of brainstem (e.g. midbrain infarction)
 CST hasn’t crossed yet, so LMNs to contralateral body affected!
o CST still in cerebral peduncle; won’t decussate until cervico-medullary junction
 Cranial nerve LMNs innervating same side of face are affected!

Reflexes
Reflexes = direct connections between motor / sensory systems; bypass processing steps
If a function is lost:
o reflex integrity means lesion is inside brain (beyond reflex arc!)
o reflex loss means lesion is causing segmental dysfunction (cut reflex arc!)
 For example, deep tendon reflexes lost means there’s dysfunction at that segment level!
Common reflexes
st
Pupillary light CN 23 Vestibulo-ocular CN 83/4/6 Deep 1 order sensory
Pupillary near CN (2)3 Gag CN 910 tendon neurons 
Blink CN 57 Jaw jerk CN 55 (UE/LE) spinal LMNs

Example: Blindness with intact pupillary light reflex

 If patient is blind but has intact pupillary light reflex, that means lesion can’t be in optic nerve!
 Must be in occipital lobe (or somewhere “behind reflex” like that!)
14
 Major concepts of localization
Parsimony: simpler explanation is usually better

3 major questions:
1. What’ s the level?
a. Supratentorial = cerebrum, CN 1-2
b. Infratentorial = brainstem, cerebellum, CN 3-12
c. Spinal (cord or nerves)
2. Inside or out?
a. Intra-axial or Extra-axial (CNs extraaxial)
3. More than one lesion?
a. If more than one: territory / tissue specific or non-specific?

Where’s the level?

Symptom Quality
Symptoms Mnemonic
CORTEX: Attic As
 aphasia-amnesia-agnosia,  Aphasia  Abulia
Supratentorial  apraxia, dementia-delirium, seizure  Amnesia  Anosmia
BASAL GANGLIA: rigidity-bradykinesia-freezing, dystonia  Agnosia  ‘Anopsia’
CN 1-2: anosmia, visual loss, photopsia  Apraxia (blindness)
 stupor-coma Downstairs Ds
 hearing loss, dizziness,  Diplopia
 nausea/vomit  Dysarthria
Infratentorial
 anisocoria, diplopia, nystagmus  Dysphagia
 dysmetria, dysrhythmia, ataxia*
 Dysphonia
 jaw/tongue/palate/ vocal weakness
respiratory (diaphragmatic) failure Basement Bs
Spinal loss of deep tendon reflexes limbs  Breathing  Broken reflexes
bowel & bladder dysfunction  Bowel/bladder

Pattern of Symptoms
Face & hand, but not leg (think homunculus)
Supratentorial
 (If motor, top ½ face spared)
Crossed syndromes
Infratentorial
 Head on one side, body on other
 Sensory “level” (dermatome)  Distal symmetric numb feet ± hands
Spinal  Both legs only (paraparesis/plegia)  Myotome / dermatome pattern loss
 Four limbs but awake  Individual nerve root problem

Intra-axial (≈CNS) or Extra-axial (≈PNS)?

Quality of symptoms Pattern of symptoms
Cerebrum,  Cognitive or affective dysfunction, stupor-coma  Homonymous field cut
Intra-axial brainstem /  Complex motor (rigidity-dystonia-chorea, ataxia…)  ‘UMN’ facial weakness
cerebellum, SC  UMN signs (spasticity, hyperreflexia, Babinski...)  Crossed brainstem syndromes
 Monocular visual loss
CNs/spinal nerves,
 Root, plexus, nerve distribution of
roots, plexi, sense  Hearing loss
weakness and/or sensory change
Extra-axial organs, skin  Tenderness, myotonia
 Bilateral motor structures involved
receptors, NMJ,
without sensory
mm
 Single cranial nerve
15
Notes:
 Tenderness almost always from 1° muscle disease (e.g. inflammatory myopathies)
o Exception: transverse myelitis (sensitization of central pain neurons)
 Bilateral motor w/o sensory chain almost always extra axial
o ALS / motor neuron disease is exception
 UMN is intra-axial, but LMN doesn’t have to be extra-axial
o Lower motor neuron CELL BODIES are intra-axial

More than One Lesion?

Linked to vascular territory
 Anterior circulation
o R. hemiparesis & aphasia with L. eye blindness: ICA (ophthalmic & MCA)
o Proximal arm & proximal leg: ICA borderzone
 Posterior circulation
o Vertigo, nausea, vomiting with visual field defect: vertebral (PICA & PCA)

Linked to Physiologic State

Example: ↑ intracranial pressure
 Characteristic “constellation” of signs / symptoms (but appear to be “all over the place”)
 Sx: Headache, blurred / transiently obscured vision, diplopia
 Signs: papilledema, esophoria / esoptropia or frank uni/bilateral 6th n palsies

Linked to Tissue Type

Classification Affected tissue Example Signs / Sx

 Headache, ‘stretch signs’
Meninges Meningitis  Multiple cranial-spinal nn.
Gross Tissue  Isolated reflexes lost
 Blindness, jaw pain, HA, anemia, weight loss
Blood vessels Vasculitis
 Mononeuritis multiplex
Cell type Motor neurons ALS-SMA
Mitochondria  Visual, auditory, weakness, cardiac arrhythmia
 Diplopia, visual loss, sensory
Subcellular Myelin Demyelinating dz
 Ascending weakness, reflexes
compartment
NMJ MG / botulism
Channels Migraine, seizures
Neurotransmitter Serotonin Depression

Multifocal: no linkage to lesions

 Think: what could be causing this?

Examples:
1. Multiple cancer mets to brain / cord
2. Multiple stokes (e.g. A-fib)
3. Multiple petechial hemorrhages (e.g. trauma)

16
 Coma, Persistent Vegetative State & Brain Death
Epidemiology of Coma
 Cardiac arrest survivors (150k), severe TBI (100k) represent majority of coma pts
 30K in “minimally conscious state” (partial response), 6k in vegetative state (can be aroused, but response cut off)

“Coma is like CHF or kidney failure, but with the brain”

 Cardiac arrest survivors: 80-90% initially comatose, 5-30% comatose at discharge
 Critically ill pts with mechanical ventilation: 15-20% comatose at some point
 Elderly admitted to ICU: 1/3 comatose

Coma is an independent predictor of death, functional outcome

 after ischemic stroke, intracerebral hemorrhage, TBI, cardiac arrest
 along with length of mechanical ventilation, length of stay

Glascow Coma Scale (GCS) – one of the most commonly used ways to evaluate coma

Arousal & Consciousness

Domains of consciousness
Wakefulness Awareness
Content of consciousness:
Comprises: Alertness, arousal, vigilance
 attention, executive function, memory, perception
Areas involved… Subcortical: brainstem arousal centers Cortical

Lots of redundancy in these systems (important!)

 Loss of consciousness: usually problem with
o brainstem arousal system (ascending reticular system) or
o diffuse bilateral cortical injury

Anatomy & Function (via fMRI)

Awareness Forebrain, cortex
Arousal Midbrain / thalamic junction (triggers awareness)

Self-awareness & external awareness are separate

 Comatose: can’t respond to internal stimuli! (not self-aware)
o Hyperglycemia, bladder obstruction & rupture can result!
 External awareness: cerebellum, parietal areas, etc.

Clinical Syndromes

Taxonomy: like shades of gray (blend together); better to quantify

Hypersomnolence Really sleepy
Lethargy Slight ↓ in alertness, clouding of consciousness
Obtundation ↓ alertness, ↓ interest in environment, psychomotor slowing
Stupor Behavioral unresponsiveness (can only arouse with vigorous, continuous stimulation
Coma

Approach to the unresponsive patient

Level of Consciousness
 Assess arousal: establish best response with least stimulation (least pain)
 Assess awareness / content (alert / awake / oriented? Simple  complex)
 Use standard questions & establish a trend over time

17
Motor system
 Look for spontaneous movements & meaningful activity
 Record response over time – what is best response to least stimulus
 Stimulate in midline trunk, face/head: use least noxious stimulus possible
o Name  tap  shake  midline stimulus
o Purposeful or posturing? Tone / reflexes?
o Grasp is reflexive, letting go is voluntary

The Eye
Pupillary response: CN III  lose parasymps  unopposed symps  BLOWN PUPIL on one side = neuro STEMI
 CN III stretched from midbrain herniation – bad! Need to decompress!

Ocular motility: need to move pt’s head if comatose! Pt can’t move it

 Check for spontaneous movements, EOM integrity, conjugate/disconjugate gaze
o Doll’s eye (oculocephalic reflex) in response to movement, caloric response (vestibular)

Fundoscopy (optic disc, etc.) can be useful too

CN Test in comatose pt
V/VII Corneal reflex (CN V
Other cranial Nerves sensory, CN VII motor)
 More difficult, but CN’s can be tested with a comatose pt! VII Grimace
VIII Caloric testing
Autonomic functions IX, X Gag
 Often overlooked! X Tracheal cough
I trapezius pinch response
 HR, BP, resps, temp XII tongue movements

Cushing’s reflex (brain herniation syndrome)

 Hypertension, bradycardia, tachypnea
 Means pt is in extremis
o If crushing brain, BP ↑, HR ↓, hyperventilate, vasoconstrict (trying to fill heart better, perfuse brain)

Coma
State of unarousable responsiveness with no voluntary /purposeful motor function
 Can be a transitional state (< 4 wks usually)
 Quantify with Glasgow Coma Scale (GCS) or Full Outline of UnResponsiveness (FOUR)

Results from:
 Bilateral / paramedian hemispheric (more diffuse) injury
 Diencephalic or brainstem (more specific) injury

Spectrum: Coma  arousal  awareness  consciousness

Glasgow Coma Scale

 Score motor (1-6), verbal (1-5), eye (1-4) responses
 Lowest score is 3 (no motor/verbal/eye response)

Limitations:
 No direct assessment of brainstem function (no CNs)
 No evaluation of resp pattern alterations
 Can’t test verbal component if comatose / intubation
 Limited prognostic value for verbal / eye components

18
Full Outline of UnResponsiveness (FOUR)
 Grade eye response, motor response, brainstem reflexes, respiration on 0-4 scales
o Minimum = zero, max = 16

Brain Death
Complete, irreversible loss of all brain activity
 Both necessary and sufficient to diagnose death of organism; prerequisite for cadaveric organ donation
Results from extensive hemispheric / brainstem injury

Diagnosis: exclude physiologic, metabolic, endocrine, pharm confounders Cardinal findings in brain death
 Clinical / neuroimaging evidence of acute CNS catastrophy 1. coma / unresponsiveness
 Exclusion of complicating medical conditions, no drug intoxication / poisoning 2. absence of brainstem reflexes
 Core temp ≥ 32° C 3. apnea

Vegetative State
 Signs of arousal (open eyes) but lack awareness of self or environment
o Sleep/wake cycles restored
 Persistent vegetative state if > 1 mo (non-traumatic usually > 3 mo; traumatic usually > 12 mo)

Usually from bilateral cortical / thalamic injury with relative sparing of hypothalamus / brainstem

Minimally Conscious State

 Arousal mechanisms present & rudimentary elements of awareness
 Transient, inconsistent but unequivocal behaviors suggesting awareness of self / environment
o Follow commands, verbalize in appropriate context, attend to stimuli, visual tracking

Usually from cortical and/or thalamic injury

Delirium
Acute confusional state; acute onset of altered mental status with impaired attention
 Fluctuating course
 Disorganized thinking, psychomotor agitation or withdrawal

From physiologic, metabolic, endocrine, pharm disturbances; can also be from frontal or right parietal injury

Locked-in syndrome
Not a consciousness disorder: wakefulness & awareness preserved
 Quadriplegia, anarthria; classically preserve ability to blink & look upwards

From injury to pons or midbrain

 destruction of CST & caudal corticobulbar tracts with sparing of tegmental arousal systems
 cortical areas still working, but cut off from everything else

Other Disruptions of Consciousness

Seizures can disrupt consciousness (generalized tonic/clonic, absence, complex partial seizures)
 nonconvulsive seizure status (status epilepticus) detected in up to 20% critically ill pts w/ altered mental status

General anesthesia too!

19
 Arousal, awareness, and various states of consciousness

Coma, anesthesia: arousal, awareness both decreased

Vegetative state: arousal preserved, not aware
Minimally conscious: arousal, some awareness preserved
Locked in syndrome: both arousal & awareness preserved

Parietal association areas

involved with awareness

(note that there’s some activity

in minimally conscious state,
but not in vegetative state)

Wakefulness vs awareness:
 At some point (brain death), this damage becomes
irreversible – to the left of that line, can’t recover (to the
right, you can)

Wakefulness over time: note that there’s a continuum of responses

 Best progression: from coma  vegetative state  MCS 
conscious wakefulness, but can have death from coma or
permanent VS / MCS at any point along the recovery

Causes of Coma / Unconsciousness

Structural Non-structural
Bilateral /
Bilateral / diffuse
paramedian Toxic Metabolic Endocrine
hemispheric injury
brainstem injury
 Hemorrhage,  Sepsis
 Trauma, Stroke
infarction, tumor,  Electrolyte  Myxedema
 Hypoxic ischemic encephalopathy  Medication overdose
trauma, CPM imbalance coma,
 Tumor, CNS infections  Drugs of abuse
 Compression by  Organ failure hypothyroidism
 Inflammatory/immune encephalitides  Environmental exposures
posterior fossa  Wernicke’s  Adrenal failure
 Hydrocephalus
mass encephalopathy

Ethical Implications
 Poor compliance with AAN guidelines – need to ↑ education of providers!
 PVS: 1% prognosis of moderate disability, good recovery < 3 mo: but 0% at 6 mo
 Need good prognostic ability to be able to recommend whether to withdraw care or not!

20
 Cerebrovascular Diseases
See Cerebrovascular Diseases in Neuro: Pathology for more complete description of anatomy
Definitions
Cerebral infarction caused by interruption of blood supply to a portion of the brain,
Ischemic stroke
with focal neurological deficit lasting > 24 hrs
Neurologic deficit due to ischemia that completely reverses within 24 hrs and does
Transient Ischemic Attack (TIA)
not produce an infarct on imaging studies
Bleeding into:
brain parenchyma Intracerebral hemorrhage
Hemorrhagic stroke
ventricles Intraventricular hemorrhage
CSF / subarachnoid space Subarachnoid hemorrhage

Approach to stroke diagnosis

 Where is it? (neuro exam, brain imaging studies to confirm – diagnosis is based on neuro exam)
 What is the vascular anatomy / pathology? (vascular imaging)
 What is the cause?
o Large vessel atherosclerosis o Cardiac embolism o Small vessel disease (lacunes)

Anatomy: Overview

Anterior circulation Posterior circulation

Vertebrals  basilar, PCA
Carotids  MCA, ACA
 Bilateral motor, visual
 Contralateral motor, sensory, vision
 Dizziness, ataxia, nystagmus
 Aphasia, neglect
 Crossed syndromes

Territory Symptoms Picture

• Contralateral motor and sensory loss
Lateral frontal, (primarily face + arm)
parietal, • Dysarthria, aphasia (dominant)
MCA
temporal lobes • Neglect (non-dominant)
• Contralateral visual loss
• Gaze deviation towards lesion

• Contralateral weakness of foot and leg

Medial frontal, • Sensory loss of foot
ACA
parietal lobes • Frontal lobe signs
(apathy, cognitive slowing)

Occipital, • Contralateral hemianopia

PCA medial • Cognitive impairment
temporal lobes (medial temporal lobe)

Emboli, etc. tend to head to the MCA

21
Vertebrobasilar System
Basilar gives off:
 PICA (just where vertebrals join), AICA, pontine branches
 SCA (sup. cerebellar), PCA (posterior cerebral)
 P-com to join anterior circulation

Cerebellar infarct (PICA) Basilar artery infarct Basilar artery thrombosis

 Vertigo, nystagmus Pontine, midbrain Bilateral pontine ischemia
 Gait, limb ataxia ischemia  Coma, quadriparesis
 Falling towards side  Hemipontine pure Can lose all voluntary
motor hemiparesis movement but eyes – locked in!
of lesion

Etiology of Ischemic Stroke

Large artery atherosclerosis

Common sites: Ischemic Stroke: Etiology
 Extracranial (ICA)  Large artery atherosclerosis
 Vertebrobasilar atherosclerosis  Cardioembolic stroke
 Small vessel disease (lacunar stroke)
Large vessel TIA: usually from atherosclerosis  Other vasculopathy
 Coagulation disorder
 Repetitive (often have Hx of prior TIA)
 Stereotyped (same vessels as previous TIAs – fixed lesions)
 Can be blood pressure related (orthostatic symptoms)

Carotid Artery TIA

 Numbness, weakness of contralateral face / arm (whole MCA territory affected)
 Aphasia if in dominant hemisphere
 Ipsilateral amaurosis fugax
o (sudden clouding  loss of vision in one eye b/c blood flow ↓ to retina)

Risk of recurrence: % stenosis and symptoms are predictive

Carotid Endarterectomy (remove plaque on inside of artery)

 Standard of care for symptomatic carotid stenosis
o NNT = 6 in 2 yrs vs. best medical therapy (usually aspirin) ofr pts with minor stroke, ≥ 70% stenosis by angiography
 Less valuable for asymptomatic carotid stenosis
o NNT = 67 in 2 yrs; use CEA if you have good surgeons (need low complication rate to be worth it)

Treatment of Carotid Stenosis: Summary

< 30% stenosis medical treatment (aspirin)
> 70% stenosis, symptomatic significant benefit of CEA over medical therapy
> 60% stenosis, asymptomatic modest benefit of CEA; tailor to pt and surgeon
st
High risk for CEA complications can use carotid artery stenting (in trials for 1 line)

22
Intracranial Large Artery Atherosclerosis
 Intracranial carotid artery, circle of Willis, vertebrobasilar atherosclerosis
 Treatment: ANTIPLATELET therapy with ASPIRIN
o Equivalent to anticoagulation with warfarin but fewer serious bleeding complications
o Intracranial angioplasty, stenting being investigated

Cardioembolic Stroke
 Atrial fibrillation (LA mural thrombus, esp. in older pts)  Valvular disorder (mitral stenosis, prosthetic valve)
 LV thrombus (acute MI, DCM)  Cardiac tumor (e.g. cardiac myxoma)
 Bacterial, non-bacterial endocarditis  Aortic arch atheroma

Presentation
 Sudden onset, maximal deficit at onset
 MCA territory is most common (straight shot)
 Multiple cortical strokes in differing vascular territories suggests cardioembolic stroke

Treatment: Balance risk of recurrent embolism vs risk of bleeding

 Anticoagulate for high risk conditions (warfarin) for 2° prevention of recurrent stroke
 Don’t anticoagulate BACTERIAL ENDOCARDITIS (can cause aneurysms, can rupture with anticoagulation)
 No benefit from immediate anticoagulation with IV heparin acutely

Lacunar Stroke
Small infarcts in territory of penetrating arteries

“ministrokes” – but a bad term (a small stroke can

Lenticulostriates
Thalamoperforants
cause huge symptoms if in the right place – strategic
infarct)
MCA
Pathogenesis: atherosclerotic plaques occlude orifice
of small vessels, or lipohyalinosis of small vessel
closes it off (overlap with large vessel stenosis)
PCA

Brainstem
Basilar
Penetrators

Lacunar Syndromes
Symptoms Lacunae in…
 Weakness of face, arm, leg (often
equally affected)
Pure motor Internal capsule
 Absence of objective sensory loss,
hemiparesis (or pons)
visual field defect, aphasia
(MOTOR ONLY)
 Hemibody sensory loss
Pure sensory  No weakness, visual loss, aphasia Thalamus
stroke (can have sensory hemiataxia)

23
Treatment of lacunar stroke
 Antiplatelet therapy: aspirin, clopidogrel (Plavix), aspirin + dipyridamol)
 Risk factor control (BP is #1, also cholesterol, DM?)
Management of Acute Stroke
 Supportive care  Thrombolytic therapy
 BP, glucose, fever control  Endovascular therapy
 Acute pharmacotherapy

In Inpatient Setting
 Admit to stroke care unit (certified, better adherence to guidelines)
 Telemetry for 24 hrs, then prn (check for a-fib)
 BP, vital signs q4h, neuro checks q4h, swallowing evaluation, glucose checks, DVT prophy

Glucose and Stroke

 Diabetics, acute hyperglycemia at time of infarct have worse outcome after stroke
 Mechanism unclear (↑ lactate around ischemia? Gene induction?), uncertain benefit to fixing hyperglycemia

Temperature
 Fever worsens outcome (↑ 1° C, risk of poor outcome doubles); greatest effect in 1st 24 hrs
 Treatment: aggressive acetaminophen or physical means; search for underlying cause
o Hypothermia under investigation (hard to do – people shiver!)

Blood Pressure
Normally autoregulated (constant blood flow to brain across wide range of BP)
 Autoregulation impaired / lost in area of infarction, so ischemic tissues are perfusion-pressure dependent!
 Hx of HTN: autoregulation shifted to higher pressures! (bad)

Treatment: no proven optimum range of BP in acute stroke

 avoid hypotension
 treat hypertension only if SBP > 220, DBP > 120, or signs of end organ damage (“permissive hypertension”)

Antithrombotic therapy
 Rule out intracranial hemorrhage (CT/MRI); tailor Rx to suspected etiology

Acute stroke:
 Give aspirin 325 mg PO (small beneficial effect w/in 24 hrs)
 Acute anticoagulation (heparin, warfarin) discouraged (↑ bleeding)

Secondary prevention
 Do use antithrombotic therapy later (with aggressive HTN, DM, hyperlipidemia, cig smoking management)
 Aspirin and statins are most powerful to prevent stroke
 Warfarin in pts with A-fib (prevent mural thrombi)

24
Pharm Review: Role of Antithrombotics in Stroke
Mechanism Notes
irreversible platelet inactivator  ↓ 1 yr mortality in acute stroke – works!
Aspirin
(COX inhibitor)  Gastritis / GI side effects
Clopidogrel Selective irreversible inhibitor of  Equivalent to aspirin for prevention of recurrent stroke but
(Plavix) ADP-induced platelet aggregation  ↑ bleeding (bad)
 Ineffective as monotherapy
Phosphodiesterase inhibitor
Dipyridamole  Maybe slightly better than aspirin alone if in combo
(↓ aggregation)
 Major side effect: 30% get severe headaches
HMG CoA-reductase inhibitors  Significant reduction in stroke risk
Statins (block rate-limiting step in cholesterol (even if “normal” chol values)
biosynthesis)  Try to get LDL < 70 mg/dL
 ↓ stroke risk, ↓ intracerebral hemorrhage risk
AntiHTN Various  ACEi / ARB may be particularly useful (even in pts with
relatively normal BP)

Thrombolytic Therapy (rTPA)

Tissue plasminogen activator:
 serine protease, converts plasminogen  plasmin in presence of fibrin, leads to thrombolysis

rtPA (Alteplase) = recombinant TPA

 Major risk: intracranial bleeding (but no ↑ risk death)
 Only FDA-approved therapy for acute stroke

Endovascular therapy
Various options available:
 Intra-arterial thrombolysis (thrombolytics directly to clot)
 Intracranial angioplasty, stenting
 Intra-arterial mechanical embolectomy
 Intra-arterial ultrasound combined with thrombolysis

25
 Pupils & Eye Movements in Cerebrovascular Disease
Oculomotor Systems
Shift Gaze / Attention Stabilize Gaze / Attention
(Fast movements) (Stop / slow movement)
 Fixation, VOR suppression
 Voluntary / volitional saccade / Vergence
 Vestibular pursuit (VOR / OTR)
 Reflexive saccade
 (Conjugate) visual pursuit / vergence pursuit
 Nystagmus quick phase (VOR / OKN)
 Gaze holding

Remember the basics of extraocular muscle movement

 Vertical, horizontal, torsional (extort: top out; intort: top in)
 4: intort; 6: abduct (lateralize); 3: everything else

Basic scheme
Voluntary EOMs front of brain * (CN 3/4/6 nuclei,
Reflexive EOMs back of brain α -motor neurons for
Primary machinery* brainstem EOM)
Tuning cerebellum

Brainstem Machinery
Midbrain Vertical /Torsional Gaze & Holding; Vergence
Pons Horizontal Gaze
Medulla Horizontal Holding

Horizontal section: note that:

 medial longitudinal fasiculus MLF) runs along the back of
everything; connects CN 6 & 3 for horizontal gaze
 Cerebellum (accuracy center) is right near everything
 Cranial nerve nuclei are in logical places (see previous lectures)

Supranuclear control systems determine / shape inputs to eye system

Saccades
Eye-only vs. eye-head shifts
 When eye moves alone: shift, then hold
 When head moves too (real life)
o Lead with eyes  head turns; eyes correct back

Eyes only Eyes + head

26
Pulse-step physiology
 Move eyes (burst)
 Hold eyes there (sustained ↑ tonic impulse)

Machinery (how does this happen?)

 Parapontine Reticular Formation (PPRF) – horizontal gaze center
o Initiates saccades; ipsilateral
 Reciprocal innervations with local inhibitory loops
 Complicated anatomy: one part is “gas” (burst), one part is “clutch” (terminate burst), one part is brake (hold; “integrator”)

Horizontal Leftward Voluntary Saccade: “Look to the left”

1. R. frontal eye field
2. R. saccade center
3. L. horizontal gaze center
4. L. 6th nucleus (L eye out)
5. R. MLF
6. R. 3rd nucleus (R eye in)

KNOW THIS LEVEL OF DETAIL‼

 Think of anatomy: where is the lesion?
 Lesion in R FEF, for example, knocks out the contralateral 6 & ipsilateral 3, so you
won’t be able to look away from the lesion and you’ll tend to look towards it

Cerebral gaze palsy (“preference”)

60 year-old woman presents with sudden-onset left hemiplegia. She is confused and
neglecting the left side, but able to follow commands. Her eye movement exam reveals eye deviation to the
right, and an inability to make voluntary eye movements to the left in response to verbal commands.
 Both eyes affected, voluntary saccades knocked out
 Lesion here in right frontal eye field (knock out L 6, R 3: can’t look left!)
 Right MCA ischemic stroke or something like that

INO (Intranuclear opthalmoplegia)

45 year-old man presents with sudden-onset diplopia. He feels a little unsteady on his feet, but has no other symptoms. His eye
movement exam reveals an exotropia (wall-eyed) and an adduction (medialization) failure in the right eye on attempted leftward
gaze. The deficit is overcome by convergence.
 Can’t bring right eye in towards nose voluntarily, but can follow finger heading towards
nose (convergence)
 Lesion in right MLF (“intranuclear” = between 3 and 6 nuclei)
o e.g. right brainstem stroke
o Look left: L. CN 6 ok (L. eye out), but R. CN 3 not connected (R. eye doesn’t go in)

Convergence Pursuit
“watch my finger” as I move it towards your nose
 Bilateral (both eyes need to move in)

Machinery:
1. Bilateral motion perception areas (MST)
2. Bilateral frontal eye fields
3. Bilateral vergence centers
4. Bilateral 3rd nuclei (both eyes in)

Note that MLF is nowhere near pathway (convergence preserved in INO)

27
 Pupils: Efferent Pathway
Efferent (Motor) pathway
 EFFERENT problems with one pupil cause ANISOCORIA (asymmetric SIZED pupils)
Parasympathetics Sympathetics
Role Constrict pupil in light Dilates pupil in darkness
Outside skull
Inside skull
 Hypothalamus  exit in thoracic SC 
 CN II  Edinger-Westphal nucleus 
sympathetic trunk  over lung, under
Anatomy  parasympathetics out on CN III 
subclavian 
 ciliary gangion short ciliary nerves 
 up ICA  trigeminal ganglion 
 constrict pupil
 out on CN V roots  dilate pupil

Picture

Defect BIG, POORLY REACTIVE pupil, SMALL pupil that DILATES POORLY in darkness,
causes… with anisicoria maximal in BRIGHT light with anisicoria maximal in DIM or NO light
BIG ptosis on side of BIG PUPIL SMALL ptosis on side of SMALL PUPIL (“Horner’s”)
(3rd nerve affected too – levator palpebrae m.) (Sympathetics: superior, inferior tarsal mm.)

Ptosis

Right 3rd nerve palsy

42 year-old man presents with sudden-onset diplopia and a severe headache. His eye movement exam reveals a
moderate right ptosis, an exotropia (wall-eyed), and a dilated, non-reactive right pupil. His left eye moves
normally, but the right has limited movement other than normal abduction (lateralization).
 CN III affected (6 ok: can still abduct)
 Big ptosis, extropia, dilated pupil = 3 nerve palsy
rd

 Berry aneurysm (compresses CN III – little white circles in picture)

Left Horner Syndrome

48 year-old woman presents with a 10-minute episode of word-finding difficulty. She has had a left frontal headache for the past
two weeks that came on after a fall. Her exam reveals slight left ptosis and subtle anisocoria, with the left eye pupil smaller. The left
pupil dilates slowly when the lights are turned off, and anisocoria is more obvious in darkness. Ocular motility is normal.
 Baby ptosis, anisocoria in dark  sympathetics (can’t dilate in dark)
 Left carotid dissection (prior to stroke)
o Sympathetics in wall of carotid
o THERAPEUTIC EMERGENCY
 (anticoagulate – unlike AO dxn, can have thrombotic sequelae!)

28
 Pupils: Afferent Pathway
Left Relative Afferent Pupillary Defect (RAPD)
77 year-old man presents with a month of bitemporal headaches and one day of acute vision loss in the left eye.
His exam reveals hand motions vision in the left eye. The left pupil responds to light, but there is a left relative afferent pupillary
defect on the swinging flashlight test. The left optic disc is pale, swollen

“swinging flashlight sign” – penlight in R, then L eye; Affected eye appears to dilate paradoxically when you light on it

 Double decussation in afferent light reflex:

CN II has synaptic outputs to EW nucleus on BOTH SIDES

 NO ANISOCORIA in AFFERENT DEFECT

(both eyes respond the same)
o But when you shine light in bad eye (CN II damaged,
etc), both pupils “dilate” (don’t constrict)

Shine light in… Response Explanation

Both constricting maximally

(plenty of light to trigger constriction)
Good eye
Light “seen” by EW nucleus: 100%

Both eyes “dilate”

(less light getting in to trigger constriction)
Bad eye
Light “seen” by EW nucleus: ≈ 50%
(depends on extent of defect)

Giant Cell arteritis (ischemic optic neuropathy), etc. – affect optic nerve

29
 CNS Infections
Anatomical Considerations
Key features of CNS:
 sequestered from systemic compartment (BBB)
 limited regenerative potential (neurons) – almost irreplaceable (gial cells: low turnover, promote scarring)
 little extracellular space (easy cell-cell spread)
 specialized receptors (eg Ach receptor for rabies, heparan sulfate for herpes)

Bony protection: calvarium; dura tightly bound together

 Epidural infections: usually from bone infection (osteomyelitis); remain localized
 If bacteria get into subdural space, infection spreads rapidly over hemisphere

BBB: good & bad

 Excludes most microorganisms but also most inflammatory cells / Abx / Ab (hampers clearance)
 Limited endogenous defenses in CSF, low C’ levels, low Ab levels, few phagocytic cells, etc.

CSF:
 Subarachnoid space: pathogens can undergo rapid growth here; spread through CNS
 Lumbar puncture is KEY in evaluating / treating CNS infections

Meningitis
18 year old male, military recruit presents with CC of intense headache, fever and stiff neck.
Meningitis = inflammation of the meninges (diffuse CNS infection)
 bacterial / fungal / parasitic growth in subarachnoid CSF space or
 intracellular growth of bacteria / viruses in arachnoid, ependymal cells

Causes of meningitis
Bacterial meningitis: 20k cases /yr, most deaths in neonates (even though only 10% total cases)
Neonates (< 28d) Children Adults Older (>60)
 enteric bacilli (esp. E. coli)  Strep pneumo
 Neisseria meningitidis*  Strep pneumo
 Group B Strep  N. meningitidis
 Strep pneumo  Listeria
 Listeria  H. influenza (vaccine)
* most cases of pyogenic meningitis are sporadic, but N. meningitides also causes epidemic disease (Africa)
Meningococcal meningitis (N. meningitidis): typically young adults living in barracks / dorms; preventable by vax

Viral meningitis
 Frequent (75k/yr); VIRAL ≫ bacterial meningitis
 Enteroviruses (late summer, early fall); West Nile (more encephalitis), others – think mosquitos, travel

Pathogenesis of Meningitis
 Bacteria / virus invades CNS from blood (↑ risk with ↑
magnitude, duration of bacteremia/viremia)
o Capsid polysaccharides: resistant to phagocytosis,
better chance of invasion
o Intracellular bacteria often elude this clearance too

 Rapid multiplication in subarachnoid space (lack of

immune defenses)  Release of bacterial cell wall
components  inflammation, proinflammatory cytokines
 Brain, blood vessel inflammation
Pathology: Cloudy, purulent meninges
filled with bacteria (purple – right) 30
Clinical Manifestations of meningitis
 Headache, fever, nuchal rigidity are classic
 Obtundation, seizures common; lethargy, nausea/vomiting, rash, ataxia

Signs on physical exam (basic idea: stretching inflamed meninges is painful)

If not treated:
 collection of pus at base of brain forms: CN palsies (VI, VII, VIII especially), CSF obstruction  hydrocephalus
 Infection of vessels: can produce septic occlusion  infarction of brain, multifocal neuro deficits

Rash: May progress to purpura fulminans, associated with multiorgan failure

 (Waterhouse-Friderichsen syndrome – N. meningitidis  adrenal gland infection  hemorrhage, DIC, etc.).

Diagnosis of meningitis
CSF is KEY:
Infection Pressure Cells Protein Sugar
Viral meningitis Normal mononuclear (10-1000) ↑ Normal
Bacterial meningitis Normal or ↑ PMNs (>100)* ↑↑ ↓↓↓
Subacute meningitis (e.g. TB) Normal mononuclear ↑↑ Normal to ↓
* WBC > 2000, PMN > 1180 is 99% predictive of bacterial meningitis

Other Techniques
 Bacterial: culture / Gram stain; immunoelectrophoresis (capsular polysaccharides)
 Viral: usually can’t culture, use PCR

Management of meningitis
 LP (ASAP!)
 High risk of herniation: > 60 yo, immunocompromised, Hx of CNS disease, seizures w/in 1 wk, abnormal consciousness,
focal findings (if none of these symptoms, 97% of time there’s no mass effect)

Pharmacotherapy: start ABX IMMEDIATELY

 Empiric antibiotics: ASAP! (during or right after LP!)
o Cefotaxime + vancomycin for community acquired meningitis
o + Ampicillin for immunocompromised (to cover Listeria)
 Acyclovir if pleocytosis is mononuclear (think viral)
o Herpes simplex encephalitis is only viral one to distinguish urgently: others often self-limited
 Corticosteroids in acute bacterial meningitis in children w/o HiB vax or adults with ↑ ICP, high bacterial cell ct
o Otherwise ↑ risk of serious gastrointestinal bleeding, not worth it

31
Clinical course of meningitis
 15-30% die even with prompt treatment (highest with pneumococcal meningitis)
 Venous thrombosis, cerebral edema possible with bacterial meningitis
 Neuro sequelae: seizures, hydrocephalus, cranial nerve deficits common
o Kids: deafness, hearing loss o Adults: facial nerve palsies

Chronic Meningitis
Meningo-encephalitis syndrome lasting 4+ weeks; Less than 10% of all cases of meningitis
 Fever, headache, meningismus, alterned mentation, seizures, dementia, other neuropsych presentations
 CSF: Mononuclear pleocytosis + elevated protein
 Consider infectious, neoplastic, non-infectious causes
o TB meningitis (immunocompromised, immigrants) – can cause meningitis, abscesses, epidural
infections affecting spine (Pott’s disease) in HIV pts

Bacterial Brain Abscesses

38 year old male presents with CC of new onset focal seizures while on skiing trip. No preceding sx, headache, focal weakness, or CVA
risk factors. Recently had had a root canal performed. Exam: mild left hemiparesis.

Abscess: foci of purulent infection developing from either:

 Spread of contiguous focus of infection (ears, nasal/mastoid sinuses, TEETH – dental work!)
 Hematogenous spread (lung / heart, e.g. purulent pulmonary disease, subacute bacterial endocarditis, etc.)
Invasive procedures too: vascular catheters, other instrumentation  bacterial seeding  abscess

Etiology: mostly mixed flora of aerobic & anaerobic bacteria

 Streptococci (60-70%), also S. aureus, enterobacteriaciae, bacteroides
 Fungi / parasites too (see later)

Appearance:
 Ring-like lesions on T1 w/contrast
o Walled off; rim is vascular / edematous & enhances with contrast, pus doesn’t
Bacteria TB Toxo
Liquefactive necrosis Caseating necrosis Solid necrosis

Clinical Manifestations
 “Classic triad” – headache, focal signs, seizure
o But the triad occurs in FEWER THAN 50%
 CSF is usually sterile (would need to aspirate cavity!)

Treatment:
 Multiple abx to cover common organisms
o Ceftriaxone, metronidazole (anaerobes), Naficillin (S. aureus), Ceftazidime (P. aeurg), Vanc (MRSA)
 Anticonvulsants may be helpful
 Surgical DRAINAGE to determine specific flora, help abx penetrate, prevent rupture
 Avoid STEROIDS (decreases CNS penetration!)

Spinal epidural abscesses

 Diabetics, pts on hemodialysis, IV drug users
 Local pain & tenderness  rapid course
o segmental pain along nerve roots, paresthesias below level  irreversible paraplegia!
 Surgical emergency (Dx & drain!)
o use spinal MRI (compressive lesion involving disk space, anterior to cord)

32
 Encephalitis
28 year old female secretary presents with a 3 day hx of 102 fever, mild confusion and headache. Family says she’s had brief episodes
of “left arm twitching uncontrollably, being out of it, with lip-smacking”. Exam shows disorientation, mild hemiparesis.

Encephalitis: inflammation of the brain

 most commonly caused by viruses

Etiology
 common: HSV, Arboviruses, Enteroviruses, Mumps, CMV, EBV, VZV, HIV, Measles
 less common: Adenovirus, Colorado tick fever, Influenza, LCM, Parainfluenza, Rabies, Poliomyelitis, Rubella

Life threatening encephalitis: usually due to:

 HSV (sporadic)
 Arboviruses (epidemic; mosquito-borne; e.g. West Nile encephalitis, others)
 Rabies: uniformly fatal encephalitis; < 5 cases in USA / yr

Pathogenesis
Herpes simplex encephalitis (HSE)
 HSV-1 usually; localized infection in brain
o acquired in childhood, latent in trigeminal ganglia, reactivates (cold sores,)
o can spread along nerve fibers, uniquely localized to orbital frontal & medial temporal lobes
o Host has pre-existing immunity (needs to spread continuously to avoid blood) – neurons & glia affected
Arboviruses:
 Spread from blood to brain following arthropod bite (mosquito or tick)
 Few / no sx during systemic infection; 1:20-1:1000 spread to CNS
 Diffuse infection, neurons only affected
 Case-fatality rates range (50% for Eastern equine, 5-15% for West Nile, <1% for LaCrosse)

Clinical manifestations of encephalitis

 NEUROLOGICAL DEFICITS (vs mengingitis: no neuro deficits!)
 Fever, headache, nausea, vomiting, altered mentation, seizures, hyper-reflexia, meningismus
HSE Arbovirus encephalitis
Focal signs (rare in other forms) – hallucinations, More diffuse disease (rapid depression of consciousness, frequent
bizarre behavior, focal seizures, hemiparesis, aphasia generalized seizures) – but can be indistinguishable from HSE
Evolve over days to weeks Very rapid progression

Diagnosis
 CSF: ↑ pressure, mononuclear cells (lymphocytes), protein ↑, glucose normal
 Culture usually negative

Arboviruses: virus-specific IgM in CSF (rapid diagnosis)

HSV: CSF PCR sensitive, specific (empiric tx without brain biopsy

 MRI: can see frontal & temporal lobe hemorrhage & necrosis (see pics)

Treatment
 HSV: ACYCLOVIR REDUCES MORTALITY (70% w/o tx, <25% with tx)
o Need rapid diagnosis & treatment of HSE!
 Otherwise: supportive care

33
 Lyme Disease
25 year old male med student presents with CC of “Bell’s facial palsy”. He has had fevers and arthralgias for 2 weeks.
Exam: 6 cm “target” rash on arm. Left ‘peripheral pattern’ facial palsy

Etiology: Borrelia burgdorferi

 carried by Dermacentor variablis (American dog tick) and
Ixodes scapularis (black-legged “ deer” tick) – NE USA

Signs / symptoms
 Cranial nerve VII palsies
 “Bull’s eye rash”
 Meningitis / encephalitis /
radiculoneuritis, can mimic lots of
other diseases
 MRI: can mimic MS or ischemia

Course: rash, neuro symptoms: later neuro symptoms (?)

Diagnosis: ELISA (false positives possible; confirm with Western)
Treatment:
 If chronic neuro symptoms + (Hx Lyme dz, + lyme serology, or CSF
abnormalities): give antibiotics
o 4 week course of IV ceftriaxone or 60 days PO doxyxcycline
 No evidence for abx in “Post-Lyme syndrome”

Neurologic Infections in Immunocompromised Hosts

Need to be precise about what type of immonocompromise the patient has
Example Susceptible to
Humoral (antibody) deficit Mult. myeloma, splenectomy Encapsulated bacteria (H. flu, S. pneumo, enteroviruses)
Cellular (T-cells) deficit AIDS Toxo, cryptococus, CMV / JCV
Granulocytes deficit After chemo Fungal (Aspergillus, C. albicans, Mucor), Gram negs

Opportunistic infections: exposure to ubiquitous organisms

that are normally of low pathogenicity

Reactivated infections: remote Asx primary infection,

become reactivated from latency if immune deficiency
acquired

Neuro complications in HIV (can have combo):

 directly HIV-related
 from complications of immune deficiency

Opportunistic Infections in Advanced HIV

 Occur with CD4 < 200; may be multiple in 15%
 May require lifelong maintenance therapy until immune system recovers (HAART)
 CSF PCR helpful for some infections
 Imaging characteristics very helpful
 Biopsy 90% sensitive, but 7% morbidity ~ so avoid unless absolutely necessary

34
Cryptococcal meningitis
Etiology: Ubiquitous yeast; CNS infection in 5% AIDs pts
Presentation: Headache, altered mentation, cranial neuropathies, fever, vomiting
 NECK STIFFNESS UNCOMMON (limited CSF inflammatory response!)

Pathology: Extensive meningial invasion, tons of budding yeast forms

 Form cryptococcomas frequently, esp. basal ganglia
 Prominent jelly-like capsule

Course: Complication: obstruction of CSF outflow  ↑ ICP

Diagnosis: Cryptococcal Ag in CSF or Cx (Normal CSF cells / protein in 50%)
Treatment: Ampho B x 14 d (induction); follow with fluconazole x 10 wks
 Remember liposomal ampho is a little better if renal impairment

Cerebral toxoplasmosis
Etiology: Toxoplasmosis gondii, obligate intracellular protozoan; toxoplasmosis in 5-10% AIDs pts
Presentation: Fever, altered mentation, seizures, focal neuro signs that develop subacutely (days – wks)

Pathology: Multifocal necrotic abscesses

 scattered throughout hemispheres
(esp basal ganglia)

Pathogenesis: Reactivation of latent organisms

(encysted in brain)

Course: Reactivation common, need lifelong suppressive therapy (pyrimethamine)

Diagnosis: CT/MRI: RING-ENHANCING mass lesions
 not specific: CNS lymphoma, abscesses similar

Treatment: Pyrimethamine & sulfadiazine + folinic acid (prevent bone marrow suppression)
 leads to clinical, radiological improvement in ~80% pts in 10 days
o RELs in HIV: treat for toxo & see if it gets better; if not, lymphoma?
 Steroids only if large lesion, mass effect

Primary CNS lymphoma (PCNSL)

 2% AIDs pts develop primary CNS lymphoma
 B-cell origin, associated with EBV infection
 Multicentric, aggressive: progressive neuro deterioration with encephalopathy, focal signs, seizures

Progressive Multifocal Leukoencephalopathy (PML)

Etiology: Reactivation of latent JC Virus (a papovavirus) infection with immunodeficiency (HIV or natalizumab)
 Natilizumab: MS therapy, blocks alpha 4 integrin / vascular cell adhesion; ↓ immune response

Presentation: Primary JCV infection usually asymptomatic; PML in 5% AIDs pts

 Progressive hemiparesis, hemianopsia, aphasia, ataxia
 NO HEADACHE

Pathogenesis: JCV infects oligodendroglia  patchy white matter foci of demyelination

Pathology: inclusion bodies in deformed oligodendroglia, demyelination, bizarre giant astrocytes

Course: Before HAART: death in wks / months

35
Diagnosis: MRI virtually pathognomonic (Bx not usually required)
 Multiple, asymmetric areas within subcortical white matter
 no prominent enhancement or mass effect

Treatment: HAART (alpha-interferon or mirtazipine (antidepressant) as adjunct)

Listeria monocytogenes
 Common cause of bacterial CNS infection in immunodeficiency (cancer chemo, renal transplant, corticosteroids)
Risks: GI colonization, ↓ T-lymphocytes, Mϕ
Presentation: subacute fever, altered mental status, focal neuro signs in setting of bacteremia
Diagnosis: CSF: PMN pleocytosis; Cx: + for blood, CSF
Treatment: Ampicilin (erythromycin, chloramphenicol if allergic to PCN)

CMV Encephalitis
 Important cause of CNS infection in transplant recipients & HIV pts
Presentation: headache, fever, altered mental status
 focal neuro signs, meningismus uncommon
 Can infect lumbosacral nerve roots (subacute cauda equine syndrome)

Pathology: necrotizing infection of subependymal region or brainstem

 Inflammation, necrosis, CMV “OWL’s EYE” inclusions
Diagnosis: CSF CMV PCR is useful (esp. in AIDS)
 difficult (CSF cx usually (-); viral blood cultures may be (+))
Treatment: ganciclovir (esp. CMV retinitis)

Slow and Chronic Infections of the Nervous System

Chronic CNS infections (e.g. syphilis): run course over many years; unpredictable appearance of varied complications
Slow CNS infections (e.g. CJD): more predictable incubation with progressive buildup, preditable course
 need to differentiate both from static sequelae of acute bacterial meningitis, viral encephalitis

Syphilis
 a spirochete; causes varied neuro disease
Presentations:
 Secondary syphilis (6wks – 3mo post infection): may see benign, mild meningitis (CNS involvement in 25% w/o Tx)
 Ocular manifestations (uveitis, neuroretinitis, episcleritis)
 Late-stage syphilis:
Time after 1° infection Possible manifestation
3-5 years Meningovascular syphilis  stroke
8-10 years Progressive dementia (“general paresis”)
10-20 years Chronic arachnoiditis (“tabes dorsalis”) – primarily posterior SC roots involved

Diagnosis: syphilis serology (VDRL+ / RPR↑, etc. even if pt immunosuppressed)

Treatment: high dose IV PCN (not consistently effective in neurosyphilis / with HIV – reexamine at 6 mo!)

Direct HIV-1 involvement of nervous system

 Neuro sx in HIV: 50% from opportunistic infections, 50% from HIV-1 effects itself
 Pathogenesis not entirely understood

36
HIV-associated dementia
 A chronic viral encephalitis in 15-20% AIDS pts

Presentation: Progressive subcortical dementia with CD4 < 500

 ↓ cognition, behavioral changes, motor dysfunction
 impaired short-term memory, imbalance, slower reaction times
 apathy & social withdrawal
 psychomotor slowing with sparing of language

Diagnosis: Clinical mostly (see above)

 FLAIR: deep white matter hyperintensities & central atrophy
Pathogenesis:
 perivascular Mϕ are major target of HIV infection in brain; NOT NEURONS
 reactive astrocytosis, microglial nodules, multinucleated giant cells (Mϕ fuse)

Treatment: HAART (aggressive) – can ↓ sx in a few weeks

Prion Diseases
Prion diseases: transmissible spongiform encephalopathies (TSEs)
 caused by infectious agents without nucleic acids
 spongiform: post-mortem brain has large vacuoles in cortex and cerebellum
 beta-sheet formation (PrP) characteristic

Prions = misfolded proteins (“small proteinaceous infectious particles which resist inactivation by procedures that modify nucleic acids”)

Kuru and Creutzfeld-Jacob Disease are two human prion diseases

 Kuru = ritual cannibalism in Fore tribe of Papua New Guinea

CJD
 Presenile dementia with progressive course and death in < 6 mo
 Presents at 50-60 yo with triad of progressive dementia, myoclonus, characteristic EEG findings

Rare (1/million worldwide, 85-95% sporadic; 5-15% familial)

 Iatrogenic: corneal transplants, dural grafts, contaminated growth hormone

Diagnosis: Specific marker protein (14-3-3) >90% specificity, sensitivity

Pathology: pathognomonic: neuronal loss, gliosis, spongiform appearance

Animal TSE
BSE Bovine spongiform encephalopathy: cows
BSE: England, 80s, changes in food processing system Scrapie Sheep
 Prion-contaminated nervous tissue into food chain TME Transmissible mink encephalopathy
CWD Chronic wasting disease: mule deer, elk
New-variant CJD: unusual CJD-like cases in young adults
 Early behavioral disturbances, paresthesias, ataxia, slower progression
 Extensive amyloid plaque formation in brain

37
 Multiple Sclerosis / Demyelinating Diseases
Demyelinating Diseases
Destruction of previously normal myelin sheath in CNS with accompanying inflammatory response
 myelinoclastic process

Contrast to dysmyelinating disorders, when myelin doesn’t form / delayed / arrested / maintenance disturbed
 e.g. leukodystrophies (myelin deficient in CNS / PNS), lipid storage diseases, aminoacidopathies
 Adrenoleukodystrophy (ALD): X-linked disorder with combined demyelination / dysmyelination

Multiple Sclerosis: overview

 Inflammatory demyelinating disease of the brain and spinal cord that usually presents at 20-45 yo
 Genetic predisposition with environmental trigger
o Pathogenesis: precipitating microbial infection that through molecular mimicry or release of sequestered
antigens results in chronic autoimmunity in genetically predisposed host
o HLA-DR2, IL-2 receptor alpha, and IL-7 receptor gene polymorphisms associated with MS
 MRI and spinal fluid aid diagnosis
 Partly effective treatments exist to prevent immune cell activation and migration
o interferon beta, glatiramer acetate, and natalizumab

Epidemiology of MS
 Far and away most common demyelinating disease
 Most common cause of disability in young adults, annual cost in US $6.8-11.9B
 250-300k in US; 2/3 FEMALE, ↑ in Northern Europeans; onset: 15-50 yrs
 ↑ in temperate higher latitudes of both hemispheres

Immunopathogenesis of MS
Polygenic disease: inheritance confers susceptibility to autoimmunity
 Inflammatory response genes implicated: HLA-DR2, IL-2 receptor-α, IL-7 receptor-α

Environmental trigger(s): virus, toxin, etc. provoke through molecular mimicry or release of sequestered antigens
 Autoreactive T-cells activated, traffic into CNS, release proinflammatory cytokines 
 ↑ adhesion molecules on brain vascular endothelial cells 
 ↑ BBB permeability, non-specific immune cell recruitment
 Demyelination  attempts at remyelination 
 eventually scarring / gliosis / axonal degeneration

What does myelin do?

1. rapid conduction of nerve impulses
2. protection of nerve fibers
3. trophic support

Clinical Courses
Relapsing and Remitting (RR)
Secondary Progressive (SP)
Primary Progressive (PP)
Clinical Features of MS
85-90% at onset
RR pts can convert to SP:
50% after 10 years, 80% after 30-40 yrs
10-15% are progressive from onset

Course is highly variable

 Some: malignant, disseminated, fulminating (5-10% pts, esp. younger)
 Some: RR/SP with benign course, few symptoms
38
Even RR can progress stepwise (see top picture to right)
 MRI shows continuing inflammation / demyelination even
during clinical remissions!
o MS is a chronically active disease

Symptoms:
 Visual  Impaired coordination, balance  Bowel, bladder
 Sensory  Heat sensitivity  Sexual
 Fatigue  Burning/electrical pains  Cognitive
 Dizziness (vertigo, dysequilibrium)  Motor  Psychiatric (depression)

Signs:
 Sensory loss Incontinence, abnormal sphincter function
 Weakness, spasticity, hyperreflexia, Babinskis  Depression and memory loss
 Impaired coordination (limbs and gait), action tremor  Fluctuation with temperature
 Nystagmus, impaired eye movements, or monocular visual loss

Later signs / symptoms: para/quadriplegia, urinary incontinence, constipation, impotence, cognitive impairment, etc.

Diagnosis of MS
Dissemination in space and time
 2 or more episodes of neurologic dysfunction with associated signs referable to CNS, or
 Chronic progression for more than 6 mo without other definable cause

Clinical diagnosis; need exclusion of other conditions

 MRI can be used to establish dissemination in time & space after 1st clinical episode
Aids to MS Dx
MRI of brain / spinal cord
Surpasses all previous diagnostic tests; can use to follow pt (serial imaging)
New lesions are Gadolinium enhancing
o Paramagnetic substance; injected IV; indicates BBB is “ open” (active inflammation)
Features:
 High signal T2-weighted lesions that are:
o Perpendicular to ventricles (Dawson’s fingers)
o Pericallosal, juxtacortical, in posterior fossa, spinal cord
 Low-signal T1 lesions (“black holes”) – axonal loss
 Contrast-enhancing lesions,
 lesions changing size, lesions coming / going / accumulating

“Dawson’s Fingers”
(perpendicular to ventricle)

39
Can also use to measure disease activity (Serial MRI)
 most lesions occur in periventricular white matter
o (but can’t follow clinically- redundancy of pathways; small lesions have no good clinical correlates)
Finding Indicates…
Accumulation of T2 periventricular lesions Ongoing disease activity (bad prognosis)
Contrast enhancement BBB breakdown (disease activity)
T1 low signal lesions (“black holes”) Tissue loss (disability, poor prognosis)

CSF
Oligoclonal bands (IgG) – 2 or more in CSF but not paired serum sample
 Seen in 85% of MS
 Lacks specificity: can also see in other inflammatory dz, CNS infection

Exclusionary too: infections (culture, ↓ glucose), malignancy (cytology, ↑ protein)

Evoked potentials
 Can see slowed conduction (optic nerves, brainstem, SC pathways)
 Lacks specificity and sensitivity; supplanted by MRI

Lab tests to exclude other diseases

 Need to exclude other better explanations that can mimic MS
 The full workup: a lot of stuff! ESR/ANA (Lupus), SSA (Sjogren’s), B12, Lyme titer, RPR (Syphilis), EBV, CMV, HIV, HTLV-I
(HAM/TSP), ACE, CXR (sarcoidosis), VLCFA (adrenoleukodystrophy), biopsy (rarely – tumor, etc)

Pathology of MS
Gross Findings
 Multiple, irregularly-shaped, sharp-edged plaques
o Slightly pink / swollen  gray, retracted, opalescent with age
 More severe cases: Atrophy (anterior horns of lateral ventricles, cortical atrophy too)

Microscopy
 Loss of myelin (perivenous at first, with monocytes / lymphocytes around)
o Areas of myelin loss enlarge with time
 Loss of oligodendroglia (make myelin); ↑ astrocytes & lipid-laden Mϕ (foamy – eating myelin)

Mimics of MS on MRI
 ADEM (Acute  Sarcoidosis  Histiocytosis  Lupus
disseminated  Vasculitis  HTLV-1  Behcet’s disease
encephalomyelitis)  Migraine  Lyme disease  HIV
 HTN/small vessel dz  Aging-related changes  Leukodystrophies
 CADASIL  Organic aciduria  Mitochondrial disease

40
 Treatment of MS

Interferon β 1a (Avonex & Rebif) Naturally-occurring cytokine

 may suppress interferon gamma (proinflammatory cytokine) &
Interferon β 1b (Betaseron & Extavia)
 block migration of activated T-cells into CNS

Copolymer of 4 AA that are highly represented in myelin basic protein

(major constituent of myelin)
Glatiramer acetate (Copaxone)
Maybe an immunological “decoy”?
 block immune attack on natural myelin (?) or
 ↑ formation of glatiramer acetate reactive T-cell (Th2 regulatory effect?)

Type II topoisomerase inhibitor

Mitoxantrone (Novatrone)
 Associated with cardiotoxicity, leukemias (use with caution!)

mAb against adhesion molecule for cell migration across endothelial barriers
 blocks T and B-cell migration into CNS; maybe Mϕ too but not PMNs
Natalizumab (Tysabri)
 1/1000 pts  progressive multifocal leukocencephalopathy (PML)
o JC virus in brain, immune system can’t respond like it normally does
 “ABC” drugs (interferons & glatiramer acetate): shown to reduce exacerbation by 1/3
 Interferon betas: decrease active MRI lesions by 70-80%

Other treatments:
 Immunosuppression (azathioprine, methotrexate, cyclophosphamide, IVIG, plasma exchange)
 Symptomatic therapies (for bladder dysfunction, spasticity, pain, fatigue, depression)

Sample case: Optic Neuritis & MS

27 yo Caucasian woman w/ CC double vision; pharyngitis, anorexia, myalgia, rigors 3 days later unilateral L. visual loss
with pain over eyebrow and L. afferent papillary defect (APD – indicates loss of II transmission)

 Swinging Flashlight test: when you shine into affected eye, dilates (both eyes actually)
o Helps ddx vs MLF lesion (INO), which could also cause blurred vision

 Optic neuritis on MRI (enhancement of L. optic nerve); other enhancing lesions too

 Labs: negative for ANA (Lupus), SSA, SSB (Sjogren’s), Lyme, ESR nL, ANCA nL (vasculitis),
Rheumatoid factor negative, ACE normal (Sarcoid), Glucose / HbA1C nL (diabetes)
o Oligocolonal bands present in CSF

Dx: optic neuritis with high risk for MS

 Pts with optic neuritis & normal brain MRI: 25% chance of developing MS in 15 yrs
 Pts with optic neuritis & one or more brain MRI lesions: 75% chance of developing MS in 15 yrs

Tx: Cortocosteroids IV x 5 days, h/a & vision get better

Course:
 6 mo later: numbness from neck down; ↓ pinprick / vibration on exam & hyperreflexia w/ Babinskis
 MRI: old lesions became smaller; several new lesions + spinal cord lesion
Definitive dx: MS (RR); started on interferon-β (or glatiramer acetate)
 Flu like side effects; does well for 4 years, then presents with ataxia & dysmetria (tremor) on finger-nose testing
 New cerebellar peduncle lesion, black holes on MRI, mild brain atrophy
 Switched to natalizumab mAb infusions

41
 Paraneoplastic Neurological Disorders (PND)
Mechanisms (generally speaking)
 immune system attacks cancer  “crossfire” / collateral damage against nervous system
 Secretion of hormones or proteins by tumor  secondary remote effects
Direct invasion too (metastasis to brain / SC, etc) – not the subject of this lecture

Paraneoplastic syndromes: sx / signs resulting from damage to tissues / organs remote from the site of malignancy
 Cancer calchexia, hypercalcemia, Cushing’s syndrome, Trousseau’s syndrome, etc.
 Associated with secreted substances (e.g. hormones / proteins) from tumor or immune-mediated rxns against tumor

Epidemiology
 Symptomatic PND are rare (≈0.001% cancer pts)
 Certain conditions have ↑ risk of PND
o Small cell lung cancer  lambert-Eaton myasthenic syndrome in 3% pts
o Thymomas  Myasthenia gravis in 15% pts

Examples of PND by Target

CNS PNS Neuromuscular junction, muscle
 Limbic encephalitis
 Subacute sensory neuropathy  Lambert-Eaton myasthenic syndrome
 Subacute cerebellar
(numbness & tingling, CSF negative, no DM, etc.) (fatigue, mm weakness; #1 frequent PND)
degeneration

Limbic Encephalitis
Features:
 Subacute cognitive decline (esp in setting of malignancy)
 EEG, CSF negative
 Hippocampal abnormalities on MRI
 Ab against tumors cross to brain; specific for hippocampus!

Sample case: 74 yo man with recent onset cognitive dysfunction; subacute abnormal behavior, speech disturbances
 EEG normal, CSF cultures, viral PCR (look for HSV encephalitis) normal
 See lung mass on CT  small cell lung cancer
 MRI: damaged grey / white matter in hippocampus (memory problems)
 Dx: Limbic encephalitis

Subacute Cerebellar Degeneration

 Cerebellar signs (ataxia, dysmetria, gaze-induced nystagmus)
 Associated with anti-Yo, anti-Hu, anti-CV2 Ab
 May have normal brain MRI, no detectable tumor on presentation

Sample case: 36 yo woman w/ 3 mo Hx of diplopia, unsteadiness: ataxia, dysmetria, gaze-induced nystagmus on exam
 Brain MRI normal, CSF normal, etc.; FDG-PET shows breast cancer
 Anti-Yo ab found

42
 Mechanism of PND
Mostly from immune-mediated responses against tumor cells
 Tumor  dendritic cell recognizes, presents Ag to lymph nodes
 Immune response: activation of specific T / B cells, specific CD8+
T-cells produced, specific Ab produced
 This is all good & normal! Helps keep tumor under control

In PND:
 Ab produced against onconeural
antigens (common epitopes
between tumor & nervous system)

 Can have Ab against any point of

nervous system (neuronal soma,
axon, NMJ, etc)

Paraneoplastic antibodies
Certain Ab have been well characterized: produced by certain tumors & result in certain syndromes
 E.g. Anti-Hu (comes from SCLC, produces limbic encephalitis, cerebellar degeneration, encephalomyelitis)
 Others (think PND if you see these): Anti-Hu, anti-Yo, anti-CV2, anti-Ri, anti-Ma, anti-amphiphysin

If you suspect PND: look for Abs (ask lab to check for PNDs; they will run whole panel) & search for mets

PND Antibody Targets

 NMDA receptor (cognitive dysfunction)  AChR (myasthenia gravis)
 voltage-gated Ca channels (L-E syndrome)  Neuronal AcHR (autonomic neuropathy)
 voltage-gated K channels (limbic encephalitis)

Cancers associated with PND

 Small cell lung cancer  Thymomas
 Testis tumors (esp. encephalomyelitis, L-E myasthenia gravis)
 Ovarian tumors  Breast cancer

Assessment / management of PND

Suspect PND: pt may or may not have known history of cancer
 PND could be at 1st presentation of cancer!
 Look for PND (Ab; imaging) & look for cancer (imaging / Bx)

Treatment of…
The primary malignancy
The immune-mediated
mechanisms of disease
The secondary problems
Note the problem: immunosuppression  ↓ control of tumor growth!
Treatment of PND
Via…
 Surgical resection/chemotherapy or radiation therapy
 Steroids
 Plasma exchange
 IVIg
 Immunosupression (e.g. cyclophosphamide)
 Anti-B cell treatment (e.g. Rituximab)
 Antiepileptics, cognitive therapy, PT and OT.
43
 Headache: Dangerous Secondary Causes
Introduction
Phenomenology
Cephalalgias: usually episodic pains in the head, face, eyes, ears, nose, mouth, throat, neck, etc.
 Usually divided into several clinical groups (headaches, facial pain, eye pain, etc)
 Lots of overlap between groups
 Use OPQRST to characterize in history
Physiology

Pain in the head: either…

Primary Secondary
No disease other than headache Caused by something else
Migraine, tension-type, cluster… Meningitis, brain tumor, aneurysm
Central pain systems
Peripheral pain receptors
 Neurons; Trigeminal nucleus – sensory from head, etc.,
(nociceptors – end organs)
 PAG: relays noiciceptive signals; thalamus

The brain parenchyma is generally the only thing that doesn’t hurt in the head
 no pain receptors (nociceptors) on neurons / glia
 central pain centers (5th nucleus, PAG, hypo-/thalamus) are few things in brain that do hurt

Where the head hurts doesn’t correspond in a 1:1 way with where problem is
 pain patterns (see picture): pain can be referred to different areas
 Can’t just use localization of pain to tell you where pathology is

Axiology

Epidemiology: Headaches are COMMON

 #1 neuro sx in primary care; lifetime prevalence 96%
 50% women, 40% men with disabling headache at some point in time in life
 > 50% have more than 1 type of HA
 20% of work absenteeism; > 1000 missed workdays per 1000 pop / yr

Most headaches are benign

 97% episodic (<72 hrs)
 60-80% tension-type, 10-30% migraine, 1-5% cluster / other “trigeminal autonomic cephalalgias” (TACs)

Diseases causing headaches can KILL

Arterial dissection Leading IDable cause of stroke in young adults (18-44 yrs)
Giant cell arteritis Most common vasculitis; permanent blindness in 30-60% untreated
Dural thrombosis Intracerebral hemorrhage in young women, sometimes just post-partum
SAH from intercranial aneurysms 22k/yr in US, 50% dead / seriously disabled

44
 Clinical approach
100k+ causes of headache - what are dangerous headaches?
SNOOP (the patient at greater risk for dangerous headache)
 Systemic disease (malignancy, AIDS, systemic symptoms / signs)
 Neurologic symptoms / signs (especially diplopia, confusion, optic nerve edema; anything except visual aura)
 Onset sudden (thunderclap HA, time to peak ≤ 5 min)
 Older (>50 yrs) Evaluation of Headache
Clinical
 Pattern change
 Pattern: Episodic, Persistent, Punctuated, New-First
 Timing: Abrupt v. Gradual Onset; By Duration
5 rules of thumb  Site: Head, Face, Eye, Ear, Tooth, Jaw, Throat, Neck
 Persistent headaches (>72h) may be bad  Special Features: coital, postural, cough, diurnal
 Abrupt-onset headaches are often bad Etiopathogenetic
 H/A with fever are usually bad  Etiology: ‘Primary’ v. ‘Secondary’; ‘Dangerous’ v. ‘Not’
(intercranial infection, etc)  Pathophysiology: Neural, Vascular, Inflammatory,
 H/A with diplopia are almost always bad Serotonergic, Muscle-Tension, Rebound… other???
 H/A with change in mental status are always bad

Headache + DIPLOPIA ≠ migraine! Just about always bad!

 Elevated ICP  Cavernous sinus infections  Giant cell arteritis
 Aneurysms  Meningitis (esp. Tb, crypto)  Brainstem stroke/hemorrhage
 Pituitary apoplexy  Brainstem encephalitis

Brain tumors & headaches

 At Dx, 31% brain tumor pts have headache, but only 8% have isolated headache (seizure, etc.)
 “Classic” morning (↑ ICP) H/A is uncommon!
 ↑ ICP is the big problem, not H/A
 Even in pts with high risk (systemic cancer patients) with H/A: only 32% have mets
o Lesion predictors: new pattern or new H/A < 10 wks, Pain not “tension-type”, Vomiting
 Exception: Kids with occipital H/A – worry about posterior fossa tumors

What can’t we miss? Things that are threatening, time-dependent, treatable, and tricky!

DANGEROUS HEADACHES

DATA C2A2N save lives

1. Dissection (carotid or vertebral)
2. Arteritis (giant cell)
3. Thrombosis (dural venous)
4. Aneurysm (leak or expansion)
5. Carbon monoxide & Colloid cyst
6. Angle closure & Angina
7. Norepi neoplasm (pheochromocytoma)

Note: DAT are chronic, ACAN are episodic

45
Dissection of carotid / vertebral arteries
 Any age, mostly < 65 yo (younger!); 50% with h/o trauma (fall, minor MVA, etc.)

Clinical features
 Sx: Frontal headache (C>V) or neck pain (V>C)
 Carotid: Horner’s syndrome (≈ 50% - sympathetic on carotid), occasional CN 9-12 palsy
 Vertebral: no findings but TIAs (dizzy – ischemic cerebellum) & pain (≈ 50%)

PGx: 50% have stroke < 90 days without Rx

Dx: angiography (CTA / MRA / DSA)
Rx: anticoagulation (counterintuitive: unlike Ao Dxn; end-process is thrombus  stroke here)

Pictures:
Left: false lumen; occluded blood vessel above
Right: MRI T1
 (bright: fat, melanin, contrast, extravasated blood)
 T1 fat-saturated axial images – remove other stuff,
see right vertebral dissection as bright crescent in
wall of vessel

Arteritis (Giant Cell, a.k.a. temporal arteritis)

 Age > 50 years (older!), most > 65

Clinical findings (no pt has all of these!)

 Gradual onset H/A, scalp / TA tender
 30-40% fatigue, fever, wt loss, arthralgias, myalgias
 Jaw claudication (34%, very specific), transient monocular blindness

PGx: 30-60% risk permanent visual loss


nd
10-30% risk of 2 eye blindness < 3 wks if untreated
Dx: ESR / CRP, temporal artery biopsy
Rx: corticosteroids (oral / IV if neuro sx)

Thrombosis of dural venous sinuses

 Any age patient

Clinical findings
 Gradual / abrupt onset, worse in AM / lying flat, ± pulsatile tinnitus
 Loss of venous pulsations (↑ venous pressure) ± papilledema (>40%)
 Hypercoagulable (>1/3) or postpartum (12%

PGx: >50% stoke < 1 month w/o Rx

Dx: LP, venography (CTV-DSA), coagulation studies
 MRV is not adequate (MR – venogram – see pic)
Rx: Anticoagulation

46
Aneurysm (leak [sentinel bleed] or expansion)
 Any age, more common > 40 yo

Clinical findings
 Rapid onset (<30m, usually < 5m) after exertion / Valsalva
 ± neck stiffness, photophobia
 Diplopia / 3rd n. palsy
 Often no neuro findings (especially A-com)

Most common sites: Pcom, PCA, basilar, SCA, ICA

 A-COM RUPTURE CAN BE ASYMPTOMATIC

PGx: > 20% mortality in 1st 2 weeks

Dx: CT (good for blood, bone, bullets) then LP (look for blood) then angiography (MRA-CTA-DSA)
Rx: Surgical clip or endovascular occlusion

Carbon Monoxide (intermittent exposure)

 Any age, #1 cause of poisoning death in US

Clinical findings
 Linked to location (goes away on vacation)
 Car, furnace, heater, gas stove – poor ventilation
 Headache plus… dizzy/lightheaded (80%), lethargic/confused
 Co-habitants symptomatic (incl. pets)

PGx: Death with no Rx

Dx: CO detectors (home), COHb levels (blood)
Rx: Avoid exposure (fix appliances, ventilate)

Colloid Cyst of 3rd ventricle

 Any age, peak in middle age (40 ± 15 yo)

Clinical findings
 Intermittent, severe, abrupt-onset, brief H/As
 Usually bifrontal, can be relieved by lying down (ball valve effect)
o Intermittent obstructive hydrocephalus
 Syncope or brief loss of consciousness often

PGx: Sudden death / herniation w/o Rx

Dx: CT / MRI
Rx: Surgical resection

47
Angle closure glaucoma (episodic  permanent)
 Any age; more common > 40, Eskimo, Chinese

Clinical findings
 Brought on by darkness (e.g. theatre)
 Can be asx if blurred vision in one eye only
 Red eye common; can miss if it resolves

PGx: blindness w/o Rx

Dx: gonioscopy
Rx: iridotomy

Angina
 > 40, vasculopathic risk factors (DM/HTN/chol/smoking)

Clinical findings
 Episodic, often exercise-induced
 Can be severe (10/10)
 Usually bifrontal / vertex (referred chest pain!)
 May be no associated chest pain!

PGx: MI/death w/o Rx

Dx: EKG, stress test, coronary angiography
Rx: CABG

Norepinephrine neoplasm (pheochromocytoma)

 Any age, peak middle age (40 ± 15 yo)
Clinical findings
 Episodic headaches, often abrupt onset
 Brief (minutes) to long (hours/days)
 Palpations, sweating, anxiety, dizziness
 Unexplained HTN & tremors

PGx: MI, stroke, death

Dx: Plasma free metanephrines
Rx: Surgical resection

Diagnostic Note: DATA CAN…

Note that ONLY THE COLLOID CYST is excluded by normal CT or standard unenhanced MRI
 Others are not excluded (normal tests are falsely reassuring)

48
 Extras: the “I’s” have it (things that present to ED instead of primary care)
Infections ICP (H3) Infarcted Pituitary
1. Cavernous sinus +/- sphenoid sinus infection
2. Orbital cellulitis +/- ethmoid sinusitis 1. Hydrocephalus
3. Meningitis +/- mastoiditis 2. High altitude
(pituitary apoplexy)
4. Encephalitis (esp. Herpes/Listeria): 3. Hypertension (arterial or venous,
Treatment often not applied! Could be Rx’d but pregnant [eclampsia] or not)
coverage not adequate!

Headaches: Clinical Approach

Of those you’ll see in practice:

 Most headaches are episodic

o Most of these are migraines (OK)
o Watch out for rare bad actors
( “ACAN” esp. aneuyrisms)

 Less commonly, continuous headaches

o Most of these are BAD (meningitis, “DAT”)
o Some can be OK (med overuse)

Episodic (<24h) Continuous (>24-72h)

 Aneurysm* (leak)  Dissection (C/V)*
 CO*  Arteritis (GCA)
 Colloid cyst*  Thrombosis (DVST)
 Angle closure  Infections
 Angina  ICP (H^3)
 Norepi neoplasm (pheo)  Infarcted pituitary (pituitary apoplexy)
* = can cross the “time divide”

Benign Headaches
 Often misdiagnosed: some things aren’t actually common causes of headache
o E.g. sinus headache, HTN, arthritis, flu/viral, TMJ syndrome, eyestrain, depression
 Overdiagnosed: migraine, tension headache
 Underdiagnosed: migraine, cluster, med overuse

Medication Overuse Headaches (MOH)

 “around the clock” headache with Q4-6h med self-dosing; severe H/A w/o meds
 Daily, worse in AM (haven’t had meds), severity ↑ with time
o Analgesic rebound cycle kicks in, eventually can’t get same effect with meds
o Can even have basal level of pain develop

Dx: clinical trend, polypharmacy, exclude original pain cause!

Rx: Detox over several weeks

49
 Primary Headaches (Migraine, Cluster, Tension)
Tension Cluster Migraine
Most common, least disabling Rare but extremely disabling Highest disease burden (prevalence x disability)

Primary headaches: idiopathic syndromes

 Disorders of brain function rather than brain pathology – neurochemical problem, not lesion
 Common: tension, migraine, cluster (trigeminal autonomic cephalalgia = TAC family)
 More rare: primary stabbing, hypnic (alarm clock), cough, exertional, sexual activity – related, 1° thunderclap, etc.
 Continuous: hemicranias continua, new daily persistent headache
 “Benign” but cost a lot of money and cause a lot of suffering

Headache Pattern:
 Acute recurring is reassuring
o Can’t tell if it’s the 1st headache (1st or worst – worry!)
 Chronic progressive is worrisome!

Migraine
Epidemiology:
 #1 referral to neurologists: prevalence: more than (asthma+diabetes) or (alz+stroke+Parkinson+epilepsy+MS) combined!
o High prevalence of bed-ridden days / yr; $13-20B/yr in lost revenue, as disabling as quadriplegia
o Lots of comorbidities: depression, stroke, MI, SLE, tons more; may escalate if untreated
 13% adult pop at any given time; 43% F, 18% M lifetime
o Up to 3.2% kids by age 7, 11% by age 15
 Adults: 3:1 F:M (prepubertal ≈ 1:1 F:M); 90% have first H/A by age 40
 Peak onset: 12-14 yo; peak prevalence: 25-55 yo
 Misdiagnosed & mismanaged!

Pearls
1. In a primary care setting, 90%+ of patients with chief complaint of intermittent headache have migraine
o Prevalent & severe enough to make an appointment!
2. Migraine is actual disease responsible for almost all “sinus” headaches
3. Migraine is most common cause of thunderclap headache (way more prevalent than aneurysm)

What is it?
A syndrome: a chronic disorder of hyperexictable brain function, the primary Sx are recurring “sick” headaches
 Chronic disease with episodic manifestations
 Think of it as “asthma of the brain”
o Preventative, maintenance care plus acute management

SULTANS
5+ headaches, 4-72 hrs with…
 Severity - Moderate or worse
 UniLateral
2/4
 Throbbing
 Activity causes worsening
1/2  Nausea
 Sensitivity to light / sound

Clinical practice: 2/3 of nausea, light sensitivity, exacerbation with activity will be migraine
50
Course & Model of a Migraine Attack
Course:
 some kind of dopamine signaling
involved before aura (pts can tell that
they’re going to get it)
 Headache follows, series of attacks
 Hypersensitive on the way down;
postdrome (like hangover) at end
Model: we know that there are triggers; H/A produce certain symptoms
 How the headache’s generated is still a bit of a mystery – “black box”

Pathophysiology
Vascular theory dominated for a long time
 Spasm  aura; dilation  pain; so tx with vasoconstrictors (triptans / ergotamines)
 Probably not true (constriction/dilation happens all the time, no measurable constaction / excitation, triptans / ergotamines
work on neurons; now have drugs that stop migraine w/o affecting vasculature)

Animal models: used now to mimic and study

Human studies
 Inter-ictal studies: epidemiology, genetics (between migraines)
 Ictal studies: harder, try to catch during attack
o can do all kinds of studies during attack

Headache Generator: Trigeminocervical (TGC) complex

 Efferent & afferent loops, blood flow to brainstem involved
 Reflex innervations between TGC & areas of brain responsible for:
o nausea / vomiting
o response to noxious stimuli (photophobia, phonophobia, etc)
Hyperexcitable brain: migraine sufferers ↑ carsickness, chemical induced H/A, etc.
Genetics:
 FHx confers 2-3x risk (1 parent: 45% risk, 2 parents: 70%)
 Caucasian > AA; Lower SES doubles risk vs highest SES
 Polygenic; single gene mutations for migraine syndromes only
o Neuroexcitatory channelopathies, others

Aura
 Transient, reversible, focal neurological deficits related to migraine
o (not seizure, hypoglycemia, TIA, etc)
 Usually stereotyped for single patient
o Visual / scintillating scotoma
o Unilateral sensory or dysphasia
 Gradual, creeping over 5 min, ≤ 60m
 Single individual can have migraine w/o aura, migraine with aura, aura w/o migraine
 Only ¼ migraneurs ever have aura

Cortical Spreading Depression: the mechanism of aura

 Electrical phenomenon – spread of electrical, then blood flow disturbance
 Marches across brain at 2-3mm/min (reflected in size of spread of aura)
 Easiest to induce in occipital lobe (visual); burn out at central sulcus (usually no motor sx)
o Opens BBB, activates trigeminovascular system in models: does it cause migraine?
o Can we stop migraines by stopping CSD?
Gene mutations: hyperexcitable channelopathies  ↑ CSD  ↑ auras  ↑ headaches

51
Pathogenesis Migraine Mechanisms
Initiation:  Hyperexcitable brain (largely genetic)
 Triggers act on hyperexcitable brain  Cortical spreading depression
 Cortical spreading depression (can perceive as aura)  Brainstem headache generator (TGC)
 Activates trigemino-cervico-vascular system and brainstem  Neurogenic inflammation
o Sterile neurogenic inflammation (TGC neurons act on  Blood vessel reactivity
meningeal blood vessels  inflammation)  Activation of multiple neural circuits
o Mast cells involved, CGRP, substance P, kinins released
o Neurons get revved up further  feedback loop

Peripheral sensitization:
 Trigeminal nociceptors  irritated by inflammation 
 Send pain responses to brainstem trigeminal nucleus caudalis (TNC)
o TNC signals thalamus, cortex (pain perceived)
o Over time, trigeminal system becomes peripherally sensitized (pounding, worse when bending)
 Pounding: blood vessel nociceptors now sensitized, responding to normally non-noxious stimuli
(pulse = throbbing, distension on bending)

Central sensitization
 Prolonged sensitization; TNC starts firing regardless of input
 Cutaneous allodynia (everything hurts)

Spread: Other brainstem centers activated (nausea, GI stasis, photo/phonophobia)

Sensitization hypothesis
 Migraine is a process of sequential sensitization of neurons from periphery to CNS
1° Nociceptor (TG neuron) 2° (TNC) neuron 3° (Thalamic) neuron
heightened response to stimulation
Activation Nociception with minimal or no input Enlarged receptive fields
(including mechanical)
Throbbing pain, eye movement pain, Cutaneous allodynia
Clinical Spread of pain and allodynia
pain on bending over (non-painful stimuli become painful)

Headache imaging
 Trigeminal nucleus (dorsolateral pons), PAG (midbrain) light up

Triggers
 Common: menstruation, alcohol, disrupted sleep, change in stress (well documented)
 More “aggravators” than “triggers” (often add up)
o A few can be reliable in given individuals (ID & avoid – keep a diary)
o Most are low potency / loosely correlated / only responsible for small % of migraines

 Could give pretty much anybody a migraine with enough stress

o Some people have lower thresholds / higher tendency towards migraine
o To determine if Rx needed, ask: would you take a pill every day to prevent these?
 Meds: raise threshold
 Behavior: lower / avoid triggers (counseling, etc.)

52
 Treatment of Migraine
NOTE: Pain doesn’t show up until well into the process!
 Prevention is crucial! Avoid triggers if possible
o regular sleep, don’t skip meals, don’t get dehydrated, exercise, weight control, stress management
 Give acute treatment early (stop the process!)
 Need to use preventative meds for > 1 mo
 Use migraine cocktails to hit thalamus, other areas of these loops

Preventative meds taken daily: the three “antis” (all work by ↑ threshold)
 Antihypertensive (β-blockers, others)
 Antidepressants (TCAs, venlafaxine)
 Anticonvulsants (topiramate, valproate)

Triptans
5HT agonists (serotonin = 5HT, works but not well tolerated)
 Designer drugs aimed specifically at migraine
Block / reverse vasodilation but also block neurogenic inflammation (nerve terminals, centrally too?)
Most effective migraine meds available; very safe (unless vasculopath)

CGRP: Calcitonin gene related peptide: vasodilator, mast cell activator, released from trigem nerve terminals
 Can block it (triptans or experimental agents) & treat migraine w/o affecting vessels!

Halting an aura
 Most drugs will be too slow
 Unpublished: try to zap brain with transcranial magnetic stimulation – blast brain to disrupt CSD!

Cluster Headache
Rapid (<15m onset), horrible, acute, terrible pain syndromes
Shorter than migraines (< 90m)
Need to rule out underlying cause (pituitary, carotid, post. fossa lesions can mimic)
 Get MRI/A

Timing:
 Multiple attacks in single day (up to 8)
 Attack frequency: builds up over few days, stays for few weeks, fades / remits
(“cluster period”)
 Circadian & circannual (same time of day, same season of year)
 Can become chronic over time w/o remissions)

Pathophysiology: hypothalamus (ipsi post inf hypothal) may be generator Epidemiology of cluster headaches
 Area tied to biological clock and autonomic nervous system!  4:1 M>F, onset teens to 30s
 Also: trigeminovascular / CGRP (like migraine), cranial parasymps, ICA  Prevalence 0.1%
swells  sympathetic outflow affected  partial Horner’s  Smoking is risk factor
 Get individual H/A w/in 3hrs of EtOH
Features: AUTONOMIC ACTIVITY consumption during cluster period
 Lacrimation (90%), conjunctival injection
nasal stuffiness, rhinorrhea, ptosis, eyelid edema
 ± nausea, phono/photophobia, v. rare auras

53
Presentation: the “suicide headache”
 REALLY BAD. Migraine sufferers sit in bed, these people are hitting themselves, rocking back and forth, etc.
 Screen all pts for suicidal behaviors! Excruciating pain + sympathetic arousal  can do stupid things

Treatment:
 Acute: Oxygen, rapid-acting 5HT1 agonists (nasal / injectable)
 Preventative: mostly bad studies; verapamil, anticonvulsants, lithium, melatonin; steroids?
 Invasive procedures if really bad
o trigeminal nerve / ganglion distruction, deep brain stimulation, occipital nerve stimulation

Tension-type headaches
High prevalence (80% lifetime)
Recurring primary headache defined by relative lack of other features
 10+ episodes; last 30min-7days
 2/4 of pressing/tightening (non-pulsating) quality, mild/moderate intensity, not aggravated by physical activity
 No nausea/vomiting, can have either photo or phonophobia but not both
 Not attributed to another disorder
Features:
 NO MEASURABLE MUSCLE TENSION (tension-type is misnomer)
 Bilateral, pressing, rarely activity sensitive
 Not usually disabling

Rx: NSAIDs, acetaminophen, etc. are usually effective

Episodic H/A can become CHRONIC or CONTINUOUS

Attacks of pain  more frequent

 Chronic daily headache (Migraine, tension: pain becomes constant with exacerbations superimposed)
o CDH: H/A > 15days/month
 Cluster: remissions can stop!

May represent progression of accumulating brain pathology

 “burn out” pain systems, end up with baseline pain
 Can represent medication overuse
(treat, but may still have chronic daily headache!)

Recap: the 3 primary headaches (from notes)

Idiopathic syndromes of recurring, stereotyped cranial pain
Migraine (remember SULTANS) Cluster Tension
 Highest disease burden  Rare but terribly severe
(prevalence x disability)  Sudden severe unilateral pain,  Most common, least
 Pain, polymodal hypersensitivity, nausea peculiar circadian and circannnual disabling
 Hypersensitive brain, CSD, brainstem characteristics, prominent  Usually just pain
generator (TNC, PAG), neurogenic autonomic involvement  Pathophysiology poorly
inflammation, trigeminal-vascular  Posterior-inferior hypothalamus understood
system  VIP (vasointestinal peptide) involved
 Serotonin, CGRP involved

54
 Vertigo and the Pathophysiology of Bedside Vestibular Eye Signs
Normal Vestibular Function
Vestibular system: the “sixth sense”
 Balance organ in inner ear + connection in brainstem & cerebellum
 Substrate for “sixth sense” of balance; usually operates quietly in background
 Sends signals to cerebrum & SC for walking and EOMs (to keep vision stable)

Goals of vestibular system

 Keep us (un)aware of which way is up  Keep us from crumpling to the ground  Keep vision steady when moving head

VOR = vestibular-ocular reflex

 Connection between balance organs & eye movement structures
 Keeps vision steady as we move: instantaneously rolls eyes in direction opposite any head movement

If you lose VOR: head movement makes visible world appear to move
 Use cortical vision processing to track movement, keep eyes on target during slow head movements
 Vision takes ~100ms to process (too slow to keep up with rapid, transient head movements during walking / jogging)

Anatomy of vestibular section

Inner ear: labyrinth = balance organ (semi-circular canals + utricle / saccule)
Organ Measures Subserves
Semicircular canals x 3 angular rotations of head A-VOR (angular VOR)
Utricle / saccule (otolith) linear accelerations of head L-VOR (linear VOR)

Labyrinth sits in petrous temporal bone, 8th n. exits to brainstem (8th n. nuclei)

 Goes to vestibular nuclei in brainstem (pons), then connected to

 Vestibulocerebellum (nearby anatomically)
o The inferior part: has floccus, parafloccus, nodulus

 Bidirectional connections: cerebellum & vestibular nuclei;

o also direct connections from labyrinth to cerebellum
th
(bypassing 8 n nucleus)

 Gaze-holding center in brainstem is nearby too


th th
Note: 8 n enter near low pons but 8 n nuclei are long
o Extend into medulla; can be damaged by acute stroke of the lateral medulla

Vestibular nuclei (8th) connected to oculomotor nuclei (midbrain)

 3rd & 4th – vertical/torsional
 6th and 3rd – horizontal

Remember: (2-2-4-4)
 CN 3,4 in midbrain
 CN 6 in pons

55
aVOR

How does aVOR work? Turn head VOR rolls eyes…

 Turning towards the canal(s) is ON Right Left
 Tonic firing at rest; rate changes with head motion Forward Back (up) in head
 Neural signal stimulates eyes to move in plane of canal (VOR) Towards L. shoulder towards R. shoulder
opposite head rotation

Towards is “ON”
 Head rotation = canal rotation (part of skull)
 Endolymph usually doesn’t move (inertia)
 “Disconnect” between endolymph & canal
motion causes firing (hair cells displaced,
stimulated)
 Endolymph eventually catches up, signal off again

Canal planes Motion Stimulates

 Anterior canal Turn right Right HC
 Posterior canal Turn left Left HC
 Horizontal canal Bend forward Both ACs 50%
(30° displacement / tilted up but Bend backwards Both PCs 50%
just think of it as horizontal) Tilt right Right AC/PC
Tilt left Left AC/PC

Tonic firing changes with rotation

 Turning head to right: R 8th n firing rate ↑; L. 8th n. firing rate normal
 Cerebrum interprets the asymmetry in firing as normal head rotation

Planes of rotation
Lay term Turn Bend Tilt
Radiology Axial Sagittal Coronal
Aeronautics / vestibular Yaw Pitch Roll
Oculomotor Horizontal Vertical Torsional

So what needs to happen?

Lay term Turn right Bend forward Tilt left
Canals activated Right HC Both ACs Left AC/PC
Oculomotor Roll left Roll back Tort right
 Need to activate the correct oculomotor signals to produce the correct movements!
 Just think of how eyes need to move and figure out which muscles will be activated

Testing the VOR: Head Impulse Test

 HIT = bedside test of vestibular function
Pt: look at doc’s nose; rapid head rotation to elicit a VOR response (
 If VOR is intact, eyes stay on target despite rotation
 If NOT intact, they slip off the target (go with head; see refixation saccade)

56
Otolith-Ocular Reflexes
Vestibular system: designed to control vertical & torsional eye position in response to lateral head tilts
 Used to be lateral-eyed animals (tilting head pointed one eye at floor), now our eyes point straight ahead
Vestigial otolith-ocular reflexes are suppressed by the “modern” cerebellum & brainstem (lateral medulla / midbrain)
 Come back out in disease states! See later part

Gaze-holding
Natural resting position of eyeballs is straight out
 Need to apply EOM force to sustain eyes in eccentric position
 Force generated by gaze-holding center in medulla
o calibrated by cerebellum
o different neurons calibrate gaze-holding than those cerebellar
neurons calibrating VOR, but both groups are right next to each
other in the vestibulocerebellum

Abnormal Vestibular Function

Key idea: how can we tell benign from bad?
What happens when balance system is broken?
Symptoms Signs
 Dizziness/vertigo, motion intolerance, nausea/vomit  Abnormal VOR response
 Oscillopsia (bouncing/jumping vision) +/- Diplopia  Nystagmus +/- ocular misalignment
 Unsteady walking and standing balance  Ataxic gait and tendency to fall (lateropulsion)

Dizziness
What it feels like when balance system is broken (ears telling you one thing, rest of brain something else)

Four “types” of dizziness (don’t apply well clinically)

 Vertigo (spinning / motion)  Disequilibrium (unsteady walking)
 Presyncope (near faint)  Other vague lightheadedness (nonspecific)

Causes of dizziness
“Non-vestibular”
 orthostatic dizziness (esp. anti-HTN, volume loss)
 cardiac dizziness (esp. arrhythmias, vasovagal)
 intoxication (esp. EtOH, anticonvulsants, illicits)
 post-concussive syndrome (after head injury)
 presbylibrium (a.k.a. multisensory dizziness)
 panic attack +/- hyperventilation
“Vestibular” (less common)
 BPPV (benign paroxysmal positioning vertigo)
 migraine & Meniere disease
 bilateral vestibulopathy (idiopathic/hereditary, ototoxic)
 vestibular neuritis (a.k.a. labyrinthitis, “APV”)
 brainstem/cerebellar stroke & transient ischemic attack
 other central lesions (MS, cerebellar degeneration)

Epidemiology
 Common (one of top 10 complaints in outpatients: 25%; >50% elderly)
 Tricky (DDx complex, H&P confusing)
 High-stakes (rarely serious in OPD, but up to 25% pts > 50yo in new, isolated vertigo have cerebellar stroke)

57
Vertigo
 Hallucination of (angular) motion when there is none
 Head is not moving, but you feel like it is
 Can be described as spinning, rocking, swaying (e.g. like a pendulum), etc.
 Implies asymmetry (e.g. right vs left) in vestibular inputs (can be CNS or PNS)

Nystagmus
Pendular nystagmus (slow-slow type, rare)
 Associated sx: usually oscillopsia
 Usually brainstem lesions (MS/stroke)
 Can be associated with jaw/palate motion
Jerk nystagmus (slow-fast type, rare in general pop; common in dizzy)
 Associated sx: usually dizziness / balance probs
 Results from vestibular lesions (peripheral or central) or
gaze-holding deficits (central)

Jerk nystagmus (nystagmus: from Gr. Nystagmos, drowsiness – like head nodding when dozing off)
 This is more common; rest of discussion focuses on this one

Vestibular / spontaneous nystagmus

 Lesion-related asymmetry in vestibular system produces spontaneous eye jerking
 Sslow movement in one direction (from asymmetry) then jerk back (“quick phase correction”) the other way
o Slow phase = pathologic manifestation of vestibular asymmetry (drives eyes like normal VOR)
o Quick phase = same as normal voluntary saccades (cerebrum wants to “reset” to straight ahead)
 By convention, nystagmus is named for quick phase direction

Failure of gaze-holding mechanism

 Produces eye jerking with sustained gaze
 Slow movement in towards the natural eye position with a jerk back (quick-phase correction) the other way
o Slow phase: gaze holding failure (medulla’s gaze holding center or cerebellar calibration)
o Quick phase: reset using saccade machinery (cerebrum wants to look at something!)
 Nystagmus still named for quick phase direction

Vestibular / spontaneous Gaze-holding

Lesion Tonic asymmetric activation of vestibular signals Failure of gaze-holding center
Eyes drift (slow phase) VOR (e.g. R HC > L HC, head thinks it’s turning to Back to center
because… right, VOR turns eye to left) (elasticity of orbital tissues)
Saccade machinery Saccade machinery (cerebrum wants to
Eyes correct (quick phase)
(cerebrum wants to be looking straight ahead) look at something eccentric)
See nystagmus Looking straight ahead Looking eccentrically

Clinical Approach
Textbook approach not good (vertigo = vestibular, send to ENT, presyncope – CV, send to cardio, etc.)
Timing approach (how long did it last) – hard; can use clinically.

Neuritis vs Stroke
 High stakes (35% strokes / TIAs missed in ED dizzy pts, vs 4% those with motor sx)
 Probably missing 35k/yr dizzy strokes in ED

“Acute Vestibular Syndrome”: clinical presentation of pts with either vestibular neuritis or stroke
 Sick, dizzy, puking, nystagmus
 Is it vestibular neuritis (peripheral) or stroke (central)?

58
Vestibular neuritis: vestibular nerve affected;
labyrinthitis: labyrinth affected
 Clinically: usually can’t distinguish vestibular neuritis from labyrinthitis
 Either see stroke on MRI or we think it’s something more peripherally
(one of these two)

Strokes:
 Brainstem (eg lateral medulla) strokes
 Cerebellar stroke (e.g. PICA; can swell up, crush brainstem, etc.)

 Lesions in any of these locations (vesibulocerebellum, vestibular

th
nuclei, 8 n) produce similar symptoms (acute vestibular syndrome)
o All close together too!

 AICA or PICA are generally involved

(lateral brainstem and/or cerebellar infarcts)

So how can we tell these things apart?

Symptoms can give a clue
Vestibular neuritis Stroke
Trigger Worse if moves
Duration Days – wks
N/V Prominent nausea / vomiting
Auditory ± HL/tinnitus
Neuro Mild unsteadiness Severe unsteadiness
± skew,
PE Unidirectional nystagmus directional change nystagmus
HIT abnormal HIT normal
Monophasic Pain
Onset
Postviral nausea/vomiting > dizziness

The “Eyes” have it

3 vestibulo-ocular signs (distinguish “peripheral” (neuritis) from “central” (stroke) causes of acute vestibular syndrome)
Stroke
Vestibular neuritis
Cerebellar Brainstem
Head impulse test Abnormal Normal (VOR intact) Abnormal
Skew deviation Absent Present
Nystagmus Direction-fixed, horizontal Vertical, torsional or with directional change

Head Impulse Test

If VOR intact, then eyes stay on target; if not slip off and see correction

 Vestibular neuritis: pathway interrupted; response abnormal

 Cerebellar stroke: pathway intact (skips cerebellum), response normal

o Brainstem stroke: abnormal HIT but would see other sx too

Remember to be unpredictable during this test (brainstem can figure out

what’s up and start saccading ahead of time; sign will diminish)

59
Skew Deviation
 Remember that vestigial otolith-ocular reflexes are suppressed by “modern”:
o cerebellum &
o brainstem (lateral medulla & midbrain)

If you damage the cerebellum or brainstem, vestigial reflexes take over & cause skew deviation
 eyes misaligned vertically
 Test: cover eye, uncover: positive if eye comes in & up (was down & out)

Nystagmus
3 types of jerk nystagmus relevant here:

Nystagmus: Spontaneous vestibular Gaze-holding Mixed vestibular / gaze-holding

Damage: Unilateral vestibular Bilateral or unilateral gaze-holding Damage to both pathways

Spontaneous Vestibular Nystagmus

Can be caused by: (usually PERIPHERAL, e.g. neuritis)

 medial cerebellar stroke
 lateral pontine stroke
 vestibular neuritis

Characteristics
 Persistently present (incl. look straight ahead)
 Horizontal > torsional
 Damps when looking towards slow phase & vice-versa
o “Alexander’s law” – worse if look to fast phase
 Never changes direction
(always leftward, never rightward, or vice-versa.)

Why worse if looking to fast phase (Alexander’s Law)?

Left-beating as example:
 Lesion always says “look right slowly”
 If doctor / cerebrum says “look right”, everybody’s in agreement:
look right
 If doctor /cerebrum says “look straight”, there’s a mild conflict (lesion wants to look right) – mild nystagmus
 If doctor / cerebrum says "look left”, there’s a big conflict (lesion really wants to look right) – big nystagmus

Gaze-holding Nystagmus
Can be caused by: (ALWAYS CENTRAL)
 Lateral cerebellar stroke or cerebellar degeneration
 medial medulla stroke
 other damage to gaze-holding structures
 note: NOT VESTIBULAR in nature

Characteristics
 Absent when looking straight ahead
 Horizontal
 Worse when looking laterally (eye eccentric)
o Eye drifting back to middle
 Changes direction (beats left looking left, right looking right)
 Note that cerebellum normally calibrates EOM force in gaze holding, so see this if cerebellum damaged
60
Mixed Vestibular / Gaze-holding Nystagmus
 Can be tricky: may present as if it were vestibular

Can be caused by: (CENTRAL)

 Med/lat cerebellar stroke WITH
 Med/lat medullary stroke

Features: mixture of vestibular & gaze-holding

 KEY FEATURE: CHANGES DIRECTION
(if you look away from straight-ahead beating direction)

Clinical take-home message

If you see acute vestibular syndrome; check those three subtle eye signs

“Safe to Go” Triad of Subtle Eye Signs (pt OK if all 3 true, probably vestibular neuritis or something peripheral)
1. Direction-fixed, horizontal nystagmus
a. not vertical or torsional
b. obeys Alexander’s law (worse in direction of fast phase, better in direction of slow phase)
c. no direction change in different gaze positions
2. Normal vertical misalignment (i.e., no skew)
3. Impaired VOR function (ABNORMAL h-HIT

61
 Gait Disorders & Ataxia
I have no idea what was going on in this lecture. Good luck.

Gait is like handwriting: everybody has a unique gait

Abnormality: from:
 neuro, muscular, orthopedic problem (very few neuro disorders don’t compromise balance/gait)
 voluntary / unconscious compensatory response to real or perceived deficit
o Compensatory strategy can be maladaptive

Falls are a big problem, interventions can help

Physics of balance & gait

Equilibrium = maintain center of gravity (COG) over base of support (BOS)

 Walking = controlled fall
o COG displaced forwards beyond BOS
o Step required to keep BOS under displaced COG
o Tripping: don’t get step to get BOS under COG

Gait cycle
 Look at a pt walking to assess!

Where could things go wrong?

 Muscle, NMJ, peripheral nerve
 Sensory (vestibular, visual, somatosensory)
 Spinal cord
 Cerebellum/brainstem
 Cerebrum (cautious / psychiatric / reckless)?

How to examine pt
 General gestalt
 Observe symmetry & presence of arm swing,
posture of any fixed limbs
 Signs of pain or discomfort?
 Base (distance between medial malleloli)
 Deviation towards examiner rather than fixed
direction (is the direction consistent?)

Upper motor neuron dysfunction: cervical myelopathy

 Sx: stiffness, heaviness, slowness; neck pain, incontinence, sensory loss, flexor spasms
 Signs: spasticity, hyperreflexia, jaw jerk not involved (cervical, not higher), ↓ cervical range of motion

Myelopathic gait
 Both legs circumduct; hip adduction with knees crossing (“runway model”)
 Steps short, step height reduced (scuffing)
 ↑ tone may be needed for weight bearing given paraparesis (can’t just ↓ tone: using ↑ tone to support weak legs!)

62
Hemiplegic gait
 Sort of like half of a myelopathic gait (e.g. L. sided stroke)
 Leg swings outward, in semi-circle from hip (circumduction)
o Swinging out (ankle plantarflexed, knee extended  don’t want to hit ground)
 Knee may hyperextend, ankle may excessively plantar-flex & invert
 With ↓ paresis, may only lose arm swing and drag/scrape foot

Neuropathic gait
 ↑ knee flexion for clearance; Hyperextension during stance
 ↑ step height (steppage gait) (trying to avoid tripping)
 Feet dropped rather than placed, initial contact with front of foot (foot slap)
o Weakness – can’t flex well
 Need visual feedback for foot placement

Normal pressure hydrocephalus (NPH)

Classical triad:Gait disorder + Subcortical dementia + Urinary incontinence

 Imaging shows enlarged ventricles out of proportion to atrophy

 Response to CSF drainage is best predictor of improvement with shunting procedure

Ataxia
Definition:
 Incoordination of limbs, imbalance, dysarthria / dysphagia, sensory ataxia (vestibular / proprioceptive)

Cerebellar ataxia: huge list of possible disease mechanisms

 Inborn errors of metabolism, paraneoplastic problems, nutritional (thiamine – Wernicke’s encephalopathy)
 Channelopathies, ataxia telangiectasia (DNA repair) – really rare

Workup of cerebellar ataxia

 Screen for reversible causes (vitamin E, gluten? Thyroid, PNP, etc)
 Establish molecular diagnosis (?)
 Treatment: not good options, amantadine (?) / bupropion

Workup of ataxia in general

 Thyroid function tests, B12, vitamin E, thiamine, ceruloplasm
 Ab testing for gluten sensitivity
 Hashimoto’s thyroiditis
 Paraneoplastic syndrome
 Whipple / Wilson dz
 Nucleotide repeats, other genetic stuff

Autosomal dominant spinocerebellar atrophy (apparently exists)

 Related to repeats in SCA genes (earlier onset with ↑ # repeats)
 SCA7: can see pontine, cerebellar atrophy

Ca-channel subunit gene on chr 19

 3 overlapping syndromes with different alleles
o familial hemiplegic migraine, episodic ataxia type 2 can tx with acetazolamide, spinocerebellar ataxia type 6

63
 Neuromuscular Disorders

Anatomy of the Motor Unit

Neuronopathy disease of motor neuron body itself

Radiculopathy disease of nerve root as it exits vertebral body
Motor Nerve affects motor nerve itself
Neuromuscular Junction diseases NMJ
Myopathy broad spectrum of muscle disorders

Motor unit = Motor neuron, axon, NMJ, and all fibers associated with it

Approach to Neuromuscular Disorders

 Where is it?  Sensory findings?
 Atrophy?  Reflexes?

Motor Neuronopathy Radiculopathy Motor nerve NM junction Myopathy

Focal
Asymmetric
Distribution Focal Root Multifocal Prox>Distal Prox>Distal
Distal>Prox
Generalized
Bulbar muscles Bulbar muscles
Bulbar Dependent on root Respiratory
Region Respiratory involved Facial Ocular muscles Eye muscles spared
Limbs (i.e. deltoid C5) Limb
Limbs Limbs
Atrophy Marked & Early Mild Moderate Rare Mild
Sensory None Pain None None Infrequent
Variable (UMN and/or LMNs
Reflexes Decreased Decreased Normal Normal
may be affected)
 Bulbar muscles are innervated by cranial nerves; e.g. muscles of face

Amyotrophic Lateral Sclerosis (ALS)

37 year old athletic man who notes that 2 years ago he noted that he was falling more frequently when ice skating with his wife. He
was a baseball player at that time and relays a story in which he came to bat 4 times with runners on base and failed to get a hit. On
that same day he muffed a routine out on a ball tossed from the pitcher to his position at first base. His batting average was down….

ALS = PROTOTYPIC MOTOR NEURON DISEASE (motor neuron itself)

 Also Poliomyelitis & spinal muscular atrophy

ALS: 90% spontaneous, 10% familial

Both upper and lower motor neuron signs present in ALS (disease of motor neuron itself)

Upper motor neuron signs

 Brisk jaw reflex (open jaw loosely, tap)  Hyperreflexia (brisk deep tendon reflexes)
 Brisk gag reflex  Extensor plantar response (Babkinski sign)
 Pseudobulbar features (inability to suppress emotions)  Spasticity
o emotional lability with easy laughter, crying
Note that you wouldn’t see these with a cervical myelopathy (UMN not affected)

64
Lower motor neuron signs
 Weakness (often asymmetric, e.g. 1 hand very weak, other normal)
 Atrophy (often asymmetric, e.g. mm of hand atrophic on exam)
 Fasiculations (spontaneous discharge of an axon causing contraction of muscle fibers in rippling unit)
o “Twitches” as described by pt
o Only worrisome in setting of atrophy

Criteria inconsistent with diagnosis

 Sensory loss (no numbness, tingling, etc) – sensation is normal
 Autonomic dysfunction
 Visual system abnormalities
 Polyradiculopathy / myelopathy (= spinal cord disease, e.g. cervical myelopathy)

Electromyography (EMG/NCS): a diagnostic measure to see LMN function

Looking for combination of:
 acute denervation (fibrillations, positive waves)
 chronic denervation (large, polyphasic motor units with delayed
recruitment pattern) –neurons trying to grow back

Note that in polio, would only see chronic denervation – not acute

L: Total loss of motor neurons in ventral horn; M: Tongue atrophy (with fasciulations really suggests motor
neuron disease); R: big time atrophy (loss of bulk)

Poliomyelitis
 follows polio virus infection (acute: fever, malaise, GI upset)
 50% with clinical manifestations  paralysis
 Postpolio syndrome: progressive weakness in a limb previously affected by polio (years after stable disease)

Spinal Muscular Atropy

Associated with SMN1 gene (RNA SPLICING GENE)
Clinical features:
 Usually associated with infant weakness (floppy baby) – Werdnig-Hoffman
o One of various causes of infant hypotonia (here losing muscle neurons)
 Diffuse & severe weakness (poor feeding, resp. insufficiency – paradox. resp.)
o facial & oculomotor spared
 Hypotonia, tendon reflexes reduced or absent; Normal, alert faces

Prognosis: Resp failure and death (50% by 7 mo, 95% by 17 mo); chronic course in 5%

65
 Radiculopathy

Radiculopathy: disk pressing on nerve root; often described as “slipped disk”, “ruptured disk”, “sciatica”

Pathogenesis: compression of nerve root by herniated disk

 Inner core (nucleus pulposus) of disk bulges out through outer layer of ligaments that surrounds disc (annulus fibrosis)

 Usually affects single root: think

about what muscles are involved!
 S1 = plantarflexion weakness
(gastroc); ↓ ankle jerk
Most common:
 Cervical: C7/6
 Lumbosacral: L4-L5, L5-S1

Disorders of the Peripheral Nerve

What can be affected?
 Axons
 Demyelination (GBS, CIDP = chronic inflammatory demyelinating polyneuropathy)
 Sensory neuropathy
o DRG: death/dysfunction
o Paraneoplastic (anti-Hu, with SCLC, etc.)
o Sjogrens’ , HSV (localized), idiopathic

Sensory Neuronopathy
Axonal Neuropathy Demyelinating Neuropathy
(Dorsal root ganglia)
Fiber type Sensory>Motor Motor>Sensory Pure Sensory
Often both distal and proximal
Distribution Distal>Proximal Proximal>Distal
sensory loss are equal
Reflexes Ankle Jerks Absent All Reflexes Absent All Absent
Nerve Conduction Decreased amplitudes. Normal amplitudes. Decreased sensory amplitudes
Studies Normal velocities Reduced velocities not length dependent

Myasthenia Gravis
66 year-old woman noticed double vision when looking to the right over the last 3 months . She has been
choking on solids and liquids. Her husband notes that her speech sounds as if she has a “stuffed nose”
(palate weak) . She also reports that she has difficulty getting out of her car and carrying groceries.

“Droopy face” (not Bell’s palsy – much more gradual onset)

 Assess: smile, can you whistle, etc

Pathogenesis (if autoimmune): Ab against Ach receptor

 NMJ messed up: Ach receptors may be cross-linked and
endocytosed or destroyed by C’

Symptoms
 Fatigue following exertion  Dysphagia
symptoms are often worse in the afternoon or evening. (both liquids & solids – pharyngeal weakness)
 Diplopia is key (EOM not involved in ALS)  Dyspnea
 Dysarthria  Proximal Weakness

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Signs – can follow to assess treatment
 Ocular (diplopia, asymmetric ptosis) signs precipitated  Nasal speech
with sustained upgaze  Limb weakness precipitated by sustained action of a
 Facial weakness (eye closure, inability to whistle) muscle group

Diagnosis:
 Anti-AChR Ab (85%) – diagnostic
 Tensilon test (administer edrophonium, an ACh inhibitor - ↑ ACh in synaptic cleft, transient improvement of Sx)
o Can become bradycardic (heart effects of ACh too) – don’t use anymore
 Repetitive nerve stimulation: electrophysiological way of fatiguing muscle in EMG lab (↓ over time in MG)
 Single fiber EMG

Treatment
 Most effective way: SUPPRESS THE IMMUNE SYSTEM
o Steroids, IV/IG, immunosuppressants, thymectomy, plasmapheresis
 ACh inhibitors too

Myopathies
Myopathy: “disease of muscle” (many different causes)
Myositis: muscle inflammation (subset of myopathy)

Clinical Features
 Symmetric weakness  Absence of sensory signs and symptoms
 Proximal involvement (with exceptions)  Normal autonomic function
 Preservation of reflexes

Classification: muscle can be affected by a lot of different disorders

 Muscular dystrophies  Endocrine myopathies
 Inflammatory myopathies  Toxic myopathies (statins)
 Metabolic myopathies (e.g. steroid induced)  Channelopathies, mitochondrial myopathies

Polymyositis
45 year-old woman complains of a 6 month history of difficulty going upstairs. She also complains of difficulty
braiding her daughter’s hair. She denies double vision, difficulty buttoning buttons, hand or foot numbness. On
exam she has proximal weakness in the arms and legs. Her serum creatine kinase(CK) level was >2000 (<200 nL)

No double vision = less likely MG; ↑ serum CK = muscle being broken down

Pathogenesis
 Cytotoxic cell-mediated
 CD8 > CD4 T-cells and Mϕ; B-cells rare

Clinical features
 Almost always > 20 yo
 Dysphagia, ↑ CK common
 Associated with small but definite ↑ incidence malignancy;
interstitial lung disease

Inflammatory myopathy: Lots of inflammatory cells

pouring out into muscle; chewing up muscle bundles

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Dermatomyositis
 Different from polymyositis (not just polymyositis with a rash)
 Presentation is the same (weakness, ↑ serum CK, etc)
 Also associated with malignancy and ILD like polymyositis

Histology
 CD4>CD8 T cells and Mϕ; B-cells common
 C’ deposition on capillaries
 Muscle fibers on border of fascile become atrophic

Classic features (boards)

 Heliotrope rash: looks like they’re wearing purple mascara
 Gautren’s papules (LL) – “warts” of the knuckles
 Calcinosis: calcium deposition in fascia

Inclusion body myositis

 Male preponderance > 50 yo

 Weakness of WRIST FLEXORS & QUADS – VERY SPECIFIC
 Refractory to corticosteroids (unlike polymyositis, dermatomyositis)
 No skin findings (unlike dermatomyositis)

Histology: RED-RIMMED VACUOLES and INCLUSION BODIES

MUSCLE PATHOLOGY
Pathological Process Example Pathology Pathogenesis
Fiber atrophy
Denervation
(small angular fibers)
Motor neuron
Denervation disease; Fiber type grouping Denervation and reinnervation
neuropathy
Denervation, reinnervation, and
Grouped atrophy
subsequent repeat denervation

Necrosis, phagocytosis,
Myopathy Dystrophies,
fiber atrophy, proliferation Genetic abnormality or
Inflammatory
of endomysial connective immunological attack on muscle fibers
myopathies
tissue, central nuclei

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 Muscular Dystrophy
Definition:
 Hereditary disease of muscle producing progressive weakness & wasting
 Different from acquired disorders of muscle (myositis, toxic myopathy, endocrine, etc)
 Different from hereditary nonprogressive disorders of muscle (congenital myopathies)

The Basal-Lamina – Cytoskeletal Link

MD: Breakage of link between cytoskeleton & basal lamina on outside
 Can break in several different ways and get different muscular dystrophies
o Duchenne MD: loss of dystrophin
o Sarcoglycans, others too

Possible functions of link: structural stability & signaling

Common features of muscular dystrophies

 Most due to absence / altered function of structural
component of muscle fiber
 Undergo dystrophic changes:
o Rounds of necrosis, degeneration and regeneration
o Result: remodeling of muscle tissue with fibrosis and
fatty infiltration.

Normal muscle: polygonal, Dystrophic Muscle. Left: fibrosis, variable sized fibers, rounded;
equal sized muscle fibers, etc. Middle: necrosis; Right: regeneration (influx of new cells)

Muscular Dystrophies in General

 ~ 40 different disorders

 Variable: DMD
o involvement of muscle groups (top left)
o onset
o progression
o severity
o involvement of other organ systems
FSH MD
(bottom left)

Patterns of muscle weakness in MD

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 Duchenne Muscular Dystrophy (DMD)
Epidemiology
 X-linked disorder affecting 1:3,500 live male births (common!)
 Dx before age 5, lose ambulation < 14yo
o Calf hypertrophy (false – fatty infiltration, etc)
o Gower’s maneuver: muscle weakness; walk self up off ground with hands (hip weakness)
 Deaths in early adulthood (cardiac / resp dz)

Dystrophin: largest in human genome (470kD subsarcolemmal protein)

 Lose dystrophin, lose entire dystrophin glycoprotein complex (DGC)

o Membrane associated protein complex stabilized by dystrophin

 Big so susceptible to random mutations (30% are new mutations)

o 2/3 are big deletions / duplications
o DMD phenotype: due to disruption of reading frame
o No C-terminal domain to interact with cytoskeleton

H&E (left) and Gomori Trichrome (right): Dystrophin stain: just under sarcolemma in normal sample (left);
shrunken, rounded fibers absent in DMD (right). Note one “revertant fiber” in DMD

Becker Muscular Dystrophy phenotype

 Later onset, milder course
 Mutation preserves reading frame & protein-protein interaction (still have C-terminal domain)

Limb girdle muscular dystrophies

 Many different forms molecularly
 Common feature: hip, shoulder girdle weakness
 Most autosomal recessive, 2° to mutations in structural proteins of muscle fiber

Many are sarcoglycanopathies

 Sarcoglycan: transmembrane proteins associated with DGC
o LGMD2C, 2D, 2E, 2F
o Heteromeric unit: loss of one usually leads to loss of group function

 Early childhood onset, rapidly progressive, severe / Duchenne-like Sx

o Autosomal recessive
o Associated with cardiomyopathy

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Adult LGMD (e.g. LGMD2I)

Pathogenesis
 Another break in basal lamina – cytoskeleton link
 FKRP (Fukutin related protein) mutated
o glycosylates α-dystroglycan, w/o glycosylation link to laminin-2 destroyed

Histology: similar to DMD histologically, some variability

 See lack of glycosylated α-dystroglycan on IHC

 Onset from early to late adulthood; slowly progressive

 Difficulty with standing, climbing, activities above head
 Can lose ability to ambulate
o Gower-like maneuvers in adults!

Congenital muscular dystrophy (MCD1C)

 Neonatal hypotonia  Rapidly progressive  Loss of ambulation before adulthood

Phenotype/genotype correlation
 Both correlation & heterogeneity
 LGMD2I & congenital muscular dystrophy have same mutations in FKRP – but different phenotypes!
 In patients with identical mutations (e.g. sibs), can see different IHC results, different expression, different phenotypes

Facioscapulohumeral (FSH) Muscular Dystrophy

 Aut dom, 1:20k, deletion in telemetric region of 4q (non-coding)

Findings: affects face, scapula, upper limbs

 Transverse smiling
 winged scapulae (double hump sign – deltoid is other hump)
o can fix scapulae to rib cage to treat
o Muscle weakness, can’t hold scapula down  winging
 Cachexia, muscle atrophy

Myotonic Muscular Dystrophy

 Aut dom, 1:20k, “most common” adult MD
 Multi-system involvement: congenital, opth, cardiac, GI, endocrine
 Men: frontal balding, wasting of temporalis, long face
o Facial muscle weakness: open mouth, drooping eyelids

Genetics: Trinucleotide repeat (ANTICIPATION)

 Kids affected worse than parents

Treatment
Neurologist coordinates care
 Preserve muscle strength
 Reduce contractures (have muscle imbalances)
o gastroc > tib anterior so tight heel cord
o Biceps > triceps, finger flexors > extensor

Lots of stretching, etc.

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Maintaining Muscle Strength
 Exercise: limit eccentric contractions (e.g. bear a load & extend at same time)
o Hard to do
 Pharmacology: prednisone for DMD

Cardiology

Problem Conditions Treatment

Cardiomyopathy Dystrophinopathies (DMD/BMD),sarcoglycanopathies ACEi/ARB/β-blockers
Cardiac conduction defects Myotonic MD, laminopathies, Emery-Dreifuss Pacemakers

Pulmonary Orthopedic management

 Better Tx = ↑ survival over time  Contracture reduction
 Both inspiration & expiration are affected  Scoliosis surgery (muscles weak  can tilt to
one side or another)
 Non-invasive positive pressure ventilation  Scapular fixation (for FSH MD)
(help with inspiration)
 Cough-assist (help with expiration)
 Vaccinations

Future Treatments
Combination therapy:
 gene therapy, other genetic modifications, stem cell therapy, growth factor modulation

Gene therapy: AAV vector

 Portion of dystrophin gene put in AAV vector, can get some dystrophin expression

Other genetic modifications:

Therapy Idea Downside
Antisense oligonucleotides Splicing modification of pre-mRNA Repeat administration; mutation-specific
Nonsense suppression Ribosomal read-through of stop codons in mRNA Potentially benefits only ≈ 10%

Becker MD in-frame deletion some dystrophin function

Duchenne MD out-of-frame deletion no dystrophin

Antisense oligonucleotides:
 use to skip the bad exon (with out-of-frame mutation) in DMD
 Could get a Becker phenotype instead of a truncated protein / DMD phenotype

Nonsense suppression:
 Give gentamicin or better newer agents to suppress nonsense mutations
 Works at ribosomal level

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Cell-based therapies: Satellite cells
 Cells that are normally dormant but proliferate with muscle injury

Normal roles of satellite cells:

Hypertrophy Growth, response to training
Maintenance Routine myonuclear turnover
Myofiber repair Severe exercise, localized damage
Regeneration After widespread damage

 Maybe ↑ satellite cells  regenerate muscle?

Growth factor modulation

 If you could make mm grow randomly (not fixing dystrophin / etc), you could alter slope of curve of atrophy

 Might get more years before disability

 Myostatin: negative regulator of muscle growth (knockout = jacked cow)
o Block myostatin: ↑ regeneration and ↓ fibrosis
o Conserved in humans

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 Clinical Spectrum of Movement Disorders
Identification of abnormal movements: based on phenomenology
 Tremors, dystonia, myoclonus, chorea, tics

Types of Abnormal Movements

Too Much Too Little
 Bradykinesia (slow movement)
 Hyperkinesias (tremor, dystonia, tic, stereotypy, HFS)
 Hypokinesia (small amplitude)
 Dyskinesias (TD, HD, chorea gravidarum, L-DOPA induced)
 Akinesia (less spontaneous movement)

Parkinsonism: Parkinson’s Disease, Parkinson-plus syndromes, and 2° Parkinsonism

Parkinsonism: marked by four cardinal features:

1. Bradykinesia (slowing of movements)
2. Rest tremor (rhythmic oscillation of body part when not in use)
3. Cogwheel rigidity (↑ mm tone with “ratchet feel”)
4. Postural instability (& gait impairment: slow start, festination, loss of postural reflexes)

Other common clinical features:

 Pill-rolling tremors, worse on distraction (e.g. count backwards)
 One side worse than other

Evaluation of pt with parkinsonism:

 Hx: drugs/meds that can cause parkinsonism? Risk factors for 2° parkinsonism?
 Exam: check for Parkinson-plus syndrome featuers
 MRI to rule out vascular dz / hydrocephalus / check for park+, but not to confirm PD

Parkinson disease (PD)

 About 80% of all pts with Parkinsonism
o May be a syndrome (multiple processes  PD?)
Epidemiology of Parkinson Disease
 Most not familial (can rarely get familial forms)
Prevalence: ≈ 1.2M, 1% of those over 65
o Rare familial forms: alpha synuclein, Parkin, pink1, etc.
Incidence: ≈ 50k/yr
 Pathology: DEGENERATION OF MIDBRAIN DOPAMINE NEURONS Mean onset: 62 yo
with LEWY BODY INCLUSIONS Onset before age 40 in 4 - 10 % of cases

Pathogenesis: Progression marches up brainstem

 ↓ dopamine cells  ↓ dopamine release
 ↑dopamine receptor (upregulation!)
o ↑ dopamine receptor #  give L-
DOPA  dyskinesia!
 Substantia Nigra: lose the pigmented neuron
 Lewy Body is pathological hallmark (pic)

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Non-motor features of PD
Mentation, behavior & mood Autonomic
 Depression (up to 50%)  Orthostatic hypotension (from both PD + meds)
 Dementia (bradyphrenia first, up to 40%)  GI: gastroparesis (dose failure!), constipation
 Anxiety, panic attacks  Other: skin (seborrhoea), sexual dysfunction

Basal Ganglia Circuitry in Parkinson Disease

 Left: normal, Right: Parkinson’s Disease

o In PD, the substantia nigra gets knocked out. Inhibitory signals predominate to the GPe, so inhibition of STN is
decreased, STN activates GPi, which inhibits thalamus / brain stem . Inhibition is net result

Etiology: Genes & environment probably overlapping!

PD risk factors:
 Age  Environmental factors: rural, pesticides
 Twins: concordance 75% for MZ, 22% for DZ  Protective factor: smoking, coffee drinking
 Positive family history

Treatment of PD
 Current goal: slow progression of disease (see chart to right) to limit
symptom development
 Future directions: can we intervene before onset of Sx?

Brain surgery for movement disorders: NOT EXPERIMENTAL (using now!)

 For: PD, ET, dystonia, other conditions
 Ablative (irreversible) or DBS (electrical stimulation) – ablative is much less common these days, use DBS

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Parkinson-plus syndromes
 Several distinct diseases: characterized by Parkinsonism & other features

Progressive Supranuclear Palsy (PSP)
Multisystem atrophy (MSA)
Corticobasal degeneration (CBD)
Lewy body disease (LBD):
3 subtypes, characterized by early falls & vertical gaze defects
two subtypes (“cerebellar” and “Parkinson-like”).
Early falls, limited DOPA response, ataxia in cerebellar type
path term, associated with “cortico-basilar syndrome”
a.k.a. “ Dementia with Lewy bodies” (DLB)

Secondary Parkinsonism
 Parkinsonism due to identifiable cause
Accumulation of CSF, expansion of ventricles.
Normal pressure hydrocephalus (NPH):common cause of parkinsonism; may be confused with PD

Features:
 Akinetic-rigid syndrome
Hydrocephalic
 Gait instability
parkinsonism
 Dementia
 Urinary incontinence
 Hydrocephalus on MRI

Treatment: shunt
Caused by two patterns of cerebral ischemia:
 bilateral basal ganglia stroke
 extensive confluent subcortical microvascular disease

Features: “Lower body parkinsonism”

Vascular
 Akinetic-rigid syndrome
parkinsonism
 Gait instability
 Dementia
 Ischemic disease on MRI

Treatment: risk factor prevention

Post-traumatic
Traumatic brain injury (e.g. dementia pugilistica in boxers – think Muhammad Ali)
parkinsonism
Post-infectious
Certain viruses & bacteria (e.g. encephalitis lethargica – Oliver Sacks)
parkinsonism
Lots of toxins / medications can cause
 toxins: MPTP (heroin addicts), CO, Mn, CN, methanol
Drug-induced  meds: antipsychotics, antiemetics, antidepressants, dopamine depletors, anti-HTN, anti-epileptics,
parkinsonism antiarrhythmics, antibiotics

Examples: haloperidol, risperodone, amphotericin B, metaclopromide, valproic acid, SSRIs, Ca-blockers

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 Tremor
Rhythmic oscillation of a body part caused by alternating or synchronous muscle contractions
 Rate must be constant (“rhythmic”)

Type of tremor Description

Physiological tremor
Exaggerated / enhanced
physiological tremor
Essential tremor
Parkinson tremor
 Everybody has one (not pathological)
 Due to kinetic energy generated by heart & blood circulation
Most common tremor, often not considered pathological
 Essential tremor ↑ with stress / anxiety / after strenuous exercise
 also ↑ with hyperthodroidism, certain drugs
Most common pathological tremor (5% pop?, ↑ > 50 yo)
 high frequency action tremor with both postural / kinetic tremor
 Average age of onset 45, 60% have relatives with ET
#2 pathological tremor
 Slow rest tremor most of the time; can see action (“re-emergent”) or global too

Others: cerebellar tremor (slow intention tremor), Holmes tremor (global, large amplitude, midbrain lesions), primary writing tremor
(writing only), orthostatic tremor (fine tremor, only when standing still), dystonic tremor, palatal tremor, neuropathic tremors,
cortical tremor (actually myoclonus), psychogenic tremor, etc.

Evaluation of tremor
Dx is hard! No markers, diagnosis is clinical, various sets of diagnostic criteria
• Dx criteria should be chosen depending on one’s purpose to Dx (e.g., genetic vs. clinical studies)
Exaggerated physiological tremor is indistinguishable from essential tremor on purely clinical basis (ancillary testing)

 The question: is it Parkinson Disease or essential tremor? (the big two)

Historical Features Essential Tremor Parkinson Tremor
Duration since onset 5‐10 years or more 1‐2 years or less
Response to ethanol usually positive no effect
Response to levodopa no effect usually positive
Family History positive in 60% usually negative

Examination Findings Essential Tremor Parkinson Tremor

When is it worse? when limb is in use at rest
How fast is it? fast (5‐9 Hz) slow (4‐6 Hz)
Amplitude fine coarse
What does it look like? flexion/extension of wrists "pill‐rolling"
Asymmetry minimal can be unilateral at first
What parts are involved? hands/arms, head/neck, voice hands/arms, legs/feet, jaw
Are there associated findings? usually none masked face, bradykinesia, cogwheel rigidity, gait impairment

Tremor causes disability! Lots of problems with handwriting, ↓ quality of life, impaired ADLs, etc.

Treatment of tremor
 Counseling (reassure about PD; recognize that no treatment is perfect)
 Oral medications: propanolol, primadone, combo, others?
 Botulinum toxin (off label)?
 Surgery if really severe: thalamotomy, DBS

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 Dystonia
Involuntary twisting movements or abnormal postures, caused by:
 simultaneous, often sustained contraction of two or more muscles that normally oppose each other

Classification schemes:
 by age of onset (childhood / adult)
 by distribution (anatomical site) (focal, segmental, multifocal, hemidystonia, generalized)
 by etiology (primary = idiopathic, secondary = symptomatic)

Dystonia: by anatomical site
Dystonia subtype
Focal
 Cervical dystonia
 Blepharospasm
 Spasmodic dysphonia
 Limb dystonia
Segmental
 Meige syndrome
 Oromandibular
Hemi-dystonia
Generalized
Affected region
Single body region
Neck muscles
Periocular muscles
Vocal cords
Limb muscles
Contiguous regions
Periocular – perioral (neck)
Mouth, tongue, jaw
Half of the body
Mabjority of the body
Generalized 1° dystonia
Clinical appearance
Limited to affected body region
Tilting / twisting of neck
Excessive prolonged blinking
Strangled / whispery voice
Writer’s cramp, inversion of foot
Blinking, mouth (neck) posturing
Abnormal speech, chewing
Usually arm/leg on one side
Many but not allareas

Cervical Dystonia (spasmodic torticollis)

 Most common focal dystonia; W>M, age of onset 40-60
 Insidious onset with progression in first few years; may spread to neighboring regions
 Rare remissions (<15%); usually recurs within 5 years
Named for direction of head movement
Torticollis Laterocollis Anterocollis Retrocollis
Twisting Ear-to-shoulder Chin down Head back

Dystonia: by etiology Clinical features:

Primary Dystonias  Stereotyped and patterned abnormal
 Most are genetic movements and postures
 Dystonia is the only neurologic finding  Repeatedly involves same muscle groups
 Sustained (compared with chorea) but
(except for tremor and myoclonus)
tremor or myoclonus may be present
 No identifiable cause or other inherited degenerative disease
 Has a directional component
 Often activated by voluntary movements
Secondary dystonias  Benefit of “sensory tricks”
 Acquired: trauma, infection, focal lesions of nervous system (↓ dystonic movements)
(e.g. dystonic CP, antipsychotic drugs)
o Acute dystonic reactions: shortly after starting drug or ↑ dose
 sudden onset of tonic spasms, segmental (neck/craniofacial mm, eyes)
o Tardative dystonia: with chronic neuroleptic dose (months/years)
 Gradual development of tonic spasms, segmental (trunk / neck / craniofacial mm)
 Dystonia-plus syndromes (dystonia + other features)
 Psychogenic dystonias: often paroxysmal

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Management of dystonia
Evaluation:
 FHx, age of onset (inherited cause?), duration / rate of progression
o most progress over months/years & then remain static for life
o slow / continuous suggests hereditary/degenerative or dystonia-plus syndrome
o Young onset (<30 yrs) suggests inherited cause (clinical testing for DYT1)
 Physical exam
 Brain imaging (use for hemidystonia or segmental dystonia – identifiable lesions most often present this way)

Treatment:
 Treat underlying cause (if identifiable)
 Botulinum toxin if limited # of muscles involved
 Oral meds: limited role in focal dystonias, can be effective in generalized cases
o Levodopa, trihexyphenidyl, baclofen (PO or intrathecal), clonazepam
 DBS for really bad, refractory cases
 Pay attention to depression & anxiety: big problem in these pts!

Myoclonus
involuntary, sudden, brief, shock-like movements caused by muscular contraction or inhibition (“jerk”)
 Are really “about the muscle” (can’t suppress, no urge: vs. stereotypies / tics, which are “about the movement”)

Classification: by frequency / speed, distribution, character (positive vs negative), etiology

Cortical myoclonus: “fragement of epilepsy” (abnormal cortical discharge  myoclonus)

 May or may not lead to full blown seizure (myoclonic epilepsy)
 Lance-adams syndrome: cortical myoclonus is part of post-anoxic encephalopathy syndrome
 Cortical tremor: really just a rhythmic cortical myoclonus

Subcortical myoclonia: generated by abnormal brain activity other than the cortex
 E.g. reticular myoclonus (part of post-anoxic encephalopathy, generated by brainstem)

Spinal myoclonia: generated by spinal cord, associated with longer muscle contractions
 E.g. with spinal tumor
 Segmental spinal myoclonus: one or a few spinal levels; myoclonic jerks in one or a few adjacent myotomes
 Propriospinal myoclonus: more extensive spinal pathology; many myotomes involved, spreads in marching pattern

Psychogenic myoclonus: probably most common manifestation of psychogenic movement disorders, very often paroxysmal

Evaluation of Myoclonus
 Clinical characterization; look for underlying pathology (Hx, neuro exam, MRI of brain/spine, etc.)
 Jerk analysis / myoclonus electrophysiology is very useful
o Polygram: multi-surface EMG: help follow myotome involvement, measure length (brief = cortical, long=spinal)

Treatment of Myoclonus
 Treat underlying cause (remove spinal tumor, treat inflammatory process)
 Suppress CNS hyperexcitability (Levetiracetam, pyracetam, benzodiazepines, e.g. clonazepam, valproic acid)
 Direct relaxation (botulinum toxin to affected muscles)

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 Chorea, Athetosis, Ballismus
Chorea: involuntary, irregular, unpatterned, and unsustained movements with variable timing and distribution
Athetosis: involuntary slow and irregular writhing movements most often affecting the distal limbs.
Ballismus: faster flinging movements, typically involving proximal muscle that move an entire limb.
These three often overlap: e.g. choreoathetosis, etc.

Causes of chorea
 Inherited: present in children (20+ syndromes) or adulthood
o Huntington’s disease/chorea: unstable trinucleotide repeat in huntingtin gene, aut-dom
 Metabolic processes (hyperthyroid)
 Neuroacanthocytosis
 Stroke of subthalamic nucleus (sudden-onset hemiballismus-hemichorea: just one side affected)
 Drugs: L-DOPA, dopamine agonists (phenytoin, theophylline, amphetamines / cocaine / other sympathetomimetics too)
 Autoimmune disease
o Sydenham’s chorea (post-strep infection)
o Chorea gravidarum (women during / shortly after pregnancy: immune system changes)
o SLE
 Senile chorea (perioral mm in elderly), psychogenic chorea (less common)

Evaluation
 Look for reversible causes (Hx: strep infection, pregnancy, drug history / L-DPOA?)
 FHx for hereditary forms, Brain MRI to rule out stroke / caudal atrophy in HD, ANA, etc.

Treatment:
 Remove causing condition
 ↓ dopaminergic neurotransmission in brain
o DA receptor antagonists or depletors of DA-containing vesicles in brain (riserpine, tetrabenazine)

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 Tics & Tourette’s Syndrome
Tics: repetitive and unwanted movements or sounds
 typically preceded by an urge to perform the tic.
 urge and tic can be suppressed at least for a while, but the suppression results in a buildup of inner tension that ultimately
proves irresistible and the tic must eventually be released (performed).
Coprolalia comes from the
Greek κόπρος (kopros)
Usually wax and wane in severity over time (↑ with stress); can change appearance meaning "feces" and λαλία
(lalia) from lalein, "to talk"

Three types of tics

Single movements that occur suddenly / executed quickly (cracking neck, shrugging shoulder)
Simple motor tics
 Sometimes mistaken for “odd habit”, myoclonic jerk, brief dystonic spasm
Repetitive movements that involve several steps in a row (blink one eye, tilt head, pull ear)
Complex motor tics
 Can appear to be dystonic, chroeiformic, or ballistic
Audible events (snort/sniff/clear throat/grunt)
Vocal tics
 can be more complex (repeat profanities = coprolalia, repeat what is heard = echolalia)

Tic Disorders
Tics are common but don’t usually represent a tic disorder:
 only when they cause problems (interfere with work / embarrassing)

Transient tic disorder Lasts for < 6 mo

Chronic tic disorder One or a few tics for > 12 mo
Most severe; required for Dx:
 multiple motor tics that wax/wane in severity, change over time
Tourette syndrome  At least one vocal tic
 Onset in childhood
 Duration > 12 mo

Treatment of Tic Disorders

 Neuroleptics (antipsychotics) are most effective (be careful – can develp tardative dyskinesia)
 Other meds too: Gabapentin, Tetrabenazine, Clonidine, Baclofen

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 Glossary (for reference: no need to memorize)
Term Definition
Akathisia inner sensation of restlessness often expressed by pacing or body rocking.
Apraxia loss of skilled movement
Asterixis brief lapses of posture due to loss of muscle tone; most readily seen as flapping movements
when the hands are held out in front and dorsiflexed at the wrists.
Ataxia a syndrome characterized by lack of coordination that includes dysmetria (inability to judge
distances, power, or speed), dysdiadochokinesis (inability to stop one act and follow with
another), and dysynergia (loss of coordination and harmony of complex movements) and
dysrhythmia (inability to maintain rhythm).
Athetosis involuntary, slow and continuous, small‐amplitude, writhing movements that tend to affect
distal body parts.
Ballismus involuntary, rapid, large amplitude, flinging movements that tend to affect proximal body parts
(resembles throwing a baseball).
Chorea involuntary, fluent, irregular movements of variable speed that tend to travel from one part of
the body to another (resembles dancing).
Dyskinesia a generic term for any abnormal involuntary movement, more specifically used to describe
choreiformic movements.
Dysphonia impairment in the ability to produce voice sounds using the vocal organs.
Spasmodic dysphonia is a form of focal dystonia.
Dystonia involuntary, excessive contraction of muscles leading to twisting movements or abnormal
postures that are often repetitive.
Freezing inability to initiate the next step while walking resulting in sudden halt.
Hyperekplexia abnormally increased reactivity to external stimuli e.g. unexpected noises
Hyperkinetic a movement disorder featuring too much movement, such as chorea.
Hypokinetic a movement disorder featuring too little movement, such as parkinsonism.
Hypomimia reduced facial expression.
Hypophonia reduced voice volume.
Movement disorders are a group of diseases and syndromes affecting the ability to produce and control movement
Myoclonus involuntary, sudden, brief, shock‐like movements caused by muscular contraction or inhibition.
Myokymia fasciculation‐like quivering, most frequently in muscles around the eyes.
Parkinsonism syndrome of akinesia (reduced spontaneous movement), bradykinesia (slow movements),
rigidity, and resting tremor or any combination of these.
Rigidity a particular form of muscle hypertonia characterized by ratchet‐like or cog‐wheeling resistance
to passive movements.
Stereotypy a repetitive and purposeless movement, usually a fragment of a normal movement.
Synkinesis Simultaneous occurrence of movements that do not normally go together.
Tardive dyskinesia involuntary choreiformic movements due to chronic antipsychotic exposure, most often
involving the orolingual muscles.
Tic a sudden movement (or sound) that is unwanted, often preceded by a premonition, and
voluntarily suppressible only transiently.
Tremor: involuntary, rhythmic oscillations of a body part.

Action tremor refers to tremor that appears during active use and comprises
 kinetic tremor (tremor while a body part is being actively moved, such as in finger‐to‐nose testing)
 postural tremor (when a body part is maintained in a steady posture by active muscle contraction).
 Intention tremor (amplitude of tremor increases near the target (typical of cerebellar tremor).

Rest tremor is the opposite of action tremor and reefers to shaking that develops while at complete rest.
Global tremor is a tremor that is seen “across the board”, i.e. during both rest and action.

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 Memory Loss and Alzheimer Disease
Memory is only one of the cognitive functions of the brain
 Also: learning / memory, language, orientation, calculation, recognizing faces/objects,
executive functions, abstract thinking

Memory
 Frontal lobe: initial attention, repetition
 Hippocampus: memory consolidation
o (short-term memory)
 Cortex: memory storage
o (long-term memory)

Memory Disorders
 Age-associated memory impairment
o Memory ↓ with age (expected)

 Mild Cognitive Impairment (MCI)

o Significant memory loss above “normal” age-associated
memory impairment, but still functional

 Dementia: umbrella term to cover various conditions

o Memory loss + loss of at least one other cognitive ability
o Loss of function in daily life
o Can be caused by a variety of pathologies (Alz dz, vascular lesions, Lewy Body dz, AIDS, EtOH, iatrogenic)
o “Senile dementia” is no longer used as a term (replaced by AD)

Alzheimer Disease
 Atrophy  hippocampus affected first  initially: memory symptoms

Plaques & Tangles

 Plaque: gum-like collection of β-amyloid
 Tangles: abnormal p-lation & aggregation of tau

Both cause cell death, inflammation, brain atrophy

 Plaques stain positive for inflammatory components with IHC
 Microglia activated, try to kill plaques but can’t
 Nearby cells damaged (collateral damage)

Vascular Lesions
 AD causes atrophy in hippocampal / cortical areas
o (Tangles don’t affect basal ganglia/cerebellum for the most part)

 Small or large strokes cause atrophy in cortical, subcortical areas

(“ministrokes”, etc)  vascular dementia

 Worse outcome with AD + strokes

Pathogenesis
Early onset AD (more rare) Plaques / tangles are the big problem
Late onset AD (most AD) Plaques / tangles + big contribution from ministrokes

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The nun study:
 Some nuns were not demented but had severe AD pathology
 Some had dementia despite mild AD pathology (but had multiple strokes)
 A few plaques and tangles can lead to dementia, if patients have heavy vascular pathology

Vascular Risk Factors for AD

 ↑ AD risk with ↑ HTN and ↑ high cholesterol (3x risk)
 ↑↑ with multiple vascular risk factors
o Diabetes, heart disease, ↑ BP, smoking history

 Stroke: up to 25% of patients have dementia 3mo after stroke

o vascular dementia (58%), AD with stroke (38.7%), other forms too

 Silent brain infarcts: evidence of stroke on MRI but no associated symptoms

o ↑↑ risk of dementia (2.26x)

 White matter lesions: see in lots of older patients

o Often think of them as “normal” in older pts
o Not good: ↑ cognitive decline with ↑ white matter lesions

Obstructive Sleep Apnea and Dementia

 ↑ silent brain infarcts in patients with OSA
o ↑ platelet activation, ↑ systemic inflammation, ↑
epinephrine, ↑ severe HTN, ↑ MI, ↑ stroke, ↑ CHF,
↑pulmonary HTN
o Hypercoagulable, chronic hypoxia, inflammation, etc.

Atrophy (↓ gray matter brain volume) in OSA pts

 Temporal lobes, frontal lobes, posterior areas,
parahippocampal gyrus all affected Factors that contribute
to development of AD

Evaluating Dementia
ABCs of Dementia Symptoms
 Activities of Daily Living
 Behavior
 Cognition

MMSE
 Below 25 – probably going to be referred to neurologist, symptomatic, etc.
 Below 10 – disruptive behavior starts, etc.

Clock drawing
 Great test – very high yield (requires a lot of functions to be intact)
o Some patients can carry on a good conversation but fail this
o Can follow over time to assess progression of cognitive decline

Dx: workup
 MMSE & Hx (primary physician) – talk to family separately
 CBS (anemia), B12, TSH, RPR (syphilis), CRP (inflammation), ESR (vasculitis), EKG
(vascular risk), Head CT (↑ # tests with younger patients!)

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  Clock-drawing test
 Refer to memory clinic if borderline
 PET scan in younger pts (can help, not necessary)
o Selective parietal/temporal hypometabolism (+ frontal lobes in advanced dz)

Treatment
 AChE inhibitor: donepezil (Aricept), galantamine (Reminyl), rivastigmine (Exelon)
 NMDA (glutamate) receptor blocker: memantine (Namenda): along with AChEi
 Psych meds (for agitation, anxiety, insomnia, aggression): antidepressants can help
o Antipsychotics may help too, but ↑ mortality risk
 Mild benefits only: helps ↓ behavior disturbances, etc.

MMSE < 10
 Get really hard to live with at home
 Nursing home – tell pts’ family that they need special treatment
o If they had cancer, you’d get them to appropriate care!

Prevention of AD
Risk factors:
 High BP, diabetes, obesity, OSA, alcoholism, depression, high
homocysteine, head trauma

Goal: find things that would change the trajectory of decline

 Vitamin E, Vitamin C, NSAIDs: may have synergistic benefit
 NSAIDs: ↓ inflammation (but can’t give as PGx: GI side effects, etc)

“Brain reserve”
 Memorizing lots of information: good for brain (↑ synapses in hippocampus)
 Lose synapses in AD: if you had more synapses to begin with, you’re better off!

Protective factors
 Diet ↑ in antioxidents  EXERCISE
 Fish 2-3x/wk  Leisure activities
 1-2 glasses of wine with dinner  Education, cognitive stimulation

Hippocampus is vulnerable (smaller hippocampus = more vulnerable to these insults)

 Hypoxia post cardiac arrest  Head trauma
 Diabetes  Depression / PTSD
 High BP  Aging

Memory & the Hippocampus

 Studied medical students before, just after taking, 3 mo after boards: Increase in brain volume (cortex & hippocampus!)
o ↑ cortex while you study, levels off over summer (not studying)
o ↑ hippocampus: and ↑ even over the summer (not studying)
 Hippocampus keeps working & consolidating!
Hippocampus is very plastic (good for memory!)

What determines hippocampal size?

 Genetics
 Use (going to school = ↑ levels)

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 Some Cases
70 yo man, lives wife, bad memory for names, reads technical journals, socializes, scared he has AD (mom had it)
o Talk to his wife! Has there been a progression?
o Any other medical conditions or drugs? (vascular problems, iatrogenic, etc.)
o How old was his mother when she was diagnosed? Who made the diagnosis?
o Depressed? Lots of people who present like this have depression!
o Behavior changes? Fronto-temporal dementia  mostly behavior problems!
 Dx: “Worried well” probably not dementia, memory decline but limited. Check CBC, TSH, B12, probably no CT / PET
 Tx: still help them! exercise, teach tricks for memory, evaluate for depression

75 yo dentist, lost driving in own neighborhood, wrote wrong checks, gets into arguments, accuses others of stealing,
thinks memory is fine for his age, MMSE 18
o Meds, medical problems, talk to family
o CBC, TSH, B12, MRI, PET, etc.
 Dx: Probably AD

76 yo grandmother, can’t take care of finances, figure out tip, asks people to repeat things, still likes reading,
volunteering, etc., has been taking notes more often
o Probably not AD, probably not normal  check hearing loss
 Dx: Mild cognitive impairment (primarily memory problems only!)

56 yo woman, once taught 2 languages, lost job (multiple complaints by parents  confused!), can’t take care of errands
aroud house, developed limited vocabulary even in English (give me “that thing”), ½ family got AD in 50s
 Dx: Early onset AD

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 Clinical Features of Cognitive Disorders
Distributed (bilateral) processes “Localized” (unilateral) processes
Attention Visuospatial
Executive (planning, etc) Praxis (programming of learned movements)
Memory Language
Note that “localized” processes aren’t really local – they still require networks

Attention

Attention: “physiological mechanisms which allow us to selectively focus on a subset of available sensory inputs or thoughts”

Why is attention important?

 Pre-requisite for normal cognitive function
 Impaired attention can mimic disorders of memory, language, etc.
 Attention lapses often account for everyday “forgetfulness”
o Preoccupation, “absent-minded professor syndrome” (older, lots of things on mind)

Clinical conditions that impair attention: closed head injury, delirium, R. hemispheric stroke, dementia

Delirium (encephalopathy)
Etiology
 Systemic / metabolic dz Clinical features of Delirium
o infection, hypoglycemia, kidney failure – uremia,  Fluctuating level of consciousness / alertness
liver failure, hyperthyroidism, etc.  Subacute onset of Sx
 Medication side-effects  Confusion, disorientation
o benzos, anti-Ch – benadryl!, many more esp. polypharmacy (place and time, not person)
 Drug/alcohol withdrawal  Hallucinations, perseveration
o alcoholic delirium - DTs (multiple repetitions of previous response)
 May occur in 30% of hospitalized elderly pts
To have delirium”
Diagnosis
 Healthy people must be really sick
 No single “diagnostic test”
 Dementia pts can be just slightly sick
 History: subacute onset, waxing/waning consciousness
 Impaired attention / concentration
o Digit span (how many can pt remember?), test working memory

Unilateral Spatial Neglect (Hemispatial neglect)

 Typically RIGHT HEMISPHERE lesion, e.g. right hemispheric stroke

 Pt “ignores” left half of space or left half of individual stimuli on both sides
o May fail to acknowledge hemiparetic arm (hemiparesis if stroke)
o Eat food on right half of plate, reads right half of words
 Airways  “byways”; Chair  “air

Line cancellation test: cross out all the lines; pt doesn’t attend to left side
Clock drawing test: all numbers on one side of the clock

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 Viewer-centered USN Stimulus-centered USN
Left half of things
Neglect Left half of space/view
(will attend to right side of things in left half of view)
R. Parietal lesion R. Temporal lesion (superior temporal gyrus,
Lesions (supramarginal gyrus, angular gyrus, frontal cortex,
inferior/middle temporal)
TPO junction)
Visual stream “Ventral stream” of visual information
“Right dorsal stream”
(recognition of objects, reading: representation
affected (planning movements in space, etc.: viewer-centered)
irrespective of where they are to the viewer)

Picture

Behavior is important too

 Fidgety, restless, repeatedly distracted, inappropriate behaviors (impaired executive fxn  ↓ inhibition)

HIV Dementia
 A “subcortical disease” – diffuse process (note subcortical lesions)

Clinical presentation:
 Motor slowing  Fluctuating attention
 Memory impairment  Preserved language and other cortical
 Visuo-constructual impairment functions

Key Points: Attention

• Impaired attention may produce deficits in multiple cognitive domains
• Delirium is characterized by severe, fluctuating attentional deficits
• Right-hemisphere parietal lobe injury often associated with “focal” deficits of attention, (e.g. hemispatial neglect)
• Diffuse brain injury often results in significant attentional deficits

Aphasia
Most right-handers are left-hemisphere dominant for language
Arcuate
 (and ≈ 50% left-handers) Fasiculus
 Remember: Speech ≠ Language!

Aphasia: acquired deficit of language secondary to brain dysfunction

 Usually multi-modal (involves written + spoken)
 Can have isolated deficits too (more rare): Broca’s
o Alexia: impairment of reading area
o Agraphia: impairment of writing Wernicke’s
o Pure word deafness Area

The Basic Language Model (generally the left hemisphere!)

Area Location Problems
Broca’s Posterior inferior frontal ctx Production: articulate language, motor speech, grammatical constructions
Wernicke’s Posterior superior temporal ctx Comprehension, meanings of words
Arcuate fasiculus Connects Wernicke’s and Broca’s areas

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Speech disorders
 Dysarthria (articulation – e.g. muscle weakness, ALS, MG, etc)
 Apraxia of speech (motor planning / programming of speech articulation)
 Dysphonia (voice disorder)
 Stuttering (often developmental)

 Writing, reading, other aspects of language intact in pure motor speech disorders
 Mutism (behavioral or anarthria = very severe dysarthria)

Language laterality
 Right-handers: mostly left hemisphere language
o About 5% right hemisphere dominant: “crossed aphasia”
 Left-handers: majority with left hemisphere language
o About 30% with right hemisphere language (correlates w/ FHx, degree of left-handedness)

Global Aphasia
Clinical presentation
 All modalities of language are severely impaired; no usable speech / comprehension
 Stereotypical or recurrent utterances (Broca’s pt: “tan-tan” – often profanities)
 Reading, writing, repetition also impaired
 Most severe type of aphasia
 Caused by large lesions: both Broca’s & Wernike’s areas
o Clot in entire L MCA

“Partial” aphasias
Category Description Examples
 Wernike’s aphasia
lots of words, jargon  Conduction aphasia
“Fluent” aphasias
major defect in comprehension / meanings  Anomic aphasia
 transcortical sensory aphasia
production impaired  Broca’s aphasia
“Non-fluent” aphasias “telegraphic” or “texting” speech
 transcortical motor aphasia
leave out small grammatical words

Broca’s aphasia
• Non-fluent, effortful speech; poor articulation, sparse output, sometimes agrammatic
o Telegraphic (omits function words)
• Writing impaired to similar degree as speech
• Comprehension less severely impaired (except syntactically complex sentences)

Lesions:
 Superior division, left MCA
 Posterior, inferior frontal lobe

Conduction Aphasia
 Disproportionate difficulty with repetition
 Fluent, paraphasic speech
o Semantic paraphrasia: “coat”  “jacket”
o Phonemic paraphrasia: “coat” “goat”
 Relatively preserved comprehension
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Lesion: left inferior parietal lobule (working memory)
 Problem of working memory: can’t remember exact words
o (“It’s a sunny day in Baltimore”  “it’s nice outside”)
 Role of arcuate fasiculus?
o Often see lesion here too, but if only arcuate fasiculus, no repetition problem

Wernicke’s Aphasia
• Fluent, paraphasic speech; sound or word substitutions, lots of jargon
o Neologistic jargon: not real words (“jabberisy fardle buffik”)
o Semantic: word substitutions (“coat”  “jacket”)
o Phonological: sound substitutions (“coat” “goat”)

• Normal articulation, prosody (rhythm, stress, intonation)

• Auditory comprehension & repetition markedly impaired

• Not aware that they’re not making sense (pts will talk to each other just fine!)
o Often: certain phrases preserved
o Think that they’re making sense & understanding!
o Often recover & say they didn’t think anything was wrong

Lesion:
 Inferior L. MCA territory
 Posterior, superior temporal lobe ( Wernicke’s area)

Transcortical Aphasias
 Spared repetition

Transcortical motor like Brocas with spared repetition

Transcortical sensory like Wernicke’s with spared repetition
Mixed transcortical like Global but spared repetition (echolalic, usually due to dementia¸not stroke)

Aphasia: Etiology
A symptom of brain injury, not a disease

Acute onset aphasia: usually stroke

Gradual onset of aphasia: degenerative disorders
 Primary progressive aphasia: front-temporal lobar degeneration is most common
 Creutzfeldt-Jacob dz (rare)

Key Points: Aphasia

• Aphasia is a disorder of language
• All language modalities usually involved
• Anterior lesions associated with non-fluent speech
• Posterior lesions associated with fluent speech, but receptive and expressive
• Receptive vs expressive not too helpful of a dichotomy (of you’re not receiving, you’re not expressing, etc.)

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 Apraxia
An acquired deficit of purposeful movement
 Can’t explain by ↓ strength, muscles, sensory loss, language comprehension, ↓ cooperation, confusion, delirium
 Pts rarely recognize inability to perform skilled movements

Clinical syndromes: Stroke, cortical dementia (e.g. fronto-temporal dementia), cortico-basal degeneration

Limb apraxia:
 Lesion: parietal lobe or SMA (supplementary motor area, in frontal lobe) lesion;
o Contralateral to dominant hand, but you get bilateral apraxia
 Slow to organize movement, ± improvement with demonstration, sometimes delayed
 May exchange one movement for another “throw a ball” clap hands

Apraxia of speech: Anterior lesions (Broca’s aphasia)

Agnosia
 Impairment in recognition
 Not caused by deficit in sensory processing or dysnomia (naming what they see)
 Generally modality specific (visual agnosia most commonly studied)
 Rare but dramatic Types of visual agnosia
Object agnosia Can’t recognize cup if you see
Visual object agnosia (associative): it, but can if you pick it up
 can describe physical features (color, size, shape) Color agnosia Can’t recognize colors
o but can’t recognize object! Prosopganosia Face recognition impaired
 copy line drawings, but can’t identify even after making copy!

Clinical syndromes with visual agnosia: DIFFUSE OR BILATERAL lesions

 Stroke: bilateral temporo-occipital (BASILAR artery)
 Degenerative conditions: advanced Alz dz or posterior cortical atrophy (variant of Alz dz)
 Trauma, cardiac arrest

Auditory agnosia: may not recognize words or sounds

 Can recognize picture of dog, but not bark

Amnesia
Global amnestic syndrome

 Most severe form of memory impairment

o Severe anterograde amnesia (can’t learn new information)
o Variable retgrograde amnesia (can’t recall old information)

 Other aspects of cognition preserved

o Consciousness, language/intellect, attention ok
o Implicit/procedural memory ok (can get better at doing a maze, but don’t remember practicing)
o Semantic memory ok (memory for the meanings of things)

Etiologies (e.g. hippocampal problems)

 Herpes simplex encephalitis  Alz Dz (advanced)
 Korsakoff’s syndrome  hypoxia / ischemia
 Iatrogenic (surgical lesions – e.g. HM) (hippocampus sensitive to hypoxia  bilateral damage)

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Herpes simplex encephalitis
 Uncommon, caused by common virus HSV
 Subacute onset (1-3 days) w/ severe H/A, fever, confusion, memory loss / aphasia
o AMNESIA / APHASIA + FEVER  ACYCLOVIR!

Wernicke – Korsakoff syndrome: (two-part syndrome)

 Acute: Wernicke’s encephalopathy
o eye movement abnormalities, ataxia, confusional state
 Chronic: Korsakoff’s amnesia
o Typically follows acute Wernicke’s encephalopathy
o Severe anterograde amnesia, disorientation, confabulation (make up stories)

 Thiamine (vit B1 deficiency) Wernicke, Korsakoff,

o Co-enzyme in carbohydrate metabolism and an early patient
o Classic: alcoholics (↓ dietary intake, ↓ GI absorption, ↓ hepatic storage, ↓
utilization of B1)
o Also: Dieting/exercise (ballerinas, jockies), Crohn’s disease, Gastric restrictive surgery
 Treatment: give thiamine (memory improves)
o Incidence ↓ with food fortification (even in countries with high alcohol use)

Transient Global Amnesia (TGA)

 Acute onset of memory loss, benign but scary, pretty common
 Mostly Anterograde (can’t form new memories)
o Mild retrograde component:
can’t remember day before, but can remember week before

 Preserved consciousness & self-awareness

 Self-limiting (usually recover within 12 hours)

 Etiology unknown (sometimes misdiagnosed as stroke

o Maybe very small TIAs/hippocampal strokes?
o Usually unilateral, subtle

Memory loss due to general medical conditions

 Vitamin deficiencies (B12, folate, thiamine)  Chronic pain
 Hormonal (thyroid abnormalities)  Liver disease
 Sleep disorders (sleep apnea)

Evaluating memory loss

Memory process
New learning (encoding)
Delayed recall (consolidation;
recall and retrieval affected)
Retrieval (spared recognition)
Working memory
(multi-tasking)
“Hollywood amnesia” (retrograde w/o anterograde) is atypical (person probably wants to be in ED for another reason!
What it looks like Impaired with:
 Attentional disorders
(depression, medications)
Learn information, give other tasks,  Hippocampal lesions
then patient forgets what they’d learned! (Encephalitis, Alzheimer’s)
 Executive dysfunction
Who’s the president of the US? Pt. doesn’t know.
(Fronto-temporal dementia,
Is it Obama, McCain, or Palin? It’s Obama!
Subcortical dementia)
Can’t retain sequences of numbers or words  Fronto-subcortical disease

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 Anosognosia
 Unawareness of illness
 Often: severe forms of diffuse brain injury (e.g. dementia)
o Also: focal R. parietal lobe injury
 Patients aren’t just in denial: genuinely unaware of deficits

Executive Functions

Phineas Gage: struck with tamping iron through frontal lobe  executive function changes

Executive / frontal lobe functions

• Abstract reasoning • Multi-tasking • Response inhibition
• Problem solving • Motivation • Planning

 Hard to quantify with standardized neuropsych tests

o Wisconsin Card-sorting test, trail-making test, verbal fluency test
 Bedside evaluation challenging too
o Luria “hand sequencing test” – strike table with fist, open hand, side

How much of our brain do we use? Pretty much all of it.

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 Seizures and Epilepsy
Seizure: a sudden, excessive, temporary discharge of a large group Epidemiology of Epilepsy
of neurons.  2 most common disorder seen by neurologists
nd

o 2.3M in USA, 2-5% lifetime prevalence

New-onset seizures:  All age groups, ↑ active prevalence with ↑ age
 Often present in childhood / adolescence  ↑ morbidity, mortality, $$ for society / individuals
 Biggest # of new-onset cases: OLD PEOPLE (>70yo)  ↓ quality of life, > 50% pts for rest of life
o Due to underlying causes!
Epilepsy vs seizures
Epilepsy: recurrent seizures or the propensity to have recurrent seizures
 a single seizure is not epilepsy (10% pop has seizure lifetime); about ½ epilepsy will remit (more common in children)
 Provoked seizures are seizures caused by:
o metabolic causes (e.g. low glucose), medications (e.g. tramadol), substance (e.g. alcohol), etc.)

Seizure type: determined by patient behavior and EEG pattern during the ictal event

Epileptic syndrome defined by:

 Seizure type(s)  EEG (ictal + interictal)  Response to AED
 Natural history  Etiology

Syndromes:  Seizure disorder = epilepsy

 Begin in childhood or early adolescence  Single seizure may not be epilepsy
o Juvenile myoclonic epilepsy: common, important myoclonic  Provoked seizures ≠ epilepsy
epileptic syndrome; seizures not associated with other neuro
abnormalities
 Have important prognostic value for course
Classification of seizures
Partial seizures
 begin from focal area of brain
 Symptoms depend on which part of area is affected
o E.g. hand twitches if in motor strip, etc.
 57% of all seizures, most are complex partial

Auras: mostly with temporal lobe partial seizures

 Commonly: nausea, unusual smells, déjà vu, fear
 Don’t alter consciousness, last only seconds
o But can be followed by a complex partial seizure, for instance
 Auras = simple partial seizures, often involving deep brain structures
(e.g. hippocampus), may not provoke EEG changes

Types of Partial Seizures

 Simple partial (focal, local): DON’T involve impaired consciousness
 Complex partial: impaired consciousness at outset (can be simple partial evolving to impaired consciousness)
o Most common type of seizure
o 70-80% complex partial seizures are preceded by aura
o Can have automatisms, lip-smacking, hand picking, etc. during seizure
 Partial can evolve to generalized seizures

EEG: focal, rhythmic discharge (starts in one area)

Post-ictal state: several minutes of confusion following seizure

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Generalized seizures
 begin from both sides of brain simultaneously (or at least appear to – probably deep brain structures)
 Not due to identifiable brain abnormality (may be complex genetics)
 Not progressive or associated with other neurological deficits
 80% controllable by medicine

Types:
 Absence (petit-mal): brief staring episode for several seconds
o Total unawareness but prompt return to full awareness
o Thalamus, thalamocortical projections involved?

 Tonic-clonic (grand-mal)
o Loss of consciousness
o Bilateral tonic & clonic arm/leg movement
o ± tongue biting or urinary incontinence

 Myoclonic (brief muscle jerks ± LOC / other neuro defects

 Atonic (drop attacks: pt loses consciousness & body tone  falls  can be injured)
 Clonic / tonic on their own too

EEG: everything starts discharging at once

Terminology
 Grand mal = convulsions COMPLEX PARTIAL ABSENCE (PETIT MAL)
 Petit mal = absence seizures Onset Adult / childhood Childhood
Aura Common None
(PARTIAL SEIZURES ARE NOT PETIT MAL Duration Minutes Seconds
Post-ictal confusion Yes No
EEG Focal abnormalities Generalized discharges
KNOW THIS TABLE
Etiologic Categorization of Epilepsies
Idiopathic Symptomatic Cryptogenic
 Age-related onset  CNS disorder / lesion  Presumed symptomatic
 Clinical, EEG characteristics is the cause – treat it!  Etiology unknown
 Presumed genetic etiology  Think something’s causing it but can’t find it

Predisposing factors for epilepsy

Children Adults
 cerebral palsy  head trauma (esp.  military head injury  CNS infection
 mental retardation adolescents)  civilian head injury  Alzheimer’s disease
 febrile convulsions  CNS infection  stroke  Left ventricular hypertrophy
 Tumor / AVM (later adults)
Gunshot wounds or “missile injuries” are major cause in military!

Things that get confused with seizures

 Breath-holding, hyperventilation, vasovagal events, nocturnal myoclonus, parasomnias
 Panic attacks – some pts can have seizures with fear as aura! (but only lasts a minute or so)

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 Basic mechanisms of epilepsy
 Hyperexcitability for a brief period of time  repetitive firing of action potentials
 Paroxysmal depolarizing shift (PDS)
o Prolonged depolarization
o Activation of NMDA receptors
o Inward sodium & calcium fluxes

Long-standing seizure disorders: alterations in temporal lobe synaptic organization

 Progressive neuronal cell loss  mossy fiber synaptic reorganization, sprouting
 End result: ↑ NMDA-mediated events
o Basically: injure  sprout new fibers  ↑ predilection for seizures!

Characteristics of epileptic seizures

 Abnormal synchronous firing of neuronal networks
o Note: normally have synchronous firing in brain – not just in seizures!
 ↑ excitation
 Self-limited, short duration (< 2m)
 May occur in clusters
 Multiple neurotransmitter systems involved

Treatment implications
 We have anti-epileptic drugs but not yet anti-epileptogenic drugs: can we hit that window of epileptogenesis?

Evaluating a Patient with Epilepsy

 Hx, physical, lab studies
 EEG: sleep, hyperventilation, intermittent photic stimulation, sleep deprivation, ambulatory day / prolonged video
 MRI: thin cut, coronals, T1 / T2 / FLAIR
 Also: CT/PET/SPECT/MRS/etc
 Identify comorbidities / underlying causes, monitor when in doubt

EEG
 Scalp or intercranial
 SUMMED ACTIVITY of LARGE GROUPS OF NEURONS (not single neurons)
o Summed potentials produced by dipoles
 Use for: Dx, classification, treatment decisions

EEG & Epilepsy

In individuals with known epilepsy:
 50% positive after one awake EEG (80% to 85% if sleep is included)
o 0.4-2% of adults without epilepsy have epileptiform activity on EEG
 Sleep deprivation may increase EEG yield
 A normal EEG does not rule out epilepsy (35% have normal EEG inter-ictally)

Other Imaging

CT good for emergencies, hemorrhages, skull fractures, generally not appropriate for elective evaluation
MRI imaging of choice for epilepsy
MRS can reveal cell loss (NAA/Cr)
PET Metabolism: interictal demonstrates areas of hypometabolism; specific ligands
SPECT Blood flow (interictal unreliable; ictal can show focal increases)

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 Treatment of Epilepsy
 Antiepileptic drugs (mostly don’t affect natural history)  Ketogenic diet (esp. childnre)
 Seizure surgery  Neurostimulation

Pharmacotherapy
Goals of Pharmacotherapy
 Control seizures, ↓ severity of acute / chronic side effects
 Maintain / restore psychosocial, behavior, cognitive, vocational functioning

Antiepileptics: a ton of different drugs, but haven’t rendered a lot of people seizure-free
 Pt who’s failed 3 drugs at good doses & still having seizures, < 5% chance of having a different drug work!
 All of the drugs active against partial seizures, only a few for primary generalized seizures
 Certain syndromes are more refractory to drugs (e.g. complex partial: very common & refractory)

Surgery
 Temporal lobectomy  Hemispherectomy
 Focal resections  Corpus callosotomy

 If focal seizures: go focal and remove areas of brain that are dispensable (yes, they do exist)
 Digitized EEG, imaging really helpful in surgical treatment (ID areas of cortical dysplasia)

Contraindications
 Bilateral or multiple seizure foci  Nonlocalizable seizures
 Nonlateralizable seizures  Seizures located in eloquent cortex (motor / speech, etc)

Decision for surgical evaluation

 AED failure (antieleptic drugs) – 2 or 3 tried, tolerated, failed
 Seizures are disabling (severity, frequency interfere with quality of life)
 Surgery can cause: developmental regression (in children), cognitive decline (all ages)
 About 70% seizure free at 12 mo (vs. ~8% for medical treatment)

Hemispherectomy: mostly in kids who had insult when young

 Motor / language has moved to other side; can take out hemisphere & be OK

Anterior temporal lobectomy: see pic

 Really no deficits except minor visual loss if you cut Meyer’s loop

Other treatments
Vagus nerve stimulator: pacemaker-like pulse generator
 Idea: alter background activity
 ↓ seizures (30-50% cut # seizures in half)
 No drug related side-effects but usually doesn’t make pts seizure-free (not replacement for surgery)

Other investigational tools too

 Implantable RNS: record seizures, look at EEGs, stimulate after detecting seizures: But still doesn’t make pts seizure-free

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 TNDs, TIAs, & Neuro-electrical Auras:
Pathogenesis of Episodic Neurologic Symptoms

Transient Neurologic Deficits

Categories
Mechanical Ischemic Neuro-electrical
(usually have history of triggers) (usually spontaneous) (+/- trigger history)
 Fluid dynamic (BPPV, colloid cyst…)  Global (MI / arrhythmia)  Ephaptic (trigeminal neuralgia, MS)
 Compressive (temporary entrapment…)  Focal (TIA)  Channelopathic (seizure, migraine)

Transient neurological symptoms: characteristics

 Seconds to hours (up to a few days)
 Any quality of symptom (brain-region specific)
 Some triggered (e.g. BPPV)
 Most spontaneous TNDs indicate…
Affects: Symptoms
TIA sensory ≈ motor negative >> positive
Seizure motor > sensory positive >> negative
Migraine sensory >> motor positive ≈ negative

SYMPTOMS: “POSITIVE” OR “NEGATIVE”?

Positive (“Too Much”) Negative (“Too Little”) Can’t Tell Misleading
 Limb-shaking  Paralysis/weakness
 Release hallucinations
 Tingling  Numbness  Dizziness/nystagmus
 Hemiballismus
 Flashing lights  Dim/dark vision  Confusion
 Auditory hallucinations  Hearing loss

Mechanical TNDs: BPPV

Benign positional paroxysmal vertigo
Intermittent clinical syndrome: brief, episodic vertigo & mild nausea triggered by specific head movements
 Caused by single, excited semicircular canal (usu. posterior canal) on one side
 Mechanical, due to ‘rocks’ (otolith crystals) in the canal
 Characteristic nystagmus diagnostic

Pathogenesis: Canalolithiasis
1. There are little rocks (crystals) in ear
2. They sometimes get knocked loose and fall into the posterior
semicircular canal (usually), because of its dependent loop
3. When this happens, head movements cause them to slide
around, stimulating that canal, producing intermittent vertigo

Dix-Hallpike Test:
 Turn head 45° to right, bringing R PC into register with mid-sagittal plane
 Lie patient back expeditiously onto bed, making rocks slide in R PC by applying max gravity
 See: mixed vertical-torsional nystagmus
o Upbeat, geotropic (towards the ground)
o Examined only looking straight ahead
o Fatigues quickly (seconds), reverses on sitting up (rocks slide back the other way)

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Epley Canalith Repositioning to fix (see pic)
 Start in Dix-Hallpike position
 Make 270° rotation of head, then body
 Gets rocks out of canal! Immediate fix!

Ischemic TNDs: TIA

 Come on quickly (seconds)
 Technically last <24h, most <1hr
 Different mechanisms  different clinical patterns
Mechanism of TIA Symptom Pattern Why?
Cardiac embolism vary between spells depends on where embolus goes each time
Thrombo/athero-embolism similar between spells throwing emboli, but not exactly the same place each time
Low flow across stenosis usually stereotyped every time you drop pressure, same areas affected
 Risk for stroke is highest in first few days / weeks (5% 1st 2 days, 10% in first 90 days)

Big blood vessel diseases are bad for the brain

 High risk diseases (larger vessel diseases):
o Carotid / vertebral / basilar stenosis or dissection
o Vasculitis (esp. giant-cell arteritis)
 The question isn’t “has the patient has a TIA” – it’s “ are they going to have a stroke?”
o Depends a lot on their vascular state!

Neuro-electrical TNDs: Migraine Aura

Migraine with aura

 “Recurrent disorder manifesting in attacks of:
o reversible focal neurologic symptoms
o that usually develop gradually over 5-20 minutes and last for less than 60 minutes.
o Headache with the features of migraine without aura usually follows the aura symptoms.
o Less commonly, headache lacks migrainous features or is completely absent.”
 May have variation in patient from attack to attack
ORIGINAL CLASSIFICATION
Timeline of Migraine Events
Classic migraine (with visual aura)
Event Duration Common migraine (without aura)
Vulnerability (baseline genetic predisposition) Acephalgic migraine (aura alone)
Trigger (dietary, hormonal, sensory, emotional)
Prodrome (irritability, dysphoria) (hrs-days)
Classic visual aura (fortification spectra) (min-hr)
Hemicranial headache(contra-aura) (hrs-days)
Anorexia, nausea-vomiting (hrs-days)
Photophobia, phonophobia (hrs-days)

Characteristics of visual aura

1. Positive leading edge
a. Geometric (zig-zag, dashes, triangles, stars, fireworks)
b. Often arranged in arc convex peripherally
c. Scintillating/flickering
d. White/gray or light yellow/pink
e. Hemifield start

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 2. Negative wake
a. Relative scotoma/blur
b. Located within borders of positive arc

3. Slow tempo
a. Expands or recedes slowly over minutes
b. Lasts 2-60 minutes, usually 5-30 minutes
c. Also a normal duration for TIAs! (seizures usually shorter: 3-5 min)

Occipital Seizures can have aura too: in comparison to migraine,

 More circular (less “geometric”)
 More vividly colored (less achromatic)
 Shorter (5-30 min)

Non-visual migraine auras

 Sensory auras (common): visual, somatosensory, vestibular, auditory, gustatory/olfactory
 Cognitive auras (uncommon): aphasia, confusion, memory loss
 Motor auras (rare): hemiplegia, quadriplegia

Evolution of auras
Abnormal electrical wave spreading across cortical surface of brain
Visual cortex  travel anteriorly
 Vision  Somatosensory  motor strip  language in frontal lobe)
 Most patients: stop at central sulcus (stop with sensory)
o FHM (see next) – don’t stop!

Often have modality-specific triggers for a given patient

Motor Auras (rare)
 Hemiplegic migraine: familial or sporadic; paraplegic or quadriplegic: “basilar migraine”
 Headache: like other migraines, but auras are prolonged with motor manifestations
 Most have classic visual aura & other auras (hemisensory loss, hemiplegia, aphasia)
o Progression: visual  sensory  motor  cognitive (back to front!)

Familial Hemiplegic Migraine

 Aura wave doesn’t stop at central sulcus! Goes on to motor & cognitive areas
 Channelopathy (Na/K ATpase & v-gated Ca channels)

Channelopathies
Various syndromes: FHM, also deafness, arrhythmia, ataxia, myasthenia, neuropathies
 Unifying theme: episodic neurologic dysfunction on a short time scale
 Some dysfunction is persistent/progressive and interictal, instead of just episodic / ictal with recovery

More common diseases (migraine, seizure) with transient neuro disturbances: may have similar molecular mechanisms?

Pathophysiology of Visual Aura

 Old theory: vasospastic ischemia
 Lashley measured expansion of own aura, mapped to 3 mm / min spread over visual cortex
 Leao noted same rate: excitation/depolarization (on) followed by depression/hyperpolarization (off)
o Contiguous spread (ECF), NO SYNAPTIC TRANSMISSION (NOT SEIZURE)
o Seizure: gap-junctions & synaptic transmission; aura: excitation spreads via ECF
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Neural / Spreading Depression model
1. Cortex excitable and/or irritated (genetic predisposition?)
2. Spreading depression (SD) triggered
3. Depolarizing wave (positive aura: lights)
4. Hyperpolarizing wake (negative aura: scotoma)
5. ↓ metabolic demand, ↓ caliber of vessels (“spasm”)
6. Headache cause (semi-)independent

Region-specific auras
 For instance: is Meniere’s disease region-specific aura in middle ear?
 Variety means migraine vs TIA DDx is tough

Spreading depression model explains:

 Spatial characteristics of aura (crossing vascular boundaries)
 Slow aura evolution, mix of positive and negative Sx; absence of tissue ischemia
 Regional ↓ in cerebral blood flow happen after aura has begun, persist long after it’s gone
 Modality specific triggers
o abnormal ca channels in occipital cortex, stimulate with repetitive flashing lights  set off abnormal wave cycle?
 Interictal hypersensitivity to certain stimuli (strobe, checkerboard)
 Dovetails well with channelopathy theory in FHM

Migraneurs have ↑ excitation

 Think of it as a balance: when “normal” people have ↑ excitation, still fall in “normal range” & no aura
 If migraneur has ↑ excitation (trigger), balance pushed out of normal range  aura

Spreading Depression model & pain (headache)

 Cortical spreading depression 
 lots of inflammatory mediators released 
 set off pain triggers
Details not understood

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DDx: Migraine vs. Seizure
Migraine Seizure
Time course spreads over space in 5-60m (longer is better) Evolves quickly (seconds to a few minutes)
Involves Sensory only, not motor Motor involvement
Symptoms Episodic head/neck pain < 72hrs Loss of consciousness
Aura characteristics Geometric / bland Round / bright colors
Migraine and sensory partial seizures can look very similar; seizures are usually shorter

DDx: Migraine vs. TIA

Migraine TIA
Time course spreads over space in 5-60m (longer is better) Starts “all at once” usually
Involves Sensory only, not motor Motor involvement
Aura characteristics Mixed positive & negative Negative only
Symptoms Episodic head/neck pain < 72hrs Persistent head/neck pain > 72 hrs
Migraine can mimic TIA in ALL RESPECTS!

Take-Home Points (know these)

TNDs
1. If TNDs are triggered, trigger usually indicates pathophysiology (e.g., BPPV)
2. Most “spontaneous” TNDs indicate…
TIA sensory ≈ motor negative >> positive
Seizure motor > sensory positive >> negative
Migraine sensory >> motor positive ≈ negative
Migraine
1. Migraine is a syndrome with episodic…
(1) pain (usually in the head, face, or neck), (3) polysensory hypersensitivity, and, sometimes
(2) autonomic changes (gastrointestinal > cranial), (4) neurologic dysfunction (mixed pos. & neg.)

2. Migraine with aura is a polygenetic, (presumed) channelopathic disorder of neuronal excitability

3. Predisposition (irritability) is always present, but varies with triggers (endogenous/environmental)

TIA
1. TIAs generally come on quickly (seconds)
2. TIAs technically last < 24hrs; most < 1hr
3. Different mechanisms = different clinical patterns
Mechanism of TIA Symptom Pattern Why?
Cardiac embolism vary between spells depends on where embolus goes each time
Thrombo/athero-embolism similar between spells throwing emboli, but not exactly the same place each time
Low flow across stenosis usually stereotyped every time you drop pressure, same areas affected

4. Risk for stroke is highest within days-wks

5. Big blood vessel diseases are bad for the brain

Aura
Neural hypothesis – hyperexcitable cerebral cortex & electrical spreading depression (excite/inhibit balance)

Migraine aura vs. TIA:

 Mixed positive & negative usually = migraine
 SPREAD OVER MINUTES (5-30) = migraine
o true TIAs rarely cause spreading symptoms
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 Developmental Disorders in Childhood
Developmental disorders can be:
 Structural (alterations in development  alterations in function
 Functional (alterations  MR, CP, autism, other developmental delays)

Stages of Nervous System Development

1. Induction
2. Neurulation
3. Cell Proliferation and Migration
4. Axonal Projection
5. Synaptogenesis
6. Myelination

Induction: bilaminar embryo  trilaminar embryo

Neurulation: Neural fold  groove  tube
 At about 25 days, you have a long tube with an
anterior (rostral) neuropore & caudal neuropore
 Close off around day 25-27

Neurulation: Neural Tube Defects

• Neural tube fails to close (e.g. dorsally)
• Closure at regionally distinct sites
• Overlying skeleton defective
• Failure to close leads to chemical and mechanical trauma
• Range of defects, 1/1000 pregnancies affected

Anencephaly:
failure of neural tube to close anteriorly
 Brain, ectoderm, skeletal defects
 Still see facial structure
 Incompatible with life

Spina bifida
 Posterior neural tube doesn’t close
 Range of defects
o Myelomeningocele: have neural elements inside
o Meningocele: just have meninges inside
o Spina bifida oculta: defect in skeletal elements (mesoderm) but not neural axis itself
Etiology of Neural Tube Defects
 Genetic (animal models, syndromic/chromosomal)
 Environmental (teratogens: folate is important, ↑ in insulin-dependent diabetic mothers, exposure to valproate)
 Most cases: no clear cause or FHx

Folate: involved in synthesis of nucleotides (DNA/RNA/etc, cycles through methionine, homocystiene, etc)
 ↓ incidence of NTD (anencephaly & spina bifida) with ↑ folate supplementation
 USPHS: 400 mcg folic acid daily for all women capable of becoming pregnant
o Rx, fortification of foods  ↓ spina bifida rates

Prenatal detection of NTD

 Alpha fetoprotein (AFP) – made by fetal liver, leeches out into amniotic fluid / maternal serum if fetus disrupted
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 o can detect as maternal serum alpha fetoprotein (AFP) or amniocentesis AFP
 Ultrasound useful too for detection of defects

Neurologic impairments with NTD

Like a spinal cord lesion at level of impairment
 Motor weak, no sensation below level
 Bowel / bladder impaired (sacral involvement)

Hydrocephalus common in SB pts

 2° to Chiari 2 malformations; need ventricular shunting
 Pic: note cerebellum / brainstem tugged down (due to cord
tethering)  obstructive hydrocephalus

Other impairments in Spina Bifida

 Cognitive impairments (in some: from hydrocephalus)
 Orthopedic: scoliosis, clubfeet (not moving in utero)
 Urologic: infections, stones, renal failure (bladder involvement)
 Pressure ulcers, osteomyelitis (↓ sensation & mobility)

Other NTD:
 Lipoma: Fatty tumor pulls tube down
 Tethering of cord
 Hairy patch (ectodermal malformation

Normally: as you grow, nerve fibers grow downwards

In NTD pts: scarring tethers the cord
 as the patient grows, it gets stretched (later onset problems)

Encephalocele
 Most are occipital, maybe a disorder of anterior neural tube closure
o Can be more subtle; can look like nasal polyps
 Associated with: microcephaly, MR, visual problems, hydrocephalus

Segmentation / Diverticulation of the Neural Tube

 Straw, top closed off, start doing some differential growing
o Outpatching is secondary to growing, folding, bending

 Prosencephalon (forebrain)  telencephalon (cerebral hemispheres)

 Mesencephalon  midbrain
 Rhombencephalon  metencephalon & myelencephalon

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Holoprosencephaly:
 incomplete midline cleavage of developing forebrain
(prosencephalon)

 Various degrees; Facial & endocrine abnormalities

o Single eye (cyclopsia), single central incisor, etc.
o Various genetic abnormalities (SHH, etc)

 End up with one central ventricle

Neuronal proliferation
Microcephaly vera
Disorder of proliferation: failure of neurons to proliferate
 Microcephaly at birth
o regular normal development
o variable mental retardation
 Sloping forehead, prominence of ears

Neuronal migration
Lissencephaly
“ smooth brain” or agyria-pachygyria

Absence of gyration
 due to failure of abnormal neuronal migration

Various types: e.g. Miller-Dieker syndrome (pics

 Random trivia: olive doesn’t migrate in MD-syndrome

Doublecortin

 Males have agyria

 Females have band of heterotopia
o X-inactivation: some neurons get where they’re going, some don’t

Pediatric Neurodevelopmental Disorders: Cerebal Palsy

Not discussed here: mental retardation (3% prevalence), autism, epilepsy syndromes

Cerebral palsy
Abnormal control of movement & posture (MOTOR DISORDER) – “CP” doesn’t imply causation
 Voluntary movements that are normally complex, coordinated, varied  limited, stereotypic, uncoordinated
 Non-progressive abnormality of the developing brain

Etiology / Epidemiology:
 1.5-2.5/1000 live births (↑ in premature, low birth weight, twins)
 Prenatal / postnatal events often involved
 Can co-exist with other brain injury manifestations (MR, seizures, autism, vision, hearing)

Spectrum of motor dysfunction

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  Classified by type, distribution of motor abnormality (rarely pure presentation)
o Spastic: 50% (hemiplegic, diplegic, quadriplegic)
o Dyskinetic: 20% (extrapyramidal, choreathetoid)
o Ataxic (10%) or mixed (20%)

Pathogenesis of CP: many possibilities (two given here)

Periventricular leukomalacia (top pic)

 Damage to tracts that will become myelinated (e.g. internal capsule)
 Result: spastic diplegia
 Various mechanisms can be responsible

Injury to Basal Ganglia (bottom pic)

 Hypoxic/ischemic encephalopathy
 Infection
 kernicterus (hyperbilirubinemia in the newborn)
 Results in extra movements!

Degenerative diseases
 Heterogeneous group of disorders characterized by loss of previously acquired skills
 Contrast to the static encephalopathies (MR, CP, autism)

A lot of different kinds: lysosomal storage diseases, mitochondrial disease, peroxisomal disorders, copper metabolism,
amino/organic acids, vascular disease / stroke syndrome, others. Focusing on lysosomal storage diseases here

Difficult to diagnose
 Is this progressive or static (esp. early)?  Classified by biochemical abnormality
 “Endless” list of disorders  Findings don’t appear all at once: evolve

Classification of degenerative diseases

Gray matter (neurons) White matter (myelin & fibers)
(compare to AD in adults) (compare to MS in adults)
 ↓ psychomotor development  Lack of coordination  spasticity (Babinski,
 Intellectual deterioration (dementia in peds!) hyperreflexive)
 Seizures  Peripheral neuropathy
 Retinal involvement  Optic atrophy (± cortical blindness)
 Ataxia  Ataxia

Tay-Sachs: a prototypical gray matter disorder

Normal at birth
Early course:
 Exaggerated startle to sounds (≈ 6mo)  deterioration in motor abilities
 Axial hypotonia (shoulder girdle weak) & spasticity
 Seizures,
 Blind with pendular nystagmus; cherry red spot over macula
Late: megalencephaly

Populations: ↑ in Ashkenazi Jews, French Canadians

Cherry red spot:

 Cells packed full of storage protein, die; remaining macula  red spot
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Molecular abnormalities:
 Accumulation of GM2 gangliosides in neurons
o “trash not getting taken out”
 Hydrolysis of gangliosides: need
o Hexosaminidases (A & B)
o GM2 activator protein needed

Clinical management:
 Carrier detection & prenatal diagnosis in at-risk populations
 Symptomatic treatment (pharm Rx in development; nothing good available now)

Metachromic Leukodystrophy (MLD): a white matter disorder

 Progressive demyelinating disease

 Defect in arylsulfatase A
 Variable presentations (late infantile, childhood, adult
o Spasticity, ataxia, vision loss, areflexia
 Tons of other leukodystrophies too (krabbe, ALD, Canavan, Alexander)
 No screening (no specific populations at risk)

Legs held in extension, arms flexed (stronger muscles winning)

MRI: hyperintensity in myelinated areas (injured)

Treatment:
 Bone marrow transplant
 Other stem cells? Gene therapy?
 Symptomatic therapy

Exam Questions: KNOW THESE

Match the developmental malformation and its stage of development.
Myelomeningocele (A) A. Neural tube closure
Holoprosencephaly (B) B. Segmentation/Diverticulation
Anencephaly (A) C. Synaptogenesis
Lissencephaly (D) D. Neuronal migration

A patient with an open posterior lumbosacral meningomyelocele would be expected to have all but one of the following:
A. Chiari malformation which resulted in hydrocephalus
B. Bowel and bladder dysfunction
C. Normal amniotic fluid alpha fetoprotein
D. Paralysis of leg muscles

Lysosomal degenerative diseases of the nervous system may be divided into those affecting gray matter and those affecting white
matter primarily. Choose the best answer for each of the early clinical manifestations listed below:

A – Gray matter, B – White matter, C – Both

 Seizures (A – gray)
 Retinal involvement with “cherry red spot” (A – gray)
 Affects myelinated fibers(B – white)
 Spasticity (B - white)

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 Pharmacology: Neuro
Review of Neurotransmitter Disorders in Neurology ............................................................................................................. 2
Pathophysiology and Treatment of Parkinson’s Disease ........................................................................................................ 6
Anticonvulsant Drugs ............................................................................................................................................................ 11
General Anesthetics .............................................................................................................................................................. 16

1
 Review of Neurotransmitter Disorders in Neurology
Glutamate: major excitatory neurotransmitter
 > 70% synapses in sensory, motor, memory circuits
o most abundant neurotransmitter

 Flavor enhancer in food (MSG), but BBB blocks entry to brain

Glutamatergic synapse:

 Glu produced from Gln in pre-synaptic neuron, packaged into

vesicles  Ca-dep release into synaptic gap
 PUMPS: Reuptake into astrocytes via EAAT (excitatory AA
transporter); transport back to neuron as Gln
o Require energy (Na/K ATPase)
o These pumps responsible for most energy / glucose
consumption when brain is activated
o PET: shows ↑ glc consumption (↑ density of synapses &
activity: used to monitor dementia, etc.)

Post-Synaptic Glutamate receptors:

 NMDA: Ca , Na enter, ↑ nNOS  NO release
+2 +

o + feedback: strengthens synapses  memory

 AMPA: Ca+2 (& Na+) enter, intracellular activation (fire!)
 Metabotropic: linked to 2nd messengers  metabolic changes

Receptors: clustered in post-synaptic density

 Specificity of glutamate at synapse: which receptors are present post-synaptically?

What does glutamate do?

• mediates synaptic activity in the auditory and visual circuits (listen to lecture and see the slides)
• activates the circuits that encode long term memories (remember what was talked about)

GABA: major inhibitory neurotransmitter

 GABA = γ-aminobutyric acid
 synthesized from glutamate (via GAD: glutamate decarboxylase)

GABA-ergic synapse
 Pumps remove GABA (into glia here too like glu) to inactivate signal
 Complicated recycling to form glutamate
 End result: ↑ Cl- flow  hyperpolarization (inhibitory)

GABA receptor: different subunits = different affinities

Benzos: act on GABA / benzodiazepine receptor

2
 Glutamate / GABA balance

Glutamate is excitatory; GABA is inhibitory

 Net effect depends on balance between glu / GABA effects

Architecture
 Glutamate synapses: more numerous (3:1)
o but synapses farther away from soma (dendritic spine) – less control!
 GABA synapses: fewer, but more control (on dendrite necks) – closer!

Regulation:
 Can traffic receptors in/out of post-synaptic density to modulate function
o ↑ AMPA: ↑ excitability; ↓ AMPA (sequester): ↓ strength of synapse

Seizures: abnormal sustained repetitive depolarization of neurons in brain

 accompanied by change in motor activity, sensation, attention, thought processes
 From imbalance between glu & GABA (↓ inhibition, ↑ excitation)
 Epilepsy: repeated seizures

Memory formation
 Requires activation of excitatory synapses in HIPPOCAMPUS(Gr. “sea horse”)

LTP: Long-term potentiation

 physiologic correlate at synaptic level of
memory formation in hippocampus

 Activity-dependent plasticity: easier

/ potentiated excitatory firing after
intense stimulation (high-frequency
firing)

 ↑ AMPA  “potentiated” (memory

is enhancement of these connections)

Brain Development & Plasticity

Glu / GABA balance regulates pruning of synapses in adolescent cerebral cortex
 Glu: Reduces excess synapses, stabilizes remaining synapses

 Co-incident pre- and post-synaptic firing preserves synaptic connections

o If both fire together: trophic factors released  synapse preserved!
o “neurons that fire together, wire together”

Activity needed for neurons to remain alive & healthy too!

 also needed in recovery of brain after injury (esp. children)

Plasticity
 Changes in neuronal activity  rearrangement of neuronal circuits
 Common in developing brain
o e.g. learn to play strings in childhood: practice with left fingers  expand area of R. cortex dedicated to that task
o e.g. surgically remove cortex for intractable childhood epilepsy: can often regain speech up to 7-14yo
o Based on surplus of synapses in childhood

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Glutamate-Mediated Excitotoxicity (the “dark side” of plasticity)
 like a “power surge” damages computers ↑ excitatory pathways =
↑ vulnerability to excitotoxicity
Can happen in: stroke, hypoxia-ischemia, hypoglycemia, trauma, seizures ● hippocampus ● cerebral cortex
● thalamus ● cerebellum
Basic mechanism:↓ delivery of glucose / oxygen
 Glu can accumulate in synapses (pumps don’t work without glucose)
 Lack of oxygen  mitochondria don’t work  membrane depolarized
o Mg usually blocks NMDA receptor
o when membrane depolarized, Mg block removed (Ca floods in)

End result: Glu receptors open excessively (↑↑ Ca+ entry postsynaptically: toxic)

Hippocampus especially vulnerable (seizures, ischemia)  amnesia (memory loss!)

Glutamate, GABA and neurologic diseases: Summary

• Glu /GABA used in > 85% of brain synapess
• Glutamate is essential for normal brain function, learning, memory, plasticity
• Hypoxia and hypoglycemia lead to a build up of synaptic glutamate, causing excitotoxic damage
• High glutamate can cause damage in degenerative disorders, e.g. motor neuron disease

Topiramate: blocks AMPA glutamate receptors (prevent migraine; treat epilepsy)

Serotonin
Serotonin fibers: come from raphe nuclei in brainstem
 midbrain  diffuse projection into cerebral cortex

Serotonin (5-HT): synthesized from tryptophan

 AADC synthesizes; VMAT packages into vesicles
 Vesicle release like glutamate
 5-HT transporter for re-uptake (SSRIs block)

Involved in headache (esp. migraine) & depression

 SSRIs: selective serotonin re-uptake inhibitors
o Used to treat depression
 “Triptan” drugs: serotonin agonists
o Act post-synaptically
o used to prevent / abort migraine headaches
Dopamine
Dopamine: Catecholamine neurotransmitter, esp. in basal ganglia (caudate, putamen focused on movement)

Synthesis: Tyrosine hydroxylase is

rate-limiting step

Pathways:
 Nigrostriatal (movement)
 Mesolimbic (reward,
reinforcement)

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Role of dopamine: keeps us moving & keeps us motivated
 Mesolimbic dopamine neurons mediate reward, attention
o Humor, money activate
o COCAINE: blocks re-uptake pumps (↑ synaptic *dopamine+  euphoria); strongly reinforced (addictive)
 Striatonigral pathway faciliates movement

Parkinson’s Disease Schizophrenia

Type of disorder Movement Neuropsychiatric
Dopamine Degeneration of dopamine neurons Overactivity of dopamine neurons
Mesolimbic dopamine pathway
Nigrostriatal dopamine pathway
Pathway Reward, reinforcement: ventral tegmental area  limbic
Movement: Substantia nigra  basal
affected system (nucleus accumbens, amygdala,hippocampus, medial
ganglia  thalamus  cortex
prefrontal ctx)
• Rhythmic tremor
• Muscle rigidity • Hallucinations, delusions
• Stooped posture • Disorganized thought / speech
Symptoms • Difficulty rising and initiating movement • Impaired social cognition
• Micrographia • Avolition / apathy
• Depression (↓ dopamine)
Treatment L-DOPA (↑ dopamine) Antipsychotics (block dopamine receptors)
Psychiatric – gambling, hypersexuality Parkinsonian sx (block dopamine signaling in basal
Rx Side effects
rarely (reward circuitry) ganglia too; go away if stop tx)

Parkinson’s disease: see pic (degeneration of dopamine neurons in substantia nigra)

Things that look like PD:
 Rigidity caused by psychiatric drugs that block dopamine receptors (neuroleptics)
 Degenerative disorders or repeated head trauma (e.g. boxers)
 Inherited disorders of dopamine metabolism

Acetylcholine
ACh neurons: project from basal forebrain to cerebral cortex
 Released into synapse, broken down by acetylcholinesterase
o Choline from AChE taken back up into presynaptic terminal
o Note contrast to others: not pumped back in

Involved in Alzheimer’s disease (Ach neurons degenerate early in Alz Dz)

 ↓ Ach  memory loss, behavioral changes

Drugs for AD:

 AChEi (inhibit acetylcholinesterase  ↑ Ach  ↑ memory, behavior)
 Memantine: block NMDA receptors
(very active in AD: NMDA implicated in overexcitation / excitotoxicity)

Summary (from slides)

Glutamate: the major excitatory neurotransmitter in the brain

 Glutamate excitotoxicity: diverse types of brain damage (stroke and other disorders)
GABA: is the major inhibitory neurotransmitter in the brain
Serotonin is involved in migraine headaches and depression
Degeneration of dopamine neurons causes Parkinson’s disease
Alzheimer’s dementia is associated with loss of acetylcholine neurons

5
 Pathophysiology and Treatment of Parkinson’s Disease
Basal Ganglia Review
Basal ganglia: group of subcortical nuclei interconnected
with cerebral cortex, thalamus
 Caudate, putamen, globus paladus, subthalamic nucleus,
substantia nigra

Two main pathways from striatum (caudate, putamen)

Direct pathway ↑ thalamo-cortical activity “gas pedal”
Indirect pathway ↓ thalamo-cortical activity “brake pedal”

Nigro-striatal dopamine pathway

 Modulates basal ganglia output
 Connected heavily to striatum
 Net effect of DA: release brakes & step on gas
o (↑ thalamo-cortical activity)
 If ↓ DA  ↓ thalamo-cortical activity
o (not enough gas, not letting go of brakes)
o Functionally: slowed / reduced movement

Parkinson Disease
Parkinson disease is a dopamine deficiency disorder
 Loss of dopaminergic innervations of caudate / putamen  cortical regions
o Nigrostriatal neurons knocked out
o Pallor in substantia nigra, Lewy bodies Clinical features (4 classic)
 Pharm strategy: replace dopamine Typically asymmetric and responsive to L-DOPA
1. Rest tremor
During life: Dx based on examination 2. Bradykinesia
 Can also visualize loss, not equal on both sides 3. Rigidity
 Loss greater in putamen than caudate 4. Postural Instability

Not just dopamine: various neural systems involved at various levels of neuroaxis (involves other nuclei)

Development of disability: Need to get down to 80-90% loss of brain DA!

Dopamine
 Tyrosine hydroxylase is rate limiting step of synthesis

Problems with using dopamine itself

1. Unstable molecule; degrades on exposure to O 2 in air, body fluids
2. Degraded rapidly by MAO & COMT in liver, other tissues after oral
administration
3. Doesn’t cross BBB
4. Causes extreme nausea

Major strategies of pharm therapy

 L-dopa
 MAO-B inhibitors
 Direct DA receptor agonists
 COMT inhibitors
 Anticholinergics

6
L-DOPA
 Remember DA can’t cross BBB; L-DOPA can cross BBB

AADC converts L-DOPA to DA to act in nervous system

 AADC is ubiquitous enzyme, so L-DOPA gets converted all over the place
(not just at target): less than 2% L-DOPA reaches target

 Strategy: inhibit peripheral AADC  ↑ L-DOPA going to brain

Mechanism of Action: Dopamine receptor agonist (via DA, active metabolite)

Effects: L-DOPA converted to DA via AADC (both peripheral and in nervous tissue); augments DA signalling (↓ in PD)

Adminstration:
 Short half life (1-2 hrs); must give several times throughout day
 can result in large swings in serum [L-DOPA]
L-DOPA
Metabolism: Can cross BBB (DA can't).
 Less than 2% reaches CNS (rapidly metabolized by AADC in liver, other tissues).

Toxicity: big swings are bad: involuntary movements (↑ peak doses); recurrence of symptoms (↓ trough doses).
 chronic spiking blood levels may play role in development of delayed dyskinesias.
 Acute side effects: nausea, orthostatic hypotension, hallucinations
 Chronic side effects (50% of pts after 5 yrs): wearing-off, on-off phenomenon, disabling dyskinesias

Mechanism of Action: L-DOPA with carbidopa (an AADC inhibitor)

Effects: L-DOPA as above; Carbidopa blocks AADC peripherally, increasing delivery to CNS.
 Effectively reduces rest tremor, rigidity and bradykinesia
 Less effective in reversing postural instability

Adminstration: Short half life (1-2 hrs); must give several times throughout day
sinemet  can result in large swings in serum [L-DOPA].
(L-DOPA + carbidopa)  Controlled-release preparations help, but:
o slower onset of action, reduced peak blood levels, and longer duration of action

Metabolism: Can cross BBB (DA can't). Much still metabolized in liver (COMT)

Toxicity: big swings are bad: involuntary movements (excessive peak doses); recurrence of symptoms
(low trough doses). chronic spiking blood levels may play role in development of delayed dyskinesias

Side effects of L-DOPA therapy (overview)

 Acute side effects: nausea (all), orthostatic hypotension, visual hallucinations
o Taper dose up to help avoid
 Chronic side effects:
o Dyskinesia (Abnormal involuntary movements)
o Response fluctuations: “end of dose deterioration” or “freezing” – suddenly can’t move (weird!)
o Psychiatric complications develop with time (confusion, visual hallucinations)

Controversy: are these effects from medication or from disease progression?

 Probably disease progression, although there is concern about “pulsatile” L-DOPA treatment

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MAO-B inhibitors
E.g. Deprenyl (selegiline)

Background story: young heroin users with advanced Parkinsonism in California

 Were trying to synthesize MPPP (synthetic heroin analog), got MPTP instead
 MAO-B converts MPTP  active toxin (MPP+)  rapid, irreversible parkinsonism
o Blocking MAO-B blocks MPTP  MPP+
o Maybe there’s a natural equivalent “toxin” that MAO-B converts? Try blocking MAO-B?

These are supposedly MAO-B selective, but if you ↑↑ dose, you get MAO-A and MAO-B inhibition (side effects!)

Mechanism of Action: MAO-inhibitor, for Parkinson Disease

Effects: Probably related to irreversible MAO inhibition (increases DA by decreasing breakdown) -
symptomatic, not neuroprotective

Indications: Parkinson Disease (complements other anti-PD meds)

Adminstration: twice daily, generic available
selegiline (edepryl)
Metabolism: Complex pharmacokinetics:
 L-amphetamine, L-methamphetamine are metabolites
 parent compound has MAO-B inhibiting activity too
 need to follow MAO-B inhibition as kinetic parameter (not serum levels of drug / dose)
Toxicity: well tolerated; rare weight loss
Other: shown to prolong time until L-DOPA is needed.

MAO-B inhibitor: like selegiline, but once-daily (longer duration of action)

rasagaline (Azilect)
No L-amphetamine / L-methamphetamine metabolites (probably not clinically relevant)

COMT inhibitors
 Inhibit COMT (reversible, selective); ↓ conversion of dopamine  3MT
o Don’t cross BBB; increases peripheral L-DOPA concentration
o Helps stabilize L-dopa concentrations over time
 Like L-DOPA, need to give 3-4x/day (combination med with sinemet)
o Short half life (0.8-1hr)

Mechanism of Action: COMT inhibitor.

Effects: helps block hepatic metabolism of L-DOPA (increases half-life in brain, L-DOPA to brain)
Entacapone
Administration: with sinemet (L-DOPA + carbidopa, an AADC inhibitor). Need to give 3-4x daily (like L-DOPA
(Comtan)
Metabolism: don't cross BBB: increase peripheral L-DOPA, helps stabilize concentrations over time
Toxicity: generally well tolerated with occasional GI complaints, can cause urine to turn reddish brown

Tolcapone: linked to fatal liver failure, best avoided

8
Dopamine Receptor Agonists
 Direct stimulation of DA receptors
 Side effects: nausea, somnolence, hallucinations, orthostatic hypertension
o Generally well tolerated, either alone or in combination

Bromocriptine Parlodel
Older, Ergot-like; more side effects
Pergolide Permax
Pramipexole Mirapex
Newer, Non-ergot-derived; less side effects
Ropinirole Requip

Mechanism of Action:Non-ergot DA receptor agonists (directly stimulate DA receptors).

Adminstration: multiple daily doses (like L-DOPA)

pramipexole (Mirapex) Toxicity: Generally well tolerated (alone / in combo).

 Nausea, somnolence, hallucinations, orthostatic hypertension.
ropinirole (Requip)  Can see mental status changes in elderly, daytime sleepiness
 compulsive gambling (unusual side effect)

Other: Above info for pramipexole; riponerole is very similar

Other DA receptor agonist options?

Dopamine Agonist Availability? Mode of Delivery L-DOPA Dopamine Agonists
Cabergoline Europe Once daily pill Efficacy excellent good
Apomorphine Apokyn Intramuscular injection nausea
Rotigotine Neupro Skin patch Short-term somnolence
side effects hypotension
hallucinations
dyskinesias
DA agonists may slow DAT loss? Long-term
on-off phenomena
dyskinesias
 Not great results (not halting disease progress) side effects
accelerated disease?
on-off phenomena

Anti-cholinergics
 Theory: some kind of ACh / dopamine balance that you can restore? ↓ DA so ↓ Ach? Nebulous idea.

Mechanism of Action: Anti-cholinergic agents (anti-PD)

Effects: Restores "Ach/DA balance" in theory (less DA in PD, so cut down on Ach)
benztropine (Cogentin)
Indications: Parkinson Disease, especially in younger patients with tremor as predominant complaint.
 Generally contraindicated in elderly (cognitive problems)
trihexyphenidyl (Artane)
Toxicity: impaired cognition, constipation, urinary retention, dry mouth
Other: Use in PD largely supplanted by MAO-i and direct DA agonists

Amantadine
Mechanism of Action: anti-Parkinson Disease agent, multiple effects (poorly understood)
amantadine Effects: weak anti-cholinergic, weak DA-releaser, weak glutamate antagonist
(Symmetrel) Toxicity: hallucinations, insomnia
 effects common to other anticholinergics too: impaired cognition, dry mouth, constipation, urinary retention

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 Treatment of Parkinson Disease: General Points
No set “best treatment” – begin with L-DOPA, MAO-B inhibitor, whatever & start combining
 Use combinations of drugs!
 Want to raise dopamine (replace, inhibit metabolism, etc)

Neurosurgery (DBS)
 Reduce abnormally increased activity of GPi and STN
 Surgical ablation (pallidotomy) or inactivation by high frequency electrical stimulation (deep brain stimulation)
 Not initial therapy (1% intraoperative risk of stroke): use for advanced PD

Good surgery candidate Poor surgery candidate

Good response to L-DOPA Poor response to L-DOPA
Prominent tremor Prominent gait and balance trouble
Prominent dyskinesias Prominent dysphagia
Significant on-off swings Co-morbid dementia
Few other co-morbidities Co-morbid dysphagia
Refractory psychiatric problems

Take home message:

 We don’t have any good medications to slow the disease progression yet!
 These are symptomatic therapies!

Future: better DA therapies, address non-DA deficits (NE, 5-HT, etc), refine DBS, stem cells, halt dz process!, genetics?

10
 Anticonvulsant Drugs
Anticonvulsant drugs: reduce intermittent, uncontrolled electrical discharges in the brain associated with seizures
 Reduce high frequency sustained repetitive activity, but not normal activity needed for cognition
 In contrast, anesthetics suppress both normal physiologic activity and seizure activity

Seizures: sustained repetitive firing of neurons

 “Organizes” activity: entire electrical activity taken over by signal (often from temporal area)
 Neuronal level: sustained repetitive neuronal depolarization
o During seizures: Na, Ca enter (glutamate)
o During recovery: Cl enters (GABA)
 Seizures: TOO MUCH GLUTAMATE and/or NOT ENOUGH GABA

Activity of voltage-gated sodium channels allows for this repetitive firing

Activity-dependent actions of anticonvulsants

 Proteins for Na, Ca channels assume different conformations as they open & close
 Anticonvulsants: bind open channels preferentially (selective for areas of ↑ activity like seizure)
o Targeting epileptic neurons (activity-dependent): goes where it’s needed!

Mechanisms of Action
• Directly block rapidly opening/closing voltage
dependent sodium channels to inhibit
sustained repetitive firing
• Directly block voltage dependent calcium channels
• Increase activity of GABA synapses
• Reduce activity of glutamate synapses
• Bind to synaptic vesicles

Na-channel blockers
directly block rapidly firing Na channels to inhibit sustained, repetitive firing
• Phenytoin (diphenylhydantoin)
• Carbamazepine
• Lamotrigine
• Valproic Acid (dipropylacetic acid)

Mechanism of Action: Anticonvulsant, blocks rapidly opening Na channels

Effects: bind open channels selectively, limiting sustained repetitive transmission

Indications: use for common seizure types

(generalized / focal motor seizures, partial seizures with behavioral manifestations)

Metabolism: Saturable hepatic metabolism

(low levels = 1st order, high levels = zero order like alcohol: saturate enzymes - can have sudden unexpected toxicity)
phenytoin
Toxicity:
 High levels: ataxia, nystagmus, also gum hypertrophy, increased hair
 Bradycardia & cardiac arrhythmias if administration too rapid
 Purple glove syndrome with IV phenytoin (skin / venous damage; can use pro-drug "Fosphenytoin" - water
soluble with extra PO4 group - to avoid)
 Induces metabolism of carmazepine
 Teratogen
Other: less sedating than barbituates

11
 Mechanism of Action: Anticonvulsant, blocks rapidly opening Na channels
Effects: bind open channels selectively, limiting sustained repetitive transmission

Indications: use for common seizure types (generalized / focal motor seizures, partial seizures with behavioral
manifestations). One of most prescribed anticonvulsants

carbamazepine Metabolism:
 Hepatic metabolism to epoxide metabolite
 Induces own metabolism

Toxicity: Few cognitive side effects.

 Don't use in absence seizures (can make them WORSE!).
 Teratogen

Mechanism of Action: Anticonvulsant, blocks Na channels associated with pre-synaptic glutamate release
Effects: limits sustained repetitive transmission

Indications:
 common seizure types (generalized / focal motor seizures, partial seizures with behavioral manifestations).
 Also used for less common seizure types e.g. generalized absence seizures
lamotrigine
Metabolism:
 Hepatic metabolism via glucuronidation
 half life prolonged by other drugs (e.g. valproic acid).

Toxicity: Severe skin rashes in 1% children, 0.3% adults. Teratogen

Mechanism of Action: Anticonvulsant

 blocks rapidly opening Na channels
 enhances GABA / BZ receptors
 may have other mechanisms?

Effects: bind open channels selectively, limiting sustained repetitive transmission; other mechanisms too?
valproic acid
Indications: useful for all seizure types
Metabolism: Hepatic metabolism (as fatty acid)

Toxicity:
 Fatal hepatic necrosis in children < 2 yo, especially if on second anticonvulsant (incidence 2/1000).
 Slows metabolism of phenobarbital, lamotrigine.
 Teratogen (strongly associated with spina bifida, can reduce risk with folic acid)

Ca-channel blockers
directly block voltage-dependent Ca channels

Mechanism of Action: anticonvulsant

 blocks voltage-dependent Ca channels

Effects: Decreases excitatory signaling (blocks Ca reuptake into

ethosuxamide presynaptic neuron and Ca influx into post-synaptic neuron)

Indications: Generalized absence seizures

Toxicity: Teratogen
Glutamate & GABA agents
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 • Normally glutamate and GABA work together: glutamate depolarizes neurons and GABA comes along a little
later to repolarize them
• In a seizure, too much glutamate depolarization with too little GABA repolarization
• GABA is synthesized from glutamate (cycling!)

GABA Agents (want to ↑ activity)

Most common way: activate the GABA receptor

 GABA drives Cl into neurons, hyperpolarizing & inhibiting
Can also: block GABA transaminase, block re-uptake of GABA

Enhance GABA Receptor

 Barbiturates: Phenobarbital, Pentobarbital, Valproic Acid
 Benzodiazepines: Lorazepam, Diazepam
Block Re-uptake of GABA
 Tiagabine
Block Metabolism of GABA
 Vigabatrine

Mechanism of Action: barbituate anticonvulsants

Effects: Enhance GABA / benzodiazepine receptor function, increasing chloride influx and
causing hyperpolarization / inhibition of synaptic transmission

Indications: powerful, use for common seizure types (generalized / focal motor seizures, partial seizures with
phenobarbital behavioral manifestations)
primidone
Metabolism: in liver, long half lives, 1st order kinetics over broad range.
 Primidone converted to phenobarbital & PEMA (both anticonvulsants) via in vivo metabolism.
Toxicity:
 Cognitive and behavioral side effects, depression.
 Teratogen

Mechanism of Action: benzodiazepine anticonvulsants

Effects: Enhance GABA activity (bind benzo receptor), increasing inhibitory signaling
lorazepam
 (hyperpolarizes by increasing Cl influx postsynaptically)
diazepam
Indications: used for rare seizure types, 1st line IV in status epilepticus
Toxicity: powerful but sedative, cognitive side effects

Glutamate Synapses (want to ↓ activity)

 Drugs not as well developed as they are for GABA synapses
Topiramate: blocks AMPA receptors
Mechanism of Action: Anticonvulsant, blocks AMPA glutamate receptors
topiramate Effects: decreases excitatory glutamate signaling
Toxicity: Memory & speech problems (AMPA receptors involved in memory formation)

Dextromethorphan (cough syrup) & felbamate block NMDA receptors

Levetiracetam binds to synaptic vesicle receptor

Mechanism of Action: Anticonvulsant, binds SV2A vesicle protein on synaptic vesicles
levetiracetam Effects: inhibits Ca-mediated glutamate exocytosis from pre-synaptic neuron
Toxicity: teratogen

13
 Clinical use
Sodium channel drugs Relatively selective, fewer cognitive side effects
GABA-R/benzoR drugs Most powerful, but have sedative, cognitive side effects (used in status epilepticus)
Glutamate drugs Potentially protective but also cognitive side effects
Often need to combine drugs with different mechanisms (don’t put two of the same together – make ‘em complimentary)

Indications
Most common seizure types: generalized or partial (focal) motor seizures, or partial complex seizures
 Carbamazepine, phenytoin, valproic acid, phenobarbital, lamotrigine or combinations effective for many pts

Generalized absence seizures (3/second spike wave activity)

 ETHOSUXAMIDE (blocks Ca channels), valproic acid, lamotrigine
 Carbamazapine can make these seizures WORSE

Rare seizure types (epileptic encephalopathies of childhood: very chaotic, hypsarrhythmia pattern: very high gain on EEG)
 Benzodiazapines, valproic acid, ketogenic diet, ACTH (hormone)

Pharmacogenetics: starting to find specific mutations in some syndromes & ID treatment based on known mutations

Side effects of Anticonvulsants

Severe skin reactions: Stevens-Johnson Syndrome, Toxic Epidermal Necrolysis
Drug-drug interactions (interfere with each other’s metabolism)
 Phenytoin: induces metabolism of carmazepine
 Valproic acid: slows metabolism of phenobarbital, lamotrigine
 Pharmacogenetic markers have been discovered (affect anticonvulsant action, metabolism)

Teratogenicity
 Anticonvulsants cause BIRTH DEFECTS! “anticonvulsant embryopathy” (20-28% exposed infants vs 8.5% controls)

Anticonvulsant embryopathy
• Microcephaly, growth retardation, cleft palate, finger, neural tube, urogenital, heart malformations, NTD with valproic acid
• Most occur in first month of gestation (often before mother knows she’s pregnant
• Mechanism: Anticonvulsants antagonize folic acid ↑ oxygen free radicals
• Can ↓ activity of epoxide hydrolase (detoxifies oxidative metabolites of certain anticonvulsants)
• Other drugs, genetics  ↓ epoxide hydrolase  ↑ risk

14
  Valproic acid strongly associated with spina bifida
o ↓ spina bifida with folic acid: all women on anticonvulsants should take folic acid

 Anticonvulsants can alter metabolism of birth control pills too!

 Alterations in endogenous hormones  ovarian dysfunction

Status Epilepticus
30 minutes of continuous seizure activity or 2 or more seizures without full recovery of consciousness
 Can damage brain, impair other organ function

Therapy
 ABC support (airway, breathing, circulation)
 IV access with glucose-containing fluid
 IV anticonvulsants (lorazepam or diazepam  + phenytoin
 + phenobarbital  anesthesia with benzos / general
anesthesia)

Adverse effects of treatment:

 Coma (benzos), apnea / need for ventilator, cardiac
arrhythmias, skin damage (phenytoin)

Anticonvulsant therapy in children

Often TEMPORARY
 Up to 70% children started on anticonvulsants for seizures can discontinue after several years seizure-free

↑ risk of need to continue with:

 Older age at onset  FHx of seizures
 large # seizures before remission  past Hx of status epilepticus
 presence of chronic neuro disability (e.g. CP)

15
 General Anesthetics
Classification of General Anesthetics based on Usage Profile
Inhaled Intravenous
Potent, volatile agents Induction agents Continuous agents
 Halothane
 Sevoflurane  Thiopental
 Propofol
 Isoflurane  Propofol
 Remifentanil
Nitrous Oxide (N2O)  Desflurane  Etomidate
 Dexmedetomidine
 Ketamine
 Ketamine
Potent (need small %)
Volatile (stored as liquid,
need to pass through vaporizer)

Definition of Anesthesia: a reversible state of unconsciousness characterized by:

• hypnosis (loss of awareness),
• amnesia (loss of antegrade memory),
• analgesia (insensitivity to pain),
• immobility (gold standard for anesthetic potency)
No other unconsciousness state fulfills all 4 criteria

Minimum Alveolar Concentration (MAC)

(actually a median)
 Basically an ED50: concentration that abolishes movement to noxious stimulus in 50% of pts (e.g. incision)
 Potency = 1/MAC (lower MAC = more potent)

MAC ↓ with: old age, other sedatives, hypothermia (need less anesthesia)
 Genetic variation may affect MAC in animals

Anesthesiologist knows MAC for population

(but needs to determine MAC for individual by careful observation)
 95% CI = MAC ± 25%

4 Stages of Anesthesia
Classic: 4 stages of depth of anesthesia

Stage I Analgesia, amnesia

Delirium: more historical; don’t see with modern
Stage II
anesthetics (very short)
Stage III Surgical anesthesia (where you do surgery)
Medullary depression (anesthetic overdose):
Stage IV hypotension, ↓ respiration  apnea (need life
support or will arrest)

Stage IV reached during operations sometimes:

but anesthesiologist picks up sign, reduces concentrations

Anesthetics have a relatively narrow therapeutic index

16
 MAC: clinical implications
MAC-awake (0.3 x MAC) the point where you lose ability to respond to commands
1 x MAC 50% of pts immobile, surgical stage
1.3 x MAC 95% of pts immobile
2-4 x MAC bad; pts will die without life support

Sample question: at what sevoflurane concentration would you expect a 95 year old female pt to lose ability to respond to
commands (if MAC is 2% for sevoflurane)?
A) 2% B) 2.4% C) 0.6% D) 0.4%
Why D? MAC-awake is 0.3 x MAC, but she’s old (↓ MAC) so you need an answer that’s less than 0.3xMAC

Inhaled Anesthetic Pharmacokinetics

Anesthesiologist: sets machine to get to anesthetic partial pressure in brain, SC to levels for stage III anesthesia
 Machine trachea  bronchi  alveoliDiffuse along partial pressure gradient into arterial blood (pulmonary circ) 
 Some goes into solution, some undissolved; undissolved proportion of gas generates a partial pressure in blood
 Circulates  diffuses into brain along partial pressure gradient  hits receptors 
 back into venous circulation  lungs
 Eventually, the partial pressures equalize in the lungs and net diffusion stops

4 Key Points of Anesthetic Pharmacokinetics

1) Onset of anesthesia determined by partial pressure, not the concentration, of anesthesia in CNS (PCNS)
2) At equilibrium: PCNS = Palv (partial pressure in CNS = partial pressure in alveoli)
a. So changing PAlv governs the onset of anesthesia
b. Equilibrium set by anesthesiologist (Pmachine)
3) Blood flow into brain does not affect the magnitude of PCNS at equilibrium
a. But it does affect the time to reach equilibrium
4) Other factors that determine time constant for PCNS
a. Solubility (partition) coefficient (λ) of the anesthetic gas: physical property of gas, defines relative
affinity of anesthetic between two compartments
b. Gradient between arterial (or alveolar) and mixed venous
partial pressures of anesthetic

Gas laws:
• The partial pressure of a gas dissolved in a liquid = partial pressure of
the free gas in equilibrium with that liquid.
• Partial pressure of an anesthetic gas (Panes) rises at roughly equal rates in
all compartments but with a phase delay (brain<muscle<fat)
• The phase delay is governed by the time constant for the compartment
(tissue group).
• At equilibrium, the partial pressure is equal in all compartments.

Solubility

Henry’s Law: Concentration= Partial pressure(P) × Solubility Coefficient(𝛌)

HIGHLY SOLUBLE GAS has LOWER PARTIAL PRESSURES on both sides of the membrane
• See example slide: ↓ solubility constant means that you have a higher partial pressure for a given concentration
• Drug design: want more & more insoluble gases (can reach target partial pressures more easily)

17
Time constants (τ)
 Flow rate & volume capacity determine the time to reach the set partial pressure
𝒕
 𝑷𝒄𝒐𝒎𝒑𝒂𝒓𝒕𝒎𝒆𝒏𝒕 = 𝑷𝒇𝒍𝒐𝒘 (𝟏 − 𝒆𝝉 )
(𝝀𝒄𝒐𝒎𝒑𝒂𝒓𝒕𝒎𝒆𝒏𝒕×𝒗𝒐𝒍𝒖𝒎𝒆𝒄𝒐𝒎𝒑𝒂𝒓𝒕𝒎𝒆𝒏𝒕)
 𝝉= = capacity (l) / flow (l/min)
𝒇𝒍𝒐𝒘𝒄𝒐𝒎𝒑𝒂𝒓𝒕𝒎𝒆𝒏𝒕
o For alveoli: τalv = FRC/VA (= capacity / flow)

 Without removal (uptake) from a compartment, it takes

o 3τ for Palv to reach 95% of equilibrium partial pressure (Pequil)
o 1τ for Palv to reach 63% of equilibrium partial pressure (Pequil)
 Example (see slide): If FRC is 3L and VA = 6 L/min, then τalv = 0.5 min, so you’ll reach 95% Pequil in 3τ = 1.5 min

Breathing deeper lets you reach equilibrium more quickly (↑ VA so ↓τalv)

So in a patient:
1. Palv equilibrates with Pmachine in 3τ (1.5 min in example above), where τ = FRC / VA
2. Part equilibrates immediately with Palv (big surface area of lung in contact with whole cardiac output)
3. PCNS equilibrates shortly thereafter based on time constant for specific anesthetic in CNS

Tissue groups:
 Brain: 2% of body mass but consumes lots of cardiac output
 Muscle: 50% of body mass, consumes about the same as brain,
isoflurane is more soluble
 Fat: 20% of body mass; note that solubility is much higher for isoflurane
o Anesthesizing morbidly obese person: deposit anesthetic in fat compartment
o Dissolves in fat compartment  takes a long time to mobilize anesthetic & pt wake up
o Obese pts remain groggy for much longer

Example: How long will it take brain partial pressure to equilibrate, if isofluorane has a blood/brain solubility coefficient (λ) of 1.6,
volume of adult brain is 1.4 L, and blood flow to the brain is 20% of CO (1L/min)?
 τbrain = λ*vol/flow = 1.6*1.4/1 = 2.2 min, so 95% of Pequil is reached in 3x2.2 = 6.6 min

Uptake
 In real life, uptake slows rate of rise of Palv (anesthetic being removed from alveoli into pulmonary blood flow)
o Analogous to creating a larger arterial blood compartment
 ↑ uptake from lung (= slower rise of Palv, higher capacity of blood compartment) with:
o ↑ solubility of anesthetic (↑ λblood/gas)
o ↑ CO
o ↑ partial pressure gradient (between arterial blood & mixed venous blood: Part – Pven)
 Pven reflects partial pressure of venous blood
coming back from all compartments, weighted
by % cardiac output received (so brain & heart 𝐿 𝜆 × 𝑄 × (𝑃𝑎𝑟𝑡 − 𝑃𝑣𝑒𝑛 )
are big players) 𝑼𝒑𝒕𝒂𝒌𝒆 =
𝑚𝑖𝑛 𝑃𝐵
Anesthetic uptake stops when Pven = Part
 after some time, well-perfused tissues are saturated  no gradient for net diffusion

Time course of anesthesia

1st minute Part = Pven = 0 so no uptake from lung (Palv ↑ very rapidly)
Next few minutes Palv, Part ≫ Pven so Part – Pven ↑↑  ↑ uptake from lungs  slows rise of Palv
Equilibrium Pven≈Part so no net uptake; Palv ≈ PCNS, equilibrium

18
Sample question: how do you know when anesthetic has reached equilibrium?
 Exhaled anesthetic concentration = inhaled anesthetic concentration

Factors that speed induction

Inspired gas concentration
Alveolar ventilation
Lung capacity (FRC)
Gas solubility
Cardiac output
(or pulm blood flow)
Airway effects
Gas Property Patient Physiology Anesthesiologist Decision
- -  Gas concentrations ( “overpressure”)
- spontaneous ventilation mechanical ventilation
-  (e.g., child) -
Less soluble -
- ↓(e.g., shock) -
Non-irritant

Shock: pt will go to sleep very quickly & hit stage IV with normal concentration of anesthesia! (↓ CO, so faster induction – ↓uptake)
Anesthesiologists: sometimes give temporary “OD” (called “overpressure”) to speed induction, then turn it down
Irritation: pts will refuse; would take longer

Anesthesiologists cannot measure Panes.

• They can only measure inspired and expired anesthetic concentrations.
• Concentration  partial pressure
• Even though concentration is measured as vol%, it is abbreviated as F (fraction of 1).
• Equilibrium is: FA = FI
• where FA = alveolar anes conc ( Palv) and FI = inspired anes conc (PI).
• Speed of induction of anesthesia: FA / FI

Inhaled Anesthetics in Current Use

Chemical Blood:Gas
Anesthetic MAC, % Metabolism Comments
Structure Solubility Coefficient
Slow onset/recovery
Halothane Alkane 0.75 2.3 <40%
Myocardial depressant.
Medium onset/recovery
Isoflurane Ether 1.2 1.4 Minimal
Slightly pungent odor.
Rapid onset/recovery
Sevoflurane Ether 2.0 0.69 <5%
Emergence delirium.
Rapid onset/recovery
Desflurane Ether 6.5 0.42 Minimal
Airway irritant
Other Must be given with O2
Nitrous oxide >100 0.47 None
N=N-O and other anesthetics

Note: Nitrous oxide has high MAC; would be lethal in doses needed for total anesthesia (need to give others)
Desflurane: irritant; need to induce with something else first

Development: want as insoluble as possible with halothane (=2.3) as the baseline (possible, but with a price):
• Isoflurane =1.4, but airway irritant (coughing)
• Sevoflurane =0.69, but emergence delirium
• Desflurane =0.42, but severe airway irritant (laryngospasm)

Elimination of inhaled anesthetics

↓ FI by anesthesiologist  ↓ FA  ↓ FBrain
 Just the reverse of uptake & distribution Faster elimination by:
 ↑ ventilation
Metabolism inconsequential except for halothane  ↑ pulmonary blood flow
 ↓ solubility 19
Malignant Hyperthermia: the only anesthetic disease
Molecular defect: Autosomal dominant inheritance
 point mutation in RYR1 (Ca++ release channel) gene (50% of patients)
 sustained Ca++ release from sarcoplasmic reticulum
Incidence: 1:4000 (mild) – 1:250,000 (fulminant)
Triggers: volatile anesthetics, succinylcholine
Manifestations: muscle rigidity, temp, heart rate, pCO2, pH, rhabdomyolysis
Therapy: Dantrolene (a muscle relaxant)
Diagnostic Test: contracture test (caffeine or halothane) – muscle contracts, doesn’t relax: diagnotic

IV General anesthetics
General Overview
• Very rapid induction of sleep (20-60 sec)
• Work in one circulation time
• Useful for emergency surgery (“rapid sequence induction - RSI”)
• Get endotracheal tube in before pt can vomit
• Oxygenate, apply cricoid pressure (keep GI contents down), get tube in, release pressure
• Do not provide all 4 components of anesthesia
• usually combined with other sedatives, opioids, or volatile agents (“balanced anesthesia”)

3 compartment model
 inject into central compartment (V1)
 rapid distribution to V2 (highly perfused tissues, e.g. brain) - so rapid effect
 slow distribution to V3 (muscle, then fat)
o note that ↑ time to wake up with ↑ fat
o Gradual return (hours) of anesthetic from V3 to the central compartment 
metabolized (liver) eliminated.

Offset time after continuous infusion depends on infusion duration

 “context sensitive half-time”: Longer infusion = groggy for longer
 If rate of elimination is faster than V3V1 rate, then [drug]brain ↓ fast  wake
up quickly. Example: propofol (pts. wake up promptly)
 If V3 is big and rate of elimination is slower than V3V1 rate, then drug is
slowly released from V3, maintaining [drug] in V1 & V2, prolonging effects.
Example: thiopental (takes 6x longer to wake up than propofol)

IV Anesthetics in Clinical use

See next page for table

Ketamine: NMDA glutamate channel blocker

 Different from other IV anesthetics:
o wide-eyed but unresponsive to command (dissociative anesthesia)
o Profound cutaneous analgesia
o Stimulates SNS (unlike others): ↑ HR, ↑ BP, bronchodilation, ↑ CBF
 Phencyclidine (PCP = angel dust) is a derivative

Another question: a burn patient requires debridement (really painful):

anesthetic binding to which molecular target is most likely to produce analgesia & sedation w/o depressing respiration
A) NMDA receptor B) Opiod receptor C) GABA receptor D) α2 adrenergic receptor
Answer: use KETAMINE (cutaneous analgesia, doesn’t depress respiration)

20
 Molecular Cardio-respiratory Adverse Effects
Clinical Use
Target Effects
 Rapid sequence induction
 BP,  BP
Thiopental (for emergency surgery)
hypovolemia  Extravasationtissue
 Continuous infusion
 Apnea necrosis
(for seizures or brain edema)
 Induction agent
 Continuous infusion  Anaphylaxis (egg, soy)
Propofol GABA  Mild BP
(for diagnostic procedures)  Burning sensation
agonists  Respirations
 Continuous infusion + opiod during injection
(for surgical procedures)
 Rapid sequence induction  Inhibits 11-
Etomidate for emergency surgery  Apnea hydroxylase
(esp. unstable pts) cortisol. (continuous
infusion contraindicated)
 “Dissociative” anesthesia (open  ↓ seizure threshold
eyes, but unresponsive)  HR (relatively contra-
 Profound cutaneous analgesia  Stable BP and indicated in epilepsy)
Ketamine NMDA (anesthesia for burn dressing respirations  ↑ intracranial
blockade changes)  Bronchodilator pressure (contra-
 Rapid sequence induction (used for severe indicated in head
for emergency surgery asthma in ICU) trauma)
(esp. unstable pts)  Oral secretions
 Excellent sedative
(e.g., long-term ICU sedation)
 Stable
Dexmedetomidine central 2  Little or no withdrawal syndrome
respiration  Very expensive
agonist after prolonged infusion
 BP
 Combined with opioids for
anesthesia in OR
 Combined with sedative  Chest wall rigidity
(e.g.,propofol) or inhaled (need neuromuscular
opioid anesthetic in OR  Apnea blockade and
Remifentanil
receptor  Useful when very rapid offset is  BP endotracheal intubation
desired (metabolized by plasma before patient can be
cholinesterase) ventilated)

Molecular Mechanisms of Action

Old model: the Meyer-Overton Rule
• Anesthetic potency  solubility in olive oil
• Inference: nonspecific action on hydrophobic lipid moieties in cell membranes
• Now generally replaced by specific molecular models

21
Drug Class based on Target & Effects:
Hypnosis & Slowing of
Analgesia
Examples Action Amnesia cortical EEG
(NMDA effect)
(GABAA effect ) (GABAA effect )
Etomidate,
Act primarily via specific GABAA receptors
Group 1 propofol, and
(with different subunit types).
barbiturates
Less selective; target:
N2O and  glutamate receptors
Group 2
ketamine (NMDA, AMPA, kainate)
 two-pore K+ channels.
Volatile Least selective group
Group 3
anesthetics Target many molecular sites.

Volatile Agents
 Target both inhibitory & excitatory receptors (less specific)
 Either:
o ↑ inhibitory ion channel and/or
o ↓ excitatory ion channel

GABA
 GABA released from inhibitory presynaptic neuron  binds
postsynaptically  opens chloride channel
 Hyperpolarizes post-synaptic membrane (inhibitory)
 General anesthetics bind to a separate site on the subunit and appear to increase the sensitivity of these
subunits to GABA. This prolongs the postsynaptic inhibitory current in response to GABA discharge.

22
 Pathology: GI
Esophageal Pathology ............................................................................................................................................................. 2
Stomach Pathology ................................................................................................................................................................. 9
Small Intestine: Inflammatory & Non-Neoplastic Disorders................................................................................................. 16
Inflammatory & Nonneoplastic Disorders of the Colorectum .............................................................................................. 23
Colorectal Cancer .................................................................................................................................................................. 31
Pediatric GI / Liver Disease ................................................................................................................................................... 37
Normal Liver Anatomy & Injury Patterns .............................................................................................................................. 44
Alcoholic Liver Disease .......................................................................................................................................................... 50

1
 Esophageal Pathology
Normal Anatomy Review
Where can things get stuck?
 Cricoid cartilage, Arch of aorta, Atrium, Diaphragm

Layers of the esophagus

3 parts:
 Nonkeratinizing stratified squamous epithelium
 Lamina propria (loose connective tissue with small
vessels, scattered inflammatory cells)
Mucosa o has lymphatic channels unlike in colon –
different staging of carcinomas
 Muscularis mucosae (thinner than muscularis
propria, thicker than muscularis mucosae in other
areas of GI tract)
Loose connective tissue with
 abundant lymphatics (tumor spread)
Submucosa  scattered inflammatory cells
 nerves, ganglia of Meissner’s plexus
 esophageal submucosal glands (modified salivary
glands; anatomic marker of esophagus)
Thick muscle layer with Auerbach’s plexus ganglia
Muscularis
 Proximal 6-8cm: striated muscle
propria
 smooth muscle distally
Rest of GI tract: has serosal coat
Esophagus: Loose connective tissue / fatty tissue
Adventitia
 Allows tumors, infections that penetrate muscularis
propria to go directly to mediastinum

Note that biopsy samples MUCOSA ONLY!

 but disease can affect any layer!
Tensile strength (surgery) is in submucosa! (weird – loose connective tissue)

Neuromuscular / Anatomic Diseases of the Esophagus

 Agenesis (congenital; don’t develop esophagus)
 Atresia / fistula (congenital; atretic segment of esophagus: thin / non-canalized cord; fistula if connected to trachea)
o Aspiration, inability to feed, pneumonia can result
 Achalasia (see below)
 Webs & rings (mucosal ledges that protrude into esophagus)
o Proximal = webs (e.g. Plummer-Vinson syndrome, iron deficiency anemia + glossitis + cheilosis in middle-aged/older F)
o Distal = Schatzki’s rings

Achalasia
 Degenerative disorder of intra- or extra-esophageal nerves
 Usually primary; can be secondary (Chagas dz, diabetes, amyloid)
 Lack of peristalsis, ↑ tone / incomplete relaxation of LES
o Leads to stricture (narrowing) – lumen gets too small

2
 Esophagitis
Inflammation of esophagus (but some of these conditions, e.g. reflux esophagitis, don’t show much inflammation)
Etiology:
 Medications/Drugs  Allergy  Infections
 Trauma  Radiation  Reflux

Medications / Drugs
 Mostly older patients / multiple meds  stricture
 Injury from direct mechanical effect of pill or
toxicity of medication itself

Directly caustic to esophageal mucosa:

 Iron pills (esp. ferrous sulfate)
 Fosamax (alendronate sodium)
 Potassium chloride
 Aspirin / NSAIDs Iron Pill Esophagitis:
 May or may not see rusty
Ischemic Injury: Kayexalate golden brown pigment
 exchange resin for hyperkalemia in renal failure  causes ulcer
 Ischemic injury from hypertonic sorbitol  can pick up better with
 See big crystals iron stain

Chemotherapeutic agents: inhibit proliferation of basal zone cells (rest of GI tract too)

Others:
 Lye / bleach: direct caustic effect (young children, psychiatric patients)
 Pills that get stuck in esophagus can locally damage too (mechanical / pressure effects or caustic med)

Fosamax & many others: Kayexalate: big crystals Chemical esophagitis (lye):
can’t see actual drug (just ulcer) caustic burns with narrowing

Biopsy of drug related esophagitis:

 Non-specific changes: acute inflammatory cells (PMNs in squamous epithelium), erosions / ulcers
 Iron & Kayexalate are the only two agents you can actually ID on pathology

Ulcer vs. erosion

 Ulcer: damage all the way down to muscularis propria or deeper; can cause perforation
 Erosion: doesn’t extend into submucosa

Course:
 Superficial lesions often heal without scarring
 Deeper lesions can heal with scarring and stricture formation
3
Trauma
Etiology:
 Nasogastric tubes (hosp pts)
 Swallowed objects (children, psych pts)
 Burn trauma (hot liquids out of microwave)
 Mallory-Weiss tear: longitudinal laceration in GE junction region
o Usually result of pressure effects of severe vomiting (e.g. alcoholics)

Esophagitis from trauma Top, right: thermal injury (microwave)

(NG tube lesion – note erosion) Note mummified layer, sharp contrast to
intact zones

Allergic Esophagitis
Epidemiology: Unusual
 Usually infants / children with allergies to milk / other dietary components
 Can occur in adults (diet or medication allergies)

Presentation: dysphagia, may have strictures, dysmotility from prolonged injury

 Esophagus alone or part of more generalized eosinophilic gastroenteritis
 Could also be from parasites (not usually in US)

Treatment: May improve with elemental diet, ± steroids (?)

Biopsy: marked infiltration of EOSINOPHILS

 In mucosa, lamina propria, deeper tissues

Esophagitis from Infections

 Bacterial, fungal, or viral: fungal & viral are most clinically relevant
 Especially in immunosuppressed pts (HIV, cancer) – often have concomitant infections with 2+ organisms

Bacterial esophagitis

Primary infection is rare; pretty much everything has been described as causing it
 Really only see in profound neutropenia (e.g. cancer chemo)
 Mycobacteria (MAI / TB)
 Actinomyces (sulfur granules)
 Treponema palladium (2° / 3° syphilis)

Secondary infection of damaged esophagus is more common

 commonly mixed flora

Big crusts of purple-staining bacteria;

usually only in profound neutropenia)

4
Fungal esophagitis
Candida albicans CANDIDA ESOPHAGITIS:
 Usually opportunistic IMMUNOSUPPRESSED PATIENTS
 Superinfects ulcers in non-compromised hosts  systemic steroids
 chemotherapy for cancer
 Pathology:  immunosuppresion
o Gray-white plaques (squamous cells, candida, inflamm. cells) post-transplant
 low birth weight babies
o yeast / hyphae / pseudohyphae (“Spaghetti & meatballs”)
 AIDS pts
o Acute inflammatory cells (PMNs) in squamous epithelium
o Best seen with PAS stain

Others:
 Aspergillus
 Histoplasma capsulatum

Candidal esophagitis:
Yeast, pseudohyphae, hyphae
gray-white plaques

Viral Esophagitis
Big two: CMV (cytomegalovirus) & HSV (herpes virus)
 Also varicella zoster virus (VZV), etc

CMV esophagitis
 Usually opportunistic (HIV / transplants)
 Can super-infect pre-existing ulcers
 Usually results in ulcer formation
 Pathology:
o in GRANULATION TISSUE in base of ulcer
o BIG CELLS WITH OWL’S EYE INCLUSION (or binucleated) – Cowdry A inclusion (has a space around it)

Herpes Esophagitis
 Mostly HSV-1, most often opportunistic infection
o Occasionally in non-immunosuppressed
o Neonates: can be acquired intrapartum (HSV-2)

 Multiple, shallow, punched-out ulcers

 Pathology: need to biopsy EDGE of ulcer

o “Smudged” Cowdry B intranuclear eosinophilic

inclusions in SQUAMOUS CELLS at edge of ulcer
HSV: Multiple shallow HSV: cells with inclusions at edge
“punched-out” ulcers of ulcer in squamous epithelium
o IHC stain can help ID

Virus Location Cell size Inclusion “Smudged”

CMV Center Big Owl’s eye (Cowdry A) Cowdry B inclusions
HSV Edge Normal Smudged (Cowdry B)

5
 Esophagitis: Reflux
Gastroesophageal Reflux Disease (GERD)
 Most commonly adult Caucasian males Predisposing factors for GERD
(think FAT WHITE GUYS)  ↓ LES tone (ETOH, scleroderma, etc.)
 NG tubes (interference with LES)
o But can affect M / F / all races / infants
 Hiatal hernia
 Reflux of gastric contents into esophagus  damage
 Achalasia (↓ clearance of refluxed material)
o gastric acid, pepsin
 Diabetes (gastric secretions accumulate)
o duodenal alkaline bile / pancreatic secretions
 Obesity, pregnancy, many more

Pathology of GERD

Epithelial injury
 Balloon cells: cells opened up by damage, emptied out
 Vascular lakes (dilated small blood vessels)
 Erosions / ulcers if severe

Proliferative changes (↑ turnover from damage)

 Widening of basal zone
 Elongation, ↑ # of vascular papillae
o Usually go 1/3 of the way up; now > ½ way

Inflammation
 Usually mild
 SCATTERED eosinophils
(fewer than in allergic esophagitis)
 May be some PMNs too

Complications of GERD
Severe complications are unusual
 Can develop: ulcer, bleeding from ulcer, stricture formation (scarring / deep injury)
 Barrett’s esophagus: develops in ≈ 10% pts with symptomatic reflux

Barrett’s Esophagus
Replacement of normal squamous epithelial lining of tubular esophagus by columnar epithelium
 (metaplasia: replacement of one cell type by another not normally found
in that location)

Can be replaced by either:

 gastric-type mucosa (cardiac or oxyntic-type)
o Cardiac: glands; top (cardia) of stomach
o Oxyntic: parietal, chief cells; middle (fundus) of stomach,part
that makes acid
 “distinctive-type” mucosa (INTESTINAL metaplasia)
o Features found only in small bowel & colon (GOBLET)

Classification of Barrett’s
 In US: need INTESTINAL METAPLASIA to be called “Barrett’s” – don’t know if you got Bx from right place
o Most prone to develop dysplasia & adenocarcinoma
 Other countries: also consider gastric-type metaplasia “Barrett’s” (maybe we should too)

6
Diagnosis
 Pathology: GOBLET CELLS in esophagus (really shouldn’t be there!)

 Endoscopy: tongues, patches of reddish salmon-colored columnar mucosa

o Normal esophagus: grey/pink/pearly squamous epithelium
o Short-segment: < 3 cm, more common
o Long-segment: > 3cm; more likely to progress to esophageal adenoCa

Pathogenesis
 Not clear: associated with chronic reflux; unlikely that it’s direct metaplasia of SSE
 Probably destruction  re-epithelialization by columnar epithelium;
 Cell of origin unknown: pluripotent stem cell?

Presentation:
 NO SX caused by Barrett mucosa itself
 Sx of GE REFLUX only

Importance: pre-neoplastic condition!

 Can lead to esophageal adenocarcinoma
 Metaplasia  dysplasia  adenoCa

Risk of progression to adenoCa

 10% of all pts presenting with Barrett’s have or will develop adenoCa
(incl. pts w/ adenoCa on presentation)
 about 0.5% / yr will progress from BE  adenoCa

Esophageal Adenocarcinoma
Adenocarcinoma = tries to recapitulate glands

Epidemiology:
 50% esophageal cancer in USA, ↑ in past 20 yrs (obesity)
 White males in high socioeconomic groups (same guys who get Barrett’s)
 Risk factors: Barrett’s, males, whites, obesity, smoking, alcohol

Gross pathology: adenocarcinoma in background of velvety columnar Barrett’s mucosa

 Usually lower 1/3 of esophagus (begins at GE junction)
Dysplasia: precancerous cytologic changes following metaplasia
 high grade = close to cancer (big nuclei, complex gland structure)

Dysplasia in Barrett’s Mucosa: Esophageal adenoCa: shouldn’t see glands

↑ grade with more atypia, bigger nuclei, down at bottom (invading!)
more disorganized glands
7
 Esophageal Squamous Carcinoma
Epidemiology: ↓ in comparison to adenoCA in USA
 high incidence in “developing” countries (China, Iran, southern Africa)

Risk factors: (know these)

 Males  Smoking  Lye strictures
 African-Americans  Diet: nitrosamines, nitrates  Achalasia
 Alcohol* (fish products)
* ALDH1 polymorphism in SE Asians: Japanese, Chinese, Korean; also causes “flushing” with EtOH consumption

DRINKING & SMOKING have a SYNERGISTIC effect (multiplicative: potentiate one another)

Site of esophageal squamous CA: mostly middle 1/3 (50%)

 Vs. lower 1/3 for adenoCA
 Site determines which mediastinal structures would be invaded (upper 1/3 is worst!)
Precursor lesion: squamous epithelial dysplasia
 “carcinoma in situ” frequent at periphery – high grade dysplasia / intraepithelial neoplasia

Pathology:
 Enlarged cells, not maturing
 Eventually undergo paradoxical maturation (abnormal keratinization)
o Form keratin whorls (“SQUAMOUS PEARLS”) – common in squamous CA

NORMAL lower esophagus mucosa / Esophageal squamous dysplasia: Squamous pearl: Eso Squamous CA (here
squamous epithelium enlarged cells, not maturing abnormal keratinization upper 1/3 – bad Pgx)

Prognosis TNM Staging of esophageal CA

T1: invades lamina propria or submucosa
5-year survival (with Tx) T2: invades muscularis propria
T3: invades adventitial fat
Overall < 15%
T4: invades adjacent structures
Superficial (T1) CA 75-80% N: Nodal involvement
M: Distant metastases
Bad survival!
 Most pts present at T3-4 – takes a long time for them to come in!
 Esophageal obstruction, extension into mediastinal / intrathoracic structures, etc. (not distant mets so much)
 Earlier detection  better survival!

Treatment:
 Radiotherapy, chemotherapy (palliative, not really curative)

8
 Stomach Pathology
Normal Anatomy Review

 Esophagus  LES 
 Cardia, fundus, body  transitional zone
 (Pyloric) Antrum 
 Pyloric sphincter 
 Duodenum

Normal Histology Review

Oxyntic (= “acid secreting”) mucosa

 Parietal cells (secrete HCl) – “fried egg”

 Chief cells (secrete pepsinogens) - pinkish
Fundus &  Surface, foveolar epithelium PAS (+)
Body o mucus secreting

FOV = foveolae (small pits)

PC = parietal cells
CC = chief cells

(cardia by GE junction similar– but no endocrine cells)

 Mucus and/or pepsinogen secreting cells

 Lots of PAS (+) – mucus secreting
o glandular epithelium too!
Antrum
 Endocrine-secreting cells (see below

LUM = gastric lumen

FOV = foveolae (small pits)
AG = antral glands

Endocrine Cell Types

 Can see all via chromogranin immunostaining
Cell type Location Secretes Function
G cells Antrum Gastrin  Stimulates ECL cells  ↑ histamine release (↑ acid from PCs)
 Trophic factors: stimulates parietal cell growth
D Cells Antrum Somatostatin  Puts brakes on parietal cells (suppresses G cells’ gastrin release)
ECL Cells Body Histamine  Stimulates parietal cells (↑ acid production by parietal cells)

9
 Gastritis
Classification of gastritis
Acute gastritis Chronic gastritis
 “Chemical gastritis” – Aspirin / NSAIDs, bile reflux, others?
 Acute hemorrhagic gastritis  H. pylori gastritis
 Acute infectious gastritis (chiefly bacterial, e.g. HP, & viral)  Autoimmune gastritis
 Other uncommon forms

Acute hemorrhagic & erosive gastritis (AHG) INITIATING FACTORS

 A.k.a. “acute gastritis” / “gastropathy” (minimal inflammation)  Ischemia (2° to hypoperfusion: stress, shock)
 Think: frat boy who drank too much  Chemicals (Aspirin, NSAIDs, bile salts, EtOH)
 NOT H. pylori
Pathological Features
 Multiple, often punctuate hemorrhages (gross)
 Damage to subepithelium:
o erosions, edema, hemorrhage
 Minimal inflammation (gastropathy)

Pathogenesis
 All causes: damage to surface epithelium  breakdown of
+ +
barrier to H ions  injurious substances enter (H ,
proteases, bile acids)  underlying capillaries / other
structures damaged  edema, hemorrhage,
+
inflammation, ↑ H secretion
 NSAIDS: initial injury may be related to COX inhibition Endoscopy: multiple punctuate & confluent superficial
 ↓ prostaglandins  ↓ mucosal protection hemorrhages; H&E: localized hemorrhages, epithelial
detachment, erosions

Chronic chemical gastropathy (NSAIDs, other drugs)

A.k.a. “reflux gastritis, reactive gastritis, NSAIDs gastropathy (minimal inflammation again)

Clinical Findings / Associations

 No Sx or nonspecific upper GI Sx  Bile reflux (mainly with gastroenteropathy: post antral gastrectomy)
 CHRONIC NSAID EXPOSURE COMMON  Others (?) hypersecretion, EtOH, other irritants?

Pathological Features:
 ANTRUM ≫ BODY (corpus) for gross changes

 Gross: Highly variable, not characteristic / diagnostic

o erythema, thickened folds
o hyperplastic polyps less common

 Micro: Repeated injury / repair (REGENERATIVE)

(NO prominent inflammation)
o ↑ SMOOTH MUSCLE
o Foveolar hyperplasia with CORKSCREW PITS
o Vascular dilation & congestion

10
Gastric Ulcers
 Can be seen in acute or chronic gastritis

Pathogenesis: ↑ acid secretion & ↓ mucosal defenses

Etiologies: MANY
 Aspirin or other NSAIDs (very common)
 H. pylori
 Acid hypersecretion (esp. duodenal ulcer pts)
 Reflux of duodenal contents (bile acids, pancreatic enzymes)  stomach (?)

Complications of ulcer disease

 Bleeding (rupture underlying vessels)
 Perforation (communicate w/ peritoneal cavity)
 Penetration (extension into adjacent organ
 Stricture (healing  scarring)

Pic: gastric ulcer (could be from whatever etiology)

Erosion vs Ulcer
Erosion  Ulcer
Shallow Full-thickness
break in mucosa break in mucosa
Can reach muscularis
Penetrates muscularis
mucosae, but doesn’t
mucosae, may go even deeper
penetrate

Gastric Ulcer: in H. Pylori (see below for more on H. pylori)

 H. pylori predisposes: metaplastic epithelium more vulnerable(acid, proteases, etc.)
 ANTRUM at TRANSITIONAL ZONE (junction with body), usually single
 Normo or hypochlorhydric
 MUST RULE OUT GASTRIC CANCER
o similar presentation, appearance, association w/ EMAG

Gastric Ulcer: with NSAIDs

 Chronic NSAID use predisposes
(not fully understood: breakdown of protection?)
 DISTAL ANTRUM (“PRE-PYLORIC”)
 can also cause ulcers throughout GI tract
(duodenum, small intestine, colon)
 NO HP infection
 Single or multiple ulcers
 Associated chemical gastritis on microscopy

11
 Helicobacter pylori gastritis
Epidemiology
 Found throughout the world
o USA: ↑ > 40 yo, uncommon in children
 (30-50% USA adults @ Bx, 20% by serology)
o Developing world: ↑ in all ages
 Importance 1st demonstrated in 80s

Microscopic appearance
(Diff-Kwik (modified Giemsa), or immunostaining)
 Curved organisms with flagellae  Look coccoid after treatment
 Adhere to gastric epithelium / in mucus  Lympho-plasmacytic chronic inflammation
o Don’t colonize other GI epithelial types (e.g. o ± active (acute) inflammation
intestine) o Lymphoid follicles present (MALT tissue)

Presentation / Consequences:
 Many asymptomatic, some have dyspepsia
 Peptic ulcer (duodenum / antrum)
 Long term – damages mucosa  atrophy and intestinal metaplasia (damage / repair cycles)
o ↑ risk intestinal type adenocarcinoma
o ↑ risk MALT lymphoma
 Link to autoimmune gastritis (?)

H. Pylori Consequences: Peptic Ulcers

Why peptic ulcers?
 Helicobacter preferentially infects D cells
 Lose D cells → ↓ somatostatin  G cells unopposed  ↑ acid

Gross Path: duodenal / antral ulcers

 often in duodenal bulb (right past pyloric junction)
 ± pre-pyloric ulcers (distal stomach, just before pyloric sphincter)
 Rugal hypertrophy (big folds)

Histology:
 Duodenal ulcer with Brunner Gland (BG) hyperplasia
o Response to persistent acidity
 Penetrating muscularis mucosae  damaged artery  bleed!
o Also penetrated pancreas?

Eradicate H. Pylori: helps prevent recurrence

See fewer duodenal ulcers these days (everybody gets abx for one thing or another  treat HP inadvertently)

12
Environmental Metaplastic Atrophic Gastritis (EMAG)
 Damage  atrophy  repair, metaplasia
Causes:
 H. pylori infection
 Diet (high salt, smoked foods, pickled foods, nitrosamines: Japan, ↓ antioxidants / green veggies)
 smoking

Major clinical correlations

 No pernicious anemia (only with autoimmune)
 Hypochlorhydria sometimes (achlorhydria rarely)
 Serum gastrin: low or normal levels
 Gastric ulcers / cancers are important associated findings

Pathology:
 Intestinal metaplasia in ANTRUM
o PAS: see RED = mucins of normal gastric epithelium
o Alcian BLUE = goblet cells (intestinal metaplasia!)
 1st appears in transition zone, lesser curve (H. pylori)
 Chronic inflammation ± acute inflammation

Stemmerman’s technique:
 Alkaline phosphatase stain
 Technique makes anything with goblet cells turn RED!
 More red = more metaplasia

H. pylori: doesn’t like to live where there’s intestinal metaplasia

 Intestinal metaplasia – like a type of defense mechanism?

H. pylori & Gastric Cancer

Intestinal type adenocarcinoma
 Intestinal-type metaplasia  dysplasia  adenocarcinoma
 ↑ risk with H. pylori infection; eradicate ↓ risk of H. pylori
 Pic: carcinoma (luminal mass) in setting of EMAG

Malt lymphoma
 Years of responding to helicobacter 
low grade lymphomas
 Mess up lymphoid tissue here
 Pic: normal MALT area
(physiologic)

H. pylori: Overview of Consequences

13
 Autoimmune Metaplastic Atrophic Gastritis (AMAG)

Gastritis by etiology & location (KNOW THIS)

Autoimmune BODY messed up Antrum OK
H. Pylori ANTRUM messed up Body OK

Patient
think little old ladies (autoimmune: F>M)
 AA / latina / white affected about the same; inherited predisposition

Pathogenesis
 Ab against intrinsic factor or parietal cells  damage to oxyntic mucosa (body)
o Parietal cells lost, metaplasia appears  achlorhydria
o loss of IF  B12 malabsorption  deficiency  pernicious anemia
 H. pylori normally absent

Pathology
Body / fundus only (where parietal cells are)
 DIFFUSE METAPLASIA, thin mucosa

 Loss of oxyntic glands (atrophy)

o FLAT (loss of good rugae) (left pic)

 Thinning, intense chronic inflammation (bottom pics)

 Intestinal & pyloric metaplasia (right pic)

Antrum: no metaplasia, hyperplasia

Endocrine: G-cell, ECL cell hyperplasia

Pathology
approach to
Autoimmune
Gastritis

1. Supposed to be the body: 2. Double check: from body? 3. ECL hyperplasia (↑↑ gastrin
but no parietal cells! Gastrin (-) – not antrum! from antrum b/c ↓ acid!)

Clinical correlations
 Achlorhydria, marked hypochlorhydria
 B-12 malabsorption (can  pernicious anemia / neuro problems)
 Serum gastrin: high levels (↑ because no acid made)
 Gastric cancer: ?? risk increased
 Gastric ulcer: not a problem (no acid)

ECL hyperplasia  carcinoids (neuroendocrine tumors)

 hypochlorhydria  antrum puts out more gastrin 
↑↑ ECLs – trophic effect (L. pic)
 Years of ↑↑ ECLs  can progress to carcinoids! (R. pic)
14
 Gastric Cancer
Overview (gastric cancer overall)
 3% all US cancers (↑ in males, non-whites, lower SES)
o ↓ since 1930s overall
 ↑ in Japan, Iceland, Scandinavia, Andean So. America, many developing countries
 Most adenocarcinomas arising from antral region

Risk factors for Gastric Cancer

 Metaplastic atrophic gastritis (e.g. H. pylori infection / autoimmune)
 Dietary: smoked foods (nitrites), high salt intake, poor intake of fresh vegetables / fruits / antioxidants
 Adenomatous polyps

Classification: Intestinal vs. Diffuse types

Intestinal Diffuse
 Relatively well differentiated;
recognizable glandular architecture  Poorly differentiated, e.g. “Signet ring” type
 Protruding masses  Infiltrative form: Linitis plastica (leather bottle)
 Associated with H. pylori Really hard on gross!
(chronic inflammation, atrophy, metaplasia)  Histological precursor unclear
 Low grade dysplasia high grade  adenocarcinoma  No marked decline in frequency
 Commonest type in most areas (no H. pylori association to be improved on)
 Declining frequency, western countries

L: intestinal-type carcinoma in setting of EMAG (H. pylori)

R: microscopy: can recognize cancer in certain areas L: macro view of diffuse cancer
R: signet ring cells (mucus droplet, pushes nucleus out to side)

An aside: hereditary diffuse gastric cancer

 Autosomal dominant, pts get gastric cancer in youth
o Germ line mutations  2nd hit generates problem
o E-cadherin is mutated (cells don’t stick together)
 ↑ risk for mammillary lobular cancer too in F (another cancer where cells don’t stick together)

15
 Small Intestine: Inflammatory & Non-Neoplastic Disorders
Normal Small Bowel

Brunner’s glands: submucosal glands; only in duodenum (good landmark) – secrete bicarb-rich fluid to counteract acid

Mucosa: where a lot of pathology takes place; Villi:crypt should be about 4:1 ratio in size
Villous Epithelium Crypt Epithelium

 Goblet cells: sole function is to secrete mucus  Paneth cells (pink granules) – contain lysozyme
o secrete contents into lumen
 Brush border: lots of digestive enzymes, etc.
 Endocrine cells: smaller cells (also pink granules)
 Enterocytes: do the absorbing
o secrete contents into surrounding vasculature
Disorders:
 Peptic diseases  Malabsorptive disorders  Stasis syndromes  Infections

Peptic Disease
Peptic duodenitis & peptic ulcer disease (PUD) – continuum of the same process
 Western countries, > 40 yo, M > F
• Caused by toxic effects on the duodenal mucosa by excess gastric acid
• Vs. gastric ulcers (due to altered mucosal defenses, NOT excess gastric acid)
• Helicobactor pylori infection found in 80% of patients with PUD
• Other associations: smoking, chronic NSAID use, decreased motility

Peptic Duodenitis
 Damage to the mucosa

Gross pathology:
 Most common: in DUODENAL BULB (where acid hits first)
 Looks nodular on endoscopy (Brunner gland hyperplasia): trying to respond to ↑ acid with ↑ bicarb

16
Microscopy: epithelial damage and reactive changes
 Gastric mucin-cell metaplasia
o adaptive response to chronic acid exposure
o Note that this is intestinal  gastric metaplasia!
 Brunner gland hyperplasia (nodularity)
 Villous blunting
 Acute inflammatory cells (PMNs) in the lamina propria or epithelium
o mostly seen when co-existent Helicobactor Pylori infection
 Ulcerations (indicates severe disease)

Gastric mucin cell metaplasia & villous Mucin cell metaplasia (mucin is PAS Brunner Gland hyperplasia – note ↑ number,
blunting (almost looks like colon!) positive – see enhancement, r.) extension into mucosa (normally submucosal)

(Bleeding) Peptic Ulcers

 Duodenitis  gets worse  ulcer
 Causes up to 50% of upper GI bleeds
o 5%: hematochezia (bright red bloody stools - normally lower GI)
 Bleeding most common when occurs in posterior bulb
o close to pancreatoduodenal & gastroduodenal aa.
 Intraperitoneal hemorrhage can result (life-threatening)

Gross findings:
remember: continuum with
duodenitis

 Most in duodenal bulb

 Tend to be small & circular,

rarely > 3cm

 Surrounding mucosa Duodenal bulb ulcer, Peptic ulcer in duodenum (note BG

nodular on endoscopy with pre-pyloric ulcers, rugal hypertrophy hypertrophy, proximity to pancreas,
(Brunner gland penetration into artery– bad!
hyperplasia)

Gastric (mucin-cell) metaplasia of duodenal bulb:

 correlates with ACID EXPOSURE of ANY TYPE, not H. pylori infection!
 But if you see PMNs (“active peptic duodenitis”)  H. pylori usually involved!

17
“Active” peptic duodenitis
 When you see PMNs as a component of peptic duodenitis
think H. pylori / “active” (o/w “chronic”)

Pathology:
 Gastric metaplasia, BG hyperplasia, villus blunting (chronic too)
 PMNs & H. pylori in mucosa (active only)

H. pylori & pathogenesis of duodenal ulcer

 Inhibits D-cells  releases “break” on G-cells / Gastrin 
↑ acid secretion (parietal cells)  peptic ulcer

 Multifactorial too: gender, genetics, smoking, etc.

o but if you eradicate H. pylori,
other causes aren’t sufficient to cause ulcer recurrence!

Non-peptic causes of duodenitis

 Crohn’s Disease
 Celiac Disease
 Zollinger Ellison Syndrome (gastrin-producing neuroendocrine tumor)
 Infections (Giardiasis, MAI, Crytosporidiosis, Microsporidiosis, CMV,
Whipple’s Disease)

Crohn’s disease
 Same changes of duodenitis: intramucosal BGs, ulcer, etc.
 Can see PMNs too (unusual in peptic disease)

Zollinger-Ellison Syndrome
 MULTIPLE duodenal ulcers
 Pathogenesis: gastrin hypersecretion by neuroendocrine tumor of
pancreas, duodenum  ↑↑ acid, many ulcers!
 Think ZES:
o multiple duodenal and/or jejunal ulcers
o uncommon locations
o no risk factors for PUD

Refractory ulcers w/o ZE found in smokers, site of prior duodenal perforation, gastric outlet obstruction

Malabsorptive Disorders
Malabsorbtion: impaired uptake of any substance(s) by small intestine
Malabsorbtion Syndrome: constellation of findings including
 Diarrhea  Weight loss
 Steatorrhea  Deficiency states (protein, vitamins, etc)

Lactase Deficiency
Forms:
 Infantile (rare)
 Adult onset (most common)
o Otherwise healthy adults, esp. dark-skinned races
o Brush border enzyme reduced post-childhood
 Acquired forms: due to intestinal damage (e.g. celiac dz, sprue)
18
Chief symptom: milk intolerance

Lactose tolerance test: give lactose & measure blood glucose

 No blood glucose spike after lactose feeding if no lactase!

Path: mucosa completely normal (above)

 Special stain for lactase: ↓↓ lactase (right)

Osmotic diarrhea can result

 No lactase  can’t break down to glucose / galactose & absorb
 ↑ lactase in lumen, ↑ acid  ↑ luminal osmolality  suck out water

Celiac disease
 Multisystem autoimmune disorder Epidemiology
Risk factor Prevalence
st
Extraintestinal manifestations: 1 degree relative 1:22
nd
 Type I diabetes  Autoimmune hepatitis 2 degree relative 1:39
 Epilepsy  Many more Extraintestinal disorder
1:56
 Autoimmune myocarditis assoc. w/ CD
None 1:133
Pathogenesis
Environmental triggers Genetic risk factors Immunologic factors
 Gliadins (wheat)  HLA class II genes
 CD4+ T-cells that recognize dz-activating peptides
 Hordeins (barley) (HLA-DQ2, HLA-DQ8)
(↑ cytokines like IFN-γ  inflammation, injury)
 Secalins (rye)  70-80% MZ concordance

Active celiac disease (Prior to gluten-free diet)

 Clinically: malabsorption Syndrome
 Histopathology:
o FLAT Mucosa (NO VILLI)
o Epithelial lymphocytosis
o SURFACE epithelium damaged
o ↑ Crypt mitosis
o Chronic inflammation

L: normal, R: active celiac dz Intraepithelial lymphocytosis Crypts: see chronic inflammation in

Villous blunting, ↑ crypt size (arrows) lamina propria & lots of mitoses

19
After gluten free diet (1wk – 3mo)
 Marked clinical improvement (↑ wt, etc)
 Histopathology
o SURFACE EPITHELIUM RESTORED
o Slight return of villi
o Other findings unchanged

Long term gluten free diet

 Continued clinical improvement
 Histopathology
o Further return of villi
o Mitotic activity subsides
o Chronic inflammation subsides
o Some residual ↑ intraepithelial lymphocytes

Histopathology: If you add gluten back to diet

 Changes come back!
 Epithelial damage- upper villi, ↑ lymphs
 Rest of changes follow (later)

Diagnosis of Celiac disease

 Only by demonstrating resolution of mucosal damage after gluten-free diet
(need path!)
 Best in post-bulbar duodenal or jejunal biopsies
o bulbar Bx can give false negative results (see case 2: bulb looks nL!)
 Can’t diagnose with serology only

Monitoring Celiac Disease

 Can use serology: Anti-transglutaminase II, anti-gliadin ab to follow dz!

Prognosis:
 Should have complete resolution of pathology with strict gluten-free diet
 If refractory:
o Strict diet not being followed (might think they are)
o 80% have clonal T-cell population (a little more progressed)
 high risk for enteropathy-associated T-cell lymphoma (EATL)

Tropical Sprue
A.k.a. Post-infectious Tropical Malabsorbtion
 Cause unknown (no single etiologic agent identified)
 Residents of / visitors to tropics (West Indies, Indian subcontinent)

Clinical features
• Chronic diarrhea and malabsorption after infectious diarrhea
• Bacterial overgrowth (aerobic, ?toxin-producing)
• Associated deficiency states, esp. B-12, folate (ILEAL INVOLVEMENT – not CD)
• Glossitis, for instance (B12) – think tropical sprue; fix w/ B12
• Can respond to antibiotics + vitamin supplementation (B-12,folate)

20
Histology of Tropical Sprue
• Highly variable, “Non-specific” inflammatory changes

• Epithelial injury (resembles celiac disease)

• Villous blunting, crypt hyperplasia, chronic inflammation
• ILEAL involvement (vs CD: only proximal small bowel)
• Can see bacterial organisms (EM) – not in CD

• Resolves with abx & B12 Rx

Tropical Sprue (looks like CD: villous blunting,
crypt hyperplasia, chronic inflammation;
resolves with B12 + abx)

Stasis syndrome
 Malabsorption due to stasis / Causes of Stasis Syndromes
immotility of small bowel Disease-related Acquired (surgery, etc.)
 “Blind” loop or pouch
 Crohns disease, IBD
 Overgrowth of anaerobic bacteria  Entero-enterostomy
 Diverticular Disease
(balance disturbed with ↓ peristalsis)  Afferent loop
 Scleroderma of small intestine
o Deconjugate bile salts  Gastro-jejuno-colic fistula
 Pseudo-obstruction
o ↓ vitamin B12  Adhesions and partial obstructions
o Damage surface
epithelium

 Looks like partially

developed / treated CD

Scleroderma (pics to left):

preferentially destroys inner circular
layer of muscularis propria (↓
peristalsis) Scleroderma: bowel Thinning, scarring with Mucosa looks normal
markedly distended, loss of muscularis propria in SCL in scleroderma!
loss of muscle tone

Pathogenesis: Stasis  Bacterial overgrowth 

 B12 depletion (anemia)
 Bile salt deconjugation, epithelial injury (malabsorption)

Treatment: antibiotics (↑ weight gain, ↑ ability to absorb fat!)

Whipple’s Disease
 Hopkins guy (Dr. George Whipple, 1907) discovered it, so we emphasize it (even though uptodate puts the
overall prevalence at 30 cases / year); bacterial etiology confirmed in 1961

Clinical features
 Men (8-10:1); 30s – 50s
 Diarrhea, low grade fever, wt loss, abd pain, anemia, arthralgias
 Lymphadenopathy in 50% pts

21
Histology:
 Post-bulbar duodenum, jejunum
 Yellow patches / plaques on mucosa
 Characteristic finding: BLUNTED / ROUNDED VILLI full of foamy pink Mϕ
o Mϕ contain PAS-positive rod-shaped bacterial inclusions

PAS stain of jejuna Bx: Anti-T. whippelii immunostain:

Rounded villi with expansion of Normal epithelium, PAS+ foamy Mϕ positive!
lamina propria lamina propria full of
foamy pink Mϕ
Bacterial Agent: Tropheryma whippelii
 Small gram positive rods
 Extra- and intracellular (IC=mainly macrophages)
 Identification/Speciation: (related to Actinomycetes)
 Antibody reagents now available (allow for rapid diagnosis in tissue biopsies)

Treatment: abx (resolves!)

22
 Inflammatory & Nonneoplastic Disorders of the Colorectum
Endoscopyic biopsy: basic goals to distinguishL

 Normal vs abnormal:
o histology of normal colon varies by site
o endoscopy prep can cause artifacts that resemble disease (enema effects)

 Acute colitis vs chronic inflammatory disease

Normal Histology

 Lamina propria with inflammatory cells

between crypts
 Muscularis mucosae below it
 Crypts parallel; bottoms touch muscularis
mucosae

Basic terminology / concepts

Active inflammatory changes
Reflect acute injury to colorectal mucosa
• Cryptitis (PMN infiltrate in crypt epithelium)
• Crypt Abscesses (intraluminal PMNs)
Features
Chronic inflammatory changes
Reflect chronic injury to colorectal mucosa
• Crypt distortion (loss of parallelism / shortening  forked crypts)
• Crypt loss/atrophy
• Basal plasmacytosis (inflammation fills up bottom of lamina

• Erosions (breakdown of superficial
epithelium)
• Ulcers (breakdown penetrates entire mucosa)
• Acute fibrinoinflammatory exudates
• Neutrophils are the key!!!!
Not specific, found in variety of conditions
 bacterial infections
Etiology
propria so that crypts become separated from muscularis mucosa)
 Pyloric metaplasia (gastric glands replace normal intestinal crypts)
o Parietal, chief cells, etc.
 Paneth cell metaplasia: paneth cells in left colon (normally
have paneth cells in right colon, but stop by splenic flexure)
o Pink, granular cytoplasm

Can accompany any condition with repeated bouts of active

 idiopathic IBD
inflammation or other injury
 iatrogenic colitis – NSAIDs
 ischemic diseases
Active chronic inflammatory disease: when active & chronic changes occur in combo with one another
(Metaplasia – presence of fully differentiated epithelial cell not native to the site)
KEY FEATURES to distinguish acute colitis from chronic inflammatory bowel disease:
 No crypt distortion  No basal plasmacytosis

Histopathology: ACUTE changes

23
Histopathology: CHRONIC changes

Active (“Acute”) Colitis

 Forms of colitis characterized by predominantly acute inflammation
 The histologic changes are not specific for any one disease

Differential diagnosis of active colitis in a mucosal biopsy:

 Infection (Bacterial, viral, fungi)  Emerging Crohn’s disease
 Ischemia (atherosclerosis, infectious)  Bowel preparation (“enema effect”)

Histopathology
 Cryptitis, crypt abscesses and/or erosions/ulcers.
 No crypt distortion or loss!!
 No basal plasmacytosis!!
 For some forms of active colitis, specific histologic changes may also be seen to help classify the disease
o Salmonella- mucosal ulcerations over hyperplastic Peyers patches
o CMV-viral inclusions and patchy ischemic changes

Early acute self-limited

colitis (ASLC):
cryptitis (right), crypt
abcesses (center) without
crypt distortion or basal
plasmacytosis (crypts still
parallel to each other,
perpendicular to surface)
Late ASLC 
Now focal cryptitis;
regenerative changes
(healing epithelium): blue
crypts (↑ mitotic figures)

Acute infectious-type colitis

 Acute onset diarrhea ± blood (can have fevers, myalgias, etc)
 Resolves without residual inflammation or recurrent Sx (w/in 2 wks)
Etiology: variety of infectious agents (Salmonella, Shigella, Campylobacter, E. coli, C. difficile, CMV, fungi, amebiasis, etc.)
 Exact cause not usually found

Focal Active Colitis (Enema effect)

 Microscopic foci of active inflammation only (cryptitis / crypt abscesses) in o/w normal bx
 Commonly seen in followup biopsies at site of polypectomy (insignificant finding)
24
 Idiopathic Inflammatory Bowel Disease (IBD)
Relapsing bouts of active bowel inflammation lasting weeks to months!
 If you see CHRONIC CHANGES on path, think IBD
 Idiopathic etiology (lots of mechanisms), genetics involved

Ulcerative Colitis and Crohn’s Disease are the big two kinds (divergent but overlapping cliniopathologic profiles)
 Fulminant colitis: severe cases, majority of mucosa is ulcerated
o ↑ risk of toxic megacolon: dilation  ischemic necrosis, perforation (40% mortality)

Epidemiology of IBD (UC/CD)

 Most common in Westernized countries
 Usually initially present 15-25 or 55-65 yo (bimodal distribution)
Ulcerative colitis
Histopathologic Criteria
 Diffuse mucosal inflammatory infiltrate
(lots of PMNs, cryptitis, crypt abcesses)
 Basal plasmacytosis
 Crypt distortion
 Goblet cell depletion
 Paneth cell metaplasia

Distorted crypts with forking, lots of inflammation in lamina propria,

Distribution of inflammatory changes
basal plasmacytosis. Can see crypt abcesses (R pic) (PMNs in lumen)
 Left-sided colitis
 involves RECTUM (100% of time) and varying amounts of colon

Pseudopolyposis:
 confluent ulcerations with mucosa in between
 END STAGE UC
 “pseudopolyps” are really just retained mucosa with lots of
ulcers between
 Compare to FAP: actual polyps

Crohn’s Disease
 Patchy mucosal infiltrate with skip areas (part of bowel affected, then part is normal – sharp demarcations)
 Transmural inflammation (only seen on surgical resection)
 Granulomas (50% cases, can be extraintestinal too)
 Histiocytes may be very prominent
 Paneth cell metaplasia
 Creeping fat (omentum covering small bowel; since serositis can occur – transmural!)

Distribution:
 Patchy distribution, Right-sided
 Can involve small bowel! (rest of GI tract too)
25
Crohn’s Disease: Histopathology (continued)

CD: terminal ileal involvement, Basal plasmacytosis (diffuse, vs.

↑ risk stricture (transmural) structured peyer’s patches), villous Granulomas & giant cells
Patchy distribution (cecum nL!) blunting

Apthous ulcers (ulcers with intense

lymphoid infiltrate at base)
Perianal strictures & fistulas: present in >25% CD pts; can be initial manifestation

Extraintestinal manifestations of IBD

 Arthritis  Sclerosing cholangitis*
 Uveitis  Ankylosing spondylitis*
 Dermatitis (pyoderma gangrenosum, erythema nodosum)
* don’t resolve with colectomy! (others do)

Cancer risk in IBD

 ↑ risk for development of
colorectal cancer in IBD

 UC pts have 3-5% lifetime risk

(greater than Crohn’s – more
mucosa involved)

 Cancer risk ↑ with time (often

post-20 yrs of IBD)

 Surveillance Bx for DYSPLASIA

(DALM = dysplasia-associated
lesion or mass)

DALM: polyploid type: dark, dysplastic DALM: flat dysplasia (harder to recognize & manage
cells. Easier to manage (remove)

26
 Collagenous / Lymphocytic Colitis (“microscopic colitis”)
 Chronic watery diarrhea (mo  yrs), waxes and wanes
 Females>males (8:1), middle aged or older
 NORMAL ENDOSCOPY (“microscopic colitis” – need to use microscope to dx)
 NO dysplasia  carcinoma sequence! No ↑ cancer risk!

Etiologies:
 NSAID use  Autoimmune diseases (RA, autoimmune thyroiditis, scleroderma, etc)
 Celiac disease  Luminal antigen? (CC goes away if colon diverted, recurs when hooked back up!)

Histopatology: Collagenous colitis Histopathology: Lymphocytic colitis

 Irregular subepithelial collagen layer  Patchy distribution, etc.
o Normally type IV collagen, now made of  Similar to collagenous colitis:
types I/II collagen & fibronectin o but no thickened BM
 ↑ intraepithelial lymphocytes
 Surface epithelial damage
 Superficial plasmacytosis of lamina propria
 No crypt distortion
 Rare neutrophils

Collagenous colitis: thickened basement membrane (esp on trichrome stain Lymphocitic colitis: like collagenous colitis
where ECM = blue, middle); also ↑ CD3 lymphocytes (IHC stain, right) but no thickened basement membrane

Ischemic Colitis
 Insufficient blood flow
 Can effect small mucosal segment or all of colorectum
o Colon more vulnerable than small intestine (esp. splenic flexure: SMA/IMA watershed area!)

Etiologies:
Occlusive vascular diseases Infections Systemic hypotension Mechanical Factors
 atherosclerosis,  CMV
 Septic shock
thromboemboli, vasculitis  Enterohemorrhagic volvulus, intussusceptions *
 hypovolemic shock
 Most common cause of E. coli 0157:H7 (bowel twisted on itself)
ischemic colitis in US
* intusseception: most common in pediatric ileum (hypertrophied peyer’s patches form leading edge)
Histology: depends on severity & duration of injury
• Mucosal necrosis • In chronic phase, progresses to mucosal
• Hemorrhage atrophy, fibrosis of lamina propria
• Heme-laden macrophages in lamina propria • Microcrypts (trying to regenerate)
• Fibrin thrombi • Unaffected areas: acute colitis signs

27
 Histopathology of ischemic colitis

Fat in atherosclerotic plaque – can

Dilated, red bowel embolize, cause ischemic bowel

Note sharp demarcation, From infection: boggy, ischemic Lamina propria: necrosis, hemorrhage;
focal injury mucosa no inflammation, fibrotic changes.
Crypts: trying to regenerate

Microcrypts 
(top , smaller crypts:
 big-time
attempt to regenerate,
hemorrhage
lined by regenerative
epithelium)

Treatment: need to excise surgically if transmural necrosis (gangrene) before perforation!

 Sepsis is big complication

Causes of Ischemic Colitis

E. coli O157:H7
 non-invasive organism, produces shiga-like toxins
 lives in intestine of healthy cattle; meat can become contaminated in slaughter
o bacteria can go udders / equipment  milk

Routine stool cx: can’t distinguish O157:H7 & other strains

 but most labs use Cx medium to screen (based on sorbitol fermentation)

CMV infection
 “Owl’s Eye” Inclusions

28
Pseudomembranous Colitis
 Description, not an entity itself
o Most cases: from C. difficile toxin following abx therapy
o CMV, for instance, is less common cause
 Presentation: diarrhea (often bloody), fever, pain

Gross: Plaques of adherent pseudomembrane with normal-appearing intervening mucosa

Microscopy:

 Necrosis of surface, upper crypt

 Inflammatory pseudomembrane fills dilated crypts, covers

surface (“exploding out”)

Approach to Mucosal ischemia

 Age, presentation, Abx history, stool cultures, toxin assays

Diverticular disease
 Disease of western civilization (lack of fiber  colonic contraction rings, divide bowel into segmented closed chambers,
uneven contraction  ↑ intraluminal pressures  blow out through wall)
 Typically in L. colon (sigmoid)
 Herniation of mucosa through muscularis propria in regions of penetrating vessels (area of weakness)
o Muscular hypertrophy results around herniated zones

Poking right out Extend into vessel 

through muscularis mucosa bleed
Complications (acute diverticulitis)
 Perforation  Bleeding (right near vessel)
 Inflammation / abscess formation (can simulate mass-like lesion)

Diverticular disease-associated colitis (chronic)

 Looks just like IBD but ONLY near diverticula
 Diffuse or patchy colitis in area of diverticula (usually sigmoid)
 Presentation: like IBD
(rectal bleeding, crampy lower abd. pain, constipation, intermittent diarrhea)
o No hx of IBD

29
  Gross: looks like Crohn’s
 Histopath: can have granulomas & sinus tracts
o CLUE: find ACTIVE CHRONIC INFLAMMATORY CHANGES in distribution of diverticular disease
 Treatment: simple resection (don’t need to give antiinflammatories like for IBD)
Involved segment: active chronic colitis

Hypercellular lamina propria

Crypt distortion Cryptitis
(plasma cells, eosinophils)

Appendicitis
 Most common cause of acute abdomen in US (5% may develop)
o Commonly presents at 10-25 yrs
o Rarely fatal (even after perforation & sepsis: < 1%)
Etiology:
 Obstruction of appendiceal lumen (fecalith, lymphoid hyperplasia, neoplasm – rare)
 Overgrowth of normal fecal flora
 ↑ luminal pressure, compromise of intraluminal vessels  ischemia

Normal appendix; looks like less- Sections of appendix; note huge abscess Periappendiceal abscess with PMNs
well developed colon, surrounded (arrow) extending into fat (label) and foreign body giant cells
by peri-appendiceal fat responding to stool (arrows)

Possible etiologies

Fecalith (hardens, calcifies, obstructs)

Lymphoid Hyperplasia
(viral infection, etc.)

30
 Colorectal Cancer
Major Points
 Colorectal cancer is completely preventable with optimal screening, but most don’t get screened
o Precursor lesion (=adenoma) present in patient for a long time before progressing to carcinoma
 Third most common cancer in US (both M/F)
 State @ Dx determines survival
 Big-time environmental & genetic predispositions: ID families with CRC for aggressive surveillance
 70% of large bowel adecarcinoma is in the colon and 30% in rectum
o Sigmoid most frequently, transverse colon is increasing
o Location influences detectability (sigmoidoscopy vs colonoscopy ± barium enema)
 Usual histology: moderately differentiated adenocarcinoma (gland-forming)

Epidemiology
 3rd most common malignancy (M/F) – 148k/yr, #2 cause of cancer death (CFR 37%, 10% all cancer deaths)
o Men: prostate / lung, women: breast/lung
o Women: incidence ↓ since 1940s, men since 80s
 Cancer: currently #2 cause of death in US; will soon be #1 (heart disease dropping)

Basic Terminology
GROSS definitions
 Polyp: any mass projecting into the lumen (bad: doesn’t say benign/malignant, etc.)
Colorectal Polyps
 Adenoma: a benign tumor with dysplastic features; Non-neoplastic Neoplastic
clearly a pre-malignant lesion  Hyperplastic polyps  Tubular adenoma
o Sessile adenoma: attached by broad base  Hamartomatous polyps  Tubulovillous adenoma
o Pedunculated adenoma: attached by stalk  Inflammatory polyps  Villous adenoma

MICROSCOPIC definitions
 Villous: adenoma with finger-like progression
 Tubular: adenoma with tube-like glands; like a balloon with fingers inserted
 Tubulovillous: adenoma with mixed features
 Flat / Depressed lesions: CRC in setting of ulcerative colitis; no polyp phase

Natural History of CRC

Multistep progression:

Dysplastic Adenoma
Normal Field Low-risk High-risk Primary Metastatic
aberrant crypt containing
Epithelium defect adenoma adenoma AdenoCa AdenoCa
focus AdenoCa

Inside the dotted line: can potentially detect the lesion & treat (before it gets metastatic!)

Adenoma  Colorectal Cancer

 Incidence of adenomas / CA track together, except that adenoma curve is left shifted (side)
 Lesions inside lesions: see CAs inside adenomas, residual adenomas inside CA
 Natural history (in cases when adenomas not removed)
 Colorectal cancer incidence ↓ by resection of adenomas
 DNA mutations overlap

Untreated polyps
 Pts LTF, refuse surgery, not surgical candidates
 Studies: lots of cancers arise at site of previous polyps (but broad range)
31
 Normal Colon Histology: Review

 Normal crypts

(nuclei at base,
don’t extend more
than 1/6 of way up
cell towards lumen)

Crypts: Nuclei should be at BASE, extend NO MORE THAN 1/6 of the way up the cell towards the lumen
Adenoma Histology
Adenomatous epithelia
 Blue at low power (↑ N/C)
 By definition: colonic adenoma shows low grade dysplasia

Tubular adenoma Villous adenoma Tubulovillous adenoma

“Balloon with fingers inserted” Dysplastic nuclei; Pedunculated polyp here; see
 Note some crypts cut in cross-section,  Not confined to bottom 1/6 of cells fibrovascular core, mix of tubular &
others longitudinal (disarray) villous features

Probability of carcinoma in an adenoma increases with

 Size of adenoma (predominant)
 Proportion of villous component (villous ≈ “villain”, worse type)
 Presence of high grade dysplasia

↑ incidence with ↑ age

Even adenomas are late in disease process

 Aberrant crypt foci may be earliest morphological change; Kras, APC mutations found in them
Non-Genetic Risk Factors for CRC
Environmental Component
 Incidence varies dramatically across the world (10-fold) – genetics, environment, both?
 Immigrant studies: Japanese immigrants that migrate to USA
o ↑ CRC incidence with successive generations  environmental factors!

Diet & pathogenesis: Very complex process: calcium, carcinogens in cooked meat, fat, stool bulk, transit time

32
Non-genetic risk factors
 Ulcerative colitis  Smoking (esp. with certain SNPs: CYP450,
 Crohn’s disease (if long-standing) glutathione S-transferase)
 Dietary factors (vary between studies)

Genetics of CRC (overview)

Oncogenes Tumor Suppressor genes
Mutations restricted Mutations widespread
Mutations activating Mutations are deleterious
Rarely associated with LOH LOH is common
Cyto: nothing or translocations Cyto: deletions, whole chromosome losses
Not methylated Can be methylated
Function: accelerates growth, permits multilayering Function: slows growth

Key distinction: Sporadic or familial? Need for ↑ screening in families!

Colon cancer is a disease of the elderly!
 If someone in family has colon cancer < age 50 – think familial (FAP / HNPCC)
 Would be really rare for sporadic forms to present < age 50

Genetics: Inherited Colon Cancer

Familial Adenomatous Polyposis (FAP
 Rare condition
 Colon studded with innumerable polyps (100s1000s)
 Patients present at young age

APC: tumor suppressor gene, chromosome 5q (good for 2-hit hypothesis)

Plays a role in BOTH FAP and sporadic CRC!
 FAP families:
o affected members have one allele mutated in germline
o 2nd hit happens in tumor
 Sporadic: both alleles inactivated somatically
 Mutations occur very early in CRC carcinogenesis (both FAP & sporadic)
o Normal function: binds, promotes degradation of β-cateinin (growth factor) in cytoplasm
o With mutation: β-catenin is unchecked, migrates to nucleus, activates transcription, ↑ growth, etc.

Treatment: surgical resection of entire colon (total colectomy – each polyp could progress to cancer!)

Hereditary Non-Polyposis Colon Cancer (HNPCC / Lynch syndrome)

 “Family G” – described by Alfred Warthin – young onset R-sided CRC
 Site: HPNCC generally right sided; sporadic left sided
o First approximation ONLY! Not always true
 Still pass through polyp phase: just don’t see innumerable polyps like FAP

Onset / inheritance: Autosomal dominant; Mean age 44 yo, 90% penetrance

Site: 70% proximal to splenic flexure, though 30% distal!
Histology: more likely poorly differentiated, mucinous, signet ring cells, intense lymphoid infiltrates
Associated CAs: (take a FHx for CA): endometrium, stomach, ovary, small bowel, renal pelvis and ureter

33
Microsatellite Instability
 Novel length alleles in tumor as compared to patient’s germline
oSerendipitously discovered when mapping for HNPCC:
small repetitive genome elements (microsatellites) were unstable
 Lymphoid infiltrates correlate with MSI

Mismatch repair (MMR) is the culprit in HNPCC

 DNA repair system for rapid repair of DNApol errors
 MMR function genes mutated (can’t repair  MSI / cancer!)
o hMSH2, hMLH1 are best documented

Autosomal Dominant inheritance

 1st “hit” inherited in germline (one MMR gene defective)
o Germline cells are therefore still MMR competent –1 functional copy
 nd
2 hit in tumor (LOH, etc)  MSI / cancer!

Lynch syndrome: term when defined MMR defect is identified in HNPCC family

APCAshkenazi mutation
 6% of Ashkenazi jews
 Gene not “mutated” (not a dysfunctional protein) but at risk for mutation
o Changes A to T to make 8As in a row: AAATAAAA  (A)8
o (A)8 is hypermutable  (A)9
o End up with dysfunctional APC from frameshift mutation
 2-5x ↑ lifetime CRC risk

Peutz-Jehgers Syndrome: “Spots & Polyps”

 Buccal mucosa spots & hamartomas (↑ CRC risk)
 1/25-30k births
 Aka “hereditary intestinal polyposis syndrome”

Overall: remember that

 Sporadic colon cancer is more common
 FCC (familial colorectal cancer) is “basket term” for unidentified inheritable forms
 For FCC: HNPCC > FAP > others

Genetics of Sporadic Colon Cancer

Multistep Progression (chart): basic idea, but not every tumor needs to go through this exact sequence of steps

Genomic instability is big feature of colon cancer

 Lots of microsatellite instability
 Either MSI or chromosome-instability

Average CRC has 80 mutations, but only ~ 15 are

“driver mutations” – rest are “passengers”

34
K-Ras
 K-ras (Kirsten ras, 12p) most commonly mutated in CRC (of 3 viral “Ras” homologs)
 Involved in cell-cycle regulation, G protein, active and in-active conformations
 Commonly mutated in sporadic CRC to constitutively active form
 Mutations in this oncogene are highly restricted to a couple codons (12 and 13) and are activating.

Long Arm of Chromosome 18 (18q)

 Often deleted in sporadic CRC (not in MSI-associated CRC)
 Entire long arm often deleted
 Contains 3 tumor suppressor genes (DCC – colon cancer, DPC4/Smad4 – pancreatic cancer)
o DCC = “deleted in colon cancer”, DPC4 = “deleted in pancreatic cancer” – nice names!

p53 tumor suppressor gene

 Tumor suppressor gene on 17p
 Most commonly mutated in all of cancer cells
 Transcription regulatory activity (cell cycle G1, mitotic spindle checkpoint controls)
o Mutations may cause genomic instability
o p53-mutated cells resistant to ionizing radiation & chemo-induced apoptosis
o Interacts with other oncogenes / tumor suppressor genes

Goal: know how genotype should impact treatment (chemosensitivity, etc.)

Staging of CRC
Duke’s staging (info?)
 Duke’s A – Mucosa / submucosa with no muscularis propria / nodal involvement; good prognosis (95% @ 5yrs)
 Duke’s B – Into / past muscularis propria but no nodes (80% @ 5 yrs)
 Duke’s C – Local mets to regional lymph nodes (60% @ 5 yrs) Stages of CRC
 Duke’s D – widely metastatic, probably will die (5% @ 5 yrs) Stage I: T1-2 N0 M0
Stage II: T3-4 N0 M0
TNM staging Stage III: Any T N1-2 M0
 T1 confined to submucosa Stage IV: Any T Any N M1
 T2 invades into muscle layer
 T3 invades through muscle layer
 T4 invades other organs / structions / perforates visceral peritoneum
 M for distant mets
 N for nodes (N1 = 0-3 nodes; N2 = 4+ nodes)

Spread / Metastasis of CRC

 Direct extension (contiguous structures / peritoneal cavity)
 Lymphatic vessel invasion (LN metastases)
o Unlike stomach, lymphatics in colon LP/MM are inaccessible – need to invade into submucosa to have mets
 Venous invasion (hepatic metastases via portal vein)

Cancer invading muscularis propria serosa CRC invading CRC metliver: total replacement
blood vessel of liver parenchyma 35
 Screening for CRC
EARLY DETECTION is KEY: resect if stage I/II w/o LN involvement - much much better prognosis
 People aren’t getting screening: only 20% getting fecal occult blood; only 34% getting colonoscopy

Assay Sensitivity Cost Invasiveness

Occult Blood 70-80% $1-8 “None”
Barium Enema 80% $180-230 Somewhat
Sigmoidoscopy 60% $205 Highly
Colonoscopy 90% $2,000 Highly

Colonoscopy is best (although $$) Virtual colonoscopy: pretty good but not gold standard
 Bowel prep needed (not great fun for patient)
 Still need bowel prep, still some (but lower)risk of perforation
 Invasive; need general anesthesia
 Sensitivity only about 90%
 Risk of perforation (1/1000) and death (1/5000)
 High false positive rate
 Gold standard; miss rate < 6% for polyps ≥ 1 cm

nd
Need to do 2 (real) colonoscopy to remove any lesions
 Superior to barium enema for followup

Fecal Occult Blood: inexpensive, really low risk, but low diagnostic sensitivity (81-92%)
 Low positive predictive value too (only 20%: high false positive rate)

Guidelines for screening

 Start at age 50
 FOB – test annually
 Colonoscopy – every 10 years
 If positive for adenoma or if FHx + , colonoscopy performed more frequently

Flat/Depressed neoplasms: especially important in CRC in setting of ULCERATIVE COLITIS

 36% of adenomas in UC – need to use spray dye technique; often missed

Molecular screening for CRC

 Proof of principle only now – maybe in the future
 Targets K-ras, p53, APC, Bat26, highly amplifiable DNA

Treatment of CRC
Adjuvant 5-FU (after surgery) is mainstay of therapy Other chemo options
 ↑ dz-free survival 20% @ 4 yrs; only about 1/3 pts benefit from it Oxaliplatin
rd
(3 generation Pt compound)
 Multiple actions: Irinotecan (topo I inhibitor)
o Incorporated into RNA, prevents processing Erbitux (anti-EGFR Ab)
o Inhibits thymidylate synthesase (de novo nucleotide synthesis enzyme)

Patient Specific Chemotherapy (Example: anti-EGFR Ab)

 Goal: only give expensive / dangerous chemo to pts who will benefit (based on genetics)
 FDA-approved for CRC; EGFR-expressing metastatic CRC resistant to irinotecan
 Sensitivity: correlates with presence of EGFR amplification and lack of Kras/braf mutations
o Do Kras test beforehand!
o Check: EGFR by FISH for amplification (also do IHC before use to document)

Post-genomic era cancer treatment / research: If we know all mutations…

 Probably not too much impact on prevention
 Potentially very high impact on early detection
 If therapeutics are available, we can tailor them (↑ efficacy, ↓ relapse?)

36
 Pediatric GI / Liver Disease
Most common: infections, IBD, etc. (in adults too) – these are congenital conditions (specific to peds)

Amniotic Fluid: About 1000 cc at term, always being turned over

Depleted by fetal swallowing if you obstruct fetal GI tract in utero, end up with polyhydraminos (too much fluid)
Repleted by fetal urination (micturation) Renal dysfunction in utero causes oligohydramnios (too little fluid)

Meconium:
 Composed of: mucinous GI tract seretions, bile, shed intestinal epithelial cells, desquamated fetal skin
 Normally passed within 24h of birth
o Meconium passage in utero: implies that fetus is distressed
o FAILURE to pass meconium w/in 24h: implies GI tract obstruction

Hirschprung’s disease
In utero arrest of the normal cranial to caudal migration of ganglion cell precursors,
resulting in non-innervated, aperistaltic bowel

Epidemiology: 1/5k births, 4:1 males, 10% familial, 3-10% of Down’s syndrome pts

Normally: neurons migrate down; form two plexuses around GI tract Hirschprung’s: aganglionic segment from rectum  up with
no ganglion cells (right); proximal to that the colon is dilated
(and would have normal ganglia)

Normally: ganglion cells migrate cranialcaudal

 submucosal (Meissner’s, between inner circular/ outer longitudinal mm layers) & myenteric (Auerbach’s) plexuses
 Functions: RELAX SPHINCTERS & ↑ MOTILITY

Hirschprung’s: don’t migrate

 Distal bowel: cells don’t make it down, ends up aperistaltic; dilation occurs proximally
 Extent depends on how early arrest occurs (more with early arrest); rectum always involved
o 75% cases: confined to distal bowel (only 8% total bowel)

Clinical Presentation:
 Failure to pass meconium within 1st 24 hrs
 Chronic constipation, abdominal distention
 Rectal exam: BLAST SIGN: insert finger, manually relax sphincter  poop shoots across the room (built up pressure)
 Complications: intestinal perforation, enterocolitis

37
Diagnosis: would need laparotomy to get down to myenteric layers (not ideal) – see pic

Endoscopic biopsy: looks at mucosa only, but can still use

 Absence of ganglion cells (both myenteric & submucosal plexuses) if you get a piece
 Acetylcholinesterase stain: ↑ pre-sympathetic parasympathetic fibers, with abnormal extension into mucosa
o Abnormal localization of cholinergic nerve fibers (not being directed by ganglia)

Drawing H&E Acetylcholinesterase

Normal

Ganglia in submucosa; few cholinergic fibers in mucosa Ganglia in submucosa No staining in mucosa
Hirschprung’s

No ganglia;↑ cholinergic fibers in mucosa No ganglia Intramucosal nerve fibers (+)

Treatment: Surgical resection of aganglonic segment, with excellent prognosis

Meckel’s Diverticulum
Persistent remnant of the vitelline (omphalomesenteric) duct

Vitilline duct: connection between midgut & yolk sac (embryology)

 Midgut: herniates into umbilical cord at week 6, rotates, then returns to
abdomen at 10 weeks gestation; connection to yolk sack obliterated normally
 Can have vitelline ligament too (just thin connection to umbilicus)

Clinical Presentation
 COMMON: 2% of general population has one, most asx
 Usually at terminal ilieum with small bowel mucosa lining
o 2 cm, 2 feet from ileocecal valve, 2% of population

Pathogenesis:50-70% have gastric mucosa  ectopic acid production

 Gastrin secretion  acid made by parietal cells  dumped out on small
bowel, which lacks protective mechanisms of stomach (Brunner glands,
pancreatic/biliary secretions, etc.)
 Leads to mucosal ulceration & lower GI bleeding (often painless)
99
Diagnosis: TC-pertechnetate scan (“Meckel scan”)
 picks up ectopic gastric mucosa; can see diverticulum
38
 Meckel’s Normal mucosa to left, ectopic gastric mucosa Ulceration of Meckel’s diverticulum (bleeding)
Diverticulum to the right (parietal cells, make acid, etc)

Pathology: Small, 1-5cm outpouching of ileum, characteristically on anti-mesenteric border

 contains all layers of bowel (true diverticulum)

Treatment: Resect if symptomatic

Gastrointestinal Atresia, Stenosis, Web

In utero ischemic damage to formed bowel causing variable degrees of luminal obstruction

Epidemiology: 1/1300-1/2000 live births

 Duodenum (50%) > jejunum / ileum (40%) > colon (10%)

Atresia: Complete obliteration of / failure to form the lumen of a hollow viscus

Stenosis: Gradual narrowing of gut lumen
Web: Discrete mucosal / submucosal band partially obstructing the lumen

Clinical presentation
 Polyhydramnios in utero (not eliminating amniotic fluid)
 Bilious vomiting, failure to pass meconium, abdominal distension

Treatment: Surgical resection

Duodenal atresia is distinctive:

 Associated with Down syndrome (1/3 Down pts)
 “Double bubble” sign on radiology
(gas distention of the stomach & proximal duodenum;
separated by pyloric constriction)

Tracheoesophageal Fistula / Atresias

Incomplete separation of lung bud from foregut

Normal development:
 trachea / esophagus develop from single tube (foregut)
 larynx/trachea/lung pinch off as lung bud

Epidemiology: 1/2000 – 1/35000 births

 30% have other malformations (cardiac, anorectal; determine prognosis)

Fistula: abnormal communication between hollow viscus & another organ

Atresia: complete obliteration of or a failure to form the lumen of a hollow viscus

39
Clinical Presentation
 Polyhydramnios in utero
 Choking on secretions, respiratory distress worse on feedings
 Can’t place gastric tube

 Often get esophageal atresia & tracheoesophageal fistula together

 Can also have one or another; symptoms are slightly different
o Esophageal atresia (blind pouch): mucousy babies, can’t swallow, no air in abdomen
o Tracheoesophageal fistula: baby feeds  cyanotic (food goes into lungs)

Treatment: immediate surgical reconstruction

Meconium Ileus
Obstruction of distal ileum by thick, viscid meconium of a child with CYSTIC FIBROSIS
 Important to make diagnosis: essentially making CF Dx too (15% CF pts)
 Meconium too thick; ileum is narrowest portion of small bowel (blocks!)

Clinical presentation
 Failure to pass meconium w/in 1st 48 hrs; abdominal distention
 X-ray: dilated small bowel proximally with microcolon distally
 Complications: perforation & meconium peritonitis (sterile b/c meconium sterile)

Treatment
 Uncomplicated: hypertonic enema (wash out)
 Complicated: surgery

Thick meconium  block ileum Histology: thick, viscid meconium Meconium peritonitis: multinucleated
obstructs ileum, sticks to mucosa giant cells eating meconium (brown)

Meconium peritonitis:
 Multinucleated giant cells react to foreign material (meconium)
 See brown pigment inside
 Don’t see many neutrophils like diverticulitis (sterile, irritant type reaction)

Meconium plug syndrome

 Often confused with meconium ileus
 Meconium impacted in colon, not ileum
 Not associated with CF

40
 Neonatal Hypertrophic Pyloric Stenosis
Progressive hypertrophy of the pyloric sphincter, causing obstruction
Epidemiology: 1/400 live births, Males > F (5:1), first born = ↑ risk, ↑ among 1st degree relatives
 Etiology unknown

Clinical presentation:
 Non-bilious projectile vomiting develops between 2-6wks
 Vigorous gastric peristaltic waves (can actually see) – trying to push food through pylorus
 Olive-shaped mass in upper abdomen can sometimes be palpated (Hypertrophic pyloric sphincter!)

Pathology: inner circular smooth muscle layer up to 4x thicker than normal; often disorganized muscle fibers
Complications: dehydration, metabolic acidosis, hematemesis (ulceration 2° to distention)

Treatment:
 Myotomy of pyloric sphincter with excellent prognosis: Just cut pyloric sphincter longitudinally!

Thickened pyloric sphincter Barium swallow: barely Giant peristaltic waves

(cross-section) passes through pylorus (seen just post-feeding)

Neonatal Necrotizing Enterocolitis (NEC)

An acquired, multifactorial process resulting in segmental necrosis of bowel

Epidemiology: Bane of NICU: mostly in premature, LBW babies (2.5% of NICU)

Pathology: simple bowel ischemia / infarction (but etiology not so simple)

Clinical presentation: classic triad

 Abdominal distension
 Bilious vomiting
 Bloody stools

Radiological findings: “double contour” of bowel wall (gas between layers)

Etiology: multifactorial
 Vascular: excessive blood shunting away from gut (stressed!)
 Direct mucosal injury: initiation of enteral feedings damages mucosa
 Infectious: epidemic NEC – multiple babies in NICU

Pathology:
 Ischemic necrosis of bowel wall (Ileum is 1st site involved)
o Mucosa dies first (L pic, most metabolically active & farthest from blood supply)  Transmural eventually

 Overgrowing bacteria (feeding on transmural necrosis) produce H2 gas in dead bowel wall
o Pneumatosis cystoides intestinalis (gas cysts in the intestine, R pic)  “double contour sign” on radiology
41
 Prolonged Neonatal Cholestasis / Jaundice

Key question: Is it extrahepatic or intrahepatic? (treatment different!)

DDx of prolonged neonatal jaundice (↑ conjugated bilirubin)
Extrahepatic Intrahepatic
Etiology Biliary atresia (40%) Neonatal hepatitis (50%)
Others: choledochal cyst, tumors Others: idiopathic bile duct paucity, bile acid metabolism errors, etc
Treatment Surgery Medical (surgery makes it WORSE)

Extrahepatic Biliary Atresia

Idiopathic inflammatory & fibrous obliteration of the extrahepatic bile ducts
 Liver choking on all the extra bile!

Presentation: normal at birth, jaundice (2-3 wks)  cirrhosis (3 mo)

Diagnosis: Disida scan: inject isotope, see normal pick-up, no excretion into duodenum (blocked)

Pathology
Gross Bile Ducts Liver
 Bile ductule proliferation
 Inflammation
 Periportal fibrosis
Findings Shrunken, hardened biliary tree  Injury
 Sparing of zone 3
 Progressive fibrosis
(centrilobular area)
Biopsy? Avoid! (would have to do laparotomy) Yes (no laparotomy needed)

Treatment:
 Kasai procedure: resect all the bile ducts; paste jejunum right to the liver
o Problem: putting bowel (bacteria) in direct contact with liver
o Buy time until transplant
 Liver transplant: best, if available
Bile duct Liver
Normal

Open lumen
Extrahepatic biliary
atresia

Shrunken, basically no lumen Bile duct plugs, bile ductile proliferation

42
Neonatal Hepatitis
Inflammation primarily of hepatocytes
 wastebasket term (any disorder that presents with cholestasis w/o structural cause)

Etiology: variety of causes

 Infection (TORCH, hep B/C)
 Metabolic: α-1-antitrypsin deficiency, CF
 Idiopathic

Diagnosis:
 Disida scan: poor uptake by liver, but do get excretion into duodenum
o Liver injured, but no obstruction of biliary tree

Pathology:
 uniform hepatocellular disarray (portal and centrilobular)
 giant cell transformation
 minimal bile duct proliferation
 liver biopsy isn’t specific for the different etiologies!

Treatment: medical treatment for underlying disorder

43
 Normal Liver Anatomy & Injury Patterns
Objectives to the lecture (will be exam questions)
1. Definition of cirrhosis
a. bridging fibrosis + nodules of hepatocytes
2. Which hepatitis virus has the highest rate of chronic infection?
a. “C” is for “Chronic!” - HCV
3. What are the histologic features of acute & chronic hepatitis?
a. Acute: parenchymal collapse, lobular disarray, inflammation, ballooning degeneration, cholestasis
b. Chronic:fibrosis, apoptosis, lymphocytes, necroinflammatory necrosis

Basic Anatomy

Hilum: Portal vein, hepatic artery, common bile

duct in vascular sheath

Outflow: hepatic vein

Zones: defined better metabolically than

anatomically

 zZone 1 near portal triad

 one 3 near central vein,

Histology: always start with bile duct

 Looks like beaded necklace
 Zone 1 is right around it

Recovery after injury

The liver can recover after injury!
Partial hepatectomy: can totally regrow the rest of the liver!

Acute injury  if not fatal, can get full restoration

Chronic injury  scarring  very slowly reversible

Below, left: mouse liver regenerating;

Below, right: human liver regenerating (CT)

44
 Basic Patterns of Liver Cell Injury
Ballooning Feathery degeneration Coagulative necrosis Apoptosis Necroinflammatory injury
Cell swelling Foamy cytoplasm Groups of ghost cells Individual “mummified” Inflammation + hepatocytes
Description Clumping organelles, hepatocyte, red, nucleus
cytoskeleton starting to fragment
Etiology Fatty liver disease Biliary obstruction Hepatic artery thrombosis Viral hepatitis Chronic viral hepatitis
Pathogenesis Loss of osmotic control Toxic effect of bile salt Ischemic injury Programmed cell death Immune mediated necrosis

Picture

Chronic Injury
Repeated acute injury  chronic injury
Chronic injury: Gross Chronic injury: Trichrome

Fibrosis (scarring), hepatocyte nodules (regeneration)

fibrotic areas are white, nodules of hepatocytes are brown
 Blue = collagen, red = hepatocyte nodules
Caused by any chronic liver injury Caused by any chronic hepatitis

Cirrhosis
CIRRHOSIS = BRIDGING FIBROSIS + NODULES OF HEPATOCYTES (know this!)

Bridging fibrosis: from portal tract to portal tract or central vein

 Molecular model (no need to know): injury  inflammation  cytokines / growth factors / chemokines 
fibroblast activation  + TGFβ  collagen production  fibrosis

45
 Hepatitis
Hepatitis = inflammation associated with hepatocyte death / injury
 Causes: viral hepatitis, autoimmune hepatitis, drug-induced hepatitis
Acute hepatitis Chronic hepatitis
Timing Days to weeks At least 6 months
 Toxins
 Viral hepatitis (A, B/D, non-hepatitis-virus)
Causes Acute, recurrent hepatitis / injury
 Alcoholic liver disease
 Genetic / metabolic
 Parenchymal collapse  Ballooning degradation
 Fibrosis  Lymphocytes
Histology  Lobular disarray  Mϕ infiltrates
 Apoptosis  Necroinflammatory necrosis
 Inflammatory infiltrate  Cholestasis

Cartoon

Acute Hepatitis

Lobular disarray (no architecture; can’t tell Parenchymal collapse: see wrinkled
where you are); also inflammation & Gibson’s capsule (hepatocytes↓ 
ballooning degradation parenchyma shrinks!  saggy)

Complications of cirrhosis
What’s bad about viral hepatitis?
 Hepatic encephalopathy
 Could resolve, or develop fulminant or chronic hepatitis
 Varices
 Chronic hepatitis  stable, or…  Ascites
o Hepatocellular carcinoma  Splenomegaly
o Other complications: see text box

46
 Chronic Hepatitis
Major questions:
Is injury occurring? Has recovery occurred?
 Are hepatocytes dying?
 Does the patient have fibrosis?
 What types of injury are occurring?
 Are there hepatocyte nodules?
Necroinflammatory / ballooning / coagulative necrosis
Necroinflammatory Injury (below) Fibrosis
Top: cartoon with varying degrees Top: cartoon with fibrosis, ± scarring
Bottom: see lymphocytes pouring out Bottom: fibrosis (↑ collagen in trichrome, lower pic)

Specific Diseases: Viral Hepatitis

Hepatitis A
 RNA virus
 Fecal-oral transmission
 NO CHRONIC INFECTION
 Rarely fulminant
 Anti-HAV

Pathology: inflammatory changes, mostly unremarkable

Hepatitis B
 Many don’t know that they’re infected

 DNA virus
 Blood, etc. transmission
 Acute & chronic forms
 Diagnosis:
o HBsAg = infection acute / chronic
o Anti-HBc+ HBsAg = chronic infection

47
Pathology:
 Ground glass hepatocytes, grayish in middle
 IHC for surface antigen

Ground glass hepatocytes IHC: HBsAg + More ground glass hepatocytes (arrows)

Hepatitis C
 Most patients develop chronic hepatitis (85%)
o Remain stable or progress to cirrhosis

 RNA virus
 Blood-blood transmission
 “C” MEANS CHRONIC
 Anti-HCV can detect
 Viral RNA: very low fidelity RNApol (↑ diversity)
Pathology:
Nodular portal inflammation Intracellular fat
(Dense lymphocytic infiltrate into portal tract)

Specific Diseases: Autoimmune Hepatitis

Pathology Features Type 1 Type 2
 Chronic but can look acute Age (10-20 / 45-70 yo) (2-14 yo)
 Bridging necrosis Women (%) 78 89
 Lymphocyte infiltrate Concurrent immune disease (%) 41 34
Autoantibodies ANA Anti-LKM
 Prominent IgG positive plasma cells
Gamma globulin elevation +++ +
Histology Plasma cells Plasma cells
PCs: vaguely triangular; have eccentric nucleus Progression to cirrhosis (%) 45 82
with white tuft next to it

Bridging necrosis, lymphocytes + PCs Lots of plasma cells (arrows & lymphocytes Dense lymphocytic infiltrate

48
 Specific Diseases: Drug-induced Hepatitis
Intrinsic Idiosyncratic
 Predictable  Unpredictable
 Sufficient dose induces injury in everyone  Depends on metabolic rate
 Immune system stimulation involved
Example: Tylenol – give enough and everybody gets liver damage Example: reaction to PCN
 Drug-induced hepatitis may be histologically indistinguishable from other types of liver injury

Acetaminophen Isoniazid Procainamide Methotrexate

 Coagulative necrosis
 Minimal inflammation  Diffuse necrosis  Enhanced SER
Change?  Periportal lymphocytic  Ground-glass Portal fibrosis
Mushrooms, α-methyl inflammation appearance
dopa can do this too
 Periportal (inflammation)
Where? Zone 3 (near central vein) Portal triad
 Diffuse (necrosis)

 ischemic injury
Mimics: Viral hepatitis Viral hepatitis B Chronic viral hepatitis
 hepatitis

Picture

49
 Alcoholic Liver Disease
Alcoholic Fatty Liver
Fat accumulation
a regular, reversible accompaniment of heavy alcohol consumption
 Nutritional & toxic effects (e.g. acetaldehyde)

 Holes: accumulation of lipids / TGs dissolved out during tissue formation

 Know it’s fat because it’s a droplet (liquid at body temperature
 Patients can present with fatty liver as only abnormality
o Hepatocytes can work just fine even if they look like this
o abnormal LFTs result from hepatocyte injury (acetaldehyde production, etc)

Mitochondrial damage (GIANT mitochondria)

Mitochondrial damage from acetaldehyde exposure EM: can see remnants of cristae in giant mitochondria

Alcoholic Hepatitis
 Active hepatocellular injury + inflammation seen in some alcoholics after many years of abuse

Clinical manifestations:
 ± jaundice
 ↑↑ AST, ↑ ALT (but lowish: defect in production of ALT). AST > ALT
o Most severe acute alcoholic hepatitis may have “normal” ALT (impaired production!)

Histology: combo of focal hepatocellular injury, active inflammatory response, active intralobular pericellular fibrosis

Category Histological findings Notes

Focal hepatocellular injury
Acute inflammation
Hydropic degeneration
“alcoholic” / “Mallory’s” hyaline
Focal cell necrosis / drop-out
Mostly PMNs
Irregular hyaline cytoplasmic inclusions
 accumulation of keratin-like filamentous proteins
 related to IFs
 represents disruption of cytoskeleton
PMNs‼ (vs lymphocytes in viral hepatitis)

Active intralobular Often seen with Greater degree of fibrosis than in comparable
pericellular fibrosis sclerosis of hepatic veins* degrees of other liver dz
Alcoholic hepatitis: most severe in centrilobular regions
 ± fat accumulation, cholestasis (not needed for Dx)

*Veno-occlusive disease: primarily centrilobular; affects small draining hepatic veins

50
 Veno-occlusive disease
Swollen hepatocytes (arrow)
Mallory’s hyaline Pericellular fibrosis (more severe: centrolobular region);
Mallory’s hyaline (open arrowheads),
(EM) (trichrome) small vein here half obliterated by
PMN –rich response (closed arrowheads)
fibrosis / cellular reaction

Non-Alcoholic Steatohepatitis (NASH)

Same histologic / clinical picture as alcoholic hepatitis, but not in alcoholics!

Risk factors: metabolic syndrome, ↑TGs, DM, obesity, HTN, etc.

 Anything that causes endoplasmic reticulum stress can lead to this
o Portal endotoxemia, for example
o Fat itself doesn’t play a huge role NASH Severe NASH
(post-jejunal-ileal bypass)
Example: pts who got early jejunal-ileal bypass
 endotoxemia from infection of blind pouch
 Obesity + ER stress (endotoxins)
 Produced non-alcoholic steatohepatitis!

NASH = (“steato”)hepatitis in context of NAFLD

 fatty liver background
 inflammatory changes like alcoholic hepatitis

Can progress to cirrhosis!

Cirrhosis
A disease in its own right!
 Can come from alcoholic or non-alcoholic hepatitis or variety of other etiologies

↑ intrahepatic resistance to blood flow is key problem

 Obliteration of small intrahepatic veins is the big problem

Complications: Hepatic encephalopathy, ascites, esophageal Varices (can rupture!)

 from portal hypertension / shunting of blood away from hepatocytes and
 reduced functional hepatocyte mass

Oten considered irreversible: but in early stages, can see reduction of fibrosis / architectural distortion / portal HTN
 if you can stop the active injury!

51
Cirrhosis: Pathology
Histologic definition: interconnecting bands of fibrosis and nodules of “regenerated” hepatic parenchyma

Esophageal varices big, dilated vein just under epithelium Ruptured varix with Rupturing varix: dissected
(gross) (varix) – more to right, but this one = bad “blood blister” through epithelium

Cirrhosis (trichrome): nodular distortion Cirrhosis: see lots of fibrosis! Veno-occlusive disease (same
& tons of fibrosis as above: cirrhosis destroys
small intra-hepatic veins)

Hepatic Veinograms: Recovery from cirrhosis

normal (left): note fine branching; Left: active alcoholic cirrhosis (bands / nodules)
alcoholic cirrhosis (right) – bigger / truncated veins, Right: same pt after 20 yrs of abstinence (structure restored!)
simplified structure – obliteration of small veins!
↑ resistance in alcoholic cirrhosis!

52
 More Fun Facts About Cirrhosis
 in France, ↓ cirrhosis during WWI/WWII (↓ EtOH availability!)

The Study (histologic features of alcoholic liver disease)

Looking at heavy drinkers to see what histological changes correlate with disease
 Bigger fat droplets = more fat in samples
 Hepatocellular injury is associated with presence of acute fibrosis, not fat accumulation!
 After 1 month of abstinence: ↓ fat accumulation, ↓ hepatocellular injury, fibrosis was mixed response
o Presence of alcoholic hyaline seemed to be important

Prognostication of how much portal HTN @ 1 mo:

What predicts what CWHVP will be in 1 mo?
 Prothrombin time (good)
 CWHVP (really good) at baseline
 HISTOLOGY (super good)

Take home point: biopsy every alcoholic with possible

cirrhosis (just kidding)

53
 Primary Liver Tumors
Overview of Neoplasm
By cell type
Cell type Benign Malignant
Focal nodular Hyperplasia*
Hepatocyte Hepatocellular carcinoma
Hepatic adenoma
Von Meyenburg Complex*
Cystadenocarcinoma
Bile duct Bile duct adenoma
Cholangiocarcinoma
Cystadenoma
Hemangioma Angiosarcoma
Vascular
Infantile Hemangioendothelioma Hemangioendothelioma
Mesenchymal/mixed Mesenchymal Hamartoma Hepatoblastoma
*Note: Von Meyenburg complexes and focal nodular hyperplasias form mass lesions, but are not truly clonal processes .

By age
Age Tumor
Hepatoblastoma
Infant
Infantile Hemangioendothelioma
Hepatocellular Carcinoma
Children/young adults Fibrolamellar Carcinoma
Hepatic Adenoma
Hemangioma
Bile duct adenoma
Adults Focal nodular Hyperplasia
Hepatocellular Carcinoma
Cholangiocarcinoma
Hepatocellular carcinoma
Older Adults
Angiosarcoma

Vascular tumors
Hemangiomas (benign)
 Most are cavernous hemangiomas
 Most common primary tumor of the liver
 Benign, composed of dilated blood vessels
 Usually small, incidental findings

Gross:
 Single, dark, red-colored
 Spongy consistency (blood vessels)

Histology:
 Thin-walled vessels, dilated, ± thrombi
 Scarring / hyalinization / obliteration of blood vessels can replace
center
 ± large “feeder vessels” at periphery

54
Infantile Hemangioendotheliomas (benign)
 Rare overall but still #1 liver lesion in 1st yr of life

Presentation:
 Can present with high-output cardiac failure
o (AV shunting / thrombocytopenia from platelet sequestration)
 May present only with hepatomegaly / diffuse abd. enlargement
 PE: palpable hepatic mass / diffuse enlargement
 ½ have cutaneous hemangiomas Multiple red spongy nodules

Prognosis: tend to spontaneously regress at 6-8 mo

Gross: multiple lesions, spongy  fleshy in appearance

 Vs. hemangioma: frequently multiple, not subcapsular

Histology: irregularly-shaped small vessels in sparse fibrous stroma

Irregular vessels in sparse fibrous stroma
Angiosarcoma (malignant)
 Extremely rare that arise from blood vessels of liver
 Risk factor: chemical exposure
o thorotrast, vinyl chloride (dry cleaning), arsenic

Gross: tan-white or hemorrhagic, can be spongy

 Small nodules scattered throughout liver
o Occasionally: single mass
Distorted blood vessel + atypia More sheet-like pattern

Histology: pleomorphic endothelial cells

 Form small channels, can contain blood
 Have atypia (as opposed to benign lesions)
 Multiple possible histologies:
o poorly formed vascular channels
o solid sheets
o growing along sinusoids (hardest to Dx)
Normal liver Angiosarcoma growing
along sinusoids

Hepatocellular Tumors
Focal nodular hyperplasia (benign)
 70% pts are female, usually 30-50 yo (OCP  trophic or ↑ risk rupture?)
 Not always a neoplasm (may not be clonal) but in DDx for liver masses
o Thought to arise from vascular malformation (A-V shunting)
o Can be single or multiple
o No risk for malignancy; NOT in cirrhotic livers
Gross:
 Well circumscribed, most (< 5cm) with central fibrotic scar (1/3 to ½)
 On non-cirrhotic background

Histology:
 Focal lesion: looks like “focal cirrhosis”
 Bands of fibrosis, bland hepatocyte nodules
 Abnormally thick-walled vessels (AV-shunt) often in tumor center
 Central scar (not always present)

55
Hepatic adenomas (benign with risk of malignant differentiation)
 Typically women of reproductive age, most with OCP use (85-90%) with estrogen
o OCP use may be remote – need good history
 Can be seen in several other rare conditions (androgen use, glycogen storage dz type I,III)
 NOT in cirrhotic livers

Possible complications:
 Risk of progression: 10% can progress to cancer
 Rupture → intraperitoneal hemorrhage (#1 risk)
 Can recur if not completely excised

Gross:
 Well circumscribed, 75% encapsulated
 Frequently have areas of hemorrhage
 Non-cirrhotic background

Histology:
 Uniform, bland hepatocytes
 Often partially encapsulated
 Can show ↑ steatosis vs. non-neoplastic liver (right)
 Thin-walled vessels (left, arrowhead) can be at ↑ risk rupture

Hepatic adenomas can progress to cancer

A. Gross: see area of hepatic adenoma (arrow), uninvolved liver
B. Junction of hepatic adenoma (left) and HCC (right)
C. Adenoma (left), hepatocellular carcinoma (right)
D. Reticulin stain of (C); shows ↓ reticulin along sinusoids in HCC

Hepatoblastoma (malignant)
 Malignant neoplasms
 Infants / young children (almost always < age 3); 2:1 Male:F
 Mutations in wnt-signalling pathways strongly linked to hepatoblastomas (β-catenin)
 ↑ AFP (α-fetoprotein) in 90% cases (USEFUL!)
o Infant with liver mass and ↑ AFP = hepatoblastoma in almost all cases
o Monitor AFP after surgery to check for recurrence

Gross:
 Non-cirrhotic livers (babies)
 Solitary, usually well-circumscribed in right lobe of liver
 Hemorrhage, necrosis, calcifications

Histology:
 Predominantly of primitive epithelial cells (left)
 With admixture of immature mesenchymal cells (right)
 Unusual pattern of growth
o in liver, unique to hepatoblastoma

56
Hepatocellular carcinoma (malignant)
 HCC is one of most common cancers worldwide (4/10k in USA, ↑ in SE Asia)
 In USA: HCC is 80% of primary liver carcinomas

Risk factors:
 Chronic HBV hepatitis (most important world-wide)
 Chemical carcinogens:
o Aflatoxin B1 (toxic metabolite of Aspergillus flavus: contaminant of grains / legumes in Asia / Africa)
o HBV + Aflatoxin B1: synergistic effect
o Thorotrast, vinyl chloride, arsenic too (now more rare exposure)
 Cirrhosis from chronic HCV is most common risk factor in USA (more chronic HCV)

Epidemiology of HCC in USA

 Average 61 yo; rare before age 40 (get hepatitis C in 25-35 yo age range; takes time to develop)
 70% men; ↑ incidence in USA

Prognosis:
 Generally bad (≈ 6 mo)
 Worse with: Age (> 5), male, tumor stage / grade, presence of cirrhosis
 Often not detected until late stage
o Screen for HCC in high risk groups (serum AFP, CT scans)
o Can resect if you see it early

Gross
 Can be in both cirrhotic (80%) or non-cirrhotic liver
 Well circumscribed ± capsule
 Can be greenish (bile) or yellowish (fatty)
 Can be multifocal or one large nodule + “satellite nodules”
 Fed by abnormal hepatic artery growth (upper right in pic)
o Good for radiology (vascularized)

Histology:
 ↑ mitotic figures, ↑ cellularity
o Thickened hepatocellular plates (> 3 cells)
o ↓ reticulin staining
 NO portal tracts
 Abnormal arterioles
 AFP-expressing (1/3 patients) HCC: No portal tracts ↑ N/C ratio, no portal tracts
 Can have lots of different patterns too!
Standard cancer changes too: ↑ N/C ratio, hyperchromatic, etc.

Vascular invasion: ↑ risk recurrence

Abnormal arterioles: found in L: Normal, R: HCC ↑ proliferation AFP + with IHC

lobules too, not just portal tract Note ↓ reticulin stain in HCC (↑ mitotic figures)
57
More HCC Pathology
More Possible HCC Patterns

Pseudoacinar structures ↑ fat ↑ glucose ↑ proteins (inclusions) ↑ Lymphocytes

Vascular invasion: ↑ risk recurrence
 HCC invading small
vessel (big tumor
thrombus)

HCC invading portal v.

Produced thrombus (see
thrombin, etc.)

Fibrolamellar carcinomas (malignant)

 Subtype of HCC (5%)
 Younger patients (≈ 25), no gender predilection
 Just as aggressive as usual HCC
o No cirrhosis in background (↑ survival rate)
o More likely to go to lymph nodes vs typical HCC

Gross: Background non-cirrhotic

Histology:
 Bands of dense fibrosis (fibro-) that tend to run parallel to each other (-lamellar)
 Abundant pink cytoplasm, big nucleoli

Bile duct tumors

Bile duct adenoma (benign)
 Small, solitary, sub-capsular benign neoplasms of bile ducts
 No malignant potentially
 Usually incidental finding
o (while pt undergoing abd. surgery for another cause)
 Can mimic metastatic disease: small firm white nodules

Cholangiocarcinomas(malignant)
 Arise from bile ducts anywhere w/in biliary tree
o If in hilum of liver = Klatskin tumor
 Risk factors for EXTRA-hepatic cholangiocarcioma are different than intra-hepatic
Extrahepatic cholangiocarcinoma Intrahepatic cholangiocarcinoma
 Cirrhosis from any cause
Diseases that cause chronic biliary tree inflammation
 HCV
 PSC, Caroli’s disease, parasites
 EtOH
Extrahepatic cholangiocarcinomas are ↓ in frequency: we’re getting better at treating PSC, etc.
Intrahepatic cholangiocarcinomas are ↑ in frequency: ↑ HCV, ↑ cirrhosis in USA

58
Gross:
 White, firm, well-circumscribed
o Elicit lots of desmoplasia
o Never encapsulated
 ± background cirrhosis (risk factor)

Histologically:
 Malignant proliferation of poorly formed infiltrating
small glands that form duct-like structures
 Desmoplastic response (firm on gross exam)
 Perineural invasion

Dysplasia is precursor to cholangiocarcinoma

Metastatic disease
Metastatic lesions to the liver are 16x more common than primary liver neoplasms in autopsy
 90% show MORE THAN ONE NODULE
 Pancreas, colon, breast, stomach, lung

Colon carcinoma (met to liver) Neuroendocrine carcinoma (met to liver)

59
 Pathophysiology: GI
Disorders of Swallowing & Reflux Disease .............................................................................................................................. 2
Gastric Acid Secretion & Peptic Ulcer Disease ........................................................................................................................ 7
Fat Absorption & Malabsorption .......................................................................................................................................... 13
Mechanisms of Diarrhea ....................................................................................................................................................... 19
Celiac Disease ........................................................................................................................................................................ 25
Inflammatory Bowel Disease ................................................................................................................................................ 29
Gastrointestinal Motility ....................................................................................................................................................... 34
Functional GI Disorders / Irritable Bowel Syndrome (IBS) .................................................................................................... 39
Gallbladder ............................................................................................................................................................................ 42
Acute & Chronic Pancreatitis ................................................................................................................................................ 47
Pancreatic Cancer ................................................................................................................................................................. 53
Pediatric GI ............................................................................................................................................................................ 56
Liver Tests ............................................................................................................................................................................. 58
Hepatitis: Basics .................................................................................................................................................................... 63
Viral Hepatitis........................................................................................................................................................................ 66
Inherited and Metabolic Liver Disease ................................................................................................................................. 71
Cholestatic Liver Disease....................................................................................................................................................... 76
Autoimmune Hepatitis, Alcoholic Liver Dz, and Non-Alcoholic Fatty Liver .......................................................................... 81
Portal Hypertension & Cirrhosis ........................................................................................................................................... 86
Liver Transplant..................................................................................................................................................................... 93
Liver Review .......................................................................................................................................................................... 96

1
 Disorders of Swallowing & Reflux Disease
Introduction
 Humans swallow 600x / day; without apparent effort / forethought normally
 Swallowing involved in nutrition, oral hygiene, airway protection, social interaction

Physiology of Swallowing
Between swallows: nasal cavity / larynx in communication with pharynx (breathing)
 Upper esophageal sphincter (UES) tonically closed
o Esophagus sealed off; don’t fill with air on insp.
o Barrier to regurgitation
 Upper esophagus, pharyngeal constrictors = striated mm.
 Lower esophagus = smooth mm.

Deglutition: initiation of swallowing

1. Lips seal oral cavity
2. Blade of tongue moves contents up, back, through palatine arch
3. Nasopharynx closes (soft palate ↑, sup pharyngeal constrictors contract)
4. Airway closed (epiglottis deflects, larynx ↑, vocal cords approximate)
5. UES relaxes

Progressive peristaltic wave

 Starts in upper pharynx, moves down length of esophagus
 Contractile wave  pressure wave
o forces bolus down
o enough pressure to swallow standing on head
 Constriction below, dilation above bolus

Entry to stomach: LES relaxes so bolus can pass into stomach

Sphincters: Areas of higher pressure, relax in coordination

 Prevent regurgitation (LES)
 Regulate flow of air (UES - direct air into larynx)

Flow is determined by pressure gradient

𝚫𝐏 pressure gradient viscosity
𝑭𝒍𝒐𝒘 = = 𝑹𝒆𝒔𝒊𝒔𝒕𝒂𝒏𝒄𝒆 ≈
𝐑 resistance radius𝟒

Patient’s sensation of where problem is isn’t that specific

 Symptoms are always at or below where patient perceives it
 Food piles up above site of obstruction; spasm above level of problem, referred sx, etc

Mechanisms of Dysphagia
Structural disorders Motor disorders
 Paresis
 Luminal stenosis
 Sphincteric dysfunction
 Diverticular formation
 Spastic disorders

2
 Structural Disorders
Luminal Stenosis
Stenosis ≈ stricture ≈ narrowing
 Something narrowing the channel
Examples of stenotic lesions
 Inflammatory strictures – “ benign”
 Malignant strictures – often abrupt narrowing
 Schatzki’s rings – ≈ 10% middle aged individuals

Presentation:
 Pure solid food dysphasia
 Bolus-size related (sx only when can’t pass)
 Better after vomiting (undigested food) Luminal
Likelihood of symptoms
 ↓ Sx: avoiding difficult-to-chew foods, cutting/chewing diameter
well, washing down with lots of H2O < 12 mm everyone is symptomatic
 ↑ Sx: distracted & not able to control behavior 10-20 mm symptoms vary (severity / presence)
(eating out, booze, rushing, etc.) > 20 mm no one has symptoms
Sx only when lumen ≈ 50% compromised
Evaluation:
Barium swallow: First test to order on pt with swallowing disorder
 swallow radiodense material while radiologist takes X-ray snapshots
 Pharynx: whole event takes 1s; often use video recording for pharynx (esophagus slower, can do series)
 Info: where’s the problem; likely to be benign / malignant, motility disorders?

Endoscopy: Complementary to barium swallow (do 2nd – Dx, get tissue Bx, for treatment!)
 Left: secondary to chronic reflux and scarring
 Middle: tumor (looks like tissue); do Bx
 Right: Schatzki’s ring (shelf of tissue)

Variance between these too; depend on behavior / condition

Treatment: Esophageal dilators or surgical resection

 Dilation: lots of different ways (balloon, etc) – stretch the channel
 Resection: esp. if malignant
 Treat underlying problem: strictures will narrow again!
o E.g. reflux strictures: ↑ time to recurrence with PPI therapy

Diverticula
outpouchings coming out from esophagus
 NB: diverticulosis occurs in colon: totally different

Zenker’s diverticulum:
 1/10k-1/100k; mostly older people (more common than esophageal diverticula)
 occur in hypopharynx just above UES

Esophageal diverticulum: most often distal esophagus

Pulsion diverticulum: diverticulum that results in ↑ intraluminal pressure

 “wear & tear” phenomenon

3
Presentation:
 Dysphagia for solids & liquids with regurgitation of undigested food (lay down  spill out)
o Regurgitation often hours after ingestion
 Zenker’s – risk for aspiration – coughing during meals, at night, etc.
 Esophageal diverticula: usually relatively asymptomatic (down lower, not spilling out)

Pathogenesis: see two pathologies in both pictures

 Most result from downstream obstruction  keep pressing (on area of weakness?) above (“wear & tear”) 
o Bulge  pressure ↑ still  bulge grows  diverticulum!
 Also see: strictures below diverticula

Treatment
 Remove obstruction (will recur even with resection if obstruction not fixed)
 Surgical resection (diverticulectomy) usually needed too if severely symptomatic

Paresis
Neurologic dysphagia:
 Neurologic conditions (strokes, ALS, head/neck trauma, brain surgery)
 Neuromuscular disorders (MG)
 Myopathic conditions (polymyositis, MD)

Presentation:
 Dysphagia for liquids & solids
 Associated with airway penetration & regurgitation
o Penetration: material enters larynx but doesn’t get below vocal cords
o Aspiration: material gets below vocal cords into trachea
 Swallowing: usually protects respiratory system; in paresis, not clearing out material!

Normally during swallowing: many systems working to protect breathing (see above)
 Inhibition of respiration, elevation of larynx, approximation of vocal cords, inversion of epiglottis, pharyngeal clearance

Note that this is a really important mechanism: lots of redundancy

 After epiglottectomy – pts don’t always aspirate!

Sclerodermatous esophagus:
severe weakness of esophagus is the problem
(vs. neurogenic where nerves are problem)
 Affects smooth muscle of esophagus
o Pharynx, upper 1/3 esophagus work fine
(striated mm)
o Lower esophagus looks flaccid
(no contraction: smooth muscle)
 LES weak too (poor clearance + fulminant reflux)

Diagnostic approach
1. Barium studies (most helpful) – barium radiography w/ spot films
a. videopharyngoesophagram if pharynx is problem (pharynx too fast for spot films)
2. Manometry (assess contractile strength)

Treatment: drugs aren’t too effective for striated muscle

 Treat GERD if LES weak

4
Sphincteric Dysfunction (Achalasia = prototype)
 If the sphincter doesn’t relax, then it behaves like a stricture
 “ Functional obstruction” (not anatomical)
 Rest of this applies to achalasia (other forms possible too)

Pathogenesis: selective loss of inhibitory neurostimulation to myenteric plexus ganglion causes…

 Paresis (esophagus affected)
 Sphincteric dysfunction (↑ LES pressure, LES can’t relax)

Presentation:
 Dysphagia for solids & liquids
 Delayed regurgitation of recognizable food eaten hours before,
especially if they lie down is CLASSIC

Evaluation
 Barium swallow
o narrowing, column of barium
o air-fluid level, solid food retained
 Endoscopy:
o normal folds, just narrows dramatically,
o need to rule out stricture
 Manometry:
o aperistalsis of esophageal body
o failure of LES relaxation

Treatment: directed at weakening / tearing the muscle

 large diameter balloon dilatation (common – tear / rupture muscle) – see pic above
 surgical myotomy (also common – cut away some muscle)
 Smooth muscle relaxants (Ca channel blockers, etc – experimental, some success)
 Intrasphincteric botulinum toxin (safe, but only lasts ≈ 1 yr)
o Ach, substance P are excitatory (contraction)
o VIP, NO are inhibitory (relaxation)
o in achalasia: problems with inhibition
o Botox: ↓ contraction (degrades SNAP-25, ↓ vesicle release), restores balance

Cornflake study: way to measure the degree of esophageal retention

 Follow transit of food with radioactive labeling (e.g. cornflakes)
 Less radiation than barium esophagram – good for assessing response to Tx

Esophageal Spasm
 Diffuse esophageal spasm (DES): one extreme of esophageal dysmotility
 Tertiary contraction: individual abnormally coordinated contraction (also in normal, asx people)

Presentation:
 Dysphagia for liquids & solids
 Regurgitation immediately after swollowing
 ± chest pain (squeezing phenomenon), often sharp, radiates to back (can mimic angina too!)

Pathogenesis: unclear!
 Similar sx seen in pts with abnormally high but peristaltic contractions (nutcracker esophagus)
 May be related to visceral hyperalgesia (abnormally ↑ levels of sensory perception)

5
Treatment of DES:
If idiopathic:
 Nitroglycerine / Ca channel blockers
o to relieve idiopathic spasm / chest pain
o Side effects! (smooth muscle relaxants, ↓ BP)
 Tricyclic antidepressants may help with visceral hyperalgesia
 Surgery (long myotomy: use sparingly – cut esophageal smooth muscle down its length)
If secondary: usually GERD (treat GERD!)

Gastroesophageal Reflux Disease (GERD)

Reflux itself: occurs in majority of people on daily basis
GERD (disease): causes symptoms on recurring basis (how much, how frequently, how long does it stay in esophagus)

Presentation:
 BURNING PAIN IN CHEST & SOUR MATERIAL IN MOUTH are classic, esp at night
 Chest pain, dysphagia, sore throat, hoarseness, cough, asthma too

Pathogenesis:
 Weak / deficient anti-reflux barrier
o Anatomy of esophago-gastric junction (barium study / endoscopy)
o Strength / function of LES (manometry)
 ↓ saliva (Sjogren’s) – can’t neutralize acid
 Stomach emptying problems, frequent transient relaxations, impaired
esophageal clearance, impaired gastric emptying, etc. also involved

↑ anatomic risk: (↑↑ if both!)

 Hiatal hernia (EG junction displaced above diaphragm)
 Low LES resting pressure

Evaluation:
 Continuous reflux monitoring (best test available)
o pH or esophageal impedance + pH
 “PPI test”: give PPI to see if symptoms relieved (empiric trial with high dose PPI)
 Barium esophagram; endoscopy: not too sensitive
Erosive esophagitis &
stricture
Continuous reflux monitoring: pH monitoring
 Cath down through nose, measure pH and/or impedance
o Impedence: can detect non-acidic reflux!
 Normal physiologic reflux occurs during day, after eating, rapidly cleared
 Pathological reflux:
o more prolonged periods, at night
o esophagus stays acidic (not clearing)

Treatment:
 Dietary / life style modification
o Coffee, tea, chocolate, fatty foods, alcohol, smoking, smaller meals
o Avoid lying down after eating, elevating the head of the bed.
 Acid suppression (H2RAs, PPIs)
 Prokinetics (in theory – improve stomach emptying): Erythromycin, , metoclopramide, , domperidone, tegaserod
 Surgery: fundoplication (wrap lower end of esophagus with stomach, produces artificial barrier)
6
 Gastric Acid Secretion & Peptic Ulcer Disease
Normal Anatomy & Physiology of the Stomach
4 regions
 Cardia
 Fundus
 Body
 Antrum

Rugae = folds
 contain gastric pits  open into 4-5
gastric glands

Greater, lesser curvatures

Insets: endoscopy

Role of Stomach in Digestion

• Holds ingested food
• Degrades food (chemically /physically)
• Delivers chyme to the small intestine
• Enzymatically digests proteins (pepsin)
• Secretes intrinsic factor required for absorption of vitamin B12

Cell Types in the Stomach

By Location
Cardia Fundus and Body (oxyntic mucosa) Antrum and Pylorus
 Parietal cells
 Gastrin cells (G cells)
 Chief cells
 Mucous cells  Mucous cells
 Mucous neck cells
 Endocrine cells  Endocrine cells
 Endocrine cells
 D cells
 Enterochromaffin-like cells (ECL)

Note that ECLs secrete lots of stuff: Gastrin, Histamine, Endorphins, Serotonin, cholecystokinin (CCK), somatostatin

7
Microscopic anatomy of stomach

Stomach lining / protection

 Exposed to harsh conditions: HCl (pH 2), pepsin, but pH ≈ 7 at cell surface
 Mucosal protection (see above right)
o Bicarbonate-rich mucous is secreted and coats the stomach wall
o Epithelial cells are joined by tight junctions
o Gastric glands have cells impervious to HCl
o Damaged epithelial cells are quickly replaced
 Prostaglandins are main mediators of protection
o ↑ mucosal blood flow, mucous secretion, bicarb secretion, restitution
o If mucosal prostaglandin synthesis impaired (NSAIDs), protective
mechanisms are impaired!
o Pathogenesis of NSAIDs: both direct toxicity & inhibition of prostaglandins

Acid Secretion

Parietal cells in lower / middle oxyntic glands

 Basal state: lots of tubulovesicles in cytoplasm
 Stimulation  tubulovesicles fuse  form secretory canalicular complex

Canuliculi: long microvilli with H/K ATPase enzymes on apical cell membrane
 Require lots of energy (lots of mito)
 H+ from carbonic anhydrase (CO2 + H 2O  H2CO3  H+ + HCO3-)
 Cl enters canuliculi via Cl channels (net: make HCl)
 K channels allow K to flow back out of cells (for more exchange for H)
o Basal state: not many K channels open
o Secretory state: K channels open, K returned to cell, HCl secreted

Net result: 100-160 mmol HCl secretd (pH ≈ 1) – 2.5L/day

 Also secrete: water, Na, HCO3, mucus

8
Regulation of Gastric Acid Secretion

Molecule Released from Binds to Effects

Stimulation of Gastric Acid Secretion

ECL cells (oxyntic glands) H2 receptors (parietal cells) ↑ acid secretion

Histamine
Mast cells (lamina propria) H3 receptors (D-cells) ↓ somatostatin release (↑ acid secretion)
M3 receptors (parietal cells) ↑ acid secretion
Vagal nerve endings
Acetylcholine ECL cells ↑ histamine release (↑ acid)
(postganglionic parasymps)
D-cells ↓ somatostatin release (↑ acid secretion)
Parietal cells Proliferate, release acid
Gastrin G-cells (gastric antrum)*
ECL cells ↑ histamine release

Inhibition of Gastric Acid Secretion

Somatostatin D-cells (gastric antrum)** Parietal cells ↓ acid production / secretion
* Gastrin secreted in response to gastrin-releasing peptide (GRP), presence of food (esp AA) in gastric lumen
** Somatostatin secreted in response to ↓ pH in gastric lumen (protective! Shut off acid!)

Molecular mechanisms

Parietal cell stimulation

1. Histamine  H2 receptor  Gs protein 
↑ adenylate cyclase  ↑ cAMP
2. Ach  M3 receptor  ↑ Ca release

Both cAMP / Ca ions activate protein kinases

 Shape transformation of parietal cell
 Release of gastric acid

Vagal nerve:
 Direct Ach action and
 ↑ GRP production (↑ gastrin release)

Gastrin:
 Stimulates parietal cell directly
 Gastrin receptors on ECL  ↑ histamine  activates parietal cell indirectly

Parietal cell inhibition

 Somatostatin  Gi protein  ↓ adenylate cyclase  ↓ cAMP

o Prostaglandins: similar mechanism to inhibit parietal cells
o Also: somatostatin  inhibits ECL cells  ↓ histamine release

 Vasoactive intestinal peptide (VIP), secretin also inhibit parietal cell function

9
 Physiology of Gastric Acid Secretion
Basal (fasting) acid secretion
 Gastric acid secreted continuously under fasting conditions in diurnal pattern
o Lowest secretion in morning, highest in evening
o ↑ vagal tone  basal hypersecretion in some people; also temporary hypersecretion in stress
o Women secrete less acid in basal state than men!

Physiologic acid secretion (3 phases)

Phase Timing Mediated by Acid secreted in response to Inhibition from…
 Loss of appetite
Prior to food
Cephalic Vagus nerve Sight, smell, taste or thought of food  Depression
entry
 ↓ parasymp stimulation
 Distention of the stomach by food
(stretch receptors)
Once food  pH < 2
Neural reflex  Direct action of food on gastrin release
Gastric enters  Emtional upset
pathways  Direct stimulation of the G cell
stomach (overrides parasymps)
(by amino acids and digested food)
 Chemoreceptors (peptides, caffeine, ↑ pH)
 Distention of duodenum
As partially
 Digested proteins in the small intestine  Presence of fatty, acidic, or
digested Release of
Intestinal*  Direct stimulation of parietal cells hypertonic chyme
food enters gastrin
(by absorbed amino acids)  Duodenal irritants
duodenum

* entry of gastric contents into duodenum also leads to inhibition of gastric acid secretion (via secretin release)

Gastric Contractile Activity

 Peristaltic waves (3/min) in stomach
 Basal electrical rhythm: from interstitial cells of Cajal (“gastric pacemakers”)
 Most vigorous mixing / peristalsis: near pylorus
 Chyme: with each contraction, either
o delivered through pylorus in small amounts to duodenum or
o forced back into body for further mixing

Gastric Emptying
Regulated by: neural enterogastric reflex and hormonal (enterogastrone) mechanisms
 Inhibits gastric secretion / duodenal filling

CHO-rich chyme: moves quickly to duodenum

Fat-rich chyme: digests slowly (food stays in stomach longer)

Peptic Ulcer Disease

Risk factors:
• H. pylori gastritis • NSAIDS • Family history
• Aspirin • Smoking • Acid hypersecretion (Zollinger-Ellison syndrome)

Diagnosis: clinical; lots of other stuff is similar

 can use upper GI endoscopy / barium studies too

10
Pathogenesis of PUD:
 Causative: H. pylori, acid, NSAIDs / ASA, Pepsin
 Protective: prostaglandins, mucous production, bicarb, mucosal blood flow

Complications of PUD: Bleeding, perforation, obstruction

Treatment of PUD:
 If bleeding: upper endoscopy (treat bleeding), give IV PPI
 If perforated or endoscopy doesn’t stop bleeding  surgery
 If H. pylori present: treat with abx + PPI
o Clarithromycin + amoxicillin + PPI
o Metronidazole + tetracycline + bismuth + PPI
 Avoid: NSAIDs, aspirin, smoking
 Treat with PPI / H2RA

Pathogenesis of PUD: NSAIDs

Double effect; big cause of PUD (esp. gastric ulcers)
 Local caustic effect (local cell toxicity)
 ↓ prostaglandin synthesis  ↓ cytoprotection, mucous secretion
o Inhibits arachadonic acid pathway (inhibit COX-1  ↓
prostaglandin synthesis  ↓ production)
COX-1: constitutive expression, involved in tissue homeostasis
COX-2: inducible expression, involved in inflammatory response

↑ Risk for adverse GI events with NSAIDs:

• Prior GI bleeding • Steroid use • Older age
• Anticoagulant use • Higher dose

Pathogenesis of PUD: H. pylori

 Extremely common (2B worldwide, 30% in developed countries); have detectable IgG
 Fecal oral transmission  colonizes gastric mucin (NOT invasive into mucosa)
 ↑ gastric acid production
o Releases cytotoxins, chemotatic factors  ↑ PMNs  chronic inflammation
o ↓ antral D cells  ↓ somatostatin  ↑ acid
o Also makes histamine analog (H3 agonist  ↓ somatostatin release)
o Makes urease (helps protect from HCl)

Complications of H. pylori (most are asymptomatic!)

 Gastritis  Gastric lymphoma (MALT lymphoma)
 Peptic ulcer disease (gastric / duodenal ulcers)  Gastric acenocarcinoma

Diagnosis of H. pylori
 Histology  Fecal H. pylori antigen test  Serology – IgG
 Rapid urease test  C13 or C14 urea breath test o Can’t distinguish between
 Culture current and past infection

Eradicate h. pylori in pt = cure H. pylori gastritis / PUD

11
Duodenal ulcer
 Deep, non-healing defect in mucosa of duodenum
 Most commonly in duodenal bulb
 90% caused by H. pylori (↑ acid in stomach  into duodenum)

Symptoms: epigastric pain, indigestion, nausea

 Worse with fasting (2-3h post meals)
 May wake patient at night

Findings: ulceration, gastric metaplasia (leads to peptic duodenitis), gastrin mucin cell metaplasia
Treatment: H. pylori eradication, gastric acid suppression

Gastric ulcer
 Most in antrum
 70-80% H. pylori related
 NSAIDs (↓ prostaglandins) can be involved too

Symptoms: epigastric pain, nausea, ± wt loss (afraid to eat)

 Pain 15-30m after eating (vs duodenal – 2-3h)
 nocturnal pain / pain when fasting rare

Treatment: H. pylori eradication, gastric acid suppression

 NSAIDs are bad

Zollinger-Ellinger Syndrome / Gastrinoma

ZE syndrome: disorder of acid hypersecretion
 Gastrinoma: ↑↑ gastrin  ↑↑ acid Classic triad of ZE Syndrome
1. Basal gastric acid hypersecretion
Diagnosis of ZE 2. Postbulbar duodenal ulcer
 serum gastrin >1000 pg/ml (150 nL) 3. Pancreatic gastrinoma (islet cell tumor)
 Basal acid output measurements (↑)
 Secretin stimulation testing: measure serum gastrin before / after
o Normally: no ↑ in serum gastrin after IV secretin
o ZE: ↑↑ serum gastrin

Clinical Presentation
 Diarrhea in 1/3 (damage prox. intestinal mucosa, inactivate pancreatic enzymes: hyperacidity, ↑ fluid load - ↑ secretions)

May be related to Multiple Endocrine Neoplasia type 1 (MEN1) – 1/3 ZE pts

 Characterized by hormone secreting tumors: check parathyroid, pituitary
o Hyperparathyroidism (80%), islet cell tumors (50-60%), pituitary tumors (40-50%)
o In MEN1, gastrinomas are malignant and multiple

Treatment of ZE: PPI in high doses, most die of metastatic gastrinoma (50% at 10 yrs)

Stress ulcers
 Common in ICU, typically single / multiple erosions/ulcers in fundus / body of stomach
Pathogenesis: related to ↓ mucosal blood flow (sepsis, burns, hypotension)
 ↓ mucosal blood flow  ↓ PG synthesis  ↓ mucous, bicarb secretion
Prevention: prophylaxis with H2RA / PPI

12
 Fat Absorption & Malabsorption
Introduction / Definitions
 Absorption: passage of foodstuffs into the body; essential function of the GI tract
 Malabsorption: defects in this process.
o Generalized (e.g. celiac dz) – malabsorb CHO, proteins, fats
o Specific (e.g. pernicious anemia) – only malabsorb B12, for instance
o Steatorrhea: symptom of malabsorption of fat (Odorous, greasy, hard-to-flush stools)
 Fat: easy to detect in feces; colonic bacteria metabolize only a small fraction

Triglycerides: 40% of diet; 9 kcal/gm (concentrated calories); Fat is mostly triglyceride

 If you malabsorb fat, you also malabsorb fat-soluble vitamins (ADEK)

Overview of Fat Absorption

Purpose: ↑ lipid / H2O interface (where lipolysis happens)

Fat emulsified by gastric mixing
1. Emulsification  contractions against closed pylorus  jet spurts backwards
 Shearing forces emulsify; emulsion stabilized by other dietary constituents
Small intestine: peristalsis  more agitation, then stabilized by bile
Released from proximal small intestine (fatty acids & certain AA stimulate)
Acts on gallbladder & pancreas
2. Cholcystokinin-
Gallbladder: discharge contents into duodenum (contract GB, relax sphincter of Oddi)
pancreozymin
Pancreas: discharge zymogen granules into acini; ↑ synth of new enzymes
(CCK-PZ)
 Proenzymes activated by enterokinase on surface of small bowel mucosal cells
 Active enzymes: hydrolyze dietary fat  more FA  ↑ CCK-PZ release (self-perpetuating)
Pancreatic lipase: hydrolyzes dietary triglyceride
 Secreted in active form (not proenzyme)
 Absorbs to oil-water interface
3. Pancreatic  Partial hydrolysis
lipolysis (1-ester bonds only; makes 2-MG and 2 FAs)
 Works rapidly; pH optima in presence of bile acids 6-7 (duodenal pH!)
 10x excess (need to lose 90% pancreatic fxn to have steatorrhea)

13
 Colipase: secreted 1:1 with pancreatic lipase; activated by trypsin
 ↑ activity of pancreatic lipase 40-50%:
 associates with bile salts on micelle surface; “docking station” for pancreatic lipase

Other enzymes in pancreatic juice

 nonspecific esterase (hydrolyzes cholesterol esters / ester lipids)
 phospholipase (hydrolyzes lecithin, releasing 1 FA & soluble 1-lysolecithin)

Bile acid micelles:

 Lipolytic products (FAs, MG, etc):
insoluble in water; would stay in lipid droplets
 Soluble in bile acid micelles (↑1000x with ↑ *bile acid+)
note that TGs are NEVER soluble, no matter what [bile acid]

Bile acids (cycle = enterohepatic circulation)

4. Micelle  Synthesized in liver (from cholesterol, conjugated with taurine / glycine)
formation  Stored in gall bladder  secreted (CCK-PZ)
 Solubilize lypolitic products (which are absorbed in jejunum)
 Bile acids actively absorbed in ileum, returned to liver via portal circulation  re-excreted
EFFICIENT: Less than 5% bile acid lost into colon / day; bile salt pool makes 2 loops / meal

For micelles to form: need [bile acid] > critical micellar concentration (CMC, ≈ 2mM)
Cholesterol, vitamins ADEK need micellar solubilization but not lipolysis
Medium chain TGs need lipolysis but not micellar solubilization (lipolytic products soluble)

Micellar lipid taken up into enterocyte by carrier transport

5. Mucosal uptake
 favorable gradient: from fatty acid binding protein

Inside enterocyte: FA go to ER for TG resynthesis

6. TG resynthesis /
 Primary pathway: monoglyceride acylation (2-MG + 2 FA-CoA  TG + 2 CoA)
reesterification
 Fasting: secondary pathway (acylation of α-glycerophosphate, phosphatidic acid  TG / phospholipid)

Purpose: make newly resynthesized TGs aqueous-soluble

 Lipid droplets given lipoprotein coat
 Extruded through lateral, basal cell membrane
7. Chylomicron
formation

8. Lymphatic Chylomicrons are too big to go to capillaries  go to lacteals (small lymphatics)

transport  Lacteals  lymphatics  thoracic duct back to general circulation

14
 Defects in Fat Absorption
Stage Possible defects
Motility affected (think surgery) lose gastric churning or pyloric barrier
1. Emulsification  vagotomy, gastric resection, gastric motility dysfunction, gastro-jejunostomy
 Diabetes: stomach fails to contract like it should
2. CCK-PZ Fat doesn’t get to the duodenum (so ↓ stimulus for release)
release  Gastrojejunostomy: bypasses duodenum  ↓ secretin, CCK-PZ release

Exocrine pancreatic insufficiency

 Alcoholics (large quantities)  destroy exocrine pancreas (± endocrine too – DM)
3. Pancreatic  Chronic pancreatitis, CF, pancreatic duct obstruction, lipase inhibition, congenital deficiency too
lipolysis Low pH in duodenum (ZE syndrome) can inactivate pancreatic lipase
Note: Need pancreatic lipase < 10% of normal to have steatorrhea
 (lose 85% of function, might be fine; 90%  severe steatorrhea!)

Enterohepatic circulation affected

 ↓ bile acid secretion (liver dz, bile duct obstruction)
4. Micelle
 Interrupted enterohepatic circulation: surgical resection of terminal ileum (don’t resorb)
formation
 Precipitation of bile salts in intestinal lumen (↓pH, drugs – neomycin, cholestyramine)
 Deconjugation of bile acid (overgrowth of bacteria)

5. Mucosal Epithelial cell damage:

uptake  celiac disease, tropical sprue, intestinal infections, small intestine resections

Failure to synthesize protein coat (Abetaliproteinemia)

6. Chylomicron
 make TGs but get hung up in enterocyte (can’t get out); abnormal RBC membranes too
formation
 Anderson’s disease too (unknown etiology)
Interfere with transport of lipid from intestine
7. Lymphatic  Tumors / infections / trauma involving mesenteric / thoracic lymphatics
transport  Whipple’s disease: interfere with flow of lymph through villi, intestinal lymphatics
 Intestinal lymphangectasis: developmental hypoplasia of lymphatics

Clinical Evaluation of Malabsorption (in general)

When to suspect malabsorption?

Symptom Substance malabsorbed Symptom Substance malabsorbed
Weight loss Calories Edema Protein
Steatorrhea Fat Tetany Ca, Mg
Diarrhea OH-Fatty acids Osteoporosis Ca, protein
-
Bloating H2O, H2, CO2 (methane) Milk intolerance Lactose
Anemia Fe, B12, Folate Bleeding / bruising Vitamin K

Findings that suggest net malabsorption

• Hypoalbuminemia • Prolonged prothrombin time
• Hypocalcemia • Reduced carotene levels

15
 Evaluating Fat Malabsorption
Key question: why is fat being malabsorbed? Where’s the problem?
Intestine
Stomach Removal
Intraluminal Mucosal
2. CCK-PZ release
5. Mucosal uptake 7. Lymphatic system / to
1. Emulsification 3. Lipolysis (MGs/FAs)
6. Chylomicron formation thoracic duct
4. Micelle formation (biliary tract)

Categorization of Tests
Disordered phase Tests
Intraluminal  Lundh test meal / bentiromide test
 D-xylose absorption test  Small bowel series
Mucosal
 Lactose tolerance test  Mucosal biopsy
 Glucose hydrogen breath test  Schilling test
Intraluminal and/or mucosal
 Small bowel culture
Removal  Mucosal biopsy  Mesenteric lymphangiography
Specific Tests for Fat Malabsorption
Initial tests: is there net fat malabsorption?
Quick but not as precise
 Stain stool with “Sudan”
Stool Sudan staining  fat droplets show up yellow
 4+ fat droplets / HPF  steatorrhea

Better test, harder to do

72-hr fecal  Pt: ingest 100g fat / day; poop in paint can, keep in fridge, analyze for fat
fat collection Normal: Should absorb 95% of fat (see ≤ 5g/day in stool)
Abnormal: see > 5g/day (malabsorption)

Later tests: evaluate mucosa

Small intestine mucosa is good first step: easiest to evaluate!
Simple sugar: normally absorbed by intestine; doesn’t need intraluminal digestion
 Eat  absorbed (intestine)  liver  urine elimination (w/in 5 hrs)
 Measure: D-xylose in urine
D-Xylose
If intestinal mucosa abnormal:
 ↓ d-xylose absorption  ↓ d-xylose in urine
rd
Other causes of ↓ urine excretion of d-xylose: renal dysfunction, bacterial overgrowth, 3 space fluid (ascites)

Small bowel series: use barium contrast

 (outline mucosa, look for mucosal abnormality)
Small bowel
series  Floculation: dilution of barium (small bowel retaining fluid)
 Can see stricture, dilitation too
Capsule  picture: left is abnormal; flocculation/stricture present
endoscopy
Capsule endoscopy: swallow small pill
 send pictures to transciever on pt’s belt

16
 Endoscopy (peroral)  use pinch biopsy forceps to get small bowel mucosa
 Allows for pathologic evaluation of mucosal disease

Jejunal biopsy Findings can be:

 Diagnostic (Whipple’s dz, AB lipoproteinemia, intestinal lymphangectasia, amyloidosis, giardiasis, coccidiosis)
 Characteristic (Celiac dz, tropical sprue, eosinophilic gastroenteritis, Crohn’s)
 Non-specific / normal (pancreatic insufficiency, bile salt deficiency, bacterial overgrowth)

Examples of jejunal biopsy

 Villi absent
Celiac disease  Crypts elongated (trying to ↑ SA)
 Plasma cells, lymphocytes in lamina propria

 Villi abnormal but now present

Post-treatment  Crypts are gone
 Plasma cells / lymphocytes now absent

Later tests: evaluate intraluminal problems

Test for pancreatic insufficiency

 Chymotripsin (pancreas) cleaves PABA from
bentiromide

Bentiromide Give 500mg bentiromide, measure 6 hr urine sample

test  Normal pt (pancreas OK): free PABA released in duodenum 
absorbed  conjugated in liver  excreted in urine
 Severe pancreatic insufficiency (< 5% normal fxn)
↓ PABA excretion

Test for bacterial overgrowth of small intestine

 Ingest glucose, breath collected / analyzed
Glucose
Hydrogen If bacterial overgrowth:
Breath Test
 H2 produced by bacteria
 Detected in exhaled breath!

17
Vitamin B12 and the Schiling Test

Vitamin B12: normally (need IF & terminal ileum receptors to absorb B12!)
 Ingested, combines with R factor in stomach
 Duodenum: R factor hydrolyzed from B12 by pancreatic lipase
o Intrinsic factor then binds it (IF from parietal cells of stomach)
 B12-IF  taken up in ileum (specific receptors)

Schilling test:
1. Give 1000 g IM of nonradioactive B12 (both treat patient & saturate body stores so radiolabeled B12  urine!)
2. Give oral dose of radioactive B12
3. Collect 24 hr urine (normally > 7% will be excreted in urine)
a. If not absorbing: excreted in colon!

Parts of the test: distinguish why B12 absorption is messed up

Add __ with radioactive B12 Pernicous Anemia Ileal disease / resection
Part I Nothing (no IF) Abnormal Abnormal
Part II Intrinsic factor Normal (corrects!) Abnormal
Part III Broad spectrum abx Abnormal
Part IV Pancreatic enzymes Abnormal

 Note: if ileum missing, then can’t correct B12 absorption (pernicious anemia = no IF; add IF and it corrects!)
 Ilectomy – takes years post surgery to develop (big B12 stores)

Algorithm for Evaluation of Fat Absorption

18
 Mechanisms of Diarrhea
Epidemiology
Developing countries: Acute Diarrhea
 Mostly kids < 5yo: 3.2 episodes / yr, total burden not decreasing (population ↑)
 Mortality: 20% mortality of kids < 5yo (1.9x106 deaths / yr), 0.15% CFR (↓ with ORS introduction)

In USA
 2/3 of people get acute diarrhea in a year; 1/3 of those food related, 2/3 probably viral, etc.
 Chronic diarrhea: 3M yr (40% are irritable bowel syndrome – idiopathic), huge burden in cost
 Killer in USA too (esp. elder population; death rates ↓ with time in kids)
o Hospitalized old people: 3% with diarrhea die!

Normal GI & Water

Daily intestinal water balance
Intake Output
 Oral intake: ≈ 2L / day  Absorb 98% of water in intestine
 Organ secretion: ≈ 7L / day (majority!)  Only ≤ 200 mL out in stool!
o Gut both absorbs & secretes water (absorption ≫ secretion)
Secretion: water follows active electrolyte transport osmotically (aquaporins or tight junctions)
 Note: if no net sodium transport in gut lumen, still have hydrostatic pressure pushing water out into gut! (secretory state)

Definition of Diarrhea
 Too much water lost in stool!
o Normal stool water: 130 mL / 24h
o Diarrhea: > 200mL / 24h (3SD > normal)

Absorption & secretion (small intestine: right; colon: left)

 Absorption of sodium in villus
 Secretion of chloride in crypts

Epithelial cells: are vectorially oriented

 Apical or basal side, divided by tight junctions
 Asymmetric distribution of transport proteins

Small intestine Na absorption

Basolateral side: 3Na/2K ATPase, pumps sodium out
 Need energy!
 Makes lumen negative (electrochemical gradient)

Apical side: all transport proteins; several types, regional distribution

 Electrogenic: charge moves when sodium moves
o ENAC (colon): epithelial Na Channel
o Na/X : e.g. SGLT1 – sodium glucose linked transporter 1 (D-glucose, D-galactose taken up)
 Neutral: no net movement of charge
o Sodium/chloride cotransporter
o Na/H exchanger (NHE3); linked to Cl/bicarb exchanger
 Linked by carbonic anhydrase in brush border; H2O + CO2 H++HCO3-
 H+, HCO3- created  pumped out by the two pumps

19
Segmental Distribution of Intestinal Na Transport Proteins

Neutral: mostly in Ileum / colon

Glucose / AA: mostly in jejunum

Jejunum Ileum Colon

Na/D-Glu ++++ +
Na/L-AA ++++ +
Neutral NaCl + ++++ ++++
ENac + ++++

Glucose acting on SGLT1: stimulates NHE3 being put into apical membrane (linked)
 NHE3 is the key sodium absorption protein (neutral NaCl)
 Absorbs Na in exchange for extruding H+
 Coupled to Cl/bicarb exchanger

Neutral NaCl absorption in small intestine

1. Explains most basal Na absorption in small intestine in fasting
2. Explains ↑ ileal Na absorption in post-prandial state
3. Only process in Na absorbing cells inhibited in diarrheal diseases
4. ↑ in CF (contribute to meconium ileus?)
5. Linked to SGLT1 glucose transport?

Colonic Na absorption

SCFA = short-chain fatty acid / hydroxyl exchanger

Colon is more efficient than small intestine (compare to kidney)

 Small intestine: 9L in, 1.5L out
o Large volume, low efficiency (like proximal tubule)
 Colon: 1.5Lin, 0.13L out
o Small volume, high efficiency (like distal tubule)

Intestinal Cl Secretion
 same mechanism as lots of other places

Na/2Cl/K cotransporter and 3Na/2K ATPase in basal membrane

 Basal conditions: apical Cl channels not working
 Insert Cl channels  secretion
(Physiologic secretory state, diarrhea, other diseases)
 Note that K is required here

Intestinal secretogues (↑ secretion)

Some work from lumen, others in blood, others in mucosa / submucosa
Bacterial enterotoxins Humoral agents Laxatives
 Cholera  Vasoactive intestinal peptide (VIP)  Endogenous (bile acids, FAs)
 E. coli  Prostaglandin E  Exogenous (commercial)
 Staphylococcus  Calcitonin

20
 Dynamic Balance: Secretion / Absorption
 Normally absorption > secretion
 postprandial: brief shift (secretion > absorption) – don’t want to always have to run to bathroom real fast

What regulates balance? Neurohumoral environment

Inflammatory cells, COX, Lipoxygenase, nerves, cytokines, etc.
 Changes with eating
 Diarrheal diseases are exaggerations of this process

Diarrheal Disease
Diarrhea: in some part of digestive tract, the balance shifts: absorption > secretion

GI tract has EXTRA ABSORPTIVE CAPACITY

 Needs to overwhelm the absorptive capacity of remaining parts of digestive tract!
o Need much bigger problem to have diarrhea from proximal source!
o E.g. eat something, stomach starts secreting  stomach rumbles  can be absorbed by rest of GI tract
 Small intestine normally absorbs 7-9L but can handle 12L; colon normally absorbs 2-3L but can handle 4-6L

How was this determined?

 if you give nonabsorbable molecules during diarrhea & then perfuse, end up with more liquid (net secretion!)
 ↓ *noabsorbable test molecule+ concentration

Mechanisms of Net Intestinal Secretion

1. Inhibition of active electrolyte absorption
2. Stimulation of active electrolyte secretion
3. ↑ luminal osmolarity
4. ↑ tissue hydrostatic pressure

All diarrheal disease can be understood by these mechanisms! Most common: combination of #1 / #2

Cholera
 V. cholera  releases cholera toxin  ↑ cAMP  ↑ electrolyte secretion
o Lose up to 1L stool / hr! Would go into shock (need fluid replacement or ORS)
 Fecal-oral contamination (need 1M organism inoculum!)
o 10% get any diarrhea, 1% of those get this really bad diarrhea
 Can rarely see in US too – but good toilets are best way to go

Fluid replacement
 Cholera cot – collect bucket; measure volume with dipstick
 Need to replace fluids (ORS / IV)

Molecular pathogenesis

1. Production of cholera toxin (bacterial enterotoxin)

a. 1A/5B toxin (A=active, b=binding), released by bacteria
b. Binds GM-1 ganglioside receptor (brush border), A/5B subunits endocytosed
2. A/5B move into retrograde pathway (membrane  golgi ER)
3. In ER, A1 subunit (active) cleaved off, A1 subunit enters cytosol
4. A1 facilitates ADP ribosylation of adenylate cyclase’s Gs subunit (arginine)
a. Gα activated, so AC (on basolateral membrane) activated
b. Note that VIP activates AC in pancreatic cholera, but by a different mechanism
21
 5. ↑ AC  ↑ Cyclic AMP: activates PKA  p-lates stuff
a. PKA localized to different places in absorptive vs secretory cells
Absorptive cells: ↓ Na absorption Secretory cells: ↑ Cl secretion
 inhibits NHE3 (sodium absorption inhibition)  P-lates CFTR (insert Cl channel in apical membrane)
 only thing it does (PKA fixed to NHE3 by NHERF)  P-lates Na/K/2Cl (↑ insertion - ↑ activity)
 Na/substrate transport processes maintained –  P-lates K channels* (insert in apical membrane: K out
good for ORS!) with Cl, keeps cell electrically negative)
*lose A LOT OF POTASSIUM (BIG PROBLEM IN CHOLERA)

Bicarbonate ↓ in cholera
 Crypt: both Cl and HCO3- secretion via CFTR & Cl / HCO3- exchanger
 Villus: extra Cl in lumen from ↑ secretion exchanged for HCO3- - even more bicarb lost

Cholera: blood electrolyte findings

 ↓ K, ↓ HCO3 in blood
 Blood [Na] actually high (total body water ↓)

Oral Rehydration Salts

 Give glucose: can convert gut to absorptive state
 Na / glucose cotransporter NOT AFFECTED by cholera toxin
 Na, K, Cl, HCO3, glucose (or sucrose / starch / AA) to draw Na in
o Gatorade designed for loss of electrolytes in sweat (inadequate [electrolytes] for cholera)

Recent advances in ORS

 Hypo-osmolar solutions are better (≈ 220 mOsm/L) - ↑ absorption, ↑ effectiveness (solvent drag)
 Ceralyte (rice-based ORS): both starch & protein; may have anti-secretory effect, ↓ duration of diarrhea
 “Resistant (high maize) starch”
o ORS usually using just small intestine absorption
o non-metabolizable starch will enter colon  can take advantage of short-chain fatty acid transporter

22
Other mechanisms of cholera pathogenesis
 Affects enteric nerves
 Release intestinal prostaglandins
 Affects enteric serotonin-containing cells
o Large neural component!
Block serotonin cells  block 50% diarrhea
 Other cholera toxins (multiple!)
o Zonula occludens toxin: ↓ number of strands  makes
more permeable TJs (more water pulled through with chloride secretion)

Other diarrheal diseases work via ↑ cAMP too! Various ways to ↑ cAMP:
Prostaglandins UC, Crohn’s, medullary thyroid carcinoma, ganglioneuroma
Neurohumoral substances VIP Pancreatic cholera, ganglioneuroma, oat cell carcinoma of lung
Secretin Pancreatic cholera
Cholera toxin
Bacterial enterotoxins
Heat labile E. coli enterotoxin
Laxatives Bile salts, dioctyl Na sulfosuccinate, ricinoleic acid

cGMP, DAG, Calcium produce similar effects to cAMP: ↓ Na absorption, ↑ Cl secretion

cGMP: also ↓ Na absorption, ↑ Cl secretion
 Heat stable E. coli enterotoxin, Yersinia enterocolitica
 Heat stable E. coli toxin A: has AAs that are similar (basically simulating post-prandial state)

↑ intracellular calcium: also ↓ Na absorption, ↑ Cl secretion

 Neurohumoral substances (serotonin, AcH, neurotensin, substance P)
 Enterotoxins (C. diff, norovirus)
 Laxatives (senokot)

Diarrhea from ↓ Na absorption alone

Mechanism
Decreased Na absorption
Na absorptive cell damage
Increased motility
Decreased villus blood flow
Examples What’s going on?
Serotonin released in blood  inhibits NaCl absorption
Carcinoid syndrome
in small intestine (↑ calcium)
Celiac sprue
Can’t absorb Na
Viral gastroenteritis
Hyperthyroid Things moving too fast to absorb
Ischemic bowel Can’t take blood away fast enough

Celiac Disease
 “Villus Atrophy” – villi no longer there
 Sensitive to gluten, toxic reaction breaks down epithelial cells
 Bigger crypts, lots of inflammatory cells in lamina propria
 Secretion WORSE if you infuse glucose (epithelium can’t take it up, glc is osmotic agent to draw water out)

Celiac disease is more uniform (ORS doesn’t work well)

Viral diarrhea is more patchy (can still use ORS – works in intact areas)

Why diarrhea in celiac disease? Multiple mechanisms

1. ↓ brush border hydrolases (↑ unabsorbed osmoles) 3. Crypt hyperplasia (↑ secretion)
2. Villous atrophy  malabsorption 4. Inflammation  ↑ secretion

23
 Diarrhea due to ↑ luminal osmolarity
Disaccharidase deficiency
Lactase deficiency Very common (normal throughout world) – diarrhea after milk
Sucrase – isomaltase deficiency (primary / secondary) – diarrhea after table sugar
Trehalase deficiency Trehalose: diarrhea after mushrooms
Lactulose: synthetic disaccharide (no such thing as lactulase)
Cause diarrhea by ↑ delivery of osmoles!
Lactase deficiency
 Normal: Lactose’s β-bond broken by lactase in brush
border (proximal 3 ft of jejunum)  glucose + galactose
o Now two molecules: ↑ osmolality?
o Nope, normally: lactase found very close to SGLT 1
(glucose taken up right away)

 Lactase deficiency: lactose stays in lumen, ↑ osmolality

in colon (COLONIC DIARRHEA)
o Bacteria break it down to acid pH, H2+CO2,
short chain fatty acids - gassy

Note that malabsorption of fat doesn’t cause osmotic diarrhea

 forms micelles / precipitates, so doesn’t contribute enough to ↑ osmolality

Paradoxical Diarrhea: from ↑ tissue pressure

Normally: give ouabain (blocks all active transport); gut still secretes (hydrostatic pressure)

Paradoxical diarrhea: Partial small bowel obstruction can present with watery diarrhea
 ↑ hydrostatic pressure proximal to obstruction  diarrhea!

Pancreatic cholera (VIPoma) syndrome

Rare condition, a.k.a. Verner-Morrison Syndrome, not discussed in lecture

 Watery diarrhea (> 1L / 24h) which persists when patient fasts
 Hypokalemia
 Hypochlorhydria

Etiology: abnormality in non-B islet cells of pancreas

 Islet cell carcinoma, adenoma, hyperplasia
 Basically a VIPoma!
o ↑ VIP, other hormones  activates AC/cAMP system

Really rare (1/10 million per year, or about 670 cases worldwide)

24
 Celiac Disease
Key Points
 Gluten Induced Enteropathy, a.k.a. Celiac Sprue, Non-tropical Sprue
 Permanent, genetically determined auto-immune illness initiated by cereal prolamines (gluten/gliadin)
 Small bowel mucosal lesion causes intestinal malabsorption
o Villous blunting
o Intraepithelial lymphocytosis
o Chronic inflammation
 Clinical & histologic improvement on gluten withdrawal.

Clinical Overview
 Not rare (1:70-300; ↑ Europe, Argentina, ↑↑ Finland, 1:250 in Baltimore)
 Presentation: many ways (classically malabsorption + steatorrhea)
o Also: iron deficiency anemia, depression, osteopenic bone disease, ADEK loss sx
 Associated with autoimmune diseases
 Screening: with tTG IgA, CONFIRM dx with duodenal biopsy
 Treatment: avoid gluten; prognosis is good

Pathogenesis
Dysregulation of a usually suppressed T-cell response to gluten (HLA-DQ2 / HLA-DQ8 carriers)

Overview
1. Genetic basis (HLA-DQ2 / DQ8)

2. Gluten peptides taken up / processed

(DQ2, altered permeability, tTG involved)

3. Pathogenic CD4+ T-cells activated

(DQ2/DQ8 restricted T-cells, B-cells make Ab)

4. Tissue damage results

Genetic Factors
 Strong (70% MZ concordance, 10-15% in 1st degree relatives)
 Need HLA-DQ2 or HLA-DQ8 (In some pops, 30-35% are DQ2 or DQ8)
 Other genetic / environmental factors involved (only 2-5% gene carriers develop disease)
o 13 SNPs have also been implicated
o Cytokines during infection? Cross reactive AA sequences (HP, adenovirus)?

Environmental Trigger: Ingestion of Grain Products

Immunogenic peptides
 At least 11 peptides recognized by T-cells have been identified
 Not all subjects respond to all peptides (usually 1-5)
 No one peptide recognized by all celiac pts
Grain Prolamine
Grain prolamines: where immunogenic peptides come from! Wheat Gliadin
 Cereal prolamines initiate damage (not intrinsically toxic) Rye Secalin
 Corn / rice tolerated well (rice krispies, cornflakes OK) Barley Hodein
25
Processing of Grain Products  immunogenic peptides
 Need presence of HLA-DQ2 or HLA-DQ8
 Circulating Ab generated to enzyme (tissue transglutaminase, TG2)
o Most positive screening pts are asx
o Gliadin crosslinked to TG2  autoantigen

 TG2: deamidates certain gluten peptides  ↑ peptide affinity to HLA-DQ2 / HLA-DQ8

+
o Generates more vigorous CD4 Th1 T-cell activation
o Results in intestinal mucosal inflammation, malabsorption, 2° sx, autoimmune diseases
o Gluten: elicits innate immune responses that act in concert with adaptive immunity

Management of CD
Clinical Presentation

“Classical” presentation:
 Failure to thrive  Diarrhea, steatorrhea
 Weight loss  Abdominal pain
 Protuberant abdomen  Dramatic response to gluten
 Bloating (cranky kids) free diet

Varying forms (subtle deficiencies more common than classical presentation)

 Classical celiac disease (childhood)  Dermatitis herpetiformis
 Late onset, non-specific GI Sx  Asymptomatic c.d. (test relatives)
 Extra-intestinal presentations  Latent celiac disease
 Oligo-symptomatic

Represents a pathologic spectrum (see pic)

“Classical” case “Oligo-symptomatic” case
14yo M w/ diarrhea / anemia (2-4yo), undiagnosed. 34yo female, asx,
Delayed growth / puberty. Voluminous, foul-smelling, grey liquid stools. Unexplained iron deficiency anemia,
Anemia, low: FE /B12 / albumin /Ca /K /carotene. Osteopenia on scan, TG-2 positive
Cousin: CD; older sis / mom w/ thyroid dz, sis w/type I DM (autoimmune conditions) No FHx of celiac dz

Diagnostic Approach to CD
 Characteristic histological findings
 Response to a gluten free diet
o Clinical, serological, ± histological
 Endoscopy: scalloping of duodenal fold (suggestive)
 Duodenal biopsy (from endoscopy)

Clinical Presentation: remember, can be non-classical

Think about CD if you see unexplained…

 Anemia  Neuropsychiatric manifestations
 Osteoporosis  Related autoimmune conditions*
 Obstetrical problems  Dermatitis herpetiformis

* DM type I (3-8% have CD!), autoimmune thyroid dz (≈5%), Addison’s, alopecia areata, sjogren’s, dermatitis herpetiformis

26
Dermatitis Herpetiformis
 Erythematous macule > urticarial papule > tense vesicles
 Servere pruritis, symmetric distribution
 90% have no GI Sx, but 75% have villous atrophy
 Gluten sensitivity!

Non-specific GI symptoms:
 Altered bowel habit, bloating dyspepsia, abdominal discomfort, fatigue
 CD is 7x more common in IBS pts

↑ risk of Celiac Disease (and therefore ↑ index of suspicion) in…

 1 /2 degree relatives of CD pts  Autoimmune thyroid disease (5%)  IBS (3.4%)
st nd

 Down’s syndrome (12%)  Iron deficiency anemia (10-15% if sx, 3-6% if asx)  Chronic fatigue (2%)
 Type I DM (3-8%)  Microscopic colitis (15-27%)  Osteoporosis (1-3%)

Serologic tests
 tTG IgA (tissue transglutaminase IgA titer)
o Has high sensitivity / specificity for initial evaluation
o Good to monitor compliance / screen at-risk
o Can use to rule-out CD (high sensitivity if negative)
 ALL EMA / tTG positive pts should undergo small bowel (duodenal) biopsy
o gold standard for Dx
 HLA DQ Screening possible for screening too (negative can rule-out)
o DQ2/8 are susceptible to disease

Screening relatives is IMPORTANT!

Risk of Celiac Disease
General population 1.0%
Among people who are DQ2 or DQ8 positive 2-3%
st
People with unknown HLA and a 1 degree relative who has CD 10-15%
st
People with DQ2 or DQ8 and a 1 degree relative who has CD 20-30%

 Screen if
o Index case has proven celiac disease
o Relative willing to undergo diagnostic testing, treatment, will benefit from treatment
o If relative is symptomatic, approach should be DIAGNOSTIC, not screening!

Treatment
 Remove gluten from diet (GFD = gluten free diet) 3 Days surface epithelium damage reversed
2 weeks 70% have clinical improvement
Why seek a strict adherence to a gluten free diet? 6 weeks most have clinical improvement
 preventing, reversing and/or treating complications 4-6 weeks serological improvement (monitor compliance)
 Improved QOL (even for those detected by screening)  Corrects iron deficiency
 Improves unexplained infertility  Probably benefits overall cancer risk
 Improves osteoporosis  ? Effect on occurrence of autoimmune disorders

BAD grains GOOD grains

 Wheat  Rye  Couscous  Rice  Corn  Sorghum buckwheat
 Barley  Triticale  Kamut  Potato  Oats  Tapioca
 Bulgur  Spelt  Arrowroot  Soybean

27
Refractory Celiac Disease
80-90%: either ingesting gluten or have wrong Dx
 Type 1 refractory: respond to oral / topical steroids
 Type 2 refractory: pre-malignant condition
o 50% develop Enteropathy-associated T-cell lymphoma (ETAL) w/in 5 yrs!

Celiac disease & enteropathy-associated T-cell lymphoma

o 3x relative risk (in un-Rx’d CD) for ETAL
o CD on GFD > 5yrs: no ↑ risk ETAL / GI cancer (treatment = ↓ risk!)

Pathophysiology of Symptoms of Malabsorption

Fat malabsorption: steatorrhea
 Unabsorbed fatty acids are hydroxylated by enteric bacteria
o produce floating stools, rancid fats  foul odor
o Alter small / large intestinal fluid movement (net secretory diarrhea)
 Loss of calories  weight loss
 Loss of ADEK Vitamins (K- follow with PT)

Carbohydrate malabsorption
 Malabsorb sugars (e.g. D-xylose)
 Osmotic diarrhea: lose disaccharidases
 Gas, bloating, abdominal discomfort: from fermentative products
 Fatigue

Protein malabsorption
 Protein Losing  Edema
Enteropathy  Malnutrition

Vitamin / mineral malabsorption

Vitamin / Mineral Deficiency Absorption

Iron Anemia Duodenum (best)
B12 Anemia, glossitis* Ileum
A Night blindness
D Osteoporosis, hypocalcemia, tetany
Fat-soluble Vitamins With Fats**
E ↓ healing
K Bleeding
* Sprue = “sore tongue” in dutch (B12 deficiency  glossitis)
** ↓ absorption with overgrowth of bacteria (impaired motility, dilatation)

Celiac disease: dilated jejunum / ileum Glossitis: 2° to B12 / folate deficiency Tetany: 2° to Ca deficit (vit D)
 stasis  bacterial overgrowth

28
 Inflammatory Bowel Disease
Inflammatory Bowel Disease
(chronic relapsing / remitting disease of intestinal tract – 1M in USA)
Ulcerative Colitis Crohn’s Disease
Indeterminate
Ileitis
Proctitis (28%) Left-sided dz (25%) Pancolitis (47%) Colitis (10-20%) Ileocolitis (45%) Colitis (32%)
(22%)
% = % at time of diagnosis

Ulcerative colitis Crohn’s disease

Distribution

starts in rectum, moves more proximally, colonic only anywhere in GI tract (rare upper GI), mostly colon / Ileum
Endoscopy

 Edema, thickening of colon, loss of vasculature  Punched-out ulcers (apthae)

 Superficial ulcerations ± bleeding  Stellate or linear ulcers / cobblestoning (≈ street)
 Diffuse / continuous ulcers, can encircle colon  Patchy / focal / asymmetric distribution
 Severe: colon becomes tubelike  Severe: Macroulcerations & pseudopolyps

 Strictures RARE  Strictures COMMON

 Rectal involvement ALWAYS @ DX  Rectum commonly spared
Histology

Superficial mucosal ulceration Transmural inflammation

Less frequent Abdominal pain Frequent
Clinical manifestations

Frequent Bloody diarrhea Occasional

Never Abdominal mass Frequent
Never Intestinal obstruction Frequent
Almost never Perianal disease Frequent
Never Fistulae Common
PROTECTIVE Effect of smoking DETRIMENTAL
Less common Systemic Sx (EIMs*) COMMON
* see below for EIMs in Crohn’s
29
Crohn’s Disease (some extra info)
Progression of Crohn’s:
Inflammation Obstruction Fistulization

Ulcer goes the whole way through

 Abdominal pain
 Cramps  Diarrhea, pain
 Tenderness
 Distension  Air/feces in urine
 Diarrhea
 Vomiting  Enteroenteric, enterovesical,
 Weight loss
retroperitoneal, enterocutaneous

Extraintestinal manifestations of Crohn’s disease

 Aphthous stomatitis (canker sores)
o aphtha = ulcer
o stomatitis = inflammation of mucous lining of mouth
 Episcleritis, uveitis
 Arthritis
 Vascular complications
 Derm complications
o Erythema nodosum (tender red nodules under skin)
o Pyoderma gangrenosum (ulcers  grow  become necrotic
Therapy of IBD
Goals
 Induce remission & maintain remission
 ↑ QOL,
 Avoid long-term toxicity

Spectrum of therapies (balance efficacy with potential toxicity)

Antidiarrheals, bile sequestrants, antispasmodics,
Supportive agents
pain management, etc.

Aminosalicylates sulfasalazine, help with local inflammation

anti-inflammatory, ↓ immune system
Corticosteroids  prednisone, prednisolone
(doesn’t help maintain remission)
Antibiotics metronidazole, quinolones (see pathogenesis)
alter immune system work your way up
Immunomodulators  anti-TNFα, 6MP/azathioprine,
to more aggressive therapies!
methotrexate / cyclosporine, etc.

30
 Pathogenesis of IBD
Dysregulation of inflammatory response to a luminal pathogen in genetically predisposed patients
 Environment, microbes, epithelial barrier, microbial sensing, innate / adaptive immunity, leukocyte trafficking involved

Environmental factors
 Don’t know exactly how these work (from UC CD
epidemiology) Smoking ↓↓↓ ↑↑↑
 Smoking: ↑↑ Crohn’s, ↓↓ UC (best studies!) Appendectomy ↓↓ none
High sanitation level in childhood None ↑↑
Perinatal infection, breast feeding, OCP too? High refined CHO intake None ↑

Microbes
We know that bacteria are involved in IBD:
Animal IBD models require bacteria
 Specific bacteria ID’d
IL-10 knock-out mice
 Animal models require bacteria
 Grow in germ-free environment: no colitis
 Serum immune reactivity
 Grow in normal environment: develop colitis
 Efficacy of abx / probiotics for treatment!  Expose to only certain bacteria: still develop colitis

Normally:
 1014 cfu/g stool! Lots of bacteria & diverse species, 80% can’t be cultured
 Most: Firmicutes (mostly clostridia) & Bacteroides
 Hard to study (source material debated: feces / aspirates / mucosal biopsies?)

Altered intestinal bacterial flora levels in UC/CD pts

 Bacteroides, campylobacter, collinsella, clostridia, bifidobacteria, enterbactereacea, helicobacter (non-pylori)

Serology for IBD

Antibody Antigen NonIBD(%) CD (%) UC (%)
pANCA Histone H1 <5 15 65
ASCA Anti-saccharomyces cervisiase Ab <5 60 5
OmpC E. coli <5 38 2
Anti-I2 Pseudomonas fluorescens 19 54 10
All recognize bacterial antigens!
Antibiotics, probiotics help in IBD
 Abx shown to help in Crohn’s colitis, Crohn’s fistulas, pouchitis
 Probiotics shown to help in UC, Crohn’s colitis, pouchitis

IBD and the Immune Response

if we all have bacteria, why do only some patients get IBD?
Normally
Bacteria, intestinal mucosa have adapted to each other
Highly regulated innate, adaptive immune responses in GI tract
 Innate immunity: fast, less specific, no memory
 Adaptive immunity: slower, specific, memory response

Remember: Innate immunity responds first (PRRs, etc), then

primes adaptive immune response

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Innate Immunity & IBD
Epithelial cells: 1st point of contact with bacteria / line of defense against infection
Normally In IBD
 Barrier function Intestinal permeability defects in CD pts
 Produce cytokines / chemokines after bacterial invasion  (also in 10-15% 1 degree relatives; mouse models too)
st

 Interact with innate / adaptive immune cells Defects  IBD pts more prone to microbes

Pattern Recognition Receptors

 On innate immune cells; normally activated by PAMPs (pathogen-associated molecular patterns); 2 classes:
o TLRs: Toll-like receptors (on cell surface)
o NODs: Nucleotide oligomerization domain (intracellular PRRs)
 PRRs are dysregulated in IBD
o TLRs 2-6: bacterial lipoproteins, dsRNA, lipopolysaccharides, flagellin
o NOD2: bacterial peptidoglycan
 ↑ activation of downstream immune responses (↑ cytokines, antimicrobials)

Specific innate immune genes & IBD (Crohn’s, specifically)

Gene What product does More
1st gene associated with CD
 Predictive of early onset, ileal dz, ↑ structuring / fibrostenosis
 Localized in Mϕ, dendritic cells, paneth cells (distal small intestine – like CD!)
o Paneth cells: make defensins (natural antimicrobials)
NOD2 Intracellular PRR
Defect in NOD2:
 can’t eradicate intracellular organisms (lose controlled response)
 ↓ defensin production
IRGM Autophagy* “Immune-related GTPase”; expression levels influence efficacy of autophagy
ATG16L Autophagy* Mutations: impaired anti-bacterial autophagy
*autophagy = self eating (digest / recycle proteins / organelles, encapsulate & destroy bacteria)

Adaptive Immunity & IBD

Remember the CD4+ T helper cells?
Role Proinflammatory cytokines produced
Th1 Mediates cellular immunity (Mϕ driven) IFNγ, TNFα
Th2 Mediates humoral immunity (B-cell driven) IL-4/5/6/13
Th17 Manages transition between innate / adaptive immune responses TNFα, IL-6/17
 Regulated by Treg cells (suppressive T-cells)

Original theory
 CD is Th1-mediated, UC is Th2-mediated
 But TNFα antibodies are current top line therapy for BOTH CD & UC
o In this theory, only Th1-mediated CD should respond to anti-TNFα therapy

IL-23 Receptor
 SNPs in IL-23R are associated with both UC & CD (one is protective, another confers risk for both)
 IL-23: inflammatory cytokine produced by activated Mϕ / dendritic cells
 IL-23R: found on Th17 cells, Mϕ, and dendritic cells (NOT Th1/Th2)
o In clinical trials: IL23R Ab for Crohn’s!

32
New theory: Th1 ↑ in Crohn’s, Th2 ↑ in UC, Th17 ↑ in both!

Normal: T-cell differentiation in homeostasis IBD: balance shifts towards inflammation

Gut Homing of Inflammatory Cells

 Normally: inflammatory cells use integrins to traffick to gut
o α4β7 integrin interacts with gut endothelium’s MAdCAM-1 (roll, arrest)  diapedese, etc.

 Natalizumab being used to treat Crohn’s (also MS) – anti-α4 integrin antibody
o Stops leukocytes from homing to gut endothelium (and bbb)
o Remember PML can be a complication (not cool)

Pathophysiology: KEY POINTS

 Bacteria influence the development of colitis.
 IBD patients are genetically predisposed to disease
 IBD patients have compromised intestinal barriers
 IBD is likely influenced by aberrant sensing and processing of microbial antigens
o Altered PRR function: PRRs (TLRs and NODs) influence microbial sensing and are associated with IBD.
o Autophagy compromised: IRGM and ATG16L (autophagy genes) are associated with Crohn’s.
o 3 of 4 known CD genes are directly related to bacterial sensing or processing.
 A dysregulation of the T-cell balance contributes to IBD
o Th1 (Crohn’s), Th2 (UC), and Th17 (both) cells are all implicated in IBD
 Blocking T-cell activation or gut homing is effective in treating Crohn’s disease

33
 Gastrointestinal Motility
Regulation of GI motility: Normal Physiology
Segment Function Motility
Proximal  Accumulation, storage  Tonic movement of chyme
(fundus, body)  Regulates intragastric pressure  No phasic motor activity
Stomach
Distal  Grinding of food Phasic motor activity
(antrum)  Responsible for emptying (≈ 3 contractions / min)
Fed state Digest, absorb nutrients Mix / absorb
Phasic
Small Intestine Keep swept clean of bacteria / other Propel non-absorbed
Fasting state (≈12 / min)
residue residue
Contractions not as organized
 Absorb excess fluid  Mixing: Intermittent short segmental to-
 Salvage unabsorbed nutrients and-fro patterns
Colon (via bacteria)  Storage (next): relatively quiescent
 Permit defecation  HAPC (high amplitude peristaltic
 Transit time: 36 hours contractions ): promote defecation
(Intermittent ; ≈ 5/day)
Store feces & eliminate
Anorectum See below
(in a “socially acceptable manner”)

Anorectum
Storage:
 Rectum is storage reservoir
 Puborectalis, internal/external anal sphincters:
tonic contraction

Defecation:
 Response to voluntary defecation or ↑ rectal pressure
 Puborectalis relaxes
 Internal & external anal sphincters open

Enteric nervous System

Extrinsic component: parasympathetic & sympathetic innervations
Intrinsic component: 500 million neurons embedded in bowel wall
 Myenteric (Auerbach’s) plexus
 Submucosal (Meissner’s) plexus
Note: you can get reflexes from intrinsic system without CNS input!

5 groups of cells:
1. Smooth muscle
2. Enteroendocrine cells
3. Nervous tissue cells (neurons & glia)
4. Inflammatory cells (mast cells, lymphocytes, macrophages, granulocytes)
5. Interstitial cells of Cajal
o Non-neural elements
o Communicate with neurons and smooth muscle
o Intrinsic myoelectric frequencies
o Control frequency and propagation of contractions

34
Signalling in enteric nervous system
 Most molecules still unclear
 Serotonin: major stimulatory neurotransmitter
o Stored in enteroendocrine cells
o Released in response to intestinal stimuli
 Others: acetylcholine, substance P, etc.

Electrical Activity
 Rhythmic electrical activity
 Interstitial cells of Cajal  membrane depolarization 
hit threshold, fire AP repolarization  contractions Migratory motor complex

Fasting state Fed state

Migratory motor complex (MMC) Slow contractions in stomach / small intestine
 Clears stomach / intestine of residual food / debris ≈ 90 min  Stomach (3/min)
o Triggered by motilin (erythromycin)  Small intestine (12/min)
o Blocked by gastrin infusion  Colon: disorganized, but stronger

 Less pronounced in colon  Duration of fed state ↑ with ↑ calories, fat

 Lose MMC  bloating, distension (bacterial overgrowth)  Disrupted by opiates

Disorders of GI Motility (Overview)

 Gastroparesis  Irritable bowel syndrome
 Functional dyspepsia  Constipation
 Small intestinal bacterial overgrowth  Chronic intestinal pseudo-obstruction
o anything that disrupts MMC will ↑ growth / stasis o ↓ rhythmic contractions in fed state
o bloating / malabsorption o As if they were obstructed, but no focal point
(small bowel just not contracting)

Gastroparesis
Delayed emptying of stomach in absence of mechanical obstruction

Symptoms
 nausea  dyspepsia  bloating  weight loss
 vomiting of undigested food  epigastric pain  heartburn
Symptoms: severity can be highly variable, can be intermittent

Pathogenesis:
Destruction of gastric enteric nerves / interstitial cells of Cajal
Normal Gastroparesis
 Proximal stomach expands to accommodate food;
 Loss of fundic accommodation (bloating, early satiety)
maintains intragastric pressure
 Altered or absent antral phasic contractions (delayed emptying)
 Solids broken down (1-2 mm particles) by contractions
 Visceral hypersensitivity (pain)
 Gastric emptying: 50% in 2 hours, 90% in 4 hours

Etiology
Systemic disease Neuro / psych disorders Iatrogenic Idiopathic
 diabetes: 29%  autonomic dysfunction  Surgery
 (36%)
 paraneoplastic syndromes  spinal cord injury (vagectomy, partial gastrectomy: 13%)
 connective tissue disorders  Parkinson disease  Drugs (anticholinergics, tricyclics,
Post-infectious??
 anorexia dopamine agonists, opiates; radiation)

35
Diagnosis of gastroparesis
Physical examination: Prevalence of Gastroparesis:
 Early: normal  Not known
 Late: ± sucussion splash, wt loss, signs of dehydration  Women > men (7:1)
 30-50% of DM pts have delayed gastric
Laboratory tests: emptying (autonomic neuropathy?)
 No blood test
 use CBC / metabolic profile, amylase, pregnancy test, TSH to exclude other conditions

GI structural tests:
• Upper GI series (exclude obstruction)
• Endoscopy (exclude obstruction / gastric inflammatory process)

Gastric Motility tests

 Gastric emptying study: Scintigraphy
o Give egg substitutes & bread with nuclear tracer, take images over 4 hours
o Calculate how much emptying is going on
o Normal: > 90% emptying @ 4 hours
 Antroduodenal manography, electrogastrogram (EEG) – not widely available

Management of gastroparesis

 Dietary modification
o smaller, frequent meals (less stomach expansion  less discomfort)
o ↓ fat (fat slows gastric emptying)
o ↓ fiber (can sit in antrum, form large “vegetable balls”)
o Liquid supplements (don’t need as much churning, empty faster)

 Glycemic control: high glucose can slow emptying

 Medications: antiemetics and prokinetics

 Less frequently used: endoscopic therapy (botox?), gastric electrical stimulation (only works in some patients), percutaneous
gastrotomy / jejunostomy (bypass stomach), total gastrectomy (last resort)

Medications:
 Erythromycin:
o macrolide; stimulates motilin receptor; no known antiemetic effect
o Stimulates antral contractions & initiates MMC

 Metoclopramide
o Dopamine antagonist, also affects serotonin receptors
o Central antiemetic effects
o Induces antral contractions, fundic relaxation, ↑ antroduodenal coordination
o Side effect: tardative dyskinesia (low but very serious risk)

 Domperidone
o Peripheral dopamine antagonist (similar effects to metoclopramide)
o Central antiemetic effect (unclear why)

36
 o Not FDA approved

Constipation
Unsatisfactory defecation characterized by infrequent stool and difficult stool passage
 Symptom, not a disease!
 infrequent defecation alone is NOT SUFFICIENT to define constipation
o If you’re going infrequently but no problems – not constipation

Stool:
 Typically variation (normal!)
 Most stool should normally be type 3 or type 4
 On average: transit takes 36h through colon, 50-150g stool/day

Physiology: Normal
1. Segmental to-and-fro contractions to mix stool
2. Long quiescent periods for storage
3. Infrequent high amplitude propagating contractions (HAPC) to move stool (5/day)
4. Successful relaxation of anorectum to expel stool
Problems with any of these can lead to constipation!

Etiology of constipation: common (20% American adults); multifactorial

 Endocrine disorders  Neurologic conditions  Obstruction

(hypothryroidism, diabetes)  Connective tissue disease  Hirschsprung’s disease
 Metabolic derangements  Medications (over 100 listed)  Defecatory disorder
(hypercalcemia, hypocalcemia)  Functional

Hirschprung’s Disease
 Normally, neural crest cells migrate caudally towards anorectum during development
o Arrested in Hirschprung’s  absent ganglion cells in distal bowel
 Loss of internal anal sphincter relaxation with rectal distention
 Associated with constipation but symptoms variable based on length of involvement
 Usually detected in childhood but not always

Clinical Classification of Constipation

Normal transit constipation
Functional constipation (> 60% cases)
 stool frequency normal, but pts feel
constipated
 Probably due to perceived difficulty
w/ evacuation or hard stools
 Bloating, abd. pain, discomfort
 Fiber / osmotic laxative helps
Slow transit constipation
A.k.a. colonic inertia
 More common in young women
 Infrequent bowel movements
 ↓ # neurons and ICC
 Delayed emptying of proximal colon &
fewer HAPCs
Defecatory disorders
A.k.a. pelvic floor dysfunction, functional
outlet obstruction, dyssynergy
 Inability to extrude formed stool from
anorectum
 Can’t coordinate muscles or structural
abnormality
 Treatment: retrain muscle
(biofeedback) or correct structural
abnormality

Clinical Evaluation of Constipation

 History & Physical:
o Sx, stool frequency, stool form, any maneuvers they have to do to get stool out
o Eliminate other systemic conditions
o Rectal exam (tone, etc)

37
  Lab testing (TSH/Ca) – usually don’t do
 Radiography / endoscopy to exclude obstruction (colonoscopy, barium enema)
 Physiologic tests if needed

o Colonic scintigraphy

o Radiopaque marker transit study (Sitz marker study)

 Swallow radiopaque capsule; look at transit speed over time

o Anorectal manometry
 Catheter across sphincter; ask pt to bear down
 Look at pressure inside sphincter (pic: L = rest, R = squeeze)

o Barium defecography
 Put paste in rectum; have pt squeeze it out
 Not popular with pts

Management of Constipation
For normal transit constipation:
 Lifestyle modification:
o ↑ activity (if you’re more active, bowel activity ↑ too)
o ↑fluid intake
o Defecate early in morning / after meals (when activity is normally highest)
 Fiber (main 1st therapy)
 Osmotic laxative (2nd therapy usually)
 Colonic stimulants
 Prokinetics (don’t work well in colon)
 Chloride channel activators (new meds – like inducing mild, controlled cholera)
 Enemas, suppositories (last resort)
o injecting something into stool helps soften it
o ↑ pressure  ↑ contractions

For slow transit constipation

 Same as previous slide, but fiber makes symptoms worse! (more bloating,e tc)
 Surgery to remove colon can be considered

For defecatory disorders

 Direct treatment to underlying disorder
 Biofeedback if functional
 Surgery if structural

38
 Functional GI Disorders / Irritable Bowel Syndrome (IBS)
Functional GI disorders: a group of disorders of the digestive tract that are characterized by
 chronic abdominal complaints
 without a structural or biochemical cause that could explain symptoms.
For instance: do a whole workup; no cause found; sx interfere with life, etc.

Why are they important?

 Affect up to 70% of the population
 Contribute to a lower quality of life compared to “structural” GI disorders
 Challenging to manage (can’t just use Rx)

Case example: 21 yo F; CC: post-prandial bloating and intermittent diarrhea

 HPI: travel to asia 1 yr ago, developed severe diarrhea x 3 wks. Dx: amebic dysentery
 Never fully back to normal stooling; now diarrhea 4xday, small volume, watery, mucous
 No nocturnal episodes / wt loss / food intolerances / fever / chills
 Meds: acidophilus; SH: “stressful”, no EtOH/smoking/etc; ROS / PE nL, labs nL
Formerly caused “mucous colitis”, spastic colitis, etc. – now irritable bowel syndrome

Irritable Bowel Syndrome

Symptoms:
 Bloating  Diarrhea (can be intermittent)
 Abdominal pain  Constipation (can alternate with diarrhea, etc)

Formal definition (Rome III) recurrent abd pain or discomfort 3d/month in last 3 months with 2+ of the following
 worse with defecation
 onset associated with change in frequency of stool
 onset associated with change in form of stool

IBS epidemiology
 20% of Western pop (70% don’t see health care provider)
 Women 2:1 vs men
 30-50yo @ 1st presentation (really rare to have 1st presentation in elderly)

Impact:
 lots of cost; 28% all physician visits (top 10); big economic impact (missing work)
 ↓ QOL (60% say sx are severe); health related quality of life worse than GERD / DM / ERSD

Clinical groups
 IBS-D (diarrhea predominant) IBS is NEVER associated with
 IBS-C (constipation predominant)  Weight loss
 IBS-Mixed  Anemia / rectal bleeding
 Diarrhea waking pt up at night
Pathogenesis
Theory: IBS pts have visceral hypersensitivity (enteric nervous system sensitivity ↑)
 Inflate balloon in rectum: IBS pts have more discomfort vs controls
 Women: ↑ sensory perception with balloon inflation (more urge to defecate, discomfort, pain)

39
Serotonin
 Key mediator of visceral sensitivity / motility
 Stimulation  serotonin released  binds to 5-HT3, 5-HT4
receptors

5-HT3 receptor: visceral sensitivity (sends signal up to brain)

5-HT4 receptor: ↑ peristalsis (synapses onto intrinsic enteric nerves)

Genetic polymorphisms
 Serotonin reuptake transporter (SERT) – determines what
active pool of serotonin is
o Maybe ↑ activity (↑ serotonin availability) in IBS?
o Also associated with ↑ visceral pain sensation

Brain function
 Maybe there’s a different cerebral response to rectal stimuli in IBS pts
 Different areas triggered in IBS vs controls (fMRI)

Why more common in women

Physiology
 Females perceive somatic pain differently, ↓ pain thresholds, ↓ tolerance, etc.
 Estrogen? Central administration of estrogens: ↑ pain response (may bind opiod receptors to ↓ analgesic
response)
Cultural
 Men: less willing to report pain; women more likely to seek health care
 Women: more self-conscious & ashamed about GI symptoms
Sexual abuse
 Up to 50% of IBS pts have history of sexual abuse

Other things associated with IBS: Migraine, chronic pelvic pain, fibromyalgia, depression, anxiety

Management of IBS
 Education, diet, pharmacology, mind/body therapies

Diet
 ↑ sensitivity / pain to colonic gas distension, so any foods that ↑ gas is bad
 Bad foods: high fiber / fat, caffeine, lactose (if lactose intolerant)
o Gassy vegetables (beans, anything with raffinose – not broken down readily – humans have no α galactosidase)
 Beano, other tricks can help
o Lactase deficiency: lactose  gas  pain; tons of people have it (esp worldwide)
o Fructose malabsorption: exacerbates IBS (malabsorbed  fermented by colonic flora  gas
 Typical American: 100g fructose / day (can only metabolize 50g/day!)

Pharmacologic therapy:
 Meds to: ↓ intestinal spasm, treat constipation / diarrhea, ↓ visceral hypersensitivity (new)
 But most pts with IBS are dissatisfied with pharm therapy (side effects, meds not good, not well educated)
 Serotonin-directed therapies
o Tegaserod (5HT4 agonist for IBS-C - constipation)
o Aloetron (5HT3 receptor antagonist for IBS-D - diarrhea)
 RCPTs not working: 40-70% placebo response rate!

40
Mind-body therapy
 “Gut directed hypnotherapy”
o Aim: return GI fxn to normal
o Reduces absenteeism, ↑ QOL, ↓ symptoms, ↓ med use / consultations
o 84% remain well 1-5 yrs after initial treatment
o Physiologic effects: normalizes rectal sensitivity in IBS pts who are hypersensitive
 Improvement correlates with better abd pain / depression

 Cognitive behavioral therapy

o “teaches IBS pts how to reframe and adjust how they evaluate and judge their symptoms”
o Better than 80% improvement at 4 yr follow-up
o Expensive, difficult to obtain (insurance doesn’t cover it)

Post-infectious Irritable Bowel Syndrome

 May be responsible for 25% of all IBS
 Reported after outbreaks of salmonella, shigella, giardia, campylobacter
o Bowels don’t go back to normal

Risk factors: long duration of diarrhea, female, psychological factors

Pathophysiology:
 ↑ T-lymphocytes, mast cells in lamina propria
 Release of tryptase, histamine  excite visceral sensory nerves

Natural history of IBS

 50% report symptoms for more than 10 years; 16% more than 20 years
o Symptoms severity: may wax and wane
 1/3 of patients initially diagnosed with IBS report complete disappearance of symptoms @ 12 years
o Maybe the post-infectious subtype?

Summary (from notes)

• IBS is associated with altered visceral sensation and motility mediated by disturbances in serotonin metabolism
• 25% of IBS is post-infectious, suggesting its pathophysiology is related to intestinal inflammation
• Pharmacologic agents targeting serotonin metabolism may allow better symptomatic control
• Currently, there are few therapies with strong evidence for reducing global IBS symptoms
• Cognitive behavioral therapy is associated with good long-term response
• Sex and gender differences are important in the pathophysiology and treatment of IBS;
these differences should impact how IBS is managed

41
 Gallbladder
Normal Anatomy of the Gallbladder
 in RUQ / epigastric region
 infrahepatic (between quadrate & right lobes)
 pear-shaped fundus (body) with hollow vicus

Ducts:
 hepatic duct from liver
 cystic duct to /from gall bladder
o cystic duct has spiral valve (of Heister) to control it
o 3-4 cm long normally
 hepatic / cystic duct join inferior to porta hepatis to form common bile duct
o Sphincter of Oddi around it
 common bile duct joins pancreatic duct @ duodenal ampulla (of Vater)

Gallbladder: has own blood supply (cystic artery)

 from right hepatic artery, a branch of proper hepatic artery (off of common hepatic artery)

Gallbladder epithelium
 Two functional layers; inner columnar epithelium participates in bile concentration
 Tight junctions well developed (resistance to passive flux of solute; passive loss of bile molecules)
 Goblet cells: secrete protective mucus

Bile
Production of Bile
Made in liver (synthesized in canalicular cells lining bile canals)
 drains into hepatic bile ducts, which coalesce (R/L hepatic ducts)
 250-1500 mL bile /day made & secreted by liver

Components of bile:
 water, electrolytes, proteins, lipids,
 bile salts
 bile pigments (bilirubin)
 pH neutral or slightly alkaline

Bile Salts
 Bile ACIDS (mostly cholate, chenodeoxycholate) are made from cholesterol (liver)
o Major pathway of cholesterol breakdown in body
 Bile acids combined with glycine / taurine  bile SALTS
 95% bile acids are absorbed by ileum

Functions:
 Aid digestive enzymes
 Emulsification (↑ total surface area of fats for more efficient digestion by lipases)
 ↑ absorption of fatty acids, cholesterol, vitamins ADEK
st
o 1 clinical sign of bile acid deficiency often vitamin K deficiency (clotting disorders!)
o Also fat malabsorption too!

No bile salts: poor lipid absorption & vitamin deficiencies

42
Bile Pigment (Bilirubin)
 Bilirubin is breakdown product of heme (from RBC)

RBC hemoglobin  Heme + Fe+2 (hemolysis: spleen, liver, bone marrow)

 Iron: recycled to bone marrow

 Heme  biliverdin  bilirubin  conjugated in liver 
o Bilirubin eliminated in bile, excreted in feces

Control of gallbladder

Liver isn’t capable of making bile in an “on-demand basis”, so GB stores bile

Between meals: storage of bile

 Gallbladder fills (from hepatic secretion pressure)
o closed sphincter of Oddi & relaxation of gallbladder smooth muscle

During meals: secretion of bile

 Fat in chyme enters duodenum  CCK released 

bile expelled
o sphincter of Oddi relaxes (smooth muscle)
o gallbladder contracts

 Nitric oxide, VIP, Ach help serve as 2° mediators

Concentration of bile
via active ion transport across tight gallbladder epithelium

 1° transport at apical membrane (Na/H exchanged)

 Carbonic anhydrase generates protons for exchange

 End result: NaCl absorbed into bloodstream  water follows  concentration

of bile

Enterohepatic circulation
Compounds recirculate between liver intestine

 Taken up through small intestine  hepatic portal blood

 Various exogenous compounds secreted by liver into bile ducts

o These compounds can be excreted again into intestine via bile
o Example: 95% bile acids are absorbed by ileum

43
 Gallbladder Diseases (overview)
 Cholelithiasis = stone(s) in GB
 Cholecystitis = inflammation of GB
 Choledocholithiasis = obstruction
 Cholangitis = infection

Sample Case: Acute Emphysematous Cholecystitis

34 year-old AA F in the ER presenting with > 18 hours of progressively worse RUQ discomfort
associated with abrupt onset of chills, nausea and vomiting. Nothing makes pain better;
breathing/movement make pain worse; similar sx in past, always go away on own. Obese,
sickle thal trait, otherwise nL. Exam: a little febrile, HR 125 (tachy), BP↓, RR↑, looks
uncomfortable. RUQ tenderness, particularly on deep inspiration (Murphy’s sign), o/w
normal. Mild ↑ WBC (inflammatory process). CXR / abd X-ray clear. U/S: shows gallstones,
pericholecystic fluid (suggests inflammation)

Murphy’s sign: pain worse on inspiration

Cholelithiasis
Cholesterol is major source of gallstones

De novo synthesis of cholesterol

 made in liver; synthesis under control of HMG CoA-reductase
 Partially esterified by ACAT,
 Secreted as VLDL cholesterol or stored in liver

Dietary cholesterol
 taken up by intestinal ABC transporter 
 transferred to apoA1 particles
 ApoA1 particles then taken up by HDL receptor
o Minor amounts of cholesterol: from LDL / chylomicron remnants, taken up by LDL receptor

Metabolism into bile acids

 Once cholesterol’s in the liver (dietary / de novo), can be metabolized to bile acids
 Classical, neutral pathway (CYP7A1, CYP8B1) is key
o CYP7A1 is KEY regulatory enzyme for synthesis
o ABC pumps pump out cholesterol & bile salts
o Liver can take up bile salts via specific transporters
 Alternative pathway (less important)

Main things to remember

 Cholesterol made in liver
 Goes through blood stream, taken back into liver
 Broken down  make bile acids (main key: make cholesterol water-soluble for excretion)

Key concepts in cholelithiasis

 Gallbladder storage of bile results in changes in its composition, (bile acids become the dominant anions)
 Bile remains isotonic during this process (bile acid monomers are rapidly incorporated into mixed micelles)
 The relative proportion of biliary lipids is largely unchanged, although the high concentration of cholesterol in
human bile makes us vulnerable to cholesterol precipitation and thus to gallstones.
 Cholesterol gallstones are common in humans, and may cause pain and cholestasis.
 The gallbladder is not essential to normal digestion, and symptomatic gallstone disease can be largely treated
by removal of the gallbladder.
44
Gallstones: predisposing conditions
 Age (lose ability to make hydrophobic material)  Gallbladder hypomotility
 Female gender, OCP, pregnancy (↑ estrogen)  Genetics
 Obesity o Responsible for 25% all gallstones (sole risk factor)
 Rapid weight reduction o ↑ in parts of Chile
(changing relative balance of bile components)

Cholesterol Stone formation

Failure of any of the mechanisms of cholesterol homestasis can change balance
between solute / solvent in bile  lead to gallstones (precipitation)

Need:
• Cholesterol supersaturation of bile
• ↑ cholesterol secretion or ↓ bile salt / phospholipid secretion
• Gallbladder hypomotility – no flow makes it easier
• Pro-nucleating protein factors (form little nidus for crystallization)

Pigmented stones
A small proportion of gallstones are black-pigment stones
 Made of calcium bilirubinate (↑Ca, ↑unconjugated bili)
 Can be due to excessive heme breakdown
o Vitamin B12 or folic acid deficiency: ineffective erythropoesis
o Chronic hemolysis (e.g. liver cirrhosis, malaria)
o Crohn's disease with severe ileal manifestation or ileal resection:
bile salt malabsorption, leading to increased intestinal bilirubin absorption +/-vitamin B12 malabsorption
o Liver cirrhosis: decreased bile salt synthesis, bile salt malabsorption, gallbladder hypomotility, chronic hemolysis
Other Gallbladder Disease
Gallbladder Disease Etiology
Symptomatic cholelithiasis Intermittent blockage of cystic duct
 Wax/waning postprandial epigastric/RUQ pain
 due to transient cystic duct obstruction by stone
 no fever/WBC, normal LFT
 Can resolve or lead to acute / chronic cholecystitis
Acute cholecystitis More continuous blockage of cystic duct  GB inflammation
 Persistent RUQ pain +/- fever, ↑WBC, abnormal liver enzymes
 Positive Murphy’s sign (↑ pain on inspiration)
Chronic cholecystitis Recurrent bouts of biliary colic /acute cholecystitis 
chronic GB wall inflamm/fibrosis.
Acalculous cholecystitis GB inflammation due to biliary stasis (infrequent) without stones.
Choledocholithiasis Gallstone in common bile duct
 May originate in the CBD(primary) or migrate from GB (secondary)
Cholangitis Infection within bile ducts due to obstruction of extrahepatic bile ducts.
 Can result from choledocholithaisis
 Charcot triad: (RUQ pain, jaundice & fever) often present

45
Cholecystitis
Basic pathogenesis:
 Stone blocks cystic duct 
 ↑ pressure, backflow  chemical irritation, inflammation 
 disruption of mucosal lining  exposure to bile salts (destructive!)

Symptoms:
 Brief impaction: can cause pain only
 Prolonged impaction: leads to inflammation (usually sterile)
o 2° infection can occur
Course:
 Wall of gallbladder can undergo necrosis & gangrene
o Emphysematous cholecystitis: gas in wall/lumen of gallbladder (bact. superinfection with gas-forming bacteria)
 Can perforate without treatment (RUQ abscess, peritonitis)

Choledocholithiasis
Pathogenesis
 Stone forms in common bile duct (either 1° or passed from cystic duct to CBD)
 Promoting factors:
o Bile stasis, bactibilia, chemical/pH imbalances
o ↑ bilirubin excretion, sludge formation
Course:
 Results in bile stasis  can lead to cholangitis

Cholangitis
Systemic bacterial infection/endotoxinemia as a result of biliary obstruction

Pathogenesis
Bile is normally sterile (flow dynamics, Sphincter of Oddi, local immune factors)
 Sphincter of Oddi disruption (instrumentation / endoprosthesis)
 Stones / tumors: Block bile duct  ↑ pressure in bile duct  flow restricted  retrograde ascent of bacteria
o Bactibilia results (bacteria in biliary tract)
o ↑ pressure  ↓ antibacterial defenses, too; cholangiovenous reflux  systemic infeciton

Etiology: Choledocholithiasis, Obstructive tumors, Others (ERCP, ascaris lumbricoides, strictures / stenosis)

Signs / symptoms / course

 Charcot triad: RUQ pain, jaundice & fever (70% pts)
 Can lead to life-threatening sepsis & septic shock

Treatment:
 Correct ECV  Emergent decompression
 Give Abx (ERCP / percutaneous transhepatic cholangiogram)
 Correct initial cause

Acute Biliary Pancreatitis

 Pathophysiology poorly understood
 Common channel theory: gallstone @ ampulla of Vater
o Obstruction theory: ↑ pancreatic duct pressure  ductal HTN, cell damage
o Reflux theory: Maybe gallstone disrupts sphincter  activated pancreatic
enzymes reflux, start activating stuff

46
 Acute & Chronic Pancreatitis
Acute pancreatitis Chronic pancreatitis
 Acute inflammation  Chronic inflammation
 Acute abdominal pain  Chronic abdominal pain
 ↑ pancreatic enzymes in serum  Progressive loss of pancreatic endocrine / exocrine
 Self-limiting function

Acute Pancreatitis
 Acute episode of pancreatic inflammation  Results from autodigestion of part of pancreas
 Very common (#3 for GI hospital admits in US)  Generally resolves completely

Diagnosis (need 2 of 3)
 Abdominal pain characteristic of acute pancreatitis
 Serum amylase and/or lipase ≥ 3x upper limit of normal
 Findings of acute pancreatitis on CT

Pathogenesis of Acute Pancreatitis

 Zymogens activated; inflammatory mediators generated, ischemia results
 Lots of local inflammation involved
 Etiologies: most commonly alcoholic & biliary (gallstones)
o can also be idiopathic

Alcohol: multiple mechanisms

 Toxic metabolites of alcohol  CCK / secretin release
 Spasm of sphincter of Oddi stimulated

Gallstones: Temporary obstruction of common duct (tx with removal of gallstone)

 See pic: gallstones; lots of fluid around pancreas

Microlithiasis (tiny microscopic gallstones)

 can’t see except for under microscope
 Sludge: can happen with prolonged fasting; can be gritty 
o Predisposes to chronic pancreatitis
 Can also cause recurrent acute pancreatitis
 Treatment: sphincterotomy (drain bile duct)

Ultrasound: gallstones vs microlithiasis

 Gallstones have characteristic acoustic shadow behind them
 Microlithiasis (sludge) is more amorphous

Other causes of acute pancreatitis:

 ERCP: Endoscopic retrograde cholangio-pancreatography (can irritate  cause pancreatitis!)
o Stent pancreatic duct (e.g. post-ERCP) to prevent
 Variations in duct anatomy
o E.g. pancreatic divisum: improper drainage (ducts don’t form properly); predisposes
 Hypertriglyceridemia
o TGs have to be really high (>1000 mg/dL) –e/g/ familial dyslpidemia
o Can cause chronic pancreatitis too
 Genetics (e.g. young onset, recurrent acute pancreatitis, chronic pancreatitis) – examples below
 Others: Autoimmune, drugs / iatrogenic, IBD-related, infectious, inherited, trauma, vascular, toxic, cancer, etc
47
Etiology: Genetics (probably FYI only)

PRSS1: Protease, serine 1

 Mutations in cationic trypsinogen gene result in hereditary pancreatitis (aut-dom)
 Gain-of-function trypsinogen (↑ activation, ↑ survival)
 Shifts balance to active trypsin
 Early onset (teens) recurrent acute pancreatitis
o ↑ lifetime risk of pancreatic adenocarcinoma (30-60%)

SPINK1: Serine protease inhibitor, Kasal Type 1

 Polymorphisms in this gene (1:400) are ↑ in childhood chronic pancreatitis, idiopathic pancreatitis
 Acts as disease modifier

Cystic Fibrosis (CFTR)

 Homozygous  classic CF (pancreatic insufficiency)
 Compound heterozygous: mild CF or minimal CF features  ↑ risk of chronic pancreatitis (modest increase - dz modifier)

Note: Pancreatic cancer risk ↑ in chronic pancreatitis (including CP due to genetic forms)

Etiology: Drugs
Whole big list – almost everything you can think of; stronger associations listed below
 Azathioprine  Thiazide diuretics  Exanatide (Byetta)  Valproic Acid  L-asparaginase
 6-MP  Furosemide  Corticosteroids  Pentamidine  Octreotide
 Sulfonamides  Estrogens  Tetracyclines  IV lipid infusions

Etiology: Infectious diseases

 Mumps is classic; coxsackie too; CMV, others esp. in immunocompromised host
 Occasionally see viral etiology in kids

Presentation of Acute Pancreatitis

 Abdominal pain  Low grade fever  Jaundice
 Nausea / vomiting  Abdominal guarding (if backing up into liver)
 Tachycardia  Loss of bowel sounds

Diagnosis of Acute Pancreatitis

 Serum labs (very helpful) – use 2-3x normal as cutoff; moderate specificity
 Ultrasound: specific, best for gallstones, poor sensitivity
 CT (esp. IV contrast): good sensitivity, specificity, can detect necrosis

Serum labs: Amylase & lipase

 Amylase can be elevated in other conditions (parotiditis, tumors, etc)
o Macroamylasemia: some people just have ↑ amylase all the time
 Lipase rarely elevated in conditions other than pancreatitis (more specific)

48
Course / Prognosis
Mortality (remember, most cases are mild)
 ≈ 10% overall in hospitalized pts; 20-30% if necrotic pancreas
 Mortality from:
o Early: systemic inflammatory response syndrome, MOF
o Late: MOF, pancreatic infections, sepsis

How to follow clinical course?

 Bedside assessment tends to underestimate severe dz  Imaging criteria (fluid collections, necrosis)
 Scoring systems can be helpful (more objective)  Serum markers (CRP, cytokines – often nonspecific)

Early indicators of severity

 Tachycardia, hypotension  Oliguria
 Tachypnea, hypoxemia  Encephalopathy
 Hemoconcentration

Systemic responses to acute pancreatitis

 Systemic inflammatory response syndrome (SIRS): Bad for prognosis
o 2+ of: Temp (> 38 or <36), tachypnea, tachycardia, WBC (> 12k / <4k or >10% bands)
o Without infection
 Multiple-organ dysfunction syndrome:
o dysfunction of more than 1 organ requiring intervention to maintain homeostasis
 ARDS: with severe onset; delayed onset, more common with hyperlipidemia

Grey-Turner / Cullen signs

 Ecchymosis (bruising) in one or both flanks (Gray-Turner) or periumbilical (Cullen)
 Indicates extravasation of pancreatic hemorrhage into those areas
 Acute pancreatitis; means poor prognosis

Ranson’s criteria: Help predict severity of acute pancreatitis

Management of Acute pancreatitis

 Supportive care, pain control, pancreas rest, nutrition, assess / treat complications
 Treat underlying cause (e.g. gallstones)
o Gallstones: extract from common bile duct with little basket
o Difficult surgery (often pretty inflamed)
 CT: assess severity / complications – dx, prognosis, complications
 Jejunal tube: bypass stomach / duodenum → pancreatic rest
o Probably better than TPN
 Usually don’t advocate prophylactic abx (but debated)

CT in Acute Pancreatitis (FYI)

Fluid collections, necrosis, pseudocysts, abscesses
 Fluid collections: common, may be complex, usually resolve spontaneously, should drain if infected / symptomatic
 Necrosis: pancreas doesn’t enhance well (not perfusing), leads to systemic complications
o Can lead to hemorrhage / infection
o Can be sterile or infected (infected  necrosis with gas)
 Pseudocysts in pancreatitis
o No epithelial lining (unlike cysts), need to ddx vs neoplasms, non-neoplastic cysts
o Localized collections of fluid, > 4wks after disease onset
o Ductal disruption, necrosis can be causes
o Complications: Pain, obstruction, infection, erosion, bleeding, rupture
 Management: pancreatic rest, wait for healing (make sure not neoplastic!); drain endoscopically now
49
 Acute fluid collection Necrosis (↓ enhancement) Severe necrosis (no enhancement)

Infection: necrosis with gas Pseudocysts Acute Pancreatitis with

(gas-producing bacteria) hemorrhage

Chronic Pancreatitis
 Gradual fibrotic destruction of pancreatic tissue
 Recurrent acute pancreatitis can lead to chronic pancreatitis (but could also have no Hx of AP)

Pathogenesis: proposed mechanisms

 Intraductal plugging, obstruction  Necrosis – fibrosis
 Direct toxins, toxic metabolites  Immune dysregulation
 Oxidative stress  Really unknown

Clinical features
 Abdominal pain (recurrent / chronic pain, really bad, often narcotic addiction)
 Don’t want to eat (avoid pain), ± steatorrhea  malnutrition
 Psychosocial decline, work-loss, big health care expenditures

Remember: need >90% pancreatic compromise before steatorrhea starts (lots of functional lipase reserve)

Histology: see fibrosis, loss of acinar tissue

Pathogenesis
 Most alcoholic
 Idopathic or other (CF, hereditary pancreatitis, hypertriglyceridemia,
autoimmune, tropical) – see next few sections

Alcoholic chronic pancreatitis

 Heavy & prolonged use (150g/day x 5 yrs)
 Males ≫ F (peak age 35 yo), but females can get it with less alcohol use
50
Signs, symptoms
 Recurrent attacks (70%)  Calcifications, ductal changes common
 Pain more severe than other CP causes  Progresses to pancreatic insufficiency faster than non-etOH etiologies

Mechanisms
 Calcification  plugging of ducts  ↓ blood flow
 Direct toxic effects, fibrosis  Cytotoxic lymphocytes

Idiopathic chronic pancreatitis

10-30% of chronic pancreatitis; bimodal presentation
 Early onset: 1st/2nd decade with severe abdominal pain; structural / functional changes later
 Late onset: 30/40 yo with minimal pain but pancreatic insufficiency, calcifications

Autoimmune pancreatitis
Lymphoplasmacytic infiltration of pancreas (lymphocytes & plasma cells!)
 Milder pain than other chronic pancreatitis
 Classic: diffuse pancreatic enlargement
 Associated with autoimmune conditions
(Sjogren’s, PBC, thyroiditis, PSC, interstitial nephritis, SLE)

Labs: serum IgG4, hypergammaglobulinemia

Imaging: looks like sausage, big, can look like mass

TREATMENT: STEROIDS!
 IMPORTANT: this is one you can actually treat!

Histology: periductal lymphoplasmacytic infiltrates (lymphocytes, plasma cells)

Tropical chronic pancreatitis

 Endemic to developing world
 Young children & adults (<40 yo)
 Nutritional (dietary toxins – e.g. Cassava plant; nutrient deficiency: Zn/Cu/Se)
 Episodic pain with speedy progression to pancreatic insufficiency, calculi, ductal dilation

Diagnosis of chronic pancreatitis

 Can be more challenging than AP, especially early chronic pancreatitis
 Usually based on anatomic / functional test

Imaging: pretty much everything you can think of

Classification: used to grade with ERCP before, now maybe MRCP better?
 Minimal change CP: absent imaging findings, painful, hard to treat (don’t want to do surgery w/o cause!)
 Etiology-based classifications too

EUS: see calcification, echogenic strands

(whiter duct walls on U/S)

ERCP: mild chronic pancreatitis ERCP: severe chronic pancreatitis

(shouldn’t be able to see branches) (lots of dilatation, etc.) 51
Function tests
 Give secretin, measure bicarb production by gland (pretty accurate)
 If steatorrhea: see in stool (sudan test)
 Can measure pancreatic enzymes in stool (not as accurate)

Management of chronic CP
 Stop alcohol / smoking
 Analgesics: non-narcotics / narcotics
 Pancreatic enzyme therapy (treat steatorrhea / blunt pain, ↓ endogenous CCK, maybe resting pancreas?)
 Treatment of malnutrition

Pain management
 Destroying nerves (neurolytics) helps in pancreatic cancer
 Stone removal / duct decompression can help
 Analgesics too

ERCP (stone removal / stent placement); no proven long-term pain relief

Surgery:
 
nd
for pain + dilated duct (pancreaticojejunostomy) for pseudocyst repair (2 line)
 for pain + nondilated duct (resection)  for biliary stricture

How are symptoms caused?

Steatorrhea
 ↓ lipase / coplipase production (pancreas hurt)
 Duodenal pH changes (↓)
o Inactivate pancreatic lipase if pH < 4.5
o Bile salts precipitate at low pH
 End result: FA in stool

Pain
Pain: Etiology  Management
Etiology Treatment
Glandular damage Analgesia
 Fibrosis of tissue
 Small duct ischemia
Pancreatic duct blockage ERCP (how bad are Sx?)
Pancreatic pseudocysts Drainage

52
 Pancreatic Cancer
Epidemiology / Etiology
 th
Pretty rare (~ 1% lifetime risk) but 4 most common cause of cancer death in USA

Risk factors for Pancreatic Cancer

 Smoking (doubles risk – causes 26% pancreatic cancer)
 Family History
o 10% have positive FHx – may be good to screen
 Diet (vitamin B12, etc.)
 Obesity (~70% increase in risk)
 Diabetes Mellitus
o 2x increase if long-term diabetes
o 1% new-onset diabetes develop pancreatic cancer within 3 years
o Insulin maybe involved?
 Occupational exposure
 Chronic pancreatitis
 ABO blood groups (A/B > O) – no idea why

Inheritability
 Inheritance involved in 10-20% pts
 “Familial pancreatic cancer”: pancreatic cancer in 2 relatives

Specific Genes (syndromic causes)

 BRCA2 (breast cancer) (3.5-10x↑ risk)
o ~ 7% pts with “apparently sporadic” disease (BC is common!)
o ↑ in Ashkenazi Jewish pts
 PALB2 identified in GWAS, risk unknown
o Fanconi anemia gene
 Hereditary Pancreatitis (50-80x↑ risk)
 FAMMM (family atypical multiple mole-melanoma) syndrome (20-34x ↑ risk)
 Peutz-Jeugers
o Melanocytic macules in buccal mucosa, digits
o Multiple GI hamartomatous polyps
o ↑ risk GI/GU/lung cancer
o 132x↑ risk pancreas cancer
 HNPCC (Hereditary non-polyposis colon cancer syndrome)

Both genetic & epigenetic events in pancreatic cancer:

 Mutations, large deletions, amplifications, genetic instability, mitochondrial mutations, DNA methylation

Pathology of Pancreatic Neoplasms

 “Usual” ductal adenocarcinoma of the pancreas

 PanINs (Pancreatic intraepithelial neoplasia, commonest
 IPMN (Intraductal papillary mucinous neoplasm)
 Mucinous cystic neoplasm
 Islet cell neoplasms
 Rare (acinar, serous cystadenoma/adenoca), lymphomas, small cell

53
Pancreatic Intraepithelial Neoplasia (PanINs)
Most pancreatic cancer evolves this way

Histology Genetic changes

Early cuboidalcolumnar changes HER2, K-Ras
Later dysplasia p53, DPC4, BRCA2

↑ prevalence of PainINs with age (esp. low-grade)

Infiltrating adenocarcinoma:
 ductal structures stain (L)
 Propensity to invade nerve (middle) - painful
 Invasion (R)

Death from mets or local problems

Pancreatic Cystic Neoplasms

Often benign lesions but also represent larger cysts that can progress to adenocarcinoma
 Intraductal papillary mucionous neoplasms: via CIS stages, etc.
 Mucinous cystic neoplasms: have a classic ovarian
stroma that can lead to cancer

Incidentalomas
 Prognostic dilemmas, ↑ $$$
 ↑ prevalence with age
 E.g. pancreatic cystic neoplasms(above)

Prevention of pancreatic cancer

Not yet in wide clinical practice; in trials to try to detect / treat asx individuals
 Use imaging + biomarkers in combo
 Screen high-risk individuals with safest modalities
 Try to develop markers to ID advanced neoplasia

Clinical Presentation of pancreatic cancer

Varies (anatomical location, local extension, biology)
 Painless obstructive jaundice  Wt loss / cachexia
 Back pain (pancreas = retroperitoneal)  New onset DM

Generally a late diagnosis (only 15% present with resectable cancers)

 4% 5-year survival!
54
Diagnosis: Clinical + imaging; no good serum test yet

Management of pancreatic cancer

Many are inoperable; hard to treat with radiation (lots of vital structures around)
 Quickly progress to bad disease (lots of vital stuff around

Whipple procedure (pancreaticoduodenectomy)

Many patients not eligible (depends on extent)
 Take out head of pancreas, gall bladder, duodenum
 Stick pancreas to jejunem; hook up the bile or hepatic duct

Volume matters
 Pts do well (if doc & support staff experienced)
 Need to refer to HIGH VOLUME CENTER (% mortality ↓↓↓)

Even with resection: survival is poor (20% 5-year survival!)

 ~ 6mo survival w/o surgery

Oncology of Pancreatic Cancer

Staging: resectable, borderline resectable, locally advanced, metastatic
 Definitions based on involvement of arteries
o Surgeons need to have SMA available for resection
 Surgery if possible, chemo for advanced cancer
o Chemo: Gemcitabine, 5-FU (older), GTX, gem/abraxane, mitomycin C, PARP inhibitors (newer)

If you have Fanconi/BRCA mutations (e.g. PALB), ↑ susceptibility of cancer to dsDNA strand breaking agents

Complications of pancreatic cancer

 Malignant Biliary Obstruction  Weight Loss
 Malignant Duodenal obstruction  Depression/Coping
 Pain

Weight loss: Pain management:

 Pancreatic enzymes if duct blocked  Identify cause of pain
 Fish oils for cachexia (EPA)  Narcotics
 Appetite stimulants for anorexia  Celiac plexus neurolysis (palliate if not going to live long)

Hope is important (pts need to recalibrate life; help them enjoy what’s left)

55
 Pediatric GI

Case 1: Meckel’s Diverticulum

Young boy (<2yo), painless rectal bleeding
 red stool (guaiac + = blood), pale, tachycardia. WBC nL, ↓ Hct (normal RBC indices), clear radiography.

Diagnostic tests to do?

 Endoscopy: hard to do in children; don’t see whole GI tract (need to sedate!)
 Barium enema: can see whole GI tract!
 NG Lavage (upper GI bleeds) – good to look for sources; nurses can do, etc.

Dark-red to maroon blood in stool – probably upper GI tract (through acid) or means it’s been there for a while

Rectal bleeding in young boy

 Intussusception? (< 2yo) – but would be painful
 Anorectal fissure? (doesn’t make Hb go down)
 Meckel’s diverticulum

Intussusception
 One part of bowel folds into another (like telescope)
 Edema  swelling, pressure  ischemia
 Radiography  see where air stops!

Meckel’s Diverticulum
Embryological remnant of vitilline duct; becomes symptomatic if ulcerates into artery  bleeds

Rule of 2’s
 2% of population
 2 cm long
 Within 2 feet of ileocecal valve

Diagnosis: 99mTc-pertechnetate scan (“meckel’s scan”)

 Often missed by CT, abdominal X-ray, etc.

Case 2: Crohn’s disease

12yo M: intermittent abd. pain, early satiety & nausea over last year (worse last few mo), lost 5 lbs (weird for 12yo);
 No vomiting / hematemesis / diarrhea / constipation / melena / dysuria / jaundice
 Same size as 9yo brother (rough genetic estimate: probably should be bigger)
 PE: RLQ tenderness; 10th % for height, 5th for weight & has ↓ with time, anal fissure / skin tag on rectal exam
o Tender, nodular, erythematous lesions on bilateral shins
o Stool is guiac positive
o RLQ: appendix, ileocecal valve, colon are there

Check: allergies (food/drugs), skin rashes, joint pain, school attendance (social?), mouth ulcers, night-time awakening
DDx: Crohn’s disease, Hirschprung’s, Celiac, others
Tests to do: CBC & ESR (if elevated ESR & ↑ WBC, then probably Crohn’s!)
 Both come back positive: Crohn’s disease
 Confirm with: colonoscopy & upper GI endoscopy / EGD with biopsies (want to see both; distinguish CD/UC)

Case 3: Cystic Fibrosis

56
4mo Caucasian Male
 Poor growth, irritability, 3-5 malodorus, bulky, non-blood stools / day
o rectal protrusion (RECTAL PROLAPSE) 2 days prior to visit (spontaneously resolved)
o Has been consuming cow’s milk protein based formula
o Was full term at birth (95th %ile), no vomiting, healthy 3 yo sister
 PE: irritable, cachexic, visibly sucking at bottle

Rectal Prolapse: tissue that lines the rectum falls down into or sticks through the anal opening.
 Sx: reddish-colored mass that sticks out from the opening of the anus, especially following a bowel movement
o The lining of the rectal tissue may visible and may bleed slightly.

Diagnosis: Cystic Fibrosis

 Confirm with sweat chloride test

Case 4: Pyloric Stenosis

6wk M with 2wk Hx of recurrent nonbilious (not green, etc) vomiting 15-20m post-meals, 10th %ile weight, 50th %ile
length, normal birth weight (losing calories – normal baby; want ≈ 100 cal/kilo for babies)
 small firm mass in mid epigastric region (“olive”)
 reflux, gastroparesis, others could be on list of DDx

PYLORIC STENOSIS
 “olive” (small firm mass in mid-epigastric region is pathognomonic)
 More common in males

Diagnosis: abd. U/S, PE, upper GI series

 Hypochloremic metabolic alkalosis, hypokalemia associated
 Upper GI series: : muscle itself becomes thickened; see stream of barium going through

Therapy:
 Initially: correct fluid, electrolyte imbalances
 Surgery is treatment of choice (pyloromyotomy) – open up thickened muscle

Diagnostic Studies: overview

Upper GI: radiology stops in everything through 3rd portion of duodenum (including C-sweep)
 Need to see duodenum cross bowel twice to rule out malrotation
o bowel doesn’t rotate right – dysphagia, pain
Barium Enema: see whole colon up to terminal ileum
Esophagogastroduodenoscopy (EGD) = upper endoscopy: see through to duodenum
Colonoscopy: colon & terminal ileum
Endoscopic Retrograde Cholangiopancreatography (ERCP): inject contrast; visualize pancreatic / biliary tracts

57
 Liver Tests
Overview
Major roles of the liver (tests based on these)
 Metabolism  Storage
 Detoxification  Digestion (bile)

General Categories of Liver Tests

Test Measures…
Serum bilirubin Overall function
Serum enzymes Cellular injury, cholestasis
Serum albumin, Prothrombin time Biosynthetic capacity
14
C-Aminopyrine BT (research only), Urea synthesis Hepatocellular function
Autoantibodies, Viral Markers Specific tests for liver diseases

Usefulness of liver tests Limitations of liver tests

 Noninvasive screening for liver dz  Low sensitivity
 Pattern can alert recognition of general type of liver disease  Lack of specificity
 Indispensable for follow-up and management  No single test accurately assesses liver function

Bilirubin
Normal metabolism:
 Hemoglobin / myoglobin broken down  heme unit + Fe
 Heme converted to indirect / unconjugated bilirubin
o transported with albumin

 Uptake by liver & glucuronidation (conjugation) 

direct / conjugated bilirubin

 Direct bili now soluble; secreted into bile  gut

o Gives color in stool

 Colonic bacteria reduce some direct bili  urobilinogen

 Urobilinogen:
o 20%  reuptake  enterohepatic circ.  back to liver
o 2%  excreted in urine

Note that:
 ↑ indirect bilirubin (unconjugated) does not give you change of color in urine
 Direct bilirubin (conjugated) – gives you color in stool; gives dark urine if there’s impaired bile excretion
o < 20% of total bilirubin is normal
 Urobilinogens: some excreted in urine (but does not give color – need Ehrlich’s reagent to detect)
o Absent from urine in total biliary obstruction; ↑ in urine in hemolysis

DDx of Abnormal Bilirubin

↑ indirect bilirubin ↑ direct and total bilirubin
st
dark urine is 1 symptom (before jaundice)
 hemolysis (↑ RBC breakdown: sickle cell, etc.)  Acute & chronic liver diseases
 Gilbert’s syndrome (decreased uptake of bilirubin into liver)  Cholestasis (intra/extrahepatic)
 Crigler-Najjar syndrome (peds – probem with conjugation)  Dubin Johnson & Rotor syndromes
(prevent bilirubin from entering bile)

58
 Differential diagnosis of jaundice
Hemolysis Liver disease Biliary obstruction
Bilirubin (direct > 20%) No Yes Yes
Color urine nL Darker Dark
Color stool nL nL or light Light
Urine urobilinogen ↑ nL or ↓ ↓

Serum Aminotransferases (AST/ALT)

What determines usefulness (e.g. for a given disease?)
Specificity Sensitivity
 Content of enzyme in liver
 Presence of enzyme in liver as compared to other organs
 Synthetic rate
 Presence in subcellular organelles affected in the particular
 Ready release from subcellular organelles / cell
liver disease
 Rate of clearance from blood

Characteristics of AST/ALT as Diagnostic Tests

 Poor correlation between level of elevation and extent of liver cell necrosis (not a linear relationship)
 Rapid decline from high levels is consistent with a single episode of necrosis
o e.g. hypotension, fulminant hepatitis - big release of enzymes from necrosis, then cleared
o want to see them falling slowly
 Elevations > 500 I.U. are rare in extrahepatic obstruction
 In alcoholic liver disease, elevations are low (<300 I.U.) with AST > ALT
o Consider other causes (e.g. acetaminophen OD) on top of alcohol!
AST vs ALT
 More AST in mitochondria
 AST is cleared more rapidly than ALT
 Pyridoxal-5’-phosphate deficiency – causes ↑ AST vs ALT

Alkaline Phosphatase
Causes of ↑ alkaline phosphatase (note: not specific for liver dz!)
 Intrahepatic cholestasis
 Extrahepatic biliary obstruction
 Space-occupying lesion in liver (neoplasm, granuloma)
 Bone disease (e.g. Paget’s disease)

rd
Pregnancy (3 trimester – placental alk phos!)

Why is alk phos ↑ in cholestasis?

 Synthesized in hepatocyte, usually excreted into bile
 If bile blocked, more goes to bloodstream
 Also ↑ synthesis (upregulation) in obstruction (can’t do it if
hepatocyte damaged

5’-nucleotidase
 Phosphatase specific for liver; not present in bone/placenta/intestine
 Use: to establish that alk phos elevation is due to liver problems
o Unexplained ↑ alk-phos: get a 5’-nucleotidease

Gamma-glutamyl transpeptidase
 Similar use to 5’ nucleotidase but not as specific; the lecturer wasn’t a fan of it.

59
 Prothrombin time or INR Serum albumin
PT / INR elevated in: Serum albumin ↓ with:
 Vitamin K deficiency  ↓ synthesis (liver)
 ↓ synthesis of factors I,II,V,VII,X  Malnutrition too
(e.g if liver compromised) Need to feed patient if albumin is low!

Poor prognosis if > 5sec above control Hypergammaglobulinemia

Ig ↑ in…
Treatment
IgG Chronic liver disease
 Give vitamin K IgA Alcoholic liver disease
 Consider liver transplant IgM Primary biliary cirrhosis

Cholestasis
Cholestasis: decreased bile flow
Diagnosis:
Physiological Morphological Clinical Lab
Stagnation of bilirubin  Jaundice  ↑ bilirubin
↓ bile flow  ↑ alk phos
in bile canaliculi, hepatocytes  Pruritis  ↑ bile acids

Intrahepatic cholestasis
Etiology: most liver diseases! Hepatitis, biliary cirrhosis, drug-induced, etc.
 Sepsis-associated cholestasis is a big one

Extrahepatic cholestasis / biliary obstruction

Causes: Choledocholithiasis, bile duct narrowing, pancreatic cancer (head of pancreas)
Diagnosis: U/S initially, ERCP / PCT / MRCP to image bile ducts, liver biopsy

Liver tests in cholestasis

Enzymes:
 ↑ serum bilirubin; direct fraction > 20% total
 ↑ alk phos (5’-nucleotidase, gamma-glutamyl transpeptidase too)
 Minimal or no elevation of serum aminotransferases

Primary biliary cirrhosis

Epidemiology: 30-65 yo, primarily women (95%), 1/10k

Symptoms: fatigue, pruritis, xanthoma
Lab tests: AMA (antimictochondrial antibodies) in 90-95%
Treatment: cholestyramine (pruritis), calcium + vit D + bisphosphonates (osteoporosis), urosdeoxycholic acid
liver transplant if needed

Alcoholic hepatitis

Increased susceptibility to alcoholic hepatitis:

 Females (smaller, less body water, metabolize faster – more acetaldehyde)
 Heterozygous for deficient aldehyde dehydrogenase (flushing!)
 Nutritional factors (undernourished or overnourished)

60
 Non-alcoholic steatohepatitis
Epidemiology: Very common these days (↑ obesity): 1.2-8.0 % of referrals
 mostly women (65-80%), 41-60 yo
 many have obesity (80%), DM type II (50-75%), hyperlipidemia (20-80%)

NOTE: ALT > AST (differentiates from alcoholic hepatitis)

Other lab values:

• ↑ Aminotransferases: 2-3X>normal
• ↑ Alkaline phosphatase (50%)
• ↑ iron and ferritin common
• Bilirubin and albumin usually normal

Diagnosis:
• Ultrasound (bright liver) – see pic
• Liver biopsy: 15-20% show fibrosis or cirrhosis; hyaline bodies too

Inherited Liver Diseases

Disease
Hemochromatosis
Wilson’s disease
Porphyria cutanea tarda
α1-antitrypsin deficiency
Autoimmune hepatitis
Primary biliary cirrhosis
Viral hepatitis
Test(s)
Serum iron, % sat, ferritin (measure fasting iron)
Serum ceruloplasmin, urine copper
Urine uroporphyrin
Phenotype (AAT)
ANA (anti-nuclear antibodies)
AMA (anti-mitochondrial antibodies)
Viral markers

Hemochromatosis
Iron storage disease with widespread tissue injury
 Autosomal recessive; associated with HLA-A mutation (short arm of chromosome 6) – homo- or hetero-zygous

Clinical features:
 Manifestations of chronic liver disease  Skin pigmentation  Hypogonadism
 Carbohydrate intolerance  Cardiac arrhythmias / failure  Arthropathy (pseudogout)

Labs: ↑ serum iron (> 170 μg/dL), ↑ % transferring sat (>55%), ↑ serum ferritin (> 300 ng/mL)
 Can do liver bx or hemochromatosis genotype too

Treatment
 Phlebotomy to remove iron; chelating agents (not as good)

Wilson’s disease
Copper accumulation in liver / brain
 Autosomal recessive, women > men

Presentation: acutely (hemolysis) or as chronic liver disease

 Can see Kayser-Fleisher ring (copper in cornea) in eye in 50%

Labs: ↓ serum ceruloplasmin, ↑ liver / urine copper

Treatment: chelating agents
61
Porphyria cutanea tarda
Deficiency of uroporphyrinogen decarboxylase (5th enzyme in heme biosynthesis

Presentation: Cutaneous photosensitivity (pic),

 Complications: Portal inflammation, cirrhosis, hepatocellular cancer

Labs: ↑ hepatic iron, ↑ urinary uroporphyrin, anti-HCV Ab often

Acetaminophen hepatotoxicity
Metabolized to N-acetyl-p-benzoquinone amine (active metabolite)

Toxicity is dose related (>15g in 80% cases)

 Blood level > 300μg/mL @ 4h is severe
 6-25% fatality rate

Course
Day 1 anorexia, nausea, vomiting
Day 2 abatement of sx
Day 3-5 overt hepatitis (↑ PT, hypoglycemia, jaundice)

Treatment: give N-acetyl cystine during 1st 16h and can prevent all these symptoms
 Supportive therapy, liver transplantation if needed

Autoimmune hepatitis

Epidemiology: Female>M, 5-200/million

Presentation: acute onset in 40%, cirrhosis @ presentation in 25%, extrahepatic manifestations common
Symptoms: Abdominal pain / tenderness, hepatomegaly (50%), amenorrhea / acne, fatigue, anorexia, intermittent fever,
arthralgias, arthritis, polymyalgia, skin rash
Prognosis: 50% 5 yr survival w/o rx
Treatment: Prednisone (good result – need to dx this one!)

Lab features: ↑ aminotransferases, hypergammaglobulinemia, autoantibodies (ANA > 1:80)

Biopsy: Periportal hepatitis, focal liver cell necrosis, lymphoplasmacytic infiltrates

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 Hepatitis: Basics

Blood supply to the liver

The only organ that uses venous blood (70-80% supply)
 In: Portal vein, hepatic artery, bile duct
 Out: Hepatic vein to IVC
 Note: bile ducts use hepatic arterial supply
(compromise hepatic artery  bile duct damage!)
Same structure preserved microscopically
 In: Portal triad: vein, artery, bile duct
 Blood flows through sinusoid
 Out: central vein HV

Transaminases (liver enzymes)

Hepatic enzymes that catalyze the transfer of amino groups to form hepatic metabolites of pyruvate (ALT) and oxaloacetate (AST)

Alanine aminotransferase (ALT) Aspartate aminotransferase (AST)

Specificity to liver
In hepatocyte cytoplasm
In hepatocyte mitochondria
Variation (zone 3-zone 1)
Half-life
More specific to liver Less specific: in muscle (↑ in seizure, MI, etc.)
LOTS (ALT predominates in cytoplasm) Less but still present
Most AST in mitochondria (80%)
Doesn’t change ↑ AST in zone 3 cells
Longer Shorter (AST↓ more rapidly)

Aspartate aminotransferase (AST)

 Remember: Most AST in mitochondria (80%), ↑ AST in zone 3 cells
 So ↑ AST (AST > ALT) if
o mitochondria damaged
o zone 3 cells affected

Both released from hepatocytes during cellular injury

 “Normal” liver enzymes: what’s in the blood reflects what’s in the hepatocytes (so ALT > AST)
 Injury (hepatitis): ALT, AST leak out, ↑ serum ALT and AST (ALT > AST, but both ↑)

Characteristic Patterns of Liver Enzymes

Ischemia / acetaminophen toxicity: Rapid, high spike

 Viral / other drugs: usually have slower rise
 Good for figuring out etiology

Alcoholic Hepatitis
 AST:ALT > 2:1
 AST rarely higher than 350 – if so, look for another cause
63
 Basics of Hepatitis
Hepatitis = liver inflammation
 Doesn’t imply contagious
 High AST / ALT don’t tell you “how sick the liver is” or “how bad the hepatitis is”
o Don’t correlate with outcome, Just tell you that something’s wrong

Zones of the Liver Lobule

Zone 1: closest to portal triad
Zone 3: closest to central vein

Cells near central vein (zone 3) have

 Less oxygen (more susceptible to ischemic injury)
 Less ALT (AST levels are the same)

Alkaline Phosphatase
Alk Phos = “sensor of bile flow”
 Hepatocytes: make the components of bile
 Alk phos: located on membrane along bile canaliculus

 If you block bile flow (cholestasis, mass)

o ↑ production of alk phosphatase
o Leaks out into blood (can’t go into bile!)

Bile acids also ↑ in blood when bile flow blocked (can’t go into bile!)

Bilirubin
Byproduct of heme degradation
 glucoronidated (conjugated) by hepatocyte to make it water soluble

Getting bilirubin from blood into hepatocyte is “free” – no energy required

 So if hepatocyte damaged, will keep importing & conjugating bilirubin

Conjugated bilirubin is really concentrated in bile,

so it “costs energy” to pump bilirubin into canaliculus against the gradient

 When hepatocyte is damaged: can’t excrete in bile (not enough energy)

 Direct bilirubin goes back into blood!  Direct hyperbilirubinemia!

Hepatocellular vs Cholestatic Liver Disease

Predominantly Hepatocellular Predominantly Cholestatic
 ↑ Aminotransferases (AST / ALT)  ↑ alkaline phosphatase
 ↑ GGT / 5’-NT / bile acids
(hepatocytes messed up) (bile flow is the problem)
Can have ↑ bilirubin in both

Cholestasis: disorder of cholepoesis & bile secretion, as well as stoppage of bile flow in intra/extrahepatic bile ducts
 Clinically: ↑ bile acids / enzymatic markers of cholestasis (mainly alk phos, confirm hepatic with GGT/5’NT)

↑ Bilirubin:
 in hepatocelluar problems (hepatocytes don’t have energy to pump it out)
64
  in cholestasis (not removing bile  ↑ gradient)

Jaundice
Jaundice is both a symptom and a disorder of bilirubin metabolism

DDx of jaundice by Lab Tests:

Hemolysis Liver dysfunction Biliary disease
Total bili ↑ ↑↑ ↑
Indirect bili ↑↑ ↑ No Δ
Direct (conj) bili No Δ ↑↑ ↑
Alk phos No Δ No Δ or ↑ ↑↑

Hepatitis: Acute vs Chronic

Acute Chronic
lasts < 6 months lasts > 6 months
recent / sudden persistent over time / years

Cases
1. 22yo med student: AST = 200 (ULN 35), ALT = 90 (ULN 35), alk phos 130 (ULN 110)
a. Hepatitis, even if bilirubin 2.0 (worse)
b. Was out partying all night: does that make sense? Yes: AST:ALT > 2 = alcoholic hepatitis

2. 46yo M with pneumonia, hypotensive yesterday with SBP 40 mm Hg, BP 100/55, h/o Tylenol 2 tabs qd x 5d, No EtOH or
past h/o liver disease. AST 5500, ALT 3000, bilirubin 6.3, alk phos 720
a. Not enough Tylenol to be the cause (but could be if Hx of EtOH intake)
b. Severe hepatitis due to ischemia: maintain BP/perfusion, expect to resolve quickly

3. 40 yo F with RUQ abd. pain; afebrile & icteric. Suspect gallstones / choledocholithiasis with dilated intrahepatic bile ducts
a. Bilirubin will be ↑ & mostly direct, Alk phos ≫> AST / ALT, Cholestatic disorder
b. Indirect hyperbilirubinemia will not be predominant; she does not have a hepatitis disorder

65
 Viral Hepatitis
Hepatitis: inflammation in the liver; see also the ID/Micro lecture (similar content)

Remember: Hepatitis doesn’t just mean Hepatitis Viruses!

Non-infectious causes of hepatitis:
• Alcohol use • Halothane • Other medications
• Acetaminophen • Isoniazid • Shock or acute obstruction

Non-viral causes of hepatitis:

 Pneumococcal pneumonia  Tuberculosis  Syphilis
 Leptospirosis  Histoplasmosis
 Sepsis  Ricketsial infections

Viral causes: CMV, EBV, HIV, adenovirus, Hepatitis viruses

Epidemiology
In USA: Acute Viral Hepatitis
 Hepatitis A > B > C

Before 1970: 1:3 chance of getting hepatitis from blood transfusion

 After 1970: stopped paying donors (drug users sell blood!)
 Other improvements: HCV tests, anti-HIV tests, ALT testing, etc. – now risk basically zero

Typical Course of Hepatitis

1. Exposure
2. Incubation (asymptomatic)
3. Prodrome (malaise, etc)
4. Symptoms & Jaundice (usually tested here)
5. Symptoms resolve, convalescence
6. Persistence for some of them

Exposure HAV & HEV HBV & HDV HCV

Transmission: (insert charts)
Fecal-oral +4 0 0
Hep A / B are fecal/oral
Sexual +1 +4 +1
Hep B is the big sexual transmission one
Blood +1 +4 +4
Hep C is blood contact mainly
Perinatal +1 +4 +2

Incubation: overlap (cant’ tell which one based on timing) HAV+HEV HBV+HDV HCV
Incubation (weeks) 2-6 6-24 6-300
Jaundice: HAV/HBV more likely to cause; HCV more rarely
% Jaundice 30-70 20-40 15-25
Persistence: inversely proportional to severity of symptoms
% Persist 0 5 80
 (↑ persistence in HCV but no jaundice)

Lab tests
 Transaminases: ↑ ALT, AST > 10x normal
 IgM antibody
 Neutralizing antibodies (= recovery)
 Viral particles (= ongoing infection) – protein & nucleic acid

66
 Prevention & Treatment

Vaccines for HAV and HBV

Medical treatment: HAV HBV+HDV HCV HEV

HAV: None, prevent secondary cases IG Pooled Specific No ?
HBV: Pegylated interferon alpha, or nucleoside/tide analogues Vaccine Yes HBV (not HDV) No No
HCV: Pegylated interferon alpha and ribavirin

Hepatitis A virus
The virus:
 Picornavirus (RNA virus)
 No envelope (bile stable)
 Cytopathic (ruptures) pathogenesis
 Capsid proteins elicit universal neutralizing antibody
(all one serotype)

Fecal-oral transmission; rarely blood (would have to be viremic)

 Endemic virus, esp. in developing nations

Presentation: Jaundice is common,

 essentially no chronic disease

Diagnosis: IgM anti-HAV (acutely)

Treatment: rest
Prevention: pre/post-exposure (vaccine)

Hepatitis B
#1 cause of liver cancer worldwide (2B infected)
 Esp. in developing countries (↓ with vaccine)

Transmission: many ways to get hep B (why it’s so prevalent)

 Vertical transmission (mother-child) common in developing countries
 Sex, blood / body fluids, transfusion, transplants, etc.

Why so transmissible?
 makes TONS of virus and extra surface antigens (serum packed)
 environmentally stable (can hang out on tables, equipment, etc).

The Virus:
 Pararetrovirus (DNA with RNA intermediate)
 4 genes (C,P,S,X), 5 proteins, lots of overlapping reading frames
o efficient but constrain evolution (vaccine!)
o Drugs: may cause immune escape
(target protein  virus mutates  change overlapping surface antigens  immune system loses response)
 Oncogenic (X-protein may play role)
 Can integrate into human genome, but not pathogenic (dead end)

67
Life cycle:
 Replication: entry  uncoating  genome incompletely closed (opened from circle) to be imported to nucleus
o Completly Closed Circular DNA (cccDNA): genome closed & repaired inside nucleus
 Makes a bunch of transcript for viral replication
 Can be INTEGRATED into host genome (stable, reservoir) – hard to eliminate
 Patients probably don’t totally clear virus (latent)
Older than 5 5 or younger
Natural history: Wide range: Sicker, but more likely to clear Less sick, but less likely to clear
 Mild infection (asx) • 30% to 50% clinically ill (jaundice) • <10% clinically ill (jaundice)
 Severe chronic liver disease  • 2% to 10% chronically infected • 30% to 90% chronically infected
o Fibrosis, subsequent cirrhosis
o Liver failure, hepatocellular carcinoma, death

Serology of HBV
Acute HBV infection with recovery Chronic hepatitis

HBsAg goes away before 6 months HBsAg and HBeAg present for ≥ 6 mo
Marker What is it? What does it mean?
 Marker of infectivity
HBsAg Surface antigen
 Acute or chronic HBV infection currently present
Anti-HBs Ab against HBs  Past exposures or previous immunization
 Total antibody against core antigen (IgG + IgM)
Total
Anti-core antigen  Could be acute, chronic, or resolved
anti-HBc
 Indicates exposure to HBV
IgM
IgM vs core Ag  Recent infection with HBV (< 6 mo)
anti-HBc
 Active viral replication, indicates active disease
 ↑HBeAg = ↑ risk progressive liver dz
HBeAg Hepatitis B e Ag
 Generally not seen w/o HBsAg
 Absence ≠ no viral replication
 Viral load (not shown above) – ongoing viral rep
HBV DNA PCR of HBV DNA  ↑ in acute and chronic infection
 Sustained loss = resolution of viral rep  resolution of liver dz
 Resolving disease
Anti-HBe Antibody to HBeAg
 Seroconversion to anti-HBe  viral suppression, ↓ infectivity, ↑ Pgx
ALT Liver enzyme  Liver function
DNA test is a good one to rely on; Normal ALT with surface antigen = healthy carrier

Treatment: Prevention:
 Interferon-α – can control infection (durable!)  Pre-exposure (vaccine)
 Lamivudine, tenofovir, etc. – can’t eradicate  Post-exposure (HB IG up to 1 week post-exposure + vaccine)
68
Lab Tests for HBV: For Reference
Acute Past exposure Past Chronic Chronic Healthy
Marker
Hep B (immunity) immunization Hep B Precore* Carrier

HBsAg + + + +
Anti-HBs + +
Total
anti-HBc + + + + +
IgM
anti-HBc +
HBeAg + +
HBV DNA + +/- +/-

Anti-HBe +/- + +
ALT ↑ normal normal ↑ ↑ normal
*Precore mutant: mutation  stop codon; doesn’t make HBeAg

Hepatitis D
NEEDS HBV: Hepatitis B (HBsAg) coat with δ antigen genome inside (D = “dependency issues”)
 Tests: for RNA, but not easy to get

Hepatitis C
Epidemiology:
 Big in US (most common cause of liver failure that requires transplant), lots in Baltimore
o Associated with: low SES, IDU, sexual practices
 Worldwide epidemic; big in Egypt

TONS OF VARIABILITY (way more than HIV) – really really hard to make vaccine
 Becomes progressively diverse after infection (innumerable variants – quasispecies)

Clinical implications of virology: Persistent, resistant to treatment, vaccine hard to develop, antivirals in development

Transmission
 Percutaneous blood exposures: IDU, rare blood transfusion, needlesticks
 Sexual transmission: unknown role of intercourse? Maybe ↑ in MSM
 Household, nonsexual: perinatal
 Nosocomial: developing vs. developed world

Natural History (Thick arrows = more frequent)

 Exposure usually results in chronicity;
o most remain stable, can progress to cirrhosis
 Most who get cirrhosis can compensate
o some develop end-stage liver dz (ESLD)
Screening:
 anti-HCV EIA (essentially an ELISA)
 HCV RNA if Treatment of HCV
o acute infection – needle stick / jaundice  Pegylated interferon-α & ribavirin
o high index of suspicion and EIA negative  No vaccine
 Can do post-exposure prophylaxis
69
 Hepatitis E
 Overall: similar to Hep A
 Incubation: average 40 days, range 15-60
 Illness severity ↑ with age

PREGNANCY is a big risk factor, can be FATAL

 (CFR 1-3% overall, 15-25% in pregnancy!)

Course: acute, ↑ ALT spike early

Epidemiology
 Most outbreaks associated with fecally contaminated drinking water
o Pig farmers have ↑ risk (zoonotic?)
 Minimal person-to-person transmission; secondary attack rare
• U.S. cases: usually hx of travel to HEV-endemic areas

Diagnosis: Consider it if non A-D hepatitis (esp in pregnancy!

 IgM for acute, IgG for chronic

Summary

5 hepatotropic viruses
TRANSMISSION COURSE KEY FEATURE
HAV Fecal/oral Self-limited No envelope = bile stability
HBV Surface antigen in vaccine
HCV Blood/sex/etc Chronic Viral diversity
HDV Needs HBV
HEV Fecal/oral Self-limited Fatal in pregnant women

 Viral particles: ongoing infection

 Anti-viral Abs: IgMs are recent

70
 Inherited and Metabolic Liver Disease
Infants Adults
 Mostly α-1 antitrypsin deficiency  Mostly hemochromatosis
 Wilson, others too  Wilson’s, others too

Wilson Disease
Autosomal recessive disorder that affects hepatocyte functions in the transmembrane transport of copper

Gene: ATP7B (a.k.a. “WND”) – encodes metal transporting P-type ATPase

Copper metabolism
1. Ingest copper
2. Absorbed in intestine
3. Portal circulation
4. To liver, metabolized
5. Most secreted with bile  feces

Ceruloplasmin: carrier protein - carries copper in various parts of the body

In liver: normally
 Uptake through a transporter (Ctr1) at
basolateral surface of hepatocyte

 Binds to metallochaperones : deliver to specific

pathway, protect against intracellular chelation

 Incorporated into ceruloplasmin

 Excreted to bile by ATP7b at trans-golgi network

Wilson disease
 Mutate ATP7b  copper accumulates in
hepatocytes
o Lots of mutations have been identified
 Oxidative damage (metal!)  cell death
 Copper: leaks into plasma, accumulates in other tissues

Epidemiology
 Autosomal recessive; 1/30k (1:100 are heterozygous carriers), equivalent in all ethnic groups
 200+ mutations, little correlation between phenotype & mutation
o (same mutations  vastly different presentations)

Clinical Presentation
Disease of the liver that can affect other organs when copper comes in
 Eyes: Kayser-Fleischer rings
o Deposition of copper in cornea (need to do slit lamp exam)
o Present in 50-60% of patients (95% of those with neuro/psych Sx)
o Can also see in cholestatic disorders
 Brain: neuropsychiatric disorders
 Heart: cardiomyopathy
 Bones: osteoporosis & arthropathy

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Diagnostic testing for Wilson Disease

Test Rationale Results Notes

Not too specific:
 Copper carrying protein ↓  Varies with age (normal 20-35 mg/dL)
Serum
 Mainly made in liver  ↑ with acute inflammation, hyperestrogenemia
ceruloplasmin
 WD: not getting Cu out of TGN  ↓ in severe renal / enteric protein loss, cirrhosis,
aceroplasminemia
 Look @ non-ceruloplasmin bound Cu ↑ Lack of specificity:
Serum copper (packaging not happening!) > 25 μg/dL  ↑ in acute hepatitis, chronic cholestasis,
 24 h urine copper < 15 is nL heterozygotes, copper poisoning
Best biochemical evidence
Hepatic
 Sampling error: from inhomogenous Cu
parenchymal  Look at copper in hepatocytes ↑ distribution (late stage WD)
copper
 ↑ in copper toxicosis syndromes too
most pts compound heterozygotes
Genetic > 200  Hard (too many mutations)
 H1069Q (50% Northern European pts)
studies mutations  Used in pedigree analysis
 A778L in 30% Asian pts

Treatment
 Chelation therapy
 Dietary therapy
 Zinc acetate:
 Liver transplant
get copper out! d-penicillamine, trientine, tetrathiomolybdate
avoid copper-rich foods: liver, shellfish, chocolate, nuts, legumes
o Drinking water: old copper pipes (e.g. Baltimore)
uses same transporter in intestine; outcompetes copper for uptake
if severe (cures! Whole defect is in hepatocyte!)

Summary: Wilson Disease

• Autosomal recessive disorder; defect of ATP7B • Treatment with chelator, zinc and liver
• Variable presentations transplant
• Multiple diagnostic tests, use in combo

Hereditary Hemochromatosis
Autosomal recessive disorder that relates to excessive iron deposition in tissues, especially in liver

Gene: HFE (↑ intestinal iron absorption, iron utilization); other mutations in iron metabolism pathway can be involved

Iron Homeostasis
1. Ingest iron (big excess – most recycled)
2. Absorption is highly regulated (don’t want too much, very little absorbed)
a. Iron taken up by transporter
b. Bound to ferritin in enterocyte
c. Exported across basement membrane to plasma
3. Used in erythropoesis, etc.  recycled

Remember: lose very little iron / day (skin shedding, etc)

 exception = menstruation

How is absorption regulated?

 Crypt-programming & hepcidin models

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Crypt-programming model
Undifferentiated duodenal crypt cells (not exposed to dietary Fe):
1. Take up Fe from bloodstream (via transferrin receptor with help of HFE!)
2. Accumulate intracellular pool of Fe
3. These crypt cells eventual differentiate into absorptive villous enterocytes
4. Daughter cells are “programmed” according to Fe pool in parent cell
a. If sufficient intracellular pool (blood Fe OK): small absorptive capacity for Fe
b. If insufficient intracellular pool (blood Fe ↓): large absorptaive capacity for Fe

In hemochromatosis: iron uptake into enterocytes messed up (HFE mutated!)

 Crypt cell ends up with low iron (can’t get iron in!)
 Low iron in cell  “thinks” that there’s low body iron
 differentiates into high absorptive capacity daughter villous enterocytes 
 ↑ iron uptake is end result!

Hepcidin model
Rate of iron influx into plasma depends primarily on hepcidin in this model
 If plasma Fe high: ↑ hepcidin synthesis  ↓ release of iron (enterocytes / Mϕ)
 If plasma Fe low: ↓ hepcidin synthesis  ↑ release of iron
 Idea: HFE involved somehow? Unknown? Somehow ↓ hepcidin  ↑ release

Epidemiology of hemochromatosis
 Most common, identified genetic disorder in Caucasian population (1:200): HFE mutations
o C282Y/C282Y homozygous (90% pts with hemochromatosis)
o C282Y/H63D heterozygous (3-5% hemochromatosis)

Clinical presentation of hemochromatosis

 Classic: Cirrhosis, bronze skin, diabetes (iron in pancreas) (now rare –early diagnosis)
 Cardiomyopathy, dysrhythmias (deposition in heart)
 Fatigue, malaise, arthralgia, hepatomegaly

Diagnosis of hemochromatosis
Need to differentiate from 2° iron overload (sickle cell / hemolysis / etc)
 ↑ AST / ALT (if liver compromised)
 ↑ transferrin saturation, ↑ ferritin, ↑ liver iron-index (measurements of iron in blood)

FHx / suspicion  blood test  HFE gene testing  liver biopsy (iron stain)
Treatment of hemochromatosis
 Phlebotomy (every week or biweekly – 250 mg Fe / 500 mL blood!)
o Target ferritin: < 50 ng/mL; transferrin sat < 50%
 Maintain ferritin (25-50 ng/mL) with maintenance phlebotomy
 Avoid vitamin C (reduce impact of rapid iron mobilization, which ↑ risk of cardiac dysrhythmia)
Survival ↑ if you get iron depletion done in 18 months!

Summary: hemochromatosis
• Autosomal recessive disorder; HFE mutation • Serum iron study and genotyping
– C282Y/ C282Y or C282Y/H63D • Phlebotomy for treatment
• Variable clinical presentation

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 α1-antitrypsin deficiency
Autosomal codominant inheritance
Gene: α1-antitrypsin: inhibitor of proteolytic enzyme (elastase)
 75 different protease inhibitor alleles have been identified
 Z-variant: single AA substitution  abnormal folding of
protein in hepatic secretory organelles

Pathogenesis
Different in lung vs liver!

Lung disease: Can’t secrete  proteolytic balance shifts

 ↑ protease activity  panacinar emphysema

Liver disease: Accumulation of misfolded protein causes cell death

Path / Lab Findings

Pathology: see PAS-positive AAT inclusions stuck in liver (can’t excrete)
Serology: small peak of α1-antitrypsin disappears!

Prognosis

Risk of lung disease: e.g. panacinar emphysema - varies with genotype

 ↑↑ for ZZ or null
 Correlates with AAT level (AAT↓  ↑ protease imbalance  ↑ COPD risk)

Risk for liver disease: also varies with genotype

 ↑ in ZZ, not null
 Correlates with misfolding of proteins (AAT misfolds in ZZ, just absent in null)

Diagnosis:
 most diagnosed in childhood
 Clinical presentation, biochemical studies (AAT in blood), liver Bx (see above), phenotyping (protein electrophoresis)
Treatment
 Family screening  Surveillance for hepatocellular carcinoma
 AAT infusion  Transplant if needed
 Treat complications / therapy for lung disease (liver transplant cures disease)

Summary: α1-antitrypsin deficiency

• Autosomal codominant • Pathogenesis differs in the lung and the liver
• Many variances • Liver transplant cures the disease

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 Non-Alcoholic Fatty Liver Disease (NAFLD)
Epidemiology: related to obesity / insulin resistance (↑)
 may soon replace HCV as #1 cause of cirrhosis needing transplant!

Progression
1. Steatosis: fat accumulating in liver
2. Steatohepatitis: fat + inflammation & death of hepatocytes
3. Cirrhosis

Insulin Insulin resistance

In normal patients, insulin release facilitates… Central component of metabolic syndrome
 ↑ fat storage  ↑ fatty acid deposition in liver cells
 ↑ lipolysis  ↑ lipogenesis

Summary: NAFLD
• The most common liver disease in the US
• Associated with obesity and metabolic syndrome
• Insulin resistance is the key component of pathogeneses

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 Cholestatic Liver Disease
Key Concepts
Cholestasis - any liver disorder characterized by impaired bile flow.
Lab findings
↑ serum alkaline phosphatase +/- bilirubin the hallmark of cholestasis
↑ GGT or 5’nucleotidase: to confirm liver-specific disease
ALT/AST Typically only mildly abnormal

Cholestasis can lead to: acute and/or chronic liver disease, cirrhosis, and hepatobiliary cancers

Pathophysiology
Bile flow: depends on multiple structural / functional components within hepatocytes & cholangiocytes
 Intrahepatic (hepatocytes) & extrahepatic (obstruction) are main categories of cholestasis

Etiology:
 Genetic or acquired defects of determinants of bile formation
 Obstruction / inflammation / destruction of cholangiocytes or hepatocytes

Bile production
 Small bile ducts (lined by hepatocytes) 
larger bile ducts; (lined with cholangiocytes)

 Bile starts to be formed by hepatocytes,

composition modified by cholangiocytes

 Small bile ducts  common bile duct  duodenum

Clinical Presentation of CLD

 Icterus, jaundice, other PE findings / features of cirrhosis

 Pruritis, RUQ pain, fevers/chills (infectious)

o Charcot’s triad, Raynaud’s pentad if acute cholangitis

 Fat-soluble vitamin deficiencies (ADEK)

A Night blindness
D Osteomalacia
E Neuropathy / rash (rare)
K Coagulopathy
Lab Tests
Alkaline phosphatase
 Made by biliary epithelium / hepatocytes, intestines, placenta, bone
 Liver disease: retained bile salts  ↑ AP synthesis, then it spills out into bloodstream

5’ nucleotidase: liver-specific phosphatase (if AP↑, make sure it’s liver’s fault!)

Gamma-gluamyltranspeptidase (GGT): liver-specific enzyme; use like 5’-NT

 ↑ with drugs that induce microsomal enzymes (EtOH / dilantin) too – not just cholestasis!

Bilirubin: ↑ direct (conjugated) bili in obstruction or intrahepatic cholestasis

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 Imaging
ULTRASOUND is ALWAYS THE FIRST TEST for ↑ alk phos with itching!

Good for Dx of… Notes

Ultrasound dilated biliary tree, gallstones.
CT Scan masses that may cause biliary obstruction NEED CONTRAST
MRI masses that may cause biliary obstruction.
MRCP strictures/obstruction MRI that specifically looks at the bile ducts.
Invasive procedure
ERCP Can see bile ducts; also possible intervention.
allows visualization of bile ducts by fluoroscopy,

U/S: Gallbladder w/ 4 stones U/S: dilated biliary tree CT: huge liver mass (arrow) MRCP: ERCP: stones &
biliary tree biliary tree

DDx of Cholestatic Liver Disease

Intrahepatic Extrahepatic
 Primary Biliary Cirrhosis OBSTRUCTION (almost always)
 Primary Sclerosing Cholangitis  Gallstones
 Drug-induced  Malignant
 “Overlap” syndromes  Infection
 Systemic diseases, incl. sepsis  Primary sclerosing cholangitis
 Rare causes

Primary Biliary Cirrhosis (PBC)

Autoimmune destruction of small intrahepatic bile ducts  inflammation, sclerosis

 Genetics / environment; Females>M (9:1)

 AMA: Anti-mitochondrial antibody (90-95% of pts, <1% normal controls: pretty specific / sensitive)

Diagnosis
 Cholestatic pattern of ↑ liver enzymes (alk phos ± bili)
o ↑ IgM, ↑ cholesterol too
 Positive AMA (presence of antibody, not titer is important)

Histology: non-suppurative cholangitis if you do a biopsy

 Inflammation / necrosis around bile ducts (“florid duct lesion”)
 Bile duct dropout (ductopenia), ductular proliferation, granuloma

Clinical Manifestations
 FATIGUE is #1 3/4 pts, doesn’t correlate with disease stage
o 20% have concurrent hypothyroidism (exacerbates)

 Itching (20-70%) Worse with night, fabric/heat, pregnancy

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Other symptoms:
 Portal hypertension
 Osteoporosis
 Hyperlipidemia:
 Vitamin deficiency
 Sicca syndrome
 Raynauds
 Fibrosing alveolitis
 Cutaneous calcinosis (see pic)
can develop in non-cirrhotic dz too (obliteration of portal vessels)
in 1/3 (4x RR) – women, too
HDL disproportionally elevated vs LDL (not atherosclerotic risk)
o Xanthomas can result! Fat under skin – see pic
(↓ ADEK) in jaundiced pts; uncommon
(dry eyes/mouth)

Management
Ursodeoxycholic acid is standard of care
 Naturally occurring bile acid, mechanism of action unclear
 Liver enzymes, itching improve
Other:
 Treat fat soluble vitamin (ADEK) deficiencies
 Cholestyramine for itching
 Liver transplant for decompensated cirrhosis

Primary Sclerosing Cholangitis (PSC)

Chronic, idiopathic, cholestatic liver disease leading to:
 progressive inflammation, fibrosis, and stricturing of intra- and extra-hepatic bile ducts

Epidemiology: 1/160k in US, 75% are MEN, majority Caucasians, typically present ≈ 40 years old
 70-80% have co-existent ulcerative colitis (like “UC of the bile duct”)

Pathogenesis: genetic & immunologic associations (HLA haplotypes)

Histology: Lymphocytic bile duct infiltration & scarring

 “onion skin” around bile duct

Clinical features
Symptoms Enzymes: cholestatic pattern
 Young men with diarrhea, bloody stools, jaundice  ↑ Alk phos (> 1000), ↑ bilirubin ↑
 Fatigue & itching  AST & ALT near normal – cholestatic enzymes

Diagnosis
 Imaging studies (U/S, MRCP / ERCP)
 Colonoscopy (look for IBD)
 Liver biopsy sometimes; exclude other disease
 Autoantibodies not usually used clinically

ERCP:
 scope down into duodenal ampulla
 end of scope has camera & some ports
 Nets to remove stones, stents to keep it open

ERCP in PSC:
 like ulcerative colitis, bile ducts have scarring & stricture
 “beads on a string” – bile behind the strictures

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Management
 Dilate / stent strictures with ERCP (percutaneous drains are alternative)
 Screen: cholangiocarcinoma / colorectal cancer in pts with UC
o Pts with both UC + PSC are at ↑↑ risk for these cancers
o Ca19-9 (tumor marker), imaging
 Liver transplant if serious but 15% recurrence rate
 High dose ursodeoxycholic acid?

REMEMBER: PBC vs PSCPBC

PBC = primary biliary cirrhosis PSC = primary sclerosing cholangitis
 Middle aged women with jaundice & itching  Young men with jaundice & diarrhea

Drug-induced Cholestasis
Meds / herbal supplements can cause acute / chronic cholestatic syndromes
 Range: from acute reversible cholestasis to chronic irreversible destruction of bile ducts; History is key

Clinical Presentation
 Majority are acute / resolve spontaneously after removal of drug
o (key to dx – temporal relationship & resolution after withdrawal)
 Jaundice, fatigue, pruritis, anorexia
 Rash / eosinophilia are possible

Pathophysiology
Variety of mechanisms of liver injury
 Interfere with uptake / transport / secretion of bile salts
 Toxic accumulations of drugs / metabolites
 Immune-mediated hypersensitivity reactions (see rash!)

Examples:
 Bland cholestasis:
 Cholestatic hepatitis:
 Cholangiolitis:
 Vanishing bile duct syndrome:
anabolic steroids, celecoxib, tamoxifen, OCPs, senna
PCNs, INH, NSAIDs, macrolides, cascara, TZDs, kava
TMP-SMX, phenytoin, carbamazipine
Chlorpromazine, tetracyclines, TPN, PCNs, macrolides, comfrey, azoles

Treatment
 Removal of suspected medication is KEY  Liver transplant if needed
 Cholestyramine (itching)  PATIENCE: can take weeks/months for liver
 ?ursodeoxycholic acid enzymes to return to normal

Overlap syndromes
 Have features of both autoimmune hepatitis and PBC or PSC

Rare causes of cholestasis, inserted for genes-to-society compliance:

 Alagille syndrome-AD JAG1 mutation, intrahepatic cholestasis, heart, eye, vertebral defects and characteristic facies.
 Progressive Familial Intrahepatic Cholestasis (PFIC, Byler’s disease)- AR leads to cirrhosis by age 10-15. Mutation of FIC-1 in type 1.
 Benign Recurrent Intrahepatic Cholestasis (BRIC)- intermittent attacks of jaundice and itching, but no permanent liver damage

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 Cholestatic variants of viral hepatitis
Essentially all hepatitis viruses (ABCE, CMV, EBV) can have cholestatic presentations
 HBV / HCV: severe cholestatic liver disease in immuncompromised hosts (Fibrosing Cholestatic Hepatitis)
o Not uncommon after organ transplants (≈ 10% liver transplants for HCV)

Systemic disease
Sepsis
 Extrahepatic bacterial / fungal infection: bacterial LPS impairs bile acid transport
 Treatment: treat underlying infection

Others
 Hepatic congestion: chronic right-sided heart failure can look predominantly cholestatic
o Hepatojugular reflex (press on RUQ, see JVP↑) & elevated indirect bilirubin are key to distinguish

 Paraneoplastic (Stauffer’s syndrome) in absence of hepatic metastases / obstruction

 Sarcoidosis: Noncaseating granulomas in liver can obstruct / obliterate small bile ducts  looks like PSC
o Larger ducts are rarely involved; looks like PSC often

 HIV/AIDs Cholangiopathy: consequence of underlying opportunistic infection

o CD4 < 100, with CMV / cryptosporidial infection
o Cholangiogram: see strictures, dilatations, papillary stenosis
o Treatment: HAART!

Extrahepatic Cholestasis (Biliary obstruction)

A GI EMERGENCY! Can cause rapidly progressive, life-threatening infection (ascending cholangitis)

Etiology:
Signs / Sx: KNOW THESE
 Choledocolithiasis
Charcot’s Triad Reynold’s Pentad
 PSC
1. Fever/rigors 1. Fever/rigors
 Infectious (worms!): strongyloides, ascaris, etc.
2. Jaundice 2. Jaundice
 Malignant
3. RUQ pain 3. RUQ pain
o Cholangiocarcinoma
o Pancreatic carcinoma (@ head of pancreas; “painless jaundice”)
4. Hypotension
o Lymphoma 5. Mental status changes

Treatment:
EMERGENT DECOMPRESSION of biliary tree + supportive care
 Fluid resuscitation
 Antibiotics (cover anaerobes & gram negs)

Approach to the patient with cholestasis

1. Suspect if ↑ alk phos
2. Confirm liver origin with GGT / 5’-NT
3. Do U/S
a. Mass: CT/MRI/Bx
b. Dilated ducts: MCRP/ERCP/PTC
c. Normal ducts: check AMA
i. If AMA normal: Bx liver

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 Autoimmune Hepatitis, Alcoholic Liver Dz, and Non-Alcoholic Fatty Liver
Autoimmune Hepatitis
First described by Waldenstrom, 1950; initially thought to be “lupoid hepatitis”; corticosteroids (general immune suppression) in 1970s

Epidemiology
 Uncommon disorder (2/10k)
 Associated with other immune disorders (e.g. thyroiditis)
 Women > Men (3.6:1)

Multiple presentations:
Asymptomatic Indolent disorder Acute disorder
jaundice, marked ↑ ALT 
Just ↑ ALT fatigue, malaise, arthralgias
occasionally acute liver failure

Histology
 Interface hepatitis
o inflammation at portal tract / lobule interface
o Lymphs / plasma cells (making IgGs)

 Bridging necrosis / fibrosis = more severe disease

Biochemical Features
 LFTs: injury mostly hepatocellular
o ↑ ALT (moderate / marked) with only minor elevation in alk phos

 ↑ Globulin fraction (usually more than 2x; γ-globulin > 1.1x)

 Autoantibodies must be present

o usually ANA, SMA(smooth muscle actin), LKM-1, SLA/LP
o none are specific for AIH (but need for Dx)

 Associated with HLA DR3 and DR4 – genetic component?

Subtypes of Autoimmune Hepatitis
Type 1 Type 2 Type 3
ANA , SMA, anti-actin
Anti-LKM1 Anti-SLA/LP
HLA DR3/4
Uncommon in US (kids from other countries) Very similar to type 1
More common in US
Associated with HCV Propensity to relapse after steroid discontinuation

Diagnosis of AIH
 Need to exclude chronic viral hepatitis (no viral markers!)
 Combination of criteria: hyperglobulinemia, antibodies (above), hepatitis on liver Bx, no viral markers

Role of Chronic HCV?

Non-organ-specific Ab occur in 25% of HCV pts (SMA/ANA most common)
 SMA not directed to actin
 Anti-LKM1 found in 10%
o Directed against CYP2D6  HCV with AIH features may require
o Often have worsening of ALT with INF immunosuppressive treatment‼
o 14x ↑ risk thyroiditis

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Therapy
Immunosuppressive therapy
 ↑ survival in severe AIH; risk-benefit ratio for milder disease is less certain
 Post-menopausal women, those with cirrhosis respond equally well

Response:
 ↓ AST, ALT to < 2x ULN, bili / γ-globulin normalize, interface hepatitis disappears (65% @ 18mo, 80% @ 3 yrs)
o Without treatment, patients get cirrhosis / complications
 Continue steroids for 1-2 yrs, then taper over 6-12 wks (continue other immunosuppression)

Summary: Autoimmune Hepatitis

 Need to recognize (significant morbidity / mortality)
 Most can be tapered off steroids, but only a minority of pts can be tapered off of all immunosuppression
 HCV pts with features of AIH may need immunosuppression

Alcoholic Liver Disease

3 major conditions: and overlap!
 Cirrhosis
 EtOH hepatitis
 Fatty liver

Small minority of heavy drinkers get liver disease!

 1 beer = 14 g of alcohol / day
 Risk starts to go up around 2-3 drinks / day (≈ 30 g)

Risk factors:
 Daily quantity of alcohol consumed  Presence of HCV infection
 Duration of heavy consumption  Genetic predisposition (twin studies)
 Nutritional factors, both obesity and malnutrition  Female gender

Clinical Features: inflammatory condition

 Jaundice  Abdominal pain  Fever
 Nausea and anorexia  Hepatomegaly

Lab features:
 Leukocytosis (inflammatory)
 ↑ AST & ALT (but mild: < 400 IU/mL), with high AST:ALT ratio
 Prolonged prothrombin time
 ↑ bilirubin (mostly conjugated)

Assessing severity
 Spontaneous encephalopathy is single worst clinical prognostic factor
 Ascites = ↑ severity

Discriminant function: can use to assess severity

4.6 × (PTpatient − PTlab control ) + total bili (mg/dL) > 93

 If > 93: 30 day mortality of 45-50% - bad!

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Pathogenesis
After heavy drinking…
 Ethanol oxidized to acetaldehyde (alcohol dehydrogenase) NAD+  NADPH in the process
 Acetaldehyde oxidized to acetate (aldehyde dehydrogenase) NAD+  NADPH in the process
 ↑ NADPH/NAD ratio  favors hepatic synthesis of FAs and triacylgylcerol
o Those processes use NADPH  NAD (so favored by ↑ NADPH!)

Molecular mechanisms
 Heavy alcohol ingestion  ↑ CYP450 2E1 and NADPH oxidase
o Acetaldehyde is highly reactive
o Enzyme induction, low GSH stores  development of oxidant stress in liver
 Alcohol  innate immune system  pro-inflammatory cytokines (TNF-α, IL-6)
o These cytokines induce NFκB and TGF-β (stimulate fibrogenesis)

Treatment
Concepts
 Eliminate offending agent
 Alter pathophysiology by addressing mechanism of injury / repair
 Target selected subgroup based on response (not too sick but could benefit from treatment)

Treatment: Most clinical improvement in 1st 6-12 months

 Abstinence is mainstay (few long-term studies on impact)
o 5 yr mortality: 45% if continue to drink, 13% if abstain

 Corticosteroids in those with most severe forms

o Rationale: anti-inflammatory, anti-fibrotic, predominantly ↓ TNF / ↓ IL6
o Benefit, esp. 30 days, but goes away @ 2 yrs (pts start drinking again)

Summary of alcoholic liver disease

 Only a minority of heavy drinkers develop serious alcoholic liver damage (15-25%)
 Alcoholic hepatitis is an inflammatory disorder characterized by jaundice, anorexia and abdominal pain
 There is a complex metabolic and cytokine-mediated interaction between different cell types leading to liver injury
 Abstinence is the cornerstone of therapy, but corticosteroids may be helpful in the most severe cases of alcoholic hepatitis

Non-Alcoholic Fatty Liver Disease / NASH

Non-alcoholic Fatty Liver Disease (NAFLD)
Most common cause of abnormal liver enzymes / chronic liver dz in USA (Hep C #1 for transplant)
 Fatty infiltration can be associated with inflammation and/or fibrosis

Risk Factors: associated with…

 Obesity  ↑ visceral fat accumulation
 Type 2 DM  Dyslipidemia (low HDL, ↑ TGs)

 Abdominal obesity (↑ waist/hip ratio) is a big one

o Different kind of fat – associated with insulin resistance, ↑ TG, ↓ HDL, HTN, etc.

 Metabolic syndrome: associated with NAFLD but interaction (cause / effect?) not well understood
o Related to insulin resistance?
Imaging:
 Normally liver = spleen for density on CT
 NAFLD/NASH: see liver < spleen (fat!)

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Pathogenesis (uncertain): Insulin resistance is key!
Normally, in fed state In NAFLD with insulin resistance
Insulin’s actions (↑ insulin release after meal) Hyperinsulinemia: ↑ insulin (resistant  try to compensate)

1.↓ lipolysis in adipose tissue 1. ↑ lipolysis (insulin resistance in adipose tissue) 

2.↑ glycolysis & FA synthesis (↑ with ↑ NADPH) 2. ↑ uptake of FFA by liver cells
3. ↑ accumulation of TGs in liver 3. ↑ synthesis of FA in liver
(insulin resistance doesn’t apply to liver & ↑insulinemia)
 End result: liver overwhelmed

Natural History of NAFLD:

 Can stay as just steatosis (NAFLD alone)
 Can also progress to NASH (see below) in a few patients
 In HCV pts, progression is much more likely

NASH: Non-alcoholic steatohepatitis

In setting of NAFLD, something leads to fibrotic changes

Risk factors for development of NASH (inflammatory changes)

 Age > 45  Diabetes Mellitus
 BMI > 30  AST / ALT ratio > 1

Prognosis of NAFLD / NASH

 When you go from fat only (NAFLD) to fat + inflammation (NASH), ↑ risk for bad stuff happening (↑ mortality!)
o ↑ risk of CVD & malignancy (top 2 causes of death, liver = #3)

Pathogenesis: Multiple “hits” probably involved: something pushes pt over the top
 adipocytokines, insulin resistance, oxidative stress / apoptosis, lipotoxicity / ER stress, etc. play a role
 Normally: balance between pro- and anti-inflammatory cytokines in liver
o Cytokine balance shifts to inflammation  necrosis, fibrosis (NASH)

1st hit obesity, DM, insulin resistance  hepatic steatosis (NAFLD)

2nd hit ↑ endotoxin levels, peroxisomal FA oxidation, FA toxicity
Result lipid peroxidation, production of byproducts 
 Cytokine balance  proinflammatory

Lab features of NASH

 ↑ AST & ALT (like alcoholic, chronic so mild ↑)
o ALT > AST in majority (vs. alcoholic etiology!)
 ↑ TGs, ↓ HDL, ↑ insulin
 Hyperglobulinemia, hypoalbuminemia, long PT are unusual
 Occasionally ↑ uric acid, ferritin, autoimmune markers
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Treatment of NAFLD
Correct insulin resistance Treat based on mechanisms of cell injury
 Diet / exercise  Anti-oxidants
 Metformin  Anti-cytokine therapy
 Thiazolidinediones  Anti-fibrotic therapy

AFLD / NAFLD: Multiple Risk Factors are Key

Big-time boozers ↑ risk, even if normal BMI
Fat heavy drinkers* ↑↑↑ risk
HCV + heavy drinking ↑↑↑ risk
*Heavy drinkers more likely to be obese too!
*RR for obesity = 2.5x!
NAFLD / NASH: summary
 Most frequent cause of abnormal LFTs
 Potentially serious outcomes in 10-15%
 Insulin resistance is a key factor in more advanced forms of NAFLD (NASH)
 Gradual weight loss is adequate treatment for those pts with steatosis without NASH
 Treatment of more advanced disease will probably require correction of insulin resistance or other approaches directed
toward mechanism of cell injury

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 Portal Hypertension & Cirrhosis
Teaching points from introductory cases
 ↑ direct bili alone doesn’t tell you if it’s bile duct obstruction or hepatocellular
 Prothrombin time is best to tell you severity of acute liver disease (short half-life of clotting factors)
o “do I have to hospitalize this guy or not?”
 After acute liver disease resolves, scar tissue in liver can remain:
o Normal liver enzymes, but ascites, spider veins, etc.

Cirrhosis: Overview
 End stage of any chronic liver disease
 Histology: regenerative nodules surrounded by fibrous tissue

Natural history:

Compensated = no symptoms,
decompensated = symptoms

Decompensation  ↓↓median survival

Symptoms:
1. Variceal hemorrhage
2. Ascites
3. Encephalopathy
4. Jaundice
(about 50% get one of these w/in 5 yrs)

Complications result from portal hypertension or liver insufficiency

Portal Hypertension
Portal vein: superior mesenteric vein + splenic vein (inferior mesenteric vein dumps into splenic vein)
 provides 80% of liver’s blood supply

Causes of Portal Hypertension

 Cirrhosis is most common cause of portal hypertension
 Site of increased resistance in cirrhosis is sinusoidal
 Other causes classified according to site of increased resistance

Type Pre-hepatic Pre-sinusoidal Sinusoidal

Example Portal or splenic vein thrombosis Schistosomiasis Cirrhosis

Pic

Thrombus (e.g. from infection post- Schistosome eggs block things up Cirrhosis: #1 for portal hypertension
Notes
delivery in umbilical vein) (see in Middle East) in USA; scarring/nodules in sinusoids

86
 Type Post-sinusoidal Post-hepatic
Example Veno-Occlusive Disease Budd-Chiari Syndrome

Pic

Obliteration of hepatic venules  ↑ Hepatic vein thrombosis = BC; post-

Notes
pressure throughout liver, portal v. hepatic portal hypertension in RHF too

Portal Hypertension from Cirrhosis: Pathogenesis

↑ intrahepatic resistance is initial mechanism leading to portal hypertension
 Splenomegaly & enlargement of portosystemic collaterals ( varices) can result

Normal sinusoid

 Space of Disse between hepatocyte & sinusoid

 Fenestrated capillaries (let large molecules out to be metabolized)
 Stellate cell: normally just stores vitamin A

 NO: normally plays role in dilating sinusoid

Cirrhotic sinusoid

 Activation of stellate cell  starts to secrete collagen

 Collagen deposition  nodules  cirrhosis
o Sinusoids contract
o Defenestration: Fenestrations clogged up, ↑ resistance

 ↓NO , ↑vasoconstrictors (adds to problem)

Key point: ↑ intrahepatic resistance is not only

 structural (sinusoidal fibrosis, regenerative nodules) but also
 functional (active vasoconstriction)

Portal hypertension can result from :

 ↑ resistance to portal flow Pressure = Resistance × Flow
 ↑ portal venous flow

Splanchnic vasodilation in portal hypertension (from ↑ NO)

 Perpetuates portal hypertension (↑ portal blood flow)

NO Paradox:
 NO would be good therapy in liver (dilate sinusoid)
 but would be bad for splanchnic bed (↑ vasodilation)

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 Summary of Mechanisms of Portal Hypertension in Cirrhosis
↑ intrahepatic resistance ↑ portal venous inflow
 Structural (fibrosis, regenerative nodules)  Splanchnic vasodilation (↑ NO)
 Active vasoconstriction (↓ NO, ↑ vasoconstrictors)

Complications of Portal Hypertension

Splenomegaly  Thrombocytopenia
Spleen gets larger (↑ pressure), removes more platelets (thrombocytopenia  pancytopenia)

Varices & Variceal Hemorrhage

Splanchnic vasodilation  ↑ portal venous inflow, variceal growth

↑ portal pressure  flow into collaterals

 most importantly in distal esophagus
 Increase in size progressively
 Worse liver dz = ↑ risk of varices,

Variceal hemorrhage is #1 cause of death in cirrhosis

 Don’t actually die from bleed itself these days, but starts downward spiral

Takes about 12 mm Hg pressure to form varices

 All people who have varices have 12 mm Hg,
but not all people with > 12 mm Hg pressure have varices!
 (some people can have high pressure, but still reserve collaterals to take advantage of)

Measurement of portal pressure: HPVG

 Can’t just measure pressure directly (can’t cath) – percutaneous, transjugular are
hard, have complications
 Hepatic venous pressure gradient is the safest / most reproducible method

Hepatic Venous Pressure Gradient (HPVG)

 Cath into jugular  hepatic vein  wedge  measure WHVP
o wedge hepatic vein pressure (WHVP) ≈ sinusoidal pressure

 Deflate balloon, pull back a bit  measure FHVP

o free hepatic vein pressure (FHVP) ≈ IVC pressure

 HVPG = WHVP – FHVP (normally ≈ 3-5 mmHg)

o ≈ gradient between sinusoid & IVC
o FHVP helps correct for ↑ extravascular, intraabdominal pressure
o reflects portal vein pressure

HVPG in various types of portal hypertension

WHVP FHVP HVPG Why?
Pre-hepatic nL nL nL you’re measuring sinusoidal pressure, which doesn’t really change
Pre-sinusoidal nL nL nL (blockage is downstream)
Good for cirrhosis: sinusoidal pressure is ↑
Sinusoidal ↑ nL ↑  (fibrosis, defenestration, sinusoidal constriction)
Post-sinusoidal ↑ nL ↑ ↑ sinusoidal pressure
Post- HF ↑ ↑ nL sinusoidal pressure is ↑, but so is IVC pressure – so no ↑ gradient!
hepatic Budd-Chiari - - - Thrombus in hepatic vein – can’t cath!

88
What predicts variceal hemorrhage?
 Larger varicies are more likely to rupture
(better predictor than ↑ pressure)
 ↑ Variceal wall tension too

 Red signs & “Child B/C” (staging criteria)

Therapies for Varices

 Vasoconstrictors
 Venodilators
 Combo
 Endoscopy
 TIPS / shunt surgery

Vasoconstrictors: try to ↓ portal flow

 Use non-selective beta blockers: ↓ CO and constrict splanchnic bed
 Octreotide, vasopressin (for acute bleeding, IV)

Vasodilators: modest effect; try to dilate

 Trying to ↓ systemic pressure, ↓ resistance in liver

Endoscopic variceal band ligation:

 Put a rubber band around it!
 Used to control bleeding varices that don’t respond to octreotide

TIPS: Transjugular intrahepatic Portosystemic Shunt

 Attempt to ↓ resistance to portal flow: shunt through liver!
 Procedure:
o Thread catheter through jugular vein to hepatic vein
o Put shunt through liver to portal vein
o Blood can flow portal vein  hepatic vein, pressure ↓ immediately
 Note that liver isn’t getting that blood now! Bypassing! (side effects)

Treatment Strategies for Varicies

Prevention of 1st hemorrhage
 Non-selective β-blockers are pretty good at preventing 1st variceal hemorrhage
o Adding nitrates (venodilators) doesn’t help too much
 Banding doesn’t have any advantage in survival vs β-blockers
o β-blockers are preferred (easier) unless very large varices (then band them!)

Treatment of acute variceal hemorrhage

General management:
 IV access and fluid resuscitation
 DO NOT OVERTRANSFUSE: get to adequate circulating volume, Hb ≈ 8 g/dL
o Too much blood  ↑ risk for re-bleed

Specific therapy
 Pharmacological: terlipressin, somatastatin /analogs, vaasopression / nitroglycerin
 Endoscopic therapy: ligation, sclerotherapy
 Shunt therapy: TIPS (if all else fails)

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Prevention of re-bleeds
 Lowest rates obtained with ligation + β-blockers
 BAND & put on β-blocker

Ascites & Hepatorenal Syndrome

Cirrhosis is most common cause of ascites
 Other causes: Peritoneal malignancy, heart failure, peritoneal tuberculosis, pancreatic causes, Budd-Chiari, nephrogenic

Pathogenesis: high pressure in two vascular beds

 Liver sinusoidal pressure ↑ and splanchnic vessel pressure ↑

 Ascites fluid is coming from sinusoidal pressure, not splanchnic pressure

o Portal vein obstruction doesn’t lead to ascites (not splanchnic bed)
o Budd-chiari: occlude hepatic vein  ascites w/o splanchnic bed pressure ↑

 Need HVPG > 12 mm Hg to develop ascites

o Get ↓ urinary sodium excretion (vasodilation  kidney senses low effective perfusion pressure)

SAAG & Ascites Protein

How to tell where ascites is coming from?

Serum-ascites albumin gradient (SAAG)

 correlates with sinusoidal pressure gradient

 SAAG > 1.1 g/dL = sinusoidal pressure > 12 mm Hg

o Means liver is cause of ascites

 Peritoneum could be making too much (cancer / TB) –

but would have ↓ SAAG

Ascites protein < 2.5 means sinusoids affected

 In Heart Failure: lots of protein in ascites

o still have fenestrations in sinusoids
o proteins can get out
o Ascites protein > 2.5

 In Cirrhosis: “capillarized” sinuosids

o collagen clogging fenestrations
o can’t get protein into ascites fluid (low ascites protein)
o Ascites protein < 2.5

Treatment of ascites

Sodium restriction
 2g per day (just enough that they can eat normal food)
 Fluid restriction not necessary unless hyponatremic
 Goal: negative sodium balance
 Careful: people with sodium restriction tend to stop eating (bad)

90
Diuretics:
 Spironolactone is #1: really high aldosterone levels in these pts Diuretic goals for ascites
o If you just use Lasix proximally, will reabsorb distally
 Shoot for 1kg in 1 wk, 2kg/wk afterwards
st

 Furosemide if inadequate weight loss or hyperkalemia

 Decrease if > 0.5kg/day
 Side effects: from diuretic: Renal dysfunction, hyponatremia, hyperkalemia, encephalopathy, gynecomastia

Refractory ascites (10% cirrhotic pts)

Diuretic-intractable ascites (80%) therapeutic doses of diuretics can’t be achieved (complications)
Diuretic-resistant ascites (20%) no response to maximal diuretic therapy
Refractory = worse survival than pts with diuretic-responsive ascites

Treatment of refractory ascites

 large volume paracentesis (take the fluid off! – but comes back in a week)
 TIPS: ↓ portal pressure, stops formation of ascites
o ↓ ascites recurrence but ↑ RISK OF ENCEPHALOPATHY (stuff not cleared by liver  brain)
o No survival difference

Spontaneous bacterial peritonitis

 ascites can get infected; most common serious infection in people with cirrhosis & ascites

Pathogenesis of SBP: ↓ immune system, ↑ bacteria

 Normally: largest component of RES in liver (Kupffer cells) – protects itself, systemic circulation
o Lots of bacteria in portal vein with every bowel movement, but all taken out by Kupffer cells

 Cirrhosis: fluid goes around the liver (bacteria can get to systemic circulation)  transient bacteremia
o Ascites can get colonized too (pressure pushes bacteria in)
o ↓ complement too (liver compromised!)

Symptoms of SBP
 1/3 have no symptoms at all‼
o Look for PMNs > 250 & empirically treat for spontaneous bacterial peritonitis if ↑ PMNs
o Cover aerobic gram negative rods
 Symptoms when present: Fever, jaundice, abdominal pain, confusion, abdominal tenderness, hypotension

Hepatorenal Syndrome
Basically:
 Cirrhosis  ↓ arteriolar resistance (vasodilating)
 Kidneys see↓ effective arterial blood volume
 RAAS, epinephrine, ADH activated
 renal vasoconstriction  hepatorenal syndrome

Creatinine tells us which pts to consider for renal transplant

 If in renal failure, only therapy is liver transplant!

Treatment of HRS
 VASOCONSTRICTORS + ALBUMIN
o Vasopressin analogues (terlipressin, ornipresin), octreotide + midodrine, noradrenaline
o Albumin: stays intravascularly; helps keep fluid there too
o Helps: HRS improves in ≈ 60%, low recurrence – but still > 50% mortality in 1 mo
 TIPS or liver transplant if severe

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 Hepatic Encephalopathy
Pathophysiology
Normally
 Ammonia from protein metabolism goes into liver via portal vein
 Comes out as urea  excreted

If blood bypasses liver or liver doesn’t metabolize ammonia

 ↑ ammonia to brain
 Acts on GABA-BD receptors in brain

Grade hepatic encephalopathy (1-4) when pt comes to hospital

 1 = confusion, 2 = drowsiness, 3 = somnolence, 4= coma

Clinical Presentation
 Asterixis is hallmark sign
 Perception of space is impaired
o E.g. number connection test , make a star with matchsticks

 Reversal in day/night sleep patterns

o DON’T GIVE SLEEPING PILLS TO CIRRHOTICS
 unless you’re sure there’s no encephalopathy
 (bad – acts on benzo receptors!)
EEG: can see triphasic waves, diffuse slowing

Precipitants of hepatic encephalopathy

Cause Notes Cause Notes
Excess protein e.g. hamburgers ↓ serum K, plasma volume  azotemia
 NH3 +H  NH4
+ +
GI bleeding most common reason –
Diuretics  Alkalosis: shift equilibrium to right,
not perfusing liver!
Sedatives / hypnotics benzo receptor! NH3 is freely permeable (more into brain!)
TIPS (bypassing liver) Infections

Treatment
↑ ammonia fixation in liver ↓ ammonia production in gut
 Ornithine bcka’s  Lactulose
 Benzoate  Antibiotics
 Shunt occlusion / reduction (if TIPS is cause)  Adjust dietary proteins
Lactulose: get rid of ammonia
 Lactulose  lactic acid in bowel, acidify lumen (trap ammonia as NH4+ in lumen)
 Gives you diarrhea too (more ammonia in frequent stools)
Summary: Natural History of Cirrhosis

Note that all the treatments talked about today

have been palliative (not fixing underlying liver
disease)

92
 Liver Transplant
For scoring systems: don’t memorize details; just what goes into them & trends
Regeneration
 Mature hepatocytes can regenerate / proliferate
 If chronically injured (stress, DNA damage), can’t regenerate
o Smart: liver doesn’t want these damaged cells to make new liver!
o Bad in severe liver damage, etc – can’t regenerate

History:
 1967 – 1st successful liver transplant (kidney, pancreas/liver 1st)

Current status
 > 15k pts on waiting list currently; 93k liver transplants have been performed (3,745 living donor transplants)
 Expensive: ≈ 400k

Survival: Good! > 70% @ 5 yrs!

Patient Selection: Indication, timing, appropriate candidate?

Indications
 Non-cholestatic cirrhosis is #1!
 neoplasms, metabolic dz, acute hepatic necrosis, cholestatic dz, more too

Hepatocellular carcinoma
 ↑ risk of cancer over time – survey for cancer.
 Transplant if you think you can avoid recurrence

Milan criteria: OK for transplant in HCC if…

 single lesion < 5 cm  no vascular invasion / extrahepatic mets
 ≤ 3 lesions, largest ≤ 3 cm  Tumor markers: ELSD & AFP > 500

Timing
 Acute liver failure (see below)
 ESLD (end-stage liver disease) – need to get a transplant!
 “Prioritization” (e.g. HCC) – given 22 points on MELD!

Acute liver failure

 transplant (but pts taking liver away from others – immediate indication)
 Acute onset of hepatic encephalopathy & coagulopathy (↑ PT) within 8 wks of jaundice
 2k/yr in US; 300-350 emergent liver transplants / yr (most can recover on own)

“Status 1” for liver transplant (life expectancy < 7d: transplant immediately!)
 Encephalopathy within 8 wks of 1 “liver symptom
st

 No pre-existing liver dz
 In ICU and: vent dependent, renal replacement therapy, INR > 2
 (Or: acute Wilson’s disease)

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 King’s college criteria
for acute liver failure – who won’t survive w/o liver transplant?
 Good positive predictive value, bad negative predictive value: If no transplant
 Will die if fit criteria, could die if don’t fit criteria
Acetaminophen-related Non-acetaminophen related
PT > 100 sec, or any 3 of:
pH < 7.3, or all 3 of:  NANB, Drug
 PT > 100 s  Jaundice  encephalopathy in > 7 days
 Cr > 3.5 mg/dL  PT > 50 sec
 Grade 3 hepatic encephalopathy  Age extremes (< 10 or > 40)
 Bilirubin > 17.4 mg/dL

Who gets a liver?

 When to refer a patient with cirrhosis for transplant evaluation?
 Sickest First! (but how to predict outcome?
 “Child-Pugh Classification”
Chronic Liver disease / cirrhosis
 MELD
Acute liver failure  King’s college criteria (see above)
Note: all 3 models (King’s College, CPT, MELD) DON’T CONTAIN AST or ALT!

Child-Turcotte-Pugh (CTP) Scoring system

 Assess 1-3 points for: encephalopathy, ascities, bili (adjust for PBC / PSC / etc), albumin, PT or INR,
o A: 5-6 (compensated cirrhosis)
o B: 7-9
o C: >10 (sick / decompensated)
 Lets you know chance of surviving surgery (transplant Childs “C” first)
 Drawbacks: subjective parameters (ascites), some parameters treatable, etc.

MELD score
 Accurately predicts short-term survival (6 mo) for cirrhosis
 Derived from Bilirubin, PT or INR, creatinine
o Lowest score (= healthiest) =6
o Highest score (= worst) = 40
o Transplant sickest first (highest MELD); Here (in this region) most patients transplanted with MELD around 20-25

 Use a calculator (complicated)

 For HCC: given 22 MELD points to start with, ↑ with every extension
o Need to prioritize (higher mortality risk even with preserved liver function  invading, etc)

Contraindications
Medical Social / Psychosocial
 Medically significant cardiopulmonary dz  Active EtOH and/or drug abuse
(won’t survive surgery) – very rigorous surgery  History of medical non-compliant
 Extra-hepatic malignancy (mets)  Inadequate social support
 Active untreated sepsis
 Extensive mesenteric / portal vein thrombosis

Relative contraindications:
 Advanced age (> 69 yo); Worse outcome in old pts if major comorbidities
 HIV (CD4 < 100 and/or ↑ VL)
 BMI > 40

94
Pre-transplant evaluation
 Hx / PE  Creatanine clearance
 Labs to confirm etiology / severity; ABO typing  Serology (HBV/HCV/EBV/CMV/EBV/HIV)
 Cardiopulmonary assessment (echo, PFT,s tress test,  3D-CT to determine hepatic vascular anatomy, screen for HCC
etc); cath if positive stress test
o NOT a contraindication if you can correct CAD
with angioplasty / bypass & good LV function

Organ allocation
1. Acute liver failure has highest priority
2. Then MELD determines priority in cirrhosis
3. Waiting time used to break ties if pts have same MELD

Regional allocation: Nation  Region  OPO (organ procurement organization)

 Algorithm: Local status 1s > regional status 1s > local MELDs > regional MELDs > national status 1s > all others

How to expand the donor pool?

 Extended criteria (eg donor after cardiac death – DCD) – not as good; no flow to liver (biliary complications)
 Split liver transplantation size matters! Big donors can be used (e.g. one big adult  small adult + child)
 Living donor liver transplant (LDLT)

Living donor liver transplant: LDLT

Technically difficult
Overall complication (35%), mostly biliary / infectious
 Catastrophic complication ≈ 0.5%
 Mortality up to 0.5% for donors!

Donor: usually an ABO compatible close relative, preferably < 60 yo (preferably < 50)
 donor must be extremely healthy, recipient can’t be extremely sick (MELD ≈ 15-20)

Immunosuppression after Liver Transplantation

 Liver is more immune-friendly than kidney; but still need immunosuppression

Complications
Immediate Late
 PNF (primary non-functioning)  Chronic
 Surgical (HAT = hepatic artery thrombosis, biliary leak / rejection
stricture)  Recurrent
 Acute cellular rejection disease
 Drug toxicity
 Infections (50% bacterial > 20% fungal > 10% viral)

95
 Liver Review
Just some key points – most covered elsewhere
Bile ducts get their blood primarily from hepatic artery supply
 Damage hepatic artery  damage bile ducts!

You need sufficient hepatic function to have…

1. Albumin synthesis These are
2. Coagulation factors exclusively done
3. Bilirubin conjugation by hepatocytes!

Lab Values
↑ Alk Phos in cholestasis
↑ AST, ALT in hepatocellular disease
 ↑ AST:ALT (> 2) is consistent with alcoholic hepatitis
↓ albumin if progressing to cirrhosis

Ascites / physical exam

(these findings are 100% sensitive)
 Vascular spiders
 Palmar erythema
 Abdominal wall collaterals (caput medusa)

Portal hypertension
Higher pressure in portal vein

 Spleen gets larger (splenomegaly)

o More platelets removed (thrombocytopenia!)

 Varicies develop (↑ flow through collaterals)

Cirrhosis
1. Portal HTN + vasodilation  splanchnic vasodilation

2. ↓ effective circulation
o Blood not in effective circulation anymore (sitting in splachnic bed)
o May have ↑ total volume, but ↓ effective arterial blood volume

3. Neurohumoral systems activated

o Na retention  ascites
o Renal vasoconstriction  HRS
o H2O retention  HypoNa

96
 Pharmacology: GI
Gastrointestinal Pharmacology ............................................................................................................................................... 2
Drugs and the Liver ................................................................................................................................................................. 9
 Gastrointestinal Pharmacology
Categories of drugs used for GI disorders:
 Peptic ulcer disease  Diarrhea
 Gastrointestinal motility disorders  Constipation
 Nausea/vomiting

Peptic Ulcer Disease

Gastric Acid production:
Inputs
 Neurologic input (Ach: muscarinic receptors)
o + acid, + mucous protection
 Gastrin (+ acid)
 Histamine (+ acid)
 Prostaglandins (+ mucous, - acid)

Roles of signals
1. Produce gastric acid
a. Parietal cell (H/K ATPase)
2. Help mucosa protect itself from acid
a. Superficial epithelial cell (HCO3- / mucous)

Drug strategies
 Acid neutralizing (antacids)
 Acid reduction (antisecretory)
 ↑ protection mucosal barrier (prostaglandin analogs)
 Eradicate H. pylori

Antacids
Mechanism of action: Clinical indications: (distant 3rd to H2RA / PPI for these)
 Basic compounds which neutralize HCl  Duodenal ulcers
 ↑ gastric intraluminal pH  GERD
 Inactivate pepsin, bind bile salts  Prophylaxis for stress ulcers

Pharmacokinetics
 Require frequent administration – rapid clearance is bad (want it to stay there)
 Caution in renal patients (cation absorption)

Pharmacokinetics Side effects

NaHCO3 very water soluble  rapidly cleared (bad) alkali & sodium load (bad for heart failure, etc)
CaCO3 rapid neutralization abdominal distension / belching
Mg alone is laxative (diarrhea)!
Combo Mg2+ / Al3+ slower absorption  longer neutralizing activity
 Al added to ↓ gut motility
Liquid is faster (doesn’t have to dissolve; ↑ surface area covered)
Product Al(OH)3 Mg(OH)2 CaCO3
Toxicities / interactions: change pH! Maalox quick

 Can interfere with absorption / bioavailability of other drugs dissolve
Mylanta  
 Can alter gastric motility (diarrhea / constipation)
Rolaids  
 Effects from cation absorption Tums-Ex 
Maalox TC  
Product names FYI, not for test Milk of Magnesia 
Acid reduction (antisecretory) therapies

H2 Receptor Antagonists (histamine congeners) (e.g. Ranitidine)

Mechanism of Action: H2 receptor antagonist (antisecretory acid reduction agent)
Effects: Competitive inhibition of histamine at H2 receptors (parietal cell)
 dose-dependent inhibition of gastric acid secretion by histamine & other secretagogues (H2 agonists)

Indications: Duodenal / gastric ulcers (treatment, recurrence of duodenal), acute & chronic GERD treatment.
 Inhibits basal acid secretion best (night / fasting), also physiologic acid secretion (feeding)
ranitidine
Administration: 1-2x/day
cimetidine
Pharmacokinetics: plasma peak 1-2h, mostly renal elimination, short half-life
famotidine
Toxicity:
 CYP450 INHIBITION (warfarin, theophylline, phenytoin)
 CNS confusion / somnolence
 Anti-androgen effects (esp. cimetidine) - gynecomastia, impotence (males), alactorrhea (females)

Other: cimetidine = Tagamet, ranitidine = Zantac, famotidine = Pepcid

Proton pump inhibitors (e.g. omeprazole)

Mechanism of Action: proton pump inhibitor (acid reduction - antisecretory therapy)

Effects:
 sufinyl group protonated in parietal cells (need acid)
 sulfenamide interacts covalently (irreversibly) with parietal cell H/K ATPase
 reduces daily acid production by 95%.

Selective Toxicity: Only acts where activated by acid (also, not on inactive proton pumps)
Indications:
 Peptic ulcers (esophagus, duodenum, stomach, esp. if H2RA unresponsive)
 erosive esophagitis from GERD
 Zollinger-Ellison syndrome

omeprazole Toxicity:
 Potential bacterial overgrowth of small bowel
 CYP450 inhibitor (watch out for phenytoin, diazepam, warfarin)
 ↑ risk of community acquired pneumonia (more bacteria; more chance of pneumonia on aspiration)
 ↑ risk of osteoporosis / fractures

Pharmacokinetics:
 Covalent bonding; long effects - days after drug disappears from plasma
o de novo synthesis of proton pumps required to increase acid production.
 Degraded by stomach acid (give enteric coating); metabolized by liver (need to adjust in liver failure)

Other: omeprazole (prilosec, zegerid), lansoprazole (prevacid), esomeprazole (nexium).

 No real increase in risk of carcinoid tumors (thought that chronic elevation of gastrin would increase ECL populations)
Protective mucosal barriers
Sulfated polysaccharides (e.g. sucralfate)
Mechanism of Action: improves protective mucosal barrier (protective to acid)
Effects:
 Activated by acid  viscous adherent gel binds electrostatically to (+) protein molecules in ulcer craters.
 Also inhibits pepsin and absorbs bile salts
Selective Toxicity: Activated by acid, works locally (not absorbed throughout body)

Indications: stress ulcers (prophylaxis), peptic ulcers, bile reflux (chemical gastritis - from duodenum to stomach)
sucralfate
Administration: Technically: should take on empty stomach (avoid binding to dietary protein / aluminum; also pH
increases after meal - less activation). In practice: usually take when you eat & at bedtime.

Pharmacokinetics: most of dose excreted unchanged in stool (works locally), aluminum accumulates with renal failure

Toxicity:
 Constipation, as an anion resin
 Binds other drugs (phenytoin, digoxin, theophyllin bioavailability reduced if given at same time)

Prostaglandin analogue (e.g. misoprostol)

Mechanism of Action: synthetic prostaglandin E1 analogue, increases protective functions of mucosal barrier
Effects:
 Antisecretory: inhibits basal, & nocturnal gastric acid secretion by direct action on parietal cells.
 Cytoprotective: increases production of gastric mucus and secretion of bicarbonate (epithelial cells)

misoprostol Indications: prevent gastric ulcers in patients on long term NSAIDs (COXi, so normal prostaglandins decreased!)
 Can use to treat constipation too!

Toxicity:
 Uterine contractions (abortifacent - DON'T USE in young women of reproductive age).
 Diarrhea, abdominal cramping

Eradication of H. pylori
 Gram-negative rod associated with gastritis, 60-95% of gastric ulcers / duodenal ulcers
o gastric adenocarcinoma & B-cell lymphoma too.
 Mechanism: ↓ antral D-cells  ↓ somatostatin  ↑ gastrin  ↑ acid production
 50% of world’s population infected, 15% of those develop duodenal ulcer

Treatment
 MULTIPLE ABX NEEDED: Single abx don’t work (lead to resistance!)
 ↑ effectiveness of pH-dependent abx (amoxicillin, clarithromycin) with PPI or H2-blocker
 Regimens: OAC (omeprazole + amoxicillin + clarithromycin); OMC (omeprazole + metronidazole + clarithromycin)
 10-14 days more effective than shorter courses
 Gastrointestinal motility disorders
Primary motor neuron in wall of gut controls motility

Receives input from:

Excitatory (↑ motility) Inhibitory (↓ motility)
 5HT3 serotonin receptor
 5HT4 serotonin receptor
 NANC (nonacetylcholine)
 ACh
 Dopamine

Mechanism of Action: 5-HT4 receptor activation (also dopamine antagonist and cholinergic agonist)
Effects: enhances smooth muscle propulsive contractionsof upper gut, accelerates gastric emptying (dopamine
normally slows things down; blocking it speeds things up).
 Also increases LES tone, has antiemetic effect (CNS dopamine antagonism)

Indications:
 gastroparesis(diabetic / idiopathic)
 GERD (increased LES tone, better gastric emptying)
metaclopramide
 nausea / vomiting

Pharmacokinetics: Half life increases in renal failure

Toxicity:
 somnolence, nervousness
 reversible extrapyramidal motor effects (Parkinson-like)
 irreversible tardive dyskinesia (inability to sit still / goes away with sleep)
Other: a.k.a. Reglan

Mechanism of Action: promotility agent; prostaglandin derivative; Cl channel agonist

Effects: Binds to ClC-2 channel on epithelial cell
 increased Cl & fluid secretion into gut lumen, softens stool and stimulates motility

Selective Toxicity: Acts at gut epithelium & works locally (fast metabolism; binds channels; doesn't get into blood)
Indications: Idiopathic chronic constipation, constipation-dominant IBS
lubiprostone
Pharmacokinetics: Negligible bioavailability; rapidly metabolized in gut epithelium
 no hepatic or CYP450 involvement
Toxicity:
 Nausea, diarrhea (too much of what you want)
 Headache, abdominal distension (more fluid into gut lumen)
 Flatulence

Mechanism of Action: promotility agent: antagonizes dopamine receptor

Effects: Dopamine receptor usually inhibits primary motor neuron in gut wall, slowing gastric motility.
domperidone  nhibiting dopamine receptor leads to more contractility.
Indications: like metaclopromide (gastroparesis, GERD, nausea / vomiting)
Selective Toxicity: does not cross BBB (no somnolence/extrapyramidal motor effects!)

erythromycin Mechanism of action: Promotility agent; macrolide; stimulates GI motility by agonizing motilin receptor

Things not to use:

 Tegaserod: MI, cerebrovascular accidents
 Cisapride: arrhythmias
 Nausea / Vomiting

 Emetic center in medulla

 CTZ: Chemoreceptor-trigger zone (area postrema) is key
o Note: M = muscarinic receptors

Why vomit?
 Get rid of toxins (smell, sense, etc)
 Protective: Less delicious to lions if you vomit all over yourself

Triggers:
 Motion (inner ear)  Local irritants
 Sensory input  Memory, fear
(via higher centers)  Gagging
 Blood-borne emetics

Receptors: lots of redundancy / overlap

 Simplified here (basics) – but dopamine, serotonin, histamine, acetylcholine are key!
Serotonin (5-HT3) Dopamine (D2) Histamine (H3)
Motion sickness (inner ear) 
Gagging   
Local irritants (chemo, radiation, bacteria, viruses) 

By knowing where these things work, you can figure out what medicine will be useful for which condition
 Note: don’t use serotonin antagonist for motion sickness – not involved in that pathway!

Mechanism of Action: antiemetic (serotonin receptor blocker)

Effects: blocks serotonin effect receptors in CNS (chemo-receptor trigger zone, nucleus tractus solitarius of
vagus nerve); may block vagal afferents in GI tract

Indications:
 Chemotherapy-induced nausea, nausea from upper GI irradiation
odansetron  hyperemesis of pregnancy
(zofran)  postoperative nausea
 NOT MOTION SICKNESS (no serotonin in that pathway)

Administration: once/day (antiemetic effect lasts long after drug cleared)

Pharmacokinetics: well absorbed from gut, CYP450 metabolism in liver (decrease dose in liver dysfunction)
Toxicity: Generally well tolerated: constipation, diarrhea, headache, light-headedness, minor EKG changes (not
clnically significant); financial toxicity ($$$!)

Others
Type Examples Blocks Special Indications
Phenothiazines Dopamine @ CTZ Motion sickness
prochlorperazine
Histamine, ACh too (better than ondansetron: anti-histamine / antiAch)
metaclopramide Dopamine @ CTZ
Prokinetics
domperidone (prokinetics)
promethazine  Post-op emesis
Antihistamines Histamine
diphenhydramine  Motion sickness
Anticholinergics scopolamine Muscarinic Ach receptor Motion sickness
activates cannabinoid Stimulates appetite too (AIDS pts)
Cannabinoids dronabinol
receptors in vomiting center?  Expensive!
 Diarrhea / Constipation: Overview
Key concepts:
 Fluid content = principal determinant of stool volume, consistency (usually 75-80% stool wt is H2O)
 Extent of fluid absorption by gut parallels transit time
o Faster transit  less fluid absorption (less time to absorb fluid)  diarrhea
o Slower transit  more fluid absorption (more time to absorb fluid) constipation

Numbers
 9L presented to small intestine each day (2 from diet, 7 from secretions)
 Making solid stool: conserves water & better bowel control
 Colon: can absorb 4-5 L /day (so it can pick up some slack if ↓ small bowel absorption)

Diarrhea:
Intraluminal agents
Put things into payload delivered to colon that absorb water (hygroscopic agents)

Hydroscopic agents Absorb excess water (↓ water content of stool) psyllium (Metamucil)
Bile salt binders Bind excess bile salts to avoid colon secretion cholestyramine (Questran)
Unknown mechanism, but bismuth has antisecretory,
Bismuth compounds bismuth subsalicylate (Pepto-Bismol)
anti-inflammatory, antimicrobial effects

Opiods
Mechanism of Action: opiod antimotility/antisecretory agent
Effects:
 ↑ fluid absorption, ↓ fluid secretion, ↓ motility (↑ transit time)
 ↓ longitudinal muscle activity (propulsion), ↑ segmentation activity (non-propulsive)
Indications: diarrhea (but not treating underlying cause)
loperamide
Pharmacokinetics: doesn't penetrate CNS in normal doses. loperamide is 40-50x more potent as anti-diarrheal than
morphine; quick onset affter oral dosing, peak 3-5h, half life 11h, hepatic metabolism

Toxicity: sedation and paralytic ileus with overdose

Other: aka Imodium

Constipation
General mechanisms of action
 Retain intraluminal fluid (osmotic / hydrophilic mechanisms)
 ↓ net absorption of fluid
 Motility effects:
o Inhibit segmenting (nonpropulsive) contractions
o Stimulate propulsive contractions

Stool softeners (emollients)

Mechanism of Action: emollient (stool softener) - anionic detergent
docusate sodium
Effects: lowers surface tension of stool (permits penetration of water, fats)
(colace)
Indications: used more for hard stools than constipation
Bulk-forming laxatives
Mechanism of Action: Hydrophilic compounds that hold water in stool
 might inhibit absorption of bile acids (stimulate H2O secretion by colon) too

Indications: used more for irritable bowel syndrome than for constipation

Mg salts
Most commonly used agents; hypertonic > isotonic for efficacy

Mechanism of action:
 Mg poorly absorbed  ↑ intraluminal osmolarity  ↑ water retention by stool
 Maybe ↑ CCK secretion (↑ bowel motility, secretion)

Stimulant cathartics
Direct effects on enterocytes, enteric neurons, muscle.

Mechanism of action: induce low grade inflammation in small bowel & colon!
 Inflammation  ↑ fluid, electrolytes  ↑ intestinal motility

Examples
 Bisacodyl
 Anthraquinones (senna)
Mechanism of action: Anthraquinone laxatives; "stimulant" cathartic (laxative)
Effects: induce low grade inflammation in small bowel & colon!
 Inflammation  ↑ fluid, electrolytes ↑ intestinal motility
Administration: not for daily use (see below)

senna Toxicity:
 melanosis coli (dark colon - reversible)
 "CATHARTIC COLON" (years of laxative abuse; becomes dilated & ahaustral; neurons lost & muscularis propria
atrophies - bowel function lost!)

Other: aloe, cascara are also anthraquinone laxatives

 Castor oil
o from castor plant bean
o stimulates fluid / electrolyte secretion in 1-3 hrs
o unpleasant taste, can be toxic to intestinal epithelium / enteric neurons

Nonabsorbable sugars
 If not absorbed by small intestine, can reach colon (metabolized to osmotically active organic FAs)
 Osmotic effect of FAs  fluid secretion, ↑ motility
 Examples: lactulose, glycerin, sorbitol, mannitol, lactose (if lactase deficient)
 Drugs and the Liver
Hepatic Drug Metabolism

Basic idea: both phase I and phase II want to make nonpolar

compounds more polar (easier to eliminate)

Phase I metabolism:
 Oxidation rxns catalyzed by CYP450 enzymes
(membrane-bound, have substrate specificity)
 Electrons transferred: substrate  ferric iron  O2
 NADPH serves as co-substrate (NADPH  NADP+)
 Some products are highly electrophilic; react with cellular metabolites

Phase II metabolism:
 Conjugation with UDP-glucuronic acid, glutathione, sulfate, amino-acids
 Catalyzed by several different transferases
 Substrate-specific (both endogenous & exogenous substrates: drugs)
 Almost all products are non-toxic, water-soluble

For polar compounds

 Low molecular wt drugs (<300) drugs are excreted by kidneys  urine
 High molecular wt drugs (> 300) are excreted into bile  stool

Phase III (transport)

 Transport proteins on cannalicular membrane: facilitate movement of conjugates into bile
 P-glycoprotein (Pgp) is a product of MDR-1 gene; can be induced by substrates for CYP3A4

IMPORTANT Definitions
Systemic clearance = hepatic clearance for drugs metabolized ONLY in the liver
Instrinsic clearance (Clint): clearance that depends on enzymatic metabolism (hepatic)
Extraction ratio (E): fraction of drug that is metabolized by “first pass” through the stomach / liver after oral ingestion

Relationship between hepatic clearance and blood flow

Equation Explanation Implication
𝑭=𝟏−𝑬 oral bioavailability = 1 - extraction ratio ↓ extraction ratio  ↑ oral bioavailability
𝑪𝒍𝒉𝒆𝒑𝒂𝒕𝒊𝒄 = 𝑸 × 𝑬 Hepatic clearance = flow x extraction ratio ↑ blood flow or ↑ extraction ratio = ↑ clearance!

For low extraction drugs, Clhepatic = Clint (hepatic clearance is ≈ the intrinsic clearance)
 The rate of clearance depends mostly on how the enzymes are working (increasing flow won’t really help)

Drugs with E close to 1 (high extraction)
LOW oral bioavailability
IV drug levels will be higher than PO if same dose
(IV skips 1st pass metabolism)
Drugs with low E (low extraction)
HIGH oral bioavailability
IV drug levels will be the same as PO
Variables that affect hepatic drug clearance
Intrinsic clearance
Hepatic blood flow Drug binding to plasma
(activity of drug-metabolizing enzymes)
 Interactions with other drugs and alcohol Drugs with high E are flow limited
(inhibition, induction)  1st pass effect! Only free drug is active
 Liver disease, Nutrition, Gender, Genetics Heart failure, shunts (e.g. TIPS) affect flow

Pharmacokinetics
 Polymorphisms exist for CYP450 isozymes
 May account for toxicity of certain drugs (e.g. isoniazide) – why do some get idiosyncratic drug rxns?
 Influence rates of elimination
Drugs & Cirrhosis
Low-extraction drugs
(e.g. antipyrine)
 For drugs that are oxidized by CYP450, the activity of enzymes decreases in advanced cirrhosis
o No drop-off until severe cirrhosis: flow doesn’t play a big role
 Hepatic clearance and intrinsic clearance decrease in parallel! (ClHep ≈ Clint)
o Enzyme activity is the key player!

High-extraction drugs
(e.g. lidocaine)
 For high E drugs, systemic clearance is normally dependent on flow (Q), not on Clint

In cirrhosis, blood isn’t all flowing through liver (portal hypertension, porto-hepatic shunting, etc)
 Intrinsic clearance becomes driving factor (how much can your enzymes work?)
 ↑ oral bioavailability: can now give lidocaine orally
o Need to lower oral doses (or would wind up with higher levels of drug)
o E.g. Propranolol: high extraction in liver; need to give less in cirrhosis
st
 (normally a lot gets cleared on 1 pass; not anymore!)

Basically: in cirrhosis, there’s “no such thing as a high extraction drug” anymore!
 ↓ flow through liver, so intrinsic clearance becomes more important

Cirrhosis: summary
 ↑ oral biovailability of drugs with high extraction ratio
 ↓ elimination of drugs metabolized by CYP450 in advanced cirrhosis
 ↓ binding (↓ serum protein) so ↑ “free drug” too!

Predictors of drug metabolism in cirrhosis

No “creatinine” for the kidney
 No correlation with AST / ALT / alk phos
 Weak correlation with albumin / PT
 Modest correlation with Childs-Pugh score
 But the good thing is that it takes severe liver damage to affect CYP450s

Recommendations for use of drugs in pts with cirrhosis

 Drugs eliminated by glucuronidation are less affected than those that are oxidized by CYP450
o Glucuronidation is pretty much intact, even in severe liver disease
 Oral administration of highly extracted drugs may lead to very high levels
 Dosing drugs w/ narrow therapeutic index should be modified in pts with advanced liver disease
 Drug-Induced Liver Damage
 Liver is major target for serious adverse affects
 Drugs are major cause of fulminant hepatic failure & frequent cause of undiagnosed liver dz
 Some drugs may be more toxic in individuals with underlying liver disease
 DILD is most common reason for post-marketing withdrawal of medications

DILD is histologically diverse:

 Hepatocellular necrosis, chronic hepatitis, steatohepatitis, granulomas, fibrosis, cholestasis, liver tumors, more!
 Some drugs have signature findings; others can cause different histology in different pts

Classification of DILD
Intrinsic hepatotoxins Idiosyncratic hepatotoxins
 Usually dose-related  Not always dose-related
 Short interval between ingestion / evidence of toxicity  Host factors play important role in risk
 Same type of injury across spectrum of individuals  Different reactions in different individuals
 Reproducible in animal models  Not reproducible in animal models

Idiosyncratic drug reactions: subclassification

Metabolic idiosyncrasy Immunologic idiosyncrasy
 Metabolism of drugs triggers “anti-stress” / anti-oxidant  Genetically determined
defense mechanisms in cells  Pt’s own immune response plays key role
 Responses / metabolism differs in pts; leads to toxicity  Aspects of hypersensitivity displayed, E.g. drug-induced lupus

Frequency of idiosyncratic drug reactions: broad range

o INH, others: more common (5-20/1k) but rarely prescribed
o Amoxicilin / clavulanic acid: more rare (.5-3 / 100k) but widely prescribed, so see more often!
o Minocycline: rare (1-10/10k) but really serious
 How often you see the reaction depends on frequency of Rx and probability of reaction
Clinical Spectrum of DILD
Hepatocellular injury Intrahepatic cholestasis Mixed hepatocellular /
(acute necrosis, chronic hepatitis) cholestatic injury
ALT ↑↑ (2-3x ULN) Minor changes ↑↑ (2x ULN)
Alk phos Minor changes ↑↑ (2x ULN) ↑↑ (2xULN)
ALT/alk phos ratio ↑↑ (> 5) ↓ (<2) Between 2 and 5

↑ risk for serious reactions

 Age  Genetic factors  Underlying liver dz (HCV /
 Gender  Obesity EtOH)
 Dose

Metabolic Hypersensitivity Syndrome

A.K.A. DRESS (drug reaction with eosinophila & systemic symptoms)

Features: hypersensitivity!
 Fever, rash, oral ulcers, lymphadenopathy, arthritis
 Cytopenias, eosinophilia
 Genetic susceptibility, family history
 ↑ risk in immunosuppressed (counterintuitive)
o HIV/AIDs, SLE, corticosteroids (e.g. TMP-SMX in AIDS)
Pathogenesis: Reactive Metabolite Hypothesis

 Most drug metabolism occurs within liver

 Phase 1 pathways (cytochrome P450s) produce oxidized, sometimes highly
reactive metabolites
 Can form enzyme – drug adducts; hypersensitivity rxn against these
 Can block MDR transport at bile canaliculi
 Reactive metabolites can bind to cellular macromolecules  cell injury
 Reactive metabolites also trigger apoptosis / release of cytokines

Case examples:

Drug-induced acute liver failure

 Drugs account for more that 50% of ALF
o 40% due to acetaminophen toxicity (55% unintentional)
o 13% due to idiosyncratic DILD
o 8% HBV, 4% HAV
o Survival lowest in those with idiosyncratic DILD

 Severe, but usually don’t need liver transplant

Acetaminophen toxicity
Histology: damage is mostly around terminal hepatic venule

Pathogenesis:
Note: APAP = n-acetyl-p-aminophenol = “acet-amino-phen”!

At normal therapeutic doses

 90% Phase II metabolism
o acetaminophen  either sulfate / glucuronide form, excreted

 10% phase I metabolism to NAPQI (CYP450 2E1)

o nasty effects (apoptosis, cytokines, binds macromolecules)
o Can normally be avoided by GSH addition  excretion

In acetaminophen overdose
 ↑ APAP  ↑ NAPQI produced  deplete GSH  can’t get rid of
NAPQI  more bad stuff happens (↑ *NAPQI+)

With ethanol ingestion too

 Ethanol processed by CYP450 2E1 & induces CYP450 2E1 too!
 ↑ CYP450 2E1  ↑ conversion of APAP to NAPQI  more toxicity!

Treatment: give N-acetyl cystine (restore GSH levels depleted by acetaminophen toxicity)

Diagnosis of drug-induced liver damage

 High index of suspicion
 Timing: of onset / resolution of sx / signs of liver disease in relation to drug ingestion
 Re-challenging is not a good idea ( can be hazardous)
 Exclude other possible disorders (DILD often mimics other liver diseases)
Management of drug-induced liver damage
 Stop drug delivery
 Don’t use generalized corticosteroids
 N-acetylcysteine helps APAP toxicity; may be of benefit for other drug reactions

Prevention of drug-induced liver damage

 Advise pts of signs / sx of liver disease
 Investigate anyone who becomes symptomatic on new drug
 Careful adherence to dosage guidelines (e.g. methotrexate, acetaminophen)
 Avoid deleterious drug combos
 Monitor LFTs (only for selective drugs: INH, etretinate, minocycline, or in those with ↑ risk factors: HCV)

Summary
• Most drugs are metabolized in liver
• Advanced liver disease affects hepatic drug elimination, particularly for those drugs that are oxidized by P450
• Drug induced liver damage most often related to metabolism of drugs to reactive metabolites that cause liver injury
• Host factors are important determinants of both metabolism and toxicity (idiosyncratic)
 Pathology: Eye
Eye Overview (I & II)
Orbit

Pear shaped, 7 bones: shock absorber

(Ethmoid, Lacrimal, Maxillary, Sphenoid, Palatine, Zygomatic, Frontal )
 Orbital fat cushions eye
 Force from trauma transmitted to bones break
 Orbital contents prolapse into sinuses; preserved
 Pic: L. orbital floor “blowout fracture”
 Includes all orbital contents
 Orbital rim = palpable opening

Openings for blood vessels & nerves

 Superior orbital fissure (CN 3/4/6, V1, symps, sup. orbital v.)
 Inferior orbital fissure (V2, infraorbital n, inf. orbital vein)
 Foramina for vessels / nerves
 Nasolacrimal canal (not really part of orbit)

Rectus muscles attach to orbital apex  form cone

 Classification of pathology: extraconal / intraconal

Remember the six muscles (4xRectus, 2xOblique) & nerves (CN3/4/6)

Clinical approach: the “six P’s”

 Pain  Proptosis  Pulsation
 Progression  Palpation  Periorbital changes

Thyroid Eye Disease

MOST COMMON CAUSE of unilateral PROPTOSIS in ADULTS
 Proptosis = eye sticking out

Can cause:
Exposure keratopathy, diplopia, compressive optic neuropathy

 Inferior, then medial rectus most often affected

o CT: thickened muscles with normal tendons

Clinically: see whites of eyes above irides

 ± conjunctiva protruding from lids
 Later: “thyroid stare”

Pathophysiology: largely unknown

 Autoimmune
 (thyroid-stimulating IGs  mimic TSH, other stuff?)

Histology: Mononuclear cells in muscle

1
 Orbital Septum
 Key anatomic landmark in surgery / trauma
 Separates true orbit from stuff outside (eyelids, etc)
 Arises from periosteum (over superior / inferior orbital rims)

Preseptal Cellulitis
Infection of structures anterior to orbital septum
 Orbital contents are uninvolved

Etiology: Staph, strep mostly

Dx: CT / MRI can help
Rx: Oral/topical/IV antibiotics, drain abscesses, fix blepharitis

Orbital cellulitis
From spread of infection into orbit through septum (anterior), orbital walls (posterior / medial), or hematogenous

Presentation:
 Proptosis
 Chemosis (swelling/edema of conjunctiva)
 Pain with eye movement
 “Frozen globe”: mobility restriction (pics) – muscles involved!
 Fever

Complications: can track into other areas

 Orbital apex syndrome (compressive optic neuropathy, othalmoplegia, blindness)
 Cavernous sinus thrombosis (cranial nerve palsies  brain abscess, death)
o WORK UP aggressively if suspected (including LP)

Dx: CT or MRI; look for abscesses, foreign bodies, sinusitis

Pic: ethmoid sinusitis (superior/medial) causing proptoic & down/out eye)

Rx: IV abx, drain abscesses / sinuses

Eyelids
Skin, subcutaneous tissue
Muscles:
Closure (protraction) Opening (retraction)
 Levator muscle and aponeurosis (CN III)
 orbicularis oculi  Muller’s muscles (sympathetics)
 Lower lid retractors
Rich blood supply to eyelids with multiple anastamoses  Lots of blood if eyelids cut

2
Chalazia & Styes
Chalazion Stye (hordeolum)
Lipogranuloma of Meibomian gland Bacterial infection of hair follicle
Infectious? Non-infectious Yes – Staph / Strep spp
Painful? Painless / subacute Painful (acute)
Involves… Meibomian gland (just subtarsal) Hair follicle
Size Usually larger Usually small

Gross /
Histology

Note lipogranuloma Lots of PMNs

Basal Cell Carcinoma of Lid

 Most common eyelid tumor
 Notched, ulcerated crater
 Usually on lower lid / medial canthus

Histology: PALASAIDING of tumor cells

Treatment: Surgical excision > radiation, cryoablation
Prognosis: very curable

Herpes Zoster

 Usually affects V1, V2, or V3

 Hutchinson’s sign: affects V1 down to tip of nose
o V2/3 & opposite side spared

Lacrimal gland & Nasolacrimal Drainage System

Lacrimal gland: Responsible for reflexive tearing

 E.g. crying, NOT basal tearing

Drainage:
 Tears wash across eye 
 Drain into punctae  Canaliculi 
 Nasolacrimal sac  Nose

Pathology
Dacryoadenitis Nasolacrimal duct occlusion Dacryocystitis

Infectious, swollen lacrimal gland Nasolacrimal duct closure (e.g. Infection of nasolacrimal sac
(esp. in kids) congenital)  mucopurlent tears (sac Rx with Abx ±surgery to drain abcess,
becomes infected) make new opening

3
 Conjunctiva
Filmy, transparent structure
 Covers whole surface of eye except cornea
 Bulbar, forniceal, palpebral sections

Histology
 Pseudostratified columnar epithelium
o non-keratinized
 Goblet cells secrete mucin (basal tearing)
 Stroma (substantia propia) is fibrovascular tissue
o Has lymphocytes, plasma cells, lymphoid aggregates

Conjunctivitis
a.k.a. “pinkeye”
Etiology: Can be bacterial, viral, allergic, toxic (can culture to help determine)

Infectious
Allergic Toxic
Bacterial Viral
Signs / Sx  Tearing, redness
 Itching  Aminoglycosides  Mucopurulent discharge
 ± ↓ vision
 Tearing  Preservatives (↑ if gonococcal)
 Preauricular adenopathy
 Mild redness  Anesthetic abuse  Papillae, crusting
 Follicles
Treatment  Antihistamines  Topical antibiotic (FQ/ TMP).
 Mast cell stabilizers  Avoid gentamycin

Cornea
Normally completely transparent (if dry)

Made of several layers of stromal & epithelial cells

 which lay in a clear, compact array
 Endothelium, epithelium  keep stroma dry

Creates refractive index (major focus device of eye)

Keratitis
 Inflammation of the cornea
 Can be infectious, immunologic, dry-eye related, toxic, or traumatic
Infectious keratitis
Pseudomonas keratitis Herpes simplex keratitis

Dendritic pattern of scarring Complete involvement of stroma

From contact lens overwear
Treatable if you get it early; otherwise can resolve into a stromal scar (cloudy)
Risk factors for infectious keratitis: dry, can’t protect it, or can’t feel it
 dry eye  Exposure keratopathy (drugs, Bell’s palsy)
 Topical corticosteroids  Corneal hypesthesia / anesthesia (previous HSV keratitis, topical anesthetic abuse)
4
Other Corneal Pathologies

Central keratolysis (severe dry eye):

Complete corneal melt (RA) Keratoplasty to fix (note sutures)
Central cornea melting

LASIK
 Use one laser to create a corneal flap
 Use another laser to reshape corneal stroma
 Can use similar idea to treat stromal scarring, etc.

Uveal Tract
Uvea = pigmented portion of eye
 Iris / ciliary body in front
 Choroid in back

Iris

 Anterior border layer, stroma

 Sphincter muscle (parasymps: CN 3)
 Dilator muscle (sympathetics)
 Pigmented epithelium

Ciliary body
 Right next to iris
 Inner non-pigmented epithelium continuous with retina
o Makes aqueous humor
 Outer pigmented epithelium
o continuous with retinal pigment epithelium
 Zonular fibers (dotted lines) attached to ciliary bodies
o Hold lens in place
o Ciliary mm pull on lens (accommodation)

Iritis (Anterior Uveitis)

 Iris infection  can spill WBC into aqueous humor
 Posterior synechiae can form (adhesions from constant inflammation

Picture:
 A, B: WBC in aqueous humor
 C: fibrin filling up chamber
 D: deposits on lens surface

CMV Retinitis
 Can be treated by ganciclovir intraocular drug delivery – drug-releasing implant

5
The Angle
 Formed by confluence of cornea, iris, ciliary body

Functions: filtration, maintenance of intraocular pressure

 Where aqueous fluid drains
 Drainage:
o From ciliary processes 
o Exchanges with vitreous 
o Through angle (lens / iris) into ant. Chamber
o Out canal of Schlemm 
o Through episcleral venous plexus

Glaucoma
 Characteristic loss of visual field (nasal, central-sparing, etc.) with specific changes in optic nerve appearance
 Often (but not always) associated with ↑ eye pressure
 Angle can be open or closed
 Major cause of vision loss in AAs

Pathophysiology: not totally understood

↑ IOP (function of rate of aqueous production, outflow, episcleral venous pressure)
 Aqueous production has diurnal fluctuation
 Outflow affected by blood, inflammatory cells, tumor cells, blockage of meshwork
 Episcleral venous pressure affected by A-V shunts, body position, head/neck diseases

Screening: measure eye pressure in pretty much everybody

 Use applanation tonometry (painless, precise)

Opthalmoscopic findings:
 See progressive optic disc cupping in glaucoma
 ↑ C/D ratio with time (notch  cup  entire nerve affected)

Visual acuity findings: lose nasal vision, central often spared esp. at first

Management of glaucoma:
Pharmacologic Laser Surgery
 Aqueous suppressants (β-blockers, CAIs)
 Argon laser trabeculoplasty  Trabeculectomy
 ↑ uveoscleral outflow (prostaglandin analogues)
 Selective laser trabeculoplasty  Tube shunts
 α-2 agonists

Angle Closure Glaucoma

 Associated with shape of eye, trauma, big cataracts, scarring
 Very treatable (laser iridotomy – put a hole in it)

6
 Lens
Anatomy: Crystalline lens with capsule, should be transparent, zonular fibers attach to ciliary processes
Histology: Surrounded by true basement membrane (capsule)
Function: Refraction: ciliary body contracts  relaxes zonular fibers  ↑ lens AP
Embryology: Lens vesicle invaginates from surface ectoderm

Accommodation

Ciliary body relaxed

Zonular fibers tight
Lens A-P diameter ↓
See far away things

Ciliary body contracted

Zonular fibers loose
Lens A-P diameter ↑
See close things

Cataracts
 #1 cause of vision loss worldwide

Gross appearance
 Lens with “blobs” in it (focal opacities)
 Yellowing = normal aging change

Risk Factors
 Age  Steroids  Diabetes  Radiation  poor nutrition
 UV light  Trauma  FHx  Uveitis  smoking

Symptoms: Blurred vision, glare, difficulty driving / reading

Treatment
 New glasses may be helpful
 Surgery: extract!
o Probe uses U/S to break up cataracts into smaller bits, then sucked out with vacuum
o Need to put intraocular lens implant after surgery (removing old one)

Vitreous Humor
 Gel-like substance (97% H2O, a little hyaluronic acid)
 Function: not well understood
 Adherent to retina at specific spots
o (ora, over blood vessels, around optic nerve)

Vitreous Detachment
 Vitreous detaches from retina
 Little “floaters” (spots of light) result – pulling on retina from inside
 Retinal breaks can result (if retina stays adherent)

7
 Sclera
 Collagen of variable diameter arranged in coarse bundles
 Extraocular muscles attach to sclera
 Traversed by nerves, blood vessels, o/w avascular
o Nourished by episclera, uveal tract
 Continuous with dura around optic nerve

Sclera is what the cornea would look like if it weren’t dry

Scleritis
Inflammation of the sclera
 Can be so thin that you see blue choroid (uvea) underneath
 Associated with RA / inflammatory conditions
 Can be thickened in idiopathic scleritis
 Inflammatory infiltrate on histology

Retina
Anatomy: Lots of Layers
Inner retina Outer retina Blood supply
 Inner limiting layer  Outer plexiform layer Note that
 Nerve fiber layer  Outer nuclear layer branches of
 Ganglion cell layer  External limiting membrane arterioles don’t
 Inner plexiform layer  Photoreceptors (rods and cones) cross each other
 Inner nuclear layer  Retinal pigment epithelium (horizontal raphe)

Light passes through lots of layers before hitting the rods & cones

Fovea: area of mostly cones (and rods), inner retina pushed away
 Small area of best sight (central vision)

Pathology of the Retina

Infectious Retinitis Embolic disease

CMV retinitis in AIDS: mixed HIV retinopathy: see cotton wool spots (L)
hemorrhage & necrosis with optic Histology: edema of nerve fiber layer; normal Retinal artery occlusion
nerve infiltrations; edema too underlying architecture

AMD: Age-related Macular Degeneration Diabetic Retinopathy

Neovascular (“wet”) AMD: This is non-proliferative: blood

Non-neovascular (“dry”) AMD vessels leak, deposit in retina (‘hard
hemorrhage, lipid exudates under
Drusen (L) ; atrophy is hallmark (R) exudate’ – blood cells, plasma)
retina; severe central vision loss

8
 Choroid (Posterior Uvea)
 Outer pigmented layer
 Outer layer of larger vessels, middle layer of smaller vessels
 Choriocapillaris:
o fenestrated endothelium
o Cubic arrangement with central feeder vessels
o Lobular blood supply

Choroidial Tumors
 Choroid is really vascular – tumors can seed here a lot
 Examples
o Lump sticking into vitreous – metastatic breast cancer (L)
o Choroidal melanoma (R)

Choroiditis
 Often goes with vasculitis
 Example: pseudomonas infection in AIDS (pic)

Coloboma
 Optic cup (becomes sclera) from prosencephalon
 Forms from flat sheet invaginates 
 has to close fissure

If the choroidal fissure doesn’t close, get a coloboma

 can look like a notch in iris, or be posterior imperfection in choroid

Optic Nerve
 about 3-4mm (15° nasal to fovea), usually ≈ 1.7mm vertical, 1.5mm horizontal
No photoreceptors overlying disc (blind spot)
 Central “cup” is free of nerve fibers

Nerve fibers: ≈ 1.4 M in all, about as long as a nerve could be inside the head!
 Visual  lateral geniculate (LGN thalamus)  optic radiations  occipital ctx
 Pupillomotor  edinger-westphal nucleus

Blood supply: rich

 Outside supply from short posterior ciliary aa
 Inner supply from central retinal artery (what you see with opthalmoscope)

Optic nerve Pathology

Optic nerve compression Optic disc edema = papilledema

Here in Wegner’s granulomatosis (orbit filled with fluid) Papilledema: ↑ ICP  disc edema
Also proptosis in this case Compressed nerve: swollen disc, congested
Can’t see vasculature, optic disc has lack of definition
9
Optic nerve Histology
 Extension of brain
 Myelination begins posterior to lamina cribosa (nerve thickens)
 Interstitial cells:
o oligodendrocytes (myelin)
o astrocytes (nutrition)
o microglia (phagocytes)
 Fibrovascular pia mater septa around myelinated nerve bundles

Visual Fields
 Good functional test of optical nerve

Suprotemporal deficits in both eyes

Normal (L eye) – note blind spot
(like pt is looking at you)

Remember this chart:

10
 Pathophysiology: Eye
Posterior Segment of the Eye ................................................................................................................................................. 2
Anterior Segment of the Eye................................................................................................................................................... 6
The Eye and the Brain ........................................................................................................................................................... 13

1
 Posterior Segment of the Eye
Introduction: Anatomy
Posterior segment = vitreous & retina

Outer retina:
 Photoreceptors are transparent
 The retinal pigment epithelium (RPE) is orange
o RPE is the orange background you see when you look into the eye
o Looking through cornea, lens, vitreous, photoreceptors

Blood supply:
 Inner retina: central retinal artery
o Inner retinal blood supply: vessels you see with fundoscope

 Outer retina: choriocapillaris

Diabetic Reinopathy
 14M with diabetes, more with glucose intolerance  8,000 become blind annually (#2 cause in USA)

Risk of vision loss ↓ with:

 Intensive control: prevent the pathology (Diabetes Control & Complications Trial)
 Laser photocoagulation: prevent the damage from the pathology

 Vision loss is a late symptom of the damage (need to screen / treat before vision loss)

Pathogenesis
High sugar levels affect retinal capillaries:
Loss of pericytes Thickening of basement membrane of endothelial cells

Pericytes = supportive cells to inner retinal capillaries Left: normal; right: thickened basement membrane
See asterisks in picture: loss of pericytes

Consequences:
 Leakage of blood vessels  macular edema
 Closure of retinal capillaries  retinal ischemia  retinal neovascularization
 Can have one, the other, or both

2
Macular edema (from leakage of capillaries)
Thickening of macula from intercellular fluid accumulation within retina

 Fluid leaks from microaneurysms and telangiectasia  accumulates near fovea inside retina
o (dilation, tortuosity of pre-existing capillaries)

 Lipid precipitates (spots) – precipitating lipoproteins that leak out with fluid

Small hemorrhages Fluorescein dye (leaking out Lipid precipitates (lipoproteins leak out with fluid)
from microaneyurisms)
Other diseases can cause similar changes too

Consequences of leakage: chronic edema  loss of retina tissue  vision loss

Treatment: Focal laser photocoagulation to leakage can ↓ risk vision loss by 50%

Retinal Ischemia (from closure of retinal capillaries)

We can’t see closure itself, but we can see consequences

Extensive hemorrhage &

Venous beading Intraretinal Microvascular Abnormalities (IRMA)
microaneyurisms

See lots of them! Veins that pass through area where Capillaries proliferating within the tissue of the retina
20+ per field of view capillary closed off  “beading” (or (↑ VEGF as capillaries closed off). Shouldn’t be able
“sausaging”) – structural change to see > 2 levels of branching

Usually don’t have much vision loss with capillary closure

 But retinal neovascularization can result (and that can cause vision loss)

Retinal Neovascularization (consequence of retinal ischemia  retinal capillary closure)

When new vessels grow on surface of the retina (vs IRMA, in tissue of retina)
 NVD: neovascularization of the disc
 NVE: neovascularization elsewhere

50% 1 year risk of NV (neovascularization) for pts with retinal ischemia

3
Vision loss in NV can result from
Vitrous hemorrhage Vessels grow into vitreous  hemorrhage into center of eye; pt suddenly can’t see out of eye
Fibrous proliferans Fibrous tissue develops  can lift retina right off of the back wall of the eye
Retinal ischemia itself much less common: retinal tissue dies

Treatment: Laser photocoagulation scattered to retinal outside macula  ↓ VEGF production

 Pt won’t see little dots (too small) from laser photocoagulation, but can cut down on some proliferation
 ↓ risk of vision loss from neovascularization by 50%

Age-related Macular Degeneration (AMD)

Retinal pigmented epithelium is nourished by choroid;
not the inner retinal capillaries

Basement membrane can be damaged in a variety of conditions

 Damage (histoplasmosis, trauma break of basement membrane, etc)
 pour out VEGF focally
 Macular degeneration = most common way BM gets damaged

Pathogenesis of AMD
Basement membrane can thicken with age (mechanism not understood)
 Various changes can result (see below)

Drusen Formation Drusen: yellowish basement membrane thickening

o (under orange RPE)

 Intermediate stage of macular degeneration

 Extensive, medium or large-sized drusen results
 Patient usually doesn’t notice change of vision
 Drusen happens just in center part of eye (unknown why)

Over years: drusen can cause RPE to atrophy away (over years)
Geographic atrophy can result (in map-like pattern)
 “Dry MD” = Drusen / geographic atrophy (depends on who’s
talking)
 Photoreceptors missing where RPE atrophy happens
Geographic Atrophy
Problem: Drusens happen in the middle of the eye, and the
macula is the area jam-packed with photoreceptors
 Lets you see detail (reading, etc) with center of vision
 Central vision lost!
Choroidal New blood vessels proliferate, penetrate basement membrane
Neovascularization  “wet MD” = choroidal neovascularization

↑ VEGF from damaged BM  choroidal vessels proliferate

o (vs inner retinal vessels in retinal neovascularization)
 Can happen with any kind of damage to BM
o trauma, infection, AMD, etc

New vessels can leak, scar tissue can result (see scar on exam)

4
Presentation
Symptoms of choroidal neovascularization (call an ophthalmologist if your patient has these!)
 Central scotoma (area of impaired vision with intact vision around it)
 Distortion
 ↓ contrast sensitivity
 ↓ color vision

Impact of AMD on patients

 Typically have difficulty with visual tasks
 Often just one eye affected – may not notice even w/ severe loss w/o covering one eye!
 Problems with reading, telling time, recognizing faces, driving

Patients really hate losing central vision in both eyes

 Rated lower than symptomatic HIV, CHF, only just above chronic renal failure / dialysis

Diagnosis
use fluoroscein to visualize choroidal neovascularization

Treatment
Antioxidants + zinc  real ↓ (albeit small) vs. placebo in progression to advanced AMD
 In almost every other part of medicine, there’s no rationale for taking vitamin supplements
 Doesn’t prevent drusen formation – only give to people who already have large drusen
 300k people per 5 yr period might avoid advanced AMD

Ranibizumab (anti-VEGF) injections if chorodial neovascularization under center of retina

↓ risk of additional vision loss, ↑ chance of improvement
 Inject into eye (really not so bad) about every months
 Costs $2k / bottle ($24k/yr!)
 95% of the time you can prevent vessel from growing more, scar tissue from forming
 But: only 30-45% of people have improvement

Summary: Pathophysiology of Posterior Segment of Eye (from notes)

Common characteristic Diabetic retinopathy AMD

Common cause of severe vision loss! Inner retinal capillaries Outer retinal basement membrane

Early pathology Asx & preventable! Intensive glucose control Antioxidants and zinc

↓ risk of vision-threatening  Focal laser to edema  Laser to non-central CNV

pathology if identified in early stages!  Scatter laser for NV  Ranibizumab to central CMV

5
 Anterior Segment of the Eye
Key Learning Points
 Cataract: most common cause of severe visual impairment in the world
Open angle glaucoma Angle closure glaucoma
Onset insidious onset more rapid onset
Description Optic neuropathy; loss of peripheral vision Optic neuropathy
Results from retinal ganglion cell death anatomic predisposition to blockage of the angle
 Small eyes (short axial length)
 Older age
 Older age
Risk factors  FHx
 Female
 Sub-Saharan African ancestry
 Asian (esp. Chinese) ancestry

The Lens
Function: focus
Structure:
 Biconvex, supported by zonules
o 9mm diameter, 5mm ant-post
 Crystalline structure
o 65% water
o 35% protein: soluble crystalline / insoluble albuminoids
o ↑ yellow-brown pigments with age
 Color perception changes

Embryology:
 Fetal development: lens surrounded by blood vessels (tunica vasculosa lentis) from back of eye
 Birth: vascular supply has atrophied, adult lens is avascular
o aqueous humor supplies nutrients; metabolism anaerobic
 Rarely: fetal vasculature can persist eye maldevelopment

Age-related changes
 Presbyopia: loss of accommodative power with age
o with ↑ age, lens gets harder but ciliary muscles, zonular fibers don’t change – can’t accommodate as well!
o Starts at birth, continues throughout life
 Cataract: clouding of the lens (see below)

Cataract
 Clouding of the normally clear crystalline lens
 Most frequent cause of visual impairment in the world (30M can’t see print / largest letter on chart)
 Cataract surgery = highly successful, #1 surgery in US medicare population

Risk factors
• Age • Radiation • Diabetes mellitus
• Uveitis • Cigarette smoking • Corticosteroids
• Light exposure (UV) • Excess EtOH consumption • Hereditary factors

DDx: Other causes of leukocoria (white pupil)

 Congenital cataract  Retinopathy of prematurity
 Ocular toxocara  Retinoblastoma
 Ocular toxoplasmosis

6
Posterior polar cataract
Anything that clouds pupil is a cataract
• Congenital, dense white opacity on posterior capsule
• Opacity extends into posterior cortex

Detection of Cataracts
Dilate the pupil
Can use the ophthalmoscope (green +3 to +5) to look at red reflex
 Cataract looks like clouding

Types of cataracts
Type Associations Drawing Picture
 Age-related (most common)
 Acquired (radiation, drugs, trauma)
 Congenital (Down’s syndrome)
Nuclear sclerosis
 Vascular (ocular ischemia)
(most common)
 Ocular disease (angle-closure glauc.)
 Metabolic (diabetes, malnutrition)
 Trauma (even years post-incident)
 Age related
 Congenital (myotonic dystrophy, Down)
 Inflammatory
Cortical cataract (eczema, atopic dermatitis)
 Metabolic (diabetes, hypocalcemia)
 Radiation (ultraviolet ?)
Can cause problems with reading, night
driving (troubling)
Posterior
 Age related
Subcapsular
 Acquired (electric shock – hit by
lightning, vitreoretinal surgery)
Clouding in  Drug use
posterior portion of
 Metabolic (diabetes)
lens
 Radiation (ionizing, ultraviolet)
Trauma

Cataracts can be associated with systemic therapies too

• Amiodarone • Phenothiazines • Corticosteroids • Hydroxychloroquine
• Gold (RA) • Miotics • Antimetabolites

Symptoms of cataracts:
• Blurred vision • Sensitivity to light
• Increased myopia (or ↓ hyperopia) • Decreased vision at night
• Glare • Difficulty reading

Preventing Cataracts:
• No specific pharmacologic therapy shown to prevent or retard the development of cataracts.
• (aldose reductase inhibitors in diabetics, aspirin, vitamins/anti-oxidants don’t work)
• Non-surgical treatment of cataract would have enormous implications in reducing blindness world wide.

7
Cataract surgery
 Most common operation in the world, success rate 98%, elective,
 Use local, topical or general anesthesia, operate on one eye at a time

Indications for cataract surgery

• Cataracts almost never cause pain, redness, discharge, or other external symptoms.
• Surgery based on functional impairment, NOT the appearance of the cataract or the Snellen acuity
• Decreased vision from cataract affecting activity, quality of life
• Inadequate view of retina compromising optimal patient care
• Cataract causing ↑ intraocular pressure, intraocular inflammation, or strabismus

Old types of cataract surgery

 Intracapsular: entire lens removed through 10-11 mm incision (older)
 Extracapsular: open capsule, deliver lens nucleus through 7 mm incision Steps in cataract surgery
• Anesthesia
Phacoemulsification is most common type today • Anterior capsulotomy – capsulorhexis
 dissolve lens with ultrasound, vacuum lens out (3mm incision) • Hydrodissection – freeing nucleus
 Can often close wound without sutures • Emulsification of lens nucleus
 Put new lens in (see below) • Irrigation and aspiration of lens cortex
 No laser operation can remove cataracts • Placement of intraocular lens

Rehabilitation after cataract surgery: when lens is removed, focusing power must be replaced!
 Cataract glasses: thick, cosmetically poorly accepted, limit peripheral vision; Contact lenses: hard for elderly patients
 Intraocular lenses: most commonly used now (since 1980s)
o Made of PMMA, silicon, acrylic; can be anterior or posterior chamber: here focusing on posterior chamber
o Haptics: little arms, hold lens in capsular bag
o Optic: 5-7mm optical zone
 Come in different strength; surgeon / pt choose postop refraction
 No accommodation!
 Multifocal lenses: provide distance / near vison w/o glasses
 Foldable lenses – can insert through self-sealing incisions (don’t need sutures)
Post-op care
 Shield / patch over night  No bending at waist / lifting > 10 lbs for 1 wk
 Eye drops (abx + corticosteroid combo) 4x/day x 1 wk  Resume all normal activities in one week

Vision recovery after cataract surgery

 Vision can be blurred for several weeks after surgery
 Some pts see clearly within several days
 20% pts develop glare, ↓ vision (usually within 2 yrs of cataract surgery) from posterior capsule opacification
o YAG laser capsulotomy: open central posterior capsule; improves vision in these patients

Open Angle Glaucoma

Definition: an optic nerve disease characterized by
 a physical change in the optic nerve head called excavation and by
 a loss of visual function in the side vision caused by retinal ganglion cell death

Symptoms:
 None initially: no pain / redness / glare / ↓ central vision
 OAG reduces peripheral vision (later in disease process)

Screening for OAG

• Screen high risk groups (AA, over 60, + FHx) yearly (computerized visual fields, stereoscopic optic disc analysis)
8
Epidemiology: 1-2% in white population > 40 yo in US / Europe; 3-4x ↑ in African Americans

Pathophysiology of OAG
 ↑ eye pressure  Poor vascular nutrition to optic nerve
 Defective connective tissue support at nerve head
 Premature apoptotic retinal ganglion cell death
 Thinning: irreversible loss of retinal nerve fiber layer
 Irreversible loss of retinal ganglion cell layer
 Morphologic changes in optic nerve  nerve fiber layer

Cup to disc ratio

 Height of cup over height of disc (e.g. 0.5 = “point 5”)
o Nerve fibers dying where they’re entering the optic nerve, so cup grows
 Symptomatic when cup/disc is asymmetric (R vs L) by 0.2 units or more

Risk factors for OAG

 ↑ IOP
 Older age (3x higher in 70s than 40s)
 African descent (3x higher in AA vs Caucasian)
 Parent / sib with glaucoma (10x ↑ risk for relatives; 10% of sibs)
 Thin corneas (AA thinner than Caucasians; maybe ↑ risk nerve damage from bowing?)
 Corticosteroids (1/3 have ↑ IOP when treated with steroids)
 Unproven: diabetes, myopia, HTN, ischemic vascular disease, gender

Diagnosis of OAG
 Intraocular pressure  Pachymetry (corneal thickness)
 Gonioscopy (examine anterior chamber angle)  Opthalmoscopy (optic nerve)

Visual field examination

 Use machine, measure peripheral / central field
 In glaucoma, vision loss:
o Starts nasally, progresses slowly
o Assymmetric between eyes
o Central (reading) vision is last
o Temporal field is spared until late

Early glaucoma damage Moderate glaucoma damage Severe glaucoma damage Glaucoma + cataract

Abnormal nasal area, just Spreading through lower nasal All but center and temporal General loss and local loss
above horizontal field field (outside of testing zone)
All are left eyes (pt looking towards you); black means reduced vision

Optical coherence tomography: computerized way to measure nerve fiber layer thickness
 Like a noncontact, non-excisional “optical biopsy” – like U/S but with light waves

9
Management of OAG
Intraocular pressure is key
 ↑ pressure = ↑ likelihood that glaucoma occurs
 ↓ pressure = protective
 But glaucoma can occur at any pressure (20% have normal pressures!)

Screening (IOP > 21 mm Hg)

 50% sensitive, 92% specific: means that 1:9 of people with IOP > 21 mm Hg have glaucoma (if 2% prevalence)

Eyedrops are usually the initial therapy; laser trabeculoplasty / surgical trabeculectomy if needed

Pharmacological therapy: drug therapy is most common in USA

Drug Basic idea
β-blockers Suppress aqueous formation
Carbonic anhydrase inhibitors Suppress aqueous formation (use topical to avoid systemic side effects)
α-2 agonists Suppress aqueous formation
Prostaglandin analogues ↑ uveoscleral outflow
Pilocarpine ↑ trabecular outflow through cholinergic stimulation – but rarely used (side effects)

Non-pharmacologic therapy
“the drain is clogged”, so…
 Laser trabeculoplasty (“Open the drain”)
 Surgery: trabeculectomy (“Create a new drain”)
o Can create a “bleb” where fluid drains out
 Slight ↑ risk infection (lose barrier)
 See pic

Angle Closure Glaucoma

The fluid “can’t get to the drain”
 Acute or chronic blockage of aqueous humor movement out of the trabecular meshwork by the iris
o Pupillary block (most common): prevention of aqueous passage through pupil from postant chamber
o ↑ eye pressure  damage to optic nerve  loss of side vision (similar to OAG)

Symptoms
 Rapid onset  Light sensitivity  Nausea (↑ pressure  vagal stimulation?)
 Pain  Headache  Blurred vision
 Redness

Acute angle closure = 20% of cases (sudden, symptomatic)

Chronic angle closure = 80% of cases (silent, like open-angle)

Risk factors: ↑ with smaller eye size, old age (55-65), females, Asian ethnicity,
 SYMPATHOMIMETICS (in cold preps, etc) are CONTRAINDICATED for
ACG (not OAG)
o Cause partial papillary dilation  ↑ lens-iris contact

Epidemiology: Mostly Asian (esp Chinese), also Inuits, less in AA / Caucasian

Pathophysiology: more common in smaller eyes

 Anterior structures tend to press themselves forward in eye
 Block of aqueous at pupil is intensified 
 Iris bows forward  obstructs aqueous flow
10
 Oblique Lighting
Diagnosis of ACG
Oblique lighting of eye: can see a shadow
on the other side (pupil bowed out)

Gonioscopy: can see peripheral anterior

synechiae (see below)

Management of ACG

Peripheral anterior synechiae

 If iris presses against trabecular
Normal: no shadow Narrow angle: see shadow
meshwork for a long time, it can
be scarred in place
 Try to avoid such permanent effects with therapy

Medical therapy:
 Pilocarpine drops (pull peripheral iris away from trabecular meshwork)
 Aqueous suppressants

Definitive therapy: iridotomy

Put a hole in the iris, restore flow
 Emergent (laser if possible, surgical if unsuccessful)
 Prophylactic iridiotomy in other eye
o 40-80% risk acute ACG in other eye over 5-10 yrs

The Cornea
 Transparent, 12 mm diameter, 500-600 microns thick
 Avascular, tear film provides nutrition to anterior cornea
o Tear film has lipid layer (oil glands), aqueous components (lacrimal
gland), and mucous (helps stick)
5 layers:
 Stroma in middle
 Epithelium on outside, endothelium on inside keep stroma dry (waterproof)
o ↓ endothelial cell density with time
 Bowman’s membrane (e pithelial) and Descernet’s membrane (endothelial) too

Corneal Transplants

Indications: loss of corneal integrity, opacification, abnormal curvature, infectious keratitis, graft failure

Procedure
 No artificial corneas
 Donor cornea: can preserve up to 10 days in tissue culture
o Screen donor for infectious disease, don’t need to match to host
 Sutures hold it in place, takes a long time to heal (avascular!)

Success ↑ with: vascularity of host, integrity of tear film, adequacy of lid closure, pt compliance

11
 Refractive Surgery
 Correct refractive error  eliminate need for glasses / contact lenses
 Current surgical technique: excimer laser & intraocular lenses

Refractive Errors
Emmetropia Myopia Hyperopia Astigmatism
(no refractive error) (nearsighted) (farsighted) (blurry vision)

Light converges Light converges Light converges

Cornea not round
on retina in front of retina behind retina
Also presbyopia: age related hardening of crystalline lens  loss of accommodative ability

Surgical Options: Excimer Laser

 Eximer = “excited dimer”
 Basic idea: change shape of corneal stroma (fix refractive error)

Older forms of surgery:

 PRK = photorefractive keratectomy (worked on surface alone – surface ablation)
 LASEK = laser subepithelial keratomileusis (loosen epithelium, lift flap of epithelium manually / mechanically)

LASIK = laser-assisted intrastromal keratomileusis (most commonly used today)

 Use microkeratome (blade) or femtosecond laser to cut corneal flap (flap has stroma)

12
 The Eye and the Brain
Sensory (Afferent) Visual System
Function: Detect & transmit visual information
Clinical assessment: Visual acuity, pupils, color vision, visual fields, depth perception

Anatomy
1. Retina: photoreceptors in outer layer are 1st cells
a. Rods & cones throughout, only cones in fovea
b. Bipolar cells connect, synapse on retinal ganglion cells
c. Retinal ganglion cells send axons to optic disc
2. Optic disc: 1.75x2.0 mm, ganglion cell axons & central retinal vessels out
3. Optic nerve: 1M axons of retinal ganglion cells  out optic canal
4. Optic chiasm: axons from nasal retina cross (temporal visual fields)
a. Right below hypothalamus and above pituitary
5. Optic tract: ipsi temporal retina, contra nasal retina (contralateral visual field)
6. Lateral geniculate (thalamus): optic tract axons synapse here
7. Optic radiations: from LGN thalamus though temporal / parietal lobes
a. Superior = inferior visual field (directly through parietal lobe)
b. Inferior = superior visual field (through temporal lobe as Meyer’s Loop)
8. Occipital / visual cortex: multilayered part of occipital lobe
a. radiations synapse here
b. Association areas just anterior (analyze data)

Afferent visual system is just about as long as it could be in the head

Visual Field Testing

 ALWAYS measure monocularly (one eye closed)
 Measure at distance and/or near
 Report as “Snellen fractional value”
o 20/20 = distance pt reads / distance normal pt could see
o GB / Canada use 6m (“6/6”), EU – report fraction (0.7 = 20/30)
 Depends on mental status & cooperation of patients

Qualitative measures (in young kids / poorly responsive pts)

 Fix and follow on an attractive object (not a light – too insensitive)

Quantitative measures: preferential looking, or with eye chart

Forced-choice preferential
looking – babies pay more
attention to stripes; make
Fix & follow (qualitative)
stripes narrower  see where
eye can’t resolve & just see
gray (kid stops looking)
Allen picture optotypes: try to
quantify for kids (non-
standard, questionable validity
(and out of date symbols)
Lea symbols: used more now
(a little more standard)
13
 Electronic testing: more accurate /
Matching tests: for older kids, etc. Snellen chart: the classic reliable; only use 10 letters (roughly same
level of difficulty)

Pupillary testing
 Objective sign of anterior visual pathway function: doesn’t depend on what patient does
 Good if patient unable, unwilling to do eye chart, or trying to game the system

Constriction: (parasympathetics) Light, sense of near

Dilation: (sympathetics) Dark, fear

Pupillary testing:
Use a bright light & have pt fixate at distance (near = constrict = confounder)
 Direct response: pupil ipsilateral to light
 Indirect response: pupil contralateral to light

Clinically: direct should = indirect response

The reflex:
 Retina  optic nerve  synapses on pretectal nucleus
 Pretectal nucleus  interneuron 
 Contralateral & ipsilateral E/W nucleus!

Afferent pupillary defect (= “Marcus Gunn pupil”)

 direct response in one eye does not equal that in fellow eye

Cause APD Don’t cause APD

Optic nerve defect  Cataract Diffuses image, but light gets to retina
Big retinal defect  Amblyopia* (“lazy eye”) Problem is in visual cortex, distal to pupil pathway
 Refractive error Defocused image doesn’t ↓ light striking retina

*Amblyopia: need experience to develop ability of occipital cortex to understand what it’s seeing
 If cortex doesn’t elaborate the right connections, end up with one eye that doesn’t see well. Treat by patching, etc.

Visual Field Testing

 Test monocularly (except for driver’s license: binocular function more important)
 Gross testing used more for neuro than ophthalmologic diagnosis
 Really boring, especially if you’re old (takes a long time)

14
Abnormalities:
 Size of lesion relates to how spread apart fibers are & how big lesion is!
 Fields are always shown from patient’s perspective

Bilateral field defect

Unilateral Heteronymous
Homonymous
field defect (temporal fields of
(same area)
each eye)
Think optic Think optic tract to
Think optic chiasm
nerve occipital lobe

A few conditions
Condition Pathogenesis Etiology Signs / Sx

No APD at first (vision ok), then…

Swelling of optic papillae
 ↓ acuity
Papilledema  axoplasmic transport blocked ↑ ICP
 Transient visual obscurations
 Permanent damage  atrophy  ↑ blind spot size

Inflammation of either:
 Idiopathic
 optic disc  ↓ central vision
 Infectious
Optic  retrobulbar optic nerve  APD
 Demyelinating
neuritis  Loss of color perception
dz (e.g. MS)
Often unilateral in young adults
F>M, can occur in fellow eye or recur

Benign systemic course except for ↓ visual

Optic nerve Astrocytic intrinsic tumor of #1 tumor in visual
acuity
glioma optic nerve pathway
Also: ↓ color acuity, APD, optic disc atrophy

Various endocrine dysfunctions (↑ or ↓)

Pituitary #1 tumor in Bitemporal visual field hemianopsia
adenoma chiasmal region  Central vision can be preserved
(some macular fibers remain ipsi)

Contralateral visual field defects

Visual field at end of PCA territory –  Exquisitely congruent (R vs L)
PCA stroke
can be only part of brain affected  Homonymous hemianiopia
NO pupillary defects! (behind reflex)

Transient cortical visual loss

Migraine See neuro section  Can be from one hemisphere, as part of
prodrome, etc.

15
 Efferent Visual System
 Aim eyes at image of regard
 Brainstem, CN III/IV/VI, extraocular muscles (rectuses, obliques, etc) involved
o Brainstem can be traumatized in motor vehicle accidents / falls
 Symptom of dysfunction = DIPLOPIA

Testing the Efferent System

Active:
 Ductions: test voluntary movements (follow a target)
 Cover test: focus at an object, block vision of one eye
o if the fellow eye has to move to find target, deviation exists (“tropia”)
Passive:
 Doll’s head: rotate head, eyes move opposite if brainstem working
 Forced ductions: with forceps on eye

Alignment: do eyes look straight ahead?

 Corneal light reflex testing
 Shine a light – see if reflection of light off of corneal surface is in the middle

Strabismus (misalignment)

Esotropia Crossing
Exotropia “Turning out”
Hypertropia “turning up”
Hypotropia “turning down”

Causes:
 Neuropathic (e.g. tumor compression)
 Myopathic (e.g. thyroid-associated eye disease)
 Neurologic (brainstem) (e.g. MS, tumor, inflammation)
 Genetic
 Trauma
 Idiopathic

Common, affects ≈ 1% pop, “crossed eyes”

 Abnormality of CNS (sensory / cortical or motor / brainstem level)
Congential (early-onset) esotropia
 Esotropia, amblyopia, ↓ depth perception
 Esotropia can signal ↑ ICP too
Ocular motor neuropathy, eye can’t move laterally
 From ischemic event to nerve, compression of nerve (tumor /
Abducens nerve paresis
aneyurism), or brainstem motor nuclei abnormalities
 Ddx includes myasthenia gravis & thyroid eye dz
Frontal lobes control voluntary horizontal gaze
Frontal lobe stroke  Stroke  ↓ output  gaze towards the lesion
 Inflammation / seizure  excess output  gaze away from lesion

16
 Pharmacology: Eye
Drugs and the Eye ................................................................................................................................................................... 2

1
 Drugs and the Eye
Overview
Eye can be easily studied (good to look @ drug effects); eye pharm is big business
History:
st
 Karl Koller: cocaine is a local anesthetic  Physostigmine (anti-AchE) 1 used to study glaucoma
 Belladonna agents dilate the pupil  Crede, 1884: silver nitrate for gonoccocal opthalmia neonatorum.
(“beautiful women” have big pupils) Now use Povidone-iodine (more effective, less toxic)

Anatomical considerations: the eye is isolated

 Cornea, lens are avascular
 Blood-retinal, blood-aqueous barriers get in the way
 Tear film, corneal epithelium provide isolation
 All protective: but in ocular therapeutics, need to be circumvented

Eyedrops
 Most agents given in eyedrop form
 Not good: too big, uncomfortable (used to swallowing), hard to administer
o Stopped by protective barriers (lashes, reflex blinking, etc)
 Enter eye by crossing cornea & sclera
 Useful for cornea, anterior segment conditions
 Effect short-lived (just hours)

Pharmacokinetics influenced by:

 Reflex tearing
 Contact time with corneal surface (↓ with tearing)
 Relative hydrophobicity / hydrophilicity:
need to navigate both lipophilic & hydrophilic layers!
o Epithelium is lipophilic
o Stroma is hydrophilic
o Endothelium is lipophilic

Drain into lacrimal sac, then nose  can achieve significant blood levels
 Insulin has been delivered in eyedrop form (proof-of-concept only)
 Sometimes pts can taste eyedrops

How to improve pharmacokinetics?

 Example: Dipivayl epinephrine (more hydrophobic than
epinephrine, hydrolyzed to epi in corneal stroma)
o Can use 17x less drug (↓ external effects)

Other ways to deliver drugs

 Subconjunctival injection
 Intravitreal injection (straight to vitreous cavity)
 Systemic (injection / IV  poor penetration, except in inflamed eye)

Drug receptors
Receptor Location
Muscarinic receptors Iris sphincter
α-adrenergic Iris dilator
Muscarinic receptors Ciliary muscle
β-adrenergic Ciliary epithelium, trabecular meshwork
2
 Drugs for Diagnosis: Mydriatics (dilate pupil)
 Important for examination posterior to iris (want to dilate pupil)
 Can have side effects (e.g. phenylephrine  can have CV effects – 3.5-6mg of active drug / drop!)

Muscarinic antagonists
 Ach  muscarinic Ach receptors of pupillary sphincter muscle → constriction
 Antagonize muscarinic Ach receptors  dilation

Mechanism of Action: Muscarinic antagonist mydriatic.

tropicamide
 Dilates pupil by antagonizing muscarinic ACh receptor of pupillary sphincter muscle
homatropine
Effects: Normally Ach binds muscarinic receptor on pupillary sphincter muscle, resulting in constriction
 so antagonizing this receptor leads to pupillary dilation
atropine
Indications: pupillary dilation (used to visualize ocular structures posterior to iris)
scopolamine
Administration: often with alpha-1 adrenergic agonist for maximal dilation

α-1 adrenergic agonists

 Stimulate pupillary dilator muscle directly (α-1 adrenergic stimulation)

Mechanism of Action: alpha-1 adrenergic agonist mydriatic.

Effects: Dilates pupil by stimulating alpha-1 adrenergic receptors on pupillary dilator muscle
phenylephrine Indications: pupillary dilation (used to visualize ocular structures posterior to iris)
Administration: often with muscarinic antagonist for maximal dilation
Toxicity: 1 drop of phenylephrine can contain 3.5-6 mg of the drug - can cause serious systemic side effects

Note: often use a combo of α-1 agonists and muscarinic antagonists to obtain maximal dilitation

Adie’s pupil
 Damage ciliary ganglion  ↓ parasympathetic input to pupil
 ↑ # muscarinic Ach receptors (upregulated)

Denervation supersensitivity results

 Testing for Adie’s pupil: instill dilute pilocarpine
 If pupil constricts with such a dilute sol’n  Dx = Adie’s pupil
o Normal pupil won’t constrict – too weak of a sol’n

Horner’s Syndrome
Interruption of sympathetic fibers to the iris dilator muscle
Normally: release norepi to stimulate α1-adrenergic receptors of pupillary dilator mm
 Ptosis, miosis, anhydrosis; small pupil on side of lesion

Lesion can be:

 preganglionic (nerve fiber that synapses in dilator muscle)
 postganglionic
(nerve fiber that synapses in superior cervical ganglion)

3
 Eyedrops: come with color coded caps
Cocaine test (for Horner’s):
Red Cycloplegics & mydriatics
 Put drop of cocaine in eye 
Green Miotics
blocks norepi reuptake into synaptic terminal
Yellow β-adrenergic agents (β-blockers)
 Normally: there’s norepi in synapse  ↑ effect  pupil dilates
 Horner’s: NO NOREPI in synapse  pupil doesn’t dilate in response to cocaine

Hydroxyamphetamine test: distinguish preganglionic from postganglionic (for Horner’s)

 Acts by releasing norepi from synaptic terminals
 Postganglionic lesion: no norepi to release (pupil doesn’t dilate)
 Preganglionic lesion: normal norepi can be released (pupil dilates)

Drugs for treatment: Relaxing the Ciliary muscle

Cycloplegia
 paralysis of ciliary muscle (responsible for accommodation)

Mechanism of Action: Parasympatholytic agents (muscarinic antagonists)

 causing pupillary dilation and ciliary body relaxation

Effects: Block normal effects of Ach on muscarinic receptors (constrict pupil, contract ciliary body)

cyclopentolate Indications:
 Dilate pupil
atropine  Cycloplegia (paralysis of ciliary muscle)

Relaxing ciliary muscle also useful for:

 inflamed eyes (more comfortable, prevent posterior synechiae)
 determining refractive status of children
 treating amblyopia & strabismus ("penalyze" good eye - like patching)

Drugs for treatment: Glaucoma

 Want to reduce intraocular pressure (function of rate at which aqueous humor is produced, rate of outflow)

Prostaglandins
 Most important these days (newest class); Different mechanism than other drugs (additive effects!)
 Actually ↑ IOP, cause inflammation in rabbits  but shown to be ↓ IOP & non-inflammatory in humans

Mechanism of Action: prostaglandin analogue, used to reduce intraocular pressure

Effects: Increase extracellular space in ciliary muscle (increase rate that aqueous humor leaves eye)
 makes ciliary muscle "spongier"

Indications: Glaucoma
bimatoprost
Administration: eye drop

Toxicity: darken light irides, cause longer / bushier eyelashes

Other: Also approved by FDA as Latisse to promote growth of upper lashes (and make $$$ for pharma). Not causing
↑ number of melanocytes (not predisposing to melanoma) - just more melanosomes per cell (darken irides)

4
β-adrenergic antagonist
Beta-blocker eyedrops; widely used, off-patent, cheap for patients

Mechanism of Action: beta-adrenergic antagonists (beta-blockers), used to decrease IOP

Effects: bind beta-2 adrenergic receptors in ciliary epithelium, thereby reducing production of aqueous humor.
Indications: Glaucoma
"-olol" eyedrops
Administration: eyedrops
timolol
Toxicity :Can be the same as oral beta-blockers (to bloodstream via canalicular membrane to nasopharynx).
levobunolol
 Watch out for asthma, chronic pulmonary disease, heart block
carteolol
 Some lower HDLs too
metopranolol
betaxolol)
Other: cAMP theory of aqueous humor production: Binding to beta-2 adrenergic receptors leads to Gs-mediated
increase in cAMP within epithelial cells, which increases ion transport / fluid flow out of epithelial cell, into
posterior chamber. Process blocked by these drugs.

α2-adrenergic agonists
↓ aqueous humor production  ↓ IOP

Mechanism of Action: alpha-2 adrenergic agonist, used to decrease aqueous humor production
Effects: bind α-2 adrenergic receptors in ciliary processes, ↓ aqueous humor production (and ↓ IOP) as a result.
brimonidine  Brimonidine may also increase uveoscleral outflow of aqueous humor
Indications: Glaucoma
Toxicity: Local allergy

Carbonic anhydrase inhibitors

Mechanism of Action: Carbonic anhydrase inhibitor, used to lower intraocular pressure
Effects: inhibit CA activity in ciliary epithelium (↓ aqueous humor production)
acetazolamide
Administration: Now available topically (previously only orally; more systemic side effects)
Indications: Glaucoma

Parasympathomimetics
 stimulate contraction of ciliary muscles
through occupancy of muscarinic receptors

 pull on scleral spur; open the trabecular

meshwork  ↑ flow of aqueous humor out
of eye

Mechanism of Action: lower IOP by increasing aqueous humor outflow

 pilocarpine: muscarinic agonist
 phospholine iodide: acetylcholinesterase inhibitor

pilocarpine Effects: Stimulate muscarinic receptors on the ciliary muscles, causing them to contract, opening the trabecular
meshwork and leading to better outflow of aqueous humor, lowering IPO
phospholine  pilocarpine: direct stimulation
iodide  phospholine iodide: ↑ Ach in synaptic cleft (AchEi)

Indications: Glaucoma

Toxicity: pilocarpine needs to be given 4x/day; also constricts pupil; not used much anymore

5
Tetrahydrocannabinol (THC)
 Marijuana popularized for glaucoma (but not really used medically)
 No eyedrops available; well characterized side effects; would need to smoke ≈ 6x/day

Drugs for treatment: Ocular Inflammation

Topical corticosteroids: Mainstay of treatment
 Side effects: potentially serious
o Exacerbate chronic herpes infection in corneal epithelium
o Chronic use  glaucoma & cataract

Topical non-steroidals
 Used for mild anterior segment inflammation
 Ketorolac is the only proven agent for CME (cyctoid macular edema) – vision loss after cataract surgery

Immuosuppressive agents: Cyclophosphamide, methotrexate, cyclosporine (if intractable intraocular inflammation)

Cycloplegic agents: Make eye more comfortable, prevent adhesion of iris to lens (posterior synechiae)

Drugs for treatment: dry eye

 Affects millions of people; scratchy, uncomfortable, etc.
 Historically: only available treatments have been palliative
o Lubricating eyedrops
o Punctual occlusion: close off the punctae  ↑ tears

Pathophysiology
 Cytokine, receptor-mediated inflammation of both lacrimal gland and ocular surface

Mechanism of Action: Anti-inflammatory agent for topical use in severe dry eye
cyclosporin A topical Effects: Suppresses inflammatory response (see pathogenesis above)
(Restasis) Indications: Dry eye (improves ocular discomfort & blurred vision)
Administration: 0.05% emulsion

Drugs for treatment: viral infection

Herpes simplex Iododeoxyuridine (topical) 1st antiviral agent used in humans

cornea / anterior segment Trifluorothymidine (topical) used more commonly now, less toxic
infection Oral acyclovir ↓ recurrence of ocular HSV infection
Herpes zoster keratitis Oral acyclovir or famciclovir For early stages
Cidofovir (IV) Once every two weeks
CMV retinitis*
Ganciclovir (intraocular implant + oral) Alternative to cidofovir
*↑↑ with spread of AIDS; involves macula; wipes out center of vision

Adenoviral conjunctivitis: Most common viral infection of the eye, but no effective treatment

Drugs for treatment: bacterial infection

Infections of conjunctiva / cornea Infections in vitreous / retina
Treatment antibiotic drops alone intraocular injection
Notes Fluoroquinolones may improve treatment IV abx for often given but unproven (blood-retina barrier)

6
 Drugs for treatment: Age-related Macular Degeneration
 Retina involved with hemorrhage, exudates; formerly all laser treatment; not very good (no reversal)
Mechanism of Action: anti-VEGF aptamer, used for "wet AMD"
Effects: used to reduce neovascularization
pegaptanib
(Macugen) Indications: Reduces rate of vision loss in "wet" age-related macular degeneration
Administration: intravitreal injection
Toxicity: Repeated injections, not pleasant, could develop infection

Mechanism of Action: anti-VEGF monoclonal antibody

Effects: mAb against all VEGF isoforms
ranibizumab
(Lucentis)
Indications: Actually improves vision in some eyes with "wet" age-related macular degeneration
Administration: intravitreal injection

Effect of ocular drugs on the body

 Eyedrops are absorbed systemically!

Ocular drug Potential systemic complications

Exacerbate COPD, heart block, CHF
β-blockers
Some lower HDLs too
Can lead to low levels of plasma pseudocholinesterase  if these pts get succinylcholine
Phospholine iodide
during general anesthesia, can lead to prolonged neuromuscular blockade
Atropine Fever, tachycardia, confusional psychosis (“belladonna agents”)

Effects of systemic drugs on the eye

Systemic Drug Ocular effects
Retinopathy of prematurity: If immature retina exposed to oxygen in the nursery, vasculature responds with
Oxygen
aberrant pattern of neovascularization

Can result in Stevens Johnson Syndrome (can cause conjunctival scarring / blindness)
Sulfa drugs
 Other drugs too, but sulfa drugs in particular
Corticosteroids Cataracts, ↑ IOP can result (esp. with steroid eyedrops, but oral steroids too – not nasal though)
Antimalarial agents “Bull’s eye maculopathy” – can damage macula of the retina
Photosensitizing  Used with PUVA treatment for derm diseases
agents  Can cause cataracts
Anti-epileptic agent
Can cause bilateral acute angle-closure glaucoma
Topiramate
 Precipitous onset of decreased vision, pain redness; stop drug to treat
 Not normal papillary block – causes ciliary body swelling  pushes iris forward  angle closed
Anti-epileptic agent (esp. drug-resistant partial seizures, infantile spasms; ↑ GABA by ↓ GABA metabolism)
Vigabatrin
Associated with visual field contraction (generally asx but maybe central vision involved too?)
Sildenafil Viagra – reports of anterior ischemic optic neuropathy (coincidental / causal not known)

7
 Pathology: Endocrinology
Pathology of Diabetes & Obesity ............................................................................................................................................ 2
Endocrine Tumor Pathology ................................................................................................................................................... 7

1
 Pathology of Diabetes & Obesity
Diabetes & Obesity
 Diabetes is an epidemic; most increase in diabetes due to ↑ rates obesity (insert series of mental maps)
 Pathology is a combo of…
o High blood sugar’s effect on multiple organ systems
o Pathology more attributable to obesity itself (e.g. fatty liver disease)

Type I diabetes mellitus Type II diabetes mellitus

 Onset < 20 yo  Onset > 30 yrs
 Normal wt  Obese
Clinical  ↓ blood insulin  Normal / ↑ blood insulin
 Islet cell Abs  No islet cell Abs
 Ketoacidosis common  Ketoacidosis rare
 Less twin concordance (50%)  More twin concordance (90-100%)
Genetics
 HLA-D linked  No HLA association
 Autoimmune  Insulin resistance
Pathogenesis
 severe insulin ↓  Relative insulin ↓

 Insulitis early  No insulitis

Islet cell pathology  Marked atrophy and fibrosis  Focal atrophy & amyloid
 β-cell depletion  Mild β-cell depletion

Diabetes: The Pancreas

 Generally, these things are seen on autopsy only (don’t biopsy the pancreas – leave it alone!)

Normal pancreatic islet Hemachromatosis Amyloid

 Endocrine part of the pancreas  Lots of iron in β cells   Some pts- clumps of amyloid of
(rest is secretory) dysfunction endocrine origin (normal proteins
 Mostly β-cells (make insulin) (e.g. “bronzy diabetes”) get misfolded)  dysfunction

Type 1 DM
 Pathogenesis not well understood – maybe viral infection  autoimmunity?
 Some genetic predisposition (a bit?)  precipitating event  progressive loss
of insulin release  diabetes?

Pathology
 Fibrotic islets with chronic inflammation

2
 Diabetes: Other Systems
HIGH BLOOD SUGAR causes the pathology of diabetes

Advanced glycosylation endproducts (AGEs) Activation of polyol (aldol reductase) pathway

 Stuff gets sugar-coated! Damages pericytes  origin of vascular problems
 HbA1c, for instance – glycosylated Hb (diabetic retinopathy, peripheral neuropathy, etc.)

AGEs: biochemistry
 Glucose + free amino groups  Schiff base + water
 Schiff base  more stable “Amadori product” (days)
 Amadori products  cross-link other proteins irreversibly 
 Advanced glycosylation end-products (AGEs)

The Kidney in Diabetes

Thickened capillary Drop lesion +

Capsular “drop lesions” Kimmelstiel-Wilson Lesions
basement membrane thick mesangium

PAS+ glycosylated gunk  PAS+ (sugary) thickened Lots of PAS+ AGEs PAS+ = sugar
can’t filter appropriately lesions; make it hard to filter Pathognomonic for DM

Vascular changes in diabetes (big vessels)

Arteriosclerosis
Kidney (other organs too) “Dry gangrene”

Blood supply cut off  “dry gangrene” (not

Big blood vessels (from ↑ BP) Big, thick blood vessels
infected, at least at first)

3
 Other Big-Vessel Problems in DM
Coronary atherosclerosis Myocardial infarcts Cerebral infarcts

Thick vessels, lots of cholesterol

The Polyol Pathway (aldose reductase) & Diabetes

Hyperglycemia  ↑ intracellular glucose

↑ glucose  metabolized to sorbitol 

 ↑ intracellular osmolarity  water influx  cell injury
 ↑ sorbitol  ↓ myoinositol  Na, K, ATPase abnormalities
 Run out of reducing equivalents (deplete GSH)  ↑ oxidative stress

Injury typically involves (think small vessels):

 Nerves
 Pericytes (diabetic retinopathy)
 Lens (cataracts)
 Kidney

Diabetic Retinopathy
↓ pericytes in blood vessels of back of eyes  aneurysms / rupture  hemorrhage

Hemorrhages Fibrosis can result (post-injury) –

Diabetic retinopathy: aneurysms
(bottom: lifting retina!) need laser photocoagulation Tx

Retinal detatchment
 Hemorrhages can lift up retina (see left picture)
& cause detatchment  vision loss!

4
 Other results of polyol pathway
Papillary necrosis Mucormycosis
Rare but serious effect
 Non-septate branching fungi
Necrosis of kidney
in SINUSES and BRAIN
papillae (a possible
 High blood sugar  good
polyol pathway
culture medium
effect in kidneys)
 Ampho B doesn’t work well
– often fatal!

Type II DM and Obesity

 Type II DM occurs mostly in obese pts, esp. with abdominal obesity; insulin reistance plays big role
 Often seen in setting of multiple metabolic abnormalities (HTN + dyslipidemia) – e.g. the metabolic syndrome!
o A.k.a. “syndrome X”
 A polygenic disorder: multiple genes + environment
 BMI = kg / m2; > 25 = overweight, > 30 = obese

Metabolic syndrome (don’t have to memorize)

 At least 1 of type 2 DM, impaired glucose tolerance, insulin resistance
 AND at least 2 of HTN, obesity, hypertriglyceridemia or low HDL, microalbuminuria
 ± hyperuricemia (when in doubt, think of gout!), hypercoagulability, hyperleptinemia

Visceral fat is worse than abdominal fat (use the type measure)

Bariatric surgery
 Bariatrics = a branch of medicine that deals with the control / treatment of obesity & allied diseases
 Lots of different ways to do it

Roux-en-Y gastric bypass (RYGB) Adjustable gastric band (Band)* Biliopancreatic diversion (BPD)
with duodenal switch
*People can eat so much they break through the band!

It works & works well!

 Wt loss usually about 100 lbs; RYGB / BPD > banding; better than any drugs
 Need to have special facilities (big everything!)
 Can fix type II DM – 83% resolve diabetes, 99% resolve impaired glucose tolerance
 Still have mortality (0.35% even in centers of excellence – CV risks, etc) – psych implications too

5
How does it work?
 Small gastric space – pts have to eat many small meals
 Ghrelin (polypeptide hormone from gastric oxyntic glands, appetite stimulant: orexigenic)
o ↓ circulating ghrelin post bariatric surgery ( ↓ appetite?)

Obesity & NASH: Non-alcoholic steatohepatitis

 Aside from diabetes, ↑ TGs can adversely affect the liver
 About 25M adults in USA have fatty liver disease; about 1M of those will go on to get NASH, 150K  cirhossis / liver failure

Pathology
 Histopathologically indistinguishable
from alcoholic hepatitis

Diagnosis
 No serum tests
 LFTs not helpful for early diagnosis
 Biopsy is gold standard –
but can’t bx 25M Americans

Treatment: have to lose wt! no other tx!

New directions
 Multidisciplinary centers for metabolic disease research (psych, biochem, endocrine, nutrition, etc.)
 Possible target: fatty acid oxidation (inhibit TG accumulation?)
 Brain is mostly in control

6
 Endocrine Tumor Pathology
Pituitary gland  Pituitary adenoma
 Thyroid heterotopia
Thyroid gland  Goiter
 Follicular carcinoma, papillary carcinoma, anaplastic carcinoma, medullary carcinoma
 Pheochromoctyoma
Adrenal gland  Cortical adenoma
 Cortical carcinoma
These are from discrete endocrine organs – but you can also have neuroendocrine tumors from cells throughout resp / GI tract
Cause morbidity / mortality both by direct invasion / metastasis and disturbance of homeostasis!

Pituitary gland
Tiny but master control center gland (makes tons of stuff)
Anterior pituitary Posterior Pituitary
Growth regulates growth
Vasopressin
hormone influences intermediate metabolism Water conservation by kidneys
Produces

(ADH)
Prolactin lactation
LH/FSH gonadal function in men/women
TSH thyroid function Oxytocin Milk let-down during lactation
ACTH controls glucocorticoid function of adrenal ctx
A.K.A Adenohypophysis Neurohypophysis
Embryology From evagination of pharyngeal mucosa (Rathke’s pouch) Contiguous out-pouching from base of brain
Histology Round/polygonal epithelial cells in cords/nests Tangled nerve fibers


Embryology


Anterior pituitary (A),

Posterior pituitary (P),
Infundibular stalk (S)

Normal anterior pituitary

 Strategic location at crossroads of various systems (CNs, optic system, blood vessels, cavernous sinuses)
o So tumors can cause disease by various mechanisms
 Derived from Rathke’s pouch (epithelial in nature)
 Nested pattern of growth maintained by reticulin framework (R. pic)

Types of cells (L. pic)

 Acidophils (stain pink)
 Basophils (darker staining)
 Chromophobes (clear, vacuolated)

Surgical approach: go in through nose

7
Pituitary Adenomas
 Only really see tumors arise from anterior lobe; vast majority are pituitary adenomas (20% intercranial tumors)
 Cytologic features are inconsistent (can’t reliably tell prolactinoma vs GH-secreting, for instance)

Architectural features: range of histologic appearances

 Classic: sheets of uniform cells interrupted rich vascular network; can be acinar as well; can invade too

Pituitary adenoma vs. normal pituitary?

Normal pituitary Pituitary adenoma
Cellular variability (acidophils, basophils, chromophobes) Cellular monotony
Architectural regularity (reticulin framework) Architectural disorder
Functional diversity Functional homogeneity

Special stains:
 Reticulin lost in adenoma (reticulin stain negative – L. pic)
o Lose lobular pattern

 IHC can be helpful diagnostically:

o see functional homogeneity as well as architectural in adenoma
o For example, + prolactin but negative ACTH/ GH (right pic)

Pituitary adenoma vs. pituitary carcinomas

How can we tell an adenoma from pituitary carcinoma (cancer)?
 Both show invasive tumor growth, cellular atypia, necrosis
 Need to demonstrate METASTATIC DISSEMINATION

Pituitary adenomas / Pathogenesis: Hypersecretory states

Note that size at detection depends on sensitivity to what’s being secreted
 E.g. prolactin: may be detected while small in young F (galactorrhea); might have to produce mass effect in older / M

Prolactin adenomas Somatotroph (hGH) adenomas Corticotroph adenomas
 Young women: galactorrhea,
 Prepubertal children: gigantism  Pituitary Cushing’s syndrome
amenorrhea
 Adults: acromegaly  Most individuals very sensitive to ↑
 Post-reproductive women / men:
 Long, insidious onset ACTH: detected when small
silent (± ↓ libido / sexual dysfxn)

8
Pituitary adenomas / Pathogenesis: hyposecretory states
Nonsecretory / Null adenomas (↓ levels of hormones due to mass effect on pituitary)
 need ≈75% destruction for clinical manifestation; slow ↓ in function

Pituitary apoplexy: spontaneous hemorrhage into pre-existing pituitary adenoma

 abrupt ↓ in function – see pic to right

Pituitary adenomas / Pathogenesis: Impingement of Anatomic Structures

Infrasellar extension Suprasellar extension
tumor grows down tumor grows up

 Compression of optic chiasm (bilateral hemianopsia)

Enlargement / erosion of sella turcica  Compress ventricular system / invade 3rd ventricle 
↑ ICP (headache, nausea, vomiting), hydrocephalus

Thyroid Tumors
Very common – but not all nodules represent neoplasm!
Thyroid heterotopias * Thyroid hyperplasia Neoplasia
 Papillary carcinoma
 Lingual thyroid  Follicular carcinoma
multinodular goiter
 Thyroglossal duct cyst  Medullary carcinoma
 Anaplastic carcinoma
*Heterotopia = Normal thyroid tissue in abnormal places
Normal Thyroid
 Butterfly shaped (2 lobes+isthmus), in front of cricoid cartilage; some individuals have pyramidal lobe

Histology
 Follicles, filled with pink thyroid material, lined by cuboidal follicular epitheliod cells
 C-cells: secrete calcitonin, involved in calcium homeostasis (hard to ID wth normal H&E)

Embryology:
 From outpouching at base of tongue (foramen cecum)
 Descends inferiorly to take up normal position (along thyroglossal duct)

9
Thyroid Heterotopia
 Remnants of normal thyroid tissue along route of embryologic descent of thyroid
Lingual Thyroid Thyroglossal duct cyst
Etiology thyroid remnant at back of tongue Thyroglossal duct doesn’t atrophy, patent  gets infected
Presentation can have dysphagia / resp. compromise Midline cyst with thyroid follicular epithelium lining it

Picture

Multinodular Goiter
 Endemic (inadequate iodine intake) and sporadic forms Clinical relevance:
 Asymmetric, nodular enlargement  Often euthyroid, sometimes hyperthyroid
 Hyperplastic: Not a neoplastic process  Cosmetic deformity, can compress structures
(histology = heterogenous)  Diagnostic dilemmas – can mimic neoplasm

Asymmetric, nodular enlargement Parenchyma: colloid-filled nodules, irregular Varying sizes / clinical appearances
scarring, focal hemorrhage / calcification

Thyroid Cancers
 Most papillary (70%), then follicular > medullary (from C-cells) > anaplastic
 papillary / follicular cancers derived from epithelium
 Medullary derived from C-cells

Follicular cancer Papillary cancer

Risk factors Iodine deficiency Radiation exposure
Genetic alterations Ras mutations, PAX8/PPAR Braf mutations, Ret translocations
Sex Female predominance (2-3:1)
Age 5th/6th decades 4th/5th decades
Distribution Solitary nodule Often multifocal
Metastatic pattern hematogenous spread (bone, lungs) lymphatic spread (regional LNs)

10
Follicular carcinomas
Gross: solitary encapsulated nodule
Histology: tightly-packed follicles surrounded by fibrous capsule

Carcinoma vs Adenoma: need invasion to be a carcinoma

 Vascular invasion  into blood vessels inside cancer
 Capsular invasion  through tumor capsule
Solitary nodule with capsule

Vascular invasion Capsular invasion

Lower left is follicular carcinoma; (Explosive! think mushroom cloud)
Note fibrous capsule around, follicles

Papillary carcinomas
Gross: Usually multifocal (pic to right: see big tumor, small focus too)

Histologic features: not present in all, but good tip-off if seen!

Psammoma bodies
 Tumor calcification
 Round, laminar, circular concretions
 50% of papillary carcinomas
Nuclear atypia
Papillary architecture
(“ground glass”, “water clear”, “Orphan Annie’s eyes”)
 Chromatin tends to aggregate right along the edge
of the nucleus – nuclei are optically clear
(hence the name)
 Intranuclear inclusions or longitudinal grooves
(like nuts – R. pic)

Can do many of these tests via cytopathology (pre-op: take biopsy, sample some of tumor)

Follicular / papillary thyroid carcinoma: Prognosis

Poor prognosis with…
Follicular thyroid carcinoma Papillary thyroid carcinoma
 Age > 45 yo
 Distant metastasis  Tumor > 5cm
 Extensive capsular / vascular invasion  Extra-thyroid extension
 Distant metastasis

11
Anaplastic thyroid carcinoma
 Disease of the elderly
 Very poor prognosis (rapidly fatal)
o papillary / follicular have longer life expectancy
o Extension into soft tissues of neck

Variable histologic patterns

 (spindle cell, giant cell, squamoid)

Probably represent transformation of a better differentiated tumor

 ↓ anaplastic carcinomas with better management of follicular / papillary thyroid carcinomas

Medullary carcinomas
 Derived from C-cells (others from epithelium)
 Tend to have nested type of growth; tumor cells spindly
 Background of eosinophilic stroma (amyloid – deposition of calcitonin peptide / precursors)

Spindled, nesting structure Amyloid background – from calcitonin / precursor deposition

Etiology of Medullary Carcinomas

Familial medullary carcinoma syndromes
MEN IIA MEN IIB
Sporadic  Medullary Carcinoma
 Medullary Carcinoma
medullary  Pheochromocytoma
 Pheochromocytoma
carcinoma  Gastrointestinal and Ocular Ganglioneuromas
 Parathyroid Hyperplasia – Adenoma
 Skeletal Abnormalities

Sporadic Familial
Age at Dx 36 20
Laterality Unilateral Bilateral
Centricity Solitary Multicentric
C-cell hyperplasia Absent Present (see pic to right –C-cell stain)

Genetic screening: look for Ret oncogene mutations these days

 Highly sensitive, specific, predictive; safe & inexpensive, one-time procedure
 Distinguishes familial / sporadic in “index cases”
 Allows for screening of family members & prophylactic thyroidectomy

12
 Adrenal Tumors: Medulla
Pheochromocytoma
 Functional tumor from adrenal medulla  secrete catecholamines (epi+norepi)
 Intermittent BP spikes, H/A, diaphoresis, vomiting, palpitations, weakness, nervousness,
pallor, dizziness, dyspnea, substernal pain / abd pain, etc.

“Rule of 10” – pretty clinically useless

 about 10% bilateral
 about 10% outside of adrenal gland (“paragangliomas”)
 about 10% malignant*
 about 10% familial (MEN IIA/IIB)

*Need to document metastatic spread to make diagnosis of malignancy

Histopathology: “balls of cells” (Zellballen) appearance

 Basophilic cells with delicate, richly vascular stroma
 Lobular growth in medulla
 Separated by dilated vascular channels

Adrenal Tumors: Cortex

Can secrete any of the different products of the cortex (depending on what the tumor makes!)
 example here: secreting cortisol (Cushing’s Syndrome)
 Glucose intolerance, moon facies, abdominal striae, etc.

Cushing’s Syndrome DDx:

Pituitary adenoma Ectopic ACTH production Functional adrenal cortical neoplasms
 Benign: functional cortical adenoma
(↑ ACTH) (e.g. small cell lung cancer)
 Malignant: adrenal cortical carcinomas

Note on Gross Appearance:

Etiology: ↑ ACTH (pituitary or ectopic) functional adrenal cortical neoplasm (↑ cortisol  ↓ ACTH
Result: bilateral cortical hyperplasia atrophy of nonneoplastic cortex (incl. contralateral adrenal)

Picture:

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Functional Adrenal Cortical Neoplasms
 End up with low plasma ACTH (↑ cortisol, hypothal/pituitary working fine, so ↓ ACTH)
 Usually solitary tumor; get atrophy of non-neoplastic cortex
 Histology: can have clear/vacolated cytoplasm or really compact cytoplasm (depends on lipid content)

Adenoma vs Carcinoma: hard to distinguish

Adenoma Carcinoma
Gross < 50g > 100g (bigger)
Invasion absent sometimes present
Necrosis absent sometimes present
Microscopic
Mitosis absent may be abundant
Atypia Usually minimal sometimes marked

Small, isolated solitary tumor; histology has Huge, invasive, aggressive gross appearance;
bland, vacuolated appearance, less atypia – cells show marked atypia and local invasion –
maybe an adrenal cortical adenoma? adrenal cortical carcinoma

14
 Pathophys: Endocrinology
Principles of Endocrinology & Metabolism ............................................................................................................................. 2
Diabetes Mellitus .................................................................................................................................................................... 4
Carbohydrate Metabolism & Hypoglycemia ......................................................................................................................... 11
Dietary Management of Diabetes & Hyperlipidemia ........................................................................................................... 14
Thyroid Pathophysiology ...................................................................................................................................................... 17
Pituitary Gland ...................................................................................................................................................................... 26
Endocrinology of Aging ......................................................................................................................................................... 33
Adrenal Pathophysiology & Multiple Endocrine Neoplasia .................................................................................................. 35
Gender Development............................................................................................................................................................ 46
Puberty .................................................................................................................................................................................. 50
Growth .................................................................................................................................................................................. 56
Obesity .................................................................................................................................................................................. 61

1
 Principles of Endocrinology & Metabolism
 Homeostasis is the key principle of endocrine physiology
 Endocrine glands are key nodal points in hormonal signaling pathways

Endocrine disorders are:

 Prevalent (mild > extreme forms)  Treatable (meds ≫ surgery ≫ radiation)
 Diagnosable (often thought of as difficult)  Personalized (therapy tailored to physiology)

NEWS ALERT: There’s an obesity epidemic in the USA! Metabolic syndrome, diabetes, hypercholesterolemia, too

Diagnosis
 History: mostly pattern recognition (not too much pathognomonic stuff)
 Exam: test hypotheses; discovery:
o asymptomatic thyroid nodule: 5% are cancers
st
o absent Achilles tendon reflex can be 1 sign of diabetic peripheral neuropathy
 Lab testing is big: (need context – fed/fasted, time of day, etc).
 Imaging: use selectively! Make a biochemical Dx first.
 Pathology: check tumor prognosis

Disease Mechanisms
 Gland hypoplasia (developmental defect)
Congenital /
 Hormone biosynthetic defect (abnormal hormone or enzyme gene)
hereditary
 Hormone resistance (abnormal hormone receptor / signaling protein gene)

Acquired gland failure

Deficient hormone action  Physiologic atrophy: e.g. menopause / andropause
 Inflammatory (autoimmune – e.g. type I DM, infection)
Acquired  Destruction (tumor, drugs, surgery radiation)
Accelerated hormone metabolism
Acquired hormone resistance (e.g. type II DM)

Autonomous function (hyperplasia, adenoma)

Abnormal gland stimulation (trophic hormone or antibody – e.g. Graves’)

Excessive hormone action
Ectopic hormone production

Tissue hypersensitivity

 Can cause oversecretion, undersecretion, or neither

 Can be sporadic or hereditary (Multiple endocrine neoplasia syndromes, others)
Neoplasia of endocrine glands
o Think hereditary if: FHx, multiple, early onset
 Can be benign or malignant

2
Primary vs Secondary Hormone Deficiency
Primary deficiency: end gland is defective
Secondary deficiency: defect in upstream gland in pathway
Also applies to hyperfunction!

Remember the hypothalamus – pituitary adrenal axis? Me neither.

 Hypothalamus makes corticotropin releasing hormone, which acts on pituitary to make
adrenocorticotropic hormone, which stimulates adrenal gland to make cortisol

Primary adrenal insufficiency: adrenal gland defective (↓ cortisol)

Secondary adrenal insufficiency: pituitary defective (also ↓ cortisol)

 If hypothalamus messed up: call it “3°”or can call it “2°” if not sure where problem is (hypothalamus vs pituitary)

“Secondary” “Primary”
Hypothalamic
Pituitary Hormone “End-hormone”
Releasing Hormone
CRH ACTH Cortisol
TRH TSH Thyroxine
GNRH LH/FSH Testosterone/Estradiol
GHRH GH IGF-1

3
 Diabetes Mellitus
Introduction / Diagnosis of Diabetes
Diabetes: need ONE of...
Fasting plasma glucose ≥ 126 mg/dL
Casual plasma glucose ≥ 200 mg/dL AND symptoms of diabetes
Oral glucose tolerance test ≥ 200 mg/dL (2 hrs post 75g oral glc load)
HbA1c ≥ 6.5%

Pre-diabetes: need ONE of…

Fasting plasma glucose 100 – 125 mg/dL (“impaired fasting glucose”)
Oral glucose tolerance test 140 – 199 mg/dL (“impaired glucose tolerance”)
HbA1c 5.7 – 6.4%
Pre-diabetes: the level of glucose tolerance between normal & diabetes

 Note that there are 3 types of prevention – most physicians end up working in 2° / 3° prevention
 Preventing complications is key to management

Acute Complications of Uncontrolled Diabetes

 Directly due to hyperglycemia and/or insulin deficiency
 Can be quickly corrected by adequately controlling hyperglycemia

Symptom Pathophysiology
1. Polydypsia Hyperosmolarity (glucose adds 5.5 mOsm/L per 100 mg/dL) + dehydration  thirst
Polydypsia  ↑ fluid intake  large urine volumes
2. Polyuria
Glucose-induced osmotic diuresis
3. Weight loss Calories lost as glucosuria  negative caloric balance, wt loss
4. Polyphagia Inefficient utilization of ingested calories & glucosuria. Insulin  ↑ appetite?
5. Blurred vision Lens stiffens (sugars – not retinopathy early!)
Others: poor wound healing, vaginitis, gingivitis, dental caries (↓ vascular flow, ↑ sugars – good for infections, etc.)

4
Endstage acute complications (FATAL IF NOT TREATED)

DIABETIC KETOACIDOSIS
metabolic acidosis; fatal if untreated
Virtually complete lack of insulin  unrestrained lipolysis  hepatic conversion to ketone bodies 
Pathogenesis
ketone bodies accumulate as organic acids  acidosis
 Kussmaul respirations  Metabolic acidosis
Diagnosis
 Hyperglycemia  + ketones in blood / urine
 Insulin
Treatment  Electrolytes
 Fluids

HYPEROSMOLAR NONKETOTIC STATE:

severely high blood glucose with dehydration but no acidosis; also fatal if untreated
Insufficient insulin (but enough to suppress ketogenesis)  ↓ glc utilization, ↑ hepatic glc output 
 massive osmotic dieresis, dehydration ± pre-renal azotemia (↓ renal blood flow)
Pathogenesis
 ↓ renal excretion of glucose (can’t clear large ↑ endogenous glc production)
 Vascular collapse
 PG > 1000 mg/dL
Diagnosis  Little or no acidosis or ketosis
 Osmolarity > 340
 ± insulin
Treatment  Fluids
 ± electrolytes

Long-term complications of Diabetes

 Can occur in any type of diabetes (type 1/2/others) – happen over decades
Macrovascular Microvascular
Neuropathy
 Peripheral vascular
 Retinopathy  Peripheral symmetrical
 Coronary artery
 Nephropathy  Mononeuropathies
 Cerebrovascular
 Autonomic neuropathies

Unifying hypothesis for complications: maybe oxidative stress?

 Activation of protein kinase C (stress response cascade)  ↑ polyol pathway activity  ↑ sorbitol, fructose
 Nonenzymatic glycation of proteins  ↑ AGEs  ↑ hexosamine pathway flux

Macrovascular Disease: accelerated atherosclerosis

 Cardiovascular disease is the cause of death in 76% pts with diabetes!
o ↑ coronary artery, cerebrovascular, peripheral vascular diseases (2-4x)
o Eliminates the normal relative protection from atherosclerosis in pre-menopausal women

Pathogenesis: theories / risk factors

 Atherogenic shift: ↑LDL, shift to small-dense LDL  Hyperinsulinism  atherogenic?
 HyperTG, ↓ HDL-C  HTN, smoking are risk factors too
 Hypercoagulable, pro-inflammatory; ↓ fibrinolytic
activity

Management:
 Pay special attention to known risk factors: BP, chol, smoking, blood glucose / A1c
 Preventative measures (aspirin, exercise)
 Preventative foot care

5
Microvascular Disease: diabetic retinopathy
 #1 cause blindness in adults 20-74 yo
 Related to duration of diabetes & glycemic control
 ↑ risk with hyperglycemia, presence of nephropathy, ↑ BP
o Pregnancy may transiently exacerbate retinopathy in type 1 DM pts

Nonproliferative Preproliferative Proliferative

 Cotton wool spots (soft exudates)

 Microaneurysms
 Beading of veins; tortuous capillaries  Neovascularization
 ↑ vascular permeability

Vitreous hemorrhage:
 If untreated, can bleed into vitreous  lose vision suddenly!

Pathogenesis: theories
 Vasoproliferative factors (IFG, VEGF)
 Ischemic / intraocular pressure changes
 Basement membrane, mural cell leak

Management:
 Prevent (good glucose control)
 Early detection (eye screening)
 Laser photocoagulation (if macular edema / proliferative retinopathy detected)
 Vitrectomy (to replace late-stage, scarred vitreous
 Experimental: vasoproliferation inhibitiors (anti-VEGF)  into vitreous

Microvascular disease: diabetic nephropathy

 Leading cause of ESRD
Clinical manifestations: progressive, persistent proteinuria
1. Microalbuminuria 1st sign 30-300 μg/gm creatinine
2. Clinical proteinuria ≈ 12 yrs later (> 300mg / 24h)
3. Can progress to uremia ≈ 6-8 yrs later (↑ BUN, Cr)
4. ESRD ≈ 6-8 yrs later
Can stop or slow progression with modern treatment
Pathogenesis: theories
 ↑ renal blood flow  hyperfilitration  ↑ intraglomerular pressure
 Genetic predisposition to HTN
 Thickening of glomerular capillary basement membrane

6
Management:

 Blood glucose, BP control

o ACEi/ARB – extra ↓ risk for kidney dz

 Dialysis / renal transplant if end-stage

Nodular glomerulosclerosis: End-stage renal disease
Kimmelstiel-Wilson disease Fibrosis, inflammation,
sclerosis, arterial thickening

Microvascular disease: diabetic neuropathies

Peripheral symmetrical polyneuropathy Autonomic neuropathy Mononeuropathy
 Distal, stocking-glove 
 Erectile dysfunction (most common)
progresses proximally
 Enteropathy (constipation /
 Symmetrical Peripheral or cranial
diarrhea), gastroparesis
 Numbness, tingling, dysaesthesias  Single nerve pain / palsy
 Orthostatic HTN
 Rapid onset, resolves over wks / mo
 Cardiac: can have painless
Management: glycemic control, symptomatic
myocardial ischemia (dangerous!)
relief (eg. gabapentin), preventative foot care

Pathogenesis: metabolic Schwann cell defect Pathogenesis: probably similar to

Pathogenesis: ischemic
(↑ sorbitol and/or ↓ myoinositol); peripheral neuropathy, but affecting
(“microinfarcts” of the nerve)?
1° axonal degeneration (unclear etiology) autonomic nerves

Pictures: neuopathies

Interosseal muscle wasting (diabetic Neuropathic ulcers (diabetic

CN III palsy (diabetic mononeuropathy)
peripheral symmetrical polyneuropathy) peripheral symmetrical polyneuropathy)

“The diabetic foot”

Pathogenesis: Combination of peripheral neuropathy and peripheral vascular disease
 Peripheral neuropathy: lack of sensation, undetected trauma from blisters
o even painless fractures (“Charcot’s foot”)
 Peripheral vascular disease: relative ischemia, ↓ blood supply  ↓ healing
 Infection: ↓ immune defenses
 Altered biomechanics (fallen arch)

Management:
 Difficult combo: Immobilization, abx, revascularization, time
 Goal: prevent / minimize amputations (gangrene / infection)

7
 “Diabetic Control” & long-term diabetic complications
Diabetic control: keep blood glucose levels as close to normal as possible
 Self-monitoring of blood glucose (prick finger), or
 HbA1c (glycated hemoglobin): indicator of glycemic control over 2-3 months (life span of RBC ≈ 120d)

In some, it’s easier; in some, it’s really hard – so individualize targets

 In general:
o HbA1c < 7% is very good control*
o HbA1c > 9% is poor control
*DCCT – diabetes control & complications trial, 1995: HbA1c < 7% gets retinopathy, nephropathy, complications ↓↓ @ 9yrs

Long-term benefits of good diabetic control:

 Prevents microvascular complications (UKPDS trial: ↓ retinopathy, albuminuria, etc)
 Macrovascular complications ↓ too – but need to look at other risk factors too (BP, lipids – multifactorial)

Short-term benefits: ↑ energy, ↓ “polys” (reverse acute symptoms)

Type 1 Diabetes Mellitus

Definition: Characterized by autoimmune beta cell deficiency, usually leading to complete insulin deficiency (after a
"honeymoon" period), therefore requiring exogenous insulin administration for survival.

Epidemiology: far less common than type 2 (5-10% all diabetes), ↑ in N. Europe, ↓ in Asia

Pathophysiology of Type 1 DM
An autoimmune disease:
 Circulating autoantibodies in ≈ 80% at dx; precede onset by 3-4 yrs
o Anti-islet-cell
o Anti-GAD (glutamic acid decarboxylase)
o Anti-insulin
 Lymphocytic infiltration of pancreas on path (“insulitis”)
Associated with other autoimmune dz
o Vitiligo o Addison’s disease
o UC o Rheumatoid arthritis
o Hypothyroidism
 Associated with certain MHC alleles (↑ or ↓ risk)

Triggers: lots of hypotheses, not well proven

 Viral induction  β cells express HLA antigen?  Molecular mimicry?
 1° islet inflammation (TNFα, cytokines)  immune response?  IL-1 = β-cell toxin?

Genetics: Less hereditary than type 2, Not well worked out

 exception = MODY, Maturity onset diabetes of the young – aut-dom, 6 specific genes ID’d
 If hereditary, often associated with thyroid / adrenal / other endocrine abnormalities

Clinical characteristics
 Onset usually < 35 yo
 Frequently negative FHx
 Thin / normal body wt
 Ketoacidosis is more common end-stage acute complication
(complete insulin deficiency)
 Labile metabolic state (blood glucose bounces up and down – little or no endogenous insulin – see pic)

8
Treatment:
 Type 1 always requires insulin therapy (multiple doses daily)
 Metabolic lability  harder to treat
 New directions: window of opportunity for prevention (prior to β-cell destruction)? Better insulin delivery?

Type 2 Diabetes Mellitus

Definition: diabetes characterized by insulin resistance and a relative (rather than absolute) insulin deficiency

Epidemiology: most common form by far (90% cases), prevalence in population proportional to (abdominal) obesity
 Disease of prosperity: too many nutrients!
 ↑ in AA, Hispanics, Native Americans vs Caucasians

Pathophysiology
 No evidence for autoimmunity
o no HLA associations, anti-islet Ab, link with autoimmune dz
o Not inflammatory (see AMYLOID DEPOSITS in islets)

β-cell defect AND peripheral insulin resistance

Peripheral insulin resistance

 ↓ biologic effect of plasma insulin on all tissues
o Hepatic glucose output not suppressed
o Peripheral glucose utilization subnormal
 Many hypothesis, much research, little knowledge about intracellular causes / association with abdominal obesity
o Not just a change in # / affinity / configuration of insulin receptors or abnormal insulin / proinsulin
o Post-receptor abnormalities that “disconnect” insulin receptor from downstream signal / GLUT4 insertion in PM?
 Obesity is most common cause of insulin resistance (esp. abdominal obesity)
o Pregnancy, corticosteroids, stress, aging, heredity, other causes also cause resistance
o ↑ FFA  insulin resistance? Not entirely understood

β-cell secretory defect

 Lose 1st phase insulin secretion (see pic)
 ↓ insulin secretory capacity over yrs / decades
o ↑ need for pharm therapies, worse metabolic lability, even need for
exogenous insulin treatment can result

Natural history is for progression of secretory defect over the years!

 Initially ↑ secretion to match ↑ resistance , but can’t keep it up

 β-cell secretion starts to fail
 If insulin resistance stays the same (obesity), but secretory defect ↑,
then you get a gradual increase in blood glucose

Diabetes (hyperglycemia) develops when pancreatic insulin secretion is

inadequate to overcome the degree of tissue insulin resistance

 Need ↑↑ “assistance” from drugs over time

 Even if you need insulin therapy, though, there’s some residual insulin secretion
o Less metabolic lability than type 1 DM!

9
Clinical Characteristics
 Onset usually > 35 yo (not always: current epidemic of childhood type 2 DM in overweight youth)
 FHx usually positive! (stronger heritability than type 1 DM)
 Usually (80%) associated with obesity
 Endogenous insulin reserve present; often have HYPERINSULINEMIA
 Can treat with diet / exercise alone or ± oral insulin agents ± exogenous insulin
 Relatively stable metabolic state (not prone to wide swings)

Genetics
 Active field – esp. with genome-wide screens (≈ 10 genes associated, strongest is TCF7L2 but still only ↑ risk 50%)
 Other associations will be found: probably polygenic + environmental
Type 1 vs Type 2 Diabetes Mellitus
Type 1 Type 2
Formerly known as IDDM, Juvenile Onset NIDDM, Adult Onset
Without Insulin Rx Ketoacidosis, death Usually, no ketosis
Age of Onset Usually <35 Usually >35
Obesity Unusual Common
Family History Usually Negative Usually Positive
HLA Association Yes No
Endogenous Insulin Usually Absent Usually Present
Insulin Resistance Usually Absent Usually Present
Metabolic Course Labile Usually Stable
Response to Pills No Yes
Etiology Autoimmune Non-Autoimmune

Other Types of Diabetes

Secondary diabetes
Diabetes with well defined cause:
 Loss of pancreatic tissue (pancreatectomy, chronic pancreatitis)
 Excess counterregulatory hormones (e.g. acromegaly, hyperadrenocorticism);
 Drug-induced (e.g. thiazides)
 Rare insulin receptor abnormalities

Gestational diabetes
Diabetes first diagnosed during pregnancy

Pathophysiology: ↑ counter-insulin hormones in pregnancy  insulin resistance

 If pregnant woman’s pancreas can’t mount normal response to insulin resistance, diabetes during pregnancy

 Maternal hyperglycemia can transmit trans-placentally  fetal pancreatic hypertrophy

o Fetal hyperglycemia + hyperinsulinism large, fat baby with ↑ complications

 Maternal glucose metabolism usually returns to normal post-partum

o But indicates a borderline pancreatic β-cell function (↑ risk type II DM later in life!)
Summary
Insufficient insulin causes dysmetabolism
 Absolute insulin deficiency in type 1
 Relative insulin deficiency + peripheral insulin resistance in type 2
Acute complications of diabetes are directly and immediately due to hyperglycemia
Long term complications of diabetes are due to years/decades of dysmetabolism
10
 Carbohydrate Metabolism & Hypoglycemia
Overview of Carbohydrate Metabolism
Rise in blood glucose (after CHO containing meal) Fall in blood glucose (between meals, overnight)
Stimulates insulin secretion, which causes… Suppresses insulin secretion, which causes…

 Utilization of circulating glucose as energy substrate  ↑ hepatic glucose output

(↑ glycolysis) (↑ glycogenolysis / gluconeogenesis)
 Suppression of new glucose formation  ↑ Lipolysis
(↓ gluconeogenesis (make FFA available for oxidation as energy substrate)
 Storage of excess circulating nutrients in storage forms  ↑ Proteolysis
o FFA  adipose tissue TG (provides AA substrate for low-level of gluconeogenesis
o AA  protein needed for obligate glucose-dependent organs: brain,
o Glucose  liver / muscle glycogen kidney, RBC)

Role of Insulin: “metabolic traffic cop”

 If you’ve just eaten carbs: use it for energy; don’t store it
o And if you’re going to store, do it efficiently (fat = 9 cal/g; CHO = 4 cal/g because you need to solubilize in H2O)
o If you weigh 80 kg; 25% body fat, you can fast for 90 days: 25% x 80 kg @ 9cal / gm, figure 2000 cal/day
 If you’re fasting: protect your blood glucose level (keep brain going); use stored calories for energy

Liver Adipose Muscle

High Insulin Glycolysis (use of ingested glucose)
Lipogenesis (lipid storage) Protein Synthesis (protein storage)
(Anabolic) Glycogenesis (carb storage)
Low Insulin Gluconeogenesis
Lipolysis (FFA release) Proteolysis (AA release)
(Catabolic) Glycogenolysis (glucose release)

Three States of Metabolism

Timing Metabolic changes

↑ insulin secretion
for ≈ 3 hrs after eating  Dietary CHO enters cells  main food source
Post-prandial
(“fed state”, “absorptive”)  FA synthesis  FAs stored in adipose tissue
 Glycogen synthesis  excess CHO stored in liver, muscle

↓ insulin, ↑ glucagon
 Glycogenolysis, hepatic gluconeogenesis (support blood
4-24 hrs after eating
Post-absorptive glucose without dietary CHO around)
(“overnight fast”)
 Lipolysis activated (freeing FA from adipose tissue)
 Fatty acids become main source for glucose fuel

↓↓↓ insulin and ↓ glucagon

 Hepatic glycogen largely used up
Prolonged fast* > 24 hrs after eating
 ↓ glucagon  ↓ gluconeogenesis
 Lipolysis takes over, lipid becomes main fuel source
* Can’t keep glycogenolysis & gluconeogenesis going forever!
 Glycogen stores are limited
 Gluconeogenesis causes negative N balance, depletes muscle mass, and weakens the person!
o For every AA trans-aminated into gluconeogenesis, nitrogen lost as urea / ammonia!

11
 Normal Blood Glucose Homeostasis

Normally blood glucose is tightly controlled between 65-140 by…

 “closed-loop” regulation of insulin secretion

 Counter-regulatory hormones
(act in opposition to insulin: “insulin against the world!”)
o Glucagon, epinephrine, corticosteroids, growth hormone, norepi
o Protect glucose if it falls too low

Counter-regulatory hormones produce the “fight or flight response” – in response to stress, crisis, hypoglycemia
↑ blood glucose (glucose = fuel for exercise) Rapid heart beat (ready to run or fight)
↑ anxiety (mental alertness, apprehension) Sweating (dissipate excess heat)
Vasodilate periphery (optimal muscle oxygenation)

Hypoglycemia

Documented Low Plasma Glucose Whipple’s Triad

Lower limits of normal: (a working definition of hypoglycemia)
 12-16h fast: ≈ 60 mg/dL  Documented low plasma glucose
 Prolonged fast: as low as 30-50 mg/dL  And symptoms of hypoglycemia
 And response to CHO administration
Symptoms of Hypoglycemia

Adrenergic (fight or flight) – see above Neuroglucopenic

 Diaphoresis  Confusion
 Hunger  Emotional lability
 Tremor  Slurred speech Neuro signs: from focal
 Palpitations  Headache
 Blurred vision  Somnolence seizure to psych
 Anxiety  Pupilary dilation
 Weakness  Coma
Due to ↑ counter-regulatory hormones trying to bring blood
Not enough glucose for brain metabolism!
glucose back up (epi, norepi, etc!)

Disturbing but not as dangerous (mild/moderate hypoglycemia) VERY DANGEROUS – SEVERE HYPOGLYCEMIA – TREAT‼

Response to CHO administration

 Carbohydrate (oral or IV) will specifically ameliorate the symptoms (adrenergic or as severe as coma!)
o See dramatic response in 10-20 minutes – even waking up from coma
o E.g. give orange juice to someone hypoglycemic  feel a lot better!

Fasting vs. Post-prandial (“reactive”) Hypoglycemia

Fasting hypoglycemia Post-prandial (“reactive”) hypoglycemia

 Occurs post-absorptively (> 10hrs after a meal)  Occurs after absorptive phase (≈ 2-4h after meal)
 Unusual and definitely abnormal  Thought to be common
o Requires an explanation! o not often due to a defined disease
 Must be documented by plasma glucose + objective symptomatology  Hard to document

12
Fasting hypoglycemia: partial DDx

 Diabetes treatment (certain oral agents or insulin)

Excess exogenous insulin
 Factitious / foul play

 Insulinoma (insulin-secreting pancreatic adenoma) – see below

Excess endogenous insulin  Sulfonylurea ingestion (diabetes treatment or factitious)
 Nesidioblastosis (islet cell hyperplasia in newborns)
 fulminant hepatic failure
 alcoholic hypoglycemia
Hepatic disease
 CHF
Defective gluconeogenesis
 Glycogen storage diseases*
 Cachexia
Defective gluconeogenic substrate
 Uremia
 Adrenal insufficiency
Counterregulatory  Hypopituitarism
hormone deficiency  Glucagon deficiency
 Growth hormone deficiency
Unusual – if using tons of glucose, for instance
Extrapancreatic tumors  Fibrosarcomas / fibromas (↑ glucose consumption)
 Hepatomas (can make insulin-like factor)
*GSD are rare; at least 10 forms known, most present with fasting hypoglycemia in children

Insulinoma:
 Diagnosis:
o Symptomatic fasting hypoglycemia (abnormal to develop Sx, even during prolonged fast!)
o Inappropriate hyperinsuilinism (may be subtle), or
o 72h diagnostic fast (look for symptomatic hypoglycemia / inappropriate hyperinsuilinism)
 Plasma glucose falls, but insulin doesn’t – insulin should drop like a rock to preserve PG, but doesn’t!
 Management: image to localize, surgery to remove (80% are benign & surgically cured!)

Postprandial (“reactive”) hypoglycemia: partial DDx

Controversial diagnosis – rarely proven but commonly diagnosed

Post-oral glucose
 Alimentary hypoglycemia (rapid gastric emptying, after gastric bypass surgery, for instance?)
o Maybe excess GLP-1 stimulation from rapid gastric emptying?

 Possible early diabetes? “Functional” reactive hypoglycemia? Questionable.

o Maybe mild hypoglycemia  feel sx  counterregulation brings glucose back
o Maybe too high / late of an insulin spike?
o Is it a disease? Does it cause symptoms? Malingering? Controversial.

Rare specific sensitivities (usually pediatric diagnoses)

 Leucine sensitivity
 Hereditary fructose intolerance
 Glactosemia

13
 Dietary Management of Diabetes & Hyperlipidemia
Goals of diabetes management
Targets
1. Try to get blood glucose in normal range (as close as possible)
Pre-prandial 80-120 mg/dL

Glycemic
2. Lipid / lipoprotein profile that ↓ risk macrovascular disease
o DM is a cardiovascular risk equivalent (= previous MI) Post-prandial (2h) < 180 mg/dL
3. Blood pressure that reduces risk of vascular disease Bedtime 100-140 mg/dL
HbA1c 7%
Other goals LDL Cholesterol < 100 (<70?) mg/dL
 Prevent/treat chronic complications Blood Pressure < 130 / 80
o (obesity, dyslipidemia, CVD, HTN, nephropathy)
 Encourage healthy food choices (keep pleasure of eating – only limit if good scientific evidence)
 Address individual / cultural needs

Carbohydrates
 Sugars (↑ blood sugar acutely)
 Starches (later & longer-lasting)
 Fiber (don’t raise sugars like other complex CHOs – really good!)

Monosaccharides Glucose, galactose, fructose

Simple CHOs
Disaccharides Sucrose (table sugar), lactose
(1-2 molecules)
Polyols (sugar alcohols) Have alcohol moiety: sorbitol, mannitol, etc.
Malto-oligosaccharides (maltodextrins)
Oligosaccharides (3-9 molecules)
Complex CHOs Others: raffinose, stachyose, fructo-oligosaccharides
(3+ molecules) Starch: amylose, amylpectin
Polysaccharides (> 9 molecules)
Fiber: cellulose, hemicelluloses, pectins, hydrocolloids
Note: not just “sugar”!

Recommendations:
 CHO and monounsaturated fat should be 60-70% of energy intake
 Get it from whole grains (dietary fiber), fruits, vegetables, low-fat milk
 Total amount more important than source / type for diabetics
 Use other CHO sources instead of sucrose-containing foods (to help loose weight)
 Non-nutritive sweeteners: don’t cause cancer

Adjustment in intensive insulin therapy

 E.g. 1 unit / 15 g carbohydrates
 Based on CHO content of meal; pre-meal blood sugar
 Fixed insulin doses possible if consistent daily CHO intake

Proteins
 Should be 15-20% daily energy (no restriction if normal renal function)
 Does not increase plasma glucose in type 2 DM but can ↑ serum insulin response
 Protein requirements may be greater than RDA in pts with uncontrolled diabetes
o From ↑ protein turnover; worry about protein malnutrition in developing world

High protein low CHO diets: Atkins, South Beach

 Long-term effects unknown: LDL cholesterol / wt loss maintenance?
 Short-term results: do get weight loss & improved glycemia
 Better to have a sustained lifestyle change (these are hard to maintain)

14
Fats
Polyunsaturated fatty acids (Ω-3)
Monounsaturated fatty acids
Saturated fatty acids
* cis forms are “healthy” form of monounsaturated fats – trans-fats ↑ CVD risk
Linoleic acid, α-linoleic acid Vegetable / plant oils
Eicosapentoic acid (EPA)
Fish, plankton
Docosohexanoic acid (DHA)
Oleic acid (cis-form)* Plant/nut oils, nuts
Elaidic acid (trans-form)* Margarine, hydrogenated oils
Lauric acid, myristic acids, palmitic Red meat, poultry, dairy products,
acids, stearic acids processed grains

Type of fat Total cholesterol LDL HDL Triglycerides

Saturated    
Monounsaturated  
Transunsaturated 
Polyunsaturated 
N-3 fatty acids 
Plant sterols*  
* corn, soy, vegetable / plant oils

 Saturated fat just does pretty much everything bad  Polyunsaturated fats help lower LDL a little
 Monounsaturated fats (here cis) help lower LDLs  Fish oils (omega-3) lowers TGs
 Trans-unsaturated fats raise LDLs  Plant sterols help lower LDL / total cholesterol

Recommendations
 <7% of energy intake from saturated fat (↓LDL-cholesterol)
 Dietary cholesterol intake <200 mg/day (↓ LDL-cholesterol)
 Minimize intake of transunsaturated fatty acids
 Polyunsaturated fat: 2 or more servings of fish per week recommended

General Energy Intake & Obesity

 Insert mental recreation of fat maps; make joke about Mississippi

Recommendations:
↓ energy intake Lifestyle changes
 education (food labels)
 drop 500-1000 calories vs maintenance  reduce fat (< 40% daily energy)
 shoot for 5-7% weight loss to start (manageable)  regular physical activity
Pedometer with goal (e.g. 10k steps/day) can be useful
Exercise and behavior modification are adjuncts

Dietary Management of Chronic Diabetic Complications

Hypertension
HTN + diabetes:
 ↑ risk of CVD (coronary heart disease, stroke, peripheral vascular disease),
 ↑ risk of other vascular complications (nephropathy / ESRD, retinopathy)
Systolic Diastolic Action
OK < 130 <80 At goal for diabetic patient
Prehypertension 130-139 80-89 Behavior therapy alone (3mo) then add pharm therapy
Hypertension ≥ 140 ≥90 Behavior therapy + pharm therapy
15
Behavior modification
 ↓ sodium (2300 mg/day, or 6000 mg sodium chloride)
o Can use salt substitute (replace half of Na with K) – careful in chronic renal failure / on diuretics
o High salt: smoked meat / fish / hot dogs, lunch meats / canned soups, frozen foods, cheese, processed snacks,
condiments (mustard, relish, pickles, soy sauce, ketchup)
o If sodium per serving size is more than 10% of RDA, don’t buy it!
 ↑ potassium, magnesium, calcium (DASH diet: fruits/veggies @ 5-9 / day, low-fat dairy @ 2-4 / day)
 Modest weight loss
 Exercise

Dyslipidemia
Goal: Lower LDL-chol (prevent CVD)
 Limit saturated fat & transunsaturated fatty acids to < 7% energy intake
o If weight loss not desired, replace with CHO or monounsaturated fat
 ↑ plant stanols / sterols, soluble fiber

Improvement of metabolic syndrome dyslipidemia (↑ TG / LDL, ↓ HDL)

 Improve glycemic control (fix insulin resistance  ↑ physical activity
 ↑ lipoprotein lipase activity)  More monounsaturated fats
 Modest weight loss  ↑ soluble fiber and plant stanols / sterols
 Restrict saturated fats

Calculating Carbohydrates
1 ADA CHO exchange = 1 serving = one starch / bread = 15 g CHO

Calculate: total CHO – (1/2 x dietary fiber)

 E.g. 42 g total CHO, 6 g fiber = 42-3 = 39g = 2.6 starch servings

So how much CHO do I have left?

 E.g. on 1800 calorie diet; want ~ 50% from CHO (900g) = 11.25 servings per day
 So the patient has 11.25-2.6 = 8.65 servings (around 130g left)

16
 Thyroid Pathophysiology
Basic Anatomy
Thyroid is at the base of neck in the center,
 Below the thyroid cartilage, has nothing
to do with thyroid gland
 Pyramidal lobe – embryological
remnant of the thryoglossal duct
 Easily palpable (very close to skin), can
impinge on other structures

Embryology review

Thyroid descends can get thyroglossal duct cysts or other remnants of thyroid Lingual thyroid (ectopic thyroid
down front of neck, duct anywhere along the pathway (pics) gland) – mass in back of mouth
ends up at base (posterior midline); can be only
thyroid in body! Careful in removal!

Hypothalamic – Pituitary axis

Hypothalamus secretes TRH
 TRH = thyrotropin releasing hormone (thyrotropin = TSH)

Higher brain centers (e.g. cold exposure) can trigger TRH release
 E.g. when baby born: TRH  TSH surge when leaving warm womb

TRH acts on anterior pituitary to release TSH

 TSH = thyroid stimulating hormone

TSH stimulates thyroid to make T4 (and a little T3)

 Goes to target cells throughout body
 Negative feedback too (onto hypothalamus, anterior pituitary)

Pituitary Hormones, TSH, and the TSH receptor

 LH, FSH, β-hCG, and TSH all have common α-subunits with different β-subunits
o All are glycoprotein hormones made by pituitary (except hCG – from placenta)
o β-subunits confer biological specificity

TSH binds to TSH receptor in thyroid

 GCPR, α/β subunits of receptor, etc
 Mediates iodine uptake, Tg biosynthesis, Tg T3 / T4
 All the steps needed for thyroid hormone synthesis!

17
The Thyroid
Organized into spherical follicles
 Lined by thyrocytes
 Contain colloid
(which contains thyroglobulin, storage form of thyroid hormone)

Production of thyroid hormone:

 Iodine comes in from capillary side, gets trapped
o 2Na+/I- symporter (NIS) brings it in

 Brush border on inside of follicle (remember, thyroglobulin in colloid)

 Thyroid hormone made at interface (brush border)

o Iodine binds to tyrosine residues on thyroglobulin
o Forms iodotyrosines  linked together to iodothyrosines

 Pinocytosed back into thyrocytes

o Eventually released into bloodstream

Pendrin: transports iodine across brush border

 Also in endolymphatic sacs in ear
 Pendrin’s syndrome: no enzyme, congenital deafness & hypothyroid

TPO: Thyroid peroxidase

 Mediates binding of iodine to thyroglobulin
o Iodine must be oxidized with locally produced peroxide first!

 T4 formed from coupling: two diiodotyrosines  thyroxine (T4)

 T3 can also form: one diiodotyrosine + one monoiodothyrosine  triiodothyronine (T3)

Much more T4 is formed & released than T3 (ratio is 20:1)

Thyroid Binding Proteins

In the bloodstream, T4 / T3 bound to proteins
 99.97% bound, only 0.03% free T4

 Thyroxine-binding Globulin (TBG) is main one

 Thyroxine-binding prealbumin (binds vitamin A too)
 Albumin binds a bit

18
What happens when TBG levels change?

TBG excess TBG deficit

(e.g. pregnancy: estrogen  ↑ TBG) (cirrhosis, etc)

TBG sucks up free T4 (↓ at first); but then pituitary senses ↓ TBG excess  more free T4  downregulate TSH, T4
free T4 and secretes more TSH  ↑ T4, sucked up by TBG
End result: SAME FREE T4, MORE TOTAL T4 End result: SAME FREE T4, LESS TOTAL T4
Remember free T4 is what can enter cells – free T4 sensed, free T4 ( T3) has biological effect

T4  T3 in peripheral tissues
 E.g. liver, muscle  1,5’ deiodinase removes one of the iodines
o “Selenoproteins” – enzyme has selenium atom inside

 T3 is the main thyroid hormone that mediates action

o T4 is like a prohormone!

Really complex system: there are three different iodinases

 T4  reverse T3, for example – no biological activity
 D3 converts T3 to T2 (in placenta  regulating T3 toxicity in utero!)

Dynamic balance
 100% T4 made in thyroid
 About 80% T3 made in periphery

Regulated pathway: deiodination inhibited by

 Fasting
 Illness
 Glucocorticoids
 Iodine contrast agents
 drugs (propylthiouracil, propranalol, amiodarone)
 selenium deficiency

If you’re hungry, sick, etc. – don’t want to make T3 (would speed up metabolism!)
 BMR ↓ with starvation (not a good way to lose weight)
 Very low T3 in ICU! “euthyroid sick state”
 T3↓ but rT3↑ (deiodinase enzyme levels adjusted)

19
Thyroid hormone receptor family
 Nuclear receptor superfamily
 Constitutively bound to chromatin
 Involved in DNA binding / transcription
o to upregulate / downregulate gene expression
o E.g. ↓ TSH, ↑ hepatic proteins
o Often complexes with retinoic acid receptor (RxR)

Thyroid hormone resistance:

Defect in receptor:
 target tissue receptors can’t bind or translate activity into signals

 Feel OK (clinically euthyroid)

 ↑ free T4 / T3, ↑ or normal TSH
o pituitary is also insensitive, so upregulates!

The Thyroid in Disease States

Primary hypothyroidism Primary hyperthyroidism Central hypothyroidism

↓ T4/T3 ↑ TSH ↑ T4/T3 ↓ TSH ↓ T4/T3 ↓ TSH

Thyroid smaller, so ↓ T4/T3, Thyroid bigger, so ↑ T4/T3, Thyroid normal, pituitary messed up , so
pituitary upregulates TSH pituitary downregs TSH ↓ TSH  ↓ T4/T3

Thyroid Function Testing

Two main strategies

Measure thyroid hormone itself
(but can be misleading)
 Protein binding alterations can’t be detected
 nonthyroidal illness different conversions (rT3, etc)
 Can’t ID subclinical thyroid dz
Measure TSH*
(unique to thyroid, more definitive but can be misleading)
 Central hypothyroidism**
 Soon after therapy of hyperthyroidism
 Nonthyroidal illness (↓ TSH with someone really sick)

*Depends on log-linear relationship between TSH & T4

 Pituitary is really sensitive to TSH, so ↑ TSH by a factor of 1  ↑ T4 by a factor of 100

** in central hypothyroidism, can have a dysfunctional TSH that is picked up by assay but not active!
 If someone’s hypothyroid, they should have a high TSH – normal TSH suggests central hypothyroidism

20
Algorithm for Thyroid Testing
Down the middle: normal! No more testing

Low TSH (left) – measure T4

 If low, suspect severe illness / central hypothyroidism
 If normal, suspect subclinical hyperthyroidism
 If high, suspect garden-variety hyperthyroidism

High TSH (right) – measure T4

 If low, that’s garden-variety hypothyroidism
 If normal, suspect subclinical hypothyroid
 If high, suspect TSH-secreting tumor (really rare)

Subclinical (“mild”) hypothyroidism

 Really common, may develop after inflammation of thyroid, etc.
 T3/4 are just a little low (for that person), TSH keeps climbing to keep up
 After years, T3/T4 exit “normal” range

Subclinical (“mild”) hyperthyroidism

 T3/4 are just a little above normal for that person
 TSH is really sensitive, keeps dropping to ↓ T3/T4
 Eventually hit overt hyperthyroidism

Radioactive Iodine Uptake

Pt ingests radioactive thyroid, measure with Geiger counter the next day @ neck
 ↑ uptake in Graves’ disease (overactive)
 ↓ uptake in thyroiditis (thyroid is “sick” – not taking iodine in, although TSH levels high)

Thyrotoxicosis (hyperthyroidism)
 Just means you’re hyperthyroid (looking “toxic” - tachy, sweaty, like you have an infection)
 State of tissue exposure to ↑ concentrations of thyroid hormone
 Common: lifetime 2% prevalence in females

Symptoms: “hypersympathetic / hypermetabolic” state

 Fatigue, nervousness, hyperactivity, ↓ cognition  Heat intolerance, ↑ perspiration
 Menstrual disturbances, gynecomastia  Weight loss, ↑ appetite, diarrhea
 Tremor  Weakness

Signs:
 Eyelid retraction (Graves’ disease  proptosis)  ↑ reflexes
 Warm, moist (diaphoretic), smooth skin  Osteopenia, hypercalcemia, hypercalcuria
 Tremor  Onycholysis (nails separates from nailbed, get
 Goiter dirt under)
 Tachycardia, arrhythmias, A-fib, SBP ↑, DBP ↓

Etiology of Hyperthyroidism
Graves’ disease is #1
 Can also get toxic nodules (benign lumps in old age), subacute thyroiditis, very rare TSH tumors

21
Graves’ disease:
Typical patient: young woman with goiter, periorbital swelling

Epidemiology:
 #1 cause of hyperthyroidism
 occurs in 2% women, has genetic influences (but only 40-70% MZ twins)
 Sex ratio 5-10:1 Females ≫ Males (hormonal?)

Signs / symptoms:
 general hyperthyroid symptoms, can hear bruit over thyroid (pretty specific finding  ↑ blood flow through thyroid)
 Diffuse goiter
 Ophthalmopathy: (present in 90% pts, ± clinically obvious): NO SPECS
o No findings
o Only stare
o Swelling
o Proptosis
o EOM dysfunction (inf. rectus is #1 – can’t look up)
o Corneal involvement
o Sight loss (ischemic optic neuropathy)

 Dermopathy: pretibial myxedema

o Usually in front of shins; Myxedema – usually in hypothyroidism
 Thyroid acropachy = clubbing

Etiology:
 Autoimmune disease: thyroid stimulating antibodies (TSAb)
o Against TSH receptor but stimulate growth / function
o Bypassing TSH  stimulating thyroid receptors!
 Possible triggers: smoking / stress / infection
 ↑ autoreactive helper T cells (APCs / suppressor cells?)

Ophthalmopathy: Fibroblasts in eye have thyroid receptors (stimulated by TSH)

Diagnosis:
 Thyroid Stimulating Abs (can see in hashimoto’s thyroiditis too)
o only see in autoimmune thyroid disease;
o Hashimoto’s- damage is too great  ↓ thyroid function
 Radioactive iodine  check thyroid uptake (should ↑ enhancement)

Found concurrently with other autoimmune conditions

 Prematurely gray hair
 Vitiligo

Toxic nodules
“Hot” thyroid nodules are more common in older people
Graves’ disease is a disease of younger people
 “Hot” because they make T3 + T4
 ↑ T3/4, but ↓ TSH from pituitary, so contralateral
lobe atrophies (common idea in endocrinology)
 Some have genetic mutations

Treat with radioactive iodine (taken up  kills nodule)

22
Toxic Multinodular goiter
 Just a more extreme case of the solitary toxic nodules
 Goiter just means big thyroid

Labs in hyperthyroidism
 ↑ free T4 in serum
 ↑ serum T3
 ↓ serum TSH
 Radioiodine uptake ↑ in most forms of hyperthyroidism
o ↓ in thyroiditis, factitious, struma ovarii

Treatment of Hyperthyroidism
Antithyroid drugs Radioiodine Surgery
 High cure rate
 Non-ablative  > 90% cure rate, 100% hypothyroidism
 Serious complications
 Side-effects: 5-20%  Simple, most cost-effective, few side effects
 Expensive

Rare causes of hyperthyroidism

 Pituitary adenoma: making TSH (TSH↑  T3/4 ↑ too)
 Factitious thyrotoxicosis: patient is surreptitiously iodine (form of Munchausen syndrome)
o RaI uptake is low – already full of iodine (mimics thyroiditis)

Hypothyroidism
Systemic syndrome characterized by deficiency of thyroid hormone (or, rarely, intrinsic resistance to its effects)

Primary hypothyroidism Secondary (central) hypothyroidism

Due to dysfunction of thyroid gland Due to dysfunction of hypothalamus / pituitary gland

Symptoms of hypothyroidism
 Fatigue, lethargy, sleepiness  Slight weight gain, ↓
 Mental impairment, depression, dementia appetite
 Menstrual disturbances (esp menorrhagia)  Constipation
 Cold intolerance  Arthralgias
 Dry skin, ↓ perspiration  Paresthesias

Signs of hypothyroidism
 Goiter  ↓ body hair
 Slow speech, hoarseness  Dyspnea, hypoventilation,
 Cool, dry skin sleep apnea
 ↓, slow reflexes  Multifactorial anemia
 Bradycardia, pericardial effusion  Hypoosmolar state (hypoNa)

23
Dermatologic manifestations
 Symptoms: dry, yellowed skin
 Signs: myxedema (nonpitting edema due to GAG deposition)
o different than pretibial myxedema in Graves’
o Cool, dry skin with brittle nails too

Growth in kids:
 Obesity, ↓ growth, immature body proportions
 Resolves with TSH administration

Etiology of hypothyroidism

Developing world: Iodine deficiency is #1!

 2B in world are iodine deficient
 Can see endemic goiters in some areas!
 Most devastating effects are in utero (“cretinism”)
o Congenital hypothyroidism – all people in pic to right are same age!

Developed world:
 Hasimoto’s thyroiditis (autoimmune) is #1
 Also:
o congenital absence of thyroid / enzyme defect
o postablative (RAI / surgery)
o drugs (lithium, amiodarone / other I-containing drugs)

Hashimoto’s Thyroiditis
(a.k.a. “Autoimmune thyroiditis”, “chronic lymphocytic thyroiditis)

Epidemiology: mostly females (10:1 F>M), ↑ with age

 Associated with other autoimmune disorders:
o type I DM, autoimmune adenitis, vitiligo, premature gray hair

Pathogenesis: autoimmune T-cell & B-cells

 lymphocytic infiltrate, circulating Abs
o Anti-TPO = anti-thyroid-peroxidase
o Anti-TG = anti-thyroglobulin

Lab findings
 Total serum T4: ↓ (but be careful of binding protein abnormalities)
 Free serum T4: ↓
 Serum T3: ↓ or nL
 TSH: ↑ (unless central)
 RadioI uptake: usually low, but overlaps with normal

Treatment of hypothyroidism
 Thyroxine (T4), either brand name or generics (preparation of course)
 L-T3 (Cytomel): has specific indications

24
 Thyroiditis
Subacute thyroiditis
 Self-limited, nonsuppurative inflammation of the thyroid
o Infectious disease, often preceded by viral illness
 Systemic symptoms: malaise, fever, ↑↑↑ ESR
 Big, really painful thyroid(see pic to right)
 Mild hyperthyroidism followed by mild hypothyroidism; usually complete recovery

Painless / postpartum / lymphocytic thyroiditis

 Transient hyperthyroidism (2-3mo) followed by transient hypothyroidism (2-3 mo)
o May be recurrent, hypothyroidism may be permanent (20%)
 Often in postpartum women (5% post-partum women, ↑ with DM type 1)
o Can also get Graves’, transient / permanent hypothyroidism post-partum

 Thyroid gland normal or slightly enlarged; not tender

 Positive antithyroid Abs in most pts (autoimmune)
o Sort of a variant of hashimoto’s thyroiditis

Labs in Thyroiditis
 ↑ T3/4  ↓ TSH
 ↓ uptake of radioactive iodine

Classic “triphasic” course:

 hyperthyroid  euthyroid  hypothyroid
o TSH is normal  eventually high (hypothyroid)
o Can see lots of variants in post-partum period

Thyroid for Dummies: what can go wrong with the thyroid?

Problem Examples
can make too much thyroid hormone  Graves’ disease
 (overactive thyroid, hyperthyroidism)  Toxic nodular goiter
 Chronic lymphocytic thyroiditis
can make too little thyroid hormone
 Ablation of thyroid with radioiodine
 (underactive thyroid, hypothyroidism)
 Surgery
 Subacute thyroiditis
can become inflamed
 Postpartum thyroiditis
can become enlarged (goiter) or develop one or more lumps (nodules)

25
 Pituitary Gland
Anatomy Review

Pituitary sets in sella turcica, hangs down from infundibulary stalk

Forms functional unit with hypothalamus

 Nuclei in hypothalamus release releasing / inhibitory factors 
 enter median eminence, cross into fenestrated capillaries 
 to anterior pituitary (posterior has separate physiology
 ↑ or ↓ synthesis & secretion of certain hormones

All of these hormones are under stimulatory control

(need releasing factor to be produced / released)
 Exception: prolactin (dopamine is an inhibitory factor)

Negative feedback systems at work too: true for pretty much all of the axes
 Hormone can feed back on hypothalamus, anterior pituitary

Nomenclature of lesions
 Microadenoma*: < 1 cm in diameter  Secretory: produces hormone in excess
 Macroadenoma*: > 1 cm in diameter  Nonfunctional: ↓ hormone production
* normal height of pituitary is 9mm so > 1 cm is growing out of sella turcica!

Normal radiographic appearance

C=chiasm

I = infundibulum (L) or internal carotid

artery (R)

SS = sphenoid sinus (out to nasal area)

CS = cavernous sinus (contains CNs
AP = anterior pituitary
PP = posterior pituitary

26
Lesions: radiographic appearance

Microadenoma: Small macroadenoma:

Macroadenoma: has pushed normal
Hypodense lesion(arrow). ≈4cm hypodense lesion, see deviation of
pituitary to top of sella turcica
(pituitary 9 cm tall) pituitary stalk (S), displacing pituitary

Macroadenoma: has eroded bony floor of

Huge macroadenoma: invaded cavernous Massive pituitary tumor, occupying entire
sella turcica  sphenoid sinus; grown up
sinuses on both sides; also invading sphenoid sinus, obliterating sella tucica,
through top of sella  compressing optic
temporal lobe necrosis  cyst formation
chiasm, touching hypothalamus!

Clinical Manifestations of Pituitary Lesions growing in Sella Turcica

HPI should have three main focuses:
Hypopituitarism Neurological defects Hypersecretion
First “innocent bystander” for growth – When tumor  macroadenoma
lesion can grow, compress, destroy cell population.  Compresses optic chiasm, other Tumor can start secreting!
 ↓ TSH / LSH /FSH  ↓ peripheral hormone levels adjacent structures

Hypopituitarism
Gonadotrophin deficiency
TSH deficiency ACTH deficiency GH deficiency
Women Men
 ↑ fat, ↓ lean body mass
 Fatigue  Weakness  ↓ exercise capacity,
 Amenorrhea  Infertility
 Cold intolerance  Orthostasis performance
 Infertility  ↓ libido / impotency
 Dry skin  Dizziness  ↓ muscle strength
 ↓ 2° sex  Small testes (no FSH)
 Constipation  Pallor  ↓ HDL chol,
characteristics  ↓ 2° sex characteristics  Weight gain  Hypoglycemia  ↓ bone mineral density
 Impaired cardiac fxn
These are secondary deficiencies – nothing wrong with the end organ!
Can get these singly, in combo, or all (panhypopituitarism)

How to tell 1° from 2° deficiencies?

 Primary hypothyroidism: see ↑ TSH
(trying to get more out of the thyroid – pituitary OK)
 Secondary hypothyroidism: see ↓ TSH
(TSH is the problem!)
 Same thing for gonadal, other axes
27
Neurological deficits
 Lesion is growing in a confined space
 Floor of sella turcica is all around it (saddle)

Cavernous sinuses separated by thick dura (less common involvement)

Above (optic chiasm) – thin dura (more common involvement)

1. Tension-type headache is early sign: tumor grows up, stretches diaphragmatic sella (has nerves in it)
2. Optic chiasm compression is next: inferior posterior portion compromised (SUPERIOR TEMPORAL FIELDS)
a. Can be one or both sides  eventually bitemporal hemianopsias

3. cavernous sinus invasion (less common)

a. Contains CN 3, 4, V1/V2, 6
b. CN 3/4/6 – EOMs
c. CN 3 – papillary constriction
(parasymps)

Failure of L eye abduction: Failure of R. eye abduction;

L cavernous sinus invasion (L CN 6) not constricting R. pupil:
R cavernous sinus (R CN 3)

Secretory adenomas
See below for more detail

Secretory adenomas (in order of prevalence)

1. Prolactin Galactorrhea / amenorrhea
2. Growth hormone Acromegaly
3. ACTH Cushing’s syndrome
4. TSH Hyperthyroidism

Presenting Symptoms of a pituitary adenoma

Putting it all together:
 Headache  Hypogonadism  Adrenal dysfunction
 Visual abnormalities  Hypothyroidism  Secretory syndrome

Secretory Adenomas
Prolactinoma Population: women with % with prolactinoma
 #1 for secretory pituitary adenomas Amenorrhea 20%
Galactorrhea 30%
Clinical manifestations: either biochemical or mechanical Infertility 35%
Galactorrhea + oligoamenorrhea 70-75%
Mechanical origin: physical effects (as discussed above):
↓ gonadatroph function, visual field defects, CN palsies, H/A

Biochemical origin: due to ↑ prolactin level

 infertility  ↓ libido  dyspareunia
 abnormal menstrual cycles  osteopenia 2° to associated estrogen insufficiency  impotence
 galactorrhea  ↓ gonadotroph function  gynecomastia

When prolactin is high, it feeds back to the hypothalamus and shuts off gonadotrophin releasing hormone function
 ↓ LH, ↓ FSH (2° form of hypogonadism)
28
Galactorrhea: can be present in males or females!

DDx of hyperprolactinemia is large!

 Physiological causes: exercise (even a little), stress, post-prandial (get fasting

level), post-coitus, pregnancy, suckling, slow-wave sleep

 Pathological causes:
o prolactin-secreting tumors (prolactinomas)
o 1/3 of growth-hormone secreting tumors too! (check GH with ↑ prolactin)
o Large sellar masses / hypothalalmic masses
 Dopamine is inhibitory: if ↓ dopamine, ↑ prolactin (but coming from normal pituitary)
 If normal pituitary is making prolactin, treatment is surgical! (prolactin usually > 200)
 If tumor is making prolactin (prolactinoma), treatment is medical!
 IF PROLACTIN > 250, it HAS to be a PROLACTINOMA! (small prolactinoma can be < 250)
o Primary hypothyroidism, polycystic ovary, renal failure can ↑ prolactin
o Drugs: dopamine receptor blockers, catecholamine depletors
o Chest wall trauma (suckling reflex from nipple to brain  disrupt  ↑ prolactin – uncommon)

Diagnosis
 Elevated fasting prolactin
 R/O pregnancy, hypothyroidism, renal failure
 Drug history (no D2 receptor antagonists?)
 MRI if everything else ruled out

Acromegaly (growth hormone secreting tumors)

 #2 most common but still uncommon (3-4/million)
 Tend to be diagnosed in 40s
 Mean age of death in 60s if untreated (cardiac disorders)

Clinical features of acromegaly (distinctive – think “Jaws” from Bond movies)

 Enlargement of hands, feet, other organs (e.g. heart)
 Facies: distinctive
o coarsening of facial features
o soft tissues grow (tip of nose, etc)
o bony abnormalities
(hypertrophy of frontal sinuses  look like neanderthal)
o mandible sticks out (underbite) - prognathism
 Vision defects, headache,  Galactorrhea
prognathism  ↑ perspiration
 CARDIOMEGALY  HTN
 Thyroid can grow & be nodular  Splenomegaly
 Frontal bossing  Polyps, enlarged colon
 Enlarged nose, tongue, lips  Carpal tunnel syndrome
 Deformed sella turcica  Osteoarthritis
 Skin tags  Sleep apnea

Takes about ten years to develop these features

 but changes are insidious changes (don’t notice!)
 Want to make early dx: better chance of reversal, prevent side effects; soft tissues reverse, bone changes don’t
 Compare to older pictures – look for coarsening!

Acromegaly + gigantism: excess GH while growth plates are still open  can get ↑ vertical growth (gigantism)
29
Diagnosis of acromegaly
 Growth hormone releasing hormone (GHRH) stimulates GH release
 Somatostatin is inhibitory (SRIF)
 Most of the effects of GH are due to generation of IGF-1 (insulin-like growth factor 1)

ACROMEGALICS have ↑ IGF-1 – used for diagnosis

If there’s a mild ↑ in IGF-1 and you suspect acromegaly

 do a glucose tolerance test but look for growth hormone
o Normal patients: growth hormone ↓ after a meal
o Acromegaly: growth hormone doesn’t respond to glucose

ACTH-secreting tumors & Cushing Syndrome

 Various causes, complex Dx: not just ACTH-secreting tumors
 Complex syndrome, really nasty
 moon facies, plethora (redness), violaceous stretch marks, abdominal
obesity, easy bruising, buffalo hump, acne, etc.etc.etc.,

TSH-secreting tumors
 Least common
 TSH stimulates thyroid to make too much thyroid hormone  hyperthyroidism
 Like Graves’ w/o eye findings (tremor, SOB, wt loss, weakness, tachycardia, insomnia)
 Primary treatment: surgical

Craniopharyngioma
Squamous epithelial tumor arising from stalk (or hypothalamus, or 3rd ventricle)
 Has solid & cystic components
 Peak incidence in childhood
 Significant headaches  panhypopituitarism; also diabetes insipidus
 Surgical excision if small; destructive when they get large
 Recurrence: try surgery again, ± radiation

Empty Sella Syndrome

Invagination of diaphragm sella (stretched piece of dura above) by CSF
 Starts to pancake pituitary across floor of sella
 Pic: see little crescent shaped pituitary being pushed down by CSF

Normal function in 95% of cases

 Remarkable compression, but slow  can adapt!
 no intervention needed if function ok
 Need to DDx from cyst (cyst can progress!)

Pituitary Apoplexy
Spontaneous hemorrhage into pituitary tumor (2-5% of all untreated pituitary tumors)
 Severe H/A, N/V, fever, stiff neck – pts usually go right to ED
o “worst headache of my life” – usually misdiagnosed as subarachnoid hemorrhage, meningitis
o Visual loss, diplopia, ptosis too (expansion of blood)
o Meningismus sx from necrotic tissue exploding into CSF
 Panhypopituitarism (hemorrhage)  acute cortisol deficiency (can be life threatening!)

30
 Hypopituitarism: monohormonal failures
 Usually inherited (can be acquired)
 Kallman syndrome: failure to elaborate gonadotrophin releasing hormone (↓ LH/FSH) – 2° hypogonadism
 Isolated ACTH / TSH / GH possible too

Secondary…
Hypothyroidism
Sex hormone deficiency
Glucocorticoid deficiency
Treatment of Hypopituitarism
Cause Treatment
 can’t rely on TSH like in 1° (TSH messed up!)
↓ TSH
 need to rely only on free T4 & symptoms
 Testosterone (patch, gel, injections)
↓ GRH
 estrogen / progesterone (OCP)
 Prednisone / dexamethasone (potencies different; all replace glucocorticoids)
 Maintenance dose + extra dose for stress
↓ ACTH o Extra maintenance if just a little sick
o 10x dose if severe illness, surgery, etc
o Wear medical alert tag

Disorders of the Posterior Pituitary

Neurogenic Diabetes Insipidus Deficiency of vasopressin
Syndrome of Inappropriate ADH Excess vasopressin Release
Remember ADH = vasopressin

Posterior pituitary: just a storage depot for vasopressin & oxytocin

 two hypothalalmic nuclei (supraocular, paraventricular) synthesize vasopressin, oxytocin
 Axons run down to posterior pituitary, terminals in posterior pituitary
 Signal  release into circulation

Vasopressin:
brings in free water back from renal tubules into plasma
 Binds V2 receptors  translocates aquaporins via cAMP into
apical membrane
 Plasma osmolarity is #1 regulator of [vasopressin] in the blood

↑ vasopressin when we’re dehydrated

o > 280 osmolarity = osmotic threshold  release vasopressin; autonomic process
o Thirst threshold is about 292 (start to drink more water to take advantage of vasopressin)

Vasopressin also concentrates urine (↑ urine osmolarity,↓ plasma osmolarity)

Neurogenic diabetes insipidus

Deficiency of vasopressin
 Less commonly from vasopression receptor inactivation (renal; very rare)
 Central diabetes insipidus: when posterior lobe of pituitary fails to secrete enough vasopression
o NOT from tumor – can actually remove part of posterior lobe and not have DI (axons run above)
o Can if lesion is in upper stalk or higher (larger lesions or lesions higher up in stalk)

31
Pathophysiology:
 Can’t get aquaporins in to concentrate urine  very dilute urine, polyuria 
 dehydration / hypotension if can’t get to water!

Etiology:
• Post-operative (e.g. transsphenoidal) – most common • Metastatic tumor
• Head trauma (#2) • Infiltrative disorder (e.g. sarcoid)
• Idiopathic (#3) • Aneurysm
• CNS tumor (e.g. craniopharyngioma) • Pituitary adenoma

Signs / symptoms: polyuria, polydipsia, dehydration, dilute urine, ± hyperNa

DDx of polyuria: hyperosmolar states (hyperglycemia - DM), neurogenic DI, nephrogenic DI, 1° polydipsia (psych pts)

Dx of DI
 Serum osmolarity > 295 (hyperosmolar)
 Urine osmolarity < 800 – should have tons of vasopressin; should be around 1200! Not diluting!
 Water deprivation test: deprive pt of fluids, then get these values (keep from compensating by drinking)

SIADH: Syndrome of inappropriate secretion of ADH

 Excessive secretion of vasopressin (opposite of DI)
 Leads to excessive water retention, hypoNa
 Most common cause of non-iatrogenic hyponatremia

Keep making & secreting vasopressin even when osmolarity is low!

These are euvolemic patients with hypoNa

Check plasma osmolarity (mostly sodium) and see it’s low

 But urine is inappropriately concentrated
 Shouldn’t have ADH around!

Causes: many! Meds, tumors, pulmonary disorders, CNS disorders, etc.

32
 Endocrinology of Aging
Thyroid Hormone
Overt or subclinical hypothyroidism affect 7-15% of people > age 60 (esp women)
 Overt hypothyroidism  hyperlipidemia, ↑ risk CHD. MUST TREAT
 Subclinical hypothyroidism: common; TSH ↑ but no symptoms
o ↑ risk of overt hypothyroidism
o So: check TSH levels, follow ± treat (?) subclinical hypothyroidism in the elderly

Consequences of Aging

 Muscle mass ↓  Intra-abdominal fat ↑  Bone mass ↓

o Strength ↓ o Glucose intolerance o Fracture risk ↑
o Balance ↓ o Hyperlipidemia
o Hypertension  Exercise capacity ↓
o Diabetes  Cognitive skills ↓
o CVD
 Sexual desire / function ↓

From graphs:

↓ muscle strength

Body composition:
 ↓ muscle
 ↑ fat

Hormones that Decline with Age

Hormone Name
 Normally if ↓ GH, give GH
Estrogen, progesterone Menopause
 Open question: should these declining Growth hormone Somatopause
hormones be prescribed for healthy elderly pts? DHEA Adrenopause
Testosterone Andropause, “male climacteric”
Estrogen & Progesterone Replacement
Benefits of replacement Risks of replacement
 ↓ menopausal vasoactive Sx  ↑ risk of breast cancer (long-term)
 Slow bone loss  ↑ uterine cancer with unopposed estrogen
 ↓ risk CAD (?)  ↑ venous thrombosis

Growth Hormone
 Note lower levels, smaller peaks with age
 ↓ somatostatin C (like IGF-1) with age, too (gradual)

Aging – looks like growth hormone deficiency in adults

 Maybe we should be replacing GH?

33
 GH replacement in healthy elderly
Effects of GH deficiency
Effects Potential Risks
 ↓ muscle mass  Joint pain
 ↑ lean body mass (good)
 ↑ intra-abdominal fat  Carpal tunnel
 ↓ total body, abdominal fat
 ↓ bone mass  Fluid retention
 ↑ fracture risk  HTN
 NO CHANGE in FUNCTIONAL STATUS
 ↑ SBP  Diabetes
 Total / HDL chol = inconsistent
 Hyperlipidemia  Cancers? Accelerated aging?

Hard to interpret results of replacement of GH in elderly:

 limited #, variable duration / doses, short-lived vs decades of decline
 Essential and valuable in those who have GH deficiency (congenital or post-surgical) but not clear in aging

GH: Hucksters, Scam Artists, & Other Scallywags

 ORAL GH JUST DOESN’T WORK – need to inject (high discomfort, high costs)
o Can’t “enhance” GH releasing hormone with oral supplements either
 “Life extension” / “aging prevention” industry – just straight up wrong to take advantage of old folks
 Illegal to sell GH to avoid aging or boost athletic performance

DHEA (dehydroepiandrosterone)
DHEA and DHEAS (DHEA sulfate) are readily interchangeable
 Synthesized in zona reticularis of the adrenal gland
 Secretion mediated by ACTH but no feedback on pituitary/adrenal axis (no way to ↓ ACTH)

A small amount of DHEA can eventually be converted to testosterone

 Way more DHEA than T in the body
o most prevalent of gonadal steroids
 DHEAS > DHEA in serum
 DHEA/S are pretty inactive as an androgen, though

In aging: marked ↓ DHEA levels with time (both men & women)
 Variable amount of decline from one to another
 DHEA often marked as a super-pill to prevent all sorts of aging stuff
o No evidence whatsoever to support these claims (not a fountain of youth, miracle pill, antidote for aging)

Major effect of taking DHEA (even by mouth): raises DHEA / DHEAS blood levels
 At least you can take it by mouth!
 A little ability to increase estrogen / T levels? Maybe IGF-1? LDL cholesterol lowering? Not well proven.
 Maybe ↓ body fat, ↑ body mass. Probably does “increase skin status”

RCT in elderly:
 NO physiologically relevant beneficial effects on body composition, physical performance, insulin sensitivity, QOL

Only should be used for adrenal insufficiency (not for healthy old folks)

Testosterone
↑ age  slow ↓ testosterone, ↓ male sexual function: But no evidence that those two things are related or causal

Risks of testosterone replacement: ↑ BPH, worse prostate cancer, sleep apnea, ↑ Hct, ↓ HDL-chol, Sleep apnea

Take-home: don’t give T unless the patient is severely T deficient (from another cause)

34
 Adrenal Pathophysiology & Multiple Endocrine Neoplasia
Overview of Adrenal Pathophysiology
Glucocorticoid & mineralocorticoid deficiency Addison’s disease, Congenital Adrenal Hyperplasia
Glutocorticoid excess Cushing’s syndrome
Mineralocorticoid excess Hyperaldosteronism
Catecholamine excess Pheochromocytoma
Multiple Endocrine Neoplasia syndromes
Normal Embryology, Anatomy, & Physiology
Embryology
Adrenal cortex / medulla are functionally separate organs
 Cortex: mesynchemal origin; invaded by neural crest cells (2 mo gestation)
 Medulla: NCC  chromaffin cells (secrete catecholamines) under ↑ local *glucocorticoid+

Anatomy
Note that :
 Cortex / medulla have separate arterial supplies
 Medulla exposed to cortical venous effluent

 Right adrenal drains directly into IVC

 Left adrenal drains into left renal vein

Nerve supply:
 Cortex: efferent symps / parasymps regulate blood flow
 Medulla: symps  catecholamine release

Histology & Function: out in = salt  sugar  sex  violence

Zona glomerulosa Aldosterone “salt”
Cortex Zona fasiculata Glucocorticoids “sugar”
Zona reticularis Androgens “sex”
Medulla Catecholamines “fight / flight”

Corticosteroids:
 glucocorticoids (e.g. cortisol)
 mineralocorticoids (e.g. aldosterone)

Glucocorticoids: Physical Function

From zona fasiculata (“sugar”)

In stress situations (sepsis, hemorrhage, surgery), glucocorticoid secretion can ↑ 10x

 ↑ survival: affects cardiovascular system, CHO / lipid metabolism, immune system
 In adrenal insufficiency  can have life-threatening adrenal crisis if stressed w/o glucocorticoid replacement

Cardiovascular Actions
Goal: maintain blood pressure
Cortisol (glucocorticoid) Aldosterone (mineralocorticoid)
Generally works faster Generally works on longer time scale
 ↑ myocardial contractility, ↑ SV, CO  ↑ renal Na retention, K excretion
 ↑ vascular sensitivity to pressor effects of  ↑ intravascular volume
catecholamines  Some direct effects on myocardium too
Chronic ↑ glucocorticoids / aldosterone  hypertension
35
CHO / Lipid metabolism
Goal: maintain fuel to brain (↑ blood glucose)

Effect of glucocorticoids (cortisol) Effect in chronic cortisol excess (Cushing’s Syndrome)

↑ appetite, gut absorption
↑ hepatic gluconeogenesis
protein wasting, skeletal myopathy
 (substrates from glycogen, protein, lipid)
↓ peripheral glucose uptake: insulin resistance
insulin-resistant diabetes mellitus
 (↓ glucose transporter function)
Activates lipolysis
body fat redistribution (trunk, mesentery, mediastinum)
 (abdominal fat retained, peripheral fat eliminated)

Immune function
Goal: limit inflammatory response to infection – a “check” to keep immune system from getting out of control

Lymphyocytes Granulocytes Other

 Redistribute T & B cells (away from circulation)  Redistribute to circulation   ↓ Eos, Mϕ, monocytes
 T cell apoptosis granulocytosis  ↓ histamine, prostaglandin, TNF
 T / B cell, NK function inhibited  ↓ Chemotaxis, phagocytosis  ↓ vascular permeability

Chronic glucocorticoid excess  excess immune suppression  ↑ susceptibility to infection (bacterial / viral / fungal)

Glucocorticoids: Regulation (cellular level)

Nuclear receptor binds DNA  affects gene transcription, etc.

Cortisol is active, Cortisone is inactive

 11HSD: 11-β hydroxysteroid dehydrogenase (conversion)
 11HSD2 inactivates at tissues

Activity of glucocorticoids regulated locally by:

 11HSD activity
 Nuclear receptor protein presence/absence

Glucocorticoids: Regulation (H-P-A axis / negative feedback)

Remember: CRH (hypothalamus)  ACTH (pituitary)  cortisol (adrenal)

 ↑ cortisol inhibits CRH & ACTH synthesis & release (negative feedback)
 CRH / ATCH release is pulsatile

CRH pulses:
 Stimulate ACTH synthesis & secretion
o Important for daily-type stresses, diurnal variation, etc.
 In extreme stress: vasopressin can also cause ACTH release

ACTH pulses:
 Stimulate secretion of:
o cortisol (principal glucocorticoid)
o aldosterone (mineralocorticoid)
o DHEAS / androstenedione (weak androgens)
 ↑ steroid hormone biosynthesis (↑cholesterol  pregenolone conversion – rate limiting step, + other steps)
 ↑ adrenal growth
36
Clinical significance
 Resistance to negative feedback is the hallmark of glucocorticoid excess (Cushing’s Syndrome)
 Withdrawing exogenous glucocorticoids (e.g. post therapy) may suppress HPA axis
o Already ↓ CRH, ACTH from ↑ exogenous glucocorticoids

Circadian variation in cortisol secretion

 Plasma cortisol peaks in the morning, lowest ≈ midnight
o small, decreasing peaks through the rest of the day (tapering down)
 Cortisol deficiency  really really tired all the time

Mineralocorticoids: Regulation
Produced in zona glomerulosa (e.g. aldosterone: “salt”)

Under dual regulation

Angiotensin II High levels of ACTH
primary stimulus for mineralocorticoid synthesis & secretion can be a secondary stimulus for mineralocorticoid release

Clinical significance:
 ACTH deficiency doesn’t usually produce mineralocorticoid deficiency, but
 ACTH excess can lead to mineralocorticoid excess

Adrenal / Immune Systems: Negative Feedback

Net effect is to dampen immune response

 part of negative feedback to keep immune processes in check

Immune stimulus  ↑ TNF / IL-1, IL-6 from mononuclear cells

 triggers ↑ CRH, ↑ ACTH, ↑ cortisol
 ↑ cortisol has immunosuppressive effects
o Also triggers negative feedback (as shown above)

Ends up trying to achieve a sort of “balanced” immune response

37
 Adrenocortical Insufficiency

Primary AI: indicates damage to adrenal cortex (Addison’s disease) Primary Secondary
 Adrenals knocked out so ↓ aldo, ↓ cortisol ACTH High Low
 ↑ CRH, ACTH (negative feedback from cortisol removed) Cortisol Low Low
 ↑ renin, ↑ AT I/II (↓ aldosterone  ↓ renal blood flow) Aldosterone Low Normal

Secondary AI: indicates damage to hypothalamus / pituitary (↓ ACTH production)

 Aldo still produced – although adrenals are small (↓ ACTH), they can still make some
 Patients can partially compensate with aldosterone: don’t have as many vascular issues (partial compensation)
 ↓ cortisol but ↓ ACTH too (pituitary is damaged!

Clinical manifestations of adrenocortical insuficiency

Severity depends on
 Rate, degree of loss of adrenal function
 Whether aldosterone secretion is preserved
 Level of concurrent physiological stress

Symptoms Signs
 Weakness  Abdominal pain  Weight loss  Dehydration*
 Sleepiness / fatigue  Postural light-headedness*  Hyperpigmentation*  Loss of pubic / axillary hair
 Anorexia  Salt craving  Hypotension*
 Nausea / vomiting
* especially in primary adrenal insufficiency
Addison’s Disease = autoimmune 1° adrenal insufficiency

Hyperpigmentation: ↑ CRH  ↑ ACTH production.

 ACTH and MSH (melanocyte stimulating hormone) are both made from POMC (precursor protein)
 ↑ stimulation of ACTH production  ↑ MSH too  hyperpigmentation!
Loss of pubic / axillary hair: ↓ androgens (in post-menopausal women adrenals are source of most androgens)
38
Acute adrenal crisis
 Muscle, joint, abdominal pain  Clouded sensorium
 Intractable vomiting, severe dehydration  Electrolyte disorders
 Hypotension resistant to pressors
Give EMPIRIC GLUCOCORTICOID TREATMENT!

Lab findings
 HypoNa*  ↑ BUN/Creatinine*  Eosinophilia
 HyperKa*  HyperCa (rare)  Lymphocytosis
 Hypoglycemia  Anemia
*mostly primary (vs secondary)

Etiologies of primary adrenal insufficiency

 Autoimmune destruction (can be isolated or polyglandular) = Addison’s disease
 Adrenal hemorrhage (associated with anticoagulant Rx, meningococcemia)
 Metastatic carcinoma (need > 90% replacement by tumor)
 Infections (TB, fungal, CMV)

Etiologies of secondary adrenal insufficiency

 STEROID HORMONE WITHDRAWAL (#1 most common)
o After glucocorticoid treatment > 2/3 wks, therapy should be tapered down
o HPA axis needs to recover: have been suppressing higher levels (ACTH, CRH)
o If patient is stressed while axis suppressed, they’ve basically got functional adrenal insufficiency
 Tumors (hypothalamic / pituitary) – less common

Diagnosis of adrenal insufficieny

Short ACTH (cortrosyn) stimulation test: Best initial study of choice for adrenal insufficiency of any cause
 Give ACTH, check cortisol (adrenals should produce cortisol > 18 mcg/dL)
 But won’t work in recent onset 2° AI (adrenals haven’t atrophied yet)

Plasma ACTH level: to differentiate 1° vs 2° (ACTH ↑ in primary, ↓ in secondary)

CRH, metyrapone tests

 Used to detect recent onset secondary AI; stimulate the H-P-A axis centrally, rarely used now
 CRH: stimulates pituitary
 Metyrapone: entire H-P-A axis (cortisol synthesis inhibitor) but can therefore exacerbate AI!

Treatment of AI: Basic Principles

1. Individualize for primary vs secondary

a. Secondary: hydrocortisone (= cortisol) alone
b. Primary: hydrocortisone + mineralocorticoid (cortisol + fludrocortisones)

2. Mimic normal diurnal changes (avoid overtreatment)

a. Normal basal production 10-12 mg/m2/day

3. Anticipate ↑ requirements during stress

a. Fevers, other mild illness: 3x dose
b. Surgery / severe illness: 10x dose (“stress dose steroids”)

39
 Congenital Adrenal Hyperplasia
Family of disorders with specific defects in steroid biosynthetic enzymes
 Relative ↓ in cortical secretion  ↓ feedback suppression of CRH, ACTH 
 ↑↑ ACTH secretion  ↑ production of cortisol precursors (upstream of enzymatic block  ↑ androgens)
 Long term ↑↑ ACTH  overgrowth of adrenal glands (hyperplasia)

21-hydroxylase deficiency: Example of CAH

Most common example of CAH
 varying degrees of cortisol/aldosterone deficiency & androgen excess

Mild block (e.g. heterozygote):

 ↑ ACTH can drive a little more through the pathway

Severe block (e.g. homozygote)

 can’t drive through to make cortisol / aldosterone at all

In both cases, block leads to ↑↑ precursors  ↑ andro, T

Attenuated form Salt-losing form

Partial block of enzymatic activity (e.g. heterozygote) Complete block of enzymes (e.g. homozygote)
 Common cause of hirsuitism & irregular menses  Life-threatening cortisol & aldosterone deficiency
 Only apparent in females  Defect present at birth
 Mild excess of testosterone & androstenedione  Androgen excess in females

Hypercortisolism (Cushing’s Syndrome)

Cushing’s Syndrome Cushing’s Disease

Generic hypercortisolism regardless of cause Hypercortisolism from an ACTH-secreting pituitary tumor

Clinical Manifestations of Hypercortisolism

System Manifestations
General truncal obesity with peripheral wasting, moon facies, cervicodorsal fat
Skin cutaneous atrophy, abdominal striae (purplish, not silvery like post-pregnancy), acne
Cardiovascular hypertension, edema, cardiomyopathy (rare)
Muscle proximal myopathy (often severe)
Bone osteoporosis, aseptic hip necrosis
Reproductive amenorrhea, hirsuitism, virulization
Metabolic insulin resistant DM, hyperlipidemia
Immune broad immunodeficiency, esp T-cell
Psychiatric mood swings, depression, mania (esp. on very short time scale) psychosis

Very characteristic appearance:

 Note abdominal obesity with thigh wasting
 Moon-like, full, reddish facies

40
Etiologies of Hypercortisolism
 Cushing’s disease: pituitary ACTH-secreting tumor
 Ectopic:
ACTH-dependent
o small cell lung cancer
o Carcinoid, medullary thyroid, pheochromocytoma
 Exogenous glucocorticoid treatment (#1 – iatrogenic)
ACTH-independent
 Adrenal adenoma or carcinoma
 Mostly in severe alcoholics (can resolve if stop EtOH)
Pseudo-Cushing’s
 Also possible in major depression  can get central activation of axis

ACTH-dependence stems from etiology:

 Cushing’s disease: very high doses of cortisol can sometimes counteract high ACTH levels
 Ectopic ACTH: no matter how much cortisol you jack up, you can’t ↓ ACTH levels
 Adrenal tumor: too much cortisol being produced, but hypothal / pituitary negative feedback working OK (ACTH suppressed)

Diagnosis of hypercortisolism
INITIAL STUDIES
Urinary free cortisol
24 h urine collection  measure cortisol
Method:
(24h: integrates circadian variation)
Cushing’s syndrome: ↑↑ (3x nL)
Results: Milder elevations: Cushing’s, pseudo-Cushing’s, or
stress (repeat test)
Comments: INITIAL STUDY OF CHOICE

Midnight Salivary Cortisol

Method: Get saliva sample at midnight (≈ plasma free cortisol
Normal: should be really low (lowest circadian level)
Results:
Cushing’s: inappropriately “normal” or “high”
Comments: Alternative initial study

CONFIRMING HYPERCORTISOLISM
LOW-DOSE dexamethasone suppression test
Give dexamethasone 0.5mg po q6h x 2d
Method:
Collect plasma cortisol
Normal: should suppress plasma cortisol (< 1.8mcg/dL)
Results:
Cushing’s: have impaired feedback suppression by low doses of exogenous corticosteroid (> 1.8 mcg/dL)
Comments: Doesn’t distinguish Cushing’s disease vs other causes of hypercortisolism

41
 BIOCHEMICAL LOCALIZATION
Plasma ACTH
Method: Collect ACTH from plasma

Low ACTH (<5 pg/mL) and ↑ cortisol:

 ACTH-independent (exogenous vs. adrenal tumor)
Results:
Normal / high ACTH (> 15mcg) and ↑ cortisol
 ACTH-dependent (pituitary Cushing’s dz vs ectopic ACTH)

If massive elevations, likely ectopic ACTH

Comments:
If elevations modest, need more testing

HIGH-DOSE dexamethasone suppression test

Dexamethasone 2mg po q6h x 2d or 8mg overnight
Method:
Collect plasma cortisol or 24h UFC
Pituitary Cushing’s disease: most cases suppress > 90%
Results:
Ectopic ACTH / adrenal tumors: rarely suppress > 90%

Pituitary tumors often retain partial feedback suppression;

Comments: adrenal tumors & ectopic-ACTH tumors rarely do
Test unreliable by itself (lots of false positives / negatives)

Petrosal venous sinus sampling

Cath petrosal venous sinuses draining each pituitary hemisphere.
Method:
Give CRH, then measure ACTH from drainage & periphery
Calculate central:peripheral ACTH gradient
Results:  Pituitary tumors: gradient >3 (often >10)
 Ectopic ACTH: no central:peripheral ACTH gradient

GOLD STANDARD for localizing ACTH-DEPENDENT CUSHING’S

Comments:
Specialized, not available in all hospitals

After these steps:

 Radiography: MRI of pituitary, occasionally chest/abdomen
Summary of Glucocorticoid Function Tests
Useful in…
Test
Glucocorticoid insufficiency Glucocorticoid excess
24 hour urinary free cortisol 
Midnight salivary cortisol 
Basal
Basal plasma ACTH  
Basal plasma cortisol Potentially misleading
Low dose dexamethasone suppression 
Suppression
High dose dexamethasone suppression 
ACTH stimulation (of adrenal) 
Stimulation CRH stimulation (of pituitary) 
Metyrapone stimulation (of hypo/pituitary) 

42
Treatment of hypercortisolism
Etiology Treatment options
 Trans-sphenoidal pituitary surgery
Cushing’s disease
 Post-operative pituitary irradiation
Adrenal tumors Adrenal surgery
Ectopic ACTH Surgery (if possible)
 Cortisol synthesis inhibitors (ketoconazole, metyrapone, mitotane)
Refractory / inoperable disease
 Rarely: bilateral adrenalectomy

Hyperaldosteronism
Endocrine causes of hypertension: Cushing’s syndrome, Hyperaldosteronism, or pheochromocytoma
Clinical features:
 hypoK: urinary potassium wasting
 hyperNa: suppressed plasma renin (in 1° hyperaldosteronism)
Etiologies
 due to adrenal cause (adenoma / hyperplasia), or idiopathic
Primary  Diuretics, CHF, renal artery stenosis

Secondary  renin-dependent (multiple etiologies  ↓ renal blood flow)

Diagnostic evaluation
1. Identify primary vs. secondary hyeraldosteronism
a. After repletion of Na / K, check plasma renin / aldosterone
b. If ↓ renin and ↑ aldosterone, think primary
c. If ↑ renin and ↑ aldosterone, think secondary
2. Confirm non-suppressible hyperaldosteronism with salt-loading test (salt tabs or IV normal saline
3. If primary hyperaldosteronism, identify etiology (adrenal tumor vs. hyperplasia)
a. Adrenal CT
b. Adrenal vein sampling (aldosterone / cortisol)
c. Aldosterone-producing adenoma will lateralize; idiopathic hyperaldosteronism won’t
Treatment
 Adenoma: surgery
 Idiopathic: aldosterone receptor inhibitors (spironolactone . eplerenone)

43
 Pheochromocytomas
Rare catecholamine-producing tumor of medulla
 ≈10% extra-adrenal (paragangliomas)
 20% familial, 20% malignant
 NEED TO DX (can provoke life-threatening hypertensive crisis)

 The metabolites (metanephrines / VMA) are more stable (good for diagnostic measurement)

Clinical manifestations
 More frequently paroxysmal than static (come in waves – minutes to hours)
 Usually spontaneous; occasionally in response to abdominal manipulations / strenuous exertion
o not in response to emotional distress like anxiety
 Can resemble hypoglycemia (activation of sympathetic pathways)

Symptoms / signs
 Headache  Nausea  Chest pain  Light-headedness
 Diaphoresis  Tremor  Dyspnea  HTN (often severe)
 Palpitation  Nervousness  Pallor > flushing (vasoconstriction)

Locations of pheochromocytomas
Solitary adrenal Bilateral adrenal Extra-adrenal Malignant
80% 10% 10% 15-20%

Hereditary disease associations

Multiple Endocrine Neoplasia Type 2 (Medullary thyroid cancer, pheo, hyperparathyroidism)
Von-Hippel Lindau Disease (VHL) (CNS and retinal hemangiomas, renal carcinoma, pheo, paraganglioma)
Neurofibromatosis (NF-1) (Café au lait spots,cutaneous neurofibromas, pheo)
Succinate Dehydrogenase B and D (Paraganglioma and pheo)
SUSPECT if tumors are EARLY ONSET, BILATERAL, OR EXTRA-ADRENAL‼

Diagnosis
 Recognize distinctive symptom complex or HTN that’s really severe
 Then: confirm biochemically, then localize

Biochemical test of choice: 24h metanephrines / plasma metanephrines

 Stable catecholamine metabolites, usually ↑ > 2x ULN in pheochromocytoma
 Interference possible (certain antiHTN meds, drug/alcohol withdrawal)
 Urinary catecholamines, VMN have lower sensitivity

Optional follow-up test: clonidine suppression test

 Indicated if metanephrine ↑ is modest (1.5-3x); get plasma metanephrines before / after clonidine
 Metanephrines suppressed by clonidine in normal individuals; stable/↑ in pheo

44
Anatomic localization: with CT/MRI, 123I-MIBG, FDG-PET

Treatment
1. Pre-op preparation
a. Anesthesia, other major procedure w/o α-blocade could induce hypertensive crisis
b. α-adrenergic blockade (phenoxybenzamine usually used)
c. AVOID ISOLATED β-BLOCKER USE (can worsen HTN by inhibiting β-2 adrenergic receptors)
2. Adrenalectomy (laparoscopic)

Multiple Endocrine Neoplasia Syndromes

Two distinct syndromes: MEN1 / MEN2
 Both aut dom inheritance of multiple endocrine tumors
 DNA-based diagnosis of pre-symptomatic patients possible

MEN1: Parathyroid, Pancreas, Pituitary

 Inactivating mutations of the Menin gene (function obscure)

Clinical manifestations: 3P’s (Parathyroid, pancreas, pituitary)
 Cardinal lesion is parathyroid adenomas (>90% penetrance by age 30)
 GI tumors (40%) incl. gastrinoma, carcinoid (serotoinin), insulinomas
 Pituitary tumors (30%) incl. prolactinoma, non-secretory, ACTH, GH

Diagnosis:
 Ionized calcium, PTH, FHx  Gene testing difficult  Prolactin, gastrin, others

Treatment
 Parathyroid: 4 gland resection with forearm re-implantation
 Pituitary: similar indications for surgery / DA agonists as in sporadic disease
 GI:
o PPI for gastrinoma
o others have similar indications for surgery,
o somatostatin analogues to control hypersecretion in inoperable tumors

MEN2: MTC, Pheo, Parathyroid

 Activating mutations of RET tyrosine kinase receptor
 Cardinal lesion is medullary thyroid cancer (25% MTC hereditary; 75% sporadic)

3 characteristic syndromes
MEN 2A MTC (>90% by age 30), pheo (≈50%), hyperparathyroidism (≈15%)
MEN 2B MTC (early onset, often aggressive), frequent pheo, mucosal ganglioneuromas, marfanoid
FMTC Isolated MTC, often later onset / less penetrant

Diagnosis:
 Need DNA testing (RET gene mutation) – test known MEN2 families & MTC pts, even w/o obvious FHx
 If test positive in asymptomatic person (e.g. relative)  prophylactic childhood thyroidectomy (prevent MTC)
 Surveillance for pheochromocytoma & hyperparathyroidism

45
 Gender Development
Introduction
Original theories of gender development: learning influenced psychosexual development
Current model: androgen exposure, genes on Y chromosome
Novel predictors: parent attitudes may play a role
Importance of studying: influences how we understand sex and gender

Definitions
 Gender Identity (GI): f
 Gender role (GR):
 Sexual orientation:
 DSD:
undamental sense of belonging to one sex
behavior designated as masculine or feminine
attraction to sexual partners
disorders of sexual development
o (sensitive to patients: replace intersex, pseudohermaphrodites, sex reversal, etc)

Embryology

Sex ducts: all embryos start out with ‘em; may or may not continue

 Mullerian ducts  internal female reproductive structures

(upper vagina, cervix, uterus, etc.)

 Wolffian ducts internal male reproductive structures

(seminal vesicles, epididymes, vas deferens, prostate)

Starting point: Undifferentiated gonadal tissue (all embryos)

Male development
 If embryo is 46XY and SRY+, develops into testis; makes:
Makes Mullerian ducts disappear
Mullerian inhibiting factor (MIF) peptide hormone
(embryo won’t have female internal reproductive structures)
Promotes Wolffian duct development
Testosterone androgen
(embryo will have male internal reproductive structures)
DHT (dihydrotestosterone) Promotes masculinization of external genital structures
more potent androgen
(5-α reductase: T  DHT) (embryo will have male bits)

Female development (not as well understood)

 If there’s no Y chromosome and no SRY, get ovaries (quiescent: make no hormones)
Mullerian ducts develop
No MIF
(embryo will have female internal reproductive structures)
Wolffian ducts regress
No Testosterone
(embryo won’t have male internal reproductive structures)
No masculinization of external genital structures
No DHT (dihydrotestosterone)
(embryo won’t have male bits - female by default)

Example: 46XY with 5-α reductase deficiency: can’t convert T to DHT

 No masculinization (female external genitalia!)

50+ types of DSD: so what do you do?

46
 Optimal Gender Theory (John Money)
John Money (Hopkins PhD – gender identity clinic)
 Identified gender identity vs gender role
 Believed that GI is learned, GR is in part hormonally programmed

“ Optimal Gender Theory” (Money)

 If GI is learned, DSD newborns should be reared according to sex that genital phenotype most resembles
o Problem: limited long-term follow-up
 Easier to surgically construct female genitalia than male genitalia
o Problem: it may look right, but maybe it doesn’t work right (cosmetic vs function)

Criticism of optimal gender theory (90s):

 Paper published on XY kids raised as females; noted that they often assign themselves back
 John/Joan – had male identical twin; circumcision mistake; reassigned / surgery  female, reassigned self to male in teens
 Intersex society of North America started to criticize

“Biology is Destiny” Theory of Gender

Replacement for optimal gender theory
Different takes:
 Early androgen exposure masculinizes the brain and subsequent behavior in humans
 Genes encoded on the Y chromosome masculinize the brain and behavior in humans
 Both masculinize the brain and behavior in humans in an additive or synergistic manner

Frank Beach: 1st behavioral endocrinologist; looked at guinea pigs

 Castrated male rats
o gave T  start mounting stuff
o gave E show lordosis (submission)
 Similar for female rats – estrogen / testosterone seems to control behavior

Congenital Adrenal Hyperplasia (CAH) – 21-hydroxylase deficiency

 Most common cause of XX-DSD
 Formerly called “female pseudohermaphrotism”
 Life-threatening condition (often fatal in 1st 10 days of life if not caught!)
o Easier to pick up in genetic females
o Genetic males – harder (supposed to look like this!) – often die
o Now: newborn screening in all states in USA

Can’t make cortisol so ↑ cortisol precursors (↑ androgens)  external masculinization

 Full penis
 Labia completely fused (empty scrotum – no testes! Ovaries!)
 Spectrum (Prader 0-5; femalemale)

Prader 0 Prader 1 Prader 2 Prader 3 Prader 4 Prader 5

 Simple virilizers (≈ prader 0-2) or salt-losers (prader 3-5 – tend to lose salt)

47
Raised female (external) but have had lots of androgen exposure
 Should have both Mullerian & Wolffian ducts (no MIF but yes T)
 Totally functional as females, but with Wolffian ducts too
o Can’t ethically take away child’s fertility potential to raise as a boy

Research question: If prenatal androgen exposure is important, should have more masculinization with ↑ androgens
 Salt-losers have more androgen exposure than simple virilizers; compare to sisters / controls

Question
Satisfaction with female rearing (better off as male?)
Have you questioned your female rearing?
Sexual orientation (Kinsey scale)
Vs. friends, etc.: how masculine are you?
Past life: How feminine? How masculine?
Result
No differences between groups (GENDER IDENTITY)
Dose-response with androgen exposure
(I’m hirstute, I have menstrual problems, etc.)
Salt users more towards bisexual end of scale
Dose-response with ↑ masculinity (GENDER ROLE)
Everybody says they ↑ femininity with time
 (Learning? Puberty? Combo?)
Salt-losers: ↑ masculinity early, but ↓ with time

Conclusion: genetically female but exposed to lots of androgen:

 Gender role and sexual orientation can be changed, but NOT GENDER IDENTITY

Congenital Androgen Insensitivity Syndrome (CAIS, AIS)

 46XY DSD with female genitalia
 Have testes in abdomen
 Testes work fine (making T, made MIF)
o So internal male structures (Wolffian)
o but no internal female structures (Mullerian)
o Converts T to DHT just fine, but no external masculinization
 No androgen receptor  no pubic hair, etc. either

Clinical presentation: no menses, no pubic hair, normal breasts

 Has lots of T  can convert to estrogen with aromatase (breast development)

Question: does rodent model apply to humans? Exposed to lots of T in utero (should masculinize brain?)
 All CAIS females were heterosexual, satisfied with gender identity role
 Really feminine! Maybe because the T is being converted to E(not best population to study)

46,XY Complete Gonadal Dysgenesis (CGD)

Really rare; a.k.a. “Swyer syndrome”
XY but can’t differentiate into testes (no SRY, etc.)
 Gonadal streaks instead of testes
 No T, no MIF (female external genitalia, Mullerian ducts  female)

Research question: what’s the influence of the Y chromosome alone?

 All really female-typical; just about all female heterosexual (n=3 for this study)
 Y chromosome alone has no influence on sexuality in humans
 Raise these babies as girls

46, XY DSD with ambiguous genitalia

 What do you do if you don’t know what fertility potential is?
 Almost always reared female

48
Study: various conditions; all 46,XY DSD with ≈ the same external genital appearance
Reared female Reared male
Gender identity  75% satisfied  75% satisfied
(satisfaction with rearing)  25% dissatisfied  25% dissatisfied
(“intersex”, homosexual orientation) (intersex, gender change)
Sexual orientation 39% exclusively female heterosexual 95% exclusively male heterosexual
Gender role More feminine (↑ with time) More masculine (↑ with time)
Early androgen exposure might have role in sexual orientation – or maybe other factors at play?

“Biology is Destiny” theory – evidence

“Early androgen exposure masculinizes the brain, subsequent behavior in humans”
 Not true for GI (think CAH, 46,XY with ambiguous genitalia)
 May be true for GR and sexual orientation (CAH-SL and 46,XY with ambiguous genitalia)
o Take into consideration in assigning gender roles

“Genes encoded on the Y chromosome masculinize the brain and behavior in humans”
 Not true for GI, GR, or sexual orientation (CAIS and CGD)

“Both early androgens / Y-chromosome masculinize brain / behavior in an additive / synergistic way)
 Not true for GI (46,XY with ambiguous genitalia reared female)
 May be true for GR (46,XY with ambiguous genitalia reared female)
 Not true for sexual orientation (only 39% of 46,XY with ambiguous genitalia reared female are heterosexual)

What to do with these babies?

46,XY DSD with Quigley 3/4 (pretty ambiguous) – what to do?
 Appearance of genitalia alone can’t predict long-term gender development (25% chance of dissatisfaction)
 Look for other predictors

Parental factors?
 Parental support purported to be primary factor that promotes well-being (not studied much)

Parents of kids with chronic diseases

 Parent stress  ↓ behavior / social / emotional outcomes of kids with cancer
 Stress in parents  ↑ depression in type 1 DM kids
 More overprotective  ↑ adjustment difficulties in kids
 Moms > Dads for getting stressed out

Hypothesis:
 Maybe parents of children with life-threatening DSD at greatest risk for stress, overprotection, perceived child vulnerability
 Maybe parents reading children discordant with genetic sex at greatest risk for stress, overprotection, etc.
 Maybe parents of children with ambiguous genitalia at greatest risk for stress/overprotection / perceived child vulnerability

Turns out that ambiguous genitalia and raising girls will ↑ parental stress

49
 Puberty
Puberty: physiological process causing development of 2° sexual characteristics and leading to reproductive maturity.
Normal Puberty: Physiology

Hypothalamus: neurons that make GnRH (peptide hormone)

 Travels via pituitary portal system to…

Anterior Pituitary: gonadotrophs stimulated by GnRH

 Secrete LH / FSH  travel through systemic circ to…

Gonads: Stimulated by LH/FSH

 produce testosterone and/or estrogen

What do sex steroids do in puberty?

• Cause secondary sexual characteristics
• Accelerate growth; contribute to pubertal growth spurt
• Accelerate closing of growth plates (stop growing after puberty)

Steroid From… Effects

Androgens Adrenals Sexual hair (M/F)
Virilization if ↑↑
Estrogen Ovary Breast development (F)
Testosterone Testes Pubic hair, virilization (M)

Where do sex steroids come from in puberty?

Pituitary kicks things off
 ↑ LH  testis  testosterone
 ↑ LH/FSH  ovary  androstenedione  estradiol
 ↑ ACTH  adrenal  DHEA/DHEAS  androgens

Pulsatile GnRH Secretion

Hypothalamus releases pulses of GnRH

 GnRH & LH: “in a relationship”

o GnRH pulses are very synchronized to subsequent LH pulses
o If GnRH↓, LH↓

 GnRH & FSH: “it’s complicated”

o FSH is also coupled to GnRH but not as tightly

50
Theca cells
 LH hits GCPR  AC  ↑ cAMP  ↑ androgen synthesis Leydig cells
 ↑ androstendione  steroid  crosses to follicular cells  LH hits GCPR  ↑ AC  ↑ cAMP 
 ↑ production of testosterone
Follicular cells
 FSH hits GCPR  ↑ AC  ↑ cAMP → ↑ conversion of (FSH acts on Sertoli cells to promote somatogenesis)
o Testosterone to estradiol (aromatase)  Not involved in steroid production
o Androstenedione (from theca cells) to estrone

Normal Maturation of the Reproductive Axis

Fetal development
Gonad*
Hypothalamus Pituitary
Male Female
 Testes develop
GnRH neurons
↑ LH, ↑ FSH (if testes-determining factors around)  Ovary develops, E2 secreted in
migrate down
 Testosterone secretion starts (1st trimester);
nd
(2nd trimester) 2 trimester
(1st trimester)
increases to mid-pubertal levels at birth!
Note: gonadal development is separate from pituitary / hypothalamic development – NO GnrRH / LH / FSH NEEDED!

Infancy
Pulsatile secretion of GnRH at delivery!
T production in males (peaks at 3 mo)
GnRH  Secretion of LH / FSH
E2 production in females (peaks at 6 mo)

 Gonads continue to develop for ≈ 1 year

3-8 yrs
 GnRH not released (so serum LH, FSH, T, E2 low – axis quiescent)
 6-7yrs: start secreting adrenal androgens (DHEA / DHEAS)

8-10 yo: Female puberty begins

Pulsatile secretion of GnRH  pulsatile secretion of LH / FSH
 LH to theca cells  androstenedione (AD)
 FSH to follicular cells  AD  T  E2
 E2 production  breast development, skeletal growth

Adrenals produce androgens  pubic hair

 “adrenarche” – separate process

51
11-14 yo: Male puberty begins
Pulsatile secretion of GnRH  pulsatile secretion of LH / FSH
 LH to Leydig cells  testicular enlargement, T production (some E2 too)
o T  ↑ penile length, male pattern hair
o T + E2  skeletal growth, close growth plates
 FSH to Sertoli cells  spermatogenesis

Puberty: Clinical Assessment

Tanner Stages
 Describe the 2° sex characteristics during different times of puberty
 Five stages (1=infantile, 5=adult)
 Specific stages for:
o Breast development (contour of breast / areola)
o Pubic hair (distribution / quality)
o Male external genitalia (testes size / penis length / changes in scrotal skin)

Girls: pubertal events

Whole thing takes around 5 yrs

 Breast development Begins ≈ 10.5 yrs, takes ≈ 4yrs

 Pubic hair After breast, takes ≈ 3 yrs
 Menarche Stage 4 (≈ 12.5 yrs)
o after maximal growth velocity
o Age of menarche ↓ slightly over last century

Boys: pubertal events

Starts later than girls; takes ≈ 4-5 yrs

 Testicular enlargement First (≈ 11 yrs)

 Spermarche ≈13 yrs
 Growth spurt after stage 5 (later than girls)
 Axillary / facial hair ≈ 14 yrs
 Voice changes ≈ 14.5 yrs

Boys vs Girls
Why are men taller than women?
 Peak height velocity is earlier & lower in girls than boys
 Growth spurt lasts longer in males

Abnormal Puberty (pathophysiology)

Criteria for puberty
Criteria for puberty Sex steroid functions
Development of secondary sex characteristics Cause secondary sex characteristics
Accelerated growth rate Accelerate growth / contribute to pubertal growth spurt
Evidence of premature fusing of growth plates on hand X-ray Accelerate closing of growth plates

52
Definitions
Females Males
Breast development < 8 yrs and/or Testicular enlargement < 9 yrs and/or
Precicious puberty*
Pubic hair development < 8 yrs Pubic hair development < 9 yrs
Secondary characteristics ≥ 13yrs
Delayed puberty Testicular enlargement ≥ 14 yrs
Menarche ≥ 16yrs
Proposed (controversial): breast development <7 in whites, <6 in AA unless rapid progression

Precocious Puberty

Basic approach:
Isosexual Contrasexual (always peripheral origin)
Central: premature activation of hypothalamus / pituitary
 ↑ all gonadotropin levels (LH/FSH/T/E2) Males  breast development

Peripheral: gonadotropin-independent (gonads alone) Females  virilization

 ↑ T/E2 but ↓LH/FSH (neg feedback)

“Gonadotrophin dependent” (central) precocious puberty (isosexual)

Activating hypothalamus / pituitary (↑ GnRH)
 ↑ all gonadotropin levels (LH/FSH/T/E2)

Etiology: what could activate this axis?

 Tumors (GnRH-secreting; LH/FSH-secreting have never been described; other hypothal tumors)
 Idiopathic (most common)

Diagnostic Criteria
 Tanner 2 breast < 8 or enlarged testes < 9
 Accelerated growth velocity
 Accelerated bone age (degree of maturation of bones of left hand - ↑ with sex steroids)
 Pubertal LH/FSH or pubertal response of LH/FSH to GnRH stimulation
 Exclude pathologic etiologies of CPP before you call it idiopathic (imaging)

Treatment: GnRH analogues (agonists) – e.g. Depot Luprolide (Lupron)

 Seems counterintuitive!
 Induce pituitary desensitization
o Give GnRH at a constant level
o Gonadotrophs  ↓reg amt of GnRH receptors!
o LH pulse at first, then ↓ LH secretion /synthesis with time

 Effects:
o ↓ growth velocity (↓ sex steroids), ↓ bone age advancement
o Final height improved (may not reach target height
o Fertility maintained

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Isosexual gonadotrophin-independent (peripheral) precocious puberty
2° sex characteristics appropriate for sex; ↑ T/E2 but ↓LH/FSH (neg feedback)

Males: some process is causing testosterone / androgen production!

 Not coming from ovaries or pituitary LH/FSH pathway!

 Testis can be doing their own thing (unregulated)

o Tumors making T
o Mutations in LH signaling pathway (FMPP – see below)
o McCune – Albright syndrome (aut-recessive)
(G-proteins downstream of LH receptor tonically on)

 Adrenal gland can be turned on

o Adrenal tumors
o Congenital adrenal hyperplasia (CAH)
o Premature adrenarche (idiopathic)

 Testosterone cream / spray gels (kid gets inadvertent exposure)

Familial Male-limited Precocious Puberty (FMPP)

 Mutations in LH signaling pathway
 X-linked (not in females)
 LH receptor tonically ON  Leydig cells make T even without LH
 Precocious puberty as young as 4-5 yo

Females: some process is causing estrogen production!

 Not coming from testes or pituitary LH/FSH pathway

 Ovaries can be doing their own thing (unregulated)

o Tumors making andro  estradiol
o McCune – Albright syndrome (aut-recessive)
(G-proteins downstream of LH receptor tonically on)
o McCune-Albright present in F, not FMPP (X-linked)

 Adrenal gland can be turned on

o (estrogen-secreting adrenal tumors are rare though)

 Estrogen creams / gels or consumption of OCPs

McCune – Albright syndrome

 Autosomal-recessive; causes precocious puberty in both boys & girls
 Activating mutation in Gs proteins downstream of LH/FSH receptors
o Constitutive activation  unregulated steroid production
 Can enter puberty as young as 2-3 yo

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Contrasexual gonadotrophin-independent (peripheral) precocious puberty
2° characteristics not appropriate for one’s sex

Males: estrogen-producing processes Females: androgen-producing processes

 Adrenal tumors  CAH (most common)
 Gonadal tumors, feminizing  Adrenal tumors (adrenal cortical carcinoma)
 Drugs: digoxin, spironolactone (antagonizes androgen receptors),  Gonadal tumors
THC (lots of pot ↑ E2), methadone, E2  Exogenous androgens
 Liver disease (can’t metabolize steroids  ↑ E2 – last stop in pathway)  Premature adrenarche

Treatment of gonadotrophin-independent precocious puberty

Challenging: if you can’t take tumor out, try to ↓ steroids / effects (stop production or block binding)

Drugs Mechanism Idea behind Rx

Testolactone / anastrozole Aromatase inhibitors ↓ E production
If E2 increased
Tamoxifen with ± success Estrogen antagonist ↓ estrogen effects
Ketoconazole Blocks steroid production by P-450 enzymes ↓ steroids
If T increased
Spironolactone Competitive inhibition of androgen receptor ↓ androgen effects

Delayed Puberty
Females Males
Secondary characteristics ≥ 13yrs
Testicular enlargement ≥ 14 yrs
Menarche ≥ 16yrs
Classification
Hypergonadotropic hypogonadism Hypogonadotropic Hypogonadism
↑ LH/FSH but gonads not working ↓ LH/FSH (pituitary or hypothalamic dysfunction)  gonadal failure
aka primary hypogonadism, gonadal failure Secondary hypogonadism

Primary hypogonadism (hypergonadotropic)

Why aren’t the gonads working?
Gonadal dysgenesis (gonads not formed well) Insult / injury to gonads
 XXY (Klinefelter’s syndrome)  Chemo, radiation, tumor
 XO (Turner’s syndrome)  Autoimmune destruction, infection

Secondary hypogonadism (hypogonadotropic)

Why no LH/FSH production?

 CNS disorders (disorders of pituitary, hypothalamus)

 Chronic systemic disease (adaptive mechanism – shut down reproductive capacity; mechanism not understood)
 Isolated gonadotropin deficiency (rare – can’t make GnRH, LH, etc.)
 Constitutional delay of puberty (most common cause – “late bloomers” – just start puberty later)
o Rule out other causes – pituitary imaging, etc.

55
 Growth
 Any serious illness can affect a child’s growth: an important “vital sign” in pediatrics
o normal growth in a kid doesn’t r/o serious illness, but abnormal growth  ↑ concern for significant illness

Normal growth
 Height / length most affected by hormones
 Growth curves: the importance is in both:
o the absolute value (e.g. way over / under normal)
o the trajectory (e.g. from 75th to 10th %ile rapidly)

Normal growth:
• Height between the 3rd and 97th percentiles
• Track along a percentile line on the growth curves: mostly true from 2 to 8-10 yo
• Growth velocity > 2 inches/yr (5 cm/yr): mostly true after 4 yo
• Height appropriate for genetic potential

Normal growth may not follow all of the characteristics of normal growth: atypical isn’t always abnormal
 But evaluate these kids (e.g. look at growth & compare to normal growth variants)

Normal variant growth patterns

rd th
Outside of 3 /97 %iles
 By statistical definition, 6% normal, healthy kids fall outside this range
 No specific evaluation needed as long as growth o/w normal
o normal velocity, not diverging further, consistent with genetic potential

Calculating genetic height potential:

 Average parents’ height after correcting for sex difference in mean adult height (5in = 13 cm M>F)
Father's height+ Mother's height± 5in
o MPH = 2
o Add 5 in for a boy / subtract 5 in for a girl

 Can also just average percentile

th th
o (e.g. if mom in 20 %ile, dad in 20 %ile  kid too)

 Target range = MPH (mid-parental height) ± 4 in (10 cm)

Not tracking along %ile line (between 2 and 8-10 yo)

Why between 2 and 8-10 years?
“crossing linear percentiles of infancy”
 Only about 1/3 of infants won’t cross percentiles during infancy (1/3 up, 1/3 down)
o Birth size really depends on in utero factors > genetics
o Cross %ile up = small infant of tall parents
o Cross %ile down = large infant of small parents
 Crossing %iles can still be abnormal in infancy! But look at it in context of parents

Growth after 8-10 yrs of age highly dependent in timing of puberty

 Earlier puberty = can cross up
 Later puberty = can cross down

56
Not growing ≥ 2 in/yr (5 cm/yr) after 4yo

 Growth velocity higher in kids < 4yo

 Growth velocity ↓ until adolescent growth spurt starts

Note that 50% of all boys will have ≤ 5cm/yr growth in early adolescence

th
Nadir of 50 %ile hits the cutoff
 Sensitivity / specificity of 5cm/yr changes with age! Not very specific in early adolescence.

Note too that later puberty means your growth velocity nadir occurs later & lower
 > 50% of these kids will have growth ≤ 5cm / yr
th
o Graph (lower) only 50 %ile lines
 Interpret growth velocity in context of pubertal development
o Kids in middle of puberty should be growing faster

Constitutional delay of growth & development

 Often cross percentiles ↓ early in life

 Delayed puberty (boys normally 9-14, girls normally 8-13; menarche ≈ 12.5)
o Delayed bone age
o Often have FHx of delayed puberty
o Growth velocity often dips below 5 cm/ yr

 Growth curve appearance:

o Start growing along %ile
o but then diverge further from curve in adolescence (peers growing, they’re not)
o Ultimately catch up (normal final height)
o Only really detect when kid reaches final height

Abnormal Growth Patterns: Short stature: height < 3rd %ile

Etiology:
 Normal variants of growth
 Chronic systemic disease
 IUGR
 Chromosomal abnormalities
 Genetic syndromes
 Skeletal abnormalities
 HORMONAL ABNORMALITIES
(genetic short stature, constitutional delay of growth & development)
(may be only manifestation of dz, e.g. IBD)
(intrauterine growth retardation – 50% cases have poor catch-up growth)
(Turner, Down)
(Prader Willi, Russel-Silver)
(chondrodysplasias, rickets)

Hormones involved
Stimulate growth Impair growth
 Thyroid hormone
 Glucocorticoids (cortisol) – slow linear
 Growth hormone
growth & stimulate appetite (↑ weight gain)
 Sex hormones (androgens, estrogens)

57
Hypothyroidism
 Example: girl starts to cross %iles ↓, TSH is really high and T4 low: primary hypothyroidism.
o Treat with L-thyroxine; growth jumps back up

Etiology in peds:
Congenital Acquired
Autoimmune
Most from aplasia (1:3k, most sporadic) / dysplasia of thyroid
Primary (Hashimoto’s – mostly
Dyshormonogenesis too (aut-recessive, enzymes affected more rare)
adolescents)
Central Often with other pituitary hormone defects Worry about tumor, etc.

Evaluation: get TSH + Free T4 (1° & central hypothyroidism – need thyroxine for central)
 Both are possible in kids!

Congenital hypothyroidism
 Used to be leading cause of mental retardation; now have uniform newborn screening
 If hypothyroidism is a possibility in children < 2-3 yrs old, test early (preserve brain development)
o Compare results to age-specific normal ranges!
 Normal T4 range is higher than infants than adults (reported normal range often adult normal!)

Growth hormone deficiency

 Pulsatile secretion, stimulated by GHRH, inhibited by somatostatin

 GH stimulates IGF-1 production

o liver  circulating IGF-1
o local sites too – e.g. chondrocytes (IGF-1 for bone growth)

 IGF-1 levels are stable throughout the day (random samples are informative)
o Vs. growth hormone – random samples useless (varies throughout day)

 Growth is stimulated by:

o IGF-1 (locally produced > circulating)
o Growth hormone itself (IGF-1-independent actions)

Lab tests for GH deficiency

IGF-1 level
(↓ in GH deficiency)
Sensitivity:
 poor in young kids
 good* in older kids
Specificity: poor
*IGF-1 (good sensitivity) and IGFBP-3 (good specificity) are pretty good in combo for older kids
IGFBP-3
Provocative GH stimulation tests
(↓ in GH deficiency)
IGF-binding protein Stimulate GH release with: GHRH, arginine, L-DOPA,
Production stimulated by GH clonidine, hypoglycemia, propanolol, exercise, sleep.
Sensitivity: poor Lack of appropriate rise of GH suggests deficiency
Specificity: good*  actual “cut-off” is pretty arbitrary
Tests are imperfect (tricky Dx to make)

58
Congenital Hypopituitarism
 ↓ GH especially for relevance of this talk

Suggestive findings:
 Midline defects (cleft lip/palate, single central incisor)
 Micropenis in male infant (< 2.0cm at birth) – from gonadotropin and/or GH deficiency
 Hypoglycemia (from cortisol / GH deficiency)
 Prolonged jaundice / hepatitis (hypothyroidism)
 Visual problems
o Septo-optic-dysplasia: optic nerve atrophy, abnormality of corpus callosum, hypopituitarism
st
o Nystagmus in an infant may be 1 clue of visual impairment

Acquired hypopuitarism
 ↓ GH especially for relevance of this talk

Etiology:
 Brain tumors, other malignancies , Histiocytosis X
 Radiation  Vascular disturbances (strokes)
 Trauma (MVA)  Inflammatory disease (or autoimmune)

A couple of case examples

Glucocorticoid-associated growth failure

 Growth very sensitive to exposure to excess glucocorticoids

 Most cases of excess in children are IATROGENIC

 Cushing’s syndrome is rare in peds, but does occur

o would have ↑ weight with ↓ linear growth (bottom line)
o vs. obesity due to caloric excess, growth velocity is normal (or accelerated) – top line

Abnormal Growth Patterns: Accelerated Growth

Much less common complaint in pediatrics than growth failure
DDx of accelerated growth:
 Genetic syndromes (Marfan’s, Sotos)  Excess calories
 Constitutional or genetic tall stature, early puberty, etc.  ENDOCRINE DISORDERS (this talk)

59
Growth Hormone Excess
 Exceedingly rare
 Marked by ↑ IGF-1 level
 Results in
o abnormally tall adult stature (gigantism) if in kids
o Acromegaly if onset in adulthood

Sex Hormone Excess (androgens and/or estrogens)

 Central precocious puberty (H-P-gonad axis turned on at pathologically early age)
 Peripheral precocious puberty (non-gonadotropen-dependent sex hormone production)

Sex hormones involved in pubertal growth spurt

 PP  Growth acceleration in childhood, but SHORT FINAL HEIGHT
 Growing too early & closing growth plates too soon!

Central precocious puberty

 More common in girls than boys

Boys Girls
Normal age of puberty onset 9-14 yo 8-13 yo*
First sign of central puberty Enlargement of testes (< 2.5 cm) Thelarche (breast development)
*Puberty beginning in girls between 6-8 yo may be normal!

Peripheral precocious puberty (non-gonadotropin-dependent sex hormone production)

 Adrenal: present with androgen effect in both girls & boys
o Congenital adrenal hyperplasia or tumor

 Gonadal: generally present with androgen effect in boys and estrogen ≫ androgen effect in girls
o Tumor
o McCune – Albright Syndrome
o Testotoxicosis in boys (activating mutation of LH receptor
o Exogenous / environmental sources

Sample cases

Note that testes are small – probably not central!

T coming from andro (adrenal gland)

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 Obesity
Definition of obesity: an accumulation of adipose tissue that is of sufficient magnitude to impair health

weight (kg)
 Clinically: estimate using BMI BMI = BMI Classification
height in m 𝟐
< 18.5 Underweight
o Has limitations (Ray Lewis = 33 kg/m2) 18.5- 24.9 Normal
o Not good in muscular, ↑ fluid – weight needs to be fat! 25-29.9 Overweight
30-34.9 Class I Obesity
 In children: usually use percentiles 35-39.9 Class II Obesity
th
o > 85 %ile for age / sex = at risk for overweight 40 Class III Obesity
th
o > 95 %ile for age / sex = overweight

Other measures of obesity (accurate; get % body fat - mostly research)

 Measure with calipers
o 7 skin fold sites or 3 skin fold sites; do calculations / sum / etc
 DEXA scans (dual-photon densitometry; tell lean body mass from fat)
 Densitometry by underwater weighing (completely submerge)
o Compare wt in water, out of water
o Fat-free mass is more dense than less dense; compute % body fat
 Densitometry by ADP (air displacement plethysmography)
o put in chamber, raise pressure – compute % body fat
o Limited size – not everybody can fit in!
 Bioelectrical Impedance Analysis
o Electricity goes slower through fat than muscle! Compute % body fat
o Measure resistance, reactance, etc.

Fat Distribution
 Abdominal fat: visceral fat is really important clinically (vs. subcutaneous fat)
 Measure by proxy:
Men Women
Waist Circumference > 40 in (102cm) > 35 in (88 cm)
Waist / Hip Ratio > 1.0 > 0.8

 Can measure by imaging too (x-sectional MRI)

Epidemiology of Obesity
 Hey, did you know there’s this series of maps that shows obesity trends over time in the US?

↑ obesity with:
 Black > Hispanic > White; Bigger disparities in women, growing (ha!) in men
 Living in states with a country radio station : NPR affiliate ratio of > 5:1 (especially Mississippi)

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 Pathophysiology of Obesity: Energy Balance
Calories in = calories out.
 If intake > expenditure, you gain weight. Details unknown.
 Genetics, social / cultural issues, psychological issues, cytokines / hormones (leptin,
adiponectin, etc) probably involved.

Calories in: pretty much just what you eat.

 Can be measured accurately, although it’s tedious.

Calories out: 24 hr energy expenditure

 Resting BMR (≈ 50%)

 Activity expenditure (spontaneous, e.g. fidgeting, and unrestricted, exercise)

o Really variable across patients

 Thermic effect of food (moving across the food)

o Varies a bit with type of food, etc.

Regulation
 Hypothalamus involved a lot (CNS side)
o regulates satiety / appetite
 Fat cells produce Leptin, Ghrelin, etc.
 GI system produces CCK, ghrelin, etc.

 Feedback systems  energy balance regulation

o Hungry? Rest? Be active?

Disruption of Energy Balance

 Genetic Probably 40-80% of variance
 Environment Probably causing recent rapid rise
 Gene/environment interactions Genetically “at risk”  respond differently to environment
 Other causes

Monogenic Obesity (all very to extremely rare)

 Leptin deficiency (e.g. ob/ob mouse)

 Leptin receptor deficiency (e.g. db/db mouse)
 POMC deficiency (proopiomelanocortin)
 PC 1/3 (prohormone convertase 1/3)
 Melanocortin-4 receptor (MC4R) deficiency

Polygenic Obesity
 Probably explains “susceptibility” to obesity; may have multiple variants
o Previous evolutionary advantage? “thrifty” metabolically?

 Common “known” genetic variants: slight susceptibility to obesity; no treatment implications

o Fat mass and obesity associated (FTO) gene o Beta-2 adrenergic receptor
o Peroxisome proliferator-activated receptors (PPAR-γ) o Perilipin

 Probably many unknown variants too

62
Genetic syndromes associated with obesity
 Bardet-Biedl  Prader-Willi  Weaver
 Fragile X  Turner
More in notes – most have other characteristics associated with them – often mental retardation

Consider genetic syndrome if:

 Obesity onset > 6 mo (leptin signaling pathway defect?)
 Other abnormal physical findings / developmental delay (Prader Willi, Bardet-Biedel, others?)

Consider endocrine syndrome if growth velocity decreases (r/o hypothyroidism, GH deficiency – think Cushing’s?)

The (Toxic) Environment

 Food available, abundant: cheap, high fat, calorie-dense
o Portions getting bigger (e.g. bagels get larger, soda, etc.)
 ↓ physical activity (labor-saving devices, community planning – don’t walk, do laundry, take stairs, etc).

Other reasons for energy imbalance

 We don’t only eat when hungry (celebrations, comfort, social gatherings – e.g. churches, ‘because it’s there’)
 We choose inactivity over activity (TV, computers, video games)

Iatrogenic weight gain

• Insulin or insulin secretagogues • Mood stabilizers (e.g. lithium)
• Glucocorticoids • Antidepressants (e.g. tricyclics)
• Psychotropic medications (e.g. olanzapine) • Anticonvulsants (e.g. valproate)

Other (Novel) risk factors for weight gain

Risk factors Notes
Fetal origins (unfavorable uterine environment) Low birth weight  obesity later (“programmed” to conserve energy?)
Breast feeding (protective) 4% ↓ risk obesity with each month of breast feeding
Environmental toxins Bisphenol A, phytoestrogen-like compounds
Sleep deprivation < 7-8 hrs associated with obesity
Viral infections Adenovirus 36? obesity in animals, ↑ prevalence in obese humans

Other causes of weight gain / obesity

Really uncommonly the cause – but check if sx / hx suggestive
• Hypothyroidism • Insulinoma
• Growth hormone deficiency • Hypothalamic disorders
• Cushing syndrome (injury or congenital malformation)
Consequences of Obesity
Medical Consequences of Obesity
Whole huge list of conditions across every system

 GI: incontinence, impotence, kidney stones, NASH  Cardiovascular: cerebrovascular disease, CAD, cor
 Repro: ↓ fertility, polycystic ovary syndrome, impotence pulmonale, HTN
 Derm: chronic skin infections, acanthosis nigrans  Oncology: ↑↑ cancer
 Vascular: venous insufficiency, DVT  Pulm: Asthma, sleep apnea, Pickwickian syndromes
 Many, many more…
End result: ↑ mortality, years of life lost (BMI 45 @ age 20: lose ≈ 11 yrs of life!)
 J-shaped curve: ↑ with underweight & overweight; Asians ↑ morbidity with lower BMI (different genes!)
63
Other consequences of obesity
 Discrimination (housing, employment, socially)  Disability
 ↓ QOL  $$$ ($78.5B in 1998, ≈9% total expenditure)
Why is obesity so bad?
 Fat isn’t just an inert storage tissue: adipose tissue is an endocrine organ
o Adipokines (Leptin, IL-6, TNF-α, adiponectin, etc) have many effects
o ↑ monocytes, lymphocytes – inflammatory state
o + feedback loops set up  downward spiral

Treatment of Obesity
Lifestyle, medical, or surgical
Lifestyle modification
 Combo of low calorie diet, ↑ physical activity, behavior modification
 Realistic goals: aim for “healthier weight,” NOT ideal weight
o Slow, incremental process to goal
o Short-term goal: 5 TO 10 % LOSS, 1 TO 2 LBS / WK
o Interim goal: maintenance
o Long-term goal: additional wt loss, if desired, + long-term maintenance

Lifestyle: Diet
Diet: look for 500-1000 kcal deficit / day,
 Women: 1000-1200 kcal/day Balanced deficit diet
 Men, women > 165 lbs: 1200-1600 kcal/day CHO (55%) high fiber (↑ satiety)
 try to lose 1-2 lbs / wk 3500 kcal = 1 lb Protein (15%) lean sources
Total fat (< 30%) “Low fat” useful – if ↓cal too!
Low-carb diets (15-20 carbs / piece of bread)
 Atkin’s diet: induction phase (20g/day carbs) gradual ↑ carbs
 South beach: low carb, but more allowance for fruits / veggies
 Protein power: 75 gm protein / kg IBW, < 30g carbs
 Carbohydrate addict’s diet: 2 complementary meals + 1 reward meal

Low fat diets: e.g. Ornish, < 10% cal from fat
Meal replacements: e.g. SlimFast, may be better than traditional diets

Effects of different diets:

 Whenever you lose weight: ↑ HDL, ↓ LDL / TGs / glucose / insulin / CRP
 No clinically important differences across diets

Key points on weight-loss diets

 It’s the calories that count (low carb – more wt loss @ 6mo, but similar @ 12-24 mo)
 Compliance, perserverence key (stick to it longer = lose more weight)
 Tailored diet may be more effective (studies limited by high attrition)

Lifestyle: Physical Activity

 Modestly contributes to weight loss  ↑ cardiorespiratory fitness
 May decrease abdominal fat  May be most important in weight maintenance

Want 30-60 min of moderate intensity physical activity on most / all days of week!
 You need to exercise a lot to burn significant amounts of calories (obese = need less exercise to burn same amt)
 Exercise alone - not really good for weight loss

64
Lifestyle: behavior modification
 Self monitoring is most effective tool (write down what you eat & when you exercise)
 Stimulus control, meal planning, contingency management can be used too
 ± Cognitive restructuring, problem-solving stress-management training

Lifestyle modification: Summary of Results

 Most studies: 5-10% initial body wt loss
 Without maintenance strategies, most or all weight regained by 12 mo!

Pharmacotherapy of Obesity
Two FDA-approved drugs for long-term (2yr) use; to be used with comprehensive program
 BMI ≥ 30 or BMI ≥ 27 with risk factors / diseases (HTN, dyslipidemia, CVD, type 2 DM, sleep apnea)

Orlistat (Xenical) Sibutramine (Meridia)

Dose 120 mg po tid before meals 10 mg po qd to start, can ↑ to 10 mg or ↓ to 5 mg
Action Inhibits pancreatic lipase  ↓ fat absorption Norepi, serotonin, dopamine reuptake inhibitor
↓ absorption of ADEK (fat-soluble vits)
Adverse effects ↑ HR / BP
Soft stools, anal leakage
Cost $170 / mo $104 / mo
More ↓ CVD risk factors More weight loss
Lose about 5.7 lbs more than placebo @ 6mo Lose about 9.5lbs more than placebo @ 12mo
Lose about 6.4 lbs more than placebo @ 12mo ↓ glucose but no change in lipids, BP, ↑ HR
Efficacy ↓ chol, BP, insulin, glucose
Don’t induce more weight loss after ≈ 6mo treatment
More effective than placebo in maintaining wt loss up to 2 yrs

Short-term use: all sympathomimetics (stimulants)

 don’t use longer than 12 weeks - ↑ risk of primary pulmonary HTN
 Side effects (what you’d expect with sympathomimetics
Generic Name Brand Name Usual Dose
Phentermine resin Ionamin 15-30 mg per day
Phentermine Adipex-P, Fastin, Oby-Cap 18.75-37.5 mg per day
Diethylproprion Tenuate, Tepanil 25 mg 3x per day (75 mg SR)
Benzphetamine Didrex 25-50 mg 1-3x per day
Phendimetrazine Bontril, Plegine, Prelu-2, Xtrozine 17.5-70 mg 2-3x per day

Other drugs: FDA approved for other indications (but if you can kill 2 birds with one stone…)
 Fluoxetine, sertraline (Prozac, Zoloft)  Metformin (Glucophage)
 Buproprion (Wellbutrin)  Byetta
 Topirimate (Topamax)

Investigational drugs
 Leptin  3 -adrenergic receptors
 Ciliary neurotrophic factor (rhvCNTF)  Cholecystokinin-A receptors
 Cannabinoid-1 receptor blocker (rimonabant) – was promising but FDA didn’t approve (psych side effects)

Supplement: billions of dollars / yr, but generally unsafe: either toxic or actual drug used in unregulated way

65
 Bariatric Surgery
Indicated for patients with class III obesity
 BMI ≥ 40 kg/m2 or
 BMI ≥ 35 with comorbid conditions AND failure of prior therapy
o Most insurers require period of “medically supervised” wt loss before approving surgery

Contraindicated if…
• Reversible condition causing the obesity • Lack of comprehension of (or ability to comprehend)
• Current drug or alcohol abuse risks, benefits, outcomes, alternatives and/or lifestyle
• Uncontrolled, severe psychiatric illness changes required with surgery

Roux-en-Y is most common - malabsorptive

 Make a small stomach pouch (limit food intake)
 Bypass duodenum and some of ileum (cause malabsorption)
 Most common, but lap-band ↑ in popularity

Most other surgeries are restrictive

 Gastric banding (e.g. “lap band”) – put a band around the stomach to restrict!
 Sleeve gastrectomy – turn stomach into small tube

Results: lose ≈ 20-30% of body weight; avg 20 kg loss in 8 yrs

 It works! Bypass > banding for long-term results, but both effective
 Clinical outcomes: see resolution of DM, HTN, dyslipidemia, sleep apnea (60-80%ish)
o ↑ improvements with more wt loss (BPD / RYGB > banding)
o ↓ mortality too (12% controls vs 8% surgery @ 12 yrs) – only therapy to ↓ mortality

Mechanism of changes:
 ↓ calorie absorption (↓ intake + malabsorption, improvements from wt loss)
 Neuroendocrine – GI axis involved? May see improvements in glucose homeostasis before wt loss in RYGB

Complications: both GI related and from doing surgery in obese pts

 Use nutritional supplements & follow-up to prevent!
 Mortality ≈ 0.3 – 2.2% (↑ with medicare, being older)
 VOLUME OF SURGERY performed by SURGEON is KEY (like any surgery)

Prevention of Obesity

• Approach like cigarettes: Multi-pronged • Access to healthy, affordable foods

• City planning: sidewalks, parks • Schools : Lunch programs, Physical Education,
• Buildings: stairwell access Vending machines
• Unhealthy food advertising

66
 Pharm: Endocrinology
Mechanism of Insulin Signaling............................................................................................................................................... 2
Oral Antidiabetic Agents ......................................................................................................................................................... 6
Insulin .................................................................................................................................................................................... 11
Thyroid Pharmacology .......................................................................................................................................................... 15
Pituitary Pharmacology ......................................................................................................................................................... 20

1
 Mechanism of Insulin Signaling
What does insulin do?
↑ glucose uptake Fat cells, muscle cells ↓ glycogen breakdown Liver, muscle
↑ glycogen synthesis Liver, muscle ↓ gluconeogenesis Liver
↑ DNA / protein synthesis All cell types ↓ lipolysis Fat cells

Type 2 Diabetes Mellitus

Two defects
 Insulin resistance (but if alone, can compensate by ↑ insulin secretion)
 Defect in insulin secretion (if you can’t ↑ insulin secretion in face of ↑ resistance  diabetes)

Treatment:
↑ insulin levels ↓ insulin resistance
 Give exogenous insulin
“insulin sensitizers”
 ↑ endogenous insulin secretion

Normal Insulin Secretion

Pancreatic beta cell: glucose channels open up ion channels, trigger release!

1. ↑ extracellular glucose 
2. more glucose into cell (via GLUT2) 
3. metabolized  ↑ ATP in cell
4. ATP binds to potassium channel / sulfonylurea receptor (SUR) 
5. closes K channel
6. K channel closes  depolarization of cell membrane 
+2 +2
7. Ca channels open↑ Ca 
8. ↑ exocytosis of insulin (via secretory vesicles)

Pharm correlate: Insulin Secretagogues

Increase endogenous secretion – bind to sulfonylurea receptor  block K channel  insulin secretion
 Sulfonylureas, meglitinide analogues

Hyperinsulinism (an aside)

Uncontrolled insulin secretion  hypoglycemia, e.g. in babies

 Congenital defects caused by

o inactivating mutations (SUR/K-channel complex, etc) or
o other aspects of cascade

 Treatments:
o Diazoxide: binds to SUR, makes it harder to close  ↓ insulin secretion
o Ca+2 – channel blockers

Insulin Signaling
Peptide hormone (can’t just cross lipid bilayer) – insulin receptor is a cell surface receptor
 2α, 2β subunits; insulin binds α subunit, triggers conf change in β-subunits (transmembrane)
 β-subunit is tyrosine kinase  autophosphorylates  ↑ activity  P-late other stuff
 IRS-proteins (insulin receptor substrate) bind new phosphotyrosine motifs on insulin receptor
o Gets P-lated on tyrosine residues too!
 Effector molecules bind to IRS, receptor molecules then: PI-3, MAPk, others

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PI3-kinase cascade
 ROLE: “METABOLIC CASCADE” – alters glucose / lipid metabolism
 Induces translocation of GLUT4 to plasma membrane (muscle / fat): ↑ glucose intake

 PI3-kinase binds to p-lated IRS

 Lipid kinase (p-lates phosphoinositol in 3 position)
 Other junk binds, eventually serine-threonine
kinases, blah blah blah, GTS

MAPK
 ROLE: “MITOGENIC PATHWAY” -
ACTIVATES CELLULAR PROLIFERATION
(goes to nucleus, etc)

 Lots of stuff binds to p-lated tyrosines,

Grb2/mSOS involved, GTP-ras proteins  RAF 
MAPK etc

Note that both PI3K and MAPK pathways are engaged by many other pathways (IGF, PDGF, EGF receptors) too!

Exercise: AMP-activated protein kinase

 Another signal to trigger GLUT4 insertion (muscle cells need more energy when exercising)
o Burn ATP  ↑ AMP  ↑ AMP-activated protein kinase (AMPK)

 Short-term: ↑ glucose intake

o triggers GLUT4 translocation into membrane

 Long term:
o ↑ glucose intake (↑ GLUT4)
o ↓ gluconeogenesis (↓ PEPCK , rate-limiting step
o ↓ proteins for lipid synth & metabolism

Insulin Signaling: Key Points

 Transmembrane cell surface receptor
 Complex cascade (multiple kinases & phosphatases)
o Tyrosine kinase (insulin receptor)  autophosphorylation  Tyrosine p-lation of other targets
o Adapter / scaffold proteins (IRS) & serine / threonine lipid kinases

Major cascades
PI-3 kinase MAP kinase
metabolic pathway mitogenic pathway

Insulin Resistance
 Seems like PI3K pathway is defective (↓ metabolic pathway) but normal MAPK pathway
 ↑ insulin (↓ PI3K pathway)  ↑ MAPK pathway (still normal)
o Mitogenic stimulation may play role in development of atherosclerotic disease

What causes insulin resistance?

 Genetic defects (strong heritable risk)
 Environmental effects (obesity causes insulin resistance)
o ↑ visceral fat is major contributor; subcutaneous fat may be protective
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Molecular mechanisms
 Serine/threonine p-lation inactivates things (blocks interaction of IRS with p-lated insulin receptor)
 Tyrosine p-lation activates things

In insulin resistance
 ↓ tyrosine p-lation of insulin receptor & IRS proteins (less activation)
 ↑ serine/threonine p-lation of insulin receptor & IRS proteins (more inactivation)

↑ S/T p-lation (INACTIVATING) with:

 Hyperglycemia (vicious cycle!)
 TNF-α (↑ in obesity)
 Mitochondrial dysfunction (genetic or induced by obesity)

P70 S6 kinase: causes S/T p-lation of IRS  ↓ activity

 normally induced downstream of insulin receptor activation – feedback
 Inhibited by AMPK activation
 Stimulated by amino acids  ↑activity (↑ AA in obesity)
o Calorie restriction  ↓ AA, ↑ AMPK  ↓ P70S6 kinase  less inhibition of IRS  more insulin signal!

GLUT4 expression
 ↓ in adipose tissue in insulin resistance (responsible for some of insulin resistance)
 In muscle / adipose tissue: ↓ insulin-stimulated translocation of GLUT4 to plasma membrane (↓ signaling)

Fat Muscle Liver

10% glucose gets stored in fat 90% of insulin-stimulated glucose uptake Maintains normal fasting glucose

Primary insulin resistance in one tissue can cause secondary insulin resistance in other tissues!
 Adipose tissue mainly affected by ↓ GLUT4 expression
o only 10% of glucose handled this way – but bigger 2° effects
o Adipose tissue proteins can circulate, alter metabolism in other tissues

FFA, Leptin, TNFα, resistin: ↓ insulin sensitivity

 Visceral fat produces more TNFα and resistin
(insulin resistance – bad!)

 Also, adipokines from visceral fats reach liver in high

concentrations (inhibit insulin signaling)

Adiponectin: ↑ insulin sensitivity

 Subcutaneous fat produces greater amounts of
adiponectin (insulin sensitizing – maybe
protective!)

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Metformin
 Insulin sensitizer
 Acts mostly at liver (↑ insulin sensitivity  ↓ hepatic glucose production)
 Smaller effect: ↑ peripheral insulin sensitivity (↑ glucose uptake in muscle, fat)

Mechanism of action: not completely understood

 Activates AMPK, alter P70S6 kinase activity?
o May inhibit mitochondrial ox-phos  ↑ AMP levels? Mimicking exercise state?

 Short-term effects: ↑ GLUT4 insertion (↑ glucose uptake into muscle, fat)

 Long-term effects: (probably more important)
o ↑ GLUT4 expression (more sensitivity)
o ↓ gluconeogenesis enzymes, alter fat metabolism enzyme expression

Insulin Resistance: Main Points

 ↓ insulin receptor and IRS tyrosine phosphorylation (proximal steps of signaling)
 ↑ S/T p-lation of IR / IRS (inhibits tyrosine phosphorylation)
 ↓ GLUT4 expression in adipose tissue
 Primary insulin resistance in one tissue can cause secondary insulin resistance in another tissue
o Insulin resistance in fat can cause insulin resistance in muscle, liver
 AMPK, P70 S6K are involved in insulin signaling and insulin resistance
o Sensors of “how much energy is in the cell?”

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 Oral Antidiabetic Agents
Basic pathophysiology: peripheral insulin resistance + progressive deterioration of β-cell secretory function

Available therapies vs. causes of hyperglycemia

Cause / Defect in type II DM Solution
↑ hepatic glucose output Metformin (hepatic glucose output inhibitor)
↓ insulin secretion Sulfonylureas (insulin secretagogues)
Peripheral insulin resistance TZDs (enhancers of insulin sensitivity)
Ingested CHO α-glucosidase inhibitors (slow CHO ingestion)
Incretins don’t “prime” the β cells Incretin mimetics (enhance incretin effect)
Insulin secretion inadequate Add endogenous insulin

Metformin
 A biguanide
 History: available until 1960s in USA; reintroduced 1995
o related phenformin found to cause fatal lactic acidosis; metformin banned 1970-95

Mechanism of Action: A biguinide oral antidiabetic agent.

 decreases hepatic glucose output; sensitizing liver to insulin.
 Does not increase insulin secretion.

Effects: In DM, uncontrolled HGO; metformin helps suppress it.

 best in controlling fasting blood glucose, which is most dependent on HGO).
 Does NOT cause hypoglycemia (doesn't stimulate insulin secretion).
 Can cause mild weight loss too.

Indications: type II diabetes (a good 1st line drug)

Administration: give 2-3x daily (3h half life); does have XL form (doubles half life, but still usually dose bid)
metformin
Toxicity:
 GI side effects are common (15%: GI intolerance - diarrhea, bloating, somewhat dose-related).
 Lactic acidosis less frequent but more complicated (inhibits mitochondrial ox-phos; can rarely lead to
accumulation of lactate. Life threatening acidosis if lactate over-produced / under-cleared due to co-
morbidities). Contraindicated in settings of:
o increased lactate production (CHF, surgery with hypotension, ischemia, binge alcohol drinking)
o decreased lactate clearance (e.g. renal insufficiency).

Metabolism: excreted unchanged in the urine

The Bottom Line: A good option for type II DM; usually 1st choice oral agent unless contraindicated / not tolerated.

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 Sulfonylureas
 History: French soldiers in WWII  hypoglycemic with new sulfonamide abx

Mechanism: stimulate insulin secretion

 Activate sulfonylurea receptor,
 which blocks ATP/ADP-dependent K+ channel,
 depolarizing membrane & thereby
 triggering Ca+2-mediated insulin release

Structural differences:
 All have sulfonylurea group
 Older agents: simple side groups
 Newer agents: larger, less polar side groups  ↑ potency 100x!

Mechanism of Action: sulfonylurea oral antidiabetic agent. Stimulates insulin secretion

Effects: see above.
 Chlorpropramide: an older SU; has short, polar side chain (less potent)
 Glipizide: a newer SU; has long, less polar side chain (more potent

Indications: type 2 diabetes

 (as 1 or 2 choice - metformin usually first - either alone or in combo with other therapy)
st nd

Toxicity:
 hypoglycemia (overdose causes excess insulin secretion).
 Unusual: hepatotoxicity (tranaminasemia) & allergic responses (can cross react w/ other sulfa allergies)
chlorpropamide  modest weight gain.
glipizide  Black box warning: death by CVD (but not yet confirmed).

Metabolism:
 Chlorpropramide: Excreted unchanged in the urine - so LONGEST-ACTING SU (>24h).
o AVOID IN RENAL DISEASE
 Glipizide: virtually entirely metabolized to inactive products in liver –SHORTEST-ACTING SU (6-12h).
o AVOID IN LIVER DISEASE

Other: glipizide = Glucotrol.

The bottom line: Good option for type 2 DM treatment.
 Can be 1st or 2nd choice (metformin usually first) oral hypoglycemic agent,
 alone or in combo with other oral agents, or combined with insulin therapy

Other sulfonylureas
Class Examples Structure & potency Metabolism
 tolbutamide (Orinase)
Simple side groups  Mostly metabolized by liver,
Older  tolazamide (Tolinase)
less potent excreted in kidneys 
 acetohexamide (Dymelor)
 glyburide (Micronase, Diabeta) Larger, less polar side groups Duration of action: around 12h
Newer
 glimepride (Amaryl) 100x more potent

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 Short-acting Non-sulfonylurea Insulin Secretagogues
Mechanism of Action: short-acting non-sulfonylurea insulin secretagogues
repaglinide Effects: Structurally distinct from sulfonylureas & don't act at SUR, but same insulin secretory effect
Indications: not major players in managing diabetes - occasionally if post-meal glucose is shooting up
nateglinide Administration: used pre-meal
Metabolism: rapidly metabolized to inactive metabolites by the liver

Thiazolidinediones (“TZDs” or “Glitazones”)

History: new class; 1st marketed 1997, unique mechanism of action / potent enhancers of insulin effect (sensitizers)

Mechanism of Action: thiazolidinedinone (TZD) oral hypoglycemic agents.

 Reduce peripheral insulin resistance ("insulin sensitizers")

Effects: Activate nuclear receptors in PPAR-γ family of genes to reduce peripheral insulin resistance.
 Do NOT cause hypoglycemia; can act synergistically with metformin & sulfonylureas (potentiate insulin)

Indications: Moderately effective as monotherapy but not first line (cost, weight gain / fluid retention).
 Usually considered 3rd line
 Act synergistically with sulfonylurea & metformin

rosiglitazone Toxicity:
 Cause weight gain in many people  ↑ adipocyte mass.
pioglitazone  Can cause fluid retention and even CHF.
 Very expensive.
 Increased risk of forearm fractures, especially in women.
 Earlier TZD: rare but fatal fulminant hepatic necrosis (not current TZDs).
 Rosi was associated with increased MI in one study (not confirmed subsequently); took a big hit.

Other: Rosiglitazone = Avandia, pioglitazone = Actos.

The bottom line: Established, effective, act to improve insulin sensitivity in type 2 DM.
 PIOGLITAZONE > ROSIGLITAZONE right now (MI history, etc)
 will FDA / practicioners / pharma pull plug on rosi?

α-glucosidase inhibitors
History: available in USA since 1996.
Mechanism of Action: alpha-glucosidase inhibitors; oral antidiabetic agents.
 inhibit pancreatic alpha-amylase & membrane-bound intestinal alpha-glucosidase hydrolase enzymes.
Effects: Delay digestion of ingested CHO, slowing rise in blood glucose. Only modestly effective.
Selective Toxicity: Act entirely on intestinal brush border
acarbose
Indications: Use mainly for post-prandial glycemia (although limited by GI side effects)
miglatol
Toxicity: Major side effect is flatulence & diarrhea (changing GI flora)

Metabolism: <2% of oral dose absorbed, excreted unchanged in the feces

The bottom line: limited by their GI side effects, but may have some use in post-prandial glycemic control.

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 Incretin mimetics
Incretins: normal, endogenous hormones that enhance insulin secretion in response to oral CHO

 Dose of glucose stimulates more insulin secretion if given orally than IV

 Incretins: “prime” β-cell when meal is all the way
 Basically signals to the body that meal has been ingested
 GLP-1 (glucagon-like peptide-1) is classic incretin – secreted by K-cells of small bowel

Mechanism of Action: incretin mimetic oral antidiabetic agent. Mimics endogenous incretin function
 incretins "prime" the beta cells in response to oral CHO load (released from K-cells in small bowel)
 incretins are why more insulin secreted after oral vs IV glc.
Effects: Incretins have multiple effects (all beneficial)
recombinant  prime beta cells (more insulin secreted)
GLP-1  slow gastric emptying (so hyperglycemic load is not too abrupt)
analogue  suppress pancreatic glucagon secretion (so liver doesn't keep making glucose)
(Byetta)  cause satiety at CNS level

Indications: Type 2 DM. Weight reduction is a really popular feature.

Administration: injections (like insulin, but causes weight loss - not weight gain)
Toxicity: can cause nausea (may require discontinuation)

Mechanism of Action: amylin analog antidiabetic agent.

pramlintide Effects: Sort of like an incretin mimetic, but not technically (analog of pancreatic, not intestinal hormone)
Indications: type I or type II DM

DPP-IV Inhibitors
Mechanism of Action: DPP-IV inhibitors, oral antidiabetic agents.
 Prolongs action & enhances effect of endogenous incretins

Effects: dipeptidyl peptidase-IV (DPP-IV) mediates rapid metabolism of endogenous incretins.

sitagliptin  So blocking DPP-IV will prolong action of normal, endogenous incretins.
 Increases insulin secretion, slows gastric emptying, inhibits glucagon secretion,
saxagliptin  but does NOT cause notable satiety(disadvantage vs. GLP-1 - WEIGHT-NEUTRAL)

Indications: type 2 DM
Administration: oral administration (advantage vs. GLP-1)
Other: sitagliptin = Januvia, saxagliptin = Onglyza

Combining oral agents & insulin

 Anticipate ↓ in β-cell function and possible eventual requirement for insulin therapy in type 2 DM
 Start with basal insulin & add prandial as needed
 Anticipate insulin resistance; increase dose more aggressively than in type 1 DM

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 Summary
Drugs Summary

Does not act as an insulin secretagogue

 but↓ hepatic glucose output; may ↑ peripheral glucose utilization.
Metformin
 Can be used in conjunction with sulfonylureas.
 Has the useful property of promoting weight loss.

Enhance the secretion of insulin

 Often used clinically as the first choice to treat type 2 diabetes, (if diet and exercise have
Sulfonylureas
failed)
 Sulfonylureas vary by metabolism, which determines duration of action.

Repaglinide
Not sulfonylureas but also act as insulin secretagogues
Nateglinide

Thiazolidinediones act specifically by sensitizing muscle and other cells to insulin’s action.
(rosiglitazone,  Side effects include weight gain and fluid retention.
pioglitazone)  Rosiglitazone has been tarred with possibility of increasing risk of myocardial infarction

acarbose alpha glucosidase inhibitors, slow carbohydrate absorption

miglatol  But have GI side effects.

Incretin mimetics new, parenterally administered, analogs of normal endogenous incretins.

(exenatide)  role in diabetes therapy is being established now.

DPP-IV Inhibitors new, orally administered, agents that inhibit the breakdown of endogenous incretins.
(sitagliptin)  role in diabetes therapy is being established now.

10
 Insulin
 Note that there’s no oral insulin (pills aren’t insulin).
 Type 1 diabetics can have a “honeymoon period” (some residual insulin secretion), but eventually need insulin by injection
Introduction
Goal: replace inadequate endogenous insulin secretion
 by reproducing as closely as possible physiologic insulin secretion (basal & post-prandial)
 in order to normalize (as much as possible) glucose insulin dynamics
 Easy to say, hard to do!

Remember insulin’s roles:

Directs fuel either towards
 storage (high insulin = anabolic) – use circulating glucose; store excess fuel (glycogen, TGs, protein)
 release (low insulin = catabolic) – minimize glucose usage; release fuel (glycogen, TGs, protein)

Liver Adipose tissue Muscle

↑ glycolysis
High insulin ↑ TG synthesis ↑ AA uptake
↑ glycogenesis
↑ gluconeogenesis
Low insulin Lipolysis Proteolysis
↑ glycogenolysis
Too much insulin = hypoglycemia, Too little insulin = hyperglycemia, No insulin = ketoacidosis

Exogenous insulin is not very physiologic

 Delivered in open loop fashion (person with diabetes controlling; has to estimate dose needed)
 Delivered subcutaneously (peripheral venous system, not hepatic portal vein)

Preparations of Insulin
History: previously beef / pork pancreas preparations (1-3 AA difference, but worked well)

Human insulin: 1983, from recombinant DNA technology (1st pharm use), identical AA sequence
 Now all use is human (↓ allergenicity / Ab response); cheap to manufacture (e.coli / yeast), limitless supply

Insulin analogs: optimize for pharmacokinetics (5 on market now)

Concentration of insuilin
 Measured in units (originally defined in mice); 1mg ≈ 22U (only use conversion in research settings)
 USA: almost all U-100 (100U/1cc solution); rarely U-500, U-40 sometimes internationally

Pharmacokinetics: Key to Clinical use

Native insulin has a 6.5m T1/2 when delivered IV – so would need need to deliver continuously!

Clinical use: inject into subcutaneous space

 rate of absorption from SC space to bloodstream determines time course of biological action
 Dimer / hexamer formation controls rate of absorption: only absorbed as a MONOMER
o So the more it hexamerizes, the slower it’s absorbed

Long-vs-slow acting: Useful to have both:

 slowly-absorbed insulin (reproduce basal secretion) and
 quickly-absorbed (reproduce prandial secretion)

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 Examples Time course Administration Notes
 Insulin Lispro (Humalog) Onset: <≈ 15m More rapid-acting than unmodified, “regular” human insulin.
Fast-acting Give right
 Insulin Aspart (Novolog) Peak: 1-2h Have less tendency to hexamerize / dimerize
insulin analogues before meal
 Glulisine Insulin (Apidra) Duration: 3-4h  more in monomer form, absorbed more quickly

Onset: 30-45m Anticipate

Short-acting Regular insulin Unmodified human insulin – same aa sequence
Peak: 2-4h meal by 30-
human insulin (Novolin-R; Humulin R) Used to be most quickly absorbed until analogs came along
Duration: 3-6h 45m

Intermediate- NPH (“neutral protamine Onset: 2-4h Can mix with Insulin crystallized w/ protamine – cloudy, insoluble suspension
acting human Hagedorn”) Peak: 4-10h short-acting; Crystallization slows solubilization
insulin (Humulin-N, Novolin-N) Duration: 10-16h give q12h  Then broken down to monomers in skin
*often called “peakless” ; actually unpredictable peak over 24h
Onset: 2-4h
Has acid pK; stored as liquid at acid pH
Insulin glargine (Lantus) Peak: 24h*
 Precipitates in tissue @ physiologic pH (slows
Duration: 20-24h
Long-acting insulin absorption; requires gradual dilution to dissolve)
analogs *called “relatively flat” peak;
Onset: 2h
Duration of action somewhat more predictable than glargine
Insulin detemer (Levemir) Peak: *
Complexed to fatty acid; binds albumin in SC tissue
Duration: 16-20h
 Absorption slowed until gradually released from alb.

Quick Summary
Fast Acting: Insulin Lispro, Insulin Aspart: Human Insulin analogs (i.e. amino acid substitutions from human insulin)
 ultra-short acting, taken immediately before meal, may be mixed with other insulins.

Short Acting: Regular Insulin (R): Unmodified human insulin, short-acting, taken 30-45 min. pre-meal, may be mixed with other insulins.

Intermediate Acting: NPH Insulin (N): Forms a less soluble, cloudy suspension of insulin, lasting 10-16 hours.

Long Acting Insulins: Glargine and detemir are the longest acting insulins, with smoother action over 24 hours than NPH
 Glargine Insulin: a human insulin analog, with aminoacid substitutions that change pK, soluble in acid vial but precipitates in skin.
 Detemir insulin: a human insulin analog, bound to a fatty acid that binds to albumin in skin.

12
 Some notes about clinical use (from case studies)
 Start with basal + prandial, then fine-tune without overwhelming.
o Think – when is he low / high? Is long-acting or short-acting insulin controlling at that time?
o Adjust dose up / down as needed
 Teach to
o increase fast-acting insulin when ready to eat a big meal (nutritional adjustment); or
o decrease if going into meal low (correctional adjustment)
 Can give insulin 1,2,3,4x daily or with external insulin pump

External insulin pumps

 Still all open loop systems – don’t sense glucose; user has to choose dose
 Deliver as basal rate (recycles every 24h) & bolus doses (chosen by pt with each meal)
 Deliver only fast-acting insulin –require high level of understanding / self-care (can get in trouble with misuse)

Using insulin in type 2 diabetes

 Use if insulin secretory reserve fails (>50% type 2 DM in 9 yrs after onset)
 Often combine insulin therapy with continued oral agents as insulin started
 High dose requirements vs. type 1 – insulin resistance!

Combined insulin / oral agent therapy

 Often start basal insulin only at first (↓ hepatic glucose output; assist endogenous insulin)
 Continue oral agents
Sulfonylureas Promote insulin secretion during the day in response to meals
 more physiologic than exogenous insulin
Metformin Can help insulin’s suppression of hepatic glucose output
TDZs Can help muscle / adipose tissue respond to insulin
 Intensify insulin regimen as needed (add fast-acting) depending on pattern of blood glucose
 Discontinue oral agents as insulin regimen intensifies (start completely replacing pancreatic insulin)

Conclusion: The oral agents often eventually fail to control type 2 diabetes, due to the natural history of beta cell
decline over the years with type 2 diabetes. When glycemia fails to meet target levels, it is necessary to add, or switch
to, insulin by injection.

Complications of Insulin Therapy

Hypoglycemia
“Insulin reaction” – far and away most common side effect!
 Seriousness can vary enormously (mild interruption in day to coma; can – rarely – be fatal!)
 Self-treated (pt recognizes, takes some CHO) or requires intervention (pt becomes too confused to recognize)
 HYPOGLYCEMIA WILL HAPPEN as you use insulin – but keep it from becoming severe!

Insulin allergy
 Due to IgE anti-insulin antibody, now rare (human insulin used)

Skin changes (two opposite responses)

 Lipoatrophy: loss of SC fat at site of injection
 Lipid hypertrophy: physiologic lipogenic response to insulin)

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 New / Research Approaches to Insulin Delivery
 Not yet ready for prime-time
 Pancreas transplantation (or isolated islets) – usually if pt needs kidney transplant too (& therefore
immunosuppression is already going to happen)
 Aerosol-delivered insulin: promising, but marketed in 2006 but cumbersome; poor sales; removed from market
– future unclear
 Stem cell research: can get em produce insulin but glucose responsiveness / amt of insulin not enough het

Summary

 Insulin actions are multiple and highly tissue specific

 Insulin is conventionally delivered subQ, with various modifications and preparations affecting absorption
 Once absorbed, insulin is cleared with a biologic half-life of about 6.5 min.
 Many factors affect the hypoglycemic effect of a given insulin dose, including
o obesity-induced insulin resistance
o counterregulatory hormones.
 Clinical use of exogenous insulin is not very “physiologic”
 Skillful use of insulin can prevent diabetic complications, relieving enormous personal and societal suffering

14
 Thyroid Pharmacology
Treatment of Graves’ Disease
Sample case:
 20 yo F w/ Grave’s disease Sx/signs; mild eye findings, thyroid ↑ 1.5x in size.
 TFTs: fT4↑ 2.3 ng/dl (0.8-1.8), T3↑ 250 ng/dl (80-180) TSH↓ <0.1 mU/L. 24 hr RAIU (↑) = 40% (↑).

Summary of treatment options for Graves’ disease

Advantages Hypothyroidism Disadvantages Cost
Antithyroid Drugs Nonablative Low frequency Not definitive, side-effects $
Radioiodine Definitive 100% Fear $$
Surgery Definitive 100% Complications, discomfort $$$

Antithyroid drugs
 More popular for younger patients  Experts more likely to use radioiodide for older pts

Thiourea and its derivatives, PTU (6-propyl, 2-thiouracil), MMI (1-methyl, 2-mercaptoimidazole)

PTU (6-propyl, 2-thiouracil) MMI (1-methyl, 2-mercaptoimidazole)

Mechanism of Action antithyroid drugs; multiple mechanisms
 Inhibit iodine utilization by thyroid (inhibit organification, iodine binding to Tyr residues
in Tg)
Effects  Inhibit couplingof iodotyrosines.
 Possible immunosuppressive effects.
Also inhibits T4T3 conversion peripherally
Selective Toxicity thiourea derivative, trying to avoid goitrogenic effects
Graves' disease (esp. popular for younger pts to avoid radioactive iodine).
Both  Remission in 30% pts overall (10-70% depending on other factors).
Indications

Not good for amiodarone toxicity(too much iodine around, so you can't use it all up!
↓ T3/T4 Less effective at lowering T3/T4 More effective at lowering T3/T4
First line? NOT FIRST LINE (less effective, more toxicity) FIRST LINE
100 mg tid to start (shorter t1/2) 10-30 mg/day; single dose (longer t1/2)
Administration
Give for about a year, then taper (no increase in remission rate for longer therapy)
Half-life Shorter Longer
Bound to serum
Kinetics

75% Nope
proteins?
In breast milk? Nope Yep (but still OK for baby)
Generally Not dose-related (idiosyncratic); more serious Dose-related, less serious
Minor reactions Fever/rash, not-dose related Fever/rash, dose-related
Toxicity

Agranulocytosis not-dose related dose-related

Hepatocellular Hepatitis (can be fatal – black box warning) Cholestasis (very rarely fatal)
ANCA / vasculitis Yes No
 takes 4-12 weeks to achieve euthyroid state (just blocking synthesis of new hormone) ,
Other depending on baseline severity, thyroid gland size, drug dose.
 MMI > PTU for use except in 1st trimester (MMI = teratogen?)

15
Methimazole used more than PTU:
 longer half-life, less frequent doses (better  side-effects dose-related, more predictable, less
compliance) serious
 
st
better lowering of T3/T4 Exceptions: 1 trimester (MMI – maybe teratogen?)

Really Crazy Details: Inhibition of Organification (if you learn this, you’re a better man/woman than I)
Normally:
 TPO, a 107 Kd, membrane bound, 10% CHO heme protein enzyme, sticks out into lumen off of apical membrane
 Under action of endogenously-generated H2O2, the Fe of TPO becomes oxidized  TPOox
 If an iodide anion comes along, it can become oxidized by this iodinated Fe  TPO-Iox (iodinating species)
 TPO-Iox can then iodinate a tyrosine on thyroglobulin

With antithyroid drugs:

 Anti-thyroid drugs are substrate for this iodinating species
 Get iodinated themselves
 Means less tyrosine-TG is getting iodinated
 Use up all TPO-Iox to make iodinated drug compounds

With iodine excess (e.g. amiodarone)

 Way more iodine around  ↑↑ iodotyrosyl-TG formation
 Can’t use drugs to treat well – just too much iodine (can’t use it up)

Immunosuppressive effects of PTU: PTU gets concentrated in the thyroid gland; ↓ T/B cell function in thyroid gland

Remission: what influences chances of having remission?

Factor Chance of remission ATD as first line therapy
Large Goiter lower No
Severely abn. TFT’s (↑↑ T3) lower No
Prior relapses lower No
Neg TSI (thyroid stimulating Ab) Yes
Smoking no effect -----
Eye Disease no effect -----
Age no effect -----

Treatment of Hyperthyroidism
Iodine
Substrate for making thyroid hormone – but you can give it to treat hyperthyroidism (counterintuitive)
 Large pharmacological doses have different effects (trying to “protect thyroid” from iodine OD)

Mechanisms of action
 Blocks iodine trapping  Blocks thyroid hormone release
 Blocks organification  ↓ thyroidal blood flow

Preparations: Lugol’s solution or saturated solution of potassium iodide (SSKI)

Limitations:
 Thyroid “escapes” from inhibitory effects after 10-14 days
 Potential for longer-term exacerbation of hyperthyroidism

Indications: use for quick action / emergent conditions / temporary use (escape!)
 Quick / temporary ↓ *thyroid hormone] while waiting for more definitive therapy
o RaI takes some time to work; or while waiting for thyroidectomy

16
  ↓ thyroidal blood flow  ↓ blood loss during surgery for hyperthyroidism
 “Thyroid storm” - severe / complicated hyperthyroidism
β-blocker therapy for thyrotoxicosis
 Often used for symptomatic relief but DOESN’T normalize altered metabolism, O2 consumption
o E.g. tremor, etc.
 Use long-acting drugs: Inderal LA, nadolol, atenolol, metoprolol
 Side-effects: bronchospasm, CHF, fatigue, Raynaud’s
o Can use Ca-channel blockers in asthma if too tachycardic

Thyroid storm
Thyroid storm: Constellation of signs & symptoms associated with severe hyperthyroidism and:
 Fever  Change in mental  ± CHF, liver failure, coma, death
status

Some precipitating event (surgery, trauma, infection etc.) occurs first

Treatment
Treatment Blocks
Iodine Its own uptake
Lithium (for release) Release of thyroid hormone
Antithyroid drugs thyroid hormone synthesis
PTU
high dose steroids T4 T3 conversion
propranolol (not other β-blockers)
β-blockers action of T3 on heart

So give iodine, antithyroid drugs, β-blockers, glucocorticoids

 Start antithyroid drugs first (establish block)
 Then administer iodine (after an hour or so – don’t ↑
synthesis)

Radioactive Iodine for Hyperthyroidism

 A pill that you take once, but patients are afraid of radiation!

 Treatment of choice for most adults, but many don’t want it

o Cures 80% of patients with one dose
o Takes 2-6 months for full effect

 Actually have transient increase in TSH receptor Ab for first few months!
o If these women get pregnant, TSH receptor Ab can cross the placenta 
cause neonatal Graves’ disease

 INEVITABLE HYPOthyroidism results (not a “side-effect”) – 50% @ 1 yr, 2-3%/yr afterwards

o 15-20% get transient hypothyroidism after 2-3 months too
o Need life-long followup

Concerns
 No evidence for infertility / birth defects / cancer
 ABSOLUTELY CONTRAINDICATED in pregnancy
 Can get transient worsening of thyroid function (1% pts) – “radiation induced thyroiditis”

17
 o Use ATD pretreatment in older pts - but ↓ cure rate with PTU (makes thyroid “radio-resistant”)

 May worsen pre-existing Graves’ eye disease, esp. in pts that smoke cigarettes
o ↑ risk with severe hyperthyroidism, high TSAb titers, smoking, untreated postablative hypothyroidism
o Can use steroids (e.g. prednisone 0.5 mg/kg x 4-6 wks) to prevent worsening, but own side effects
Hypothyroidism
Sample Case: 55 yo F with CC of 6 mo progressive fatigue, cold intolerance, constipation; ↑ 10 lbs, feels depressed
 Mother, daughter both have “thyroid problems” (think Hashimoto’s)
 PE: P=60, skin cool dry, thyroid enlarged, firm symmetrical, reflexes delayed
 Labs: FT4↓ 0.6 ng/dL (0.7-1.8); TSH↑ 42mU/l (0.5-5)

 Most common endocrine deficiency state (~ 2% women, mild hypothyroidism in 7-15% older adults)
 Dx usually straightforward; serum TSH is most sensitive single test

Goals of therapy: Give back what they’re missing (reverse clinical hypothyroidism, prevent long-term consequences)

Limitations: can get iatrogenic thyrotoxicosis and cardiovascular compromise

Historical treatments
 Fresh sautéed sheep thyroid, dessicated thyroid

LEVOTHYROXINE (T4) IS PREPARATION OF CHOICE

 Brand name ≈ generic
 Liothyronine (T3) only for specific indications

T4 (Levothyroxine, Thyroxine)
Mechanism of
Replaces T4; converted to T3
Action:
Indications hypothyroidism
 use TSH to guide (to goal 0.5-2.5 to 3 mU/l; want to get them in lower half of normal range
(0.5-6))
 free T4 is often slightly ↑ to keep serum T3 / TSH normal
o thyroid not making its normal 20% of available T3
 Individualized dosing
o Severity, etiology of hypothyroidism
o patient characteristics:
Dosing:
 older needs less - slower metabolism
 pregnant woman needs more: thyroid makes more during pregnancy).
 For outpatients < 60yo, no heart disease use full replacement dose (1.5-1.8 ug/kg/day).
 For older patients or heart disease, start with 25-50 ug/day → increase 25-50/mo (TSH
monitor)
 Dose on lean body mass, esp. for very obese pts
 in thyroid cancer, don't want too much TSH around (lower TSH goals)
 Single daily dose (lots protein bound, long half-life).
 Don't take with calcium or iron.
Administration:  Can adjust time of day to maximize compliance
o weekly dosing or catch-up is suboptimal but acceptable
 Fasting advisable, but not essential; foods / coffee can interfere with absorption.
 50-80% absorption along small bowel
Metabolism:
 long half life 7 days (can miss dose)
18
  converted to T3 in peripheral tissues (like endogenous T4).
 Faster clearance in children (may need up to 2x dose), slower clearance in elderly
 Pregnancy:
o need higher dose (estrogen effects on TBG? trans-placental passage of thyroid hormone?).
o 75% require increased dose (50-75% increase)
o especially in 1st and 2nd trimesters (up to 20 wks)
Need to monitor! 20% are undertreated, 18% overtreated.
 clinical status important but often inaccurate.
 Use serum TSH as principal guide (0.5-2.5 mU/l), but:
Monitoring:
o can lag 1-2wks behind free T4
o generally takes 6 wks (6 half-lives) to fully equilibrate
o can't use if pt has central hypothyroidism (TSH abnormal to begin with)
No "side-effects" - allergy to dye maybe?
 Can cause ↑ oxygen consumption, exacerbate angina in heart disease / older pts (taper up).

Restoring euthyroidism can:

 exacerbate ischemic heart disease,
 provoke acute adrenal insufficiency if previously borderline adrenal fxn
Toxicity: (Schmidt's syndrome, central hypoadrenalism)
 ↑ increase ICP in children (pseudotumor cerebri).

Too much thyroxine can lead to iatrogenic thyrotoxicosis

 bone mineral loss in postmenopausal women
 A-fib in older pts
 hyperthyroid symptoms
separate T4 from drugs and supplements by at least four hours.
 Block T4 absorption: Bile acid sequestrants, Ca, Fe supplements, AlOH antacids, sucralfate, raloxifene (?)
 Speed up T4 metabolism: antiseizure drugs & rifampin
Drug
 Increase TBG: Estrogen
Interactions:
All these increase dose requirements!
 Discontinuing an interfering substance can lead to iatrogenic hyperthyroidism.
Normal T4 production is 80-100 ug/day; given 80% absorption, predicted avg requirement is 100-125 ug/day.
Other
Full replacement dose: 1.5-1.8 ug/kg/day.

19
 Pituitary Pharmacology
Introduction

Pituitary Stimulatory Inhibitory

Hormone signal signal
GH GHRH ?Ghrelin Somatostatin
ACTH CRF, ADH ?
PRL TRH Dopamine
LH, FSH GnRH ?
TSH TRH Somatostatin

Note that:
 dopamine inhibits prolactin!
 Somatostatin inhibits growth hormone

Hyperprolactinemia
Dopamine acts on the D2 dopamine receptor
 only D2 expressed in pituitary gland
 Dopamine – from decarboxylation of tyrosine

Dopamine receptor is GCPR (7-transmembrane)

 Triggers Gi subunit  ↓ adenylate cyclase  ↓ cAMP
 ↓ cAMP  ↓ PRL

Etiology of hyperprolactinemia
 Pregnancy #1 (until proven otherwise)

 Prolactinomas

 Pituitary stalk compression: All other hormones drop, prolactin increases (↓ dopamine inhibition!)

 Medicines: usually < 100 ng/mL

o Antipsychotics: phenothiazine, butyrophenones, haldoperidol, risperidone)
o Pro-motility agents: metoclopramide, domperidone
o Meant to ↓ dopamine – makes sense!
o Old anti-hypertensive drugs too (reserpine, α-methyldopa)

 Macroprolactinemia – 15% hyperprolactinemia pts; prolactin bound to Igs  ↑ half-life

o Not biologically active! Just stop checking prolactin levels

20
Treatment: dopaminergic drugs
 Used especially for prolactinomas
 Cabergoline > bromocriptine: better tolerated, better tumor shrinkage, better cure rate, longer half-life

Mechanism of Action: Ergot derivative dopaminergic drugs (for hyperprolactinemia)

Effects: Dopamine agonists
 dopamine reduces prolactin secretion (normal tonic suppression from hypothalamus; binds D2 receptor
and triggers Gi protein which inactivates AC leading to less cAMP and less PRL secretion).
 Can also shrink tumors (helps with visual field symptoms).

Indications: Prolactinomas, other hyperprolactinemias.

 cabergoline slightly better to normalize PRL (70-80 vs 80-90%), shrink tumor (50-60 vs 60-70%).
 Occasionally used for acromegaly too (some tumors respond to dopamine)

cabergoline Administration:
 bromocriptine: 2.5-5mg qd or bid
bromocriptine  cabergoline: 0.5-1mg once or twice per week (better compliance?).

Toxicity: GI side effects (dopamine agonists).

 Nausea, reduction in BP. Take with snack & before going to bed (less dizziness).
 cabergoline better tolerated (2-4% vs 5-10% can't tolerate side effects).
 cabergoline may cause heart valve abnormalities in large doses (for Parkinson's disease)

Metabolism: different half lives: cabergoline (63-109h) ≫ bromocriptine (3-7 h)

Long-term efficacy: after 2 yrs therapy, if tumor has shrunken & PRL normal on 0.5mg/wk cabergoline, 40% chance
of being permanently cured / not recurring after stopping meds

Acromegaly
Pituitary adenoma that makes too much growth hormone
 Gigantism if onset before patient is done growing

MEN-1: the “3P” syndrome (think Goliath)

 Pituitary tumor (e.g. GH-secreting)  giant
 Hyperparathyroidism  friable skull
 Gastrinoma  recurrent peptic ulcer (bad mood)

Treatment: mostly transphenoidal surgery

 Cushing developed in the 20s
 Get to pituitary through nose

Pharmacological treatment
 GHRH stimulates secretion
 Somatostatin (= SRIF) inhibits secretion
 Dopamine normally stimulates GH release, but some tumors
actually respond to dopamine receptor too!
 GH  Liver makes IGF1; acts in periphery
 GH also acts on GH receptor in periphery

Targets: dopamine receptor, somatostatin receptor, GH receptor

21
Somatostatin receptor agonists
 Somatostatin has a short half life (5-10m)
 Octreotide: a somatostatin analogue (half-life 1.7h)
o Acts best on type 2 & 5 somatostatin receptors; moderately on 3
o Most tumors express 2 & 5 (nice), but new analogues in development for all subtypes
 Longer-acting forms now used (octreotide LAR, lanrotide autogel)

Mechanism of Action: somatostatin analogue, used to inhibit growth hormone release from pituitary
Effects: Somatostatin usually inhibits GH release, but somatostatin itself has a too-short half-life.
 Octreotide: best on type 2 and 5 (+/- type 3) somatostatin receptors (most tumors express these).

Indications: Acromegaly (too much GH).

octreotide  Normalize IGF-1 in around 50% pts (full response) depending on pre-therapy IGF-1, GH level,
whether or not you express the right receptors.
octreotide LAR  Can also shrink tumors (micro > macro-adenomas for shrinkage; not as dramatic as PRLomas).
 Often used to shrink tumor before surgery
lanrotide autogel
Administration: sub-Q or IM (half-life 1.7 h for normal octreotide; give 3x/day)
 Octreotide LAR: contained in small spherules, injected; drug released slowly - administer 1x/ mo!
Big spike, then drop in octreotide levels (1st week), then slow release after that.
 Lanrotide autogel: gel injected (proprietary formula), slowly released over time.
No big spike like octreotide LAR

Upcoming therapies?
 SOM230 = new somatostatin analog (↑ affinity for other receptors)
 BIM-23A760: hybrid dopamine / somatostatin agonist (“dopastatin”) – maybe synergy?

Dopamine receptors agonists

Cabergoline used too sometimes for acromegaly – some tumors respond to dopamine
 Cheaper than injectables, oral; often tried first

Growth hormone receptor antagonists

 20-30% don’t respond to other treatments & are not cured by surgery - so try to block the GH receptor!
Mechanism of Action: Growth hormone receptor antagonist. Prevents receptor dimerization.

Effects:GH receptor is a dimer (when growth hormone binds, dimerizes). pegvisomant has two changes:
 binds tighter to receptor
 prevents dimerization
pegvisomant
(B-2306)
Indications: Acromegaly (for 20-30% pts that fail other meds & surgery).
 Just about everybody responds (normalizes IGF) – tumor receptors don’t matter (working in periphery).
 DOESN'T SHRINK TUMOR SIZE (can keep growing, too). Not for prolonged use - use radiation therapy too.

Administration: sub-Q

Summary: drugs for acromegaly

Route of Administration Mechanism of action % IGF-1 controlled Approx. monthly cost
Inhibits GH release
Cabergoline Oral 20 $400-500
(DA receptor agonist)
Octreotide, Inhibits GH release
SQ or IM 60 $1,800-2,400
Lanreotide (somatostatin receptor agonist)
Blocks GH effects
Pegvisomant SQ 90 $2,400-3,200
(GH receptor antagonist)

22
 Diabetes Insipidus
Neurogenic Nephrogenic Psychogenic
Not making ADH Not responding to ADH Psych issues
 hypothalamic diseases
 familial (usually X-linked)
(sarcoidosis, tb, histiocytosis X, lymphoma)
 post-traumatic  electrolytes abnormalities
Primary polydipsia
(hypokalemia, hypercalcemia)
 post-surgical = #1
 Drugs (lithium, demeclocycline)
 idiopathic (often followup MRI’s become positive)
ADH = vasopressin = AVP
Tumors almost never cause DI (unless there was surgery there)
Vasopression / AVP receptors
 Other subtypes: V1a (vascular smooth muscle, liver, bladder, etc.), V1b (anterior pituitary, a.k.a. V3)
 V2: Kidney subtype is most important here

V2 activated  ↑ intracellular cAMP in collecting tubules  aquaporin synthesis & insertion  ↑ water inflow

Vasopressin is not ideal as treatment: half-life is very short; also a V1 and V2 agonist (other effects!)

Desmopressin (dDAVP)
 Deamino-DAVP: two changes  much longer half-life (30-117m), V2 selective
 Used as treatment for central DI
o Other treatment: drink water (only manifest DI if you don’t have access to water!)
o Patients should experience a POLYURIC PHASE EVERY DAY to avoid HYPONATREMIA

Mechanism of Action: vasopressin analogue

Effects: Vasopressin binding to V2 receptors triggers increased cAMP, leading to aquaporin insertion and
increased aquaporin synthesis in renal tubular cells, leading to more water retention and a more
concentrated urine.
 Desmopressin is V2 selective (avoids vascular side-effects of vasopressin) and has a longer half-life
desmopressin
Indications: Central DI
(dDAVP)
Administration:
 Intranasal (rapid onset, lasts 6-20h)
 Oral (poor absorption, doses 10x higher than nasal)

Toxicity: be very careful (don't want to go hyponatremic!)

Other:Patients should experience a POLYURIC PHASE EVERY DAY to avoid HYPONATREMIA

Thiazide diuretics for nephrogenic DI only – cause natriuresis, volume contraction, ↓ GFR

23
 Hyponatremia of SIADH
Very hard to get into trouble with DI, but can be in big trouble if sodium is low
 Fluid rushes into brain  swells!

Water restriction is first line therapy

Demeclocycline is an antibiotic that can cause kidney ADH resistance at high

doses (more for textbooks than practice)

Hypertonic (3% NaCl) infusion is only for emergencies

ADH receptor antagonists: aquaretics

Mechanism of Action: ADH receptor antagonists (non-selective)

Effects: Block ADH receptor.
conivaptan
Indications: SIADH
Administration: intravenous

Mechanism of Action: ADH receptor antagonists (V2 selective)

Effects: Block ADH receptor.
tolvaptan
Indications: SIADH
Administration: oral

Other pituitary drugs

GHRH Used to test GH reserve in hypopituitaric patients (alone or with arginine; no longer in production)
occasionally used to diagnose Cushing’s syndrome or adrenal insufficiency.
CRH (Ovine)
 Very expensive ($300 / vial)
Clomifen anti-estrogen, used to induce ovulation in infertility

24
 Pathology: Bone
Non-Neoplastic Bone Disease ................................................................................................................................................. 2
Metabolic Bone Disease.......................................................................................................................................................... 8
Bone Tumors ......................................................................................................................................................................... 13
Genetic Bone Disease ........................................................................................................................................................... 17
Joint Diseases ........................................................................................................................................................................ 19

1
 Non-Neoplastic Bone Disease
Bone: a dynamic tissue!
 Heal / reacts  Atrophies  Can undergo neoplastic
 Becomes infracted  Sensitive to body transformation
 Can be infected environment

Disease categories
 Traumatic  Infection  Congenital
 Circulatory  Metabolic  Neoplastic

Normal Bone & Bone Remodeling

 Calcium is usually removed from the bone before histology
 Cortical region on outside (pink), spongy / trabecular / cancellous area inside (has marrow)
o Trabeculae should be ≈ parallel; in lines
o OsteoClasts resorb bone, OsteoBlasts lay down new bone
 15% of skeleton remodeled per year (new skeleton every ≈ 6-7 years!)

Adult bone: cortical area (C, Epiphyseal Bone remodeling: newer (left) Osteoblasts (OB) &
pink), trabecular (T, a.ka. growth plate and older (right) – dark lines Osteoclasts (OC)
spongy / cancellous) housing open (13-14 yo pt) are remodeling lines
marrow (M)

Fractures
Most common form of bone disease; usually result from trauma
 But can happen w/o trauma too – fracture with normal use (old age, osteogenesis
imperfect, etc – fragile skeletons)

Bone is the only tissue that can heal itself with tissue identical to the original!
 No scarring / fibrous tissue / etc
 Can take anywhere from 3 wks to 3 months!

1. Hematoma  (see pic below) organizes into…

2. Granulation tissue  paravascular cells adapt osteoblast machinery 
3. Cartilage formation
4. Remodeling
5. Osteoid formation

New bone + new cartilage = “fracture callus”

2
Complications of fractures
Necrosis Malunion Non-union

Incorrect healing –
fibrous core separates bone from bone (arrow
Necrotic femoral head e.g. ulna + radius
need to re-break to treat!
fused together

Special types of fractures

Stress fracture Pathologic fracture

process of cracking little by little pre-existing lesion makes bone weak  bone breaks

Heterotopic Ossification
 After hematoma: fracture callus can develop in soft tissue (adjacent to bone)
 Bone “healing” outside of bone – bone thinks that hematoma is fracture  tries to heal
 From single or repetitive trauma – or no history of injury!

Fast vs. Slow-growing processes: sclerotic border

Sclerotic border:
When something goes wrong (e.g. tumor) – body tries to wall it off

Slow-growing Fast-growing
Can put a sclerotic border Can’t keep up
around it (no sclerotic border seen)

3
Bone irritation  encapsulation

 Something irritates the bone  reaches out; tries to encapsulate

 Example: elephant man (Joseph Merrick – NF type I?)

Osteonecrosis
Bone infarction (segment of dead bone) - focal bone death due to vascular occlusion
 Pic: wedge-shaped infarct

Caused by:
 Trauma (traumatic injury to blood vessels – fractures / dislocations)
 Systematic processes
 Almost never atherosclerosis, unlike other infarcts!

Final common pathway of osteonecrosis: INTRAVASCULAR COAGULATION

Predisposition to osteonecrosis with: (KNOW THIS)

 Hypercoagulable Blood:
o Alcoholism (3 beers / day!)
o Steroids (15% of transplant patients, 30% SLE patients)
o Sickle cell disease
o Cassion disease (Nitrogen bubbles in blood – e.g. the bends)
o Gaucher’s disease (↑ foam cells in marrow: inborn error of metabolism)
 Fat swelling
 Lipemic serum

Osteonecrosis can be spontaneous too

 Hip, knee, shoulder
 Femoral head: tenuous blood supply: 15k / yr in US, ages 20-40, usually men

Histologic features
 Absence of osteocytes from bone (empty lacunae)
 Necrotic marrow (fat necrosis  calcifies)
 Lots of remodeling (try to repair  extra dense)

Radiology: HYPERDENSE (remodeling, calcified fat necrosis)

Empty lacunae, fat necrosis ↑ bone remodeling! Radiodense bone infarcts

4
 Paget’s Disease
PAGET’S DISEASE: FOCAL OR MULTIFOCAL INCREASED AND CHAOTIC BONE REMODELING (KNOW THIS)
 We all remodel bone 15% a year – but in Paget’s, it all goes crazy

Pathophysiology: Starts with wave of non-physiological osteoclast-mediated osteolysis

Infectious etiology? A slow viral infection from childhood?

 Viral particles found consistently
 Geographic predilections
 Familial clustering

Epidemiology:
 Disease of older people (10% of people over 50)
 Mostly Northern European descent, clusters in families

Distribution: Axial skeleton (spine, pelvis, skull) is most common

 Could also be portion of one bone, entire skeleton

Architectural destruction of bone: pain, deformity, fracture

Key Radiological Finding: COARSE TRABECULAE (know this)

 Bones are brittle  BANANA FRACTURES

Microscopic Findings: ↑ blue remodeling lines  “MOSAIC PATTERN”

Other complications
 Anemia  Heart failure
 CN Palsies (thick skull – close off opening)  Paget’s sarcoma

BANANA FRACTURE
Normal (left) and Paget’s progression (right three).
COARSE TRABECULAE (brittle bones – like
First osteolysis (arrow), then COARSE TRABECULAE & DEFORMITY
snapping a banana in half)

Microfractures  remodeling Skull deformities – from remodeling Thick skull  CN palsies!

5
 Osteomyelitis
 Bones get infected! Bacteria love to grow inside bones!
 Once you get infection in the bone, hard to get out – walled off by bone’s reparative process

How do bacteria get there?

Primary Osteomyelitis Secondary Osteomyelitis
Hematogenous (2/degree to septicemia) Direct implantation of organisms (trauma, etc).

Primary osteomyelitis
Most commonly in children
 Staph aureus - lots of PMNs, etc
 Lands in metaphyseal area of long bones
 Pain, fever, leukocytosis, ↑ sed rate

Primary osteomyelitis in adults

 Spine (spondylitis) is most common site
 Follows GU tract
 Post-manipulation

Secondary osteomyelitis
 Direct implantation following trauma (think open fractures)
 Can also be from infection in tissues just adjacent to bone

Acute / Chronic osteomyelitis

Acute osteomyelitis: treatment successful in 95%, but 5% progress to chronic osteomyelitis
Chronic osteomyelitis: can be long standing (many years) - See bony reaction to organisms

Radiographical Comparison
Acute osteomyelitis Chronic osteomyelitis

aggressive destructive radiolysis abundant radiodense reparative bone

(infection eating away at bone) (bone walling infection off; harder to treat)

Sequestrum: piece of dead bone inside cavity in bone after osteomyelitis

 Surgery – take it out, or bone spits it out through skin via sinus tracts!
o Stinky pus  smell!

6
 Test Question Material (STUDY THIS AND YOU’LL BE GOOD)

1. Definition of Paget’s disease: Exaggerated chaotic bone remodeling, focal or multifocal.

2. The following are complications of Paget’s disease:

a. Fracture d. Sarcoma
b. Deformity e. Cardiac failure – high output
c. Cranial nerve palsy

3. The following conditions predispose to osteonecrosis:

a. Steroid therapy d. Caisson disease
b. Alcoholism e. Gaucher’s disease
c. Sickle cell disease

4. Compare the radiology of primary vs. secondary osteomyelitis (etiology?)

5. Radiology:
a. Acute osteomyelitis shows aggressive destructive radiolysis.
b. Chronic osteomyelitis shows abundant radiodense reparative bone.

6. The following are symptoms of osteomyelitis:

a. Acute severe bone pain d. Fever
b. Leucocytosis e. Sometimes swelling
c. Elevated sed rate

7. What is a sequestrum? piece of dead bone inside cavity in bone after osteomyelitis

7
 Metabolic Bone Disease
Disorders of the chemical milieu of the body which leads to decreased bone mass (know this!)
 End result can be SKELETAL FAILURE – just like renal failure / cardiac failure
 Pain, fractures, deformity can result

Osteopenia / osteoporosis
 Terminology reflects how much of bone is gone (osteopenia  osteoporosis
 Plain X-ray does not indicate osteopenia until 30% bone mass gone - bone strength is reduced by 50% already!
 DEXA (dual-energy X-ray absorptiometry) can diagnose in early stages
o T-score – how dense is bone vs population; -2SD = osteopenia, -2.5 SD = osteoporosis

Normal

Metabolic
bone dz

↓ density, more brittle ↓ bone density (dried sections) ↓ density, thinner trabeculae

Four categories of metabolic bone disease

 Focal osteoporosis  Primary osteoporosis
 Specific endocrine abnormalities  Secondary osteoporosis

Focal osteoporosis
Disuse osteoporosis: “Use it or lose it”

Walking is really important

 femur bends a little bit every time you take a step, generates a little electricity
o (piezoelectric charge: from inorganic crystal in organic matrix)
o electricity  helps preserve bone & keep it healthy (remodeling)

Weight-bearing is needed for a healthy skeleton; affected in

 Weightlessness: e.g. being an astronaut
 Bedrest: affects entire skeleton (0.9% / wk)
 Post-traumatic: Crutches, for example – 3 mo  focal osteoporosis
o Pic: R half of skeleton ↓ density – crutches!

 Hyperuse can lead to ↑ bone density!

8
 Endocrine Abnormalities
Primary hyperparathyroidism
Epidemiology: after DM / hyperthyroid, most common endocrine disorder; < 5% have clinical bone disease
Etiology: parathyroid adenoma  ↑ PTH  bone resorption  ↑ serum Ca, ↓ serum PO4
 Nowadays, secondary hyperparathyroidism (renal dz) is more common cause of bone disease
o 1° hyperparathyroidism most often diagnosed early (routine screening)
o Same findings in both! Tunneling resorption!

Pathology: see TUNNELING RESORPTION

 In all pieces of trabeculae in a sample
o Osteoclasts dissolving bone  to release calcium
 Fingers (DISTAL PHALANGES) are most sensitive for earliest radiographic changes

Tunneling Resorption: osteoclasts Radiography: erosion of tufts of distal phalanges & periosteal resorption
resorbing bone in all pieces of trabeculae! Generalized resorption too

Vitamin D deficiency
 Inadequate sun exposure + inadequate / inhibited dietary intake
o Need ≈ 1g calcium, ≈ 600-1000 IU vitamin D per day (4 glasses of milk)
 ↓ vitamin D  Can’t absorb calcium  bones don’t mineralize
Children Adults
ricketts osteomalacia (soft bones)

Ricketts
 Short stature
(growing epiphyseal plate doesn’t mineralize)
 Deformity (bones are soft bow-legged)
 Neuromuscular abnormalities

Radiography:
 WIDE EPIPHYSEAL PLATE
 SKELETAL DEFORMITIES Top left: bow-legged

Above: cartoon of widened

epiphyseal plate (not mineralizing)

Left: widened epiphyseal plate

(even palpable at the wrist! 9
Osteomalacia
From: lack of sun exposure, poor / unusual diet, GI dz or surgery
Epidemiology: Common!
 33% institutionalized pts, 50% home-bound elderly. At end of winter: 42% AA women Vit D deficient!
 Related to cultural habits (clothing, food)

Radiography: WIDE OSTEOID SEAMS

 Lots of osteoid being made normally (healthy osteoblasts)
o but not mineralizing!
 ↑ red (green = mineralized / calcium) on undecalcified section

Renal bone disease (an aside)

 Vitamin D deficient  osteomalacia! Also hyperparathyroidism (↓ Ca)

Osteoporosis
A “geriatric disease that begins in childhood”
 Peak bone mass is ≈ age 30

If you don’t reach your peak bone mass, you’ll hit skeletal fragility early!
 “Female athletic triad” – osteoporosis, amenorrhea, skeletal fragility
o Think figure skaters, gymnastics, ballerinas, etc.
o ↑ bone stress, but amenorrheic & malnourished (doesn’t balance out)

Risk factors:
 Female, white, Northern-European Descent, Asian
 Fair hair / skin, tall, thin body habitus

Protective:
 dark skin (although ↓ vitamin D)
 obesity! (↑ estrogens)

Burden: Really expensive (hip fractures alone: $7.1B) – 26M women, 2.5M fractures / yr – 54% post-menopausal women
Prevention is key: once you lose bone, it can’t be replaced

Primary osteoporosis
Decreased bone mass associated with old age

Kyphosis  get shorter with old age

 wedge compression fractures in vertebrae 
 kyphosis (“Dowager’s hump”)

Fractures in primary osteoporosis

 Spine, Hip, Wrist are common targets
 can get all (sit down, fall, brace with wrist) at once

Patterns of bone loss

Senile osteoporosis Post-menopausal (accelerated) osteoporosis

10
Senile Osteoporosis
Epidemiology: Age-related, both men & women, all cultures & epochs

Pathogenesis: gradual loss of bone secondary to OSTEOBLAST SENESCENCE

 Remodeling rate is normal – just don’t fill in the gaps the whole way
Normal remodeling Remodeling in senile osteoporosis

Osteoclasts eat away at pit Past 35-40 years old – bone replaced < bone eaten
Osteoblasts fill back in with same amount of bone Doesn’t quite match up – lose bone!

Post-Menopausal Osteoporosis

Certain women have an accelerated rate of bone loss

 exquisitely sensitive to estrogen loss at menopause!

 ↓ estrogen  ↑ bone resorption

o Estrogen  inhibits interleukins
o Interleukins  stimulates osteoclasts

 ↑ bone remodeling: ↑ resorption & slightly decreased bone deposition

Secondary Osteoporosis
Pattern of generalized bone loss that occurs in patients who are not yet pre-menopausal or not in old age group
 Consider it if the patient is young & osteoporosis is unexplained (e.g. 40 yo)

Causes: lots! Including…

Steroid excess: long-term steroids
 organ-transplant pts
 auto-immune disorder pts
Amenorrhea
 Long-term steroids: 30% have vertebral crush fractures
 May cause 40% reduction in bone mass; as low as 10 mg prednisone / day
 Note that steroids cause both osteonecrosis and osteoporosis
 50% young female athletes
 25% reduction in bone density in eating disorder pts

11
 Test Question Material (STUDY THIS AND YOU’LL BE GOOD)

1. Bone turnover: 15% of skeleton/yearly

2. Features of metabolic bone disease:

a. Decreased bone mass
b. Skeletal fragility

3. Definition of osteomalacia (soft bones):

Failure to mineralize the bone matrix (osteoid) so get wide osteoid seams.

4. Causes of osteomalacia: (Lack of vitamin D)

a. Lack of sun exposure
b. Poor or unusual diet
c. Gastrointestinal surgery – can’t absorb vit D
d. Renal disease: Inability to synthesize 1,25 dihydroxyvitamin D in the kidney

5. Enhancing factors of bone loss:

a. Steroid excess
b. Estrogen deficiency/testosterone in men

6. The histologic features of hyperparathyroidism: tunneling resorption.

12
 Bone Tumors
Benign vs. Malignant
Orthopedic diagnosis: surgeon, radiologist, pathologist, oncologist (team effort)
 Use: Hx, radiographs, CT / nuclear scan / MRI, Bx

Categorization
Metastatic carcinoma Primary bone tumors
Myeloma (20+ types)
Start somewhere else, go to bone Start in bone Benign: Malignant:
More common in adults More common in young people sclerotic border! growing, fracture

Metastatic Carcinoma
A BONE LESION in a patient OVER 50 is METASTATIC CARCINOMA UNTIL PROVEN OTHERWISE (20:1 odds)

Histology:
 Cells growing in clusters (organoid pattern)
 means that the cells are epithelial in origin
 Picture: clusters of cells growing in bone

Most common cancers that metastasize to bone

(can really be any type of carcinoma) – marks stage IV disease
 Breast  Lung  Stomach
 Kidney  Prostate

Clinical settings:
Pt w/ known primary Patient presents with
presents with bone pain / lesion bone lesion initially
 Metastatic carcinoma!
 Metastatic carcinoma!
 Usually LUNG (or kidney)
 Take tissue sample (confirm metastasis)
 Look for primary (full body imaging)

Treatment: prevent pathologic fracture; local pain control

Location: Metastatic carcinoma favors the AXIAL SKELETON (KNOW THIS)

 Most commonly spine; also pelvis, proximal femurs

 Batson’s plexus: why is the spine commonly affected?

o susceptible to backflow from other areas
o valveless veins connecting:
 deep pelvic / thoracic veins to
 internal vertebral venous plexuses

13
 Radiographic appearance: osteodense or osteolytic
Blastic (radiodense) metastasis Lytic metastasis
Cancer produces
osteoBlasts – form new bone osteoClasts – break down bone
signal, activates:

Pictures

Radiodense lesions, osteoblasts being activated (R)

Radiolytic lesions, osteoclasts activated (R)
Often prostate (or breast) cancer

Features of metastatic carcinoma (summary)

 Older adults  Osteolytic & osteoblastic
 Always epithelial  Malignant
 Axial skeleton

Primary bone tumors

 At least 20 types; may be benign or malignant
 Has same tissue differentiation that bone has
o Osteoid, Cartilage, Fibrous

AROUND THE KNEE (DISTAL FEMUR, PROXIMAL TIBIA) is most common site of primary bone tumors (KNOW THIS)

Some types:
 Osteoid osteoma  Endchondroma – osteochondroma  Giant cell tumor
 Osteosarcoma  Chondrosarcoma  Ewing’s sarcoma

Primary bone tumors: Bone-Forming Tumors

Osteoid-Osteoma (benign)
Small proliferation of mesenchymal tissue with osteoid formation
 Affects diaphysis of long bones; NO BIGGER THAN A PEA
 Can remove by resecting nidus; not malignant

Patients: between 5-25 years old

Typical presentation: 10 yo with hip pain, keeps awake at night

 Pain relieved with ASPIRIN (tumor makes prostaglandins)
o Prostaglandin secretion can cause side effects
o Pain out of proportion to size of tumor

Radiography: small radiolucency with reactive bone around

 Reactive bone stimulated by tumor

Histology:
 Small lesion
 See secretion of pink osteoid

14
Osteosarcoma (malignant)
 Most common primary bone malignancy (85% under age 30)
 Adolescents & young adults
 distal femur & proximal tibia

Treatment: chemotherapy  surgery (remove bone)

 Natural Hx – got huge (pumpkin-sized – just keeps growing), then met to lungs  death
 These days: limb salvage procedure:
o Radical excision
o insert composite prosthesis, can adjust length with growth!
o 60-80% survival

Radiography: radiodensity in ugly looking pattern

Gross: big, ugly-looking tumor invading bone

Histology: highly atypical pleomorphic cells (malignant) synthesizing osteoid

Cartilage-Producing Tumors
Chondrosarcoma (malignant)
Big, cartilage-making, malignant tumor (chondro-sarcoma)
 Can occur in medullary canal or surface of bone
 Produce lots of cartilage  bone destruction

Treatment: Excise with clear margin

Radiography: big, fluffy-looking

Histology: see cartilage (blue!

Osteochondroma (benign)

 MOST COMMON BENIGN BONE TUMOR

 Not malignant – smaller, growing off of bone
o Feels like little bump off of bone

Radiography: looks like a little piece of broccoli

Treatment:
 leave it alone unless it’s bothering the patient, then chip it off with chisel!

Endchondroma (benign)

 Benign cartilage tumor INSIDE the bone

o remnant of epiphyseal plate
 Extremely common incidental finding
 Mature hyaline cartilage within medullary canal of bone

Radiography: fluffiness (cartilage) inside of bone

15
 Other Primary Bone Tumors
Giant Cell Tumor (benign but locally destructive)
 Not malignant, but LOCALLY DESTRUCTIVE
 Likes to hang out in ENDS of bones

Histology: see giant cells! Probably osteoclasts; destrying bone

Radiography: hypodense (radiolysis!) @ epiphyseal end of bone

Treatment: (see 3 pics, near right)

 Curette it – spoon it out!
 Phenol
 Cement – fill it in; put metal
on, screw it in

Ewing’s Sarcoma (most malignant tumor in bone!)

Often fatal (extensive metastasis)

Histology: Undifferentiated tumor, big blue cells

 Special stain (CD99) can detect

Radiography: highly destructive bone process

 Ugly, hard to distinguish features

Epidemiology:
 15% primary tumors (6-7/yr @ JHH)
 CHILDREN / YOUNG ADULTS (Age 5-47, 85% between 5-20)

Treatment: Chemo + wide surgical excision

Summary Table

Metastatic carcinoma Primary bone tumors

Patients Older adults Adolescents, young adults
Types Always epithelial Twenty different kinds / subtypes
Location Axial skeleton Distal femur / proximal tibia
Radiography Osteolytic & osteoblastic Specific radiographic patterns
Malignant? Always malignant Benign & Malignant

16
 Genetic Bone Disease
Of 5K known congenital disorders, 500 affect the skeleton (directly or indirectly)
Indirect Single gene mutations (direct)
 Neurofibromatosis (most common gene defect)  Skeletal dysplasia (or)
 Gaucher’s  Constitutional Bone Disorder
 Mucopolysaccharidoses
 Alkaptonuria 160 types identified – lots of genes involved in bone stuff!

Skeletal Dysplasias
 Short stature (little people)
 Abnormally shaped bones – joint problems
 Skeletal fragility

Most diagnosed by Epiphyseal dysplasia Metaphyseal dysplasia

radiographic findings –
no good histopathologic
findings to Dx
 Which part of
bone is affected?
Epiphysis,
metaphysic,
diaphysis?

Osteogenesis Imperfecta (“brittle bone disease”)

MOST COMMON SKELETAL DYSPLASIA (20k/yr in USA)

BAD TYPE 1 COLLAGEN

 Mutation in one of two genes that encode type I collagen

Patients: looks small, fragile, lots of breaks

Big spectrum of disorders

 Type II: lethal in utero (bones break  fetal death)
 Type I : milder phenotype
 Many types (at least 7 phenotypes)

Radiography: can have thin, distorted bones (pic: femurs)

Type 1 OI (mild phenotype)

can present more insidiously, may not be diagnosed until adulthood
 Break bones more frequently
 BLUE SCLERA can be a key diagnostic feature (↓ collagen)
 Can have bad teeth too

17
Achondroplasia
SECOND most common skeletal dysplasia (10K in USA)

Defect in CARTILAGE SYNTHESIS

 Spine is normal length, but long bones are short
 Develop joint problems (shorter long bones, misshapen)

Genetic defect:
 Chromosome 4
 Mutation in gene for FGFR3
o (fibroblast growth factor receptor 3)

Test Question Material (STUDY THIS AND YOU’LL BE GOOD)

1. McCarthy’s #1 Law: Any patient over 50 with a bone lesion has metastatic carcinoma until proven otherwise.

2. Metastatic carcinoma most commonly involves the axial skeleton:

a. Spine
b. Pelvis
c. Shoulder girdle

3. The most common primary malignant bone tumor is osteosarcoma.

4. Primary bone tumors usually affect children, adolescents, and young adults.

5. Osteogenesis imperfecta is the most common skeletal dysplasia.

a. The genes affected are those that synthesize type 1 collagen.

6. The general clinical features of skeletal dysplasias (may not all be present in a single phenotype).
a. Short stature
b. Skeletal fragility
c. Deformity
d. Joint symptoms

18
 Joint Diseases
Major categories Manifestations:
 Traumatic  Pain & tenderness
 Infectious  Stiffness
 Degenerative  Swelling
 Reactive Inflammatory  Instability
 Metabolic
Side effects: ~ 18%: depression (functional problems)
Can be:
 Single joint with mild transient problem Test for joint disease:
 Multiple joints / permanently crippling  Physical exam
 Synovial fluid
Epidemiology: major problems!  Radiography
 Every adult has something wrong with their joints
 Back pain is #1 presentation to general physicians

Normal joint:

Uniform joint space SM = synovial membrane Surrounded by capsules & ligaments

(articular cartilage isn’t (makes fluid); C =cartilage
radiodense)

Trauma
“bread & butter” of orthopedic surgeons
 Synovitis
 Torn meniscus
 Osteochondral fracture

Osteochondral fragment:
 chip off a piece of bone  dies  hangs out in the joint  causes damage
 See picture (right)

Septic Arthritis
 Joint can be infected (e.g hematogenous spread)
 GONOCOCCUS is #1 cause in young people
o N. gonorrhoeae (check for gonorrhea)

 Treatment: drain

19
 Osteoarthritis
Definition: FAILURE OF THE ARTICULAR CARTILAGE (KNOW THIS)
 Everything else is a secondary reaction to this!

Radiography:
 Narrowing of the joint space
 Subchondral sclerosis (whitening under cartilage)
 Osteophytes (bone spurs)
 Subchondral cysts

Findings:
 Hip, knee, spine
 usually pain & stiffness (limitation of motion), deformity
 Insidious onset with relentless progress

Epidemiology
 Affects the elderly, Males > females
 Weight-bearing joints affected primarily
 ALL people > 65 have some evidence (70% sx; 50% bothersome)

Causes: END STAGE of a bunch of different diseases

Secondary osteoarthritis Primary osteoarthritis
“Primary failure” of articular cartilage
 Fracture or other joint injury Probably actually secondary to something
 Osteonecrosis  Ligamentous laxity  Hard bones
 Infection  Genetic weakness of cartilage  Body stature of gait (hereditary)
OVERUSE does NOT CAUSE OSTEOARTHRITIS
Histology:
 Change in articular cartilage (clefting, cloning, erosion)  Underlying bone  sclerosis (deposition), osteophytes nearby

Left: normal bone; middle: cartilage beginning to crack

right: cartilage worn away, bone getting denser underneath

Eburnation: Far left: normal;
bone polished by middle: OA;
opposite bone Right: total hip
 like ivory replacement

Treatment: Total Joint Replacement

 Mostly hips / knees (170k each) – where you mostly get osteoarthritis
 Really great – but only last 10-12 yrs, then you have to redo them
20
 Inflammatory Joint Disease
Classic example: rheumatoid arthritis

Systemic disorder in which synovial membrane is one of the targets

 Bone, cartilage, ligaments affected secondarily
 Big inflammatory response  cytokines  hot, painful joints

Categories
 Rheumatoid arthritis  Arthritis with systemic disease (Lupus,
 Juvenile rheumatoid arthritis psoriasis, ulcerative colitis, lyme disease)
 Ankylosing spondylitis

Rheumatoid arthritis
Epidemiology: Onset in 20s or 30s, women > men, 1% Caucaisans,
Clinical findings: Variable progression, few or many joints, targets the hands, hot, swollen, inflammatory joints

Pathogenesis
 Systemic disease; targets synovial membrane, which makes cytokines  adjacent osteopenia
 Autoimmune disease: 75% have Ab to collagen of smooth muscle
o Rheumatoid factor (RF) – usually an IgM, reacts with IgG

Pannus: granulation tissue membrane (synovial origin)  destroys articular cartilage

 Fibro-inflammatory membrane, produces cytokines, etc
 Eat into bone from synovial membrane
 MECHANISM of destruction of articular cartilage is EROSIVE PANNUS

Radiography: See osteoporosis

 lots of cytokines; don’t get dense sclerosis like osteoarthritis)

Osteoporosis: little holes in bone Ulnar deviation: destroying ligaments,

(where pannus eats away) eating away at cartilage
Juvenile Rheumatoid Arthritis
 Lots of other organ systems involved (liver / heart)
 Tend to plateau, then get better
 Findings:
o multiple deformities
o fixed forward head
o receding chin (mandibular ossification centers close early)

21
Ankylosing spondylitis
 “sero-negative spondylo-arthropathy”: spondyloarthropathy = inflammatory joint disease of vertebral column
 Characterized by enthesopathy: inflammation of ligaments & insertions into bone
o Results in bone infusion & osteophyte production
o Whole spine can fuse together (“BAMBOO SPINE”)

Presentation: usually back pain, ↑ sed rate

Epidemiology:
 ≈ 229k MEN, 89k women
 Beings before age 40 (avg age 26)
 Variable presentation
 90% HLA-B27 positive

Metabolic arthritis
Gout
Pathogenesis:
 Deposition of sodium urate crystals (needle-shaped) in / around joints
 Provoke response - giant cell reaction with amorphous material (sodium urate)
o Tophus: combination of crystals & inflammation
o Can be subcutaneous nodules or destructive bone lesions
 Like pannus, gout crystals can eat their way into the bone  “chronic gout”

Radiography: radiolucent

Pts with chronic hyperuricemia: Asymptomatic, Acute synovitis (50% big toe), or Chronic tophi

Tophus Sodium urate crystals Aggregations of Gouty tophi: sodium urate precipitates with cellular
(needle- shaped) crystals reaction (involving bone on left)

Tophi (radiography) – Gouty tophi

big erosions, looks kind of blurry

22
Calcium Pyrophosphate Deposition Disease
Crystal arthropathy due to calcium pyrophosphate deposition
 Pretty common (esp. older people), may or may not cause osteoarthritis

Three clinical presentations:

 Asymptomatic
 Acute pain (pseudogout) – acute synovitis)
 Chronic deposition  osteoarthritis

Test Question Material (STUDY THIS AND YOU’LL BE GOOD)

1. Enthesophathy: Inflammation of the ligament insertion resulting in an osteophyte

2. Pannus: A granulation tissue membrane arising from the synovial membrane which erodes adjacent bone and
cartilage.

3. Osteoarthritis: Failure of the articular cartilage.

a. Overuse does not cause osteoarthritis.

4. Gout is the tissue deposition of sodium urate.

5. Pseudogout is the deposition of calcium pyrophosphate.

6. Radiographic features of osteoarthritis:

a. Joint space narrowing
b. Subchondral sclerosis
c. Subchondral cysts
d. Osteophytes

23
 Pathophysiology: Bone
Hypercalcemia......................................................................................................................................................................... 2
Hypocalcemia .......................................................................................................................................................................... 9

1
 Hypercalcemia
Role of Calcium
System Role
Bone formation Vital mineral component of bone; makes bone strong / rigid
Blood clotting Activates many clotting factors
Muscle contraction Binds to troponin (myosin  binds actin)
Intracellular signaling Regulates intracellular proteins (e.g. via IP3)
+2
Nervous system Membrane potential / depolaraization; Ca -mediated exocytosis of neurotransmitters
+2
Endocrine system Ca -mediated exocytosis of hormones
Cardiovascular system Regulates membrane potential /contraction of muscle cells

Mineral Metabolism
Overview
In response to hypocalcemia (↓ serum Ca+2)

Parathyroid: ↑ PTH
1. Calcium sensing receptors (CaSR) turned off 
2. ↓ intracellular Ca+2 
3. ↑ PTH gene transcription & secretion 

↑ PTH: systemic effects via acting on PTH receptors

 ↑ resorption (osteoclasts)
Bone
 Releases Ca+2 & phosphorus
 ↑ Ca+2 reabsorption (prox tubule)
Kidney  ↓ phosphorus reabsorption (prox tubule)
 ↑ 1α hydroxylation of 25-OH-D3
(to active form of vitamin D: 1,25-(OH)2-D3)
 ↑ calcium & phosphorous absorption
Gut
(via ↑ 1,25-vit-D)

End result: ↑ ECF calcium without ↑ ECF phosphorous

Calcium-sensing receptor
G-protein-coupled receptor on parathyroid cells & renal tubular cells

Parathyroid: Senses variation in serum calcium  changes PTH concentration (↑ PTH with ↓ Ca and vice versa)
 If ↑ Ca , ↑ phospholipase C / IP3 / Ca signaling  ↓ PTH
+2 +2
+2
production / secretion; Ca goes back to normal

Kidney: regulates urinary calcium excretion

 Esp. located in thick ascending loop of henle
 Ca  binds CaSR  arachidonic acid metabolite  inhibits K
+2
+
channel in luminal membrane  ↓ K recycling  ↓ NaCl
reabsorption (↓ Na/K/2Cl transporter)  ↓ luminal positive
electrical gradient  ↓ calcium, magnesium passive absorption

Activate CaSR (↑ serum calcium)  ↓ PTH secretion, ↓ urinary calcium reabsorption (↑ excretion)

2
Hypophosphatemia
 PTH & vitamin D help protect against hypophosphatemia
 ↓ ECF phosphorous  ↑ renal conversion of 25-OH-D3 to 1,25-OH2-D3)
o Gut: ↑ absorption of phosphorous / calcium
o Bone: ↑ resorption (releases calcium & phosphate)
o Kidney: ↑ reabsorption of phosphorous from glomerular filtrate
 As ↑ ionized calcium, ↓ PTH secretion (↑ renal tubular reabsorption of phosphorous, ↓ renal calcium reabsorption)
o Phosphorous returns to normal & serum calcium maintained

Hypercalcemia: Overview
Common: up to 0.5-1.05 prevalence in routine multichannel blood screening
May be “factitious”: influenced by plasma proteins, pH
 Ionized calcium is what’s biologically active

Protein binding
 40-45% of circulating calcium is usually bound to protein (mostly albumin)
 If protein levels change, total calcium can change
o Ionized calcium is what’s sensed by CaSR; therefore stays ≈ same
pH
 Alkaline pH: ↓ ionized calcium levels
 Acid pH: ↑ ionized calcium levels

Corrected serum calcium: Normal albumin− plasma albumin × 𝟎. 𝟖 + [Ca+2 ]

 Corrects for albumin differences

Clinical Manifestations of Hypercalcemia

Severity:
 Ranges from life-threatening to asymptomatic
 Depends on degree, duration of hypercalcemia
o (severe & fast onset are worse)
 Correlates with level of ionized calcium!

Signs & Symptoms

“Bones, Stones, Moans, Abdominal Groans, and Psychiatric Overtones”

System Symptoms
Eyes Corneal calcification
Thirst From dehydration
Heart Arrhythmias, short QT, HTN cardiac calcification
Liver / pancreas Ectopic calcification
Kidneys Renal calculi, polyuria, renal failure
Bones Painful / fragile, show radiolucency / erosions
Brain Mental confusion, H/A, convulsions/coma if severe
Muscles General weakness
Bowel Vomiting, peptic ulceration, abdominal pain, constipation

Etiology of Hypercalcemia: DDx

↑ GI calcium absorption
↑ bone resorption
↓ renal clearance
↑ calcium intake
Misc
Vitamin D intoxication, granulomatous disorders, milk-alkali syndrome
1° / 2° hyperparathyroidism, malignancy, hyperthyroid, immobilization (± Paget’s), vit A intoxication
Lithium, thiazides, theophylline
Pheo, rhabdo, FHH, endocrine disorders
3
 Primary Hyperparathyroidism
Demographics
 Most common cause of outpatient hypercalcemia (25/100k person-years)
 2:1 female > male; peak in 5th-6th decade (think woman in her 40s-50s)

Symptomatic Hyperparathyroidism
 Stones (kidney stones)  Moans (general fatigue, weakness, arthralgia, myalgias)
 Bones (low bone mass; rarely osteitis fibrosa cystic)  Psychiatric overtones
 Abdominal groans (PUD, pancreatitis, constipation) (depression, lethargy, poor concentration)
Nowadays seeing more (80%) asymptomatic / milder presentations (routine screening – less stones / bones / etc

Renal complications: see kidney stones in 15-20%, hypercalciuria in 35%; only 2-5% pts with kidney stones have PHPT

Severe bone loss in 1° HPT: top = Cortical bone loss in Skull: mottled appearance
normal, see thick cortex with lots of hyperparathyroidism: note thinness of with little areas cleaned
cross-struts; bottom is after PHPT distal phalanges’ cortices out (cortical bone loss)
(thinning of cortex)

Etiology of Primary Hyperparathyroidism

Parathyroid adenomas!
 Usually solitary adenomas (85%)
 can have multi-glandular hyperplasia (10-15%) or carcinoma (1%) too

Ectopic parathyroids / parathyroid adenomas:

 Parathyroids usually in neck – but come from branchial pouches
 Can have ectopic parathyroids / parathyroid adenomas in mediastinum (don’t
migrate correctly in development)
 Hard to get to surgically; can detect with Sestamibi-SPECT scanning

Pathogenesis of HyperCa in 1° hyperparathyroidism

↑ PTH is the key: ↑ PTH secretion with loss of normal inhibition of PTH from ↑ serum Ca
 Parathyroid adenomas / hyperplasia are monoclonal tumors: often have MENIN mutations
 Parathyroid carcinomas: often have Rb / HRPT2 gene mutations

↑ reabsorption of calcium
↑ cyclic AMP (activation of PTH receptor stimulates AC)
Kidney
↑ 1,25-OH-D production
↑ urine phosphorous excretion
↑ osteoclast activity ↑ bone turnover
Bone
Ca / PO4 release
Gut ↑ Ca / PO4 absorption (↑ 1,25-vit-D)

4
Lab Features of 1° hyperparathyroidism

Lab feature Why?

Total/ionized calcium ↑ ↑ PTH (see above)
iPTH ↑ ↑ PTH (by definition)
1,25-vit-D (calcitrol) ↑ ↑ PTH  ↑ 1α-hydroxylation
Phosphorous ↓ kidney excreting with PTH outstrips ↑ liberation from bone and ↑ absorption from gut
Hypercalciuria - high filtered load – try to hang on with ↑ PTH but so much going through kidney
Urine calcium ↑
that more than normal ends up in urine
Urine phosphate ↑ PTH  ↓ PO4 reabsorption in kidney
Urinary cAMP ↑ Downstream result of ↑ PTH receptor activation

Syndromes of Hereditary Hyperparathyroidism

 Multiple Endocrine Neoplasia  FHH: familial hypocalciuric hypercalcemia

MEN: Multiple Endocrine Neoplasia

 85% of patients with MEN1 present with hypercalcemia at first!
 Different mechanisms for how PTH ends up getting secreted
o MEN1 from inactivation of tumor suppressor (Menin)
o MEN2a/b from activation of proto-oncogenes (ret)
 Most MEN 2a mutations in cysteine-rich domain of ret
 Most MEN 2b mutations in tyrosine-kinase domain of ret

MEN 1 MEN 2a MEN 2b

Tissues Parathyroid C cells C cells
affected Pituitary Adrenal Adrenal
Pancreas Parathyroid Nerves
Parathyroid
Presentation  calcium Thyroid tumor Thyroid tumor
Gene defect Menin gene ret gene ret gene
Inactivation Activation Activation
Tumor suppressor Proto-oncogene Proto-oncogene

Familial (Benign) Hypocalciuric Hypercalcemia (F(B)HH)

Don’t operate on these patients
 problem is that parathyroids are insensitive to calcium! surgery won’t fix it!

Autosomal dominant hyperparathyroidism

 But family members may be asymptomatic – may only discover pattern if tested

Pathogenesis: Inactivating mutation of CaSR gene in kidney & parathyroid cell

 Inappropriate PTH secretion despite elevated serum calcium
 Very low urinary calcium excretion! (good for telling vs. 1° hyperparathyroidism)
o Kidney also has mutation – so you can’t sense ↑ calcium in kidney and excrete it like you want it to

1° hyperparathyroidism FHH
Serum calcium ↑ (too much PTH) ↑ (too much PTH)
Serum phosphorus ↓ (too much PTH) ↓ (too much PTH)
PTH ↑ (big parathyroid making PTH) ↑ (insensitive)
Urinary calcium ↑ (kidney trying to get rid of it) ↓ (kidney also insensitive – doesn’t get rid of it!)

5
Clinical presentation:
 Generally asymptomatic, HyperCa with normal PTH or ↑
 ↑ renal reabsorption of calcium; ↓ urinary calcium & Ca/Cr
clearance ratio (vs other causes of hypercalcemia)
 Generally benign

Treatment:
 DON’T REMOVE PARATHYROID (won’t help at all)
 Just tell pt that they have hypercalcemia & make aware of
symptoms

Non-PTH-mediated Hypercalcemia

Bone resorption
 Mediated by osteoclasts
 Produce local growth factors – cancer likes it!

↑ osteoclast activity with:

 ↑ 1,25-Vit-D
 ↑ PTH
 ↑ thyroid hormone
 ↑ IL-17 (from T-cells), other interleukins

Hypercalcemia of Malignancy
 Most common cause of inpatient hypercalcemia
 Complicates 10-20% of cancer
o Malignancy usually obvious (not presenting sx)
 Symptomatic, severe hypercalcemia with acute onset

Mechanisms:
 Direct tumor invasion of bone
 Hematologic malignancies  secrete cytokines that activate osteoclasts
o Can ↑ differentiation to osteoclasts, activity
 Tumor secretion of PTHrp (parathyroid-hormone-related protein)
 Rarely, tumor can produce calcitriol (1,25-vit-d) or PTH

Can be a vicious cycle / positive feedback loop:

 Tumors activate osteoclasts
 Osteoclastic activity  ↑ growth factors  feed tumor

Left: normal bone formation; osteoclasts, osteoblasts More osteolytic metastasis

Right: osteolytic bone mets with RCC invading marrow (spots on X-ray)

6
PTHrp: Parathyroid-hormone-related protein
 Identical with PTH in 8/13 amino terminal residues
 Binds PTH receptor  activates adenylyl cyclase (↑ urinary cAMP)
o ↑ urinary cAMP: primary hyperparathyroidism and PTHrp-related
protein
o Looks like primary hyperparathyroidism but with ↓ PTH
 ↑ osteoclast-mediated bone resorption
 Associated with: squamous cell, renal cell, breast carcinoma

Note that urinary cAMP depends on mechanism of hypercalcemia (see pic)

 Represents downstream signaling through PTH receptor – PTH, PTHrp, etc

Biochemical Profile of HMM

Lab feature Why?
Calcium ↑ Symptomatic hypercalcemia: see mechanisms above
iPTH ↓ Suppressed: ↑ calcium via other mechanisms!
PTHrp ↑ (If PTHrp is the mechanism)
Phosphorous ↓ / nL Still getting kidney excretion
Urine calcium ↑ Lots of calcium in serum  excreting in urine
Urinary cAMP ↑ Downstream result of ↑ PTH receptor activation – by PTHrp!

Comparisons: Hypercalcemia of Malignancy

Mechanism Action Disease Labs

Osteoclast activating cytokines
LOH
Direct tumor invasion
PTHrp
Activates PTH receptor
Calcitriol High GI calcium absorption
Hematologic malignancy, MM
breast ca, solid tumors
Squamous, Renal cell, Breast
Lymphoma, Granuloma
Low PTH, Low 1,25, Low UcAMP
Low PTH, High PTHrp, High UcAMP,
Low phos, Nl/low 1,25
Low PTH, High 1,25, Low UcAMP

Excessive Vitamin D
Vitamin D Metabolism: Review

Intake: Sunlight (from cholesterol precursor) to vitamin D3; also GI intake

Metabolism:
 Liver: 25-hydroxylation to 25-OH-D3
 Kidney: 1-α-hydroxylation to 1,25-OH-D3 (active form)
o Feedback inhibition of 1αOHase
o Degraded by 24-hydroxylation (24OHase); excreted
 Both 25- and 1,25-vit-D can be degraded this way
Effects:
 Gut: active form  ↑ calcium and ↑ phosphorus

7
Vitamin D intoxication

Unregulated 1α-hydroxylase in play  lots of active vitamin D floating around

 Think sarcoid, TB, lymphoma

Granulomas & lymphomas – can produce 1α hydroxylase

 Mϕ in granulomas (TB, sarcoid, etc)
 Lymphocytes in lympomas

 Substrate driven calcitriol production, not controlled by PTH

Key lab findings

 ↑ urine calcium vs 1° hyperparathyroidism, because PTH isn’t high (no ↑ renal reabsorption)
 Normal or low cAMP (PTH isn’t high  no downstream signaling through its receptor!)

 Can also, but rarely, be caused by excessive vitamin D ingestion

Summary
• Serum calcium levels are tightly controlled by effects of PTH and 1,25 (OH)2 D on the bone, kidney and gut
• Hypercalcemia is common with a broad range of symptoms
• Mechanisms of hypercalcemia: increased bone resorption, increased GI absorption, decreased renal clearance

Primary Hyperparathyroidism—excess PTH production

Hypercalcemia of malignancy—PTHrp, osteoclast activating cytokines, direct bone invasion, calcitriol production
Vitamin D excess - granulomatous disorders

8
 Hypocalcemia
Review of Mineral Metabolism (in response to ↓ Ca)

↓ serum calcium, sensed by calcium sensing receptor

 Need intact CaSR to get PTH secretion!

Parathyroid: Calcium sensing receptor inactivated  ↑ PTH secretion

 Kidney: ↑ 1-α hydroxylation of Vitamin D
↑ Calcium reabsorption
↑ Phosphorus secretion
 Gut: ↑ absorption of calcium (via 1,25-OH-Vit-D)
 Bone: ↑ Ca+2 / PO4-2 resorption (release)

Etiology of Hypocalcemia

Parathyroid agenesis / destruction, autoimmune

Deficient synthesis or secretion of PTH
PTH-related ↓ parathyroid function
Deficient PTH action (PTH resistance) Pseudohypoparathyroidism
Nutritional deficiency, ↓ sunlight, ↓ GI absorption
Deficient vitamin D supply or activation 1a hydroxylase deficiency (renal failure or genetic)
Vitamin D- 25-hydroxylase deficiency (severe liver disease)
related Deficient vitamin D action vitamin D receptor defects (1,25-vit-D resistant)
Medications that alter vitamin D metabolism Anticonvulsants
Plasma chelators: phosphate, citrated blood products
Directly Chelation of calcium by
Bone chelators: bisphosphonates, gallium, calcitonin, cisplatin,
Ca-related bone or plasma chelators plicamycin, doxorubicin
Misc Pancreatitis, Rhabdomyolysis, Tumor lysis, Acute severe illness

Clinical manifestations of hypocalcemia

Severity dependent on:

 Level of ionized calcium (active form)
o Don’t get fooled by low serum albumin
(↓ total calcium, but same ionized calcium)
 Acuteness of onset (acute = more severe)
 Duration of hypocalcemia

Signs & Symptoms

System Signs / Sx
Eyes papilledema, cataract formation (vs corneal calcification in hyperCa)
Bones painful, fragile, radiolucent / erosions
Muscles spasms of skeletal muscles; cramps / tetany
Neuro  Mood changes, seizure, coma (also in hyperCa)
 numbness, paraesthesias (tingling – pins / needles)

Dental, skin defects

Resp laryngeal spasm, bronchospasm, muscle fatigue
Heart cardiac arrhythmias
 Q-T prolongation  Torsade de Pointes  can be fatal!

9
  Chvostek’s sign (nerve irritated)
o Tapping over parotid (facial nerve)  facial muscles twitch
o Present in 15% normal subjects
o Degree of response depends on degree of hypocalcemia
 Trousseau’s sign (BP on arm causes carpopedal spasm – tetany of muscles on hand)

Chvostek’s sign Trousseau’s Sign Prolonged QTc on EKG

Vitamin D Deficiency
 A leading cause of hypocalcemia: few dietary sources
 Almost all from ↓ vitamin D; rarely, from resistance to vitamin D

Synthesis / action: need intact skin, kidney, liver, gut

1. Absorption from diet or production from skin (sunlight)
2. Liver: 25-hydroxylation to 25(OH)D3
3. Kidney: 1α-hydroxylation to 1,25(OH)2D3 (active form)
4. Actions at target organs via vitamin D receptor
5. Eliminated by 24-hydroxylation (both 25 and 1,25-vit-D)

So for adequate function, you need:

 Source (sunlight + diet)
 Liver & kidney to do the hydroxylations
o & liver to make vit D binding protein
 Vitamin D receptors in target organs

Sources of Vitamin D: few!

 Sunlight exposure (> 90%)
 Fortified foods (milk / cereal – but need tons!)
 Fatty fish, codliver oil, egg yolks

Why is vitamin D important?

Intestines ↑ calcium / phosphorus absorption
 Promotes mineralization (maintaining Ca / Pi)
Bone  Mobilizes calcium (induces osteoclast differentiation)
 Stimulates osteoblast production of osteoclast-sensitive cytokines / hormones
 Suppresses 1α-hydroxylase in the kidney (feedback)
Kidney
 Enhances renal calcium reabsorption
Parathyroid Inhibits PTH synthesis / parathyroid cell growth (feedback)

10
Other, non-bone effects?
Cancer prevention ↑ vitamin D  more resistant to colon, bone, breast cancer
Immune modulation Kids in Finland: 85% reduction in type I DM with supplementation
Cardiovascular dz May be protective against stroke, CVD, etc.

Etiology of Vitamin D Deficiency

Defect
Deficient intake / absorption
Defective 25-hydroxylation
Loss of vitamin-D binding protein
Defective 1,25-hydroxylation
Defective target organ response
Examples
 Dietary
 Inadequate sunlight
 Malabsorption (gastrectomy, small bowel dz, pancreatic insufficiency)
 Liver disease
 Anticonvulsants
 Nephrotic syndrome (losing proteins)
 Renal disease
 Inherited enzyme defect
 Vitamin-D-dependent rickets type 2
 Vitamin D dependent rickets, type 2
 VD receptor defect

Clinical Consequences of Vitamin D Deficiency

 Osteomalacia / rickets  2° hyperparathyroidism
 Osteoporosis (decrease in bone mass)  Muscle pain / weakness

Osteomalacia Rickets
Pathogenesis Failure of the bone matrix to mineralize due to inadequate supply of mineral
Patients In adults In kids
Defects in mineralization of osteoid Defective mineralization of cartilage
Major defect throughout skeleton during endochondral bone formation
(matrix is there, but you’re not mineralizing it) at epiphyseal growth plate

Pics

Bow-legged; underweight (malnourished) Looser zones on radiography; widened osteoid seams

Rickets
Manifestation of nutritional deficiency (vitamin D, calcium, or phosphorus)

Risk factors
 Dark-skinned infants (need more sunlight exposure to make vitamin D)
o Sunscreen cuts down vitamin D synthesis too
 Urban centers
 Polar latitudes (or even Baltimore in the winter)

11
Osteomalacia
Clinical Presentation
(rickets similar in kids – just that growth plates closed in adults)
 Muscle weakness
 Skeletal pain (worsens with activity)
 Pain in lower back / hips
 Antalgic gait (shuffling, trying not to hurt)
 Fractures

Biochemical profile
Lab finding Why?
Alkaline phosphatase ↑ Marker of bone formation (↑ resorption from ↑ PTH here)
Calcium, phosphorus* ↓ or low nl Not absorbing in the gut! No vitamin D
PTH ↑ ↓ calcium (no vit D)
↓ 25(OH)D3 ↓ Good indicator of whole body vit D in people with intact kidneys
Urine calcium ↓ PTH is high – trying to recapture calcium; CSR helps too
*can present with hypophosphatemia alone!

Screening for Vitamin D Deficiency

25(OH)-Vitamin-D is best measure
 Even though 1,25-OH-Vitamin-D is active form
 25-OH reflects whole body store: circulates longer, not under PTH regulation (can get falsely normal 1,25-Vit-D)

1,25-vit-D: active form, half-life 4 hrs, concentration 1000x less, regulated by PTH

Hypoparathyroidism
 Parathyroid knocked out  absence of PTH
 Hypocalcemia and hyperphosphatemia (↓ Ca, ↑ phos) is hallmark lab finding
o Kidney isn’t excreting phosphorus (no PTH!)

Surgical destruction
Autoimmune destruction
Failure to develop
↓ PTH secretion
Mechanisms
(thyroidectomy, surgical dissection for cancer)
(autoimmune polyglandular syndrome type 1)
(DiGeorge syndrome)
(autosomal dominant hypocalcemia)

Physical Manifestations
 Subcapsular cataracts  Ectodermal changes (dry skin, coarse hair, brittle nails)
 Basal gangliar calcifications  Dental / enamel hypoplasia / absence of adult teeth

Basal ganglia calcification / cataracts

Dental / enamel hypoplasia, Ectodermal dystrophy (brittle nails),
(longstanding hypoCa, hyperPhos)
12
Biochemical profile
Lab finding Why?
Calcium* ↓ ↓ PTH  ↓ absorption, etc. (can’t respond to hypoCa)
Phosphorous* ↑ ↓ PTH  Not getting rid of phosphorous in urine
PTH ↓ By definition
25(OH)D3 Normal Dietary ingestion, liver function OK
1,25(OH)2D3 ↓ ↓ PTH  ↓ 1-α-hydroxylation in kidney
Urine calcium Relatively ↓ Except in autosomal dominant hypocalcemia
*Hypocalcemia and Hyperphosphatemia = think hypoparathyroidism

Autoimmune Hypoparathyroidism
 Isolated hypoparathyroidism or
 Part of syndrome (e.g. APS)

APS type 1 (autoimmune polyglandular syndrome)

 Newer name – APECED (autoimmune polyglandular candidiasis ectodermal dystrophy syndrome)
 AIRE1 gene
o Encodes transcription factor, expressed in immunologically related tissues (e.g. thymus)
o Functional loss  breakdown of immune tolerance to organ-specific Ag

Associated with:
 Hypoparathyroidism (93%)
 Mucocutaneous candidiasis (83%)
 Adrenal insufficiency (73%)
 Other components (2-40%)

If you see hypoparathyroidism + candidiasis + adrenal insufficiency, think APS!

DiGeorge Syndrome: Abnormal parathyroid gland development

FYI only – not on test
rd th
 Maldevelopment of 3 / 4 branchial pouches
 Congenital absence of parathyroids
 Impaired T-cell immunity  ↑ susceptibility to infection
 Characteristic facies
 “CATCH22” – cardiac, abnormal facies, thymic aplasia, cleft palate,
hypocalcemia with 22q deletion

Autosomal Dominant Hypocalcemia (Impaired PTH Secretion)

 Activating mutation of the CaSR

o Like flip side of FHH

 Low serum calcium with relatively high urine calcium

o ↑ CaSR activity in kidney!
o EXCRETING CALCIUM IN URINE!

13
Biochemical profile of autosomal dominant hypocalcemia
Lab finding Why?
Calcium ↓ ↓ PTH  ↓ absorption, etc. (can’t respond to hypoCa)
Phosphorous ↑ ↓ PTH  Not getting rid of phosphorous in urine
PTH ↓ CaSR mutated – constitutively on
Urine calcium* ↑ ↑ CaSR activity in kidney  lose calcium through urine!
Urine cAMP ↓ CaSR constituitively on  ↓ PTH  ↓ signaling through PTH receptor
*KEY FINDING – urinary Ca is ↓ in hypoparathyroidism!

Can also get ↓ PTH secretion with…

 PreproPTH gene defects (isolated hypoparathyroidism)
 Hypomagnesemia (impairs PTH secretion method)
 Hypermagnesemia (interacts with CaSR  activates  impairs PTH secretion)

PTH Resistance
Pseudohypoparathyroidism: a group of disorders with:
 biochemical hypoparathyroidism (hypoCa / hyperPhos),
 ↑ PTH secretion, and
 target tissue unresponsiveness to biological actions

Have enough PTH around, but problem is with PTH receptor

 Gsα doesn’t couple it to intracellular mediators correctly

Albright Hereditary Osteodystrophy

 Very distinctive, short stature
 Subcutaneous ossification
 Shortened 4th/5th metacarpals

But you can have same gene defect and not have hormonal manifestations – EPIGENETICS!
 Depends on which chromosome you have the defect on
 In some tissue (parathyroid, thyroid), expression is only from maternal gene

Mutation on Maternal chromosome Paternal chromosome

get Albright hereditary osteodystrophy look like Albright,
Phenotype
+ hormonal defects but don’t have hormonal defects
Name Pseudohypoparathyroidism type 1A Pseudohypoparathyroidism

Summary

• Serum calcium levels are tightly controlled

by effects of PTH and 1,25 (OH)2 D on the bone, kidney and gut
• Mechanisms of hypocalcemia include
vitamin D defects, deficient PTH secretion, deficient PTH action
• Osteomalacia and rickets— vitamin D deficiency
• Hypoparathyroidism—destructive, autoimmune, failure of parathyroid gland
development, PTH secretion
• Pseudohypoparathyroidism-PTH resistance

14
 Pharmacology: Bone
Disorders of Bone / Mineral Metabolism ............................................................................................................................... 2

1
 Disorders of Bone / Mineral Metabolism
The Bone Remodeling Cycle

Resorption: pre-osteoclasts join together to form osteoclasts,

(ruffled border, secrete H+, etc. – resorb bone)

Shift to laying down new bone (osteoblasts come in behind

osteoclasts), fill in with hydroxyapatite / collagen matrix, gets
mineralized.

Osteocytes are osteoblasts that get left behind, trapped in the

newly formed bone

Medications for Bone Disorders: Overview

Nutritional Inhibitors of bone resorption (anti-catabolic) Stimulators of bone formation Others
 bisphosphonates
 Calcium  recombinant parathyroid
 estrogen, testosterone  glucocorticoids
 vitamin D hormone (PTH 1-34)
 selective estrogen receptor modulators (SERMs)
 calcitonin

Calcium & Vitamin D

Insufficient calcium or vitamin D  ↑ PTH  ↑ bone resorption

Calcium
 ↓ fractures 30-50% (need vitamin D)
 Active & passive absorption throughout small intestine
o Active: 1st part of SI (duodenum), Passive: rest of SI
o If no duodenum: just ↑ calcium intake more  ↑ gradient  ↑ passive absorption

Recommended Calcium Intake: Male & Female Age Calcium (mg/day)

 listed as total intake (dietary + supplements) 0-12 months 210 (< 6mos), then 270
 can get into trouble with too much calcium – kidney stones, etc 1-3 years 500
4-8 years 800
 Labels based on 1000mg / day (3% = 30 mg)
9-18 years 1300
19-50 years 1000
Dietary intake: 50+ years 1200
 No calcium-rich foods in diet = ≈ 250mg / day Pregnant or Lactating Women
 Dairy products = 300g/ serving 18 years or younger 1300
 Broccoli, brussel sprouts, cabbage, etc. have some (60mg) 19-50 years 1000
 More with collard greens, bok choy, chard, etc. (150-250mg)
 Firm tofu (506mg) & almonds (378mg) have a lot
 Calcium fortified foods can help too!

Supplements: Hard to get enough calcium through diet alone (often need supplements)
 Different supplements have different % of supplement as elemental calcium
 E.g. CaCO3 is 40% calcium by weight (can use MW to figure it out).
 Carbonate > tricalcium phosphate > citrate > lactate > gluconate (only 9%)

2
Vitamin D: Physiology

In skin (or leaves if you’re a plant):

 In both animals (cholesterol) & plants (ergosterol), from sterol precursor

o Small difference in final product (D2, ergocalciferol) from plants
o But D2 has similar affinity for vit D receptor in liver / kidney

 Sunlight: opens ring;

o then spontaneous cistrans transformation in skin (trans-D3)

In body: Start off with D2/3 from skin / sunlight or ingestion (diet)

 25-hydroxylation in liver  25,OH-D3

o Need major liver damage to affect

 1-hydroxylation in kidney  1,25-(OH)2-D3 (active)

o More frequent: kidney damage affects this step
o When Cr ≤ 60 (relatively mild renal insufficiency),
start seeing ↑ PTH (↓ Ca absorption)

 24-hydroxylation of 25OHD3 or 1,25OHD3 to excrete

In target tissue: binds nuclear vitamin D receptor

 Need active form: 1,25(OH)2D3

 Somehow endocytosed into cell

 Binds nuclear vitamin D receptor

 Receptor in conjunction with RXR binds VDRE: vitamin-D responsive

elements to affect gene transcription, changing mRNA levels

Downstream effects:
Intestine Bone Immune cells Tumor microenvironment
↑ bone mineralization  ↓ proliferation
↑ absorption of Ca + Phos
 ↑ alk phos Induces differentiation  ↑ differentiation
 ↑ Ca-binding protein
 ↓ collagen  ↓ angiogenesis
Also inhibits its own 1-α hydroxylation & induces 24-hydroxylation – feedback! Blocks PTH action too

From sunlight:
 In most of USA, sunlight too weak to make vitamin D from September to March (incl. Baltimore)
 Getting harder & harder to get enough

Vitamin D: Optimal Status

Previously, lower limit of normal was ≈ 10 ng / mL (where bone defects start)
 But at these levels, PTH is all ramped up to maintain Ca homeostasis!

Now: at least 32 ng/mL (80 nmol/L) recommended

o Normalizes PTH, intestinal calcium absorption responds normally, fracture risk reduced
o This is a minimum – be generous ( need > 100 ng/mL) to have problems

3
Vitamin D deficiency: REALLY PROMINENT (>65, inpatients, even medical people!); Rickets starting to recur !

Dietary recommendations: probably way too low

 <50 (200 IU), 51-70 (400 IU), 71+ (600 IU), max 2000 IU
 800 IU / day with calcium: ↓ hip fractures

Dietary sources of vitamin D (IU) – very limited

 Fish: 200-350 IU (lots in cod liver oil)
 Dairy: 100ish IU
 Fortified OJ, beef liver, cereal bars, eggs – some but not much
 Multivitamin: 400 IU (pretty much everybody needs supplementation)

Pharmacologic formulations of vitamin D:

Oral Preparations Time to peak activity Duration of action Typical daily dose
cholecalciferol (D3)
4 - 8 wks 4 - 16 wks 400 - 1000 IU
ergocalciferol (D2)
calcidiol (25-hydroxyvitamin D) 2 - 4 wks 4 - 12 wks 50 - 200 µg
calcitriol (1,25 dihydroxyvitamin D) 1 - 3 days 1 - 3 days 0.5 - 1.0 µg

 Note: only ergocalciferol is available in prescription form

 IV calcitrol is the only parenteral form available (rarely used)
 Would only ever use calcidiol (25-OH) if severe liver failure
 Need to use calcitrol (1,25-OH) for renal insufficiency

Bisphosphonates
Target function of osteoclasts (no resorption  no bone formation)

Structure:
 P-C-P moiety (bind hydroxyapetite)
 R1 should be OH – enhances binding to hydroxyapatite
 R2 – determines potency
 Nitrogen-containing bisphosphonates are the ones used today

Mechanism of action
 Bind bone surface at remodeling sites (specificity!)
 Ingested by osteoclasts, cause cell death by one of two mechanisms:
Incorporated into ATP, produce cytotoxic analog
Non-N-containing BPs etidronate
Rarely used – can cause osteomalacia
Inhibit osteoclast mevalonate pathway(Farnesyl-PP synthase)
alendronate
N-containing BPs  Block prenylation of regulatory proteins 
zoledronic acid
 Stops resorption & causes apoptosis

4
 Mechanism of Action: non-nitrogen-containing bisophosphonate anti-resorptive agent.
 Eaten by osteoclasts, then incorporated into ATP, produces cytotoxic analog & subsequent cell death
etidronate Selective Toxicity: Binds hydroxyapatite (targeted to osteoclasts, which eat it up!)
Indications: older, not used much anymore
Toxicity: Causes osteomalacia!

For nitrogen-containing bisphosphonates in general: see below for distinctions

Mechanism of Action: nitrogen-containing bisophosphonate anti-resorptive agents.

 Inhibit farnesyl-PP synthase, in osteoclast mevalonate pathway
 so osteoclasts can't prenylate proteins

Effects: prenylation needed for membrane ruffling, vesicular trafficking, actin ring formation, OC survival.
 Inhibition leads to loss of osteoclast function and apoptosis!

Selective Toxicity: Binds hydroxyapatite (targeted to osteoclasts, which eat it up!)

Indications: osteoporosis, Paget's disease

Metabolism: biggest problem is that they're really hard to absorb

risedronate  for oral administration have to give 1st thing in morning with lots of water and wait 30 min to eat (60m
alendronate with ibandorate). Remain upright until after breakfast!
ibandronate  Fast / complete uptake into bone; slow release.
zoledronic acid  Excretion mainly renal - no metabolites. New agents: q7d or q1mo

Toxicity:
 upper GI disturbances with oral formulations.
 flu-like symptoms (fever / myaligia) with 1st IV dose.
 Musculoskeletal pain (can be diffuse; rarely systemic or severe. Can happen at any time in Tx!).
 Osteonecrosis of jaw (very rare; 1/50k)

Contraindications:
 Hypocalcemia (esp. if pt depending on bone supply for Ca - vit D deficiency, hypoparathyroidism, etc -
bisphosphonates would block!).
 Swallowing disorders (pill just sits there) or inability to remain upright after oral dosing (to protect
esophagus - don't go back to bed!).
 Significant renal insufficiency (CrCl < 30 mL/min)

Effective for Fx of…

Medication Non- Side effects Notes / doses
Spine Hip
spine
Alendronate    Upper GI Daily, weekly oral
Risedronate    Upper GI Daily, weekly, monthly oral
Bisphos

Monthly oral, quarterly IV

Ibandronate  Acute phase reaction
Used a little less than others
Yearly IV
Zoledronic acid    Acute phase reaction (25% after first dose) nd st
↓ risk 2 hip Fx after 1 !

5
 Estrogen (& testosterone)
 Major hormonal determinant of bone mass conservation in men and women
 Effects are complex: production, lifespan, function of osteoclasts / blasts

Major action: REDUCES BONE RESORPTION

 Normally: preosteoclasts’ RANK receptors bind RANK ligand
on stromal cells / osteoblasts, triggering differentiation into
active osteoclasts

 With estrogen: MORE OSTEOPROTEGRIN (OPG) PRODUCTION

o OPG – a “decoy receptor”
o binds RANK-L and covers it up
o Preosteoclasts’ RANK receptors can’t bind 
no differentiation into active osteoclasts

Estrogen is also the major regulator of bone mass in MEN! (not testosterone)
 Produced mainly by peripheral aromatization of testosterone (adipose tissue)
 Estrogen receptor alpha mediates most estrogen action in bone

Selective Estrogen Receptor Modulators (SERMS)

SERMS have different effects in different tissues (mimic estrogen in some; oppose estrogen in others) – but how?
 SERMS – not really structurally similar to estrogen
 Two estrogen receptors: α & β
o Different SERMS induce different conformations in the same receptor
o Receptors can bind directly to DNA or be tethered by other proteins
o Complexes can bind co-regulators – which can vary between tissues
 Effects vary – based on binding & cofactors present

Two SERMS primarily used clinically

Breast Uterus Bone
Tamoxifen antagonist agonist agonist
Raloxifene antagonist antagonist agonist
 Bolded things are good: antagonize estrogen in breast / uterus  ↓ cancer
o Raloxifene therefore has a more advantageous profile
 Raloxifene is the only one approved for bone (but also ↓ risk breast / uterine cancer)
 Tamoxifen used for breast cancer; but get bone effects too

Mechanism of Action: selective estrogen receptor modifier

 approved for use as an antiresorptive agent (bone effects).
 Estrogen agonist in bone, but antagonist in uterus / breast (good for cancer)
Effects: In bone: INCREASES OPG PRODUCTION (OPG binds to RANK-ligand on osteoblasts / stromal cells as a decoy
receptor, covering it up so that the pre-osteoclasts' RANK receptor can't bind and trigger differentiation into active
osteoclasts). Therefore decreases bone resorption.
raloxifene
Administration: daily oral dosing, no time restrictions.

Toxicity:
 thromboembolic events(1/2000 pt-yrs - an estrogen agonist effect!)
 Hot flashes & leg cramps(exacerbation in early post-menopausal women).
 CONTRAINDICATED IN THROMBOEMBOLIC DISEASE (PMH or even strong FHx).
 Careful in liver disease, no dosage change with age or renal insufficiency.

6
 Calcitonin
Naturally occurring peptide hormone made by thyroid C-cells
 But if you take out thyroid or get MEN with MTC, no bone effects – don’t know what it does @ physiologic doses

Mechanism of Action: recombinant calcitonin.

 Natural peptide (thyroid C cells), but physiologic function unknown.
 At pharm doses: inhibits bone resorption by binding to osteoclast GPCR
Effects: decreases bone absorption (slower effect) and increases calcium excretion from kidney (both lower calcium)

Indications: For initial treatment of hypercalcemia

 rapid calcium-lowering effect; increased urinary excretion of Ca reduces serum Ca ~ 2mg/dL.
recombinant  Often give calcitonin while waiting for bisphosphonate to kick in!.
calcitonin  Widely used for treatment of post-menopausal osteoporosis, but efficacy in question (no dose-response).
 Weak anti-resorptive agent, possible analgesic effect (bone and fracture pain).

Administration: nasal or subcutaneous, nasal gives less flushing, is primary way it's used today.
Toxicity:
 For nasal calcitonin: local effects (nasal congestion, irritation, sores. Epistaxis. Headache. Sore throat).
 For osteoporosis, is best tolerated but least potent.
Other: Salmon calcitonin used (more potent!)

PTH 1-34 (teriparatide)

First 34 of 84 AA in PTH (the “business end”)
 Stimulates both osteoclasts & osteoblasts
 If you give it intermittently (e.g. qd), you get more OB effects
o Given as daily subq injection

Effects: stimulates formation of normal bone

(thicker cortex & trabeculae)

Mechanism of Action: 1st 34 AA of parathyroid hormone (recombinant).

 PTH stimulates osteoblasts and osteoclasts, but intermittently OB > OC (continuously, OC > OB).
Effects: increases osteoblast number and function, while decreasing osteoblast apoptosis, leading to:
 net bone formation. Thickens trabecular bone and cortical bone.

Indications: Only for severe recalcitrant cases of osteoporosis.

 Only approved for two years use in whole life (trial stopped for osteosarcoma in rats).
Administration: once daily subcutaneous injection.
PTH (1-34)
(teriparatide)
Toxicity: Expensive and Sub-Q!
 Hypercalcemia (11% - some need to stop drug - from increased reclamation from urine).
 uric acid increased in 13%.
 Minor side-effects: nausea, headache, dizziness (8-9%), leg cramps(3%).

Contraindications: Any high bone turnover states: Hx of skeletal malignancies or prior radiation to skeleton. Pre-
existing hypercalcemia, unexplained alkaline phosphatase elevation, or Paget's disease. Worry - PTH could cause
malignancy? Osteosarcoma in rats - probably just a rat problem, but still...

7
 Clinical Applications: Hypocalcemic disorders
Hypocalcemia with HYPOphosphatemia
Dx: probably vitamin D deficiency

Treatment:
 IV calcium to stabilize (e.g. if serious – tetany, seizures, etc), then switch to oral calcium
 Short-term calcitriol for rapid vitamin D action
 Cholecalciferol for maintenance

Hypomagnesemia may contribute to hypocalcemia

 Impairs PTH secretion & causes PTH resistance in bone / kidney
 Need to correct to permit hypoCa reversal
 Use IV magnesium in acute situations (but watch out for renal insufficiency – Mg excretion impaired!)

Hypocalcemia with HYPERphosphatemia

Dx: probably hypoparathyroidism (renal function normal)

Treatment:
 Oral calcium needed, but LOWER SERUM PHOSPHATE FIRST (<5 mg/mL): dietary restriction & phos binders
o Or else you can get calcium phosphate complexes in the bloodstream!
 Vitamin D analogues eventually

Chronic hypocalcemia with NORMAL RENAL FUNCTION

Dx: probably partially compensated vitamin D deficiency

Treatment:
 Long-term oral calcium (1000-2000 mg/day)
 Reduced dairy intake if ↑ serum phosphate
 Long-term vitamin D

Chronic hyocalcemia, HYPERphosphatemia, and renal failure

Dx: classic metabolic derangements of chronic renal function
 Phosphate retention  exceed solubility product  soft tissue calcium deposition (ca-phos) & hypocalcemia
 ↑↑ PTH for two reasons
o ↑ serum phosphate → ↑ PTH secretion
o ↓ 1α hydroxylation of vitamin D  ↓ Ca (can’t absorb)  ↑ PTH

Treatment:
 ↓ serum phosphate (dietary restriction, oral phos binders with meals, even dialysis)
 When phosphate < 5mg/dL, supplemental calcium & calcitriol (no other form of vitamin D – need 1,25!)

Hypercalcemic disorders
Acute hypercalcemia
Dx: usually from ↑ bone resorption (previously also from milk alkali syndrome - ↑ intestinal resorption – but rare now)

Treatment of choice: intravenous bisphosphonate (e.g. zoledronic acid)

 Shutdown bone resorption  ↓ calcium

Can use parenteral calcitonin as an adjunct in first 48 h

 Rapid onset / offset, whereas bisphos action is delayed
8
Glucocorticoids for Hypercalcemia
Effective in 3 conditions:
 Hematologic malignancies (multiple myeloma, lymphoma)
 Vitamin D toxicity
 Granulomatous diseases with high calcitrol (1,25(OH)2D3)

Mechanism unclear: inhibitory effect of glucocorticoids on many actions of calcitriol

Osteoporosis
Calcium & Vitamin D
 Increases bone acquisition during growth, leading to ↑ peak bone mass  helps prevent later osteoporosis
 Slows age-related bone loss
 ↓ fragility fractures (especially hip in elderly)

Effective for Fx of…

Medication Non- Side effects Notes / doses
Spine Hip
spine
Estrogen /   Current use: <5yrs,
 ↑ risk breast cancer, thromboembolic events
progesterone perimenopausal
Raloxifene  Hot flashes, thromboembolic events ↓ risk breast cancer
Calcitonin  Flushing / nausea w/SQ; nasal preferable Studies small, high drop-out
Alendronate    Upper GI Daily, weekly oral
Risedronate    Upper GI Daily, weekly, monthly oral
Bisphos

Monthly oral, quarterly IV

Ibandronate  Acute phase reaction
Used a little less than others
Yearly IV
Zoledronic acid    Acute phase reaction (25% after first dose) nd st
↓ risk 2 hip Fx after 1 !
Teriparatide Hypercalcemia, local injection reactions
  Daily SQ injection
(PTH 1-34) Osteosarcoma in rats w/ prolonged exposure

Notes:
 most were tested in high risk pts except estrogen / progesterone (Women’s Health Initiative)
 Bisphos were generally tested in daily dosing; now longer dosing intervals
o Fx data assumed from bone density similarities, but more rigorous studies would be nice
o Zoledronic acid is the exception – originally tested in yearly IV

Paget’s Disease
Bisphosphonates are the treatment of choice
 Higher doses than osteoporosis
 Treat for limited period of time (2mo, 6mo, etc) & stop – can be effective for years
o Re-treat if Paget’s dz changes come back!

 Use IV preparations (pamidronate, zoledronic acid) for severe disease (more potent)
o at same dose as for osteoporosis

 Indications for treatment:

o Pain
o involvement of site related to complications (long bone - Fx, skull – hearing loss, lumbar spine - Fx)

9
 Pharmacology: Psych
Introduction to Psychopharmacology ..................................................................................................................................... 2
Antidepressants ...................................................................................................................................................................... 4
Sedatives ................................................................................................................................................................................. 9
Neuroleptics .......................................................................................................................................................................... 13
Mood Stabilizers ................................................................................................................................................................... 18
Stimulants ............................................................................................................................................................................. 21
Behavioral Pharmacology of Substance Abuse ..................................................................................................................... 24
Pharmacotherapy of Alcohol Dependence ........................................................................................................................... 29
Opioid Dependence .............................................................................................................................................................. 34

1
 Introduction to Psychopharmacology
Ancient History
 Hellbore: emetic (white hellbore), laxative (black hellbore) – calming effect. Aristophanes.
th
o 19 c. – hard to dose, can cause seizures (higher doses) – stopped using
th
 Opiates: Euphoriant (poppies, 3000 yrs BC, Sumerians). Sleep inductions / anesthetic (Hippocrates, Galen). Morphine (19 c – isolated
from opium; used in military)
 Rauwolfia (snakeroot): India, used as remedy for insanity. Contains bioactive chemicals (e.g. reserpine)
Slightly less ancient history
 Chloral hydrate: chlorinated alcohol (sedative / hypnotic). When added to alcohol: “slipping a Mickey (Finn)”

th th
Bromine / bromide: sedative, popular late 19 /early 20 c. Part of Bromo-seltzer cocktail
 Scopolamine / hyoscine: from nightshades, sedatives
 Barbituates: Bayer, 1912: Phenobarbital (Luminal) – sedative / hypnotic

Modern era

st
1949: paper describing lithium (1 mood stabilizer)

st
1952: Chlorpromazine (1 antipsychotic)
 Throughout 50s:
o antipsychotics (reserpine), anxiolytics (meprobamate), etc.
 Since this “golden era”:
o not many new drugs (most are derivatives of older drugs)

Reserpine & the biogenic amines

 Used to treat HTN
o Nathan Kline – gave to agitated pts (incl. SZ pts), saw antipsychotic effects
o Depression in some too
 What’s it doing? Inhibiting vesicular monoamine transporters (depletes brain of dopamine, norepi, serotonin)

Other biogenic amines

 Iproniazid: inhibits monoamine oxidase (↑ dopamine, norepi, serotonin levels)
 Imipramine: blocks reuptake of norepi into neuron, so ↑ amount in synapse (tricyclic structure)
 Chlorpromazine: blocks dopamine receptors (antipsychotic)

Later developments
 Anticonvulsants as mood stabilizers (carbamazepine, valproic acid, lamotrigine) – for bipolar disorder
 Serotonin selective reuptake inhibitors (zimelidine, fluoxetine, 5 others) – for depression
o 1st example of rational drug design

The Current State of Affairs

Meds good but not great
 Work about 2/3 of time, sometimes miraculously well
 Often take several weeks to work, if they’re going to work
 Med trials often go several months with gradual dose increases
 Side effects common (weight gain, sedation, movement abnormalities)

STARD trial: about 60% of people respond to first med.

 Try other ones: about 10% more respond
 But “getting better” is often ≈ 50% better, and 50% relapse

2
 Future Directions
Need new ideas (better understanding of pathways, etc).

Glutamate hypothesis
 Schizophrenia: traditionally thought of as a dopamine disorder (with glutamine involved too)
 PCP / ketamine induce SZ-like sx – and act at NMDA / metabotropic glu receptors
 Studies of NMDA receptor modulators as adjuncts to therapy (glycine, D-serine, D-alanine, etc) – but inconclusive results
 Eli Lilley study: agonist of metabotropic glutamate receptors dampens glutamate response (feedback), positive results
o Subsequent studies: has no effect on weight, but maybe no effects in follow-up trials?

Progress from etiology

From perspectives: reason disease perspective (etiology  pathology  syndrome)
 Knowing etiology: what is “druggable” in the pathogenic pathway

DISC1
 “Disrupted in schizophrenia” 1
 Started with pedigree analysis, disrupted in a t(1;11)(q42.1;q14.3) translocation which segregates with schizophrenia and
related psychiatric disorders in a large Scottish family (thanks, Wikipedia).
 Various functions; including regulation of neuronal migration, mutants have enlarged ventricles
 Has helped enable drug discovery – see which pathways DISC1 interacts with; target those?

Genetic Studies
 Whole genome association studies (SNPs, microarrays, and whatnot).
o Compare SNPS in affected vs. control, see if you can find regions of the genome associated with disease.
o But small, incremental effects.
 Copy number scans: copy numbers may be important in autism, SZ
o 16p11.2 microduplications (3 or 1 copies) – SZ, autism; 3 copies - BPD
o 1q21.1 - BPD
 Epigenetics: genome-wide methylation studies (BPD, depression, SZ, autism) – druggable targets?
o Meds exist to inhibit DNA methylation & histone deacetylation (but lack specificity)

Overlap in genetics – e.g. one gene, ↑ risk many genes – may correspond with overlap in meds’ effects!

Pharmacogenomics
 Can we predict who will respond to which med? Who will have which side effects?
 First major studies completed (MDD / BPD)
 Beginning a pharmacogenetics of lithium study (using drug-responsiveness as phenotype, do GWAS)

Summary
 Psychopharmacology has ancient roots
 The modern era of seminal discovery was from 1949-1960
o Discovery of antipsychotics, antidepressants, anxiolytics, and mood stabilizers
o Almost all medications since then are derivative
o The biogenic amines, esp serotonin, norepinephrine, and dopamine, have been focus
 Need new understanding of etiology / pathogenesis to make progress; e.g. hyperglutamatergic function
 Genetic advances may create new targets; DISC1 an example
 New approaches, including study of genome-wide association, copy number variation and epigenetic marks,
should speed advances

3
 Antidepressants
What is Depression?
Mood: degree of well being, experienced more or less habitually
 Range of “normal” mood variation not well defined – ill-defined neurobiology of normal mood states
 Neurobiology of abnormal mood states better defined (e.g. depression)

Symptoms vs. disorders

 Symptoms in isolation don’t equal a psych disorder: need to meet specific criteria
o clustering in time, length of time, severity (interfere with functioning at work or at home)
 Disorder: cluster of symptoms that “take on a life of their own”

Mood disorder: change in mood which is

 pervasive, sustained, not influenced by outside events and
 accompanied by vegetative (energy, sleep, appetite) & psychomotor disturbances

 Needs to be departure from person’s normal functioning

 Tends to recur over time

Bipolar disorder & major depression are the major mood disorders

Major Depression

Major depressive episode: 5 of the following for at least 2 weeks

 Depressed mood  Psychomotor agitation or retardation
 Diminished interest / pleasure  Fatigue or loss of energy
 Wt loss or ↓ appetite (occasionally ↑)  Poor concentration
 Sleep disturbances (insomnia or hypersomnia)  Thoughts of death or suicide
Must cause clinically significant dysfunction

Bipolar disorder
Bipolar I disorder Bipolar II disorder
Requires at least 1 manic* episode Requires at least 1 hypomanic* episode
Generally: recurrent depressive & manic* episodes Generally: recurrent depressive & hypomanic* episodes
Spend ≈ 30% time depressed, ≈ 10% manic, ≈ 5% cycling Spend ≈ 50% of time depressed, much less hypomanic
*manic = dangerous behavior & psychotic symptoms,
*hypomanic = ↑ pleasurable activity, etc. but not psychotic / dangerous

Epidemiology of Mood Disorders

Disorder By gender Prevalence
Major depression Females > Males 15-25% vs 4-12%
Bipolar I Females = Males ≈ 1%
Bipolar II Females > Males 2x higher in F; ≈ 3-5%

Burden of Mood Disorders

 Unipolar Major Depression = #2 for DALY (disability-adjusted life years) – after ischemic heart disease
 Mortality: about 10-15% of pts with MD, 15-20% with BPD will die of suicide
o Having depression of any type doubles your chances of death at any age, independent of suicide (e.g. cancer pts)

4
Depression: is it Major Depression or Bipolar Depression?
Major depression Bioploar depression
 Anxiety  Insomnia (initially)  Atypical features  Hypersomnia
 Somatic Cx  Pain sensitivity  Mood lability  Psychotic features
 Psychomotor agitation  Weight loss  Psychomotor retardation?  Substance abuse
 Loss of appetite  Irritability  Quick response to antidepressants*
*if a patient suddenly gets better really quickly – be worried about BPD + overshoot!

Treatment of Bipolar Disorder: Mood Stabilizers

Mood stabilizers Adjunctive Mood Stabilizers
 Lithium  Lamictal
 Depakote  Topiramate
 Carbamazapine  Atypical antipsychotics

Antidepressants vs Mood stabilizers

Antidepressants Mood stabilizers
elevate mood in the mood disordered
promote mood stabilization in long run
(depressed  neutral, or depressed  manic)
(↓ depression by ↑ neutrality)
(maybe neutral  manic?

Standard of care: use MOOD STABILIZER first (alone or add antidepressant – lamotrigine, quetiapine)
 Don’t want to overshoot! Mood stabilizer helps keep things anchored towards neutral mood

st
Lithium / lamotrigine = 1 line; ECT/Li+antidepressant if severely ill. Add more PRN.
 See mood stabilizers lecture for more detail

Historical Treatment of Depression

Early antidepressants
Iproniazid: an MAOi
 TB med, noted to cause euphoria (1952),
antidepressant (1957), 7 MAOi meds developed
 Eventually withdrawn due to hepatotoxicity
 ↑ amines (dopamine, norepi, serotonin)
Imipramine: a tricyclic
 Developed in search for new antihistamines,
antidepressant effects (1957-60s), most widely used
1960s-90s
 Inhibit serotonin / norepi reuptake

Pathogenesis of Depression
Biogenic amine hypothesis
Major depression caused by deficiency in CNS concentration or receptor function of neurotransmitters
 Biologic amines: Norepi, epi, dopamine, serotonin
 Based on observed mechanism of tricyclics, MAOis, Reserpine (↓ CNS biogenic amines  depression in humans / animals)

5
Catecholamine hypothesis
Depression caused by deficiency of catecholamines (particularly norepinephrine)
Mania caused by an overabundance of catecholamines
 Variation: theres’ a relative increase in CNS cholinergic activity in comparison to noradrenergic activity in depression

Serotonergic Hypothesis
Depression caused by deficiency in serotonergic neuronal function
 Subgroup of pts have low CSF concentrations of 5-H1AA (serotonergic metabolite), more likely to commit suicide
o ↑ postsynaptic receptors in depression (indicates ↓ serotonin)
o Subgroups? “seritonergic vs noradrenergic” depressions?
 ↑ serotonin, norepinephrine  antidepressant effects (↓ breakdown or ↓ reuptake)

Problems with the biogenic amine hypothesis

 Antidepressants increase neurotransmitter levels quickly (days) but pts don’t improve for weeks
o Some pts don’t respond, or develop treatment resistance
 More likely: “downstream effects” lead to antidepressant effects

Classes of Antidepressants
4 major classes of antidepressants
Monoamine oxidase
Selective Serotonin Reuptake Inhibitors Dual action*/Atypicals Tricyclics
inhibitors (MAOI)
Generally block reuptake Irreversible inhibitors of MAO
Block reuptake of
Block reuptake of serotonin only of norepi & serotonin (A+B)  ↑ norepi, dopamine,
norepi & serotonin
(± dopamine) serotonin
 Venlafaxine
 Fluoxetine  Fluvoxamine  Nortriptyline
 Nefazodone  Phenelzine
 Sertraline  Citalopram  Desipramine
 Buproprion  Tranylcypromine
 Paroxetine  Escitalopram  Imipramine
 Mirtazapine

*SNRIs: serotonin – norepi reuptake inhibitors (not selective – these are dual action!)

MAOIs
Mechanism of Action: MAOI antidepressants.
 Inhibit monamine oxidase, (A+B), increasing norepi, dopamine, serotonin levels

Effects: Can be a miracle drug for some patients (although risky)

Indications: Major depression, BPD (with mood stabilizer 1st)
phenelzine
Administration: Dietary restrictions (low tyramine diet - no cheese, aged meats, wine)
(Nardil)
Toxicity:
 LETHAL in OD or combined with other meds.
tranylcypromaine
 Orthostatic hypotension is most common (can limit use).
(Parnate
 Also hypertension reaction to food with tyramine, sexual dysfunction, GI
disturbance, peripheral edema

Interactions:
 Can't use OTC cold meds
 Must be off of all other antidepressants for 1-2 wks before starting

6
Tricyclic Antidepressants
Mechanism of Action: tricyclic antidepressants
imipramine
 block reuptake of both norepinephrine & serotonin, so increased levels
(Tofranil)
Indications: major depression, BPD with mood stabilizer 1st.
amitriptyline
 Can be uniquely effective in certain patients (elderly or pts with chronic pain)
(Elavil)
Toxicity:
nortriptyline
 LETHAL in overdose. High side effect profile:
(Pamelor)
 sedation, orthostatic hypotension, EKG changes, dry mouth, bad constipation

SSRIs
Mechanism of Action: SSRI antidepressants.
 Selectively block serotonin reuptake (hence the name).
fluoxetine (Prozac)
Indications: Generally first line of treatment (mild side effect profile) for depression
sertraline (Zoloft)
 also for anxiety
paroxetine (Paxil)
Administration: once-a-day
citalopram (Celexa)
Toxicity: Few drug interactions; not lethal in overdose (good for suicidal pts!).
 Headaches, GI upset, sexual dysfunction.
escitalopram (Lexapro)
 Can cause sedation (give at night) or activation (decreased sleep, increased anxiety) -
no way to tell which patients ahead of time.

Dual action
Mechanism of Action: Dual action antidepressant - act on more than one neurotransmitter system
venlafaxine Effects: generaly block reuptake of norepi & serotonin +/- dopamine.
(Effexor)
 No tricyclic structure. May have superior efficacy, maybe faster onset of action?
duloxetine
Indications: For patients who don't respond to SSRIs
(Cymbalta)
Toxicity: varies by drug!
bupropion
increased diastolic blood pressure, GI distress, stimulating Sx
(Wellbutrin) venlafaxine (Effexor)
withdrawal syndrome (rapid-onset after missing one dose – can ↑ compliance!)
duloxetine (Cymbalta) GI distress, sedation, dizziness
mirtazapine
bupropion (Wellbutrin) often stimulating, lowers seizure threshold, tachycardia / higher BP
(Remeron)
mirtazapine (Remeron) very sedating (use for sleep), increased appetite with significant weight gain

General principles of prescribing antidepressants

 What’s worked in this patient before? FHx of successful treatment?
 Use the side effect profile - mainstay of choosing which one to give!
o sedating vs activating, appetite stimulating, sexual side effects
SSRIs often 1st line because safe in OD and relatively few side effects
Dual action also widely used – bupropion & mirtazapine unique (no sexual side effects)
TCAs not 1st line (lethal in OD, frequent side effects)
MAOIs used infrequently (need low tyramine diet to avoid HTN crisis)
 Co-morbid symptoms:
o SSRIs for anxiety
o TCAs / Effexor for chronic pain
7
Tell the patient:
 No improvement may be noticeable for 2-4 weeks
o 8 wks at maximum dose should be attempted before declaring the agent a failure
o Improvement continues for up to 3 months after starting
 Side effect complaints correlate with severity of depression & frequently improve as depression improves
o Tell pt ahead of time & try to work through it!

Response to antidepressants
st
Regardless of class, 1 time exposure to antidepressant produces 50-60% response rate
 Remission (full resolution) occurs in about 1/3 of patients
 Pts who fail 1st line treatment are less likely to respond to a second antidepressant trial

Electroconvulsive therapy (ECT)

 Produces approximately 90% response rate (clearly the most effective current treatment)

Mechanism of action: unknown, hard to study: maybe generalized ↑ in neurotransmitter function?

 ↑ glutamate (excitatory) release, ↓ NMDA receptor function
 A “big gun” – use it when you need it
 Takes on average 6 treatments (with range of 3-12, can be more)

Duration of treatment
Patient Duration
1st time episode 6-12 months of treatment
Chances of recurrence approach 95-98%
After 2 major depressive episodes
Treat for several years to lifetime – 70% ↓ in relapse over up to 3 yrs

Other uses for antidepressants

 Panic disorder  Anxiety  Insomnia
 OCD  Chronic pain  Migraine prophylaxis

New Drug Development (not for test)

Goals: want faster onset, ↑ % responders, treatment for resistant patients
Methods: rodent models (tail suspension test, forced swim test?)

Other pathways: “downstream effects”

 BDNF, CREB: lead to ↑ neurogenesis
o ↓ neurogenesis in MDD? Smaller hippocampi in MDD, antidepressants  ↑ hippocampus size: via BDNF pathway?
 Glutamate: may be overactive in depression; NMDA receptors ↓ with ECT / antidepressants
o Ketamine: NMDA antagonist – maybe a rapid onset of action? 71% response in 24h?

Summary
 People with MDD (and sometimes BP) need antidepressant medication
 Many antidepressants on the market; each works ≈ ½ the time
 Choice determined by side effect profile
 SSRIs / dual action agents are first line
 Synaptic monoamines – serotonin / norepi – play important mechanistic role
o Other pathways (BDNF / glutamate) probably involved
 Need new, faster, better drugs

8
 Sedatives
Definitions
Term Definition
Sedative a compound that produces sedation, calmness
Hypnotic a compound used to promote sleep
Sedative/hypnotic a compound with both effects (most sedatives also used as hypnotics)
Anxiolytic a compound that eliminates anxiety w/o sleepiness, essentially identical to a sedative
a compound that reduces aggression or hostility
Tranquilizer
sometimes applied to anti-psychotics (e.g., phenothiazines), sometimes to sedatives
Note: trazodone & tricyclic antidepressants cause sleepiness – should dose at night!

Benzodiazepines
Benzodiazapines bind the benzo receptor  potentiate GABA  more Cl inflow
 Sleepiness & sedation!
 Increase frequency of Cl channel opening

Metabolism:
 Both parent compounds & multiple intermediate metabolites active @ benzoR

 Many steps in metabolism

 Some drugs have shorter, some have longer half-life

o Depends on how long of a metabolism they have to
go through – something at the end of the pathway /
with faster steps will have a shorter half-life!

 Most metabolism through CYP3A4 system in liver

 Glucuronide conjugates are excreted in urine

Short half-life (2-10 hrs) Intermediate half-life (10-15h) Long half-life (≈ 1d+)
 chlordiazepoxide (Librium)
 temazepam* (Restoril)
 diazepam (Valium)
 triazolam (Halicon)  lorazepam* (Ativan)
 clorazepale (Tranxene)
 oxazepam* (Serax)  alprazolam (Xanax)
 flurazepam (Dalmane)
 halazepam (Panipam)
 prazepam (Centrax)
Not metabolized by CYP3A4: oxazepam, lorazepam, temazepam
not affected by drugs, etc. that interfere with CYP3A4!

Age-dependent response to benzos

 ↓ dose needed with older age
o ↓ liver metabolism: ↑ drug concentrations
o ↓ plasma concentration of drug needed: more sensitive to drug effect
 Titrate dose to effect – e.g. for colonoscopy

Tolerance to benzos
As you continue to give the drug regularly / day after day, pt’s response becomes blunted over time
 To get the same response, you need to ↑ dosage
 The more you give the medicine, the less effective it is (best to give infrequently)
 For short-term insomnia use only‼ (e.g. mother just died, etc – 10 pills and that’s it).
9
Experiment: give drugs on a daily basis, see how sleepy they are early and late in sleep over time
 Early, all patients on short & long-acting benzos are sleepier both early & late in sleep cycle
 Later, short-acting benzo patients are more awake late in their sleep cycle (tolerance – wearing off)
 Eventually, all patients (long- and short-acting benzos) will be more awake late in sleep cycle

Flumazenil
Mechanism of Action: imidazobenzodiazepine, a specific antagonist acting only at CNS benzo receptor
 not at other benzodiazepine binding sites (e.g. kidney)

Effects: actively displaces benzos from receptor but has little or no facilitating action on GABA transmission

Indications: undo benzo effects (overdose, bring people out of benzo treatment)
flumazenil
Toxicity: If you give after long-acting benzos, RE-SEDATION can occur
 (flumazenil - half life 40-80m - wears off before long-acting benzos - 24h half-life).
 Short-acting benzos have about the same half-life (don't see the problem)

Metabolism: eliminated by liver, half life is 40-80m

The “Z-drugs”
Three z-drugs, bind benzo receptors.
All work the same & have same side effects – but with really different prices!
 Zolpidem (Ambien) now available in generic; others are really expensive!

Mechanism of Action: Benzodiazepine receptor agonist (although chemically unrelated to benzos)

For all three: Effects: Potentiates GABA (increased frequency of chloride channel opening)
Differences are slight: they’re all really similar and $$ but only zolpidem (Ambien) available in generic
Indications: sleep aid; has little effect on stages of sleep; EEG changes similar to benzos.
zolpidem
 Few / no anxiolytic / antconvulsant / muscle relaxant effects.
(Ambien)
Other: Now available in generic!
Toxicity:
zaleplon  potential for abuse/dependence
(Sonata)  next-day somnolence / antegrade amnesia, rebound insomnia @ high doses.
Metabolism: CYP3A4 metabolism, short duration of effect, rapid onset.
eszopiclone Metabolism: longer half-life than other z-drugs
(Lunesta) Other: expensive but great marketing in USA (really popular)

Barbituates
 Bind at or near GABA receptor: ↑ duration but not frequency of opening
 Not used that much anymore for sedative / hypnotic effects!

Melatonin
 Modulates circadian rhythm
 Released from pineal gland in response to environmental light-dark signals
 Short half-life (20-30m), not specific for MT1 / MT2 receptors (key in circadian rhythm) vs MT3
o Can buy in health food stores!

10
Ramelteon: Pricey compared to benzos!
Mechanism of Action: melatonin receptor agonist
 (selective for MT1/MT2 receptors - mediate circadian rhythm in mammals)
 MT1 = sleepiness, MT2 = biological clock
Effects: reduces sleep latency (7.5-16m) but not really sleep maintenance.

Toxicity:
 No rebound insomnia & withdrawal effects
ramelteon  Teratogenic in rats (avoid in pregnancy?)
 Increases serum prolactin - infertility & osteoporosis?

Metabolism: 1-2.6h T(1/2) metabolized by CYP1A2, but also CYP3A4/2C9

 look out for inhibitors (could lead to toxic concentrations); inducers (rifampin) can ↓ effects.
 High fat meals impair absorption.

Other: not a controlled substance!

Antihistamines
Mechanism of Action: antihistamines, can cause sedative effects
Effects: Think of them as mild, OTC sedatives (often given for sedation)

diphenhydramine Toxicity: Can cause:

(and other  next-day sedation
antihistamines)  impairment of performance skills (like driving)
 troublesome anticholinergic effects (dry mouth, urinary retention)

Other: diphenhydramine = benadryl

Dosing & overdosing drugs for sleep

Lots of people want sleep pills; lots of worry about it, lots of overuse of these drugs

Oral benzos: can contribute to lethal overdose, but rarely if ever induce lethal overdose alone!
 Fatalities almost always involve concurrent alcohol or other CNS depressant use!

Approach to sleep problems:

 Don’t just give pills – INSOMNIA IS A SYMPTOM, NOT A DIAGNOSIS
o Why is the patient not sleeping? CHF? Depression?
 Look at other ways to treat too – drugs cause problems; avoid if possible!
o Use lowest dose of fewest # of drugs. 0 is best.
o Look for lifestyle changes
 Generics are cheaper than brand names

OTC sleep drugs: Look out for other ingredients (e.g. acetaminophen if taking Tylenol for other stuf too!)

11
Drugs can cause insomnia!
 Antihypertensives (β-blockers, clonidine, methyldopa, reserpine)
 Anticholinergics (ipratropium bromide)
 Hormones (OCP, thyroxine, cortisone, progesterone)
 Sympathomimetics (bronchodilators – albuterol, etc.; xanthine derivaties, decongestants – pseudoephedrine!)
 Antineoplastics
 Others (Caffeine – in anacin, Excedrin, cough/cold preparations; levodopa, nicotine, others!)

Anti-anxiety medications
Buspirone is the only pure anxiolytic

Mechanism of Action: The only FDA-approved pure anxiolytic

 mechanism of action unknown (maybe serotonin receptor stimulation, dopamine effects?)
Effects:
 no significant affinity for benzo receptor or effects on GABA binding.
buspirone
 Produces anti-anxiety effects without sedation or hypnosis. Just as effective as a benzo.

Indications: Alternative to benzos for someone with just anxiety

Administration: 2-3x/day dosing (a little bit of a nuisance)

12
 Neuroleptics
History
Henri Laborit: trying to calm down patients with antihistamines before surgery
(promethazine); asked Rhone-Poulenc drug company to give him a more
sedating drug (chlorpromazine – wasn’t a good drug b/c too much sedation)

Chlorpromazine – used for calming effects (↑ doses to psychotic pts, incl. manic
& schizophrenic pts – Deniker / Delay 1952), but the dose needed differed big-
time between patients
 Neuroleptics – Gr., to “clasp the neuron” – would cause Parkinsoninan
neuro side effects at the same dose for a given patient that brought
about antipsychotic effects (but different between ts)
 Some pts were having anti-psychotic effects without sedation – a
unique antipsychotic effect
 Both manic / schizophrenic psychoses affected (suggesting a
generalized antipsychotic action?)
 Schizophrenic pts affected more – unique antischizophrenic effect?

How do we know these are antipsychotic & not just sedating?

 Minimally sedating neuroleptics are just as antipsychotic as heavily sedating ones
 Classical sediatives (e.g. phenobarbitol) don’t relieve schizophrenic symptoms to any significant effect
 Neuroleptics quiet hyperactive pts but make retarded pts more active

Biochemistry
 Phenothiazines (phenol ring, thia = sulfur, zine = side chain)
 Kind of look like norepi / dopamine (amine rings)

Chlorpromazine: the prototype, a phenothiazine

Promazine: no chlorine, less efficacious

Haloperidol: very different structure (butyrophenone) but same pharm effects!

Mechanism of Action: Blockade of Dopamine Receptors

Conformational evidence: ↑ antipsychotic potency (↓ daily dose needed) with ↑ ability to mimic dopamine structure
 Substituents on one phenothiazine ring & side chain amine can place ring / amine
in relationship that mimics dopamine  ↑ potency

Dopamine receptor blockade:

 Antipsychotic potencies correlate better with blockade of dopamine D2 receptors
than with effects on other receptors where neuroleptics are potent (e.g. serotonin
5HT2 or histamine-H1 receptors)

Dopamine receptor subtypes: 5 known kinds

 D1-like: (D1 & D5) ↑ adenylate cyclase activity
 D2-like (D2, D3, D4) ↓ enzyme activity
 More potent drugs – block D2-like receptors more! (e.g. haloperidol – potent at D2, not at D1)

Sites of action:
Can explain therapeutic effects & side-effects
 extrapyramidal Parkinsonian side-effects
 ↑ in plasma prolactin (dopamine blocks PRL release) – can cause sexual dysfunction & amenorrhea)
13
Extrapyramidal regions
 Most prominent dopamine pathway in brain
 Cell bodies in substantia nigra  caudate, putamen (corpus striatum)
 regulates extrapyramidal motor function
 Block  extrapyramidal side effects

Limbic regions
 Cell bodies in ventral tegmental area (midbrain) 
nucleus accumbens, olfactory tubercle, central
amygdaloid nucleus, prefrontal cerebral cortex
(incl. anterior cingulate gyrus)
 Regulates emotional behavior
 Probably leads to antipsychotic effects

Hypothalamic sites
 Cell bodies in arcuate nucleus of hypothalamus 
median eminence / portal system of capillaries (regulates anterior pituitary gland)
 Blocks prolactin secretion, so neuroleptics  ↑ prolactin (amenorrhea)

Clinical Ramifications (Differential Localizations)

 D3, D4 may be more relevant to antipsychotic effects with lesser side effects (esp. extrapyramidal)
o more concentrated in limbic regions
 A few D4-selective agents have been tried, but not antipsychotic; less clinical data for D3 antagonists

Atypical Neuroleptics
Clozapine is prototype; newer drugs
 Have less extrapyramidal side-effects & no tardive dyskinesia
 Benefit negative as well as positive symptoms! (important for resuming good roles in society)

Positive Negative*
 Affective flattening
 Hallucinations
 Paucity of speech
 Delusions
 Apathy
 Bizarre behavior
 Anhedonia
 Formal thought disorder
 Social inattentiveness
*spectrum – from “withdrawal” to “failure to interact” to “wallflower”
*actually often more disabling than the positive symptoms!

Side effects of clozapine

 Can cause idiosyncratic agranulocytosis (can be fatal!) in about 1% of patients
o Was taken off market; reintroduced (do frequent hematology)
 Quite sedating
 Postural hypotension
 Major anticholinergic side-effects
 Causes drooling

14
Newer atypicals: Don’t cause agranulocytosis and cause less sedation
olanzapine (Zyprexa) really good, most effective, chemically similar
risperidone (Risperdal) developed by finding a compound with a similar receptor blocking profile to clozapine
aripiprazole (Abilifiy) somewhat unique in dopamine agonist activity at presynaptic receptors (inhibit dopamine release)
quetiapine (Seroquel), ziprasidone (Geodon) too

Mechanism of action of atypical?

 Blockade of D2 receptors is suggested to produce antipsychotic effects against positive symptoms
 Blockade of serotonin 5HT2 receptors suggested to explain efficacy of atypical against negative symptoms
o Almost all neuroleptics block 5HT2 potently, but atypicals are more potent against 5HT2 than D2

Indications:
 Lesser side-effect profile – have been used in many non-schizophrenic patients
 Agitated Alzheimer’s patients (but may lead to earlier death with negligible therapeutic benefit)
 Often used in delirious patients too

Neurologic Side-effects of Neuroleptics

Acute extrapyramidal effects
 Can mimic Parkinson’s (rigidity / tremor) or
 Involve akathisia (motor restlessness – can’t sit still) / abnormal movement

Parkinsonian symptoms: PD pathogenesis = degeneration of nigrostriatal dopamine pathway

 blocking striatal dopamine receptors with neuroleptics probably causes these side effects
 but different drugs have different incidences of these side effects!
High incidence piperazine side chain phenothiazines, butyrophenones (haloperidol)
Low incidence Clozapine, thioridazine
Why?
 Classical anti-Parkinsonian drugs (before L-DOPA) worked by blocking muscarinic receptors
 Neuroleptics themselves are anticholinergic to varying degree
 So they antagonize own tendency to produce extrapyramidal side effects
 Maybe drugs that are more anticholinergic cause fewer extrapyramidal effects? Can be given + anticholinergic!

Tardive dyskinesia
 Generally occurs after prolonged treatment (tardive) with high doses of neuroleptics
 Symptoms are opposite of acute extrapyramidal reactions
Parkinsonian acute effects rigidity, paucity of movement
Tardive dyskinesia hypermotility (like parkinson’s pts with high-dose L-DOPA treatment) – tongue, etc

Mechanism: may involve supersensitivity of dopamine receptors

 ↓ levels of dopamine (give reserpine, α-methyltyrosine to deplete) relieves symptoms
 ↑ dose of neuroleptic: paradoxically relieves symptoms (blocking new dopamine receptors)
 Typically occurs in pts with high doses, long duration of treatment
o Animal models - ↑ # dopamine receptors in response to blockade (supersensitivity)

Consequences
 Symptoms can be irreversible (even when drug discontinued)
 Hypermotility – limbs can be disfiguring; excess movements of tongue can make it hard for pts to swallow
 NO TARDIVE DYSKINESIA with clozapine (especially attractive)
o Newer atypicals – not known (not on market long enough)

15
 Clinical Profile of Atypical Antipsychotics
Clozapine Olanzapine Risperidone
Positive symptoms +++ +++ +++
Negative symptoms +++ +++ ++
EPS - - +
Sedation +++ ++ ++
Hypotension +++ ++ ++
Tardive Dyskinesia nope ? ?

Non-Neurologic side-effects
Orthostatic hypotension & sedation (from blockade of α-adrenergic receptors)
Most frequently phenothiazines with aliphatic side changes, atypicals
Less frequently phenothiazines with piprazine side chains, butyrophenones (haloperidol)

Note that this is opposite from pattern for extrapyramidal side-effects – so choose a drug based on side effects in pt!
 Young pt in college, for instance, use haloperidol (can’t deal with sedation)
 Extremely agitated, disruptive pts – benefit from sedation!
 Tolerance can develop – ramp up dosage slowly to minimize!

Weight gain:
 Occurs with some; can be big enough to preclude use of the drug
 Clozapine / olanzapine cause greatest weight gain (but most effective)
 Mechanism: blockade of histamine H1 receptors in arcuate / paraventricular hypothalamic nuclei
o  activation of AMP-protein kinase (↑ appetite)

How to treat a patient

Atypical neuroleptics are 1st line (relieve negative symptoms too!)
 Clozapine is best – but not first choice
o Works in broader range of patients (effective in great majority of pts resistant to typical neuroleptics)
o We still don’t understand the “magic” of clozapine at a molecular level
o But agranulocytosis (should try something else first)

Typical neuroleptics are cheaper (usually haloperidol)

Newer atypicals: too new to judge definitively

 Being used more broadly (like clopazine) – to calm manics & anxious patients
 NONE cause significant incidence of agranulocytosis
 OLANZAPINE appears to be best therapeutically
o or aripiprazole if wt gain is a problem

Other concerns:
 Olanzapine: rarely causes extrapyramidal side-effects (high anticholinergic potential)
 Risperidone: more likely than others to cause extrapyramidal side effects

 Olanzapine + risperidone: sedative & hypotensive (fits with α-adrenergic blocking potency)

 Zisperadone: may have greater tendency to prolong QT ( torsade de pointes)

 Aripiprazole: causes less weight gain than others

16
 Neuroleptics: a rough summary table

Major side effects Works against

Tardive dyskinesia
Agranulocytosis
Extrapyramidal
hypotensive
Drug

Weight gain
Other side effects / notes + Sx - Sx

Sedative /
Phenothiazine chlorpromazine
Butyrophenone haloperidol (Haldol)
clozapine
olanzapine (Zyprexa)
risperidone (Risperdal)*
Atypical neuroleptics
zisperadone (Geodon)
aripiprazole (Abilify)
quetiapine (Seroquel)
X X X
X X X
#1 effective atypical
XX XX X X X
Drooling, anticholinergic
XX XX ? #2 effective atypical X X
More likely than other atypicals to
X X X ? X X
cause extrapyramidal effects
X X ? Prolongs QT  can lead to TdP X X
X ? Causes least weight gain X X
X X ? X X

Basic prescribing thoughts

 Atypicals give you coverage for positive & negative symptoms
o Clozapine is most effective, but try something else first – it’s got nasty side effects (e.g. agranulocytosis, wt gain, etc)
 Frequent hematology if you’re going to use it (check for agranulocytosis)
o Olanzapine is the most effective of the rest – could be a good first choice (but still lots of weight gain)
o Aripiprazole is good if you’re worried about weight gain (least weight gain)
o The atypicals tend to be sedating – could be good (e.g. agitated, elderly pts)

 Halperidol is cheaper and less sedating, but can cause parkinsonian side effects – think about it for pts who can’t be sedated all the time!
 Watch out for tardive dyskinesia with haloperidol & phenothiazines – clozapine helps you avoid; no good evidence yet for other atypicals

17
 Mood Stabilizers
Introduction
What are mood stabilizers?
 Treat acute mania without causing depression  Prevent mania and depression
 Treat acute depression without causing mania  Mostly used to treat bipolar disorder (BP)

What is bipolar disorder?

Formerly known as “manic-depressive illness” – BP + major depression; 6th leading cause of disability (ages 15-44)
 BP I = depression + manias
 BP II = depression + hypomanias
 Historically: lots of romantic poets, other famous people – often afflicts highly talented people?

Lithium
An element: atomic number 3, has existed for 14B years, discovered in 1817 (Sweden)
 From Gr. “lithos” – stone (discovered from mineral source, unlike Na/K)

History: found to dissolve uric acid; treatment for gout; thought some mental illness could be caused by uric acid imbalance?
 Sir Alfred Garrod (1876) – recommended for mania / depression
 Modern discovery: John Cade (Australian) – thought mania due to ↑ normal product, ↓ in depression?
o Injected urine of manic pts to guinea pigs; thought they reacted badly, thought maybe uric acid?
o Injected uric acid + lithium  less toxicity; then tried on animals alone (became lethargic), so tried it on humans
o And it actually worked! Wrote paper in 1949
 Acceptance: Several pts died using lithium as salt substitute (JAMA, 1949) – scared docs
st
o 1954: controlled trial by Schou, 38 pts  efficacy; 1 placebo controlled study in 1970, FDA approved in 1970

Mechanism of Action: Mood stabilizer. Mechanism not completely understood (see below)

Indications:
 For acute mania (12 controlled trials - 70% pts improved)
o often given in conjunction with antipsychotic (e.g. olanzapine), but takes 10-30d for effect
 For prophylaxis of mania & depression
o 3x less likely to relapse vs placebo; BP II less studied but probably similar benefit, 8x ↓ suicide risk!
 For unipolar major depression to augment antidepressant
o those with Li added > 2x more likely to improve
lithium
Administration: Pretty narrow therapeutic window (0.7-1.2 mEq/L). Measure 12h after dosing.

Toxicity:
 Increased thirst, polyuria.  Hypothyroidism.
 Tremor (dose-dependent).  Interstitial nephritis
 Weight gain (very bothersome). (kidney problems with long-term use).

 If blood levels too high: dysarthria, ataxia, seizures, delirium, renal failure.
o Thiazide diuretics will increase blood levels!

18
 Anticonvulsant Mood Stabilizers
 Non-lithium mood stabilizers are anticonvulsants
Well-established Newer, may or may not be mood stabilizers
 Lamotrigine
 Topiramate  Zonisamide
 Divalproex sodium - Depakote*
 Oxcarbazepine  Tiagabine
 Carbamazepine (CBZ)
*very similar to valproic acid; great marketing in 1990s – but only evidence was for acute mania, not prophylaxis!
Lamotrigine
Mechanism of Action: Mood stabilizer (& anticonvulsant). Mechanism not really understood (see below)
Indications: bipolar disorder (prevents mood episodes - depression > mania for prevention).

Toxicity: rash (10-15%)

lamotrigine  can progress to Stevens-Johnson syndrome(0.1%).
 Minimize with slow upward dose titration (over 2 mo)

Other: First FDA-approved medication (2003) for maintenance tx of BP since Li in 1970s.

 Lithium best for controlling mania, lamotrigine maybe a little better for depression

Divalproex sodium
Mechanism of Action: Mood stabilizer (& anticonvulsant). Mechanism not really understood (see below)
Indications:
 Acute mania (as good as lithium - but antipsychotics might be better than both).
 Prophylaxis: only one good study, showed no effect (but Li didn't work either)
o so no good evidence in favor for maintenance tx.
divalproex
sodium
Administration: Get blood levels (50-120 mg/L) - check compliance & adjust dosing
Toxicity:
(Depakote)
 Nausea  Tremor  Ataxia  Weight gain
 Diarrhea  Sedation  Alopecia

Other: Very similar to valproic acid.

 Great marketing in 90s led to it replacing Li as prophylaxis, although evidence only good for acute mania.

Carbamazepine
Developed in late 50s, first used in Bp in Japan in 1971, FDA-approved as antiepileptic in 1974
Mechanism of Action: Mood stabilizer /anticonvulsant. Mechanism not really understood (see below)
Indications: bipolar disorder.
 Acute mania (good studies)
 Maintenance too (protection against relapse, more evidence than divalproex sodium)

Administration: Get blood levels (4-12 mg/L)

Toxicity:
carbamazepine  Common: vertigo, nystagmus, ataxia.
 Very rare, but potentially fatal (can be lethal in overdose):
o blood dyscrasias (agranulocytosis, aplastic anemia) hepatic failure, pancreatitis.

Metabolism: absorption is slow, erratic, unpredictable.

 Autoinduction of liver enzymes can lower blood levels. May need to increase dose with time

Other: tricyclic structure

19
 Mechanisms of Action
Inisitol Depletion? (1980s)

+2
Receptor  G-protein  inositol pathway activation (via Ca signalling?)
 Li: inhibits several components of inositol pathway  ↓ inositol  ?suppression of activity in overactive system?
 Valproic acid, CBZ may also lead to inositol depletion
 Calcium-channel subunit gene found associated with BP in GWAS?
 But: reduction isn’t consistently found; addition of inositol doesn’t consistently reverse it, and effect occurs within 5 days
but clinical change takes much longer!

GSK-3β / Wnt signaling

Glycogen synthase kinase 3 beta:
 regulates cytoskeletal processes & long-term nuclear events

 Central role in Wnt signaling pathway

o cell growth
o embryogenesis
o brain development

 Other drugs (Haloperidol, clozapine, valproic acid, Li) have effects too
 DISC-1 is also implicated in disrupting Wnt signaling

The Future
Pharmacogenetics
Mood stabilizers as tools in BP research:
o Use changes in epigenic marks common to Li / anticonvulsants to define functional candidate genes
Individualized dosing: Study gene variants: preferentially associated with clinical response to different Rx?

Rational drug design

 Understand susceptibility genes better understand pathophys better 
 new enzyme / transporter / receptor targets for pharmacotherapy

Summary
st
Lithium 1 -line for BP b/c effective for acute mania and prophylaxis of mania and depression
Lamotrigine and CBZ mood stabilizers with proven efficacy in acute mania and evidence for prophylactic efficacy
Valproate/divalproex proven efficacy in acute mania and weaker evidence for prophylactic efficacy
↑ understanding of genetics / pathophys of BP  more specific medications and more effective use of existing medications

20
 Stimulants
History
 Amphetamine: structurally similar to ephedrine / norepinephrine, 1st synthesized in 1887
 Methamphetamine: Benzedrine (methamphetamine) in 1939 (Smith/Kline/French)
o Used for asthma / allergies / viral infections; also formerly prescribed for for depression, Parkinson’s, obesitity,
narcolepsy, sexual dysfunction, loss of vitality / appetite in the elderly
o Formerly used as “pep-up drug;” e.g. for pilots during WWII
o Prescribed in US until 1980s – for dieting, increasing energy, etc.
o Illicit use today: a major problem in rural America especially (after production in basement labs started)

CNS stimulants
Effects
 ↑ attention / vigilance  ↑ BP / HR
 ↑ activity (but ↓ activity in hyperactive)  ↑ RR
 ↑ confidence / euphoria  Decongestants & bronchodilators
 ↓ appetite

Types
Type Examples Brand names Used to treat
d-amphetamine Dexedrine, Dextrostat
Amphetamines Mixed amphetamine salts Adderall
Methamphetamine Desoxyn
dl-methylphenidate Ritalin, many brand names
Methylphenidate
d-methylphenylate Focalin
atomoxetine Strattera ADHD
Legal Other dopaminergic / modafinal Provigil, Sparlon Narcolepsy
noradrenergic compounds bupropion Wellbutrin / Zyban Depression / ADHD
pemoline Cylert (off the market)
phenylpropanolamine Off the market
OTC
pseudoephederine Sudafed Nasal congestion
nicotine
Others
caffeine School
cocaine
methamphetamine “Crystal meth”
Illegal methylenedioxy-
MDMA, ecstasy
methamphetamine

Amphetamine Methamphetamine Ephedrine Methylphenidate Atomoxetine Modafinil

Like dopamine, Looks most

Same benzene ring,
norepi with extra Has extra methyl different; most
Similar to meth etc – much less Similar
CH3 and without group different use
addictive
OH (narcolepsy)

21
 Specific Drugs
Drug Brand name Indications Mechanism Pharmacokinetics
↑ norepi & dopamine release
amphetamine Dexedrine stimulant
Blocks NE/DA reuptake

Similar to amphetamine
methylphenidate Ritalin, Focalin ADHD Short-acting
Release chronic (vs recently stored) NE/DA

Blocks norepi uptake only

amoxetine Strattera ADHD
No buzz, etc!
Less clear
modafinil Provigil, Sparlon Narcolepsy A bit longer
Maybe blocks DA reuptake?

Clinical Issues for stimulants as a class

Indications
 ADHD – most common clinical use!
 Narcolepsy – specific treatment with modafinil

Other uses: less often for these

 Obesity (appetite suppressant)  Depression
 Activation / appetite stimulation in the elderly  Hypotension

Side effects
More common Toxicity*
can happen even with good dosing (if doses get too high) – progression!
Emotional problems
 dysphoria  paranoia  agitation
Feeling “spacey /
↓ appetite,  irritability  confusion  aggression
Insomnia like a zombie”
maybe growth  depression  psychosis
 anxiety

*same for people who are overloaded on meth or coke

ADHD as a Clinical Example

History:
 originally described by George Still, Lancet, 1902 – but all his pts had an explanatory Hx of brain damage
 1937: Charles Bradley, “treatment of misbehaved boys”, pts < 12yo w/ neuro / behavior disorders; respond to stimulants!
 1950s: minimal brain damage / dysfunction?
 1970s: DSM-II, behavioral disorders of childhood / adolescence, “hyperkinetic reaction”
 1980: Attention deficit disorder (ADD) ± hyperactivity used for first time (DSM-III)

Epidemiology: pretty common (≈ 5% youngsters); about 25% lose diagnosis in adolescence, another 25% in adulthood

Diagnosis: get reports from parents / teachers.

 Kind of subjective (all kids do these things – but do they do them often)?
 Criteria: we all have some degree of these things, but more in ADHD pts
o Hyperactivity
o Impulsivity
o Inattention (distractability)

22
Practical Dosing Issues for ADHD
 Stimulants are very effective for ADHD but very short-acting
o Need multiple doses throughout day; can’t dose late in day (don’t interfere with sleep)
 Side-effects are apparent: ↓ appetite, insomnia, rebound increases in hyperactivity!
 Little value for home / family – dosed during day for school; to avoid probs with sleep in evening

Possible Solutions
 Multiple dosing (but too many times for easy compliance, schools like to announce – bad deal)
 Extended release preps (but often sacrifice acute efficacy; can have problems at night)
 “Sculpting” the dose: combos of long / short-acting; combos of meds

Available stimulants for ADHD

 Methylphenidate: Ritalin, Ritalin SR, Ritalin LA; Metadate, Metadate ER, CD; Methylin, Methylin ER, Concerta, Focalin
 Amphetamine: Dexedrine, Dexedrine spansules; Dextrostat; Adderall , Adderall XR; Desoxyn
 Lots of extended release preparations, including patches recently approved
o Compress in tablet form, changing binder (delay absorption), beading technologies, pumps / containers

Stimulant Delivery Systems

Formulation Duration Examples
Line: Immediate
4h MPD (Ritalin), Dex, Adderall
 Generics above release (IR)
 Non-generics below Pulse 7-8h Rit SR, Med ER, Meth ER
Pearls 8h Dex spansule
Coverage may go to all-generic for a lot Pearls 8-12 Adderall XR, Ritalin LA, Medadate CD, Focalin XR
of providers, as some of the longer- Pump ≤12h Concerta (MPD)
acting agents are about to go generic Patch ≤12h Daytrana (MPD)
Prodrug 10h Vyvanse (Dex)

How to start treatment

 Start with short-acting at home (weekends) – is it working?
o Identify time to onset, duration of benefit, side effects; sculpt to maximize duration with few side effects
 Transition to longer-acting stimulants

Controversies
 Performance enhancing?  Promote addiction?  Cardiac risks?
 Risk of treating the unaffected?  Cause brain damage?  Research in children?
 Growth inhibition?  Cause chromsomal damage?

Stakeholders
 Patients and their families  FDA/NIH  Trial lawyers
 Doctors  Religious groups  Media

Summary
 Stimulants have a beneficial role in the treatment of ADHD and perhaps other conditions
 Concerns about side effects
 Charged issues scientifically, religiously and politically
 The solution is research

23
 Behavioral Pharmacology of Substance Abuse
The Concern
Substance abuse is really ubiquitous – perhaps the most common thing you’ll see in clinical practice

st
↑ 1 time users in recent years – especially pain meds

What’s similar about heroin, cocaine, alcohol, nicotine, cannabis, caffeine, etc?
 Big pharmacological diversity, but disorders similar from a behavioral perspective (self-administered by users )
 Disorders acquired via normal learning processes; influenced by circumstances & consequences

Mechanisms: different drugs, but end influences via midbrain dopaminergic (reward) / serotonergic (mood) systems
 Pharmacologic manipulation of these systems affect drug abuse in ways that aren’t drug class specific!
o Naltrexone (opioid antagonist, for heroin addiction) also used for alcoholism
o Serotonin reuptake inhibitors (for depression) influence alcoholism, cigarette smoking, cocaine abuse, appetite

Who’s affected? Universal vulnerability for drugs (“biological normality”)

 Not just some subset of the population that’s vulnerable – everybody’s vulnerable!
 Cross-species commonalities in drugs / patterns / influences – give an animal the same drug, they’ll get addicted in lab
 Cross-substance commonalities too – behavior similar across different substances
 Shows that drugs have direct biological reinforcing effect on the brain

Cross-species commonalities
High animal-human agreement: the vast majority of drugs that humans abuse, animals will abuse too
 Opposite also true: if not abused by humans, probably not abused by animals

Patterns of self-administration
 Varies between drug classes, but animals abuse in same pattern humans do for a given class
Opioids Alcohol / sedatives CNS stimulants (nicotine, cocaine)

Pretty steady administration with Erratic fluctuation in use (heavy use

Clock-like regularity of use –
↑ dose over time / spontaneous abstinence periods
seem to be targeting a particular blood level
(as tolerance develops) alternate, despite withdrawal)

Note that withdrawal syndromes / negative effects don’t drive use – it’s the positive, rewarding effects that are critical
 Example: alcohol: even if in withdrawal & alcohol available, will still abstain!

Cross-drug commonalities
Why is a behavioral pharmacological approach generally useful for such a varied group of substances?

 Similar vulnerability factors (genetics may be non-specific for classes – impulsiveness, etc; also availability!)
 Similar natural histories (onset in youth, chronic, relapsing, decline with aging)
 Clustering (polydrug use within individuals)
 Similar controlling variables
 Similar treatment approaches
Clustering / polydrug abuse: for example, cigarette smoking can be a marker of ↑ risk for other substance abuse
24
 Anticipatory Learning (Conditioning)
These don’t just spontaneously appear – takes learning process (think Skinner, Pavlov, etc)
 Stimuli + drug use  drug-opposite conditioned responses (opposite of Pavlovian conditioning = same response)
 Drug-opposite response perceived as drug abstinence / craving
 Contributes learning mechanism to development of tolerance (some of tolerance is learned, not just biochemical)
 Can explain some overdose fatalities(in novel settings (lose the learned portion of tolerance)

Operant / Environmental Aspects of Substance Abuse

Remember: operant conditioning (Skinner) – behavior acts in, on environment to produce consequences, which modify behavior
Conditions of Availability
Drug use / drug seeking are operant behaviors influenced by
conditions of drug availability

 As you ↑ cost / effort, ↓ drug use

o e.g. tax cigarettes, actually does work to decrease use!
 But with ↑ cost comes ↑ drug-seeking behavior
o Sometimes we’re more concerned about this behavior – e.g. crime
associated with heroin addiction – rob a store, etc.

 Problems with illegal drug use is that the two things we’re interested (use & drug-seeking behavior) are
influenced oppositely by the simplest intervention we have (prohibition)

Control by Consequences
Drug use / drug seeking are operant behaviors influenced by their consequences
 Might not seem like it (addict who loses family, health), but these are long-term, uncertain consequences
 Behavior is driven by short-term, certain consequences – e.g. the rewarding effects of the drug!

Contingency management
 Take advantage of the effects of consequences – provide short-term, rewarding consequences for abstinence!
 One of the most effective treatments for substance abuse

Remember: positive reinforcement (effect of drug), not relief of withdrawal is #1 driver of drug self-administration

Cognitive / Information Processing Distortions

Both salience& valence of drug use are changed by repeated drug administration
 ↑ salience of / responsiveness to environmental stimuli (notice cues others wouldn’t & respond to them more)
 ↑ “discounting” of the value of delayed rewards
o Everybody discounts delayed rewards somewhat: rather have less money now than more later
o But in drug users, ↑↑ “delayed discounting” – really want the immediate reward

Context, Options, Competing Behavior

 Substance abusers / vulnerable pts may face a distorted or limited array of rewarding behavioral options to
compete with drug use (contingency management – change those dynamics of the behavioral economy)

25
 Pharmacological Strategies for Drug Abuse
Strategy Mechanism
Agonist substitution ↓ Reinforcement
Blockade Extinction
Aversion Avoidance
Anti-craving Motivational
Symptom relief Humanitarian

Agonist substitution Methadone Full agonist

 So far, the most effective of the pharmacological strategies Opioids Buprenorphine Partial agonist
 Provide some reinforcement Heroin Full agonist
 Not available for all substances, but the ones we’ve got work well Nicotine
Nicotine patch Full agonist
Varenicline Partial agonist

Other strategies
Pharmacotherapies that just take away positive reinforcement tend to have poor patient acceptance / retention
 E.g disulfiram (Antabuse, alcoholism), naltrexone (opioid abuse)
 Need supportive behavior therapies to maintain medication use

Pharmacotherapies: weakness = specificity to particular type of substance abuse

Behavioral therapy: strength = can be more generally effective across various types of substance abuse

Psychosocial / Behavioral Treatments

Tend to have generalized effectiveness across various types of substance abuse

• Brief Interventions (can be very effective*) • MET: Motivational Enhancement Therapy

• Peer support groups (e.g., 12-step) • Incentives/Contingency Management
• CBT: Cognitive Behavioral Therapy

*Brief interventions, e.g. in doc’s office,: just a little benefit for a pt / practice, but cumulatively big effects on a public-health scale!

Drug Abuse Liability Assessment & Developing Reduced-Abuse Products

Goal : high risk should be more regulated & vice versa

Risk: no legal access  black market  ↑ availability!

Regulatory Scheduling
 Schedules I-V: I = most restricted, V = least
o I = no legal use in USA
o Non-scheduled = “no abuse risk”
 DEA registration required, prescribing limitations, manufacturing / distribution controls / limits

Controlled Substances Act: 8 factors to take into account when deciding how controlled a drug should be
1. Actual or relative abuse potential 5. Scope, duration, and significance of abuse
2. Pharmacological effects 6. Risk to the public health
3. State of current scientific knowledge 7. Psychic or physiological dependence liability
4. History and current pattern of abuse 8. Precursor to controlled substance

26
Prioritizing Data Sources: what gives us the best information about whether a drug will be used or not?
1. Epidemiological Experience (e.g. from other countries, past)
2. Human Laboratory/Behavioral Assessment
3. Animal Laboratory/Behavioral Assessment
4. Neurobiological Mechanisms
5. Chemical Structure (gives hints but not good for assessment)

In the lab: how to assess?

 Look at acute profile, time course of effects, drug discrimination / self-administration, assess physical dependence

Human studies: administer the drug to experienced drug abusers with broad dose range / high doses
 Want to test in the population that has vulnerabilities!
 Assess time course; include negative / positive comparators (similar to known drugs, do they like it, etc?)

Indicators of higher / lower abuse liability

Higher Lower
Similarity to known drugs of abuse Dissimilarity to known drugs of abuse
Subjective liking Little/no subjective liking
Euphoric effects Dysphoric effects
Much drug-seeking behavior Little drug-seeking behavio
Rapid onset Delayed onset
Short-to-moderate duration Very short or long duration
Physical dependence Little physical dependence
Toxicity Safety
Broad population exposure Limited population exposure

Pharmaceutical Engineering for reduced abuse liability

Growth industry – can ruin market for a drug!
 Targets: ↓ abuse risk, less restrictive regulatory scheduling, larger market

Strategies
• Restrict use (availability) • Control or slow the release
• Keep the dose low • Make it cumbersome or expensive
• Combine with another drug • Make improper use/circumvention difficult or aversive

Examples:
 Oxycontin: sustained release oxycodone – but if you chew the tablet, get the full dose! (immediately available)
 Suboxone: buprenorphine + naloxone  Vyvanse: enzymatically released amphetamine
 Concerta: methylphenidate osmotic pumps  Embeda: morphine + sequestered naltrexone
 Remoxy: non-crushable SR oxycodone  Accurox: oxycodone + niacin (aversive flushing)

Suboxone as an example
 Buprenorphine with naloxone, for sublingual administration
o Sublingual delivery of naloxone is poor  no withdrawal, only buprenorphine delivered effectively
o Injection use (misuse) delivers full naloxone  withdrawal (no fun)!

Challenges: Preserving therapeutic bio-delivery, patient acceptability & convenience, avoid excessive cost
Summary
• Substance abuse widespread throughout society and medicine
• Develops via normal learning processes; controlled by context
• Commonalities across species and across drugs
• New substance abuse treatments (both behavioral & pharmacological)
• New medications with claims of reduced abuse risk
27
 Basic Pharmacology of Major Classes of Abused Drugs
Note pharmacological diversity!

Class Examples Acute effects Chronic toxicity Overdose Physical dependence / Withdrawal
Yes
 Heroin
 Euphoria  dysphoria
 Morphine
 Pupillary constriction Death by  pupillary dilation
 Methadone
Opioids  Dreaminess Minimal respiratory  chills, gooseflesh
 Oxycodone
 Nodding depression  rhinorrhea, lacrimation
 Hydrocodone
 Nausea  yawning, insomnia
 Codeine
 diarrhea, fever
 Euphoria
 Excitement  Stoke
 Psychosis
CNS  Cocaine  Tachycardia  Seizure None / minimal
 Paranoia
stimulants  Amphetamine  Pupillary dilation  Sudden  Rebound hypersomnolence & hunger
 Aggressiveness
 Anorexia death
 Agitation
 Slurred speech Yes, can be life-threatening if untreated.
 Alcohol  Incoordination Alcohol: multiple organ  Autonomic hyperactivity
CNS
 Barbituates  Unsteadiness damage (Liver / heart / Coma  Tremor, seizures
depressants
 Benzodiazepines  Sedation brain)  Insomnia
 Stupor  Agitation, anxiety
Primarily due to tobacco Yes
 Relaxation (smoke/tar), not nicotine  Irritability, anxiety
Nicotine Tobacco products
 Mild stimulation  Difficulty concentrating, restlessness
Heart / lung dz, cancer  Hunger
Yes, With chronic use, severity similar to tobacco w/d
 Dreamy sedation Probably lung dz due to  Restlessness
Cannabis Marijuana
 Perceptual changes smoking  Irritability
 Insomnia
 Mild stimulation None identified
Yes, mild.
 Anxiety
Caffeine Coffee, etc.  Headache
 Jitteriness GI upset / irritation mainly
 fatigue
 Insomnia from beverage vehicle

Mechanisms: big differences, but ultimate influences may be through midbrain dopaminergic (reward) / serotonergic (mood) systems.
 Pharmacologic manipulation of these systems affect drug abuse in ways that aren’t drug class specific!
o Naltrexone (opioid antagonist, for heroin addiction) also used for alcoholism
o Serotonin reuptake inhibitors (for depression) influence alcoholism, cigarette smoking, cocaine abuse, appetite

28
 Pharmacotherapy of Alcohol Dependence
Definition of Alcohol Dependence
A maladaptive pattern of alcohol use, leading to clinically significant impairment or distress
 Manifested by 3 or more symptoms occurring at any time in same 12 month period (clustering)

Symptoms:
• Tolerance – need more alcohol to achieve same effect • Important social, occupational or recreational activities
• Withdrawal syndrome or drinking to avoid withdrawal given up to use alcohol
• Taking more or over longer periods than intended • Continued use despite recurrent physical or
• Unsuccessful efforts to cut down or quit psychological problems.
• Much time getting alcohol or recovering from it.

Withdrawal: can be deadly! Delirium tremens, etc. TAKE IT SERIOUSLY

 vs heroin – withdraw is nasty, but not deadly

Epidemiology
 Widespread (14% M, 6%F lifetime)
 Chronic (develop, maintained over 10+ years before treatment sought)
 Peak for meeting diagnostic criteria is from 18-30 (highest risk! Not the age range you’d expect)
 High rates of psychiatric comorbidity (25% MDD, 30% severe anxiety, 40% personality disorder)

Medicications for Abstinence (alcohol, but drugs too!)

 Here talking about maintenance – for acute withdrawal, use benzos (straightforward – cross rxn)

Main strategies:
 Punishment of alcohol drinking
 Dampening reward / appetitive pathways of alcohol
 Moderation of alcohol withdrawal symptoms
 Normalizing or compensating for abnormal neurotransmitter function (psych comorbidity?)

FDA-approved medications: overview

Medication Treatment strategy Notes
Disulfiram Punishing agent that works through avoidance
Naltrexone Reduces craving & positive reinforcement of drinking both oral & long-acting injections
Acamprosate Reduces long-term withdrawal symptoms
None of these medications have much of a market right now!

29
 Disulfram: “aversive” medication to punish alcohol drinking

Therapeutic rationale:
 Behavioral paradigms: avoidance, punishment
 Develop alcohol-free coping skills
 But punishment really isn’t the best strategy!
o Generates avoidance behaviors (not good for keeping a patient in treatment)

Mechanism of Action: Aldehyde dehydrogenase inhibitor; "aversive" medication ("punish" drinking)

 Aldehyde dehydrogenase normally oxidizes acetaldehyde to acetic acid in the liver (alcohol dehydrogenase
converts ethanol to acetaldehyde), so acetaldehyde builds up when ethanol ingested.

Effects: Punishing agent; works through avoidance of future episodes of drinking.

 Effects from buildup of acetaldehyde (toxic substance).
 Leads to facial flushing, nausea, vomiting, hypotension, headache within 10-15m of alcohol
consumption (intended effects, not side effects!).
 Rapid onset is good for punishment (closely linked to drinking!)

Indications: FDA-approved for maintenance of alcohol abstinence. Effective, if pts keep using it.
Administration: Compliance usually poor unless special strategies used.
disulfiram  Onset of effects 1-2h, peak ~ 12h, effective for 4-6d, dosed at 250-500 mg daily.

Toxicity: side-effects (different from intended effects).

 Mild: sedation, drowsiness, headache, garlic-like / metallic taste, dermatitis, skin rash.
 Moderate/severe (more rare): hepatotoxicity, peripheral neuropathy, psychosis, confusion.
 CAN'T USE IN SEVERE LIVER DAMAGE (works in liver!)

Strategies to improve compliance:

 Incentives (probation vs incarceration, link w/ methadone program enrollment, cash, continued employment)
 Medication depot implants
 Contracts (observed medication - involve family member)

Aka Antabuse

Naltrexone & Topiramate: alcohol reward reduction treatments

Alcohol works on just about every neurochemical system you can think of (good & bad news)
 A very “dirty drug” – good b/c lots of targets (options), bad b/c lots of targets (have to hit more)
Neurochemistry Pharmacology
Naltrexone*
Opioid
Nalmefene
Ondansetron
Serotonin
Fluoxetine
Dopamine Olanzepin
Glutamate Acamprosate*
GABA/Glutamate Topiramate
Cannabinoid
Neuropeptide Y
* FDA approved for treatment of alcohol dependence

30
Naltrexone: a non-selective opioid receptor blocker
Therapeutic rationale
 Pharmacologic mechanisms: receptor blockade, ↓ dopamine reward pathways
 Psychological mechanisms: extinction of drug-associated cues, ↓ reinforcement, develop coping skills

Mechanism of Action: nonselective opioid receptor antagonist

 works by blocking activation of the opioid system by alcohol.

Effects: reduces craving & positive reinforcement of drinking. Decreases:

 # of drinking days  likelihood that a "slip" will lead to a full-blown relapse
 number of drinks / occasion  self-reported alcohol "high" during a slip.
 craving / desire to drink
 Effect size is small to medium (only hitting one neurotransmitter system).
 Considerable variability between pts in response (combine psychosocial / pharm Tx;
maybe pharmacogenetic effect with mu-opioid-receptor polymorphism?)

Indications: FDA-approved for maintenance of alcohol abstinence.

naltrexone
Administration: Both oral & long-acting, injectable formulations.
 Current standard dose 50mg qd po; maybe also 100mg? PRN? long-day injectable (30d)?

Toxicity: not addictive.

 Common: mild/moderate side effects (GI upset, nausea, H/A, dizziness, fatigue, insomnia).
 Few serious side effects. Monitor liver enzyme levels. Not recommended if:
o acute hepatitis / liver failure
o narcotic analgesia (surgery or long-term) or opioid substitution therapy (blocking opioid
receptor really well!)
o pregnant / nursing.
Other:
 Has no psychoactive effects of its own (pure antagonist!)
 No known adverse interactions (alcohol or most commonly prescribed meds) - good!

Topiramate
Therapeutic rationale:
 Pharmacologic: facilitates @ GABA / antagonizes @ glutamate receptors  ↓ dopamine release
 Psychological: ↓ reinforcement, ↑ coping skills development

Mechanism of Action: facilitates GABA receptors while blocking glutamate receptors, leading to reduced
dopamine release (corticomesolimbic dopamine - reward).

Effects: Decreases reinforcement from alcohol ingestion.

 In RCTs, reduces heavy drinking days and increases likelihood of at least 1 mo w/o heavy drinking episode

Indications: Not FDA approved - for alcohol abstinence maintenance

topiramate
Toxicity: Common side effects include:
 Paresthesia (prickling / itching)
 Taste perversion
 Anorexia
 Nervousness, difficulty concentrating
 Pruritis
31
 Acamprosate: glutamate-based long-term withdrawal symptom treatment
Quick review:
 Glutamate = major excitatory neurotransmitter; primarily works @ NMDA receptor
o Glu @ NMDA: contributes to alcohol intoxication, cognitive impairment, some withdrawal Sx
 Acamprosate: NMDA-receptor antagonist
Mechanism of Action: NMDA-receptor antagonist.
Effects: reduces long-term withdrawal symptoms.
 Glutamate actions at NMDA receptor contributes to alcohol intoxication, cognitive impairment,
some withdrawal symptoms (incl. seizures, etc).
 Most research in Europe: support acamprosate for abstinence maintenance vs placebo. Has small-medium
effect size in Europe, but really no effectiveness in US pts vs placebo in a few large trials!

Indications: FDA-approved for maintenance of alcohol abstinence, but not really used in USA (see above)
acamprosate Administration: 1.3-2g/day

Toxicity:
 Mild-moderate: diarrhea (~1/3, 20% have to discontinue), nausea / vomiting, H/A.
 No evidence of CNS side effects, drug interactions, abuse liability.
 ONLY FDA-APPROVED DRUG for alcohol abstinence maintenance that can be used in pts with
LIVER DAMAGE! But contraindicated in renal dysfunction

Other: aka Campral in USA

Treatment to normalize / compensate for altered neurotransmitter function

Therapeutic rationale: Sounds logical, but doesn’t work!
 High rates of comorbidity for mood/anxiety disorders & substance abuse / dependence
 Self-medication hypothesis of substance use disorders (so if you treat depression / anxiety, maybe ↓ drinking?)
 Reduction in psych symptoms improves overall functioning

Psychiatric co-morbidity: extraordinary rates, especially in women

 Depression, anxiety, mood disorders – extremely high rates!
 Poorer treatment outcomes for pts with psych comorbidities: ↑ risk of treatment noncompliance (alcohol / psych),
alcohol relapse, psychosocial / interpersonal problems, ↑ severity of psych sx, and suicide

Trials: a whole host (meds + alcoholic pts with disorders – schizophrenia, MDD, etc)
 Most have been done with SSRIs & alcohol / depression symptoms
 Mixed results: even when depression symptoms improve, it doesn’t really improve the drinking!

New strategies: target specific serotonin subtypes to see if you can get better matching?
 Can we normalize the neurochemical to improve the drinking? Maybe yes – but forget about the psych problems!

Odansetron: 5-HT3 receptor antagonist, usually for nausea – but seems to have effects in alcoholism too
 5-HT3 receptor is a CNS site for alcohol reinforcement
 Odansetron: ↓ alcohol consumption in animal models, ↓ preference / craving in human lab studies, and ↓
drinking in randomized, placebo-controlled clinical trials

Early vs. late drinkers

 Early-onset alcoholism: maybe a serotonin abnormality, ↑ risk of drinking (impulsivity, conduct disorders, etc)
o Seem to respond better to odansetron – serotonin effects
 Late-onset alcoholism: seems to be more often related to life events, etc
32
 Complementary Functions of Combined Treatments
Psychotherapy Pharmacotherapy
May address diverse problem areas that May provide targeted relief from
aren’t targeted by meds (coping skills, decision making) aversive physical cravings / withdrawal symptoms
Therapeutic effects often require time, practice to obtain Therapeutic effects are rapid compared to psychotherapy
Enhances medication compliance Improves treatment retention

Resistance to Medications
• Anticipated unpleasant side effects • Denial about condition or disease
• Cost of medication • Influence of others
• Burden of taking daily medication • Negative perception of addiction medications

Summary

• Several strategies (e.g., punishment, reward reduction, withdrawal management) can help ↓ alcohol consumption.
• Several medications are currently marketed for alcoholism treatment
• Matching patients to medications may improve treatment effectiveness
• Approaches are needed to improve medication adherence(e.g., counseling)

33
 Opioid Dependence
 People usually use heroin / opioids 3-4x per day – titrate doses according to half life to not withdrawal
 Opioid withdrawal: “any body fluid that can come out, will come out” – vomiting, diarrhea, rhinorrhea, etc.
o But not life threatening

Maintenance Medicines for Opioid Addiction

4 FDA-approved meds: buprenorphine, LAAM, methadone, naltrexone

Buprenorphine
 Opioid mixed agonist / antagonist (partial mu agonist, kappa antagonist, ORL-1
agonist)
 Big advantage: can be prescribed without methadone clinic (!)
 Partial agonism means that there’s less maximal effect than full agonist
 Has a bell-shaped dose-response curve (see pic to right)
o Worked out in animals, not humans – morphine’s dose-response is linear

Mechanism of Action: thebaine derivative (classified in law as a narcotic).

 Opioid mixed agonist-antagonist (partial mu agonist, ORL-1 agonist, kappa antagonist).

Effects:
 Has a bell-shaped dose-response curve - maximal effect with certain doses.
 High affinity for mu opioid receptor - competes with other opioids, blocks their effects.
 Has slow dissociation (long therapeutic effect, contrasting to relatively short analgesic effects)

Indications: for maintenance treatment of opioid dependence.

 In outpatient trials: superior to placebo, about the same as moderate methadone doses. Similar
retention of pts, % opioid urine results.

Also for medically supervised opioid withdrawal (detox) - use sublingual tablets.
 Better than clonidine for RAPID (<1wk) withdrawals.
 Use similar doses as for maintenance; withdrawal should be gradual (esp. if outpatient),
 decrease dose in 2 mg increments; withdrawal symptoms can be minimal with buprenorphine taper.

buprenorphine Administration: Poor oral bioavailability - but sublingual absorption is good. IV or sublingual.
 Can combine with naloxone (4:1 dose ratio) to reduce abuse potential (naloxone = opioid
antagonist; has poor sublingual absorption, but good parenteral bioavailability - so
if injected (abuse) instead of sublingual, will precipitate withdrawal).
 Two dose sizes: small (2 or 2/0.5 mg), and large (8 or 8/2 mg).
 Taken once daily or increase dose and take less than once daily. Daily doses generally between 8-32 mg
 Big advantage: Possible to prescribe from primary care setting
o but need to be qualified, get special DEA number, limit on # pts treated.

Toxicity: Similar profile to other mu agonist opioids: constipation, increased sweating.

 Can be abused (dissolve, inject tablets) - add NX to help avoid.
 Low risk of respiratory depression with overdose (partial agonist - reports from France when combined
with benzo OD). Label notes to check LFTs in pts with liver disease.
 No evidence of CV concerns like QTc prolongation.
Metabolism: Highly bound to plasma protein; metabolized in liver by CYP450 3A4 into
norbuprenorphine, other metabolites; excreted in urine.
Other: marketed as sublingual tablets(Suboxone with naloxone, or Subutex - buprenorphine
alone). Used by about 200k pts in USA

34
LAAM
Mechanism of Action: Structurally related to methadone, but longer duration (can dose MWF).
Indications: for maintenance treatment of opioid dependence.
Administration: Prescribed through opioid treatment programs (methadone clinics) for opioid
LAAM (l-alpha-
dependence treatment.
acetylmethadyl)
Toxicity: Small # of reports of torsades de pointes
Other: No longer marketed in USA - low sales; could be picked up by another company. Didn't really
seem to make an impact (still have to go to methadone clinic)

Methadone
Mechanism of Action: full mu agonist opioid.
Effects: suppresses spontaneous opioid withdrawal & blocks effects of other opioids (cross-tolerance)

Indications: for maintenance treatment of opioid dependence.

 Efficacy dose-related; increases retention (time in treatment), decreases opioid use (and other pro-
social changes - less illegal income, less money spent on drugs, etc.)
For opioid withdrawal (detox) too:
 but can't give for more than 3 days in outpatient basis if not an approved OTP!

Administration: Good oral bioavailability with long duration of action - so once daily dosing.
 "Methadone maintenance treatment" (MMT) is a combination of medication and non-pharm
treatments (counseling, group therapy, urine monitoring, contingency interventions); MMT is more
effective than placebo.
 Administered from special clinic system - Opioid Treatment Programs (OTPs) - rare for physicians
to be allowed to prescribe outside this system. Usually dose in oral solution supervised by nurse, once a
day. Attend clinic for dose (6-7d/wk), supervised urine collection, random testing, counseling.
 Usually start at 30mg qd, titrate up as clinically indicated (10mg every few days; decrease illicit
methadone opioid use, craving, withdrawal). Avg dose ~ 80-90mg/day, up to 200mg.

For withdrawal (detox) in an OTP:

 generally lasts 7-182 days (getting longer, more gradual over time).
 3%/wk decrease (30 wk detox) more effective than 10%/wk (10wk)
 but withdrawal is less effective than indefinite maintenance for most patients

Toxicity: Generally safe & well-tolerated.

 Side effects typical for mu-agonist opioids (constipation, increased sweating).
 Rare case reports of torsades (with very high doses / other QTc prolongation risk factors).
 Risk of respiratory depression if overdose (esp. take-home doses, or if dose diverted / taken by
person with lower tolerance level).

Other: About 225-250k pts treated with methadone in USA; used since 1960s.
 Pts doing well can "earn" take-home doses - desired by pts (lessens burden of attendance); used as
contingency for treatment goals.
 In past, some OTPs run poorly (punitive rules, inadequate doses); also often community resistance to
opening new OTPs - part of motivation for having buprenorphine be office-based.

35
Naltrexone
Mechanism of Action: opioid antagonist (occupies receptor but doesn't activate)
Effects: Blocks effects of other opioids (don't get high from opioid when taking naltrexone)
 But not reinforcing (fundamentally different from buprenorphine, LAAM, methadone)

Indications: for maintenance treatment of opioid dependence.

 Generally limited use (special situations, like when mandated to use as part of licensing).

naltrexone Administration: daily (50 mg po qd) or 3x weekly (MWF, 100/100/150 mg).

 Effective if pt takes it - but often stop taking it

Toxicity: Will precipitate withdrawal in an opioid-dependent person, so don't start until pt completely
withdrawn off opioids! Generally safe, minimal side effects (label warns to watch LFTs, but this was using
high doses).
Other: Current interest - approval of extended release form (once/month by injection), currently available
for alcohol dependence. Would increase compliance!

Medications for Medically Supervised Withdrawal for Opioid Addiction (Detox)

Buprenorphine, clonidine (not FDA-approved), methadone, symptomatic treatments

Buprenorphine
 Can use sublingual tablets for Sx of opioid withdrawal – used to use injections, but should use SL now
 More effective than clonidine for rapid withdrawals
 Dosing: similar to maintenance treatment; withdrawal should be gradual (esp. if outpatient)
o Decrease doses in 2mg increments (smallest tablets, not scored; really shouldn’t crush)
o Withdrawal symptoms can be minimal with buprenorphine taper
 See card above

Clonidine
Mechanism of Action: alpha-2 adrenergic agonist (used for treatment of high blood pressure).
Effects: Useful in treating signs of withdrawal, but not symptoms (look good, but don't feel good)
Indications: treatment of opioid withdrawal
 Not an approved use - but dosing protocols well-established).
clonidine  Now decreased use with buprenorphine availability.

Toxicity: hypotension, sedation

Other: Current interest in lofexidine (another alpha-2 adrenergic agonist - marketed in UK, not available in
US, less hypotension vs. clonidine)

Methadone
 Can’t give outpatient for more than 3 days for treatment of opioid dependence (need to be an approved OTP)
 In an OTP, methadone withdrawals generally 7-182 days (getting longer, more gradual over time).
o 3%/wk (30wks) more effective than 10%/wk (10wk) declines
o Can get down to 20-30mg/day, but hard
o Withdrawal is less effective than indefinite maintenance treatment for most patients!
 See card above

36
Symptomatic treatments
Remember, opioid withdrawal in an otherwise healthy person is not life-threatening –just a higher risk of relapse
 Use buprenorphine! No need to suffer; could have relapse!
 NSAIDs, anti-emetics, fluids can help

Conclusions
 Emphasis here has been on medications, but optimal outcomes occur when combine medication with non-
pharmacologic treatments (therapy, counseling)

 Addictions treatment undergoing change (maturing as a medical field)

o more pharmacological options, greater professionalization of ancillary services

 Can be a rewarding population with which to work

o (unfortunate that most initial exposure is patients in crisis, generally don’t get to see longer-term outcomes)

37
 Pathology: Repro
Uterine Corpus & Gestational Trophoblastic Disease............................................................................................................. 2
Ovaries & Tubes .................................................................................................................................................................... 10
Prostate ................................................................................................................................................................................. 20
Cervix..................................................................................................................................................................................... 26
Vulva ..................................................................................................................................................................................... 34
Vagina.................................................................................................................................................................................... 37
Breast .................................................................................................................................................................................... 38
Placenta................................................................................................................................................................................. 47

1
 Uterine Corpus & Gestational Trophoblastic Disease
Endometrial Carcinoma
Epidemiology
Most common malignancy of the gynecologic tract (41k new cases/yr, a little less common than breast, etc).
4th most common cancer in women
North America / Europe > Developing countries / Japan
White > Black (2:1)

Histologic types
Endometrioid (looks like endometrium): > 75%
Others too (serous, mucinous, clear cell, squamous cell, undifferentiated, mixed)
o Serous is the most clinically important of the others (1-10%)

Two main types: comparison

Feature Type I Type II
Prototypical type Endometrioid Serous
Mean/median age at Dx 62 68
Estrogen-driven Yes No
Endometrial intraepithelial
Precursor lesion Atypical hyperplasia
carcinoma (EIC)
Menopausal status
Pre- or perimenopausal Postmenopausal
for precursor lesion
Typical tumor Grade Low High
Prognosis Favorable Poor
Molecular alterations PTEN, k-ras, MSI, β-catenin p53

Endometrial Hyperplasia WHO classification Cytologic atypia?

Precursor to type I (e.g. endometroid) endometrial carcinoma Simple hyperplasia
Absent
Complex hyperplasia
Simple atypical hyperplasia
Proliferation of Present
Complex atypical hyperplasia
glands of irregular size and shape with an
*clinical importance: is it atypical or not?
increase in the gland : stroma ratio
(compared to proliferative endometrium – normally pseudostratified columnar)

Normal proliferative Complex

Simple Hyperplasia No atypia Atypia
phase endometrium Hyperplasia

Hyperplasia: marked crowding of glands in both Atypia: refers to cytologic changes

Note endometrial glands More glandular Normal, proliferative More rounding of
Crowding of glands
with abundant stroma hyperplasia, lots of phase endometrium: nuclei, look more pink,
but structure not as
between branching / budding pseudostratified pseudostratified
crowded as complex
of glands columnar cells columnar structure lost

2
Clinical relevance: hyperplasia vs. atypical hyperplasia
Non-atypical hyperplasia: ≈ 2% risk of progression
Atypical hyperplasia: ≈ 23% risk of progression to carcinoma!
o Makes a difference in how you manage the patients!

Treatment of Endometrial Hyperplasia: Highly age-dependent

Women in reproductive years: Generally hormone (progestin) treatment
Perimenopausal / postmenopausal: Generally hysterectomy

Endometrioid carcinoma
(The histologic type that follows endometrial hyperplasia)

Clinical features
Most common histologic type, but least aggressive
Mean age 62yrs (36-91: wide distribution)
Presentation: abnormal bleeding & enlarged uterus (relatively non-specific)
Driven by unopposed estrogenic stimulation, so associated with conditions with ↑ estrogen:
o Obesity, HTN, DM, infertility polycystic ovarian syndrome

Gross:
Exophytic mass (projecting out into uterine cavity)
Uterine enlargement (big, bulky)

Histology:
lots of glandular crowding
o like hyperplasia, but even more crowded

Glands resemble proliferative phase endometrium

o Hence “endometrioid”
o Have tall, thin, columnar-looking nuclei

Grading:
From 1-3
Based on % of solid architecture

Grade Differentiation % solid growth

1 Well ≤5
2 Moderate 6-50
3 Poor >50

Well-differentiated: very
Poorly-differentiated:
Staging: the most important prognostic factor glandular-rich, not much solid
predominantly solid tumors
architecture
Stage 5 yr svl Definition
Confined to uterine corpus Stage IA: confined to endometrium or <50% myoinvasion
Stage I* 90-95%
Subclassfied by depth of myoinvasion Stage IB: ≥ 50% myoinvasion
Stage II 70% Cervical involvement
Stage III 60% Invades uterine serosa or adnexa, or metastasis to vagina / pelvic / para-aortic LN
Stage IV 40% Invasion of bladder / bowel, or metastasis to inguinal LN, or intraperitoneal spread
*tumor grade is very important for prognosis in stage I! If well-differentiated, no invasion – survival approaches 100%!

3
Treatment of endometrioid carcinoma

For stage I: highly age-dependent

(parallels hyperplasia treatment)

Young women (<40) – progestins are an option

(conservative treatment –regression in 75%)

Peri / post-menopausal women: TAH-BSO

(total abdominal hysterectomy & bilateral
salpingo-oophorectomy) ± radiation if poor
prognostic factors are present
Stage IA: confined to Myometrial invasion – can see
endometrium, smooth interface glands infiltrating through the
between endometrium / myometrial wall
myometrium (no myoinvasion)

Pathogenesis of endometrioid carcinoma: putting it all together

Proliferative phase Simple Complex Complex atypical Endometrioid
endometrium hyperplasia hyperplasia hyperplasia carcinoma

From unopposed Branching, budding, Development of Well differentiated at

estrogen stimulation etc atypia! first, then less so
A multi-step process that can take years to develop!

Serous carcinoma
Prototype of type II endometrial carcinoma; contrast to type I

Now an epithelial precursor replacing endometrium

o EIC = endometrial intraepithelial carcinoma

Doesn’t have the glandular precursor / nature that type I does

Histology
More papillary, instead of glandular-rich
Cytologically: much higher-grade than endometrioid

o Round nuclei instead of elongated

o More mitotic activity & pleomorphism

Treatment: very aggressive!

TAH-BSO for all stages
+ adjuvant chemo for advanced-stage disease
o Vs. type I – usually don’t get chemo

Prognosis: generally worse than type I

4
 Endometriosis
Ectopic endometrial tissue outside of the uterus

Clinical features:
Prevalence: 1-15% (relatively common); majority (80%) in reproductive age
Symptoms: dysmenorrhea, pain (lower abdominal, pelvic, back), dyspareunia, abnormal bleeding
o Infertility in up to 30% of women with endometriosis!

Laparoscopy: classic “powder-burn” appearance

Irregular dark, puckered lesion - think endometriosis

Gross: tend to get cystic if they occur in the ovary

Bleed cyclically (endometrium)  can get blood accumulation
“Chocolate cyst” – brown-colored blood

Microscopic pathology: just normal endometrial tissue in the wrong place

Endometrial glands / stroma
Hemorrhage (bleed cyclically)
Hemosiderin-laden Mϕ (cleaning up hemorrhage)

Malignant transformations are relatively rare (endometrioid, clear cell carcinoma possible)

“chocolate cyst” – blood in ovary Endometriosis in ovary: Endometriosis in bowel wall:

from endometriosis normal ovary at bottom; cyst lined can get endometriosis in lots of
with normal endometrial glands/ sites. Here, would have GI
stroma at top, bleeding into cyst symptoms too!
(with hemosiderin-laden Mϕ)

Smooth Muscle Tumors (Myometrial tumors)

Leiomyomas (“myomas,” “fibroids” - benign) or leiomyosarcomas (malignant)
Leiomyoma
Clinical features
Most common GYN tumor (endometrial carcinoma is most common malignancy)
Tends to occur in reproductive-age women (estrogen-dependent)
Presentation: Pretty nonspecific (pelvic mass, pain, bleeding)

Gross:
Can be submucosal, intramural (in wall), or subserosal (cause bleeding)
Size: microscopic to very large
Often multifocal
Are well-circumscribed (benign)
Can be degenerated, hemorrhagic, or calcified

5
Histology:
Interlacing bundles of spindled,
smooth muscle tumor cells
With variable amounts of fibrosis

Treatment:
Generally surgical
myomectomy (leaves uterus) or
hysterectomy

Non-surgical options do exist

Hormonal suppression: GnRH
agonists (suppresses H-P-gonad axis 
↓ estrogen production)
Uterine artery embolization: occlude
vessels that are feeding leiomyoma; safe
& efficacious
Normal myometrium: see Leiomyoma: very similar
overlapping, organized bundles of appearance, a little more
spindled smooth muscle cells disorganization – and in a big
circumscribed nodule

Leiomyosarcoma
The malignant counterpart to leiomyomas – but probably not linked?

Clinical features:
Median age 52 yrs, relatively uncommon
Presentation: Pretty non-specific: bleeding and/or pelvic mass

Gross:
Solitary, intramural
Not well circumscribed
More heterogenous appearance
Soft to palpation
Hemorrhagic / necrotic

Histology:
High mitotic activity
Tumor cell necrosis
Marked cytologic atypia

Prognosis (5 yr survival)
Stage I, II: 40-70%
All stages: 15-25%
Not good
Leiomyosarcoma: still see spindled cells Leiomyosarcoma with necrosis
(smooth mm. tumor) but large, atypical (pink material to the bottom)
Treatment: no ideal therapy
nuclei with mitotic activity
Hysterectomy
Surgical excision of recurrent tumor
Chemotherapy – not really too helpful

6
 Gestational Trophoblastic Disease
Pregnancy-associated diseases; lesions of the trophoblastic cells that arise in the placenta
Genetically abnormal placentas Trophoblastic neoplasms Non-neoplastic proliferations of trophoblast
Hyatidiform moles:
Choriocarcinoma
Complete Exaggerated placental site
Placental site trophoblastic tumor
Partial Placental site nodule
Epithelioid trophoblastic tumor
Invasive

Normal placenta:
At term (left)
can see chorionic villi (small rounded structures)

Earlier (right) – two layers

Cytotrophoblast layer on inside, very tightly
associated with syncitiotrophoblast layer

As the placenta matures:

Syncitiotrophoblast layer: starts acquiring multiple nuclei per cell
o a syncitium!
But the two layers are still very tightly associated

Hyatidiform moles: genetically abnormal placentas

Can be partial or complete

Complete Mole
Histology:
Markedly enlarged, edematous villi
o Instead of having small, uniform villi like above

Hyperplasia of cytotrophoblast layer

o Circumferentially surrounding the villus

Gross:
Grape-like vesicles
Fetus absent

Clinical features
Prevalence: 1/2k pregnancies in USA
Presentation: vaginal bleeding, passage of “grape-like vesicles”, uterus large for dates
Diagnosis: now usually early in gestation (≈ 10wks) – absence of fetus by U/S or fetal heart tones

Prognosis: 80% benign, 15-20% develop persistent GTD, 2-5% can progress to choriocarcinoma!
Treatment: Suction curettage, then monitor serum β-HCG levels
If β-HCG levels don’t fall: chemotherapy (required in 20%)

7
Complete vs. Partial mole
Partial mole: has all of the same changes, but less completely developed than in the complete mole
Complete mole Partial mole

Histology

Cytogenetics

Androgenic diploid karyotype Diandric triploid karyotype

Start with empty egg (no maternal DNA Normal egg gets fertilized by two sperm – ends
whatsoever), fertilized by 1 sperm, Sperm up being triploid!
chromosomes duplicate (but all paternal DNA)
Diploid Triploid
Karyotype 46XX 69XXY, 69XXY
All paternal 2 paternal, 1 maternal
Embryo / fetus No Yes (but non-viable)
Hydropic chorionic vili The same, but
Histology
Trophoblastic proliferation less marked than in complete mole
Subsequent GTD 10-30% 0.5-4%

Choriocarcinoma
A malignant neoplasm composed of trophoblast & lacking chorionic vili
Recapitulates cytotrophoblasts / syncitiotrophoblasts – but no villi!

Preceded by something (often)

Complete mole (50%)
Abortion (25%)
Ectopic pregnancy (2.5%)
Normal pregnancy (22.5%)

Gross:
Well-circumscribed
Hemorrhagic (like to invade blood vessels)
Soft

8
Histology:
Dimorphic population of cytotrophoblasts & syncitiotrophoblasts
o Maintain intimate relationship

No chorionic villi!

Destructive infiltrative growth into surrounding tissue

o Produces extensive necrosis
o Invades blood vessels

Immunohistochemistry: β-HCG!
o Good tumor marker (Dx or following pt)
o Made by syncitiotrophoblastic layer

Prognosis / course:
Highly malignant
Can spread hematogenously to any organ
o Mostly lungs, liver, brain

Treatment:
Highly responsive to chemotherapy (methotrexate)
Prognosis now excellent
Monitor serum β-hCG levels to check for recurrence

9
 Ovaries & Tubes
Normal Ovary
Gross: tucked in near fimbriated ends of fallopian tubes
Picture: white = stroma, surface epithelium on outside, cysts inside –
Smooth lined cysts can be follicular cysts where eggs develop. Yellow could
be corpus luteum

Histology: 3 tissue types / compartments

1. Surface epithelium
2. Stroma:
o Non-specific ovarian stroma
o Specialized (sex-cord) stromal cells
 Granulosa cells
 Theca cells
3. Germ cells

Primitive / primordial follicle  primary follicle  secondary follicle  ovulation  corpus luteum

Developing follicle: germ cell surrounded by…

Surface epithelium & underlying stroma specialized stromal cells
granulosa cells
(granulosa, theca cells)

Flat, columnar-to-cuboidal layer of surface Spindly stromal cells on outside, primary

Granulosa cells on inside, plump.
epithelium; spindly, non-specific stroma follicle surrounded by granulosa cells
Theca cells on outside, spindly

Corpus luteum

Lutenized follicle after ovulation

Blue = normal stroma; hemorrhagic / fibrin-
filled center. Plump, pink cells (formerly granulosa cells)

10
 Normal Fallopian Tube
Gross: Tubular structure with finger-like projections (fimbriae) at end

Cross-section Fimbriated end Serous-type epithelium: (3 cell types)

Tubular structure with muscular wall

End of tube, fimbriae drape over ovary, Some ciliated, some just secretory, some
around it; plicae (delicate projections
ovulated egg comes out & gets captured, intercalated cells too – “serous-type
into lumen). Egg highway, fertilization
pulled into tube epithelium”, can make “serous fluid”
here

Pathology of Ovaries & Fallopian Tubes: Clinical Approach

Clinical manifestations:
Pelvic mass, ovarian mass, pelvic pain
Adnexal mass (involving lateral structures – tubes/ovaries)

Differential diagnosis
Ovarian lesions Fallopian tube lesions
Non-neoplastic Neoplastic Infectious / inflammatory
Benign neoplasms Ectopic pregnancy
Cysts
Malignant neoplasms Neoplasms

Ovarian Pathology: Non-neoplastic lesions

• Surface epithelial inclusion cysts • Corpus luteum cyst • Polycystic ovary disease
• Follicular cyst • Endometriosis/endometriotic cyst (PCO)

Ovarian surface epithelial inclusions

Invaginations of surface epithelium into cortex →

o Lose connection to outside world
Lined by serous type epithelium; can be multiple
Benign / usually incidental findings but…
may be site of origin for most epithelial ovarian cancer!

11
Various Ovarian Cysts
Gross Histology Significance

Benign, non-neoplastic;
really just looks like a
normal follicle.
Follicular cyst Can be related to ↑
estrogen production –

big, taut cyst where the ovary is Thin walled cyst lined by: Most regress in 2 mo
usually solitary, can be several Inner layer of granulosa cells
Outer layer of theca interna cells

Corpus luteum bleeds

 fills up cyst with
blood
Hemorrhagic
Benign, physiological
corpus luteum cyst; can cause some
cyst hormonal abnormalities
Note large, pink lutenized granulosa
Corpus luteum bleeds, ovary filled up with Usually resolves on its
cells (middleish layer), smaller
bloody cyst, lined with convoluted yellow own
lutenized theca interna cells, inner
tissue (corpus luteum!)
layer of connective tissue + blood!

Endometriosis very
Cyst lined by endometrial-type tissue commonly involves
(glands & stroma); often chocolate- ovaries  grows as
Endometriotic colored material (“chocolate cyst”) cyst.
Cyst inside – hemosiderin-laden Mϕ, etc
Will bleed cyclically
See pictures below (endometrium)
Cyst, can’t tell what it is unless you look at
it under a microscope

Endometrial ovarian cyst: lined by endometrial serosa & glands (see close-up to right). Ovary with Endometriosis: tubular
Note hemosiderin-laden Mϕin cyst (right, top) glands, columnar cells – like
proliferative endometrium

12
Polycystic Ovary Disease (PCO)
Pathogenesis: Inappropriate gonadotrophin secretion  ↑ LH/FSH ratio
Manifestations: from excess androgens / estrogens
↑ androgens  hirsuitism
↑ peripheral androgenestrogen conversion: ↑ estrogens too
(menometorrhagia, endometrial hyperplasia, carcinoma)
Chronic anovulation (2° amenorrhea, oligomenorhea)
Infertility ± obesity

Gross: Large, “sclerocystic” ovaries

Cortical fibrosis (sclero-)

o White, hard inside of ovary

Subcapsular cysts (-cystic)

o Multiple, usually follicular cysts
o Right under a thickened capsule

Histology:
Dense, pink layer on surface (thick capsule)
o spindle cells don’t go the whole way up like they should

Multiple follicular cysts, all enlarged & lined up

o Look like the follicular cysts from before – but many
o Don’t become corpora lutea – hormones messed up

Luteinized stromal cells (bottom pic)

o Pink, eosinophilic cells with round nuclei
o Not spindly, long like they should be
o Luteinization – becoming pink, round
o Can sometimes see in PCO

Ovarian Pathology: Neoplasms

Remember the 3 types of cells? All can have benign & malignant neoplasms!
Surface epithelial neoplasms Germ cell neoplasms Sex cord / stromal neoplasms
Benign
Benign Benign
Atypical proliferative (borderline / low malignant potential)
Malignant Malignant
Malignant

Surface epithelial neoplasms

Classification of surface epithelial neoplasms into types by morphology:
Tumor Examples Features
Cystadenoma (purely cystic)
Simple, non-stratified epithelium
Benign Cystadenofibroma (cystic + fibrous)
No nuclear atypia
Adenofibroma (glandular + fibrous, no cysts)
Epithelial proliferation with stratification / tufting
Atypical proliferative
Low mitotic activity and mild nuclear atypia
(borderline / low malignant potential)
No stromal invasion
Stroma invasion
Malignant Carcinoma (malignant epithelial tumor)
Nuclear atypia, ↑ mitotic activity

13
 Classification of surface epithelial neoplasms into subtypes by type of differentiation
Subtype Resembles
Serous Fallopian tube epithelium
Mucinous GI tract / endocervical epithelium
Endometrioid Proliferative endometrium
Clear cell Gestational endometrium
Transitional cell (Brenner) Urinary tract epithelium (transitional)
Nomenclature:
Based on type of differentiation & degree of benignancy / malignancy of tumor
Basically, choose one from each table above & stick em together:
o “endometrioid adenofibroma”, “mucinous carcinoma”, “serous atypical proliferative tumor”, etc.
Can have any combo; this lecture just focuses on more common ones

Surface epithelial tumors: SEROUS TUMORS

Only focusing on these because they’re the most common

Benign: serous cystadenoma / adenofibroma

Atypical proliferative / borderline: atypical proliferative serous tumor
Malignant: serous carcinoma (the quintessential “ovarian cancer”)

Serous
cystadenoma

Cyst, clear, bland-looking surface; see ciliated epithelium  tubal differentiation!

No atypia or invasion, so benign!
MOST COMMON TUMOR OF THE OVARY

Atypical
proliferative
serous tumor Gross: See more lumps & bumps – papillary structure.

Histology: same serous epithelium (cilia, terminal bar, eosinophilic cytoplasm, etc), but growing more
although still organized. Pretty bland / low-grade cytology.

STILL NO STROMAL INVASION!

Can implant (not invading) into peritoneum – not carcinoma, so don’t need to do chemo, etc..

14
 SEROUS CARCINOMA: the quintessential “ovarian cancer”
Features (pics below all for high grade)
Stromal invasion
↑ atypia (vs. borderline tumors, above)
± psamomma bodies

Big tumor with solid & cystic Stromal invasion: here, a Stromal invasion, Psamomma bodies:
components, feels firm & gritty papillary serous carcinoma more atypia than a little calcified
invading stroma (middle of pic) borderline tumor concretions (not always)

Carcinogenesis of Ovarian Serous Carcinoma: Dualistic model

Two parallel pathways that these can arise from: Low-grade or high-grade
Low-grade pathway

Arises from cystadenoma precursor 

Through mutations, goes through borderline stages
Eventually becomes carcinoma, etc.
o Can either be invasive or non-invasive
o All are LOW GRADE

Little micropapillary structures forming –

low grade non-invasive serous Can invade (low grade invasive serous Now showing stromal invasion
carcinoma arising from atypical carcinoma), have a very atypical (definitely a carcinoma) – but here
proliferative serous tumor – but can appearance, but still low grade low grade
metastasize!

High-grade pathway
Classic, “runs in the family” form
From ovarian surface epithelium inclusions / cysts, or maybe from
fallopian tube epithelium (fimbriae) becoming dysplastic?
Dysplasia  intraepithelial serous carcinoma  can invade

Note that cystadenomas, etc. DON’T BECOME HIGH-GRADE TUMORS!

No borderline stage / atypia, etc
Only progress through the low-grade pathway!
15
 Ovarian surface epithelial inclusion (bottom) with Fimbriated end of fallopian tube might be source –
high grade serous intraepithelial carcinoma on see marked atypical cells on close up (right); this is an intraepithelial
surface, “neck” of inclusion carcinoma that can drop off into ovary, peritoneum, etc. Also stain for p53

Invasive high-grade serous carcinoma: Close-up: see high-grade lesion – very nasty looking,
here from the fimbria of the fallopian tube atypical cells with ↑ N/C ratio, etc.

Ovarian Germ Cell Neoplasms

• Teratomas • Dysgerminoma
• Mature cystic teratoma • Yolk sac tumor (Endodermal sinus tumor)
• Immature teratoma • Embryonal carcinoma
• Monodermal teratoma • Choriocarcinoma

Mature Cystic Teratoma

Benign and really disgusting
o most common ovarian teratoma
o most common ovarian germ cell tumor
typically during reproductive years

Cystic with disgusting hairy sebaceous stuff inside it

Skin-like: hair, sebum being made, etc.
Can form teeth & other structures

Histology: all kinds of different structures (Pics – see skin, hair follicles, adipose, bone, fat, cartilage, mucous glands, neurons)

16
Dysgerminoma
Malignant ovarian germ cell tumor

Gross: Solid, fleshy mass in the ovary

Histology:
Primitive germ-cell type cells, open nuclei
Usually in nests
Lymphocytes in the background

Ovarian Sex cord / Stromal neoplasms

A whole bunch of different kinds, but we’re only looking at granulosa cell tumors (more frequent)

Granulosa Cell Tumors

Arises from granulosa cells

Significance:
Malignant tumor! Can recur; often years later / slowly
Can have hormonal abnormalities, (e.g. estrogen production)
o Could get endometrial hyperplasia  carcinoma 2° to this (rare)
Usual presentation: pelvic mass

Gross:
cystic / solid tumors
often hemorrhagic
softer consistency

Histology:
classic ovoid cells
Nuclei have elongated grooves: “coffee bean nuclei”
Can form rosette-type structures with “Call-Exner” bodies inside
o Recapitulating what the granulosa cells normally do!

Metastatic Neoplasms Involving the Ovary

Pt could have an ovarian mass, but could be 1st presentation of a cancer elsewhere!

Important to distinguish primary ovarian neoplasms from metastases

• Treatment differs (e.g. organ-specific chemoRx) Primary ovarian Metastatic
• Prognosis differs (ovarian metastasis = higher stage dz) Unilateral Bilateral
Larger Smaller
Common sites of origin of metastases in ovaries Multicystic or solid Multiple nodules ± cysts
• Gastrointestinal tract Absent surface Surface and/or superficial
• colorectum #1, pancreas, stomach, appendix involvement cortical involvement
• Female genital tract (endometrium, cervix)
• Breast

17
 Metastatic Carcinoma, Ovary Metastatic Carcinoma, Ovary Metastatic Signet Ring cell carcinoma
Note multiple lesions Discrete nodules, involving (Krukenberg Tumor).Bilateral ovarian tumor,
surface metastatic, looks like signet ring. Classically
from stomach, sometimes appendix

Fallopian Tubes
Infections: Acute salpingitis, Chronic salpingitis, Tubo-ovarian abscess
Ectopic pregnancies (can be sequelae of infection)
Remember that fallopian tubes (fimbriae) may be a common source of high grade serous neoplasms in the ovary!

Acute Salpingitis

Gross: Pyosalpinx: pus, acute infection in tube

Histology:
Normally delicate finger-like structures
filled with acute inflammatory infiltrate
(lots of PMNs in lumen) – see inset

Really edematous

Progression:
Ascending bacterial infection
Acute salpingitis
Chronic salpingitis  burns itself out  fibrosis / adhesions

Picture: acute & chronic salpingitis

Swollen tube (acute) with adhesions (chronic)

(Uterus probably has some leiomyomas too)

(bottom): bilateral tubo-ovarian abscesses

Swollen, angry-looking; see purulent material inside
Ovaries / tubes are mangled together from this chronic salpingitis

18
Chronic salpingitis

Histology:
See blunting & fusion of delicate plicae
o Progression from left to right 
Simplification, fibrosis, blunting from chronic injury
Inflammatory infiltrates (bottom left)

Gross: can see hydrosalpinx

Tubes fill with water, get really swollen
Happens when chronic salpingitis “burns itself out”

Ectopic Pregnancy
After salpingitis, etc – conceptus can get stuck!  tubal ectopic pregnancy
See placental tissue inside the wall – immature placenta trying to grow

Histology:
Wall of the tube, then the villous structures of the placenta (L pic, arrow)!
Normal placenta, just forming in the tube
o Right pic: see cytotrophoblasts & multinucleated syncitiotrophoblasts in the wall!
Danger of rupture (can hemorrhage – medical emergency!)

19
 Prostate
Normal Anatomy & Histology
Prostate: right below bladder; prostatic urethra runs through it.

Key anatomical relationships

Prostate can impinge on
urethra  obstruct urine flow

Rectum just post/inf to prostate

(“window” to image & bx the
prostate – most cancers arise
peripherally – transrectal exam)

Urogenital diaphragm: prostate

intermingled with diaphragm. If
you injure this (e.g. prostate surgery) can lead to incontinence

Zones of the prostate

enlarged in BPH 
Transition zone Right around urethra
can obstruct urine flow
Central zone Anterior fibromusclar stroma Not important
Peripheral zone Around the outside where cancer arises

Normal prostate in young man – looks Prostate glands – lined by two cell Secretory cells (more cytoplasm) & basal cells
pretty homogenous (zones not well layers & separated by stroma underneath (flatter).
defined). Urethra in middle. (fibrous tissue & smooth mm) Stain: HMW cytokeratin (basal cells!)

Normal Histology: Glands have 2 cell layers

Secretory cells: more cytoplasm – make secretory products of prostate).
Basal cells: flatter; represent stem cells of the prostate ( differentiate to secretory)
not myoepithelial / contractile like breast / salivary gland
Not present in prostate cancer (don’t see HMW cytokeratin staining)

Benign Prostatic Hyperplasia (BPH)

Probably the most prevalent disease in men
↑ with age (almost every man has pathologic evidence by age 70-80)
Not all clinically apparent – but clinical disease is really common

Gross appearance: NODULAR, LESS HOMOGENEOUS, ENLARGED TRANSITIONAL ZONE

Urethra compressed to slit-like space (mechanical obstruction of urine)
o Also physiological obstruction – see BPH pathophys lecture
Transition zone (periurethral) enlarged by nodules of BPH
o Nodularity & less homogenous
20
Histology: Corresponding findings
Nodular, enlarged transition zone
Peripheral zone compressed into crescent

Cystoscopy:
Narrowed urethra (hyperplastic prostate
nodules pushing together, narrowing lumen)

Types of BPH: can be more glandular, more stromal, mix

but doesn’t make a big clinical difference
Pic (right) – a more stromal hyperplasia

Diagnosis of BPH
Symptoms: Dribbling, trouble initiating stream, may get up at night (nocturia), frequency

Can’t just look at one gland and say “that’s BPH”

There’s nothing “diagnostic” microscopically, unlike hyperplasia in other tissues
Have to look at whole picture – enlarged, nodular transitional zone?
Can’t diagnose with needle biopsy – if you do a biopsy, just looking at cancer

Digital Rectal Exam:

Prostate can be small, but have strategically placed hyperplasia BPH
o Pic (right) – median lobe hypertrophy (acts like ball valve / obstructs)

Treatment
Both to treat symptoms & prevent damage to bladder

With ↑ bladder pressure  muscles of bladder hypertrophy

o Trabeculations (L pic)

Eventually bladder gives up  urinary reflux into kidneys! (R. pic)

o Hydronephrosis, kidney damage can result

Trans-urethral resection of the prostate (TURP)

Go in and resect little bits with resectoscope (get “chips” – pic)
Check for cancer too (most in periphery, but 10-15% in middle!)

Prostate Cancer
Extremely common: probably a majority of men in their 50s have some kind of incidental prostate cancer!
↑ with age: most diagnosed in 70s-80s, but still a fair number in 60s, even 50s / 40s
#1 cancer in men (far & away), #2 cause of cancer death in men (though only small % die, high #s!)

Big difference between having prostate cancer & dying of disease! (unlike lung cancer, etc)
3X more men have clinical cancer than die of it, and 14.5X more men have “autopsy cancer” than die of it
↓ death rates since 1980s too (better treatment & detection)

Big peak of prostate cancer “incidence” in 1980s – introduction of PSA (detected a lot more, incl. non-clinical)

21
 Diagnosis of Cancer: Serum PSA (prostate-specific antigen) Where does PSA come from?
Higher serum PSA in cancer than benign (not clear why) Synthesized in ductal / acinar
Benign: probably gets secreted into urine epithelium 
Cancer: doesn’t really connect to lumen; spills into interstitium secreted into lumen 
diffuses into interstitium 
Function: a serine protease crosses vascular basement
Normal seminal fluid: gel-forming proteins trap sperm in ejaculate membrane into serum
PSA liquefies coagulum to release sperm

Common test: but also common cause of lawsuits (because it’s a cancer test)
Done, never reported back from lab / MD doesn’t get result / doesn’t inform pt / misinterpreted
Delay in Dx  alleged ↓ chance of cure  you get sued

Key: PSA IS NOT A ROUTINE TEST (it’s a CANCER TEST)

Get a rock solid mechanism to make sure test gets ordered / return / seen / acted upon if abnormal
If abnormal, consider referring to urologist (it’s a complicated test!)
DRE TRUS PSA % Cancer
Diagnostic approach: DRE, TRUS, & interpreting PSAs - - 4-10 17.9%
Abnormal DRE = ↑ risk of cancer, but pretty non-specific & not great - + 4-10 25.3%
If they weren’t free, we probably wouldn’t do DREs + - 4-10 35.3%
+ + 4-10 48.8%
Trans-Rectal Ultrasound: not a great way to dx cancer - - >10 35.7%
Mainly to guide needle for biopsy - + >10 48.6%
+ - >10 66.7%
Use DRE (±TRUS) in combo with PSA + + >10 68.6%
If DRE + TRUS positive and PSA low, still pretty good chance of having cancer
High PSA  ↑ risk of cancer, if abnl DRE too then ↑↑ risk

NO GOOD “NORMAL” PSA LEVEL

Everybody uses PSA = 4 for cutoff,
But look at chart: lots of cancer with PSA < 4 (even advanced!)
Some high PSAs in BPH too!

Variations on the PSA theme

Remember that PSA can vary by 15% just from test to test!
Variation Concept
Benign prostate tissue contributes to serum PSA, so factor out benign prostate
PSA density
Calculate PSA / weight of prostate (estimate from TRUS)

Check rate of change of PSA (3 measurements over 1.5-2yr interval – OK because prostate Ca = slow)
PSA velocity Faster PSA rise = more worrisome for cancer (even if all in “normal” range)
Cutoff: > 0.75 ng/mL/yr (72% with cancer, only 0.5% without cancer)

The older you are, the higher PSA that you’re “allowed” to have
Age-specific PSA E.g. 2.5 for 40-50, 6.5 for 70-80 – if you see a young man with PSA = 3, then that’s bad!
Problem: still not a good“cutoff” type test - ↑ risk with any ↑ elevation of cancer!

PSA exists in free & bound forms; men with cancer have MORE BOUND & LESS FREE
Total PSA = free + ACT-bound – so measure free PSA & total, calculate
Free / bound PSA
Often use in moderately elevated PSA (4-10); Bx can miss!
Only helpful if really high (>25% free = only 8% with Ca) or really low (<10% free = 56% with Ca)
22
Factors Influencing Serum PSA
Variability:
Lots of inter-assay variability (≈ 10.5% - use same lab if possible!)
Lots of biological variability (actual levels bounce around ≈ 15%)

Prostate Manipulation:
DRE causes ↑ PSA (but rarely false positive test results)
Biopsy: PSA can “leak” into circulation (may take 1mo to return to baseline)
Ejaculation: can cause false positives (abstain for 48h prior to test)

Prostate Disease:
Disease (prostatitis, BPH – and cancer) can elevate – some clinicians try Abx first (would see dramatic ↓)
Not all men with prostate disease have PSA elevations; and PSA elevations aren’t specific for cancer

Pathology of Prostate Cancer

Gross:
Involves periphery of prostate
Subtle in the gross (vs other cancers)
These days – usually small (hard to detect)

Histology: whole-mount
Cancer in peripheral zone (pic: left side)
Lose glandular structure / acini
Dense blue structure

Biopsy:
Trans-rectal, ultrasound-guided
Needle goes in sideways, get little cores
Look for cancer!

What does it look like?

(these are simple examples – in practice, prostate cancer is really tricky!)

Small, crowded glands; infiltrate between larger benign glands Special stains to ID LACK OF BASAL CELLS
Cytology: Large, central nucleoli Perineural invasion

Small, crowded cancerous glands (arrows)

infiltrating between larger benign glands Large, central nucleoli
(arrowheads)

23
 L: small glands, suspicious; R: negative stain for basal cells (cancer!) Perineural invasion (rare if benign)

Gleason Grading System

Try to identify what’s more aggressive or less aggressive
Examine PATTERN ONLY, not cytology!
Assign 1-5 to patterns – more glandular in lower #s

Gleason score = most common pattern + 2nd most common pattern

o Range therefore from 2-10
o E.g. if 70% = 3, 30% = 4, gleason score = 7
o If all the same (all 3), just double it (3+3=6)

Simplification:
Gleason ≤ 6 is well / moderately differentiated
Gleason = 7 is moderately / poor differentiated
Gleason ≤ 8 is poorly differentiated

Examples (don’t need to be able to do this)

Low grade (2+2= Gleason 4) 3+3 = Gleason 6 Sheets: 5+5 = Gleason 10 4+3 = Gleason 7

Significance of Gleason Grade

The best test for predictor of prognosis (correlates well with extra-prostatic involvement, course, etc)
For treatment: ≤6 vs > 7 can be the difference between:
o watchful waiting / treatment, surgery / radiation, excision / preservation, brachytherapy ± XRT

Course / Natural History of Prostate Cancer

Local extra-prostatic extension
Seminal vesicle invasion
Pelvic lymph nodes retroperitoneal lymph nodes

Distant mets: classically BONE (axial skeleton, ribs)

o See osteoblastic metastasis – most cancers osteolytic
o Bone’s reaction to cancer: proliferative (top X-ray)

Can go to liver, lung, etc. too

24
Prognosis of Prostate Cancer
Clinically confined variable depending on grade, margins, pathological stage
Clinically locally advanced 25% cure
Regional nodal metastases 85% progress to distant metastases in 5 years
Distant metastases 80% dead in 5 years; 90% in 10 years
Note that men with metastatic prostate cancer will eventually die of it –if they live long enough!

Implications for treatment: Think: what’s the life expectancy for this individual?
Don’t screen 80-85 year old men – won’t live long enough for it to kill them!
Young patients: screen & treat aggressively (have longer life expectancy!)

25
 Cervix
Key learning points:
• Cervical cancer and its precursors begin in the transformation zone
• HPV is the main etiologic agent for the development of cervical cancer
• Detection of HPV DNA is now utilized in conjunction with cervical cytology for the detection of cervical cancer
• Vaccines against HPV hold promise for the eventual eradication of cervical cancer

HPV & Cervical Cancers

Epidemiology: Most common in parts of Africa, S. America, Indonesia / SE Asia

The Transformation Zone

Most cervical cancers arise here
Columnar epithelium originally → squamous epithelium (squamous metaplasia)
st
o Metaplasia most active during embryogenesis, puberty, pregnancy (esp. 1 pregnancy)

Squamocolumnar junction: meeting of the two; not static (changes throughout life)
o Original squamocolumnar junction: kind of on the inside
o Ectopy (endocervical eversion) – migrates to the outside
o Transformation zone: where the change is taking place (“functional” junction)

Histology:
Area of transition between
columnar epithelium &
squamous epithelium

Gross: same thing (right pic)

Terminology: different ways of describing precursors of cervical cancer

Squamous Intraepithelial Lesions (SIL):

Classified into low grade (LSIL) & high grade (HSIL)

Cervical intraepithelial neoplasia:

Classified into CIN 1,2,3

Dysplasia vs carcinoma in situ

Mild, moderate, severe dysplasia or CIS

See chart for how to interconvert between these nomenclatures

26
 Precursors of cervical cancers
Histology: progressive replacement of the full thickness of the epithelium by immature atypical basal cells

Note gradual replacement of basal layer by more immature cells  goes more full thickness eventually.
↑ mitoses in top of epithelium (CIN3, HSIL for instance) – should just be in basal layer!

Virology of HPV
Small, circular, dsDNA virus
has 6-7 early genes, 2 late genes
More than 200 types; 40 infect female genital tract\

Oncogenic / “High risk” HPVs (about 15) Low-risk HPVs

Cause virtually every cervical cancer
Transforming genes:E6 (disrupts p53), E7 (disrupts Rb)
Cause condylomas & some LSILs
Cause most LSILs, HSILs, & infections
but they usually regress!
HPV 16,18 HPV 6, 11
Cause 70-75% cervical cancer (16 > 50%) cause 90% genital warts

Prevalence of HPV Infection

Big variations between age, sexual habits
> 80% of LSIL, 90% of HSIL, > 99% of invasive cervical cancers contain high-risk HPV types

Important: don’t think that low-risk HPV types = LSIL; high-risk HPV types = HSIL
> 80% of LSIL contain high risk HPV types!
Almost all HSILs contain high risk HPV types – majority are HPV 16
Almost all genital condylomas (warts) contain HPV 6/11 (low risk)

27
 Pathology of Squamous Lesions
Koliocytotic atypia (LSIL)
means “empty cell”
the cytopathic effect of productive HPV infection
o E4  destruction of cytokeratin matrix
Big nucleus; empty-looking cytoplasm
o Left: big, empty nucleus (compare to others)
o Right: co-localizes w/ HPV capsid Ag IHC

HPV Life Cycle: parallels Squamous Cell Differentiation

Basically: Infect at the basal cells, start expressing early genes as the
cell differentiates, and then assemble / release at the top

Superbasal zone: expression of early genes (incl. E6/7) starts

Differentiated cells: induction of all genes

Leads to viral DNA synthesis, capsid protein production
Virions assembled near the surface (LSIL)

Productive infection (make / release more viruses)

Tightly regulated
Permitted only in cells that have begun squamous maturation

Molecular Biology of HPV

HPV DNA is found in all cervical cancers / cell lines / precursor lesions – and so is HPV MESSENGER RNA

High risk (but not low-risk) HPV types can transform epithelial cell lines
in cooperation with an activated cellular oncogene, e.g. H-RAS
Need E6/E7 expression to maintain the malignant phenotype
HPV 16 alone can immortalize cervical cell lines in culture; prevent cellular differentiation  changes that mimic HSIL

High-grade lesions (HSIL)

Link between squamous differentiation & early viral gene expression is LOST

Viral E2 gene disrupted (during integration @ random sites in host chromosome)

Encodes transcription regulatory proteins
Disrupt E2  overexpression of E6/E7 (transforming genes)
o Now you’ve got overexpressed E6/E7 in replication-competent cells (basal / suprabasal)
o Increased, unregulated proliferations of these cells  susceptible to further mutagenic events  cancer!

E6/E7 of high risk HPV types bind p53 / rb gene products (respectively)
Promotes dysfunction
Not true for low-risk HPV types!

Low-grade lesions (LSIL)

In condylomas, viral DNA exists as an extrachromosomal plasmid
See positive FISH throughout cytoplasm (plasmid!)
Distinguishes vs. cancer, where HPV DNA is integrated

28
 Epidemiology & Natural History
Epidemiology
Risk ↑ with:
# of sexual partners Female sexual promiscuity, or monogamous female with
Young age at first intercourse sexually promiscuous male partner

HPV infection: precedes & predicts development of LSIL / HSIL (HPV 16/18 = highest HSIL risk)
HPV infection: relative risk of 100:1; is the biggest risk factor
Cervical cancer is an STD caused by HPV!

How common is HPV? VERY! (> 50% of people with more than 3 sexual partners)
How infectious is HPV? VERY! (If you’re HPV-, and you go out & have sex with 3 people, 70% chance you’ll get it)

Natural History
Most spontaneously regress
o About 81% will disappear within 18mo
A few persist

The “paradox”
• Paradox – HPV infection is common but cervical cancer is uncommon
• Explanation - The vast majority of HPV infections spontaneously regress, only a small proportion persist
• Conclusion – Persistence with the same type of HR HPV is the critical intermediate step from infection to cancer

Carcinogenesis
HPV infection
necessary but insufficient for cervical carcinogenesis
Other things may play a role?
Smoking? OCP use? Diet? Condom use? Sexual habits?

Need persistence of viral infection: can progress, regress

Screening
Pap Smears
It does work! ↓ incidence of cervical cancer after introduction

Problems with Pap Smears

Many more women get them than need them
E.g. women with access to health care, health conscious  low risk of cervical cancer development
Large burden on the system (lots of women, possibility of overtreatment, ↑ $$$)

Background of the problem: not great sensitivity. Of 50M Paps / yr in USA

>3M are ASCUS (atypical squamous cells of undetermined significance; < LSIL) or LSIL
Most ASCUS / LSIL are benign, but a small % associated with HSIL / invasive cancer - But small % of large # is still significant!
225K women with CIN 2/3; 2K women with cervical cancer whose Pap showed only ASCUS!

HPV Detection Tests

Pap alone: need to identify undiagnosed HSIL, but lots of benign lesions resulting in overtreatment
Solution: since HPV infection precedes, predicts development of LSIL / HSIL, add an HPV detection test
PAP + HPV PCR: enhances sensitivity of detection!
HPV testing: more sensitive, fewer false negatives

29
ALTS study:
All LSIL require colposcopy
o 83% LSIL has high-risk HPV: so HPV testing for LSIL isn’t useful for
triage (they’re going to be positive)

ASCUS and HPV negative  return for routine follow-up

o can increase interval up to 2-3 yrs – HPV negative = SAFETY!
o Only 43% of ASCUS have high-risk HPV

ASCUS and HPV positive  treat like LSIL! (get colposcopy)

o Have equivalent risk as LSIL of developing into HSIL (27% @ 2yrs)

HPV & interval of screening

If normal cytology and HPV negative (for high risk type) – very low risk for CIN3 development
o Can increase cytology interval (to 8-10 yrs) – just follow
+ high-risk HPV test has sensitivity 90%, specificity 95% for detection of CIN 3
o If persistent over 6 months, need to evaluate

HPV as a primary screen (instead of Pap)

Initially was really expensive; not so much anymore
Goal: high sensitivity with minimum # screens
Initially – probably use in combo with cytology
o Begin age ≥ 30 yrs
o Use sensitive HPV test
o Eliminate screening in older women with negative Hx / HPV test

Clinical Aspects: Screening, Diagnosis, Management

Specimen Collection: the Pap smear

 

Cervical swab Cytology: thin smear

Colposcopy

Use if abnormal Pap smear

Looks at entire transformation zone

SIL arises in the transformation zone
SIL extends into the endocervical canal

Put acetic acid on; see white lesions – site for biopsy

30
Directed Biopsy & Endocervical Curettage
Take biopsy of where you see the white lesions (from colposcopy above)
If lesion in the cervical canal, might not see on colposcopy – use curettage to get epithelial sample
Cold knife cone biopsy, loop electrosurgical excision procedure (LEEP) – other ways to get samples / remove
o Not pleasant!

LEEP (loop electrosurgical excision procedure) Cold knife cone biopsy

What are you looking for?

Cytology (Pap smear) Colposcopy Histology

 
Koliocytotic atypia, etc Acetic-white lesions, etc. Grading, etc. (from biopsy)

Management of cervical cancer precursors

Precursor Management
ASCUS, HPV- Routine follow-up
ASCUS, HPV+ Colopscopy
Colposcopy
If Bx-confirmed, loop electroexcision (LEEP)
HSIL
Cold cone biopsy (less commonly)
Hysterectomy (rarely)

31
 Types of Malignant Tumors of the Cervix
• Squamous carcinoma (most common)
– Microinvasive (<5mm invasion, <7mm lateral extent)
– Frankly invasive
• Adenocarcinoma, Adenosquamous carcinoma, Sarcoma too

Squamous Carcinoma of the Cervix

Most common type

Gross Appearance: exophytic or endophytic

Exophytic – protruding into uterine canal Endophytic – infiltrating into tissue Necrosis caused by cancer

Microscopic appearance:
Anastamosing tongues and islands of squamous cells
with abnormal cytologic features (cytologic atypia)

Tongues & islands (zoomed out) An island; note atypia (zoomed in)

Epidemiology
Decreasing in incidence, epidemiology same as SIL
Mean age 51 (range 17-90)

Course / Behavior
Local extension (invasion)  lymphatic metastasis
Prognosis depends on stage (extent of disease)
o 5 yr survival: 90-95% if Stage I; 60% for all stages (pretty good!)

Treatment
Radiation or Radical hysterectomy & lymphatdenectomy
Chemoradiation (advanced stage cervical carcinoma)

32
 Future (& current) Directions
HPV Vaccine
Use HPV L1 capsid protein for prophylactic HPV vaccine
Forms virus-like particles (VLPs) in expression systems  induce virus-neutralizing Abs
Really effective – but only against the kinds of HPV that it’s targeting!

Commercially available: Gardasil (Merck), Cevarix (GSK)

Cervarix Gardasil
HPV types HPV 16 & 18 HPV 16, 18, 6, 11
Anogenital cancers (cervical, vulval, vaginal, anal cancers; precursor lesions)
Covers Also subset of head/neck cancers
Genital warts & laryngeal papillomas
Cost ≈$100/dose (3 doses) ≈$120/dose (3 doses)

Really future directions

Role of HPV vaccines on cervical cancer?
o New vaccines? Cheaper? Eradicate?
Role of cytology screening in the future?

33
 Vulva
Key learning points:
• Vulvar cancer can be broadly divided into 2 types
– HPV related type – occurs in younger women
– Non HPV type – occurs in older women
• Like cervical cancer, vulvar cancer develops from intraepithelial precursors
• The risk factors for HPV related vulvar cancer are similar to those for cervical cancer
• When diagnosed at an early stage, prognosis is very good
Infectious Diseases of the Vulva
Human papillomavirus (causes condyloma acuminatum)
Herpes, syphilis, molluscum contagiosum too – but not focused on today

Condyloma Acuminatum (from HPV Infection)

Gross appearance Microscopic appearance

Zoomed out (L): Papillary, with stroma inside

Perianal condylomas Vulvar condylomas Close-up: cytologic atypia (≈ cervical HPV cytology)
Contain HPV 6/11
CONTAGIOUS – wash your hands after doing the exam!

Vulvar Cancer
Epidemiology: less common than cervical cancer (≈ 3800 cases/yr, 800 deaths in USA)
Etiology: see HPV type 16 in vast majority

Vulva Intraepithelial Neoplasia (VIN): Precursor Lesion

Gross appearance

White to red, pigmented

Scaly, moist, or warty
Multicentric

Microscopic Appearance

Loss of cellular polarity

Abnormal maturation
Abnormal nuclear morphology

34
Clinical features of VIN
Increasing in frequency; mean age 30 y/o
Frequently associated with condylomas, CIN, VaIN (vaginal)

Behavior / Course: Usually regress; rarely progresses to invasive carcinoma

Treatment: Local excision or laser

Squamous Carcinoma of the Vulva

Similarities: between squamous carcinoma of the vulva and cervix

Cervical / vulvar Ca coexisting frequently in same pt; similar histology, similar risk factors (lifetime # partners, cigs)
Suggests a common etiology

Differences between the two:

Feature Cervix Vulva

Invasive potential of CIS High Low
% of invasive carcinoma with adjacent CIS 80-90% 20-30%
Mean age of women with invasive carcinoma 50 y/o 66 y/p
Transit time 15 yrs 25 yrs

Gross appearance
Pathology of Invasive squamous carcinoma of the vulva
Gross appearance: see pics to right
Typically unicentric
1/3 ulcerated
3 types:
2/3 exophytic
o Keratinizing squamous cell carcinoma
o Basaloid carcinoma 3/4 involve the labia
o Warty carcinoma

Keratinizing Typical appearance like squamous

squamous cell skin cancer, etc.
carcinoma Usually not HPV-related (old age)

Form anastamosing tongues,

Keratin pearls
etc. in stroma

More like cervical cancer

Basaloid
Don’t see keratin formation
carcinoma

↑ N/C ratio, bluish

35
Warty
carcinoma

Carcinoma with more warts Invasion, form high grade lesions

Distribution of HPV / Age by vulvar cancer subtype

Tumor type % HPV+ Mean age (yrs) % < 55yrs

VIN 91 50 64
Basaloid / Warty SCC 77 59 41
Keratinizing SCC 6 67 11

Basaloid / Warty: associated with HPV & in relatively younger pts

Keratinizing: not associated with HPV & in older pts

HPV type 16 is key!

See in VIN & basal carcinoma

Important in cervical cancer (>50%)
Subset of head / neck cancers associated too!

Two BIOLOGICALLY DIFFERENT types of vulvar carcinoma

Keratinizing Squamous Carcinoma Warty / Basaloid Carcinoma
Mean age 77 y/o (older) 55 y/o (younger)
VIN Differentiated VIN Warty & Basaloid VIN
Classic cervical cancer risk factors
Early age @ intercourse
Risk factors Lack cervical cancer risk factors
Multiple sex partners
Smoking
Rarely associated with other female Associated with other female
Other tumors?
reproductive tumors reproductive tumors
HPV Unrelated HPV-related

Clinical Features of squamous carcinoma of the vulva

5% all female reproductive tumors; 90% of all vulvar tumors

Behavior: Slow growing  spreads to regional LNs

Treatment: Traditionally radical vulvectomy + lymphadenecomy;
now wide radical excision with selective lymphadenectomy
Survival (5yr): 70% for all stages; 90% for negative lymph nodes (pretty good)
36
 Vagina
Epidemiology: Even fewer lesions associated with the vagina than the vulva! (1k/yr in US)

Malignant Tumors of the Vagina

• Invasive squamous carcinoma (MOST COMMON, but still really rare)
• Clear cell carcinoma (a long time ago, was related to diethylstilbestrol – DES – exposure)
• Sarcoma botryoides (young girls), Endodermal sinus tumor, Melanoma – really rare

Key learning points

• Most vagina cancer is squamous cell carcinoma
• Like cervical cancer, vagina cancer develops from intraepithelial precursors
• The risk factors for HPV related vagina cancer are similar to those for cervical cancer

Future directions
• Will the development of HPV vaccines have an effect on management of vulvar and vaginal cancer? Probably!

Why can’t you use L1-directed vaccines for treatment of HPV (therapeutic vaccine)?
Generating neutralizing antibodies – humoral immunity
But you need cellular immunity for treatment (viruses are inside the cell, not expressing the capsid protein!)

37
 Breast
Normal Anatomy / Development

3 major components (epithelial compartments)

Terminal duct lobular unit (TDLU)
Large (excretory) ducts
Nipple

Breast is a mixture of stroma (fatty & fibrous tissue) & these epithelial compartments
varies with age of the patient (younger = more fibrous; older = more fatty)

Nipple & Large Ducts

Normal nipple Normal large duct of breast

Large ducts (carry out milk

that lobule makes)
Wide caliber duct
Skin on outside
Conducts milk
outwards
Smooth muscle around ducts
(contracts, pushes milk out)

Terminal Duct Lobular Unit (TDLU)

• Absent in male breast • Milk-producing component of the female breast
• Hormonally responsive • Where cancers arise (really proliferative!)

Structure: like a cluster of grapes

Terminal ducts / acini (same thing) , dumping into intralobular ducts  out into larger ducts & so forth
All of this epithelium is functionally the same –producing milk
Specialized stroma around it

TDLU in “resting” phase (non-pregnant, non secretory, etc).

38
 TLDU: schematic TDLU: normal / non-lactating TDLU: lactating (e.g. during pregnancy)

Bilayered epithelium Note bilayered epithelium Note lactational changes

Secretory (epithelial) cells
inner dark secretory cells secretory cell vacuolization
myoepithelial cells*
both rest on basement membrane
outer paler myoepithelial cells milk secretion in lumen
*myoepithelial cells are actin-positive – serving a contractile role (can stain to distinguish)

ALL BREAST PROLIFERATIONS except for invasive carcinoma have BOTH SECRETORY & MYOEPITHELIAL CELLS
So ABSENCE OF MYOEPITHELIAL CELLS is used to diagnose INVASIVE CARCINOMA

Inflammatory Disease
Acute Mastitis

Presentation: Fever & breast mass in a nursing mother

Etiology: Cracks in nipple from lactation  bacteria enter
Duct obstruction  stasis + bacteria  bad!

Pathology: PMNs infiltrating breast

Treatment: Hot pack (↑ blood flow) or abx; drain abscesses

Fat necrosis

Presentation: Hard mass / calcified (like breast cancer – scary!)

Etiology: Trauma usually (incl. surgery – previous Bx)

Pathology: Hemorrhage & PMNs early 

Mϕ, fibrosis, calcification (FFA bind calcium) later

Fibrosis distorting normal breast fat Close-up: multinucleate giant cells engulfing dead fat cells

39
 Benign Neoplasms
Intraductal Papilloma
The one lesion that involves large ducts

Presentation: mass below the nipple; bloody nipple discharge

Secretory cells can secrete (clear discharge), or little papillae can get twisted / necrotic (bloody discharge)

Pathology: Papillary lesion involving large (excretory ducts) – can get markedly dilated
Fibrovascular stalks lined by both myoepithelial & benign secretory cells

Papillary lesion; epithelium lining fibrovascular Close-up: both myoepithelial (pale, underneath) and
tissue, protruding into lumen of a large duct secretory (darker) epithelial cells in papillary projections

Significance: Minimal risk of cancer (less than 2x ↑ risk)

Treatment: Surgical excision & usual follow-up (monthly BSE + yearly mammogram)

Fibroadenoma
The most common benign neoplasm of the female breast

Presentation: Firm but moveable rounded mass; usually in 20-35 y/o pt

Pathology: Circumscribed mass with whorled cut surface

Biphasic: neoplastic intralobular stroma induces proliferation of epithelium

Gross: well-circumscribed; Low power: just an exaggeration / High power: reactive proliferating
fibrous. Epithelial component expansion of intralobular stroma, epithelium, but both stroma &
would be in slit-like spaces inducing epithelium to grow with it epithelium look benign

Significance: Little risk of carcinoma if simple fibroadenoma

Treatment: Excision if symptomatic & usual follow-up

40
Benign Fibrocystic Changes
Most common cause of a breast mass in USA – found in 2/3 of women over 20!

Presentation: Firm area; cysts may be painful, epithelium may calcify

Pathology: Fibrosis / cystic changes, usual ductal hyperplasia

Fibrocystic changes

Schematic

Fibrosis  distorts lobular

architecture  dilates
Gross appearance: ducts  cystic change!
opened cysts (liquid filled)
“blue-domed” (unopened) cysts

Higher power: some cysts have normal lobular epithelium (L. pic, center)
Low-power: lots of ducts, but still
Some cysts have changed - pink apocrine epithelium (L. pic, upper cyst; R. pic)!
round & still in lobular architecture
(unlike breast Ca). Cysts & fibrosis.
Apocrine metaplasia – still benign (metaplasia = one benign type to another)
Apocrine (round-topped cells, pink cytoplasm) usually found in sweat glands

Usual ductal hyperplasia (benign increase in cell number)

Note more than 2 cell layers! Lots of fibrocystic changes Ducts are nearly filled with
Can have bridging! & lots of proliferation epithelium – note slit-like spaces

Question: is this hyperplasia or ductal carcinoma in situ (DCIS)?

Hard to tell a lot of times – look for uniform cells, necrosis, other features of carcinoma
In hyperplasia, remaining duct spaces are slit-like (DCIS – often more round)

Significance: Slightly increased risk of carcinoma if you have usual ductal hyperplasia (UDH)
Treatment: Just usual follow-up

41
 Carcinoma in Situ
Definition: carcinoma cells confined within the TDLU (lobular unit) and ducts
Derived from / differentiating towards secretory epithelium
Surrounded by intact myoepithelial cells / basement membrane
Can’t metastasize (no access to lymphatics)

Two major types: Ductal Carcinoma in Situ (DCIS) and Lobular Carcinoma in Situ (LCIS)
Both impart a 10X ↑ risk of developing invasive carcinoma – but in different sites

Ductal Carcinoma in Situ (DCIS)

Presentation: most detected by mammogram as suspicious microcalcifications

Pathology: Localized disease, grows in medium-sized ducts
Multiple subtypes (focusing on two common types here)

Comedo DCIS Cribiform DCIS

Pleomorphism & central necrosis (nasty looking) Perfectly round spaces within a duct

Note secretory cells piling up, growing into middle of the duct – Cells make perfectly round spaces (sieve-like appearance)
with lots of atypia. Outgrow blood supply  central necrosis Often mistaken for hyperplasia (cells don’t look too bad – but
Malignant but confined to basement membrane are really uniform!)

Significance: Direct precursor to invasive carcinoma (local area of breast adjacent to DCIS is at risk: ↑ 10X)
Treatment: Simple mastectomy or lumpectomy + adjuvant radiation (more common today)
Tamoxifen prophylaxis to prevent recurrence for some pts

Paget’s Disease (of the Breast)

Different from Paget’s disease of the bone – actually a presentation of DCIS

Presentation: Crusting, inflammation of the nipple (can look like eczema / dermatitis)
Pathology: DCIS cells extend up the major ducts to involve skin of nipple
Histology: see ugly, pleomorphic cells in between normal epithelium

42
Lobular Carcinoma in Situ

Presentation: Incidental finding (no mass, no calcification)

Pathology: Multifocal / bilateral – see small, uniform, dyscohesive cells that fill & distend TDLU
IHC: loss of E-cadherin (explains why dyscohesive)
No gland formation, usually no necrosis

LCIS (right) – TDLU filled / distended Small, dyscohesive cells; E-cadherin lost – still see in normal
by small cells (vs normal TDLU, left) round/uniform; not forming glands glands (left) & myoepithelial cells

Significance: Indicates bilateral ↑ 10x risk of breast cancer (subsequent cancers are ductal or lobular)
Treatment: Close observation vs. bilateral mastectomy; ± Tamoxifen prophylaxis
Can’t just use lumpectomy (whole area at risk)

Carcinoma in Situ: Summary Table

DCIS LCIS
Presentation Mammogram Incidental
Usual location Medium size ducts TDLU
Origin TDLU
Architecture Forms glands Dyscohesive cells
Cytology Large cells, atypical nuclei Small cells, round nuclei
E-cadherin Intact Lost
Cancer Risk 10X ↑ risk
Site of Risk Area of DCIS Bilateral

Atypical Proliferative Disease

Presentation: incidental findings

Pathology: Have some of the features of respective carcinoma in situ, but not all
Atypical duct hyperplasia (ADH): features of both usual ductal hyperplasia & DCIS in same duct
Atypical lobular hyperplasia (ALH): some features of LCIS but not sufficiently developed

Significance: 4-5x ↑ risk carcinoma (in-between risk)

Treatment: Close follow-up ± Tamoxifen prophylaxis

43
 Invasive Breast Carcinoma

Pathology: Tumor cells invade outside of the TDLU into the surrounding stroma
Myoepithelial cells aren’t retained; tumor cells can metastasize (lymphatic access)

Epidemiology: > 99% in women; can also occur in men. 1 in 9 women in USA will develop breast cancer
184k new cases in 2008; 41k deaths (#2 cause of cancer death in women in USA)

Genetic Risk factors: Family history (# affected relatives, age of onset of cancer, bilateral cancers)
Specific genetic alterations (BRCA1/2, p53)

Other risk factors:

Environmental ↑ in Western countries
↑ with ↑ duration of exposure of epithelium to estrogen
Hormonal
nulliparity, early menarche, late menopause
Usual duct hyperplasia= 2X
Prior breast
Atypical hyperplasia = 5X
pathology
Carcinoma in situ = 10X
Age Very uncommon < age 25, increases up to menopause

Presentation
Palpable mass (e.g. BSE)
Mammographically detected lesion (early stage; more today)

Inflammatory breast carcinoma (usually advanced!)

o Carcinoma cells invade lymphatics of skin of breast
o Edema, redness, swelling of skin
o “Peau d’orange” appearance – like thick orange peel
o Firm (vs. mastitis); usually represents already metastatic dz

Metastasis
Lymphatic spread: most commonly laterally to AXILLARY LYMPH NODES
Hematogenous spread: most commonly to bone, brain, lung, liver

Pathological Types

Two main types Special types of IDC (have better prognosis)

Invasive Ductal Carcinoma (IDC) Tubular
Invasive Lobular Carcinoma (ILC) Mucinous
Doesn’t make a big difference clinically, unlike CIS

44
Invasive Ductal Carcinoma
Gross Microscopic
Stellate, hard mass
Prominent stromal fibrosis: reaction to tumor
Fixed to surrounding tissue (spiculated border)
(desmoplasia)
Gritty on cut section (calcification)
Tumor cells form ducts (to some degree)
DCIS precursor seen adjacent to IDC in 40% cases

Low power (L) - spiculated border

Mammogram & gross section:
High power (R): irregularly shaped invasive glands in a
irregular “SPICULATED” borders
background of stromal fibrosis (desmoplasia)

Invasive Lobular Carcinoma

Gross Microscopic
Architecture Cytology
Often less distinct than IDC Small cells, Round nuclei
Single files of infiltrating cells
More often bilateral & multicentric Intracytoplasmic mucin
(“INDIAN FILING”)
Look like LCIS cells

Small, uniform cells growing as single files Bland, small, uniform cells with
(“Indian filing”) around normal breast ducts intracytoplasmic mucin (“signet ring cells”)

Prognostic Factors of Invasive Breast Carcinoma

Stage Grade Estrogen / progesterone receptor Her-2/neu amplification
Stage: #1 prognostic factor
This is why mammography is thought to save lives – catch it early!
Stage Criteria 5 year survival
T: Tumor Size
I Tumor <2cm, nodes negative 80%
N: Axillary Lymph Nodes
II Tumor <5cm, +nodes or Tumor>5cm, -nodes 65%
M: Distant Metastasis
III Tumor fixed to skin or matted lymph nodes 40%
IV Distant Metastasis 10%

45
Grade (Elston grade)
Elston grade: Measures how closely the tumor resembles normal duct epithelium
Grade 1: well-differentiated
Grade 2: moderately-differentiated
Grade 3: poorly-differentiated

Estrogen receptor (ER) and Progesterone receptor (PR)

ER / PR are present on normal breast epithelium – so having ER/PR means it’s more like normal epithelium
o A good prognostic factor; ER & PR present on 2/3 of breast cancers
o Use IHC (nuclear staining – nuclear receptor) for ER to see if ER expressed

Predicts likelihood of response to Tamoxifen (estrogen receptor antagonist) - Most effective, least toxic Rx!

Her-2/neu
Oncogene, mediates cell growth; 2 copies in normal cells
Amplified in 20% of invasive breast cancer (protein overexpressed)
o Overexpression  poor prognosis, but predicts good response to Herceptin (double-edged sword)
o Use IHC (don’t see much staining in normal epithelium)

Herceptin: humanized Ab that binds Her-2/neu, prevents signaling

Treatment of Invasive Breast Cancer

Mastectomy More radical
Local therapy Get the tumor out!
Lumpectomy + radiation Tx If possible – can spare
Axillary dissection Lymphedema – try to avoid
Axillary lymph st
Did it spread? Inject dye, look for 1 lymph node – if no
node sampling Sentinel node biopsy
cancer, don’t need to take out others
May / may not need Tamoxifen ER receptor antagonist
Systemic therapy Risk of tumor vs Herceptin Anti-Her2/neu Ab
needs of patient Cytotoxic chemotherapy
Personalize to patient – age of patient, type of tumor, IHC / protein expression, side effects of treatment, etc.

46
 Placenta
Indications for Histological Examination of the Placenta
Diabetes mellitus Babies under 2.5 kg birth weight
Essential hypertension Malformed babies
Gestational hypertension, pre-eclampsia, eclampsia Stillborn babies
Rhesus isoimmunization Two vessels in umbilical cord
(and other types of isoimmunization) Unusual or equivocal macroscopic placental pathology
Pyrexia immediately prior to, or during, labor (if it looks funny)
Prolonged rupture of membranes (>24 hours) Miscellaneous (e.g., Hx maternal infection in pregnancy /
Premature rupture of the membranes (<36 wks) diagnostic procedure involving placenta)

The Normal Placenta

(Really) Gross View
Fetal surface: can see the chord coming out (usually centric). Note that arteries cross over veins.
Maternal surface: divided into cotyledons (individual lobules)
not functional units; just random separations of villi
Subchorionic cyst - incidental

Normal placenta: fetal surface. blue-

Normal placenta, here implanted in
anterior wall of uterus
Normal placenta: maternal surface.
gray or steely. Here, umbilical cord is
Cotyledons: individual lobules. Tan =
eccentric (usually more in center). Tan
adherent decidualized endometrium
areas = subchorionic fibrin

Blood Supply
Placental vessels invade the maternal blood supply to get blood for fetus
Blood comes in through uterine arteries 
Sprays blood into maternal sinusoids or intervillous space (big lakes)
available for pick-up by fetal venules  umbilical vein  back to baby
o Remember – oxygenated blood is in the umbilical venous supply

Yolk sac: part of body stalk; where germ cells / red cells come from
Yolk sac remnants: Yellow, lies between amnion & chorion
Yolk sac remnants are really common! Don’t worry about it if you see it

Yolk sac remnant: yellow, between amnion / chorion Yolk sac remnant between A=amnion & C=chorion
47
Fibrin: it’s normal to see fibrin deposited in placenta

“fibrin infarcts” aren’t real infarcts – villi are still spread widely apart
In infarcts, the villi collapse

Normal Placental Development

Embryo reaches uterus in blastocyst stage
Inner cell mass  fetus, amnion
Outer trophoblastic rim  placenta, chorion

Implantation: trophoblastic cells invade endometrium

Early development: complete covering of trophoblast around the fetus
Part away from myometrium involutes / atrophies with time (just placenta left)
Trophoblast diff  into inner cytotrophoblastic, outer syncitiotrophoblastic layers
Trophoblast invades spiral arteries of endometrium  replaces muscular wall
o Vessels  ↑ size, ↓ ability to respond to vasoactive agents (↑ blood flow!)

Baby floats in amnionic cavity, suspended inside chorion; chorion & amnion eventually fuse

Villi: become more complex, (less stroma) & more branching / more vessels over time

Early villi (left), later villi (right). Early (L) vs later villi (R), ↑ power.
Early villi vs later villi  early villi are Note later villi are more complex / Note two well-defined cell layers in
simpler & have more stroma; later villi more branching early stages; cytotrophoblast layer
more vessels / complexity / branching still present but tiny @ term

Abnormal Placental Shapes

Succenturiate lobe – incomplete involution of part of placenta Bilobed Placenta

part of placenta completely separated from rest of placental body, but covered by Actually connected, common in monkeys –
continuous layer of chorion / amnion. L = fetal surface, R= maternal surface. Note probably implants in a weird place that it
no villi between lobe & rest of placenta. Usually incidental but can be left in uterus! doesn’t like & develops away from it
Represent abnormal involution of the originally circumferential placenta

48
 Abnormal Attachments
blood fills the gap; ± placental hypoxia
↑ with multiparity, ↑ maternal age, toxemia
Abruption placenta separates early from uterine wall / cocaine use
can cause severe hemorrhage
controllable only with delivery
Invasion Accreta just stuck on
(buffer zone of decidua lost; trophoblasts enter –
of uterine Increta invades the wall
can be superficial or the whole way through)
wall Percreta whole way through the wall
creates problems during delivery – blood flow
compromised to baby if the placenta comes out
first! Often a cause for C-section
Previa (partial / total) placenta covering the cervical os
↑ with ↑ maternal age, smoking
↑ with prior scarring (C-section,etc)
Vaginal bleeding & ↑ fetal mortality!

Degrees of uterine wall

invasion Placenta previa – can be partial or total. Note that if the
placenta separates totally, blood supply interrupted!

Placental Abruption Placental Infarcts

Note infarcted cells; loss of nuclear

Placenta separated from endometrium; space filled with
Tan lesions (gross) staining; the villi are collapsed
blood  becomes clot (arrow).
(perivillus fibrin = don’t collapse)

Abruption
Need to lose about 50% of blood supply to start harming the fetus
What causes abruption? Maternal hypertension, trauma, many others
Can lead to infarcts (villi collapse together!)
Couvelaire uterus: in rare cases, blood can dissect into myometrium  shock
o See pic to right – generally requires hysterectomy

49
Extrachorial Placentas
Abruption around periphery of placenta  partial separation of amnion from underlying part of chorionic plate
Chorionic plate smaller than basal plate
Transition from membranous  villus chorion takes places farther away

Circummarginate Circumvallate*
transition area is flat marginal ring is raised

(no pics)

*ONLY CIRCUMVALLATE associated

with fetal / maternal morbidity

Multiple Gestations
Twins
Monozygous (identical) or dizygous (fraternal)
MZ incidence constant worldwide (3.5/100)
DZ varies with geography, families, use of assisted repro
USA: about 1:80 pregnancies have twins, 1/3 MZ

Monozygous twins: ONLY MZ can have monochorionic placentas

Can have dichorionic placentas too!

Diamniotic (more common – two amniotic cavities) or

Monoamnionic (more rare - ↑ morbidity / mortality!)

Which one depends on how early twinning happens

o Earlier split of fertilized egg: di/di
o Later split: mo/di (75%)
o Latest split: mo/mo

Dizygous twins: all have dichorionic placentas: all di/di (two chorions & two amnions all the time!)
20% of DiDi placentas are monozygous – it helps to know sex of DiDi twins!

Fused dichorionic, diamnionic placenta Fused monochorionic, diamnionic placenta

Have a big ridge going down the middle; also no blood vessel
anastamoses between the two. Fused = two placentas just No ridge – can’t tell where separation would have been. Lots of
pushed up against each other. M = fused membrane, would vascular anastamoses between the sides (dye injection – right)
have two amnions & one chorion at that point

50
 Velamentous insertion of cord Monochorionic, monoamniotic

Very common in twin pregnancies – cord inserts into Only one cavity – easy for cords to become
membranes; not chorion like it’s supposed to entangled; morbidity!

More Multiples

Triplets: here B/C are monozygous, A from separate

Conjoined twins: very late Quintuplets: here all were di/di
fertilized ovum. B/C were monochorionic, diamnionic; A
splitting of fertilized ovum Too much clomid
was di/di from the rest of them

Problems with Multiples

Twin-twin transfusion (Monochorionic – diamnionic placenta)

MZ twinning before chorion formation, after amnion formation
Have vascular anastamoses  blood flow imbalance (usually mild)
o MZ TWINS: one twin usually a little bigger than the other
can lead to twin transfusion : one twin “donates” blood to other
o Big twin usually dies (overload); small one can too

MoMo (twinning after both chorion / amnion formation):

↑ fetal death (entanglement of fetal cords)

Fetal Papyraceus – one twin dies in utero (pic, left)

Almost any kind of twins
Maybe a 10-20% twin loss overall?

Fetal Reduction (pic, right)

If too many twins (assisted reproduction), sometimes have to ↓ number

Acardiac fetus
Only in MZ twins, aka “twin reverse transfusion problem
Maybe an extreme version of twin-twin transfusion?
o One twin pumps blood to other  other’s heart doesn’t develop?
Here: see spinal column, primordial limb appendages, no heart

51
 Umbilical Cord Abnormalities
True knots Two vessel cord

Generally insignificant Should have 2 arteries, 1 vein; here 1:1.

↑ with: ↑ volume amniotic fluid, longer Check for other congenital anomalies (20% risk)
cord, “overactive fetus” May see remnant of other artery (right), but no change in risk of other abnormalities

Cord Insertions
Normal placenta Battledore placenta Velamentous insertion Vasa previa

vessels prolapse into

Cord is usually centric, Still normal (eccentric) = cord supported only by the membranes @ the
cervical canal –
may be eccentric but “battledore” (badminton insertion point; weak - can rupture (delivery)!
obstruction to blood
still normal paddle) Associated with TWINNING
supply

Placenta & maternal disease

Maternal condition Placental pathology Pic

Decidual ateriopathy (acute atherosis)

Pre-eclampsia /
eclampsia see atherosclerosis-type changes in placental aa.
lipid deposition
(a.k.a. toxemia of
fibrinoid necrosis
pregnancy)
thrombosis

Placental infarcts: only bad if↑ size/#

Abruption, maternal hypotension, etc –

↓ blood supply maternal circulation  O2 to placenta, so
umbilical problems won’t cause infarction!

VILLI COLLAPSE & NUCLEI DON’T STAIN

NORMAL FINDING (contrast with infarct)

Perivillus fibrin
Villi don’t collapse, nuclei stain just fine

52
Maternal condition Placental pathology
Diabetes mellitus Fetal hyperglycemia, hyperinsulinism  macroosmia, neonatal hypoglycemia, ↑ congenital abnormalities
Alcohol: placental infarction, meconium staining, chorioamnionitis
Maternal drug use Cigs: ↓ birth weight, placenta previa, abruption; nicotine  constriction  placental ischemia
Coke: abruption, IUGR, contenital fetal abnormalities (cocaine induced vasoconstriction?)

Placenta & fetal disease

Amniotic Fluid
Generated by transudation through amnion < 12wks, then by fetal kidneys (fetus urine)

Polyhydramnios = too much fluid (e.g. inappropriate swallowing – upper GI atresia)

Oligohydramnios = too little fluid (e.g. fetal kidney / urinary tract problems)
Amnion nodosum – can get precipitates of particles in AF onto amnion
If you see this pattern, think maybe there was oligohydramnios!

DDx of amnion nodosum includes squamous metaplasia

normal if only around cord insertion! Maybe irritation?
Histology: squamous metaplasia with focal keratinization

The Amnion

Reactive change in amnion

Nonspecific (acute inflammation, meconium deposition, etc)
Suggests that another lesion might be present - Look around!

Meconium staining
Green (bile content of first fetal bowel contents)
Usually takes about 6h to go from placenta across amnion to chorion,
where it gets engulfed by Mϕ
(so if you see Mϕ, you know something happened at least 6h ago)

Amniotic Bands
Amnion separated from placenta; forms strands / bands
Can entrap fetus 
intrauterine amputation / deep cleavage problems
Need to DDx vs genetic malformations!

53
 Placental / Fetal Infection
Chorioamnionitis
An ascending infection; primarily from bacterial organisms in vagina (especially group-B β-hemolytic strep, E. coli)
Gain access to amniotic space either before / after membrane rupture
st st
o 1 creates maternal inflammatory response (PMNs @ os) 1 – “chorioamnionitis”
o Fetal response more delayed (see fetal PMNs in umbilical vessels – “funisitis”

PMNs + bacteria  prostaglandin release  premature labor

o #1 cause of midtrimester spontaneous abortions
o Amniotic fluids  bacteria-filled  swallowed / inhaled by fetus  fetal pneumonia / sepsis

Early chorioamnionitis: most

Opaque membranes (not smooth / More severe chorioamnionitis –
inflammation at base of chorion (where it
glistening / slate-blue-grey like normal) full-thickness inflammation
came in around edge of placenta)

Chronic Villitis
Plasma cells & lymphocytes in VILLI
(not PMNs in membrane like chorioamnionitis)

Often villitis of unknown etiology (VUE)

But investigate viral / treponemal / other infections if warranted
Often associated with maternal disease that’s been transmitted to placenta
TORCH diseases, etc – CMV placental infection, for instance

Acute Villitis
PMNs in villi (not in membranes)
Also from maternal infections (think LISTERIA infection)

54
 Pathophysiology: Repro
Overview of Repro .................................................................................................................................................................. 2
Male Reproductive Dysfunction ............................................................................................................................................. 3
Male Infertility & Azoospermia ............................................................................................................................................... 8
Prostate Cancer ..................................................................................................................................................................... 11
Benign Prostatic Hyperplasia (BPH) & Bladder Neck Obstruction ........................................................................................ 15
Polycystic Ovary Syndrome ................................................................................................................................................... 18
Female Infertility ................................................................................................................................................................... 22
Maternal Physiologic Changes During Pregnancy................................................................................................................. 27
Pathologies of Pregnancy...................................................................................................................................................... 32

1
 Overview of Repro
Obstetrics
Infant mortality rates: big decreases (neonatal care units, antibiotics, access to care!)
Maternal mortality: blood transfusion, antibiotics – but a little bit of upwards trend recently
C-section rate has increased, so maternal mortality has increased too (drug use, other problems too)
11/100k in the USA (world average 400/100k)

Gynecology
Gynecologic oncology – lots of robotic surgeries, etc.
Female Pelvic Medicine / Reconstructive Surgery – deal with pelvic floor dysfxn, etc.
Family Planning – now a subspecialty. Research: new methods, efficacy, etc.

Reproductive Endocrinology
Reproductive Endocrinology: diagnostic medicine, etc.
Assisted Reproductive Technologies (IVF, etc)

A Multi-Disciplinary Field
Internal medicine – pts will have ob/gyn issues!
Emergency med / trauma – knowing reproductive / fetal anatomy; e.g. fetus compresses IVC
Medical oncology – family planning & chemo regimens, for example
Peds / Adolescent med – sexual issues in those populations.

Medical Discovery
Prevention of Erythroblastosis Fetalis
Problem: Rh- mom, develops anti-Rh Ab during pregnancy with Rh+ fetus, 2nd pregnancy can attack fetus
(erythroblastosis fetalis)
st
Freda Mission: maybe we can give Ab to mom during 1 pregnancy to prevent sensitization? NIH didn’t approve.
Ossining connection: Sing-Sing in Ossining, NY; research on inmates, tested the idea on them
“Rhogam” – passive immunization, big preventatitve medicine

Breaking HIV transmission chain

Initially 25-26% babies were getting vertically infected; most died in first few wks of life.
Model: give AZT to babies in 1st 12h of life. Also – give in 36th wk? FDA said OK.
Result: 67% reduction in transmission. 1994: 2000 infected infants / yr, 2004: 200. Less now with HAART

Risk reduction for health care professionals

Antiretrovirals for HIV PEP came out of the above study
Risk reduction (HIV PEP for health care workers) too.

2
 Male Reproductive Dysfunction
Hormonal Control of Testosterone Secretion
Hypothalamus  GnRH  anterior pituitary  makes gonadotrophins

FSH: stimulates Sertoli cells (supports spermatogenesis)

LH: lutenizing hormone, stimulates Leydig cells  testosterone

T feeds back at both the anterior pituitary / hypothalamus levels

CNS involved too! Acute illness, stress, etc. can affect this axis
o If you’re starving, really sick – body doesn’t “waste energy” on
making sperm, etc.

Testosterone levels during the life cycle

Stage What’s T doing?

Fetal spurt masculinization of brain, genitals
Neonatal spurt imprinting early in life?
Prepubertal inactive axis
Puberty shoots way up – all the pubertal changes
Older age senescence – drops down (≈25% men)

Also has a rhythmic quality during adulthood

Annual: higher in the fall
Daily*: higher in the late morning
Pulsatile: important for the physiologic function

* Circadian: measure 1st thing in morning!

Androgens: not just testosterone

Major players in men More mportant in women (from adrenal gland)
DHEA (Dehyepiandrostenedione)
Testosterone
DHEA-S (Dehyepiandrostenedione sulfate)
DHT (dihydrotestosterone) via 5-α reductase
Androstenedione

Testosterone & Protein Binding

Only about 2% is free, available to bind to androgen receptor
o Remember if you measure total testosterone, it’s not really telling you what’s free!
40-50% bound to SHBG (sex-hormone binding globulin); ≈48% bound to albumin

Testosterone Effects
Skin Hair growth, balding, sebum production
Liver Synthesis of serum proteins
Male sex
Penile growth, spermatogenesis, prostate growth / fxn
organs
Brain Libido, mood, cognition
Muscle ↑ strength, volume
Kidney ↑ erythropoietin (why men have a higher Hct!)
Bone marrow Stimulates stem cells
Bone Faster linear growth, closure of epiphyses, ↑ bone mass
3
These effects are not just from testosterone but from metabolites as well
e.g. bone density from estrogen (from aromatase activity), not T itself!

Male hypogonadism (low T prior to puberty)

Signs & Symptoms
Linear growth may continue (after age 18, if untreated) (no epiphyseal closure)
Eunuchoid skeleton (long legs / bones)
Lack of adult male hair distribution
Infantile genitalia and small/no prostate
Lack of scrotal pigmentation and rugae
High pitched voice (T thickens the vocal cords)
↓ libido
↓ muscle mass, strength, ↓ endurance

Etiologies of male hypogonadism

Think about what level in the axis it could be happening at
Compare T to LH/FSH levels to determine 1° vs 2°

Primary hypogonadism (↑ LH)

testicular dysfxn (E.g. Kleinfelter’s syndrome  ↓ T secretion)

Secondary hypogonadism (↓ or nL LH)

pituitary (e.g. tumor  ↓ LH/FSH secretion)
hypothalamic (e.g. Kallman’s syndrome  ↓ GnRH secretion)

Aging  all three levels? Testicles, pituitary, hypothal don’t work as well

Further workup of male hypogonadism

Physical Exam Lab diagnosis
Initially:
Terminal facial hair Serum total T (AM sample)
Lowering of voice Free T or bioavailable
Height / eunichoid proportions (longer legs?) Confirmatory:
Pubic hair distribution (diamond shaped in men, triangle in F) FSH / LH / prolactin
Testicular / prostate size (firm, normal size) Other pituitary function if needed
Further evaluation as needed

Kallman’s Syndrome: a hypothalamic defect

Sample case: 54yoM with CC anemia; Hx: rejected from service @ 17yo, never sexually active.
PE: pre-pubertal. Labs: total T ↓↓ 13 (300-800), FSH ↓ IU/mL (2-20), LH↓ 1 IU/mL (2-10).
Bone density is lower than normal (hypogonadal)

Etiology: a hypothalamic problem

Associated with other midline defects: cleft palate, nasal defects, ANOSMIA‼
Absence of nerve growth factor prevents co-migration of gonadotrophin & olfactory cells
o KALIG-1 gene: Kallman’s syndrome interval-1

Lab: see isolated hypogonadotrophic hypogonadism

4
Other Hypothalamic Causes of Hypogonadism
Note that the problem can be physiological or anatomical – or the CNS input to the hypothalamus can be messed up
Kallman’s syndrome Malnutrition
Craniopharyngioma ↓ body fat (ballet dancers, anorexia nervosa, excessive exercise)
Tumors o Male marathon runners have blunted GnRH pulses
Acute and chronic illness

Pituitary Causes of Hypogonadism

Etiologies:
Neoplasm Hemochromatosis
o Non-secretory or secretory (prolactinoma) tumor Irradiation
o Pituitary apoplexy Glucocorticoid-induced
Infectious: Granulomatous invasion (e.g. TB, sarcoid)

Labs: Low LH/FSH + Low T; hypopituitarism

Treatment: Surgery or TRT (testosterone replacement therapy); pituitary replacement if needed

Testicular Causes of Hypogonadism

Category Examples
Chromosomal Klinefelter’s syndrome
Toxins Irradiation, alkylating chemotherapy (90% of males given alkylating agents – leukemia survivors), alcohol
Infectious Mumps, echovirus
Trauma 50% will have atrophy
Autoimmune associated with polyglandular failure with Ab vs 17-alpha hydroxylase and CYP side chain cleavage enzyme
Genetic Inactivating mutation of the LH or FSH-receptor gene

Klinefelter’s Syndrome: a testicular defect

Genetics: XXY karyotype (nondisjunction during 1st meiotic division)

 ↑ risk with ↑ maternal age

Clinically: Eunichoid habitus, gynecomastia, firm testes

 Firm: hyalinization of the seminiferous tubules

Other issues: Associated with chromosomal cancers (breast, NHL)

Labs: ↑ LH/FSH, ↓ T (testicular defect)

End-organ resistant causes of hypogonadism

Etiology: Total or partial androgen receptor resistant syndromes

Testosterone is there, but can’t work on receptor
More rare

Labs: ↑ LH / FSH and ↑ T

Treatment: depends on phenotype; can give estrogen therapy

Complete androgen resistance – look like girl completely
Partial androgen resistance – fall somewhere on a spectrum
Internal anatomy: no uterus / cervix / top 1/3 of vagina (MIF!)

5
Genetic abnormalities of sex-steroid action
In all, really rare
Mutation of 5-α reductase gene
Mutations of CYP19 aromatase gene
Inactivating mutation of estrogen receptor α gene
Phenotypic females at birth who virilize with pubertal surge of T
Tall stature, nL / high T and low estradiol
Tall stature, continued linear growth

Low testosterone (low T, post-pubertal)

Signs & symptoms
more subtle & non-specific than in male hypogonadism
Loss of libido Reduction of bone density
Erectile dysfunction Testicular atrophy
Lethargy Gynecomastia
Loss of muscle mass and muscle strength Depression
Oligospermia or azoospermia

Etiologies:
Other Conditions: many associated with low testosterone state
Age, chronic illness (diabetes, HTN, hyperlipidemia, AIDS), obesity, chronic opiod use
Should we treat these people? Subject of research. What’s “normal”?

Effects of Testosterone Replacement Therapy (TRT)

Positive effects:
↑ mood, energy, libido within weeks!
↑ lean body mass, ↓ fat mass

Fractures with age

Men peak in fracture rate early (adolescents are dumb)
Then ↑ again with ↓ bone mass later in life
We tend to underestimate the impact of osteoporosis in men

Hypogonadism: see ↓↓ bone density  ↑↑ bone density with TRT!

Available forms of T for TRT

Gels ≫ patches / injectables for use; some buccal / oral too

Injectables: cheap cause “roller-coaster effect” (high peaks, then ↓ )

Gels, patches give some more stability

Side Effects of TRT

• Prostate growth (but does NOT cause cancer!) • Sleep apnea
• Undiagnosed prostate cancer (if you have it, ↑ growth) • ↓ in HDL
• ↑ hematocrit • Psychosocial issues

Patient Monitoring for TRT

If you decide to treat with TRT, need to follow the pt!

Do these @ baseline & then follow (1-2 mo, then q6m for 1st yr, then annually)
Blood work: Hgb, Hct (don’t want to go too high)PSA level, DRE (check for prostate cancer); T, LSH, FSH, prolactin
DEXA scan for osteoporosis
Check voiding symptoms
6
 Male Infertility
Categorize as pre-testicular, testicular, or post-testicular
Pre-testicular Testicular Post-testicular
Hypothalamic and Ductal obstruction
Etiologies Primary testicular failure
pituitary causes Retrograde ejaculation
Surgery
Treatment LH and FSH (Rare)Testicular aspiration
Medications
Note that pre-testicular and post-testicular can be treated & pts can have their own biological children
Really can’t do much for primary testicular failure

Conclusions
• Male reproductive disorders can be due to disease in the hypothalamic, pituitary, or testis or be non-specific
• TRT in hypogonadal men, whether young or old, is associated with improved sexual function and sense of well-
being, and improved body composition
• Long-term benefits of testosterone on longevity or frailty are unknown
• Side effects are few and can be monitored easily by measuring serum PSA and Hct

7
 Male Infertility & Azoospermia
Introduction
Definitions
Closely related but independent processes:
Erection: ability to achieve and maintain adequate penile rigidity for sexual relations
Orgasm: cerebral event associated with sexual satisfaction
Ejaculation: physical process by which sperm and seminal fluid are delivered to the urethral meatus
Fertility: relative ability to initiate conception
Can have orgasm / ejaculation without erection
o Physiologic ED, for instance: keep trying to stimulate  orgasm from flaccid penis
o Psychogenic ED: won’t have orgasm (clinical tip-off)
Can have orgasm without ejaculation, but can’t have ejaculation without orgasm (the one exception)

KEY POINTS (KNOW THESE FOR THE EXAM)

Male factor is responsible for 50% of couple infertility
Varicoceles are the most common reversible causes of male infertility
The concentration of testosterone is highest within the testis

Epidemiology of Infertility
About 15% of couples have trouble conceiving.
About 50% of those involve the male factor – either alone or combined with female factor

Etiologies of Male Factor Infertility

Varicocele is #1 (most common, reversible)
o Obstruction, ejaculatory dysfunction, cryptorchidism, others; endocrine causes are only about 1%
25% are idiopathic

Semen abnormalities: when you send semen to the lab:

About 14% normal; 14% azoospermia (no measurable level of sperm)
Oligoasthenoteratospermia (OAT) is most common (49%) abnormality detected
o Oligo = few, astheno = weak , terato = abnormal or something
o Multiple parameters are abnormal: Low sperm count, poor motility, abnormal morphology

Things that have to go right for male fertility

Step Details
1. Sperm production
Sperm aren’t viable after being produced; transit 12 ft epididymis in 7-12d
2. Epididymal sperm maturation
Develop ability to swim \ capitation
3. Delivery of sperm to cervix Erection / orgasm / ejaculation, need intact ducts, vaginal intercourse
st
1 sperm arrive in minutes; last sperm can arrive days later (“rhythm” method not good).
4. Migration of sperm to oviduct On flip side, egg doesn’t last long
sex 24h after ovulation won’t initiate conception, but sex days before could
Reversible, Ca-channel mediated.
5. Capacitation
Results in hypermotility of sperm (prep for acrosome rxn)
Fusion of inner/outer acrosome membranes  releases digestive enzymes
6. Acrosome reaction
required for sperm to go through zona pellucida & bind egg cell surface
7. Egg penetration
8. Post-fusion events Sperm only contribute 2 things to embryo: centrosome & ½ the DNA (all mito, etc. from F)

8
 Azoospermia
No sperm in semen
Differential diagnosis Diagnosis T LH FSH
Primary testicular failure
Pre-testicular endocrine Secondary testicular failure
Testicular spermatogenesis Germ cell failure NL NL
Post-testicular delivery Androgen resistance NL/
Eugonadal NL NL NL
Pre-testicular: e.g. Kallman’s Syndrome
Sample Case: 26 yo M with azoospermia; Hx of undescended testes, ejaculate volume low (0.5mL), bilateral atrophic testes &
anosmia. Testosterone ↓ (132 ng/dL), FSH/LH ↓.

Dx: Kallman’s Syndrome

no migration of hypothalamic neurons to circulation (or olfactory neurons)

Treatment
Can give LH/FSH to stimulate testes, or GnRH to stimulate pituitary
↑ ejaculate volume, sperm count  can become fertile!

Pre-testicular: e.g. anabolic steroid abuse

Sample case: 28yo body builder with azoospermia; Hx of anabolic steroid abuse. Ejaculate
volume normal, fructose positive; testosterone ↑ (1000 ng); LH/FSH↓↓

Dx: still using anabolic steroids

Giving a lot of T will shut down the H-P-G axis  not making LH/FSH
o Serum concentrations of T will be higher, but you’re not making T in
the gonads!
o Gonadal concentrations of testosterone are actually lower!

Primary Testicular failure: Varicocele

Sample case: 37 yo M with azoospermia; 2 kids (secondary infertility), ejaculate volume nL (2mL), large left varicocele, T nL, FSH ↑

Pathogenesis
Dilation of veins of pampiniform plexus, due to reflux of blood through incompetent venous valves
Progressive deleterious effect on testes (↑ scrotal temperature)

Treatment: can repair; 60% end up with sperm in ejaculate

but low sperm count; pregnancy rates only 25%: need to use other methods too

Primary Testicular Failure: Klinefelter’s Syndrome (47,XXY)

Sample case: 26 yo M with azoospermia; eunuchoid appearance with gynecomastia; ejaculate volume nL, T ↓ (156), FSH / LH ↑↑

Dx: Klinefelter’s Syndrome

Primary testicular failure is usually IRREVERSIBLE (exception: varicocele).

Etiologies: viral orchitis, toxin exposure / chemo, Klinefelter’s, varicocele
Options: donor insemination, adoption, testicular sperm extraction (newish)

9
Testicular sperm extraction:
Can find a few sperm even in 40% Klinefelter’s pts!
Can fertilize (42%) with ICSI: intracytoplasmic sperm injection
o Doesn’t need to be able to swim, etc!
Pre-implantation: embryo biopsy, FISH negative for aneuploidy

Post-testicular: delivery problems

Sample case: 32 yo with history of epididymitis. Ejaculate volume normal, fructose positive, nL testis volume, T / FSH normal

Dx: presumably delivery problems from epididymitis (obstruction)

But can get obstruction at any point along the sperm’s route
o Epidiymis, vas deferens, ejaculatory duct, etc

Seminal Fluid: normally 1.5-5mL

Testis / epididymis: 5%
Seminal vesicles: 60%
Prostate: 35%

So where is obstruction? Probably before seminal vesicles / prostate if volume nL!

Vasectomy: no appreciable change in ejaculatory volume!

Treatment of epididymal obstruction: Epididymovasostomy (right pic)

Bring vas deferens down, hook to epididymis
75% patent, but only 30% pregnancy rate
o Varies with site of obstruction, presence of sperm, etiology

Management of Azoospermia
Endricrinologic Hormonal therapy
Donor insemination / adoption
Abnormal spermatogenesis
Sperm acquisition / IVF (e.g. ICSI)
Obstruction Reconstructive surgery (or IVF)

10
 Prostate Cancer
Epidemiology of Prostate cancer (adenocarcinoma of the prostate):
MOST COMMON NON-SKIN CANCER in US Men (219k/yr)
#3 cause of cancer death (27k/yr)

Radical prostatectomy: the most frequently performed Tx for clinically localized prostate cancer

Risk factors:
Family history
Race / ethnic origin (AA > white / Asian)
Diet / trace elements (?)

Anatomy

Prostate: right around the urethra; Prostatic sphincter of the urethra is right outside the prostate gland
Different zones of the prostate
Peripheral zone – on the outside – is what you feel during a DRE; 70% of cancers arise from here

Screening / Detection
Combo of DRE & serum PSA is the most useful 1st line test to assess risk of prostate cancer in individual
DRE (digital rectal exam) – looking for nodule, induration of the prostate
PSA (prostate specific antigen) – blood test
If either one is abnormal – transrectal ultrasound-guided prostate biopsy (↑ PSA or abnormal DRE)

Staging of prostate cancer

Chance of PSA recurrence following radical prostatectomy correlates well to TNM staging
T1a (<5%), T1b (>5%), found during TURP
T1 nothing palpable
T1c: means the tumor was found on biopsy because of elevated PSA level
T2 confined to the prostate T2a: < ½ of 1 lobe, T2b: > ½ of 1 lobe, T2c: more than one lobe
T3 palpable beyond the prostate T3a: unilateral extracapsular extension, T3b: bilateral; T3c: seminal vesicles
T4 Tumor fixed or invades adjacent structures (other than seminal vesicles)
All these have multiple subtypes, just know T1c!

PSA: Prostate Specific Antigen

Most important prostate cancer serum marker
Single change 237 AA glycoprotein, serine protease, functions to liquefy human semen
Androgen sensitive, produced by BOTH MALIGNANT & BENIGN prostate epithelium!

11
Problems:
Can be elevated with prostatitis, prostate cancer, BPH, lab error, manipulation (DRE, ejaculation)
Can be decreased with long term 5-α reductase inhibitors, e.g. finasteride)

Trans-rectal ultrasound-guided prostate biopsy

Ultrasound up the rectum

Then poke a needle into prostate

Get little needle biopsies; look for

cancer with special stains

Grading of prostate cancer: the GLEASON SYSTEM

Well differentiated Gleason 2-5

Moderately differentiated Gleason 6-7
Poorly differentiated Gleason 8-10
Correlates well with likelihood of PSA recurrence after radical prostatectomy (really good stratification)

Radiographic imaging
Example: 63 y/o AA M, FHx prostate Ca; PSA 6.8 ng/mL; DRE: nodule on one side; TRUS-bx:Ggleason 3+3=6
Dx: adenoCa of prostate. Stage is T2a (less than ½ of one node, palpable but confined to prostate)
Does he need a radiographic study? Probably not (probably local only), but could order if worried

Helpful sometimes Not that helpful

CT / MRI
Nuclear bone scan / Scintigraphy
Plain radiograph
(Detect bony metastases) U/S

Approach
“Watchful waiting”
Surgery
Radiation therapy
Hormonal manipulation
Combination therapy
Treatment Options
Involves Notes
No treatment
Radical prostatectomy If: cancer localized; life expectancy > 10-15 yrs
External beam radiation and/or
brachytherapy (radioactive seed implant)
Androgen deprivation therapy Usually in palliation therapy for advanced dz
Hormonal therapy + radiation
Need to individualize for the specific patient

Radical Prostatectomy
Radical prostatectomy – means total

History
Has been growing in popularity – now #1!
st
1904: 1 radical perineal (between scrotum / anus) prostatectomy (Hugh Hampton Young; JHH)
1940s: first radical retropubic prostatectomy (behind pubic bone)
Halsted: rockstar surgeon @ JHH, wore rubber gloves, technique > strength, could get any
nurse he wanted, addicted to cocaine, then switched to morphine. Trained Young
12
Side effects of old radical prostatectomies
Life-threatening bleeding (radical retropubic prostatectomy)
Urinary incontinence in 25%
Impotence in close to 100%!

The anatomy was the problem

hit the deep dorsal vein of the penis with the retropubic approach

Anatomic “nerve sparing” radical retropubic prostatectomy

Patrick Wallace (JHH) – wanted to preserve the nerves!

Nerves from pelvic plexus go up & over the prostate

Go into penis
Responsible for erections (so let’s not cut those)

Goals of Radical Prostatectomy

1. Cancer control
2. Preservation of urinary continence
3. Preservation of potency
Results:
Cancer control @ 15 yrs: 66% PSA-elevation-free, 82% metastasis-free; 91% cancer-specific survival (really good!)
Depends on striated sphincter: incontinence after RRP usually 2° to intrinsic sphincter deficiency
Older men have thinner striated urinary sphincter
Urinary continence Injury can occur during ligation / division of dorsal vein complex – be careful!
Bladder detrusor hypertrophy, ↓ bladder compliance from pre-existing bladder outlet obstruction (e.g.
BPH) can play a role too

Modern techniques: use the daVinci robot system (pretty sweet)

External Beam Radiation Therapy

Alternative to RRP
takes 6-8 wks, minimally invasive
Side effects: erectile dysfunction, urge incontinence, rectal injury, dysuria

Brachytherapy
Another alternative to RRP
Implant radioactive seeds (100s) right into prostate
Do with trans-rectal U/S guidance
Try not to besmirch the Hopkins name by doing it poorly

Hormonal Therapy (Androgen Deprivation)

Another alternative to RRP, but: NOT CURATIVE

Goal: DEPRIVATION OF ANDROGEN (TESTOSTERONE)
PSA temporarily decreases, get a temporary symptomatic relief in most men with metastatic disease
Eventually develop hormone-refractory prostate cancer (median survival 6-12mo post-relapse)

Side effects: osteoporosis, unfavorable body composition, sexual dysfunction, reduced quality of life

13
 Conclusions
• Prostate cancer is the most common non-skin cancer in the US men
• Radical prostatectomy is the most commonly preformed treatment modality for localized prostate cancer
• Detection/screening by combined DRE and PSA
• Ultrasound guided prostate biopsy for diagnosis
• Staging (TNM) and grade (Gleason score) of prostate cancer
• Curative treatment modalities exist for clinically localized disease
• Excellent oncological and clinical outcome can be achieved with a careful surgery using nerve sparing technique
• Wide spread early detection programs for prostate cancer resulted in a downward stage migration

QUESTIONS FOR THE TEST (probably)

1) What is the clinical stage T1c prostate cancer?
a) No tumor palpable, but found on Bx after ↑ PSA

2) What are three goals of radical prostatectomy?

a) Cancer control
b) Preservation of urinary continence
c) Preservation of potency

3) What is the most common non-skin cancer in US men?

a) Prostate cancer!

4) What is PSA and how is it used?

a) Prostate-specific antigen. Most important prostate cancer serum marker
b) Single change 237 AA glycoprotein, serine protease, functions to liquefy human semen
c) Androgen sensitive, produced by BOTH MALIGNANT & BENIGN prostate epithelium!
d) Used in combo with DRE as most effective 1st line screening technique
(trans-rectal U/S-guided prostate Bx if either DRE or PSA abnormal)

5) How is prostate cancer diagnosed?

a) Transrectal Ultrasound-guided Prostate Biopsy

14
 Benign Prostatic Hyperplasia (BPH) & Bladder Neck Obstruction
Intro / Anatomy
See previous lecture for more anatomy pics

Zones of the prostate

BPH affects the transition zone – around the urethra

o Squeezing the tube shut!
Cancer is mostly in the peripheral zone

Epidemiology
More common in older men (really common in older age!)
↑ symptoms, problems with ↑ bladder size!

Pathogenesis of Lower Urinary Tract Symptoms (LUTS)

Can be from BPH or obstruction
Mass-related ↑ in urethral resistance
Age-related detrusor dysfunction
No well established cause-effect relationship: symptoms vs BPH

↑ # epithelial / stromal cells in periurethral prostate

either proliferation or impaired apoptosis
Androgens are required for normal cell proliferation; inhibit cell death
TESTOSTERONE  DIHYDROTESTOSTERONE via 5-α REDUCTASE
o DHT is more potent – works both locally (testes) and all over the body
o 5α reductase in stromal cells of prostate converts T to DHT

Steps:
1. BPH first develops in periurethral transition zone of the prostate
2. Prostatic smooth muscle: both passive & active forces
a) α-adrenergic system involved (block  ↓ prostatic urethral resistance)
3. Bladder: detrusor muscle instability / ↓ compliance
a) Trabeculation, Cellule, Diverticulum

Picture (right): if prostate squeezing in or middle lobe hypertrophies to block outflow:

↑ pressure in bladder
Diverticulae can form, or little cellules / trabeculae in between

Diagnosis of BPH
Clinical manifestations
LUTS (see above) Detrusor instability Renal insufficiency (post-renal)
Poor bladder emptying UTI
Urinary retention Hematuria

Dx: H&P; IPSS

IPSS = questionnaire (symptom index) – give to pts frequently

15
 Treatment
Want maximum efficacy and least morbidity – but for BPH, ↑ morbidity with ↑ efficacy in a pretty linear pattern!
Treatments here in increasing order of invasiveness

Medical Management
Around since the 80s; don’t have the same level of efficacy as surgery but avoid complications (morbidity,etc)

Options
α-adrenergic blockers: cut off the nerve effects on the muscles of the prostate  ↑ flow
o Phenoxybenzamine, prazosin, afluzosin, terazosin, doxazosin, tamulosin
o Bladder outlet obstruction mediated by α1 adrenoreceptors on prostatic smooth muscle
o Can lower blood pressure; can lead to retrograde ejaculation

5-α-reductase inhibitors: block TDHT conversion, so ↓ DHT  help shrink

o Finasteride, duasteride
o Embryonic development of prostate dependent on DHT; so is BPH development
o Requires long term therapy (> 6mo); usually more effective in larger prostates

Combined therapy: most effective of all medical options

Surgery: Minimally Invasive therapy

Transurethral needle ablation (TUNA), microwave therapy (TUMT), vaporization (TUVP), incision (TUIP); lasers
Put probe into urethra, probe has microwave / needle / laser / whatever, get rid of it

TURP: transurethral resection of the prostate is the GOLD STANDARD for surgical treatment of BPH

History of TURP
Brady Institute: from “Diamond” James Buchanan Brady (lots of bling, really weird guy, ate a lot)
Had BPH; was really big – so needed a doctor to treat his BPH
Dr. Hugh Hampton Young – “prostate punch” – insert blindly into prostate area, resect away
Brady got better, gave $$$ to JHH (started time-honored tradition of old rich guys coming to Hopkins for prostate Tx)

Minimally invasive: Transurethral Prostatectomy

Insert scope into bladder
Scoop out prostate with electrocautery
Fast, but you can bleed (green light laser –
don’t bleed that much)

Open / Simple Prostatectomy

The most aggressive treatment
Enucleate hyperplastic prostate tissue via a lower midline incision
Longer hospitalization, convalescence period
↑ potential for perioperative hemorrhage
Use if larger prostate (> 75g), bladder diverticulum, large bladder stones, concurrent inguinal hernia

16
 Conclusions
BPH is more common in aged men
BPH can be treated with medical and/or surgical treatment
Medical treatment includes α-adrenergic blockers and 5α-reductase inhibitors

QUESTIONS FOR THE TEST (probably)

1) How do you make a diagnosis of BPH/LUTS?

a) H&P: LUTS, poor bladder emptying, urinary retention, detrusor instability, UTI, hematuria, renal insufficiency (post-renal)
b) IPSS: questionnaire (index of symptoms)

2) What are medical treatment options for BPH/LUTS?

a) α-adrenergic blockers, 5-α reductase inhibitors. Combo is most effective

3) What is the “Gold Standard” surgical treatment for BPH?

a) TURP: transurethral resection of the prostate

4) How do 5α-reductase inhibitors work in BPH management?

a) block TDHT conversion, so ↓ DHT. (DHT is required for BPH development)

17
 Polycystic Ovary Syndrome
History
1935: Stein, Leventhal describe 7F with obesity, hirsutism, menstrual abnormalities, infertility
all had oligo/amenorrhea + bilateral polycystic ovaries; Tx with surgical wedge resection  menstruated, 2 pregnancies
called “Stein-Leventhal Syndrome”

Next decades: 1000+ cases described

Obesity in ≈ 40%; hirsutism in more than half, virilization in about a quarter (more severe androgenization)
¼ with corpus luteum at surgery (it’s not that they’re not ovulating – just that they only ovulate 1-2x/yr)

Clinical Diagnosis of PCOS

From a 1990 NIH conference: a clinical definition
A reproductive endocrine disorder characterized by both:
Oligo-ovulation / anovulation
Androgen excess Clinical (e.g. hirsutism) and/or biochemical (e.g. hyperandrogenemia)
Exclusion of related disorders Most importantly late-onset adrenal hyperplasia

Note: 2003 Rotterdam def’n said 2/3 of oligo/anovulation, hyperandro, polycystic ovaries
Means you could have nL androgen, but ovulatory problem & polycystic ovaries – or nL ovulation & the other 2
Not widely accepted in clinical practice

Clinical features supporting diagnosis:

Polycystic-appearing ovaries (not necessary for Dx in USA, but supportive)
Pubertal onset
Abnormal LH:FSH ratios Anything that ↑ GnRH pulse  preferentially ↑ LH, so ↑ LH/FSH ratio*
Hyperinsulinemia* Secondary to peripheral insulin resistance

*Note: ↑ LH vs FSH, so ↑↑ androgen production (theca cells) but not ↑ corresponding use by follicular cells
↑ insulin also contributes to ↑ theca cell function (different post-receptor cascade)
So each follicle becomes a hyperandrogenic microenvironment

Disorders to Exclude in PCOS diagnosis

21-hydroxylase deficiency NCAH Idiopathic Hirsutism Hyperprolactinemia
HAIRAN Syndrome Drug-induced
ASNs: 1/300-500 (mostly ovarian) Thyroid abnormalities

Clinical Manifestations of PCOS

Infertility ↑ risk miscarriage, gestational Type 2 Diabetes
Menstrual disturbances diabetes, hypertensive Cardiovascular disease
Obesity, especially centripetal fat disorders Sleep apnea
↑ risk endometrial cancer

Features of PCOS
Feature % with feature Feature % with feature
LH/FSH of > 2-3 40-60% Hirsutism 30-80%
AA (i.e. DHEAS) excess 25-40% Polycystic-appearing ovaries 70-80%
Total or free T 70-80% Oligo-menorrhea 60-80%
Obesity 50-60% Oligo-ovulation 100% (by definition!)

18
 Pathophysiology of PCOS
Lots of interconnectedness

KNOW THESE TWO FEATURES FOR THE TEST:

↑ GnRH PULSE FREQUENCY & AMPLITUDE  ↑ LH, ↓ FSH

Leads to ↑ androgen production (LH  theca cells); ↓ conversion to
estrogen (FSH  follicular cells) = androgen secretory state

PERIPHERAL INSULIN RESISTANCE  COMPENSATORY HYPERINSULINEMIA

Even in non-obese PCOS pts: see ↑ insulin resistance!
Further stimulates theca cells to produce more androgens
Theca cells’ insulin receptors aren’t compromised
(different post-receptor signaling pathways)

Peripheral insulin resistance can cause hyperandrogenism

But you still need a basal level of LH
GnRH agonist therapy  ↓ LH
o Can shut off androgen production – even if insulin still sky-high
o Best treatment for really severely affected women

Pathogenesis starts in puberty

abnormal LH pulsation variation; augmented GnRH effects; ↑ insulin resistance
Tends to get worse over time unless intervention (usually by placing on birth control pills)

Long-term Consequences of PCOS

Diabetes mellitus (Type 2) Lipid abnormalities Endometrial carcinoma*
Hypertension Coronary artery disease Infertility

* NEED TO GET AN ENDOMETRIAL BIOPSY (or comparable cancer assessment) in PCOS workup!

Pathology of PCOS

U/S: “String of pearls” appearance

Gross: thickened capsule Histology: nests of lutenized
Lots of small peripheral follicles
with subcapsular follicles stromal cells
(“cyst” is misnomer – these are too small)

NOT PATHOGNOMONIC: ≈ 30% of women have polycystic ovaries on U/S – incl. perfectly normal ovulatory women
Can see in idiopathic hirsutism (90%), other causes of anovulation (56%) or oligomenorrhea (87%), etc.
In PCOS: the ovaries are often enlarged as well

19
 PCOS & Associated Conditions
Obesity
Not a cause and effect relationship (PCOS doesn’t cause obesity)
But: PCOS pts with upper body segment obesity have higher prevalence of hirsuitism, menstrual irregularities
o (↑ waist:hip ratio, not normal feminine pear-shaped)
o More severe (↑ insulin resistance, ↑ hyperandrogenism, ↑ lipid abnormalities, ↑ all medical risks)

Type 2 Diabetes
Insulin resistance (regardless of obesity) predisposes PCOS pts to type 2 DM
Develop at earlier age too (impaired glucose tolerance  type 2 DM)
o Need to do a metabolic screen (e.g. FBG) in PCOS pt, regardless of age (get a baseline)
Highest risk in upper body segment obesity

Hypertension Lipoprotein abnormalities

3-4x more common in PCOS pts vs matched controls Contributes to HTN development
Hyperinsulinemia contributes to risk ↑ TGs, ↑ VLDL, ↓ HDL
influenced by age, sex

Metabolic syndrome
3+ of Central obesity (waist > 35); hypertension (> 130/85), FBG (>100), ↓ HDL (< 50), ↑ TG (>150)
Note overlap with PCOS! E.g. HTN, HDL / TG, insulin resistance affected by PCOS

Cardiovascular Disease
Surrogate endpoints suggest ↑ risk (↑ HTN, lipids, etc.) but not great data for actual risk of death
All PCOS pts should have BMI, WHR, fasting lipoprotein levels, FBG or 2hOGTT

Therapy for PCOS

The primary question: does the patient want to conceive; if so, when?
If the patient doesn’t want to conceive right now: you need to prevent endometrial hyperplasia / cancer

Goals:
Regulate menstrual cycle (prevent endometrial hyperplasia / carcinoma; ↓ likelihood dysfunctional bleeding)
Weight loss if obese – help prevent type 2 DM progression, etc.
↓ hyperandrogenism (prevent hirsutism, acne progression)
Ovulation induction (restore fertility)
↓ likelihood of long-term consequences

Menstrual Cycle Regulation

2 main strategies
Oral contraceptive pills Doesn’t want to become pregnant right now?
Cyclic progestin Want to become pregnant or
administration Doesn’t want to use OCP?
Induces endometrial decidualization & atrophy
Also improves hyperandrogenism
Medroxyprogesterone acetate 10mg
(10-15 days / month) or equivalent progestogen

20
Reducing Hyperandrogenism / Symptoms
Strategy
↓ ovarian androgen production
↓ adrenal androgen production
↑ SHBG levels  ↓ free T
Block androgen receptors
Inhibit 5α reductase
↓ hyperinsulinemia*
*really more for diabetes management than for androgen level management
Agents
GnRH agonists > OCPs > spironolactone
GnRH agonists best for severe phenotypes but high side-effects
OCPs work for most women ± spironolactone
Prednisone, dexamethasone > OCPs
OCPs
Spironolactone
Finasteride
metformin, glitazones (change insulin sensitivity)
diazoxide (↓ pancreatic secretion)
octreotide (somatostatin analog)

Combination birth control pills

↓ LH, so ↓ testosterone production
↑ SHBG, so ↑ bound T
Both lead to ↓ free T levels

Ovulation Induction
Small minority start ovulating with exercise, weight control alone
Most need fertility medications:
o clomiphene citrate, gonadotrophins (injectable)
o or ovarian drilling

Metformin really doesn’t work to help fertility

Menstrual cycle: estradiol climbs, then LH surge (ovulation occurs on

downswing), then progesterone rises & falls

Medical Management: Summary

Birth control pills are the mainstay
Progestins if you want to get pregnant
Insulin-sensitizing agents (not FDA approved for PCOS alone)

Surgical Therapy for PCOS

Now 2nd line after oral fertility medicines
Bilateral ovarian wedge resection Laproscopic electrocautery of the ovarian surface
Variable results with regard to restoration of menses, fertility, post-op pelvic adhesions
Effectively reduces ovarian androgens Temporarily reduces ovarian androgens
Basically putting 4-5 burns on each ovary to decrease
Don’t really do it anymore
androgen secretion until pt can get pregnant

Laproscopic electrocautery: “ovarian drilling” – see pic (right)

21
 Female Infertility
Introduction / Definitions
Infertility: One year of unprotected intercourse without contraception
Fecundability: Probability of achieving pregnancy within one cycle
Fecundity: Ability to achieve a live birth within one menstrual cycle

“Increase” in infertility?
Main changes may have been in availability of assisted reproductive technologies
Public more aware of possible treatments too
Increase in # women delaying childbearing
↓ availability of babies for adoption

Age & Fertility

Reproductive technology can’t really do too much about age!
Hutterites: group with no contraception & no incentive to limit family size
o Avg age of last pregnancy 40.9 yrs (11% no kids after 34, 33% after 40, 87% infertile after 45 y/o)
French donor insemination program: only half of women over 35 conceive in one year (half infertile!)

Spontaneous abortion & age

12% in women under 20 years old; up to 75% of women over 40 years old
Risk of aneuploidy ↑ with age (1:526@ 20, 1:66@40, 1:21@45)
o Even if you do get pregnant & make it to term, things are stacked against you!

Evaluating the Infertile Couple

• Seek and correct cause of infertility • Provide emotional support
• Provide accurate information and dispel myths • Counsel about when to quit

Etiology of Infertility
Really can have problems anywhere along the way (from sperm / egg to implantation, etc) – a lot has to go right!
≈ 30% pelvic / tubal pathology ≈ 30% male factor
≈ 30% ovulatory dysfunction 10% unexplained*
*really probably a lot of “multi-factorial subfertility” – somewhat low sperm count, women a little older, etc.

History
Previous fertility of each partner NSAIDS?
Smoking (big for both M&F) Cocaine doesn’t really hurt fertility,
Marijuana (heavy use hurts sperm motility) unfortunately

Evaluation of Ovulation
Techniques: all really indirect measures (conception is the only direct measure!)
History U/S documentation of follicle development / resolution
Basal body temperature charts Serum progesterone
LH detection kits (urine kit: ovulate 24-48h later) Endometrial biopsy
o can use to time intercourse

22
Basal Body Temperature Charts (take orally, 1st thing in morning)
Prior to ovulation typically <98° F
After ovulation typically >98.2° F

A little old-fashioned, but lots of people know about them

Temperature elevation of > 14 days suggests pregnancy

o 14 days = luteal phase

Can’t predict ovulation by BBT – don’t really help you get pregnant
o Tell you that you should have had sex yesterday! Need to have the sperm waiting!

Don’t go to the body temp chart right away – just have sex for fun for six months! Don’t make it a chore!

Ovulatory Dysfunction: Clinical Approach

Rule out HYPOTHYROIDISM & HYPERPROLACINTEMIA (very common / treatable causes!)
Oligomenorrheic?
o Think about polycystic ovary syndrome
o Consider hypothalamic amenorrhea (too thin / too much exercise / too much stress)

Serum Progesterone
Rises after ovulation (or at the time) – this is what makes your temperature go up
> 3 ng/mL indicates ovulation; > 10 ng/mL indicates normal ovulation
Ideal time to assess is midluteal phase (day 21 in ideal 28d cycle); confirm timing with onset of next period

Luteal phase deficiency

A somewhat controversial diagnosis (borderline = insignificant?)
Implies inadequate progesterone to adequately prepare uterus for implantation & support early pregnancy
May occur intermittently in normal women; may be a cause of recurrent pregnancy loss

Treatment: enhance follicle development (fertility drugs) and/or supplement progesterone production in luteal phase

Treatment of Anovulation
Ovulation induction with clomiphene citrate or gonadotrophins
Can start before completing work-up – pt might get pregnant & save you some trouble

Timing of Intercourse
Want sperm deposition before ovulation
Sperm remain viable in female reproductive tract for several days
Egg remains viable for 12-14h

Cervical mucous changes correlate with ideal timing for intercourse

Just prior to ovulation – best! Thin & watery – sperm go right up
Only test immediately prior to ovulation

23
Evaluation of Fallopian Tubes
History:
Ruptured appendix Previous ectopic pregnancy
Any pelvic infection (PID, trauma, etc) Hx chlamydia infection \ ↑ anti-chlamydia Ab
Complications of pregnancy and/or delivery

Hysterosalpingogram
for evaluation of fallopian tube (& uterine) problems
Cycle day 7-12: inject radio-opaque contrast through cervix into uterine cavity
Outlines uterine cavity, fallopian tubes
Perform under fluoroscopy
Risk of pelvic infection if tubal obstruction demonstrated (stir up old infection, etc)

Stuff you could see:

Hydrosalpinx (right) – big, sausage-shaped tube Filling defect – go in with
Endometriosis (left) – squashes the tube hysteroscope & see what’s going on

If hysterosalpingogram is abnormal: F/U with…

Hysteroscopy
Laparoscopy
Falloposcopy
Tubal catheterization

Stuff you could see:

Submucosal fibroids Septate uterus

Just under endometrium – would

produce filling defect like on Uterus has two endometrial cavities!
hysterosalpingogram example Easy to fix – snip wall w/ scissors during hysteroscopy
above

24
Diagnostic Laparoscopy

Completes the infertility evaluation (last step)

Can detect unsuspected pelvic adhesions, endometriosis
50% women have some findings (many insignificant)

Fill up abdomen with gas to give you some room, go in with scope, etc.

Stuff you could see

Normal ovaries (L=left, R=right & some fimbriae) Polycystic ovary (a bit bigger) Adhesions

Uterus with fibroid Thick band of adhesions More adhesions & scar tissue Chocolate cyst
Tubes going off to sides (uterus & fallopian tube) (e.g. after pelvic infection) (endometriosis)

Treatment of tubal infertility with laparoscopy

Lysis of adhesions: 50% pregnancy rate (usually go to IVF)
Distal tubal obstruction: 80% (mild) to 15% (severe) pregnancy rate
Danger of tubal ectopic pregnancy if you do surgery on the tubes!

Unexplained Infertility
Probably actually multifactorial
• Complete evaluation of couple with no positive findings
• Distinguish from “multi-factorial subfertility”
• Empiric treatment if woman older than 35 y.o. or infertile more than 3 years
• Controlled ovarian hyperstimulation/IUI (no octomoms)
• Treat cause if found (hypothyroid, hyperprolactinemia, etc)

Treatment
Ovulation Induction
Clomiphene citrate Gonadotrophins
Mechanism Weak estrogen agonist – fools FSH ± LH
pituitary, thinks ↓ estrogen  ↑ LH
Risk of multiples 10% (almost always just twins) 20% (higher order possible)
Cost $50/cycle $500-1000 for meds, more for monitoring

25
In-Vitro Fertilization (IVF)
Use for untreatable anatomic infertility or persistent infertility
Approximately $10,000 / attempt
25-35% success rate / attempt, ↓ with older women
Risk of multiples minimized (control # put back)

Procedure:
Pump full of fertility drugs, get lots of follicles going Mix sperm & egg on plate, let them do their thing for a
Put needle in, aspirate (get ≈ 1 egg / follicle) while, then put back 1-2 (not eight)

Intracytoplasmic Sperm Injection (ICSI)

Use for significant male factor infertility

Do in conjunction with IVF cycle

Adoption
Not that easy anymore!
Social services: long wait; restrictions (age / health)
Foreign: expensive (easier if Angelina Jolie)
Private: expensive, emotionally draining (like facebook but you get a baby?)

Myths about Infertility

• Stress can cause infertility
• Stop trying and it will happen
• Adopt and you’ll get pregnant

These patients are often just subfertile & might get pregnant at any time! Just try to give them the best shot possible.

26
 Maternal Physiologic Changes During Pregnancy
Introduction: Pregnancy basics
Where babies come from: the really boring version

Remember where eggs come from: 20 wk fetus has 6-7M oocytes (highest #)
↓ with atresia to 2-4M @ birth, 400k @ menarche
st
Arrest @ 1 meiotic division (diplotene stage)
st st
1 meiotic division completed @ ovulation  release 1 polar body
nd nd
2 meiotic division completed @ fertilization  release 2 polar body
o In fallopian tubes, travels down

Division
Morula while it’s a solid mass of cells (12-16 cells)
Blastocyst when it forms the blastomere cavity (50-60 blastomeres)

Implantation: 7 days post-ovulation

Need receptive endometrium (progesterone  glycogen rich, etc)

Differentiation: by day 10, invading trophoblasts form 2 layers

Cytotrophoblasts: inner layer, well-defined, rapidly-proliferating
o Make CRH, GnRH, TRH

Syncitiotrophoblasts: outer, thicker layer, syncitium (multiple nuclei, etc)

o Make placental steroids, protein hormones (e.g. hCG)
o Large surface area; line intervillous space
 (exposed directly to maternal blood)
o Lots of RER, Goligi, mitochondria

Pregnancy tests: can detect hCG in urine

Peaks early in pregnancy (≈ 10 wks) – maybe why hyperemesis ≈ this time?
hCG, LH, TSH, FSH all have identical α subunits – maybe just stimulating
things until placenta can take over progesterone production?

hPL = human placental lactogen

Inhibits insulin; linear rise throughout pregnancy

Fundal height changes:

Around 12 weeks, start to get enlargement
12 wks – should be ≈ pubic symphisis
20 wks – should be ≈ umbilicus

If these uterine sizes are off – think multiples or something wrong?

Usually get U/S when pregnancy discovered, date the pregnancy

Then usually just do @ ≈ 20 wks (can assess anatomical development)
Only get more if something’s not looking right

27
 Cardiovascular Changes
Normal Stuff
Change Why (if there’s a reason) How Notes
st
Even in 1 trimester, ↑↑↑ with stress of labor
Cardiovascular

↑ CO (46L/min) Mom needs to perfuse fetus ↑ fluid retention

↑↑ post-partum too – lose blood in delivery, but ↑
venous return (stop IVC compression by uterus)
↓ SVR, ↓ PVR (≈ 25%) Accommodate extra fluid Progesterone relaxes smooth mm ↓ both systemic & pulmonary vascular resistance
MAP / PCWP / CVP: ↑ fluid retention, but ↓ vascular Normally ↓ at first, nadir @ 24 wks, then rises
no change, HR same too resistance (relax smooth mm) Good to get baseline early (preeclampsia vs nL ↑)

Pregnancy can mimic CHF: from ↑ fluid volume!

Signs / Sx: ↓ exercise tolerance, dyspnea, peripheral edema, ↑ neck veins, L displacement of PMI; Chest X-ray can look different
Ascultation: extra fluid makes noise! ↑ S1/S2 splitting, S3 (gallop), systolic ejection murmur (L sternal border), continuous murmurs
o Diastolic murmurs  more uncommon – get a consult!
Bad stuff
Supine hypotensive syndrome
Lay back  gravid uterus compresses IVC  ↓ venous return  ↓ CO  hypotension  nausea, diaphoresis
Pretty uncommon (≈ 10% of pregnancies); most women compensate by ↑ SVR, but tilt patients during C-section or U/S

↑ risk pulmonary edema: from ↑ fluid  ↑ capillary pressure, pushes water out
Monitor fluids, check wedge pressure to keep from overloading!

↑ risk for cardiac decompensation:

50% increase in intravascular volume; CO ↑ progressively during labor  additional 50% by late 2nd stage
RL shunts made worse (↓ SVR)  cyanosis gets worse (Eisenmenger’s syndrome, VSD, etc)
Pregnancy is a hypercoagulable state (Virchow’s Triad: stasis in lower extremities, ↑ clotting factors – fetus induces liver production, endothelial damage)
o Need to use heparin (big, doesn’t cross placenta) / warfarin can cross  embryopathy (very very very rarely use)
28
Can use Schwann-Gantz catheter to measure pulmonary capillary wedge pressure, assess risk of pulmonary edema (what’s fluid status?)
Nonpregnant: (COP = 25 mm Hg) - (PCWP = 12 mm Hg) = 12 mm Hg
Pregnant: (COP = 22 mm Hg) - (PCWP = 12 mm Hg) = 10 mm Hg
Delivery: (COP = 15 mm Hg) - (PCWP = 12 mm Hg) = 3 mm Hg

Respiratory Changes
Change Explanation
↑ tidal volume Move more air with each breath
Respiratory

RR, inspiratory reserve volume unchanged Not breathing faster

↓ residual volume Big uterus, less diaphragmatic excursion
↓ ERV, ↓ TLC From ↓ RV

Chest X-ray changes: Really looks like CHF

Uterus pushes on diaphragm; Extra fluid  bigger heart (borders)
↑ markings around hilum (↑ fluid)

Change Explanation
↑ PaO2 (≈93  ≈ 105)
↑ TV  move more air – want ↑ gradient to deliver O2 to baby
↓ PaCO2 (≈40  ≈ 30)
ABG

Still tightly controlled, but 2° ↓ carbonic acid

↑ pH (≈7.35-7.4  7.4-7.45)
SLIGHT RESPIRATORY ALKALOSIS – important (e.g. if pt has asthma, have to recalibrate normal!)

Gastrointestinal Changes

Change Explanation
↑ caloric needs ↑ 300 kcal / day for baby!
↓ bowel motility Progesterone relaxes smooth muscle
↑ heartburn Progesterone relaxes smooth muscle  Cardiac sphincter doesn’t close as well
GI

↑ hemorrhoids 2° to ↓ bowel motility (Not moving things through)

↑ gallstones Progesterone relaxes smooth muscle  Biliary stasis
Pica 2° to iron-deficiency anemia! Starch, clay, ice, etc.
↑ liver protein production Liver proteins induced  ↑ clotting factors & stuff as well!

Pregnancy can mimic liver disease

Spider angiomata, palmar erythema (estrogen effects)
↓ serum albumin (diluted by ↑ plasma volume), ↑ alk-phos (heat-stable isozyme made by placenta), ↑ cholesterol (↑ steroid hormone production!)
29
 Renal Changes
Change Explanation
Dilitation of ureter Progesterone relaxes smooth muscle

↑ hydronephrosis  Dextrorotation of uterus (colon on L side) impinges more on right than left ureter
↑ ascending pyelonephritis Along with progesterone, ↑ right-sided hydroureter / hydronephrosis
(RIGHT > L kidney) About 85% of UTIs will be on the right

↑ Plasma volume  ↑ effective renal plasma flow (↑ 75%)

↑ GFR, ↑ inulin clearance Assess renal function by 24h urine (check ClCr & protein)
Renal changes

↑ CrCl (≈100 mL/min  150-200 mL/min)

Protein should stay the same Check protein - if hypertensive, can develop pre-renal failure  ↑ protein!
↑ GFR  spill more urine into glucose (normal to have 1-10g / day!)
Can’t use urine glucose in DM management if pregnant!
↑ urine glucose Pregnant women  ↑ UTIs! (more glucose)
o 10% sexually active women have asymptomatic bactiuria: get urine Cx on all women / treat!
o 1-2% of all pregnancies  pyelonephritis; ↑ risk premature delivery, sepsis, miscarriage, etc
↓ plasma osmolarity
Central osmostat is RESET: so that the woman can tolerate the ↑ plasma volume to perfuse baby!
↓ plasma Na+

Hematology
Change Explanation
↑↑ plasma volume > ↑ red cell mass: more dilute blood in pregnancy
↓ Hct Better to lose iron-poor, RBC-poor blood during delivery;
(physiologic anemia of pregnancy) Give iron supplement  ↑ RBC mass even more
Renal changes

o normally ↑ 18% in pregnancy  30% w/ Fe Rx

↑ throughout pregnancy, ↑↑ in delivery
↑ WBCs From demargination of PMNs  to 20/30k!
Probably not infectious unless ↑ bands!
In some patients, moderate ↓ platelets
Platelets usually stay the same
(gestational thrombocytopenia) – benign – vs ITP (bad!)

30

Change
↑ glucose, ↑ insulin
(esp. post-prandially)
Endocrine
Explanation
↑human placental lactogen  antagonizes insulin
So ↑ blood glucose after meals – less insulin effect, ↑ reg insulin in response
Good for fetus – better diffusion (↑ gradient mom fetus)
In borderline pts  gestational diabetes (use OGTT > 140 to screen)
o Polyuria, glucosuria don’t really help Dx (normal in pregnancy!)

Also see hypertrophy and hyperplasia of the B-cells in the islets of Langerhans.
Renal changes

↑ TBG  ↑ total T4
↑ TBG  total T4 increases (more bound), but free T4 should be the same
Free T4 should be unchanged
Moderate ↓ TSH when ↑ hCG (1st trimester; has same α subunit)
↓ TSH in 1st trimester
Enlargement from ↑ chromophobe cells

Sheehan’s syndrome: postpartum ischemic necrosis of anterior pituitary

Anterior pituitary gets bigger pituitary is very vascular: if severe postpartum hemorrhage, ischemia!
failure of lactation, amenorrhea, breast atrophy, ↓ pubic/ axillary hair, superinvolution of the uterus,
hypothyroidism, adrenal cortical insufficiency.
Can be lethal! Use IV corticosteroids + fluid replacement to treat

A Case
16 yo para 0 F @ 32 wk, H/A x 2days. BP 160/100. Dipstick 3+ protein, 1+ glucose, 2+ ketones. 10 lb wt gain over last 2 wks.
PE: grade II/IV systolic murmur. Mild RUQ tenderness (liver retaining fluid). Hyper-reflexic (nervous system irritability; along with H/A). No clonus
Labs: ↑Hct = 40, ↓ Plts = 100k, ↑AST = 200, ↑ALT = 200; ↓urine output 30 mL over 2h
Dx: severe pre-eclampsia!
Note that non-highlighted stuff is normal – so you need to know that to ID the bad stuff!
31
 Pathologies of Pregnancy
Pre-eclampsia / eclampsia syndrome
A spectrum (eclampsia - has a seizure); Usually presents in the 3rd trimester; Significant morbidity / mortality for both mom & baby

Definitions
Pre-eclampsia
Eclampsia
Mild Severe
BP > 160//110 x2 at least 6h apart Grand-mal seizure that can't be
BP >= 140/90 after 20 wks EGA
Proteinuria > 5g / 24h attributed to other causes in a
Proteinuria >= 300 mg/24h
End-organ damage woman with preeclampsia
(Generalized tonic clonic convulsions)
Eclampsia:
Overall incidence 1/2000 - 3400
o Risk of maternal death 2-10%, perinatal mortality 6-25%
Peripartum:Most withing 24h of delivery; can precipitate more rapid labor (release of prostaglandins)
o Occur antepartum (45-50%), intrapartum (20-35%), or postpartum (10-45%)
No reliable indicators (15% without HTN or proteinuria)

Potential Complications
Fetal bradycardia
Pulmonary edema
Coma / sudden death
Blindness
(maternal hypoxemia, lactic acidosis during seizure - recovers in 3-5 minutes)
(colloid osmotic pressure decreases even more)
(from massive cerebral hemorrhage)
(retinal detatchment; usually resolves in about a week)

HELLP syndrome (20% of severe preeclamptics)

Hemolysis Low platelet counts
Elevated liver enzymes +- proteinuria
Most worried about eclampsia, but HELLP patients often harder to manage / at more risk (really hypercoagulable)

Adverse Outcomes in severe preeclampsia / HELLP

Placental abruption Preterm delivery - need to get the baby out to cure mom!
Renal failure (decreased perfusion to kidneys) Intrauterine growth restriction (poor perfusion to placenta)
Subcapsular hepatic hepatoma Maternal or fetal death
(if increased liver size / low platelets, look out!)

Epidemiology of Preeclampsia
5-8% USA, 3-14% worldwide Primarily 1st pregancy
Other risk factors: HTN, vascular / connective tissue disease, renal disease, diabetes, prior preeclampsia,
antiphospholipid antibody syndrome
More common in: African Americans, Multifetal gestations, obesity, advanced maternal age

Clinical Manifestations
Cardiovascular Lack of the normal plasma volume expansion (hemoconcentration)
Endothelial cell damage causing protein loss into interstitial tissue
Vasospasm, ischemia
Neuro Temporary blindness (amaurosis) - hrs to weeks
Imaging: consider if neuro deficits, refractory, > 48h after delivery
o Findings consistent with vasogenic edema: white matter
hyperintensities, microinfarction, possible hemorrhage
Hematology Hemoconcentration - can see high Hct (40-42% - top half of normal; really unusual for 3rd
trimester - usually have mild anemia!)
32
 Low hematocrit possible too (due to hemolysis - HELLP)
Elevation of LDH (as red cells hemolyzed)
Hepatic changes Elevated ALT and AST (remember, alk phos can increase just from placental production!)
Hyperbilirubinemia (hemolysis)
Subcapsular hematoma (can rupture!)
Renal changes Normally have increased GFR, renal blood flow, with a decreased serum Cr, more urine!
Vasospasm, oliguria can lead to decreased flow through kidney - see elevated Cr, decreased
clearance
Fetal changes From impaired uteroplacental blood flow or placental infarction
Intrauterine growth restriction (IUGR) or non-reassuring feta status
More common to have low birth weight with more severe disease
Oligohydramnios (too little perfusion of fetus, not producing urine), or placental abruption

Pathophysiology: Prevailing theory: related to the degree of trophoblastic invasion

Incomplete trophoblast invasion leads to stenotic spiral arteries 
implantation site hypoperfused, endothelial cells damaged
release vasoactive peptides & leads to the signs & symptoms

Smooth muscle cells with flatter nuclei instead of trophoblasts!

Other mechanisms:
More common in daughters of preeclamptics
Genetic factors
Increased incidence of diabetes in preeclamptic
Father of one preE pregnancy is twice as likely to father prE pregancy with a
Immune maladaptation to
subsequent partner
paternal antigens
More common in 1st pregnancies (immune component)
Impaired trophoblastic differentiation / invasion?
Placental / endothelial dysfunction
Changes in vascular reactivity mediated by prostaglandins,
end up with increased thromboxane A and endothelins (potent
vasoconstrictors)
Exaggerated systemic Imbalance in proangiogenic (VEGF, etc) & anti-angiogenic factors - get less
inflammatory response capacitance (more anti-angiogenic factors & less proangiogenic factors than
before!)
Systemic maternal endothelial dysfunction: get thrombosis of arterioles,
hypertension (vasospastic factors), dysfunction of multiple organs

Management:
Termination of pregnancy (delivery of all products of conception, including placenta) with least possible
morbidity for both mom & baby

Long-term consequences
The more pre-term it occurs, the more likely that it'll happen again
o < 30 wks EGA = 40% recurrence rate! 5% recurrence of HELLP
Early-onset, severe preeclampsia at risk for thrombophilia
Recurrent preeclampsia - increased risk for chronic hypertension (recurrent vascular damage)

33
 Gestational Diabetes
Really common in pregnancy!

In normal pregnancy
Insulin resistance rises in direct proportion to increases in estrogen, progesterone, human placental lactogen
(HPL) - something about pregnancy makes it an intrinsically diabetogenic state
Don't see change in insulin receptor number / function

GDM:
decreased expression of the insulin receptor substrate 1 (decreased IRS)
decreased ability of beta subunit of the insulin receptor to undergo phosphorylation
less availability of glucose transporter
So you get less facilitation of glucose transport across the cell membrane (GLUT4 not translocated)

So beta-cell production of insulin can't keep pace w/ diabetogenic hormones(HPL, progesterone, cortisol, TNF-alpha
hPL reaches max at 38 wks Pregnancy causes a 60% reduction in insulin
Insulin production increases to 2-2.5x of sensitivity
nonpregnant state Also related to increases in maternal weight

hPL:
produced by syncitiotrophoblasts of lacenta decreases maternal glucose uptake &
acts to promote lipolysis (increased FFA) gluconeogenesis

Screen with OGTT!

Risk factors
FHx, PMH of GDM in previous pregnancy, older maternal age (>30), previous large babies (>9lbs), obesity,
history of PCOS, high risk ethnic groups (Hispanics, Blacks, Asians), complicated obstetric history

Why is GDM bad?

Baby Mom
macrosmia (excessive birth weight) Polyhydramnios (baby's peeing a lot!)
birth trauma o pre-term labor, premature rupture of membranes,
hypoglycemia primary postpartum hemorrhage can result)
FDIU (fetal death in utero) Preeclampsia
prematurity, RDS UTI
Operative delivery

Epidemiology:
5-7% of all pregnancies in USA
30-50% of subsequently developing overt diabetes (control with wt loss & exercise)

34
 Pre-term Labor
Labor: regular painful contractions which result in progressive effacement (thinning) & dilation of the cervix
Pre-term: > 24 & < 37 wks from LMP
Major clinical importance between 24-34 wks

Clinical presentation: pretty nonspecific (high rate of over-diagnosis - high index of suspicion too)
Contractions, cramping, pelvic pressure, backache
Increased vaginal discharge, vaginal spotting / bleeding

Treatments: meds to try to delay for 24h, so that you can give steroids
(increase surfactant production, reduce other complications in pre-term labors)

Epidemiology
About 12.7% all pregnancies; 2% before 32 wks, no reduction in incidence in last 40 yrs
o Older women getting pregnant, more multiple gestations
#2 cause of neonatal mortalities (after congenital abnormalities)
Responsible for 75% of perinatal morbidity / mortality (reduction with better NICU care)

Etiology:
Most spontaneous pre-term labor (50%)
30% from premature rupture of membranes (PROM, linked!)

Risk factors:
Previous pre-term delivery is #1! (OR = 8)
Multiple gestations (OR = 6), smoking (OR = 3), non-white race (OR = 2)
Maternal age <18 or > 40
UTI, bacterial vaginosis, periodontal dz, polyhydramnios, uterine anomalies, low SES, cocaine too

Outcomes:
Lots of problems, even if survive (90+% survive @ 29wks, but only 71% "intact")
Watch out for retinopathy of prematurity (if you give too much O2)
Neonatal: RDS, NEC, PVL, IVH, PDA, infection, metabolic abnormalities, nutritional deficiencies
Short-term: feeding / growth abnormalities, infection, apnea (give caffeine, monitor for SIDS),
neurodevelopmental difficulties, retinopahty, transient dystonia
Longer-term: lots of complications, incuding CP, chronic lung disease

Pathogenesis of pre-term birth

Activation of maternal-fetal H-P-A axis (stress, etc - 30%)
o Increased CRH (from stress, etc)
 Increased maternal & fetal adrenal cortisol & subsequent prostaglandin production
 Increased fetal DHEAS production, which increases placental estrogen production (throws
hormonal balance out of whack)

Inflammation (infection, etc - 40%)

o More cytokines (IL-1, TNF-alpha), more prostaglandins, causes uterine contractions
o More proteases & cytokines can break down membranes (premature rupture)
o May be due to ascending spread of bacteria from vagina, colonize decidua / fetal membranes
o Treatment implications: look for bacterial vaginosis, esp in women with previous pre-term
delivery (common, but only increases risk of preterm labor for women at risk) - treat for BV!

35
 Decidual hemorrhage (abruption - 20%)
o Release of decidual tissue factor, initiates coagulation cascade & thrombin production
o Bleeding behind the placenta (placental abruption) - increases contractions, MMPs get activated, so
cervical changes & rupture of membranes
o Placental abruption is big risk factor (increased with maternal smoking / cocaine, chronic HTN with
preE, maternal trauma, IUGR, hereditary coagulopathies)

Uterine distention (streching - 10%)

o Mechanical stretching
o Causes increase in maternal gap junctions, myometrial activation, activation of fetal membrane
cytokines

Progesterone:
17-alpha-hydroxyprogesterone caporate: only well-established primary prevention for recurrent pre-term birth.

36
 Pharmacology: Repro
Male & Female Sex Hormones ................................................................................................................................................ 2
Teratology ............................................................................................................................................................................... 6
Contraception ....................................................................................................................................................................... 10

1
 Male & Female Sex Hormones
Hormones: Review
3 pathways: Endocrine (blood), paracrine (neighboring cells), autocrine (from self).
4 general types of hormones
Type Examples (bold = sex hormones)
Glycoproteins FSH, hCG, LH, TSH
Polypeptides ACTH, EPO, glucagon, insulin, parathyroid, MSH, ADH, tons more
Steroids estradiol, progesterone, testosterone, aldo, cortisol, vitamin D
Amines epinephrine, norepi, T3/T4

Steroid Hormones
Synthesis & Secretion
Lots of protein hormones bind cell surface receptors, effects can be represented by Scatchard plots¸etc

But steroids: go into cell, bind receptor, work with NUCLEAR RECEPTORS
 Not exclusively – estrogen receptors on membranes too, for example!

Steps: steroid synthesis

 GnRH (decapeptide releasing hormone from hypothalamus) acts on anterior
pituitary to stimulate secretion of gonadotrophin proteins (LH/FSH)
 Steroid-synthesizing cells in gonads activated by LH/FSH
 Secrete sex steroids into blood
95% of steroid hormones bound to:
Steps: the “bucket brigade”  SHBG (steroid hormone binding
globulin)
 Steroid secreted into blood, travels bound to something (plasma proteins)
 CBG (cortisol binding globulin), or
o Very little is free – but that small part is important!
 Albumin
o Levels: cortisol > others > estradiol
o These proteins have high capacity, but low binding constants
 At cell, unbound steroid can enter cell, where it binds to receptor
o These receptors are structurally related
o This protein binds more tightly although there’s less of it (small capacity, large binding constant)
o Basically sucks hormone out of blood
 In nucleus – binds to DNA, acts as a transcription factor
How tight the proteins bind, how much of the proteins are around, presence of other proteins – regulate this process!

Synthesis of Sex Steroids: More Detail

CYCLIC AMP is the big common signal produced by LH/ FSH in stimulating gonads to make steroids
 Protein hormones hit receptors (LH/FSH in gonads, GnRH in pituitary, etc.)
 Adenyl cyclase makes cAMP; phosphodiesterase destroys it (I think we’ve seen this before…)
 cAMP  protein kinase cascade

cAMP: In sex-steroid-synthesizing cells

 activates mitochondrial enzymes to cleave side chain of cholesterol
 forms pregnenolone (common precursor for all steroids)
 Then progesterone – the granddaddy of all the steroids

2
LH/FSH: stimulate cAMP production in gonadal cells where they have effects! (chart)
 LH works on Leydig cells to make T, so cAMP produced there!
 FSH works on Sertoli cells to support spermatogenesis (cAMP produced)
 LH works on ovarian cells that make estrogen (cAMP produced)
 FSH works on ovarian granulosa cells, etc.

Synthetic pathway:
Note that all of this is going on in all places where sex steroids are being made
 The difference is in which pathways predominate (where’s the flow going?)
 Activity of enzymes, blockage of downstream steps, etc

Initial step: cholesterol  pregnenolone

 in mito, from ↑ cAMP – see above

Most of the rest of the steps:

 Can go one way or the other, lots of
flexibility in how the pathway can work

Aromatase: makes estrogens

 This step is pretty irreversible!
 Aromatizing the ring

Different “flow” in different tissues

Tissue Makes mostly…
Adrenal cortical cell Cortisol
Ovarian cell Estradiol
Testicular Leydig cell Testosterone
Corpus Luteum cell Progesterone, Estradiol

Effects of Sex Steroids

Estrogens vs androgens: Defined by biological activity
 e.g. castrate a male; replace with something. If effects (prostate shrinking, etc) reverse, then it’s an androgen!
 Both M & F make both – differences in amts, receptors, etc.
 Progesterone (prepares you for gestation) – more in ovarian system; but if too much  ↑ androgen effects!
 Remember TDHT for androgen effects!
o Propecia: blocks TDHT; stops male-pattern baldness!

LH & FSH in the Male

LH acts on Leydig cells (membrane receptor)  ↑ cAMP

 ↑ Leydig cell growth
 ↑ T production

FSH acts on seminiferous tubule (Sertoli)  ↑ cAMP

 ↑ proteins to support somatogenesis
 Testosterone (from Leydig cells) has similar effects – working in concert!

3
The Female Cycle

 Hypothal  GnRH  ant.

Pituitary  releases big
LH/FSH spike
 Bam! Pow! Paratroopers
away! (I think this means
ovulation happens)
 Follicle  corpus luteum,
starts secreting progesterone
instead of estrogen
 Secretory phase starts (lining
of uterus  nurturing!)
 If nothing happens, outgrow
blood supply, slough off
endometrium (menses)

Oral contraceptives
Can’t eat steroids (broken down in the stomach)
 Add an acetylene linkage to the 17-α position of a steroid  resistant to the acidity of the stomach!
 This is the basis of oral contraceptive steroids

Idea: block the process of ovulation (manipulate estradiol / progesterone)

 Feed back on hypothalamus / pituitary  shut down LH/FSH release  stop LH surge (& therefore ovulation)

Estrogens Progesterone derivatives

 Norethindrone
 Ethinyl estradiol  Ethynodiol acetate
 Norethynodrel
 Mestranol  Norgestrel
 Norethindrone acetate

Which one to use? Balance side effects for individual pt!

 Estrogens  nausea in some pts
 Progesterone  androgenic effects sometimes

Inhibitors of Estrogen Action

Idea: block estrogen action at the level of the estrogen receptor
 Tamoxifen: most utilized; e.g. for breast cancer (many BC are ER+; stimulated to grow by estrogen / ER)

Aromatase Inhibitors
Idea: block conversion of T/androstenedione to estrogens (aromatase reaction)
 Used for postmenopausal women (producing androgens from adrenal gland); e.g. in breast cancer (↓ estrogen)
 Exemestane, letrolzole, anastrozole

RU-486
 A progesterone receptor blocker  abortifactant
 (add in prostaglandin to ↑ expulsion of products of conception)

Pregnancy
 Placenta takes over  huge doses of estradiol, progesterone (end of 1st trimester)

4
 The Male System
Leydig cells  T, Seminiferous tubules  sperm
 These signals feed back on themselves,
 but note that T is converted to ESTROGEN by AROMATASE , and THAT’S what shuts off the LH secretion!
o So if you give a male an aromatase inhibitor, then this feedback is blocked!

Remember that adrenal gland makes androgens too (DHEA sulfate) – others primarily from gonads

5-α reductase inhibitors

DHT: produced by 5-α reductase from testosterone
 male pattern baldness, prostate growth mediated by DHT
 5-α-reductase inhibitors: used for male pattern baldness & BPH (e.g. finasteride)

Anti-androgens
 Block the androgen receptor itself (flutamide, others)

5
 Teratology
Introduction
Teratogenic potential of a drug:
 its ability to produce major or minor, overt or latent, structural / functional / behavioral abnormalities

In live births: 2-3% major malformations, 7-10% minor malformations

 About 25% genetic, 2-3% infection, 2-3% from drugs or environmental chemicals; most unknown

The Teratogenic Period in Pregnancy

Predifferentiation
2-4 wks  embryo is resistant to teratogenetic effects
 can repair itself (cells are pretty pluripotent, etc)

ORGAN DIFFERENTIATION
4-10 wks
Most susceptible to teratogenic agents
Organ growth: less susceptible (with exceptions)
Teratogenic events possible late in pregnancy:
> 10 wks
 Brain – CNS  Stunted growth*
 Gonads  Teeth**
* stunted growth is most common
** teeth (e.g. tetracycline) – around 24 wks

All physicians caring for women of child-bearing potential need to know these periods!
Many women don’t present until after they’re pregnant

Genetic Influences & Teratogenesis

Neural Tube Defects
5,10 methylenetetrahydrofolate reductase
 ↑ risk of NTD if enzyme mutated

 Why? ↑ homocysteine levels associated with NTD

o Don’t have this enzyme = not getting rid of homocysteine

 Treatment: folic acid supplementation

o Bypass the block (enters at 5-methyl THF)
o ↓ homocystine (now have cofactor for methionine synthase)

Mechanisms of Teratogenicity
Description Example
Direct-acting Methyltrexate
Mechanism of action itself is teratogenic
teratogens  direct action of folic acid antagonism

Indirect-acting Narcotics
Produce a teratogenic condition in the mother
teratogens  not teratogenic, but can produce hypoxia

Act through Problem: Can’t always be identified by animal expts

toxic or reactive  often through minor pathways Thalidomide
intermediate  pleiomorphism in drug metabolism in humans

6
Picture (right): methyltrexate baby
Assessing Teratogenicity in Humans
Ethical dilemma :
 can’t necessarily predict intermediates via animal models
 can’t do a randomized clinical trial (pretty unethical)
 Do it epidemiologically (based on incidental exposure)

Criteria for identifying a human teratogen

1) A sharp rise in incidence in a particular defect or malformation.
2) The coincidence of this increase with widespread use of a new drug
3) Association between drug exposure and early pregnancy and characteristically defective infants
The time frame needs to match up – e.g. exposure when the defective system is vulnerable
4) Absence of other factors common to all pregnancies yielding infants with the characteristic defect or syndrome
No confounders!

Factors that COMPLICATE establishment of causality

1) The drug may be administered for a condition that itself produces the malformation*.
2) Fetal malformation may cause maternal symptoms for which the medication is given.
3) The drug may inhibit spontaneous abortion of already malformed fetus.
4) The drug may be commonly used in combination with other drugs that produce the malformations**.
* e.g. Insulin – hyperglycemia causes the problems!
** e.g. immunosuppressants – hard to tell what’s causing the problem (always used together)

Proven or seriously suspected teratogens in humans

 Aminopterin  Progestins  Isotretinoin  Phenytoin
   Radioiodine ( I)
131
Androgens (Danazol®) Cyclophosphamide (Accutane®)
 Busulfan  Etretinate  Methotrexate  Valproic Acid
 Diethylstilbestrol  Mercaptopurine  Vitamin A  Thalidomide
 Chlorambucil  Procarbazine  Warfarin

Vitamin A: well known to be a teratogen!

 Megavitamin supplements have 20,000 U of vitamin A – at the lower limits of teratogenic doses!
 Pregnant women – don’t take megavitamin supplements (or combos of lots of multivitamins) - don’t do anything anyway

Thalidomide
 1954: synthesized by german company, “safe” in animals. Lots of clinical trials in USA, can ingest up to 14g and not die
 1959: case of phocomelia; no etiology. peripheral neuropathy concerns delayed US approval
o Weidemann (German society of Pediatrics) – 13 cases phocomelia seen by him, 27 others in his area – ↑ incidence
 1961: thalidomide linked to phocomelia; pulled from market in Germany (4000 deformed children) & UK (800)

What’s going on? Toxic metabolite to blame; not produced in animal systems
 until the right system was found
 Produces phocomelia – limb reduction defect
o Very short or absent long bones
o flipper-like appearance of hands and sometimes feet

Current use: given to pts with leprosy as a sedative; improves response to

therapy (controls type-2 - erythema nodosum leprosum - lepra reactions)
 1998: approved for Hanson’s Disease in USA (also used as adjuvant immunomodulator in inflammatory conditions)

7
Isoretinoin
Vitamin A analog, used for cystic acne
 At first, FDA decided to approve for use only in males (prevent birth defects) – provoked furor!
 Pressure from Congress, etc – approved for women (had to sign all kinds of releases, promise not to be pregnant)
 Birth defects resulted (154 pregnancies, only 26 normal infants – 21 birth defects) - knew it would happen!

Bendectin
Widely used for nausea, vomiting in early pregnancy (≈3M prescriptions in US in 1978) – works great!
 Combo drug: Doxylamine, Dicyclomine, and Pyridoxine; off market in Sweden in 1962 – anecdotal reports of birth defects
 US: doxylamine removed in 1977; no epidemiologic studies could prove associations – but can’t rule out
 Removed from market by manufacturer in 1983 (lawyers were having a field day, but no one collected anything)
o Drove courts to define who can testify as an expert

Downside of birth defect surveillance

 Still approved for use in USA – but not available! Probably the drug with the most evidence of safety in humans
 Now no drugs for nausea / vomiting in early pregnancy!

How do drugs get to the baby?

Placenta: the major barrier
Can get through by Drugs: what crosses best? Placental factors
 Simple diffusion (majority)  Surface area for exchange (↑ with age)
 Lipid soluble
 Facilitated diffusion  Membrane thickness (thinner with age)
 Small size
 Active transport  Placental drug metabolism**
 Uncharged*
 Pinocytosis  Placental tissue binding of drugs***
 Not protein-bound
 Solvent drag (must be really small)  Placental blood flow (tons!)
*LMW heparins are highly charged (& big), so don’t cross – can use to anticoagulate mom without anticoagulating baby
** if you give prednisolone, gets caught in this system, then metabolized to inactive form before crossing – good for treating mom
but not baby (doesn’t get to baby in active form)
*** digoxin is really bound – takes days to get to baby

Weak bases: (pKa close to physiologic pH)

 Fetal blood is 0.1-0.15 pH units lower than maternal blood (fetal Hb / Bohr effect –better fetal O2 / CO2 exchange)
 Weak bases can be ion trapped in the fetus (more ionized in baby!)!
 Examples: bupivacaine (Marcaine), meperidine (Demerol)

FDA Risk Classes

Category Definition
Category A Really unlikely to cause problem – really don’t think it does
Category B Pretty unlikely to cause a problem
Category C Studies not available (or some animal studies show possible harm) – MOST DRUGS ARE HERE
Category D Positive evidence of human fetal risk (but may be acceptable in some circumstances
Definitely teratogens, and risk of use of drug ≫ any possible benefit (contraindicated!)
Category X
 Only ever give with informed consent – e.g. chemotherapy possibly
Most drugs aren’t A or B – often can’t get that level of certainty from epidemiology alone

8
Use drugs in pregnancy when:
1) They offer a clear benefit to the mother and/or the fetus.
2) This benefit cannot be achieved by non-pharmacologic therapy.
3) The least toxic effective drug is used.

Future directions
 New extensive prescription databases  link pregnancy outcomes?
 Pharmacogenetics to predict susceptibility?

Test-Type Questions

Drug with 24h half life (lasts ≈5d, half-lives) & a teratogen

 If you give a woman the drug on first day of her period – what could happen?
o Nothing! It’s going to be gone by the time she conceives (≈14d – 9 days after drug gone!)

 If you give a woman the drug two weeks after her last period – what could happen?
o Pre-differentiation – either will do nothing, or could cause fetal loss

 If the woman comes to you 12 weeks after her last period, and said she took the drug 2 wks after her last period
o Listen for the fetal heartbeat – if it’s there; things are OK; if it’s not – do more workup

 If the woman is one week past when she missed her last period (5 wks from last menstrual period)
o Organogenesis (wk 4-10) – this is where the drug could cause teratogenicity
o Use U/S later in gestation to look for possible defects

 If you give thalidomide (or another really bad drug with a specific problem) @ 20 wks, what will happen?
o NOTHING – limb buds will already have formed!

9
 Contraception
Introduction
 Pop 6.83B, > 100M F use OCP. More than 80% women born in USA since 1945 have used (vs 95% in France)
Why do we need contraception?
 ½ pregnancies in USA are unintended; 50% of these are terminated by abortion
 Lack of use of contraceptive, failure of method, use of less effective method

OCP have multiple uses – not just to prevent pregnancy

 For acne: ortho-tricyclen, estrostep
 For premenstrual dysphoric disorder (PMDD) – YAZ
 Dysmenorrhea, menorrhagia, DUB, hormone therapy too – some not FDA approved

A History of the Pill

1920-30: hormonal inhibition of ovulation theorized
 anovulation during human pregnancy, can’t make animals with corpus luteum ovulate
 Progesterone suspected as inhibiting hormonal factor
1930-1940: made sex steroid hormones from animal sources (sow ovaries, etc – tons!)
1940-1950: Marker: synthesizing progesterone from diosgenin (from Mexican yams)

1950-1960: If you give a steroid orally, it becomes inactive

 But if you put a ethylene group at 17-position, then it’s orally active
 If you remove a methyl group from E, you get norethisterone (no androgen properties, acts like progesterone)
 Harvard group: clinical trials in Puerto Rico (contraception & abortion illegal in mass)
o noted that if progestagens contaminated with 1% mestranol (estrogen), ↓ bleeding

1960: first OCP (Enovid: norethynodrel + mestranol – had high doses of both progestogen & estrogen!)
 1961: 1st reported case of PULMONARY EMBOLISM
 1960s: More pills! Free love!

Combination Oral Contraceptives

An estrogen A progestogen

+
(to control bleeding) (to inhibit ovulation)
 norethindrone acetate
 norgestimate
 Ethinyl estradiol  ethynodial diacetate
 drospirenone (YAZ)
 Mestranol  levonorgestrel
 chlormadinone (Belara)
 desogestrel

Metabolism
 Absorbed in small intestine  Circulation (large 1st pass effect in liver)
 May need to use higher doses in high body weight pts

Metabolized by mixed function oxidases (e.g. 16-hydroxylase)  cleared

 Rifampin, griseofulvin, St. John’s wort, dilantin will ↑activity!
o ↓ efficacy: would have to use higher dose or backup method

Pharmacokinetics
 Peak in 1-2h, then decline (almost completely gone in 24h)
o Not “mimicking” the human changes in reproductive cycle – myth!
 Changes every time that someone swallows a pill

10
 How does the pill work?
 Direct affect on follicle maturation / ovulation  Altered endometrial lining
 Impaired tubal motility  Thickened cervical mucus

Inhibition of Ovulation
Works on the hypothalamic / pituitary / gonadal axis

 Progestagen inhibits midcycle LH & FSH surge

 Estrogen inhibits FSH
o at high doses, inhibits both LH/FSH @ midcycle 
o but these cause N/V, other side effects

Also: ↓ estrogen if pt tested

 ethinyl estradiol is a potent estrogen, but doesn’t react with Ab used in assays
 Won’t see any estradiol if pt on pill – inhibiting physiologic estrogen production

Other effects: ↓ androgens (can help with hirsutism), ↑ SHBG too

How to prescribe the pill

History: medical, reproductive / menstrual / sexual, list of current meds, blood pressure
Physical exam: you can defer PE (incl. pelvic) until after starting OCP, if the woman requests & clinician agrees
 Don’t want to make pt wait / feel uncomfortable / have to come in for yearly exam

Starting OCPs (if not pregnant)

 Begin on any day (1st day of menses, 1st Sunday after onset of menses – really doesn’t have an effect)
 Use back-up contraception for first 7 days
 Don’t need to get pregnancy test first

The “Pill-Free Interval”

 Classically: 21 days of meds, then 7 days of nothing (or placebo to ↑ compliance)
 Purpose:
o Provoke withdrawal bleed (not a menstrual period)
 Supposedly reassuring
 Can be confusing / provoke misunderstanding (doesn’t mean you’re having normal periods!)
o Reassures that pregnancy hasn’t occurred
 But it’s really arbitrary – and now we know it’s less efficacious and creates side effects!
o Hormonal changes (↑ estradiol)  pelvic pain, headaches, breast pain, bloating / swelling
o Like pre-menstrual dysphoric disorder symptoms! ↑ estradiol!

Continuous OCP use

Why not?
 Benefits: ↑ efficacy, ↓ side effects, effective PMDD therapy
 Risks?
o “breakthrough bleeding” – but not that common (esp. later in use), no difference in BP / Hb
o ↑ doses? But low dose pills – so total exposure ≈ the same; no weight gain either!
Prescribing
 Can use any monophasic pill for longer than 21 days – but breakthrough bleeding may eventually occur
 Mircette: prototype (21 active, 5 ethinyl estradiol alone, 2 inert pills)
 Lo Estrin, YAZ: can now be ordered with 24 active pills / pack
 Seasonale: continuous (84 days active, then placebo for 7 days – 4x91d cycles)
 Lybrel: no stopping (FDA-approved – but could just use any!)

11
 How to take a contraceptive pill
• Oral as a swallowed pill • Transdermal • Implants
• Oral as a chewed and then swallowed pill • Vaginal (2x dose) • Injectables
And all the previous pharmacokinetics apply!

Chewables, Rings, & Patches

Product Description
Chewable Ovocon 35 Since 2003: spearmint-flavored, chew then swallow with glass of water
Since 2001: vaginal ring with ethinyl estradiol + etonorgestrel
Nuva Ring (Organon)  1 ring for 3 weeks
 Don’t confuse with Estring (local) or Femring (hormone therapy)
Transdermal patch; 1 patch for 3 weeks
EVRA (patch)  20 mcg ethinyl estradiol, 150 mcg 17-deacetylnorestimate daily
 Anywhere on body except breast
Note: you could use any of these continuously as well!

Advantages of non-oral routes of administration:

 Less fluctuation over time! (Fluctuations produce vasomotor effects, e.g. migraines)
 Vaginal administration  ↑ thickness of vaginal mucosa  ↓ HIV infection?
 Theoretically: “imperfect use” less likely

Disadvantages of non-oral routes of administration:

 May result in ↑ amounts of steroid administered over time
 Could ↑ risk side effects (e.g. DVTs) – Ortho-Evra patch controversy

Injectables & Implantables

Product Description
1 shot q3m.
Depo-Provera  Breakthrough bleeding, BONE LOSS (in young women!)
 Post-use hypothalamic amenorrhea – don’t use if pt may want to get pregnant soon!
Sub-dermal levongesterol implant; designed to be effective for 5 years
Norplant
 Voluntarily removed from market by manufacturer
Only current implant (1 rod) currently approved for USAb
Implanon
 Efficacious for 3 years
Downside of implants: pain in the butt to get out!

12
 Side Effects of the Pill
May or may not experience; usually get acclimated with time!
• Nausea/vomiting • Bloating • Weight gain (? Prob not!)
• Headaches • Breakthrough bleeding • Acne*(?)
• Breast enlargement and tenderness
*OCPs approved to treat acne, but some pts get acne?

Which pill / doses usually doesn’t make a difference

 Except for breakthrough bleeding (↑ with lower doses of estrogen / progestin)

Risks of the Pill

CANCER?!??!!

Breast Cancer: lots of experience (years of use!) – so what’s Ovarian cancer: ↓ risk with ↑ use!
the verdict?  Lifetime risk is 1.7%; most invasive carcinoma between
 NO ↑ risk due to duration of use, estrogen dose, race, 50-70 y/o
initiation at young age, or FHx  ↓ risk with ↑ use (40% with 4 yrs, up to 60% with 12
years, persists after discontinuing!)
Colon cancer: actually ↓ risk?
 Not all studies agree; usually done with high doses; Endometrial cancer: ↓ risk with ↑ use!
mechanism not known  Lifetime risk is 3%; more common in older pts
 ↓ risk with ↑ use (54% with 4 yrs, protects for at least 15
yrs after discontinuing!)

CERVICAL EPITHELIAL NEOPLASIA (CIN): ↑ RISK

 The one exception; ↑ risk with ↑ use (this is CIN, not cancer!)
 Glandular epithelium can come out onto surface (entropion), ↑ risk of injury

Cardiovascular Risks: DVT & PEs

Background risk
 DVT: 10% risk that it’ll result in PE  10% risk for PE that it’ll result in death
 Avg risk of DVT is 4/100k women / yr  3x higher on OCPs, but 20x higher if pregnant

Coagulopathies:
 Should you screen for factor V? Probably not: NNT = 70k (to save one life) - But if you know a patient has FHx of clots, maybe

Genotype Risk not on OCP Risk on OCP

Normal 1x (baseline) 4.6x
Prothrombin mutation
2.7x 16.3x
(factor II 20210)
Factor V Leiden 2.4x 20.0x

Stroke & OCPs: no ↑ risk in pill users who don’t smoke

 But CONTRAINDICATED FOR PTS WITH MIGRAINE WITH AURA (RR ↑ 2X)

Heart attacks: only a risk for smokers > 35 years old

Bottom Line: Low Chance of Death

 Automobile driving (1/6k) has a higher risk in a year vs. OCP users (1/63k for non-smokers, 1/16k for smokers)
 Continuing a pregnancy (1/11k) has a higher risk of death vs OCP too!

13
 Emergency Contraception
 1960: if you take high dose estrogen after rape, can prevent pregnancy
 1977: take 100mcg of ethinylestradiol & 0.5 mg levonorgestel immediately, then 12h later w/in 72h
o ↓ chance of pregnancy (7.2%  1.9%)  marketed as Preven but nausea / vomiting

“Plan B”: available under the counter, w/o prescription to those older than 18
 0.75 mg levonorgestrel – take 1st dose within 72h of intercourse, 2nd dose 12h later
o Alternative: Ovrette (20 pills as 1st dose, 20 pills as 2nd dose!)
 Antiemetics (bonine, Benadryl, Dramamine, etc) 30-60m before 1st dose to minimize nausea!\

“Plan B One-step”: now known that 1.5mg levonorgestel all at once is just as effective (w/in 72h)
 Now available without prescription for those older than 17; costs $50-80
 May work up to 5d after intercourse (but with ↓ effectiveness)?

Caveats:
 Looks safe for women > 35 who smoke; no known medical contraindication
 Rifampin = drug interaction?
 Pretreatment lab tests not required; consider prophylactic prescriptions, recommend antiemetics!

IUD can be used for emergency contraception too (not FDA-approved)

 within 5d of unprotected intercourse; 7d of time of ovulation - probably most effective EC method
 Use copper-containing devices (inflammatory effect ) – prevents fertilization / implantation

Other Contraceptives
Condoms, cervical caps, diaphragms, etc
IUDs
 Merina IUD –hormones for local release (left pics)
 Paragard IUD – copper (right pics)
 Other crazy-looking IUDs (esp. historically)

How do they work?

 Inflammatory response (inert device)
o Copper may ↑ response
 ↓ endometrial receptivity; progestin  may additionally↓ receptivity

Indicated for women with children  nulliparous women have smaller uteri, so:
 ↑ Risk of infection, Intrauterine cramping, Risk of expulsion

Essure
• Micro-filaments inserted into cornual portion of fallopian tubes using hysteroscopy.
• Composed of polyester fibers, nickel-titanium and stainless steel.
• Creates local inflammatory response.
• Takes 3 months to completely block fallopian tubes.
• Is not reversible.

Future Directions
Over/under the counter OCPs? Nasal spray? Lower doses? Male contraception?
Male contraception: work continues!
 Give testosterone & progestin (implant and/or IM injection) q3m  ↓ sperm concentration (< 1M/cc) in 3mo
 Believed to be unable to cause a pregnancy; reversible 3-4mo later
 But long time til effective, response differs between men of same ethnicity, 4% failure rate
o East Asian: T alone, Caucasian: need progestin too)
14
 Pathology:
Immuno / Rheum
Autoimmune Disease: the Big Picture ..........................................................................................................................2
Autoimmune Thyroid Disease......................................................................................................................................4
Autoimmune Disease: Models & Mechanisms ............................................................................................................10

1
 Autoimmune Disease: the Big Picture
Definitions
 Autoimmunity: immune response to normal antigens of the host
o Can be induced by self-antigens (cryptic or modified), o r foreign antig ens (molecula r mimicry, etc)
 Autoimmune disease: disease caused or significantly promoted by autoimmunity

Epidemiology
Prevalence
 80+ diseases, affecting every organ system
 Affects ≈ 15-25M people in USA
o For co mparison: heart disease = 22M, cancer = 9M
o Expensive: many life-long diseases, d rugs are expensive
 Among the 10 leading causes of mortality among woman under 65

Most common autoimmune diseases

1. Grave’s dise ase Organ system Examples
2. Rheumatoid arthritis Blood Hemolytic anemia, thrombocytopenia
3. Hashimoto’s Connective tissue Lupus, RA, scleroderma
4. Vitiligo Endocrine Diabetes (type I), Graves’ disease, Hashimoto’s
5. Type I diabetes Neurological Myasthenia gravis, multiple sclerosis
6. Pernicious anemia Gastrointestinal Chronic active hepatitis, IBD
7. Multiple sclerosis Skin Pemphigus, psoriasis, vitiligo
8. 1° glomerulonephritis Kidneys Glomerulonephritis
9. SLE Heart Rheumatic fever, myocarditis
10. Sjogren syndrome

Most individual autoimmune diseases are rare

 Grave’s disease, Rheumatoid arthritis, Hashimoto thyroiditis are exceptions – pretty common

Sex Bias
Females > Males for many autoimmune diseases, but not just a simple trait

Sjogrens, lupus, thyroid disease, scleroderma overwhelmingly diseases of women

Multiple sclerosis, RA female predominance
Ulcerative colitis, sarcoid ≈ equal
Type I diabetes, ankylosing spondylitis slightly more common in males

 Sex bias usually begins at puberty – maybe hormones are key?

o estrogen tends to ↑ autoAb responses, prolactin levels ↑ in some autoimmune diseases
o autoimmune disease fluctuates during / after pregnancy
 RA classically remits during pregnancy
 Postpartum hypothyroidism – presents after pregnancy
 Bidirectional transfer of lymphocytes occurs during pregnancy (microchimerism)? Non-self lymphs  GVHD?
 X-chromosome inactivation involved?

Age, Geographic, Ethnic factors

 Predominantly diseases of young adults (but varies)

 Most occur in temporal climates (↑ in N. Europe vs S. Europe) – further from equator  ↑ prevalance
o Directly infection-related diseases are the exception - rheumatic fever, Chagas disease, etc.
o Highest rate in Finland & Sardinia (weird)
o Maybe related to vit amin D3 levels?
2
  Autoimmune diseases tend to travel together – if your patient has one, ↑ risk of another!
o Higher than general population risk  ↑ index of suspicion

 Different prevalence with different ethnic groups

o Believed to be rare in Africa (no studies – just “the word on the street”)
o But higher in African Americans! (AA > Asians > Caucasians)

 Virtually every autoimmune disease is increasing in incidence!

o (subject to ascertainment bias)
o MS, type 1 DM, others

Autoimmune Disease: the Common Threads

Genetic predisposition (polygenic)
Need to have genes & express ‘em
 Family clustering (↑ in 1st degree relatives)
 Multiple autoimmune diseases in same individual
 Twin concordance: MZ (≈ 30%) ≫ DZ (still higher than pop)
 HLA association (don’t memorize these)

Disease Haplotype
Celiac dise ase DQ2
Rheumatoid arthritis DR4, DR1
Spondyloarthropathy B27
Lupus DR2, DR8
DR3, DR4 promote
Type 1 DM
DRb1 protects

Gene defects in monogenetic syndromes a/w autoimmune disease: all important in maintaining immune homeostasis
 Different alleles for immunoregulatory genes  more susceptible to autoimmune disease
 E.g. AIRE-1, FoxP3, Fas, Fas-L, caspase 10

Environmental triggers – probably more than ½ of the risk

 Drugs, viruses, bacteria, foods, pollutants, hormones, stress
 Still need genetic predisposition
 E.g. drug-induced lupus, rheumatic fever (strep infection), iodine  thyroid disease, pesticides, etc.

The future: Predictive Autoantibodies

Can we determine the onset of the disease before destruction starts?
 Now, we’re treating late – after destruction has already started (sx)

Example:
 Type 1 DM: 3 auto-Ab = 90% chance of developing disease w/in 10yrs
 Thyroid disease: multiple auto-Ab (anti-TPO) = predictive
 Same for lupus

Summary
 Autoimmune disease is a large & growing problem in USA
 Autoimmune disease can affect any site in the body
 Common mechanisms: genetic predisposition + environmental trigger
 Autoimmunity is present before autoimmune disease is apparent

3
 Autoimmune Thyroid Disease
Introduction / Review
 Thyroid is the largest endocrine gland in the body
 Used to synthesize thyroid hormones (T4, T3) – made from modified tyrosines containing iodine
 Thyroid hormones  ↑ growth, brain development; regulate energy, heat production

Thymocytes: all this controlled by TSH binding to TSH receptor

 Blood side: NIS: transmembrane Na/I symporter brings in iodine
 Colloidal side: TPO puts iodine on thyroglobulin (in colloid space)
 TG proteolysis eventually releases T4 (and T3)

Remember the axis

 TRH  pituitary  ↑ TSH
o TSH production inhibited by somatostatin
 TSH  thyroid  ↑ T4 / T3

Autoimmune thyroid diseases (ATD)

ATD: Disorders caused by a lymphocytic infiltration of the thyroid gland

May lead to opposite effects on thyroid function

 Graves = hyperthyroidism; chronic myxedma = hypothyroidism

Classification of ATD
Grave’s disease
 Hyperthyroidism only (most common)
 Hyperthyroidism + ophthalmopathy
 Opthalmopathy only (euthyroid Graves’)
 Opthalmopathy + localized myxedma
Hashimoto’s thyroiditis
 Classic Hashimotos’ thyroiditis
 Atrophic Hashimoto’s thyroiditis (myxedema)
 Silent thyroiditis - focal thyroiditis
 Post-partum thyroiditis

4
 Grave’s Disease
Thyroid gland  diffuse goiter
Eyes  thyroid ophthalmopathy
3 major target:
 localized dermopathy (pretibial myxedma)
Skin / extremities
 thyroid acropatchy

Diffuse goiter
 Hypertrophy & hyperplasia of thyroid follicular cells  results in papillae formation
 Paucity of colloid, with scalloped margins
 Hypervascularization
 Infiltration of mononuclear cells in the stroma

What causes goiter / hyperthyroidism in Graves’ disease? TSH-R antibody – actually stimulates TSHR!
 See ↓ TSH (external stimulation of TSH-R --< feedback!

Cut section:
Gross: big, smooth, soft thyroid Histology: Too many cells
“meaty”, looks like normal muscle!

Taller cells with scalloped margins (left arrows) –

Mononuclear cell infiltrate
an artifact of fixation (indicates ↑ turnover)

Thyroid-associated Ophthalmopathy
 Clinically evident in ≈ 50% pts with Grave’s Disease
o In majority of pts w/o clinical signs, imaging shows enlarged extraocular muscles
 Usually appears within 1 year before/ after dx of hyperthyroidism
 Of pts with opthalmopathy: 90% hyperthyroid, 5% w/ autoimmune hypothyroidism, 5% euthyroid @ pres.

Pathology:
 Lymphocytes in EOM  fibrosis & edema
o probably recognizing orbital antigen that’s related to the thyroid antigen
o Activation of inflammatory cells  cytokine production (IL-1, TNFα, IFNγ) 
o Fibroblast proliferation; secretion of GAGs, edema / fibrosis!

5
 Lymphocytes in MUSCLE (extraocular mm) Lymphocytic inflammation  fibrosis

Not much space for globe Imaging: Fat, juicy extraocular Proptosis: ↑ infection risk;
to move  proptosis muscles (edematous) globes can even pop out!

Skin & Extremities

 Localized dermopathy (pretibial myxedma)
o Thickening of skin, usually on front of shin, or elbows
o Myxedema = not soft like edema (lots of proteoglycans)
 Thyroid acropachy – subperiosteal new bone formation (e.g. CLUBBING)

Hashimoto’s Thyroiditis
Forms:
 Classic (or goitrous) form  Focal thyroiditis
 Atrophic form (primary myxedema)  Post-partum thyroiditis
 Silent (painless) thyroiditis

Classic Hashimoto’s Thyroiditis

Middle-aged women with goiter
 Usually euthyroid or hypothyroid @ presentation; Can rarely be hyperthyroid (hashitoxicosis)

Chronic course (almost universal development of hypothyroidism)

Rx: Synthetic T4 (dramatic ↑ in QOL with Rx - only do surgery if compromising other neck structure)

Pathology
 Extensive mononuclear cell infiltrate in stroma (frequently forming germinal centers)
 Small thyroid follicles, lined in many areas by Hürthle cells (eosinophilic, granular cyto from ↑ # mitochondria)
 ↑ fibrosis in interstitium (↑ deposition of collagen fibers)

6
 Hürthle cells
Histology:
Cut section: yellowish (high power of abnormal follicle)
prominent mononuclear cell infiltrate,
(vs meaty, hamburger-like Grave’s d z) Eosinophilic, granular cytoplasm
compartmentalized (ectopic lymphoid follicles)
from ↑ # mitochondria

Pathogenesis:
 Mediated by T-cells
o Thyrocytes from Hashimoto’s (but not from nonautoimmune thyroids) express Fas
o T-cells recognize Fas, induce thyroid destruction via apoptosis

 In a more rare subset, thyroid destruction is caused by TSH-R blocking antibodies

o Like thyroid-stimulating Ab in Grave’s – but here blo cking!
o These patients can pass Ab to baby  neonatal hypothyroidism

 Unclear role of thyroglobulin, TPO antibodies

Risk Factors for ATD

 Thyroid autoantibodies  Genes (HLA class II, CTLA-4, thyroglobulin)
 Female sex  Environment (iodine)
 Pregnancy

Thyroid autoantibodies
 Against: Thyrotropin receptor (TSH-R), Thyroid peroxidase(TPO), Thyroglobulin (TG)
o Thyroid stimulating Ab  100% chance of getting Grave’s Disease
o Others (anti-TPO, anti-TG) associated with ↑ risk

Female sex
 About 18x higher risk (F:M)

Pregnancy
Many autoimmune diseases affected by pregnancy
 If your thyroiditis pt gets pregnant – raise your antennae!

Pregnancy ameliorates disease activity in

 Grave’s disease  Rheumatoid arthritis  Pemphigus vulgaris
 Hashimoto’s thyroiditis  Multiple sclerosis

Pregnancy makes disease worse in many cases of SLE

7
Post-partum thyroiditis
Occurrence of hypothyroidism or hyperthyroidism in women who were euthyroid during pregnancy
 About 8% of mothers!

Biphasic (triphasic?)course
 Hypothyroid (≈ 3mo after delivery)
o “I’m tired” (hard to diagnose – new baby!)
 Euthyroid, then
 Hyperthyroid

Microchimerism
 Cells from the fetus can live on in mother’s body for decades after delivery
 Likewise, mother’s cells can survive for many years in baby!

Right now, there’s only an association between microchimerism & autoimmune diseases (NOT CAUSATION)
 Can generate a graft-vs-host type response?
 But remember – most people with chimeric cells are healthy!

Genes & Environment

Hard to allocate portion of causation to genes

Approaches to identifying gene roles in causation

 Population studies for association of genetic marker with dz (e.g. GWAS)
 Family studies (ATD clustering in same families)
st
o 1 degree relatives, twin studies, adoption studies, linkage studies (do gen etic ma rker & dz run together in family?)
 Time trends & migrant studies

Twin studies
 Concordance = both twins have it / pairs in which at least 1 twin has it
 For ATD: 30% for MZ, 3.7% for DZ
o So 10x↑ risk for MZ > DZ, but only explains 30%

Specific Genes
HLA: the Human MHC
Most gene-dense region of human genome
 128 genes expressed, 96 pseudogenes; of expressed genes, 40% are immune-related

Encodes the most polymorphic proteins known (class I & class II molecules)
 Nomenclature will be changing (really complicated right now)

Many autoimmune diseases have been associated with certain HLA alleles
 Association, not necessarily causation – pathogenic risk elusive
 For ATD: not too strong of a correlation (Grave’s disease: HLA-DR3  3x ↑ RR)

CTLA-4
Cytotoxic T-lymphocyte-associated antigen 4
 Belongs to Immunoglobulin superfamily, works as homodimer
 Homolog to CD28, binds to same molecule (B7 on APCs)
 Unlike CD28 (expressed on resting t-cells), expressed on T-cell surface only 24h after activation

8
Regulation of T-cell responses depends on opposing signals transmitted through two related cell-surface receptors
 B7 - CD28 Activation (proliferate!)
 B7 - CTLA-4 Inhibition (shut it down – don’t want lymphoma!)

If you knock out CTLA-4  widespread lymphocytic infiltration of many organs

In Grave’s Disease
 Case-control studies – show CTLA-4 / Grave’s association with
certain allele variants / SNPs. Don’t know if this was causal or in
linkage disequilibrium with allele of causal variant.
 Mechanism unknown. One theory: results in ↓ levels of soluble
CTLA-4; may cause ↑ T-cell self-reactivity

Environment: Iodine
Exists in 3 forms: iodine(I2), iodide (I-), iodate ion (IO3)
 Enters body through food or water (iodide or iodate)
 Over millennia, has been leached from soil; washed into oceans (↓ in mountains, inland; ↑ in costal areas)
o ↑ cretinism inland, ↓ near coast!  led to seminal 1917 paper recognizing importance of iodine

Dietary sources
Low iodine in US diet until beginning of 20th century (started iodine supplementation)
 Added as dough conditioner (iodate); iodized salt
o Now ↓ iodine intake since 1990s (bromine salts replaced iodine in baking industry)

 Now most Americans have adequate iodine intake (except pregnant & lactating women - SUPPLEMENT)

Current sources:
 iodized salts  vitamin / mineral preparations
 milk/dairy products (added to cow feed)  iodine-containing meds (e.g. amiodarone)
 eggs (chicken feed)  iodine contrast media

When Iodine Goes Wrong

Too little iodine (< 50 mcg / day) Too much iodine
Favors development of autoimmune thyroiditis
 Euthyroid goiter first
 Mechanism unknown
 Hypothyroid goiter later
 Hypothesis: highly iodinated TG is more immunogenic?

Summary of ATD

Most frequent autoimmune diseases; Form a spectrum of thyroid diseases

o Graves: 1.1% prevalence
o Hashimoto’s: 0.8% prevalence

Pathogenesis
 Grave’s disease: mediated by a stimulating antibody directed against the TSH receptor
 Hashimoto’s thyroidits: mediated by T-cells

Know the risk factors for ATD:

 Thyroid autoantibodies  Pregnancy  Environment (iodine)
 Female sex  Genes (HLA class II, CTLA-4, thyroglobulin)

9
 Autoimmune Disease: Models & Mechanisms
How to define an autoimmune disease?
Note that these are generally treated with anti-inflammatories right now – increasingly targeting etiology

Evidence for autoimmune disease

Direct evidence Indirect evidence
Circumstantial evidence
(transfer of disease) (experimental models)
 Reproduction with equivalent Ag
 Autoantibodies
 Serum transfer to animals  Reproduction by genetic selection
 Response to immunosuppression
 Maternal – fetal transfer*  Reproduction by manipulation
 Clustering
 Reproduction in vitro o Knock-ins / knock-outs
 HLA association
 Cell transfer (SCID mouse) o Thymectomy (Treg cells)
o Transgenic mice (HLA)
*e.g. anti-Ro (Sjogren’s, Lupus); can affect AV node  heart block in children
Take home messages:
1. Autoimmune disease can be defined with varying degrees of certainty based on direct, indirect or
circumstantial evidence
2. Establishing autoimmunity as the cause of a disease usually requires transfer - direct evidence
3. Some autoimmune diseases can be reproduced in experimental animals - indirect evidence
4. Many diseases of unknown etiology show evidence of an autoimmune response,
but autoimmunity may be the result, not the cause, of the disease.
5. Autoantibodies are often useful diagnostically, even if they are not causative

How does Autoimmunity Happen?

A NORMAL IMMUNE RESPONSE directed against a self target! Stimulating normal B/T cell responses

Role of T-cells
 Most damage in inflammatory diseases probably due to CD8+ CTLs
 In order to generate autoimmunity, though, you probably need CD4+ cells directed against autoantigens
o T-cell repertoire generally degenerates with age
o We always are making T-cells that interact with self
 but we destroy them in the thymus (negative selection – but pretty “leaky”)
 and those that leak into periphery are handled by peripheral tolerance mechanisms

Autoimmunity itself isn’t the problem – it’s always happening!

But when regulatory mechanisms get messed up, you can get autoimmune disease.

10
Initiation
It doesn’t take much to dysregulate this process that controls autoimmunity  degenerates into pathology
similar antigenic determinant
Molecular mimicry
e.g. rheumatic fever, strep infection; Guillan-Barré - but not too many good examples!
Revealing cryptic antigens Normally hidden from immune system  now visible
Adjuvant effects Something providing the “danger signal”
Defective regulation
Can play a role too
Impaired central tolerance

Propogation / spread
Later in the process, can get
 Epitope spread (↑ range of antigens that immune response directed against)
o Leads to symptoms (more targets), presence of multiple auto-Ab
o Can propagate response (more damage  ↑ immune response  more damage, etc)
 Bystander effects  symptoms!
o Complement, immune complexes, antibody-dependent cell-mediated cytotoxicity
o Cytotoxic T-cells start up, Mϕ do their thing, etc.

Targets for therapy

Therapeutic agent
Anti-CD52 (alemtuzumab)
Anti-VLA-4 (natalizumab)
Anti-TNF (infliximab)
Soluble TNF p75 receptor (etanercept)
Human anti-TNF (adalimum ab)
CTLA4Ig (abatacept)
IL-1RA (anakinra)
Anti-CD20 (rituximab)
Anti-CD3
 Note that these agents are often good against more than one disease!
Don’t memorize this list
Disease(s)
Multiple sclerosis, Rheumatoid arthritis
Multiple sclerosis, Crohn’s disease
Rheumatoid arthritis, Psoriasis, Crohn’s disease
Rheumatoid arthritis, Juvenile rheumatoid arthritis, Psoriatic arthritis, Psoriasis
Rheumatoid arthritis, Psoriasis
Rheumatoid arthritis, Psoriasis
Rheumatoid arthritis, Juvenile rheumatoid arthritis, Lupus erythematosus,
Rheumatoid arthritis, Lupus erythema tosus, Vasculitis
T1D, Psoriatic arthritis

Infection & Autoimmunity

Historically, autoimmune disease has been associated with prior infection
 The problem – too many viruses (huge list, for instance, associated with MS, type I diabetes)
o Which ones are important? Which ones are actually associated?
 Autoimmune disease occurs long after viral infection gone (e.g. months / years!)

How can viral infection trigger autoimmune disease?

Molecular mimicry Altered self-antigen Antigen exposure Adjuvant effects

How do we examine this? Coxsackievirus B3 as an example

Coxsackievirus B3 (CB3) & myocarditis

 Infects 80-100% of population
 Generally causes flu-like symptoms
 Etiology in autoimmune diseases (e.g. diabetes, myocarditis)

Coxsackievirus B3 myocarditis: typically disease of young adults

 The big disease for heart failure in young adults (< age 40)

11
 Lymphocytic infiltrate Heart-specific antibodies!

Models for CB3 myocarditis

Infect mice with coxsackievirus – almost all develop a viral myocarditis, but most resolve on its own
 Rare mice strains – ongoing disease (autoantibody reaction)
 Antibodies directed against cardiac myosin or breakdown peptides

So there’s a difference between infectious myocarditis & autoimmune myocarditis

 Can go on to develop DCM!

If you immunize mice with cardiac myosin or myosin-derived peptides:

 Get the same picture of heart failure!
 Skipping straight to the autoimmune problem!

Cytokines are key

 Drive differentiation of CD4+ T-cells into different subtypes
 Control the progression of the disease
 IL-17 is key for the transition from inflammatory dz to fibrotic dz!
o Not needed for inflammatory myocarditis
o Essential for progression to DCM (via ↑ collagen deposition  myocardial fibrosis)

HLA, mice, & autoimmune myocarditis:

 put human HLA-DQ8 into mouse, ends up with spontaneous autoimmune myocarditis!

Summary
 In susceptible strains of mice, autoimmune myocarditis is induced by CB3 infection
 The immunopathological features of post-infection myocarditis can be reproduced by immunization of
susceptible mice with cardiac myosin
 The disease is dependent upon CD4+ T cells
 The disease can be produced spontaneously in HLA transgenic mice

 Most of our knowledge of the mechanisms of autoimmune diseases comes from analysis of animal models
 The progression from autoimmune disease is marked by particular cytokine signals
 Identifying these checkpoints provides opportunities for novel interventions

12
 Pathophysiology:
Immuno / Rheum
Evaluation of Immune Function .............................................................................................................................................. 2
Primary Immunodeficiency Diseases ...................................................................................................................................... 6
Secondary Immunodeficiency............................................................................................................................................... 10
Immediate Hypersensitivity Reactions ................................................................................................................................. 13
Food Allergy .......................................................................................................................................................................... 18
Specific Immunologic Treatment of Allergies: A History ...................................................................................................... 19
Systemic Rheumatic Diseases ............................................................................................................................................... 22
Osteoarthritis ........................................................................................................................................................................ 25
Phenotypic Presentation of Systemic Inflammation ............................................................................................................ 29
Gout ...................................................................................................................................................................................... 33
Rheumatoid Arthritis ............................................................................................................................................................ 40
Spondyloarthritis................................................................................................................................................................... 46
Autoantibodies...................................................................................................................................................................... 53
Systemic Lupus Erythematosus............................................................................................................................................. 57
Autoimmune Myopathies ..................................................................................................................................................... 64
Vasculitis ............................................................................................................................................................................... 70
Scleroderma .......................................................................................................................................................................... 77

1
 Evaluation of Immune Function
Clinical Features of Immunodeficiency
KNOW THESE:
 Chronic/recurrent
 Unusual severity
↑ susceptibility to infections  Caused by organism of low virulence (opportunistic pathogen)
(note – usually present with recurrent infections with typical bugs – not
PCP at first, but just recurrent pneumonia, for instance)
Autoimmune or Target cells Hemolytic anemia, immune thrombocytopenia, thyroiditis
Inflammatory disease* Target tissues Vasculitis, SLE¸ rheumatoid arthritis
Syndrome complex See table below
* For some reason, have a poor immune response to pathogens, but often a big response to self

Syndrome Complexes (for reference)

Syndrome Clinical Presentation Immunologic Abnormality
Congenital heart disease
DiGeorge Syndrome Hypoparathryroidism Thymic hypoplasia
Abnormal facies
Thrombocytopenia
Wiskott-Aldrich Syndrome Variable B- and T- lymphocyte dysfunction
Eczema
Ataxia
Ataxia-Telangiectasia Variable B- and T- lymphocyte dysfunction
Telangiectasia
Congenital heart disease
Ivemark Syndrome Asplenia
Bilateral 3-lobed lungs
Polyendocrinopathy Syndrome Endocrine organ dysfunction Chronic mucocutaneous candidiasis

Patterns of Illness Associated With Specific Defects

KNOW THIS
Illnesses
Disorder
Infection Other
Mucosal surfaces (with usual pathogens) Autoimmune Disease
Antibody  Auto-antibodies
 Sinopulmonary (Pyogenic Bacteria)
 Inflammatory Bowel Disease
 Gastrointestinal (Enterovirus, Giardiasis)
Cell-mediated Just about any kind of pathogen (think HIV-like!)
Immunity
Classically “T-cell”  Pneumonia (Pyogenic bacteria, PCP, Viruses)
deficiencies – but affect B-  Gastrointestinal (Viruses)
cells too (↓T ↓B)  Skin, Mucous Membranes (Fungi)
Encapsulated bacteria Autoimmune Disease
Complement  SLE
 Sepsis and other Blood-borne infections
 Glomerulonephritis
(Streptococci, Pneumococci, Neisseria)
Infections where there are lots of bacteria
Phagocytosis  Skin, Reticuloendothelial System (LN, spleen, liver):
(Staph, Enteric bacteria, Fungi, Mycobacteria)
 Note: defense against viruses not affected

2
 Screening for Immunodeficiency
Suspected Abnormality Diagnostic Tests
Quantitative Immunoglobulin levels(IgG, IgA, IgM)
Antibody
Antibody Response to Immunization
Lymphocyte Count
Delayed Type Hypersensitivity Tests
Cell-mediated Immunity
T-Lymphocyte (CD4, CD8)
HIV Serology
Complement Total Hemolytic Complement (CH50)
Neutrophil Count
Phagocytosis
Nitroblue Tetrazolium (NBT) Dye Test

Antibodies
 Fab determines specificity
 Fc determines effector function (Fc receptors)
 Antibody level is not the same as immunoglobulin level!
o Can have plenty of IgG around, but no antibody function!
o E.g. multiple myeloma, etc

“Immunoglobulin level” tests detect heavy chain

 Don’t tell you anything about antibody function (e.g. binding)

Characteristics of human antigens

 IgM is 1st detectable (then class switching)
 IgG:
o major part of secondary response
o #1 in serum concentration
o The only one that can cross the placenta

Time course: primary response

 Takes 5-7 days to make IgM, then comes down by 2 wks
 IgG takes 2 wks to peak, comes down by 3 wks

Time course: secondary response

 Upon rechallenging a sensitized person: IgG ≫ IgM response

Antibody / Ig related tests

Mix Ig with anti-Ig serum (e.g. anti-IgG) Ab
Nephelometry Immunoglobulins
Detect immune complex formation (rapid throughput spectrometry, etc)
Why?
 Functional assessment of human immunity
 Proof of immunity
 Evidence of past / present illness
 Characterization of autoimmune dz
ELISA Specific antibody Procedure
 Coat plate with antigen, wash
 Add test (e.g. pt) antibody, wash
 Add ligand to bind bound Ab , wash
 Add chromogen, develop plate

3
ELISA usually reported as titer (dilution)
 “How far down can I dilute this and still have it show up? 1:8, 1:16, 1:32, 1:64, etc

Can also use ELISA to measure antigen (viral / bacterial pathogens, drug levels, serum hormones, etc)
 Affix specific Ab 1st, then add test material, then antibody with enzyme, then substrate to visualize
 If antigen present, 1st Ab will capture, 2nd Ab will bind, and you’ll get a reaction

Western Blot
 Run a gel, add specific antibodies, wash, see where Ab adhered
 E.g. to detect viral particles in HIV, etc. Can be positive, negative, or indeterminate (if only some bands show up)

Detecting Cell-Surface antigens

Use to identify lymphocyte subpopulations; characterize cell types of hematologic malignancies

add fluorophore-labeled Ab, then

Fluorescence microscopy
hit with light – can visualize where Ab bound!

add Ab to fixed tissue, then

Immunoperoxidase staining
visualize with immunoperoxidase stain

sort & count based on cell surface markers

Flow cytometry
(e.g. CD8/CD4 in HIV, detection of AML relapse, etc)

Lederman’s Rule of 2/3 – KNOW THIS

For patients under 5 years old For patients over 5 years old
 2/3 of WBC are lymphocytes  1/3 of WBC are lymphocytes
 2/3 of lymphocytes are T-cells  2/3 of lymphocytes are T-cells
 2/3 of T-cells are CD4 +
 2/3 of T-cells are CD4+
Really, blood is a T-cell organ!

+
For < 5: ≈ 9,000 WBC normal. Should have 2/3 lymphs (6000), 2/3 of those T-cells (4000), 2/3 of those CD4 (2666)

+
For > 5: ≈ 9,000 WBC normal. Should have 1/3 lymphs (3000), 2/3 of those T-cells (2000), 2/3 of those CD4 (1333)

Assessment of T-lymphocyte Functions

Delayed-Type Hypersensitivity

Inject small amounts of recall antigens, intradermally

 If pt can react  mobilize monocytes, T-lymphocytes to area
 Creates red (erythematous), hard (indurated) lesion
 If no response: anergy

4
Lymphocyte Proliferation Assay
A way to measure T-cell response in the lab!

 Take pt’s mononuclear cells

 Add something that should make T-cells proliferate
o Antigen (specific response)
o Mitogen (general response)
 Add labeled [3H]-thymidine  incorporated into DNA
 Quantitiate radioactive DNA (how much were they proliferating)

Complement Function
CH50
 Used to assess complement function – how many times can you dilute serum & get 50% lysis in the assay?
 Mix sheep RBC, anti-sheep-RBC IgG, and patient’s serum
o Ab will bind RBC, then pt’s C1qrs, etc should activate C4, then the rest of the classical pathway
o Insertion of the membrane attack complex should lyse RBC if complement function intact

Complement assays
 Can also look for levels of specific components of complement in the serum!

Examples: Use in Clinical Medicine

Case 1: baby born to HIV infected mother; appears healthy – but how to determine if infected?
 Can’t use any maternal tests (we know she’s infected: ↑ viral load could ↑ probability, but doesn’t say for sure)
 IgG is not helpful at birth (will cross placenta; baby will have maternal IgG at birth. Could be helpful later)
 IgA or IgM in the baby could be good (can’t be maternal!)
 Viral antigen detection (now PCR) is much easier

Case 2: teenager with mono Sx; culturing EBV is slow & expensive. How to dx?
 IgM or IgG could be helpful depending on time frame
o remember “heterophile Ab” in EBV
 Early: target capsid Ag; later: target nuclear Ag

Case 2.5: rest of family tested: what’s their status?

 Patient IgG+, IgM+: Infected
 Brother IgG-, IgM-: Susceptible (no previous infection); possible to have really early infection
 Mother IgG+, IgM-: Previously infected & now immune
 Father IgG-, IgM+: Currently infected (get ready to be sick!)

Case 3: Gamma globulin used to treat Ab-deficient pts contaminated with HCV: how to detect infection in these pts
 Use PCR, not antibody tests (pooled IvIg from these contaminated lots could have Ab against HCV)

Case 4: severe thrush / PCP (opportunists) in infant. What’s the defect?

 Probably cell-mediated immunity (opportunistic, fungi / PCP)
 Order HIV tests, lymphocyte count, T-lymphs

Case 5: 10 yo boy with 2x bloodstream infections from encapsulated bacteria (pneumococci); now has SLE.
 Order CH50 & complement tests (complement deficiency + autoimmunity?)

5
 Primary Immunodeficiency Diseases
Disorders of the immune system in which the defect is intrinsic to the cells / tissues of the immune system
 Genetic basis for many known – polymorphisms may play a role in general population’s response to disease
o E.g. knockout  known disease; polymorphism  pt who responds poorly to treatment
 More than 150 such diseases identified; not rare in aggregate (1:500 people; as common as childhood leukemia)
 Polymorphisms in these genes the general populations  variations in susceptibility / severity of infections?

Chronic Granulomatous Disease (CGD)

Impairment of phagocytic cell function – polys / monocytes ingest certain bacteria / fungi, but then can’t kill them

Genetics
Defects leading to reduced or nearly absent production of PEROXIDE
 X-linked form: missing a subunit of cytochrome b-558 (X-chromosome)
 Autosomal recessive forms too (3) – deficiencies in other proteins in the chain
 Note: about 80% CGD pts male: 60% are X-linked forms (all male), then 40% are AR (20% male). 20+60=80%

Clinical Presentation
 Present early in life (infancy / early childhood) with ↑ infections

Infections: mostly in liver, spleen, liver, lung (lots of phagocytes!)

 Lymphadenopathy, pneumonitis, suppurative lymph nodes, hepatomegaly, dermatitis, splenomegaly
 Blood-borne infections less common

Pathogens: susceptible to CATALSE-POSITIVE organisms (no net production of peroxide)

 Staph aureus > Klebsiella, E. coli, S. epidermidis, others
 Not pneumococcus, streptococcus, H. influenza – all are catalase negative, do produce peroxide
 Unusuall pathogen patterns: see skin infections without group A strep involvement!

Prognosis:
 Initially “fatal granulomatous disease of childhood” (all died < 5-10 yo)
 Now recognizing milder forms, Abx treatment better, more experience  many survive into adulthood

Pathophysiology
Phagocytes can chemotax, phagocytose normally, but can’t kill certain organisms  those organisms cause problems

Normal killing by phagocytes: use various mechanisms

Class of Mechanism
Acidification
Toxic oxygen-derived products
Toxic nitrogen oxides
Antimicrobial peptides
Enzymes
Specific Products
pH = 3.5-4.0, bacteriostatic or bactericidal
1
Superoxide O2, hydrogen peroxide H2O2, singlet oxygen O2,
hydroxyl radical OH, hypohalite OCl
Nitric oxide NO
Defensins and cationic proteins
Lysozyme - dissolves cell walls of some Gram-positive bacteria.
Acid hydrolases - further digest bacteria

Myeloperoxidase / H2O2 / halide system is one of the most important

 Normally, discharge of lysosomal granules (containing myeloperoxidase system) into phagocytic vacuoles
 Myeloperoxidase acts catalytically to fix iodide to surface of microorganism in presence of H2O2 (or other ROS)
 Iodide fixation causes bacterial death

6
In CGD patients: defects in metabolic machinery to produce peroxide (or
other reduced oxygen species, e.g. superoxide ) in response ingestion of bacteria

Catalase: H2O2  H2O + O2

 Catalase negative organisms actually provide the machinery to
produce peroxide & can’t get rid of it  kill themselves
 Catalase positive organisms don’t make net peroxide, so not killed!

Histology: Granulomas
 Response to inability to clear pathogens

NBT Test for CGD

Nitroblue Tetrazolium (NBT) test

 Add blood & dye
 See if phagocytes have oxidative burst after you make them angry with
some stimulus
 Will turn yellow → blue dye

Management of CGD
CGD can have late presentations too
(e.g. case study – 18.5 yo with CGD and not really a problem until later in life)

Therapy: GET THEM TO A SPECIALIST

 Prophylactic antibodies (anti-bacterial / anti-fungal)
 IFN-γ (enhances what killing the phagocytes can do)
 WBC transfusions
 Bone-marrow transplantation
 Genetic diagnosis (genetic counseling, prenatal diagnosis / early in life, prognosis)

Prognosis: survival better for aut-recessive than X-linked forms

Severe Combined Immunodeficiency (SCID)

A severe deficiency of both T- and B-cell function (humoral and cell-mediated immunity!)
 Susceptible to infection by virtually any microbe
 Untreated  usually fatal w/in 1st year of life!

Genetics
Multiple forms of the disease (only need to remember ADA deficiency)
Defect Inheritance Description
Adenosine deaminase (ADA) deficiency Autosomal recessive Deficiency of purine salvage pathway enzyme
IL-2 receptor deficiency X-linked No IL2R on T-cells
ZAP deficiency Autosomal recessive Signal transduction of T-cells through TCR impaired
JAK3 deficiency Cytosolic protein, interacts with ILS receptor
RAG 1,2, recombinase deficiency VDJ recombination impaired

Clinical Presentation
Severe & recurrent infections (bacterial / viral / fungal / everything!), presenting in infancy
7
  Male predominance (75%) – X-linked forms
 Pneumonia, diarrhea, thrush, rash, sepsis (in descending frequency: from 90% to 57%)

Both T- and B-cells affected

 ADA deficiency: defect intrinsic to both T-cells & B-cells
 Lack of thymocyte differentiation (no CD4+ helper cells) is key in non-ADA pathways
o defect intrinsic to just T-cells, but ↓ B-cell function (lack of T-cell help)
o IL2R / JAK3/ IL-Rγ chain, other deficiencies – defective cytokine signaling
o Others: defective TCR signaling, receptor gene recombination, MHC I or II expression, others!

Lab Findings: SEVERE LYMPHOPENIA (REALLY REALLY LOW)

 Most severe with ADA

Pathophysiology (ADA deficiency)

Adenosine deaminase (ADA)

 Enzyme in purine salvage pathway
 If missing: deoxyATP accumulates (metabolic “poison”)
 Affects T-cells, interferes with their function

Management of SCID
 Genetic testing (carrier detection)  counsel for future pregnancies
o Prenatal diagnosis possible  Dx / Tx with bone marrow transplant before sx develop (great outcomes!)
 Enzyme replacement therapy for certain forms can be given
 Gene therapy actually possible (cloned genes  has been used successfully for pts in vivo!)

Common Variable Immunodeficiency (CVID)

 Most common cause of hypogammaglobulinemia; Tremendous variation in the way that patients present

Features of CVID
 Hypogammaglobulinemia with impaired antibody responses
o B-cell problem! Gene mutations involved in B-cell differentiation / survival / activation
o Polymorphisms in these same genes may be involved in variation in response to vaccines, etc
 Variable degree of T-cell dysfunction
 Can develop at any age
 Associated with autoimmune disease + increased risk for lymphoma
o More infection-prone  develop more immune responses  ↑ risk bystander autoimmunity risk?

Pathophysiology: not well understood

 characterized by impaired B cell differentiation with defective immunoglobulin production
 Probably multifactorial (polygenetic, maybe some forms need environmental exposure – develop @ later age)

Labs: Hypogammaglobulinemia (↓ IgG, IgA/M too)

 ± mild lymphopenia; other labs pretty much normal

Treatment: Pooled IVIG (doesn’t prevent / treat autoimmune disease, but ↓ risk infection)
 Trouble – if you get autoimmune disease, usually treat by immunosuppression – but in an immunodeficient pt, that’s bad!

8
I didn’t have anywhere else to put this slide, but I thought it was a good, simple review.

9
 Secondary Immunodeficiency
What can cause 2° immunodeficiency?
(a partial list)

CAUSE MECHANISM(S) EXAMPLES

1. Prematurity / being a newborn
2. AIDS
3. Hereditary / Metabolic dz
4. Infection
(bacteria , viruses, parasites)
5. Infiltrative / hematologic dz
6. Drugs / Immunosuppresive Rx
7. Surgery / Trauma
 Diabetes
 Malnutrition, exudative enteropathies, Iron deficiency
 Nephrotic syndrome, uremia
 Inherited enzyme deficiency states, chromosomal abnormalities
 Sickle cell disease (infarct spleen, loose filter  bloodstream infection)
Destruction of immune cells / products HIV, bacterial IgA proteases etc.
Immunomodulation of immune function EBV, measles, bacterial sepsis
Displacement of normal cells by tumor Leukemia, lymphoma, bone mets
Secretion of immunosuppressive factors Cancer, sarcoidosis
Direct injury to immune cells Cytotoxic drugs, radiation
Indirect injury to immune cells Phenytoin (autoimmune rxn)
Immunomodulation of immune function Corticosteroids, CsA
Lose serum proteins 
Burns (via weeping)
hypogammaglobulinemia
Splenectomy Lose filter function

Immunodeficiency from Infection: Epstein-Barr Virus

EBV: dsDNA virus from herpes family; genome encodes ≈ 80 proteins

 Receptor = CD21 molecule (also receptor for C3d component of C’)

 Infects epithelial cells of oropharynx & resting B-lymphocytes

o “Transforms” B-lymphs (can proliferate indefinitely)
o T-cells get activated, eliminate transformed B-cells
 “Atypical lymphocytosis” – atypical cells are the activated T-lymphs, not the B-lymphs

Infectious Mononucleosis
Acute EBV infection
 Kids: usually subclinical infection
 Adults / older adolescents  mono

 Malaise  Pharyngitis  Splenomegaly

 Fever  Tonsillitis  Hepatomegaly
 Lymphadenopathy  Headache  Rash

Bold = more common

10
Acute Infectious Mononucleosis  ↓ cell-mediated immunity
↑ peripheral lymphocytes, but ↓ cell mediated immunity!
 Patients become anergic (don’t mount DTH-type responses – e.g. false negative PPDs!)
 Have ↓ in vitro T-cell responses (↓ proliferation in response to candida atigen)

DTH:
 Inject Ag subQ (not enough to immunize); asking: are there T-lymphs around?
 If enough, T-cells specific for Ag migrate in, get Mϕ, monos, T-cells to area
 Erythema, induration, swelling

Why does 2° immunodeficiency happen in mono pts?

 EBV genome codes a protein called BCRF1, which has extensive homology with IL-10
 IL-10 (and BCRF1) have powerful effects on lymphocytes
o ↓ growth, cytokine production by TH1 cells
o ↓ Mϕ activation, cytokine release

Review of CD4+ T helper cells & the cytokine milieu

TH1 cells make cytokines like IFNγ
 involved in cell-mediated immunity/ DTH-type reactions

TH2 cells make cytokines like IL-10

 involved in humoral immunity / Ab production (B-cells)

These pathways inhibit each other (e.g. IL-10 inhibits TH1 differentiation; IFN-γ inhibits TH2)
 So EBV  ↑ “IL-10” (BCRF)  turns off cell-mediated immunity!

Measles is similar, but doesn’t make exogenous cytokine mimics

 Provokes a big antibody response (↑↑ IL-10), so ↓ cell-mediated immunity!

Immunodeficiency from neoplasms

 Obviously, if tumor infiltrates / replaces bone marrow, patient becomes immunocompromised
o Example: see a pt with immunodeficiency; ↑↑ IgG, ↑ lymphocytes – could be CLL
o Crowding out other cells; lots of immunoglobulins but not generating good antibody response
 But patients with solid tumors outside BM can also become secondarily immunodeficient!

TGF-β1 (transforming growth factor β1)

Some cancer patients have ↓ capacity to mobilize macrophages into tumor itself / abraded area of skin
 Found that their cancers secrete TGF-β1

TGF-β1
 Polypeptide, member of growth factor superfamily (insulin, growth hormone, cytokines, others)
 Helps control cell survival, proliferation, differentiation
 Can induce transformation, anchorage-independent growth of some non-neoplastic cells

TGF-β1 has a WIDE VARIETY of IMMUNOMODULATORY EFFECTS (most result in immunosuppresion)

 ↓ synthesis of IgG, IgM
 ↓ IL-1 production
o released from Mϕ / monos
o causes fever, inflammatory response, ↑ T/B cell adhesion
 ↓ H2O2 release, ↓ intracellular killing (monocytes / Mϕ) from antagonism of IFNγ
 Tons more too!
11
VEGF (vascular endothelial growth factor)
 Another secreted product of tumor cells
 Inhibits functional maturation of dendritic cells

Immunodeficiency from a drug: Phenytoin

Glucocorticosteroids, cyclosporine A, FK506, rapamycin cytotoxic drugs cause most 2° drug-induced immunodeficiency
 Acting directly on the immune system (↓ function, ↓ growth, or ↑ cell death)
 Used in transplants, for instance, to maintain grafts, etc.
 See other lectures

Phenytoin
Anticonvulsant
 An example of a drug that is not supposed to be immunosuppressive, but can be in genetically susceptible pts

Immune effects:
 Mild to moderately severe abnormalities in up to 70% of people taking
 Development of IgA deficiency is most common effect
o Lymphoma-like lesions, hypersensitivity syndromes, lymphopenia too

Mechanisms: not clear, 2 have been proposed

 Immunologic reaction: maybe phenytoin / metabolites act as haptens

o Could bind host target cells; sensitize self-lymphocytes for attack
 Lymphotcytotoxic Ab / ANA detected in as many as 30% of pts
o Appears to alter T-lymphocyte function  ↓ Ig synthesis

 Direct toxicity: some phenytoin metabolites directly toxic to

lymphocytes (and hepatocytes)

o Ability to detoxify these metabolites is genetically determined

 can predict some of susceptible pts!

o See picture: arene oxide intermediate is really reactive

Problems with immunosuppressive therapy (for allotransplantation)

Here talking about CsA, FK506, rapamycin, etc – meant to be immunosuppressive Tx

Neoplastic complications
 See cancer in 4-18% of allogenic organ transplant recipients
 Unusual cancers: Occur in younger patients (mean age 42), and unusual types
o Common cancers (lung, breast, prostate, colon, uterus) are not increased in frequency
o Skin cancers (37%, squamous:basal 2:1) and lymphomas (94% NHL) are increased
 Probably from suppression of T-cells / immune function that helps keep these cancers in check!

Infections
 ↑ risk infection with immunosuppressive therapy
 Many of the infections caused by opportunistic pathogens
 Can occur as late infectious complications (e.g. heart transplant here):
o Pneumonia (PCP, nocardia, CMV > community acquired)
o CNS infections (listeria, Cryptococcus, nocardia, toxoplasma, JC virus)
o Skin (VZV reactivation)
12
 Immediate Hypersensitivity Reactions
Immediate hypersensitivity, a.k.a. “allergic reactions” or “Type I” hypersensitivity reactions
Biophysical and clinical effects mediated by allergen exposure & release of IgE antibodies

Introduction
Allergy: increased immunologic reactivity involving IgE against an otherwise innocuous foreign substance
 Common conditions!
 Release of bioactive mediators  clinical symptoms
 Atopy = genetic predisposition to develop IgE-mediated hypersensitivity

Genes & Environment

Genetic component: MZ > DZ concordance; familial clustering, ↑ in children of parents with allergic disease

Gene / environment interaction

 Maybe Western lifestyle? Increasing prevalence in USA / other industrialized nations
 Hygiene hypothesis
o ↓ exposure to microbial antigens (excessive hygiene early in life) 
o Shift of dominance from TH1  TH2 T-helper lymphocytes

 TH1: produce IFN-γ (suppresses IgE)

 TH2: produce IL-4, others (induces IgE production)

The Immediate Hypersensitivity Reaction: Antibodies & Antigens

IgE Antibody & its Receptor
Discovered @ the Hop (Ishizaka & Ishizaka)
Production: Made under influence of IL-4, IL-13 (from TH2 lymphocytes & other sources)
 B-cells  plasma cells  secrete antigen-specific IgEb

IgE: has 5 domains, lots of CHO

 T1/2 in serum only 2-3d, but much longer bound to tissue mast cells

Receptor: FcϵRI
 Tetramer (α\β\2γ); α binds IgE, β & γ facilitate signaling
 Found on surface of mast cells, basophils
 Langerhans cells, dendritic cells, Mϕ have these too, but w\ο β chain
 ↑ FcϵRI receptors correlates with ↑ serum IgE

Immediate hypersensitivity reactions can start when FcϵRI-bound IgE are CROSSLINKED by multivalent antigens

The Antigens
 Mostly water-soluble proteins, molecular weight 10-40 kD (need to be multivalent)
 Mostly proteases (lipocalin family)
Antigen From Fancy Latin Name
Amb a 1 Ragweed (Ambrosia artemisiifolia)
Haptens Fel d 1 Cats (Felis domesticus)
 Low molecular weight substances (e.g. PCN) Can f 1 Dogs (Canis familiaris)
can be allergenic by acting as haptens: bind Bla g 1 Cockroaches (Blatella germanica)
host protein  form complex  complex Der p 1 (Dermatophagoides peteronyssinus)
Dust mites
interacts with IgE Der f 1 (Dermatophagoides farinae)

13
 The Immediate Hypersensitivity Reaction: Allergic Inflammatory Cells & Mediators
Crosslinked receptor-bound IgE  intracellular signals  release of multiple mediators

Receptor-bound IgE found on: Mediators:

 Mast cells (in tissues)  pre-formed granule-associated products
 Basophils (in peripheral blood)  newly-synthesized arachadonic acid metabolites
 cytokines, chemokines

Preformed Granule-Associated Products (e.g. HISTAMINE)

Stored within granules of mast cells / basophils; released when receptor-bound IgE crosslink
 Various kinds, histamine is the most prominent
Histamine receptor subtypes
Effects of histamine:  H1: allergic reactions
Changes in neural, glandular, vascular, muscular components of target organs  H2: gastric acid production
 Sensory nerve activation  pruritis, sneezing  H3: function unclear
 Submucosal glands  rhinorrhea
 Blood vessels  plasma extravasation, tissue swelling
 Smooth muscle  bronchoconstrictions

These changes develop within minutes: EARLY or IMMEDIATE PHASE of allergic reaction

Other products of mast cell degranulation: tryptase, chymase, chondroitin sulfate, carboxypeptidase (role not clear)

Newly synthesized products of arachidonic acid metabolism (e.g. LEUKOTRIENES, PROSTAGLANDINS)

Leukotrienes generated by mast cells, basophils, eos by lipoxygenase pathway

 “slow-reacting substance of anaphylaxis”

LT Pathway: (see right of picture)

 Arachadonic acid cleaved from membrane phospholipids
by phospholipase A2
 Converted to 5-HPTE by 5-LO (5-lipoxygenase)
in conjunction with 5-LO activating protein (FLAP)
 Then converted to LTA4 (leukotriene A4)
 LTA4: either converted to
o LTB4 (via LTA4 hydrolase) or
o LTC4 (via LTC4 synthase), which can then be converted to
LTD4, then LTE4 by peptidases

LT Effects: mediated by at least 2 receptors (CysLT1, CysLT2)

 Cysteinyl LTs (LTC4, LTD4, LTE4)
o bronchoconstriction (1000x ↑ potency vs histamine)
o Also ↑ mucus secretion, vascular permeability, swelling

 Chemotactic agents too

o Cysteinyl LTs: chemotactic for eosinophils
o LTB4: chemotactic for neutrophils

Prostaglandins: generated from arachidonic acid by COX-1 & COX-2

 COX-1: constitutively expressed in many cell types; COX-2: highly inducible in mast cells, Mϕ, PMNs
 Immediate phase: mast cells release prostaglandin D2  bronchoconstriction, vasodilation  nasal congestion

14
Cytokines & Chemokines
Mast cells, basophils synthesize, release various interleukins (e.g. IL-4, IL-13)
 Can further promote development of allergic inflammation:
o ↑ IgE production
o ↑ local influx of proinflammatory cells (e.g. eosinophils)

Cellular infiltration happens several hours later: part of the late phase response
 Symptoms (e.g. nasal congestion, bronchoconstriction) may recur!

Summary Table: Released Mediators

Mediator Effects
Histamine vasodilatation, increased vascular permeability, mucus production, smooth muscle contraction
Tryptase increased bronchial hyperresponsiveness
PAF activation of platelets, neutrophils and macrophages; smooth muscle contraction
Leukotrienes smooth muscle contraction, vasodilatation, increased vascular permeability, mucus production
Prostaglandin D2 smooth muscle contraction, increased vascular permeability

Putting it all together: the Immediate

Hypersensitivity Reaction

Need a susceptible individual

 Genetics / environment promote TH0 (naïve
helper T-cells) differentiation into TH2 cells

Upon exposure, sensitization occurs (A)

 TH2 lymphocytes interact with APCs presenting
antigen; start secreting cytokines (e.g. IL-4)
 IL-4 induces B-cells to mature into plasma cells 
start making IgE antibodies

Upon re-exposure, develop allergic inflammation

 Multivalent allergens cross-link IgE bound to
high-affinity FcϵRI receptors 
 Intracellular signals  release of preformed &
newly synthesized products (e.g. histamine,
leukotrienes) 
 Early & late phases of allergic response

Targets for treatment

1. Identify, avoid allergens behavior
2. Relieve sx: rhinorrhea, nasal congestion, bronchoconstriction anticholinergics, sympathomimetics, β-agonists
3. Attenuate histamine receptor antagonists
4. Attenuate leukotriene receptor antagonists
5. ↓ #, production of mediators of allergic inflammatory cells glucocorticoids
6. Shift T-helper cells to TH2 phenotype immunotherapy
7. Block IgE effects with an mAb omalizumab
8. Cytokine targeted agents? under investigation

15
 Allergic Rhinitis, Asthma
Epidemiology:
Prevalence of both has been increasing, especially in industrialized countries
 Allergic rhinitis: most common atopic disease (20% US pop; 40M in USA)
 Asthma: 17M Americans; lots of health care costs

Clinical Manifestations
Paroxysmal sneezing, nasal pruritis, nasal congestion, rhinorrhea, postnasal drip, sinus pressure
 For a given patient, one or more of these Sx may predominate

Seasonality
Allergic Rhinitis
 year-round (17%), strictly seasonal (41%), or perennial w/ seasonal exacerbations (42%)
 Seasonal: Trees (spring), grasses (summer), weed pollens (fall)
 Perennial: indoor allergens (dust mites, pets, cockroaches, rodents)
 Triggered: tobacco smoke, dry air
Breathlessness, wheezing, chest tightness, and/or cough
Asthma  Can also have seasonal exacerbation (sensitivity to outdoor aeroallergens)
 Up to 90% asthmatics have concurrent rhinitis sx

Cardinal Features of Pathogenesis: Inflammation & Hyperresponsiveness

This applies to both allergic rhinitis & asthma – very similar pathophysiology (maybe two parts of one disease process?)

Inflammation
 ↑ # infiltrating cells, levels of mediators in nasal lavage, broncheoalveolar lavage fluids

 Early phase (within 10 minutes)

o ↑ histamine, leukotrienes in nasal lavage (dose-dependent)
o ↑ albumin (↑ vascular permeability) and ↑ lactoferrin (↑ glandular secretion) too
o Bronchoconstriction  ↑ airway resistance (e.g. ↓ FEV1 in asthma)
o Rapid development of sx, then subside

 Late phase (several hours later, in about 50% pts)

o Recurrence of symptoms (e.g. nasal congestion)
o ↑ Eosinophils in lavage, tissue samples

Hyperresponsiveness
 Allergic rhinitis  ↓ threshold, ↑ magnitude of sneezing reflex (e.g. on histamine challenge)
 Asthma: ↓ FEV1 after methacholine challenge

16
 Anaphylaxis (& Anaphylactoid) Reactions
Anaphylaxis: a rapidly evolving systemic allergic reaction that can be life-threatening
 1/3k inpatients in USA; 1% risk of fatal outcome

Pathogenesis: Anaphylactic Reactions

 Exposure of previously sensitized person to foreign substance 
 IgE-mediated release of mediators from mast cells, basophils (↑ histamine, ↑ tryptase)

Effects on multiple organs (combination of any of cutaneous, respiratory, cardiovascular, GI manifestations)

 Respiratory distress from upper airway obstruction and/or bronchoconstriction
 Peripheral vascular collapse from vasodilatation and/or ↑ vascular permeability

Time course: generally within minutes, but can be up to an hour Signs and Symptoms % pts
 More rapid usually means more severe! Urticaria, angioedema 90
 2-23% can have biphasic pattern (recur 1-8h after initial resolution) Dyspnea, wheezing 60
Dizziness, near-syncope 29
Can be triggered by very small amounts of allergenic substance Flushed skin 28
Diarrhea, abdominal cramps 26
 Drugs (β-lactams) Upper airway obstruction 24
 Foods (peanuts, tree nuts) Nausea, vomiting 20
 Stinging insect venoms, latex, others Hypotension 20
 Idiopathic (6-20%) Nasal congestion, rhinorrhea 16
Eye swelling 12
DDx: depends on pt’s clinical presentation Chest pain 6
 May include vasovagal rxn, acute ischemia, asthma exacerbation, Headache 5
Generalized pruritus without rash 4
hyperventilation, carcinoid syndrome, systemic mastocytosis
Blurred vision 2
Seizure 2
Labs: ↑ serum histamine / tryptase (if possible to demonstrate)

Anaphylactoid reactions
“Pseudoallergic” reactions
 Same clinical picture as anaphylaxis, but not IgE-mediated

Pathogenesis: Involves same bioactive mediators released by mast cells / basophils

 Can be directly activated (IgE-independent) by OPIATES & HYPEROSMOLAR RADIOCONSTAST DYES
 Other mechanisms: C’ activation & production of anaphylatoxins  mediator release

Vs. anaphylaxis:
 DO NOT REQUIRE PREVIOUS EXPOSURE TO OFFENDING AGENT
 DOSE-DEPENDENT

17
 Food Allergy
Definition
Must differentiate from food intolerances & other adverse food reactions
 Immunologic response to a food protein (food intolerances usually CHO related)
 Exquisitely small amounts may cause a reaction
 Reactions can be severe / life-threatening

Prevalence
 6-8% of young children, 2-3% of adolescents / adults, 11M in USA
 Similar prevalence in other Westernized countries (although specific patterns vary)
 Prevalence appears to be rising

Most common food allergens

Young children Adolescents / adults
 Milk  Wheat  Peanuts
 Egg  Tree nuts  Tree nuts
 Peanuts  Fish  Fish
 Soy  Sesame  Shellfish

Shifts from childhood to adulthood:

 Most milk / egg allergy lost in childhood
 Most fish / shellfish allergy develops in adulthood
 Most peanut / tree nut allergy persists into adulthood

Signs & Symptoms

Range from chronic, low-grade symptoms to acute, life-threatening reactions

 Hives, angioedema  Wheezing / breathing difficulty

 Eczema  Hypotension, shock
 Vomiting, diarrhea, poor growth  Anaphylaxis
 Cough, congestion (a multisystemic allergic reaction – need 2+)

Clinical approach
 Specific IgE testing (serologic determination of IgE levels, ranging from 0 to 100 – ID specific antigens)
o Can follow over time – are they outgrowing food allergies?
 Avoidance diets (watch out for nutritional compromise!)
o Can easily have accidental exposures – these ingredients are common!
 Epi pen for emergencies

New approach: Desensitization – like using allergy shots to desensitize pts to environmental allergies?
 2006: milk oral immunotherapy trial for children with severe, persistent milk allergy
o Milk powder  escalate dose over weeks (hospital at first)
o Cured about ½ the kids

18
 Specific Immunologic Treatment of Allergies: A History
Pathophysiology of immune reactions

1. Need genetic susceptibility

2. initial sensitization phase:

a. allergenic substances (pollens or animal
danders land on respiratory surfaces
b. taken up by the dendritic antigen presenting
cells that line the mucosa in large numbers.
c. APC stimulate Th2 T cells to secrete cytokines
d. Cytokines stimulate B lymphocytes to produce
IgE antibodies.
e. Ab taken up by specific IgE receptors on mast
cells, thus conferring on the individual an
altered reactivity when subsequent exposures
occur. Normal individuals are different in that
early exposure to these harmless substances
ordinarily results in long term tolerance.

3. re-exposure results in a two phase reaction:

a. an immediate IgE mediated release of histamine and other mediators.
b. Antigen also restimulates prepared Th2 cells in tissues to secrete proinflammatory cytokines that attract
basophils and eosinophils. They in turn release their toxic substances, a process that occurs over some hours.

History
st
Bostok (England, 1819) 1 reported “catarrhus aestivus”, thought it wasn’t caused by “effluvium from hay” as others thought.
Morrill Wyman

th
Harvard dude, 19 c. Published “Autumnal catarrah” (about hay fever). Outed Daniel Webster, others as hay fever
sufferers. Used ENT Sx as criteria, some had cough / asthma too. Expt to see if roman wormwood (=Ambrosia
artemisaefolia = ragweed) was cause.
 Noted geographical variation in sufferers (not in mountains that have timberline, for instance)
 Saw that sufferers had ↑ sensitivity to common irritants (dust/smoke from railroad, etc)
 Basically came up with idea that ragweed pollen causes fall “hay fever” in susceptible individuals

Charles Blackley
 Manchester, England; introduced planned expts to the field, published book soon after Wyman
 Invented device for exposing greased microscope slide to wind  collect & examine pollen (POLLEN COUNT)
o Correlated pollen count & symptoms but didn’t have the math yet to examine relationship
o Performed first skin test, tried to weight inhalation by room size but not great data

Charles Richet, Paul Portier

 Lab observations – professional scientists, not GPs doing experiments in spare time
 1902 – toxins from both bacteria & other life forms had been seen to cause dz; pt serum contained “anti-toxins”
 Defined anaphylaxis (“We call anaphylactic (as opposed to phylaxis) the property of a venom to diminish instead of
reinforcing the immunity when it is injected in non-fatal doses.”) by studying jellyfish toxins
 Noted ↑ sensitivity after incubation period (basis of allergic reaction)

19
Samuel Meltzer
 Russian, reviewed asthma as manifestation of anaphylaxis (no new expts)
 Noted that anaphylactic death from bronchial constriction; also that pollen  asthma in susceptible pts, not just hay fever
– so asthma = allergy?

st
1 time that hay fever / asthma connected to immunology

William Dunbar
 German, rejected Meltzer’s idea that hay fever was anaphylactic – a toxin activated only in susceptible
 Noted that very low dilutions could produce responses – injected self with pollen extract, had severe rxn

Leonard Noon
 1911, St. Mary’s London: Thought pollens contained toxin activated only in susceptible (not aware of Meltzer)
 Started immunization trials: start with minute dose, ↑ dose, desensitize.
 Noon then promptly died of TB, left his work to John Freeman

Otto Carl W. Prausnitz & Heinz Kustner

 1920s: finally clearly established immunologic nature of allergic reactions
 Kustner: hey, I’m allergic to fish. Prausnitz: maybe you’ve got antibodies.
 Prausnitz: took some of Kustner’s serum, injected it into his own arm, then injected fish  wheal & flare!
 Controlled studies eventually confirmed; by 1968 “immunotherapy” had been coined

Teruko & Kimishige Ishizaka

 Japanese, came to the Hop eventually, discovered IgEs

IgE antibodies:
 Present in serum in nanogram amounts
 Synthesized in lymphoid tissue lining the respiratory and GI tracts
 Fix to specific receptors on mast cells and basophils
 Found in respiratory allergies and anaphylaxis

Basis of skin tests:

 wheal & erythema result from cross-linking of IgEs on surface of skin mast cells →
 release histamine, other mediators

RAST: more expensive test (radioallergosorbent test) – use allergen proteins attached to solid absorbants
 IgE attached to allergen in solid phase  detect with anti-IgE Abs

Role of T-Cells
 Established in 1990s

20
 Immunotherapy
Allergen immunotherapy appears to redirect the immune system to
help both phases of the allergic response.

 T regulatory cells (via cytokines) , stimulate Th1 T cells 

 produce IFN-gamma which both

o suppresses IgE production partially and
o stimulates IgG production

 Now, upon reexposure :

o fewer IgE antibodies on mast cells
o Th1 cells restimulated  IFN-gamma  suppresses
cytokines which mediate late phase allergic response.

Effectiveness
Hay fever Asthma
 Short Ragweed  Birch  Short Ragweed  Cladosporium (an outdoor mold)
 Mixed Grass  Parietaria  Mixed Grass  Cat
 Mountain Cedar  D. pteronyssinus (dust mite)  Dog
Treating children who develop hay fever < age 10  ↓ incidence of subsequent sensitization , ↓ asthma

Clinically
Immunotherapy mixtures made in allergy specialists offices using prepared commercial allergen extrac
 Hx + skin tests  mixture tailored to the individual’s allergies made up.
o series of 10-fold dilutions prepared, give Sub-Q with smallest dose at first
o ↑ dose 1-2x wk  largest dose
o Repeat largest dose q2-4 wks for 3 yrs
 Effects are long lasting and have been proved to be fully effective for at least three years after the last injection.

Risk: ANAPHYLAXIS
 observe pt for 30 min post-injection, have trained personnel, epinephrine on hand, ↓ dose next visit

New directions
 Anti IgE cotreatment*  Peptides*  CpG conjugates*
 Recombinant Allergens*  Liposome encapsulated extract  CpG mixes
 Engineered Allergens*  Monophosphoryl lipid A

Oral Immunotherapy
 Now being tried for various conditions

21
 Systemic Rheumatic Diseases
Definitions & Classifications
Rheumatology
Joint diseases
Systemic autoimmune diseases
Inflammatory Non-inflammatory
 Gout
 Lupus  Scleroderma
 Rheumatoid Arthritis  Osteoarthritis
 Myositis  Vasculitis
 Spondyloarthropathy
RA: both a joint disease & a systemic autoimmune disease, so it really gets rheumatologists all hot & bothered.

Etiology unknown for most of these diseases (except gout & one type of vasculitis)

For each disease, define:

 Is it autoimmune?
 What are the kinetics (slow onset / offset, etc)
 What is the phenotype (both clinical & pathological)?
 What are the inflammatory effector pathways (innate vs adaptive immune response, etc)?

Autoimmunity Autoimmune disease

An immune response that recognizes A sustained, specific, adaptive immune response generated against self-
a self-antigen components, and resulting in tissue damage or dysfunction
Remember: you need to have a disease to have a disease!
Just because you have auto-Ab titer, doesn’t mean it’s an autoimmune disease!

Normal immune responses aren’t always good

Effect of response to antigen
Antigen
Normal response Deficient response
Infectious agent Protective immunity Recurrent infection
Innocuous substance Allergy No response
Grafted organ Rejection Acceptance
Self organ Autoimmunity Self tolerance
Tumor Tumor immunity Cancer
A lot of the time, the normal immune response is ok in these conditions!

Kinetics of the rheumatic diseases

Acute Diseases Chronic Diseases
Examples Penicillin allergy RA
Exogenous Endogenous
Initiating Force
Recognizable Unclear source
Pace of Onset Rapid Subacute
Self-limited Self-propagating
Propagation
No amplifying loop Amplifying loop
Only on re-exposure to inciting agent Frequent
Flares
Memory not important Memory important
Memory No Yes
Phenotype
 Which pts are affected? (F vs M, race, etc)
 Tissues affected (small vs. large joints, axial skeleton, renal involvement, skin)
 Nature of pathology (PMNs, fibrosis, T/B cells, etc) – both damage & healing play a role

22
 Inflammatory Effector Pathways
 Autoantibodies  Complement  Cytokines  Cells
Antibodies
Have many effector functions:
 Neutralizing
 Opsonization / phagocytosis
 Lysis
 C’ fixation
 Inflammation

For each disease: is there evidence that it directly participates in tissue damage seen?

Complement
 Classical pathway: activated when Ab binds Ag
 Results in inflammatory cell recruitment, activation, ↑
capillary permeability, other effects
 Maintains homoeostasis; big in apoptotic cell clearance

Cytokines
Small “messenger” molecules involved in cell-cell communication
 Really complex system
 Try to view cytokines as individual letters
 Unique combinations provide context
o Pleiotropism, redundancy, synergy, antagonism between cytokines
o Same cytokines found all over the place – treatment can have multiple consequences

Effector Cell Types

Myelomonocytic cells
Monocytes & granulocytes (eos, basophils, PMNs)

Effector functions:
 Phagocytosis; phagosome / lysosome fusion
 Respiratory burst
 Secretion of granule products (proteases) – can be really painful!
 Secretion of pro-inflammatory mediators: TNF / IL-1 / PAF / PG / LTs)
 Secretion of anti-inflammatory mediators: TGF-β

Lymphocytes
CD4+ cells
Th group Differentation induced by Cell products Cell Targets Infectious agents
Intracellular bacteria
Mϕ
Th1 IL-12 IFNγ, IL-2
Dendritic cells
Fungi
Viruses
Extracellular bacteria
Th17 IL-23 IL-17, 21,22 PMNs
Fungi
Eosinophils
Th2 IL-4 IL-4, 13, 5
Basophils
Parasites
Note that Th17 cells are particularly noxious:
Come from same lineage as suppressor cell if the right cytokine mileu is around
23
CD8+ cells
 Cytotoxic cells
 Kill mainly by:
o Inserting pores (e.g. perforin)
o Insert granzymes 
o activate caspases

NK cells
Called “antibody-dependent cellular cytotoxicity” (ADCC)
 Targeted cells covered by IgG
 NK cells have Fc receptors which bind IgG on surfaces
 NK cells activated  lyse targeted cell

Innate / Immune cross-talk

 Innate = TLRs, PRRs, APCs, PMNs, Mϕ, etc
 Adaptive = T-cells, B-cells, etc. –can turn on Mϕ, etc.

Innate immunity can turn on adaptive immunity

 Many autoimmune antigens have nucleic acid or proteins

that bind nucleic acid

 Can bind TLRs, then activate adaptive immunity!

 Can end up with chronic response

End Results
Acute diseases: Equilibrium returns
 Controlling inflammation depends on activating pro- and anti-inflammatory forces early in the cascade
 When control of the inciting agent begins, natural anti-inflammatory forces become dominant
 Organism returned to previous equilibrium (e.g. gout)

Chronic diseases: a new equilibrium reached

 inciting agent irreversibly alters equilibrium (e.g. exposes autoantigen in novel context, breaks tolerance to self)
 Naïve equilibrium can never be re-established
 New states are chronic rheumatic disease – critical to see early in the pathway

24
 Osteoarthritis
 Most prevalent form of arthritis in the USA
 Degradative & reparative processes in cartilage & bone,  structural damage & functional compromise

Burden of Disease
The most prevalent form of arthritis in the USA
 #1 cause of joint pain, disability in aging American population
 Main indication for knee / hip replacement surgery
 Conventional Tx can ↓ Sx, ↑ function: but can’t reverse disease process

Athritis prevalence
 14.5% have self-reported rheumatic disease
 Radiology: 6.1% adults have knee OA, 3.1% with hip OA.
o Gout, RA affect ≈ 1%; lupus ≈ 0.05% of young, AA women
o In old age: spread even greater (OA ≫ RA, etc)

Site: DIP > Knee > Hip

 all ↑ with age; pattern maintained
 Women > men,
except for hip OA in pts in 50s (congenital hip dysplasias)

Clinical Features
 Use-related joint pain  Brief, self-limited joint stiffness  ↓ range of motion
(esp. climbing stairs, inclines)  Audible, grating sounds  Minimal swelling / warmth

Disease characteristics
Osteoarthritis is a non-inflammatory arthropathy
 Cool to touch; usually DIP with base of finger / wrist spared, painful with use

Osteoarthritis: Cool to touch, bony Gout: Hot, red swollen enlargements; Rheumatoid Arthritis: Base of hands
enlargements, base of finger & wrist spared painful to touch affected; marked deformities, swollen

Radiographic findings

Diagnostic findings
 Focal joint space narrowing - arrows
 osteophytes (bone spurs) - arrowheads

Additional findings
 Focal loss of articular cartilage
 Hypertrophic reaction in subchondral bone & @ joint margin

25
 Normal joint: note even joint space (cartilage is radiolucent) – OA: note focal cartilage loss Mouse model:
smooth cushion for joint  bone-on-bone contact focally denuded

Histology: note focal loss of cartilage Patient’s right joint well-preserved; left hip
joint has loss of joint space & hyperdense bone

Pathophysiology of OA
Age-related dynamic reaction of joint to insult / injury
 All tissues of the joint are involved

Most striking features

 Loss of articular cartilage
 Change in adjacent bone

End-product: not just the result of degenerative

process but attempted repair too

Key change is in cartilaginous tissue

 Leads to bone changes & osteophyte formation – other changes are secondary!

Articular cartilage
ECM (extracellular matrix)
 Synthesized, assembled, regulated by chondrocytes
 Water (70% of ECM)  provides load support
 Collagens & proteoglycans (macromolecular components)  provide tensile strength

Bundled collagen provides strength – like an iron cable

26
Pathogenesis:
 Damage to cartilage is the key pathologic feature
 Chondrocytes play a key role; activity influenced by cytokines
 Metalloproteinases mediate tissue degradation (cleave matrix macromolecules)
 Disruption in assembly of ECM
o Degradative processes  change to composition, structure, properties of articular cartilages
o compromises ability of cartilage to function / survive strenuous mechanical environment of joint

Normal ECM: well hydrated, strong – both load bearing (water) OA ECM: structural integrity disrupted by metalloproteinases;
and tensile (collagen / proteoglycans) strength intact dehydrated (lose load-bearing H2O components)

What initiates the process?

 Genetic: inherited predispositions  Epidemiology: identification of risk factors
Genetics
 Suggested by familial occurrence of OA (rare families – early onset, etc)
 Candidate gene: may encode cartilage proteins (cartilage, proteoglycans)
o COL21A: type II procollagen gene: inherited with precocious form of OA associated with chondrodysplasia
o Maybe allele variants play a role in the general population?

Epidemiology
Risk factor Trend Notes
Age ↑ with age Very important
Gender M>F before 45 yo, then F>M
Race Differs between groups: ↑ in AA women, etc
Weight* ↑ with obesity NHANES (↑ load borne by joints?)
JH precursors study with medical students: prospective cohort study
Injury ↑ with past injury to joint
 ↑ RR 5x for knee, but not statistically significant for hip
*Cumulative exposure to greater weight is an important etiologic factor for knee OA
 Target: public health efforts (injury prevention & ↓ weight) in younger populations?
27
 Treatment of OA
Goals of treatment
 Control pain  Minimize disability  Patient, family education
 Improve function  Improve health-related QOL  Avoid therapeutic toxicity
LEADING INDICATION for NSAID USE - but note that we don’t have anything to reverse the disease process

NSAIDs
Effective, but risk of toxicity (GI / renal / CNS) & possible deleterious effects on articular cartilage
 Bleeding: ↑ with age > 65 (OA pts!), PUD, corticosteroid use, anticoagulants, smoking / alcohol consumption

COX-2 Inhibitors
Receptors found in: Inhibition leads to
COX-1 Gastric mucosa GI toxicity
COX-2 Sites of inflammation Therapeutic effects

A brief history: COX-2 inhibitors introduced in 1999; sales up to $3B by 2000

 Celecoxib = Celebrex, rofecoxib = Vioxx, initial studies good!
CLASS celecoxib vs ibuprofen vs diclofenac ↓ GI bleeding events with celecoxib
↓ GI bleeding events with rofexocib
VIGOR Rofecoxib vs naproxen
But ↑ thromboembolic events!

Toxicity: ↑ thromboembolic events with COX-2!

 COX-2 inhibitors do not share the property of platelet inhibition

afforded by COX-1 inhibitors

 selective COX-2 inhibitors  ↓ vascular prostacyclin (PGI2)

 selective COX-2 inhibitors may tip the balance in favor of

prothrombotic eicosanoids (e.g., thromboxane A2)

Glucosamine / Chondroitin
OTC supplements: Lots of people were trying to replenish macromolecular components
 Initial small studies – maybe some effect (minimize joint space narrowing?)
 Lack of standardized case definition, outcome assessments, insufficient study design
 GAIT study: NEJM, 2006: no better effect for pain / function vs. placebo

Surgical Treatment
Total joint replacement is gold standard: no absolute indication (not radiological: based on functional capacity)

Arthroscopy is controversial: Arthroscopic debridement vs lavage vs sham - No difference in pain or function (1-2 yrs)

Novel Treatments
 Targeting stimuli which cause tissue destruction (cytokine / protease inhibitors)
 Stimulation of tissue repair (growth factors)

Summary
Kinetics Totally different – develops over years / decades
Tissues affected Cartilage (joint / ECM)
Specific / unique immune response joint changes, but host as a whole otherwise feels well
28
 Phenotypic Presentation of Systemic Inflammation
Introduction
Phenotypic presentation of rheumatic diseases is characterized by:

 Unique / idiomatic features of the particular disorders

 Generic features of the systemic inflammatory response

o Can be a major source of acute / chronic morbidity; attenuate = treatment strategy
o Magnitude of systemic inflammation is widely variable between disorders & individuals with a disorder

Systemic Inflammation: a double-edged sword

Good Bad
 Defense against infection Pathogenic if:
 Cancer surveillance  Overly excessive inflammatory response
 Hemostasis / homeostasis after acute tissue damage / injury  Chronic expression (meant to be acute)
 Wound healing  Pleiotropic effects of inflammatory mediators

Septic arthritis (example)

 Need inflammation to clear early infection
o if bacteria become entrenched / disseminate / bacteremia  ↑ mortality
 But robust inflammatory response results in most of the irreparable damage to the joint
 Mice that can’t produce TNF / lymphotoxin (TNF α & β) – see less joint damage but ↑ mortality!

How does it work?

 Stimulus starts it off

 Immune effectors (Mϕ, PMNs, T-cells)

generate cytokines, which act on target
tissues and also stimulate more effectors

 Effects on target tissues are helpful for

ACUTE response to the noxious stimulus!

 The problem is when it becomes chronic!

Historical Perspective
1868 Regression of tumors during bacterial infection recognized
1944 Lipopolysaccharide (LPS) isolated, tumor regressing ability identified
1962 LPS effects on tumors mediated through a serum “tumor-necrotizing factor”
1975 Macrophages identified as the source of TNF
1984 TNF and lymphotoxin isolated, sequenced, and cloned
1985 TNF receptors identified, TNF recognized as “cachectin”
early 1990’s Importance of inflammatory cytokines in RA recognized
late 1990’s commercial development of TNF inhibitors for human use

29
 Acute Phase Reactants
 Induced in response to cytokines & other extracellular signals
 Important in systemic inflammatory response
o But varies depending on acute phase reactant; can be pro-inflammatory or anti-inflammatory
 Test characteristics of some of them make good lab markers
o Cytokines circulate in very low concentrations (ng/mL) – harder to measure
o Many acute phase reactants circulate in high concentrations (mg/mL) – easier to measure
o APR often have narrow range if cytokines low, but ↑↑ if cytokines induced

Induction: From activated Mϕ (via TNF IL-1, IL-6 is key common mediator)

CRP (C-reactive protein)

 Active as a pentamer of 23 kDa subunits
 Synthesized by hepatocytes under cytokine stimulation
 Fixes C’, binds Mϕ to induce inflammatory cytokines, binds
endothelial cells to expose tissue factor
 Circulates in big volumes (good for assay!)

ESR (Erythrocyte sedimentation rate)

In inflammation, RBC tend to stick together, so they sediment faster
Possible confounding factors
↑ ESR with ↓ ESR with
 Age (↑ in older)
 ↑ plasma proteins (Igs, fibrinogen, etc..)  Polycythemia
 Gender (↑ in F)
 Microcytic anemia or variable RBC size  Extreme leukocytosis
 Temperature of sample
 ↑ plasma viscosity  Sickle cell anemia
 Smoking

Fever
Why fever? ↓ bacterial growth, ↑ killing by Mϕ / PMN, Fe sequestration, other reasons possible

Exogenous pyrogens (microbes / microbe products / toxins) stimulate leukocytes to produce endogenous pyrogens
 Mostly by monocytes, Mϕ, PMNs
 IL-1, TNF, Lymphotoxin, Interferons, IL-6

Endogenous pyrogens circulate, signal CNS via multiple mechanisms with redundancy
 Prostaglandin synthesis (PGE2) is a necessary step - No PGE receptor = no fever!
 ↑ hypothalamic thermostatic set point

Endogenous anti-pyrogens are also involved (balance)

In chronic inflammatory disease:

 synovitis, activated leukocytes, etc setting the pathway off (vs exogenous pyrogens like LPS)

30
 Anemia of Inflammation
AKA “Anemia of chronic disease” – associated with chronic infections, inflammatory diseases, neoplastic disorders

Affects Fe, erythropoietin, RBC survival

 ↓ circulating iron, iron binding capacity
 Whole body iron stores normal or ↑
 Blunted response to endogenous and exogenous erythropoeitin
 ↓ RBC life span

NOTE: Exogenous Fe / exogenous erythropoietin do NOT resolve the anemia!

Hepcidin
Small peptide hormone synthesized in liver mostly (kidney, heart, mm, brain too)
NEGATIVE REGULATOR of IRON HOMEOSTASIS
 Mouse knockout = iron overload; mouse overexpression = severe Fe deficiency anemia
 Hepcidin mutation  severe juvenile hemochromatosis

Mechanisms:
1. Regulates intestinal iron absorption
 If iron deficient: ferroportin activity unchecked  ↑ absorption
 If iron overloaded: hepcidin inactivates ferroportin  ↓ absorption

2. Regulates Fe release from liver / Mϕ storage

3.
Too little iron  ↑ hepcidin  Fe released Enough iron  ↓ hepcidin = no release

In chronic inflammation: IL-6 VIA NF-κB stimulates ↑ HEPCIDIN SECRETION

 Normally controlled by serum Fe levels;
 Inflammation: ↑ hepcidin, so simulating a iron overloaded state (↓ iron)
 Why? Free-living bacteria use siderophores to chelate iron from environment – maybe body trying to hide iron in RBC,
etc (total stores ↑, but free circulating iron ↓)

Cachexia
Loss of lean (non-fat) mass in the setting of systemic inflammation
 Distinct from frank wasting (not associated with malnutrition; fat is unaffected or increased in cachexia)
 Related but distinct from aging-associated sarcopenia
 Same wasting in all muscles near joints that are inflamed (sarcopenia); not just from disuse

Multifactorial etiology: jury still out on dominant mechanism

 Direct catabolism (cytokine-driven), or ↓ physical activity, or tons of others
 Very few studies about cytokine inhibition & effects on cachexia – maybe TNF involved in degradation?

31
 Energy metabolism
 Need glucose, FFA as energy for infection, acute injury, healing
 Acute inflammation (cytokines)  ↑ release of glucose, FFA into circulation
o Liver, adipose, skeletal muscle are primary organ targets
 Chronic exposure to cytokines associated with DM, insulin resistance, atherogenic lipid profile, atherogenesis
o Especially in setting of ↑ energy excess and other CV risk factors

Example: TNF
 Could really use any cytokine, but TNF best studied
 Basic idea: get glucose into circulation! Like an anti-insulin state

↑ TNF  ↓ insulin-stimulated glucose uptake (dose-dependent)

 Mediated by inhibiting autoP-lation of the insulin receptor
 Affects lipid metabolism too
TNF-α effects on…
Glucose metabolism Lipid metabolism
Adipocytes ↑ lipolysis, FFA release
↑ TG production (IL-1,IL-6)
Liver ↑ hepatic glucose production
↑ VLDL production (↑TG, ↓ clearance)
Muscle Altered insulin-signaled glucose uptake

Pro-inflammatory HDLs
Inflammation can lead to bad HDLs!
 Apo A-1 in HDL normally promotes reverse cholesterol process
 Inflammation  ↑ oxidants in HDL  inactivates Apo A-1; ↑ oxidants  ↑ oxidized LDL formation (bad!)

Atherogenesis / Atherothrombosis
Chronic inflammation has been linked to all stages of atherogenesis & thrombosis
 Endothelial dysfunction (earliest stages)
 Atheroma formation (potentiated by other CVD risk factors)
 Plaque instability, rupture (results in clinical events  MI)

Inflammatory cytokines have direct & indirect effects on vasculature

 ↑ vascular adhesion molecules
 Macrophage activation and recruitment
 ↑ other pro-inflammatory cytokines
 Vascular matrix remodeling (MMPs, TIMPs)
 Regulation of apoptosis of vascular SMCs
 Induction of pro-coagulant state (PAI-1)
 Modulation of glucose metabolism
 Modulation of fat/lipid metabolism
 Antagonism of anti-inflammatory pathways

Plaque Rupture
Remember: Plaques are prone to rupture at weak “shoulders”
 Inflammation: shoulders ↓ SMC, PG, collagen with ↑ Mϕ, T-cells
o not good (makes plaque weaker!)

↑ risk cardiac events & recurrent MI with ↑ systemic inflammation in humans

 2-4x higher with ↑ CRP, TNFα, etc.
 Experimental animal models too (mice w/o TNFα or + TNF inhibitors  ↓
endothelial dysfunction, ↓ chemokines, ↓ LDL)
 Humans: use TNF inhibitors to treat systemic inflammatory disease
o Maybe ↓ CVD effects? Preliminary effects (comparing pts on TNF inhibitors for other cause vs not)

32
 Gout
Epidemiology
 About 1% of men in Western world
 ↑ prevalence because of ↑ longevity, ↑ HTN / renal dz, ↑ obesity, ↑ use of diuretics / low-dose aspirin

Clinical Presentation
Acute Gout Attack
• Abrupt onset, painful, often in middle of night
• Highly inflammatory
o pain (really bad – can’t even put bedsheet over it), redness, swelling
• Intermittent, resolves in 3-7 days
• Occasionally systemic sx too (fever / chills)

Initial attack: usually lower extremities: podagra, ankles, knees, midfoot

• Monoarticular in 90% (1 joint only)
• Podagra in 50% (swelling @ big toe -1st MTP)

Labs: Definitive for gout attack

 Fluid very cloudy (lots of PMNs)
 PMNs phagocytosing monosodium urate (uric acid) crystals
o Needle shaped, yellow if parallel to axis of polarization (negative birefringence)

Chronic tophaceous gout  chronic gouty arthritis

Over time, episodes become more frequent, last longer
 Eventually: chronic destructive arthritis (continuous low level inflammation  destroys bone, cartilage)
 Often confused with RA / other chronic arthritis

Tophi (collections of uric acid crystals) deposit in joints, soft tissues around joint
 Can have extra-articular tophi in any area of body – often see deposits at earlobe

Chronic gouty arthritis; can be confused Eating away at joint / bone /

More chronic gout – note tophi
with RA. Note tophi, swelling cartilage, develop erosions
Needle aspirate Extra-articular manifestations

Needle shaped uric acid crystals in tophi Uric acid crystals in earlobe Mitral valve with tophi
33
 Gout & Hyperuricemia
 Years before the first gout attack: see ↑ serum uric acid
 ↑ level of serum uric acid  ↑ risk arthritis, ↑ attack frequency

Saturation of uric acid in plasma is 6.8 mg/dL

 Above 7.0  supersaturated  deposition
 4.9% annual incidence for serum uric acid > 9
 0.5 annual incidence for serum uric acid < 7

Stages of Gout
 A necessary precursor to gout
1. Asymptomatic hyperuricemia  No Hx of gout, no clinical manifestations, no clinical findings
 Don’t need to treat!
 Acute inflammation after urate crystal phagocytosis
2. Acute flares
 Self-limited – don’t need to treat
 Intervals between recurrent flares, urate crystals can remain
3. Intercritical period  Silent tissue crystal deposition; damage can occur in absence of flares
 Clinical decision: should you treat to prevent more flares?
4. Advanced gout  Persistent destructive arthritis with chronic symptoms

Mechanisms of Hyperuricemia
Uric acid = end product of purine metabolism
 Dietary purines = 20-50% of daily excreted uric acid; rest from endogenous production

↓ clearance of uric acid (90% gout pts)

Primary Causes of ↓ Clearance

Polygenic inheritance in familial cases
Genetics URAT1, UAT: PM ion-channel / ion-exchanger proteins in kidney; mediate urate transport
 UAT1: mediates urate reabsorption in kidney PT; blocked by probenecid
Males greater tubular reabsorption of uric acid (earlier onset of gout!)
Gender
Females estrogen is uricosuric (onset late after menopause; ↓ with estrogen therapy in postmenopausal)

Secondary Causes of ↓ Clearance

From renal disease of any etiology, or age-related ↓ GFR
↓ GFR
 ↑ serum uric acid (↓ clearance)
(obesity, insulin resistance, glucose intolerance, dyslipidemia, atherosclerosis)
Multifactorial association:
Metabolic syndrome
 ↑ reabsorption of uric acid, ↑ renal vasoconstriction (↓ GFR)
 ↑ urine acidity (altered ammonia excretion with insulin resistance)
HTN Associated with ↑ uric acid levels
Diuretics volume depletion  ↑ tubular reabsorption of uric acid
Drugs
Low-dose aspirin (ASA) blocks tubular excretion of uric acid, Cyclosporin A

34
Uric acid in the kidney

 URAT1 mediates urate reabsorption from proximal tubule

 Probenecid blocks urate reuptake (URAT1, GLUT9 too)

Overproduction of uric acid (10% gout pts)

Review of purine metabolism (don’t memorize)

HGPRT : mediates production of GMP

 Mutation: ↓ GMP,  ↓ negative feedback  ↑ flow through
uric acid pathway (upregulate earlier steps)

Allopurinol: inhibits xanthine oxidase (↓ uric acid production)

Primary Causes of ↑ Production

 Most molecular defects undefined; familial cases are generally polygenic
 HGPRT (hypoxanthine-guanine phosphoribosyltransferase): X-linked deficiencies  gout
Complete deficiency Lesch-Nyhan syndrome
Incomplete deficiency Kelly-Seegmiller Syndrome

Secondary Causes of ↑ Production

 lymphoproliferative disorders
↑ cellular (and nucleic acid) turnover  hemoglobinopathies
 tumors (e.g. tumor lysis syndrome after killing tumor cells with chemo!)
↑ utilization of purine metabolism pathway to replentish ATP
↑ turnover of ATP
 alcohol, sepsis, respiratory failure, seizures, MI
Dietary indiscretion Eating ↑ purine foods (meats, seafood, etc)

Lesch-Nyhan Syndrome
Lesch, Nyhan (1964, Hopkins)
 Lesch made this major discovery while a medical student (probably on Mon, Wed, and Thurs afternoons)

Presentation
 Rheumatologic: Hyperuricemia, premature gout, tophi
 Neurologic: Spasticity, dystonia, thrashing-movements, self-mutilations, variable intelligence

Genetic mutation: Deficiency in HGPRT (discovered 1967) – mutation in HGPRT1 gene, X-linked

35
 Diet, Purines & Gout
Dietary sources of purines
Dietary intake: 20-50% of excreted urinary uric acid - So dietary measures can only do so much!

Foods with high purine contents

 Sheep heart  Sweet breads  grouse  liver  pheasant
 Herring  Yeast  codfish  kidney  veal
 Herring roe  Smelt  goose  salmon  haddock
 Mussels  Anchovies  mutton  trout  partridge
 Sardines  bacon  turkey  scallop

Dietary intervention in gout (one study)

 Gout associated with ↑ meat, seafood protein  Beer, not wine associated
 ↓ gout with dairy intake  High fructose beverages

But dietary intervention is usually not effective!

Gout, Uricase, HTN, & Hominid Evolution

Uricase catalyzes uric acid  allantoin (more water soluble; more easily cleared by kidney)
 Humans & Apes have non-functional uricase genes; & only humans get gout
 Why? Uric acid  ↑ salt sensitivity, endothelial smooth muscle proliferation, possible risk factor for CVD, HTN
 Maybe need a little hypertension for walking upright? Perfuse brain better?

Treatment implications
• recombinant uricase (rasburicase) approved for tumor lysis syndrome
• Pegylated porcine uricase (pegloticase) in chronic gout

Does hyperuricemia cause HTN? Probably contributes.

 ↑ uric acid predicts HTN; ↑ in 25-60% adults w/ untreated essential HTN (90% adolescents w/ new-onset HTN)
 ↑ uric acid in rodents  causes HTN; ↓ uric acid  ↓ BP in adolescents with HTN of recent onset
 Probably via various effects on kidney, vasculature

Does hyperuricemia ↑ CVD risk? Hard to say.

 Some studies show, but hard to separate co-morbidities
 Animal / in vitro models: uric acid  ↑ proliferative, inflammatory responses in cultured vascular SMC

Mechanisms of Gouty Inflammation

Unlike other conditions, the trigger is known in gout – the uric acid crystal

Joint anatomy review

 Enclosed by tough fibrous capsule
 Synovium produces synovial fluid
 Usually not much synovial fluid & not many inflammatory cells

36
Role of humoral mediators

With free uric acid crystals (negatively charged platform)

 Classical C’ pathway can be activated  PMN chemotaxis, resp burst

o Ab bind to negatively charged uric acid crystals (not recognizing as Ag – just charge-based)
o C’ fixation starts; form stable C5 convertase
o C5a is a PMN chemotactic agent, also induces endothelial cells to release IL-8

 Kinin system activated  bradykinin is end product pain, edema, vasodilation

o Uric acid crystals bind / activate Hageman factor by cleavage  kicks off cascade

Role of synovial Cells

 TLRs present on synovial macrophages (TLR 2/4) & chondrocytes (TLR 2)
 Uric acid crystals recognized by TLRs (innate immune response)

Synovial Mϕ produce PGE2 (pain) & IL-1β in response

 IL-1β actions
o Fever, leukocytosis
o ↑ endothelial cell activation, ↑ adhesion molecules
o ↑ IL-8 from fibroblasts, Mϕ

 ↑ IL-8 (synovial fibroblasts, Mϕ, chondrocytes)

o End result: ↑ PMN recruitment & transmigration

Chondrocytes: participate themselves!

 Uric acid can stimulate NO release (via TLR-2)
 Enhanced by IL-1, TNF

Inflammasome
 Complex of intracellular proteins in PMNs / Mϕ
o involved in innate immune response
 Activated by uric acid crystals (& bacterial toxins, bacterial RNA)
 Activated inflammasome  ↑ interleukin production (IL-1β)

37
Role of neutrophils
Not normally in the joint - recruited by all the above steps!

Self-amplification cycle:
 PMNs stimulated by uric acid 
 Produce IL-8 and leukotrine B4
(lipoxygenase-derived arachodonic acid metabolite)
 Both are potent PMN chemoattractants !

PMNs cause damage!

 When exposed to uric acid crystals, try to phagocytose
 Release lysosomal enzymes, superoxides, free radicals
 Superoxides: mediate a lot of the damage
o directly damage joint structural proteins (depolymerize hyaluronic acid  water in the joint)
o inactivate α-1 antitrypsin (↑ collagenase, stromelysin

What initiates an acute gout attack?

 Why can some pts have ↑ serum uric acid (> saturation) but not gout attacks / tophi?
 Why can some pts have uric acid deposits and even massive tophi without having gout attacks?

Hypotheses for initiation

Disruption of micro-tophi already in the joint  release free crystals 
Joint trauma
expose ultrastructural surfaces; bind humoral factors, etc.
Sepsis, stress ↑ ATP turnover  rapid ↑ uric acid
Bedrest fluid shifts (reabsorption from joint spaces  ↑ local *uric acid+; dehydration
Alcohol, dietary indiscretions Rapid ↑ in uric acid load
pH, temperature changes Change solubility of uric acid (maybe why toe is more common – far away?)

What stops an acute gout attack?

 Gout attacks are self-limited (24-72h)
 But uric acid crystals can be demonstrated in joints for weeks after inflammation subsides!

Hypotheses for termination

Inactivation of humoral mediators
↓ neutrophils
Modification of uric acid crystals
Inhibitors of inflammation
↓ uric acid
Carboxypeptidases inactivating kinins, C5a often found in joint
 Maybe PMNs release?
 Become resistant to repeated stimulation
 Destroyed after lysis of lysosomal membranes (limited lifespan)
Ultrastructural or by surface proteins  ↓ interactions w/ humoral, cell mediators
IL-1R antagonist (natural IL-1 inhibitor) released in later stages of acute gout attack
May be solubilized from ↑ fluid in joint, or heat of inflammation

38
 Treatment
Acute gout
1. Aspirate joint (document crystals, r/o infection)
2. Control the inflammatory response
o NSAIDs, corticosteroids (prednisone oral or IV), can use intra-articular injections of steroids
o Colchicine (AVOID IV/HIGH DOSE – toxicity; can use low-dose qd to prevent recurrence)

Chronic gout
1. Remove the inflammatory stimulus
o Modify risk factors- metabolic syndrome, DM, HTN, cholesterol; dietary intervention rarely successful
o Low dose colchicine prophylaxis, if early (inhibits PMN chemotaxis – interferes with microtubules)

2. Uric acid lowering agents indicated for:

o tophi o renal stones
o joint damage ( x-ray) or chronic joint pain o frequent attacks

Type Example Notes

Uricosurics
Xanthine oxidase inhibitors
Rarely used – only in under-excreters of uric acid
(document with 24h urine collection)
Probenicid
 Not effective if CrCl < 30 cc/min
 Can cause renal stones
The classic
 Start 100 mg qd  titrate by 100 mg (up to 800 mg/d)
Allopurinol
 Adjust in renal failure
 Toxicities: rash, LFTs
New drug
Febuxostat  40 mg or 80 mg dose
 Toxicities: LFTs
target serum uric acid level of <6 mg/dl

Newer Directions

 Anti-IL-1 biologic agents- antibodies, receptors

1β inhibition to treat acute and chronic gout
 Rilonocept (soluble IL-1 receptor – not great)
Treatment of tophi Synthetic porcine peglyated uricase: pegloticase* (Krystexxa)
Elicit mechanisms of hyperuricemia in cardiovascular disease and hypertension (endothelial cell damage?

*Pegloticase
 Reduction of tophus
 Radiographic improvement too!

39
 Rheumatoid Arthritis
Inflammation: edema, warmth, erythema, pain
Joint destruction: bone erosion, cartilage erosion, ligamentous laxity / rupture

Epidemiology
 Prevalence ≈ 1%
 Peaks 35-60 yo
 F > M (2-4x)

Presentation
Joints involved:
 Generally MCP, PIP, wrists (think proximal)
 Knees, shoulders too Joints involved in early arthritis
MCP, PIP 90
Criteria for RA classification: need 4 of 7 Wrists 80
1. Morning stiffness ≥ 1 hour Knees 65
2. Simultaneous arthritis of ≥ 3 joints Shoulders 65
3. Arthritis of hand joints Ankles 50
4. Symmetrical arthritis Feet 45
5. Rheumatoid nodules Elbows 40
6. Serum rheumatoid factor Hips 20
7. Typical radiographic changes in hands / wrists
Think morning, symmetrical polyarthritis of mainly hand joints

Gross appearance

Ulnar drift & subluxation of Severe deformation, with Same process in feet – but see
Early: see swelling
joints (tendons destroyed) profound synovitis dorsal subluxation of joints

Histology:

L: healthy cartilage, a little

Normal: see thin synovium,
hypocellular – just 1-3 cells thick
RA: note thick intima (near
early proliferative change
Normal: bone, cartilage, mostly joint space), now 5-8 cells
(lower right). R: advanced,
acellular thick, still Mϕ & fibroblasts;
see big villous prominences
also big inflammatory infiltrate
(from inflammation)

40
 Normal Rheumatoid Arthritis
Synovial Membrane: Erosive pannus: activated Mϕ,
 Makes synovial fluid (hyaluronic fibroblasts in thickend synovium
acid; etc., for lubrication) (intima), with T-cell / B-cell infiltrate
 Normally thin (1-3 cells thick) behind it
 Mϕ & fibroblasts
Bone erosion results (pannus eats it
away) – normally starts at outside of
Cartilage: avascular, nutrition from
joint (where pannus is
synovial fluid via diffusion
 Radiolucent – can’t see on Xray Cartilage degradation from
activated PMNs, chondrocytes

Radiology:

Left pic: Progression (LR) of erosion:from normal cartilage, space intact (L) to Severe deformity possible: note
early, mild joint-space narrowing @ margin, to advanced, no cartilage, bone-on- osteoporosis (top two); destruction of
bone, erosion (R). Right pic: similar thing, just in foot (big MTP erosions) joints, even femoral head invading pelvis!

Joint Destruction: Mechanisms

 Synovial invasion of contiguous bone
Bone erosions
 Release of MMPs, prostaglandins, etc
 Fluid phase – PMNs? Release free radicals, proteases
Cartilage loss
 Chondrocytes activated  release MMPs, degrade own matrix

RA is a Systemic Disease
Constitutional Sx
Cachexia
Extra-articular involvement
Serology
Can reduce lifespan of patients! Most excess deaths from cardiovascular disease (infection, pulmonary dz too)
fever, wt loss
muscle atrophy, osteopenia
scleritis, vasculitis, nodules
 ↑ ESR / CRP
 ↓ albumin
 Polyclonal gammopathy
 Anemia of chronic inflammation (normochromic, normocytic)

Muscle atrophy Osteoporosis Scleritis (thin, see choroid) Rheumatoid nodules Vasculitis ( ischemia rarely)
41
 Pathogenesis
How can we explain major targeting of joints with non-articular organ involvement & ↑ mortality?
Consider genetics, environment, autoimmunity, inflammatory factors

Genetic Predisposition
 Family clustering
 MZ > DZ twins (but only 10-30% - not monogenic)
 MHC II Ag (DR4)associated with RA (but only ↑ RR 4x)
Non-MHC genes may be involved too: in breaking tolerance, regulating tissue inflammation, destruction, responsiveness to Tx’

HLA-DR4 & RA: the “SHARED EPITOPE”

Turns out not HLA-DR4 itself, but a short peptide sequence in an HLA (DR4, or 1, or 10) associated with RA susceptibility
 This is the “SHARED EPITOPE” (SE) – but why is it important?

Remember MHC II present peptides to CD4 cells

 Shared epitope sequence sits @ top of binding cleft
 Presumably, the SE itself or HLA (with SE) presenting some peptide interacts
with the TCR to generate an ↑ immune response
 T-cells seen in synovium in RA– all seems to make sense

Therapeutic implications: maybe target T-cells

 Initially tried to target CD4 – but bad effects (↓ CD4 like AIDS), not helpful
 Maybe CTLA-4 receptor? Block activation through this aberrant signaling?

Environmental factors
 Smoking is the big one (+ shared epitope + anti-CCP Ab)
 Hormonal? (F>M) Viral trigger? Maybe this stuff plays a role…

Autoimmunity
Lots of auto-Ab are seen in in RA – but RF, anti-CCP are classically the most important

Rheumatoid factor (RF) IgM vs self-IgG

Anti-CCP anti-cyclic citrullinated proteins (e.g. vimentin, fibrin)
e.g. type II collagen, glycoproteins, etc.
Ab vs cartilage-derived proteins
May be result of inflammation rather than cause

Auto-Ab may precede clinical signs / Sx of RA

 Anti-CCP accumulate earlier, in higher frequency than RF – but both accumulate
 About 50% of pts have either RF or anti-CCP by time of diagnosis
 Means that disease process started YEARS BEFORE clinical symptoms!

42
Rheumatoid factor
 IgM against Fc portion of IgG
 Only 45% positive in 1st 6 months, 85% positive with established disease
 NOT SPECIFIC for RA (chronic infection, chronic lung/liver dz, endocarditis, HCV, sarcoid, etc)

Anti-CCP (anti-cyclic citrullinated peptide) Ab

 Highly associated with HLA-DR SE+
 High specificity (and high positive predictive value) for RA
 Detectible earlier than RF; found in up to 40% RF- pts with disease (esp. early)
 Predicts erosive disease and joint damage

So what’s an citrullinated protein?

 Arginine (charged) in proteins can be citrullinated (neutral)
 Citrullination happens via PAD enzyme, with calcium

Who cares?
 Citrullination changes the structure of the protein – unwinds
o Maybe exposing new, immunogenic epitopes?
 Citrullinated peptides 
o ↑ T-cell responses
o ↑ affinity for SE-positive MHC II molecules

Relationship to smoking: a theory of pathogenesis

 Maybe smoking  ↑ citrullation of proteins

 Citrullination  bind more readily to SE-containing MHC-III
 ↑ binding  ↑ auto-Ab responses  inflammation, RA!

In fact, see ↑↑ RR in smokers with 2 SE alleles

 Synergistic!

Inflammation
1990 expt: lots of CD4+ T-cells around in RA synovium, so look for cytokines to see what’s going on
 But didn’t see T-cell cytokine products!
 Do see cytokines made by Mϕ (IL-1, IL-6, TNFα) and fibroblasts (IL-6)

TNFα: the “boss cytokine”

TNFα effects: have receptors on various cell types!
Cell type Immediate effect Downstream effect
↑ pro-inflammatory cytokines
Mϕ ↑ inflammation
↑ chemokines
↑ adhesion molecules ↑ cell infiltration
Endothelium
↑ VEGF ↑ vascular proliferation
Hepatocytes ↑ acute-phase response ↑ CRP in serum
Synoviocytes ↑ metalloproteinase synthesis Articular cartilage degradation
Osteoclast progenitors ↑ RANKL expression Bone erosion

Animal models of arthritis: mice with ↑ levels of TNFα are a good model!
 inject type II collagen/adjuvant  ↑ TNFα  arthritis. Add TNFα inhibitor  ↓ swelling, bone markers, X-ray probs, etc.
 Transgenic mice (unregulated TNFα production)  spontaneous inflammatory arthritis. Resolve with anti-TNFα antibody
43
Cytokine networks: TNFα is the “boss cytokine”

TNFα produces IL-1 and IL-6 (and IL-1  ↑ IL-6)

 TNFα is a key upstream player
 IL-6 is a key downstream mediator
 And IL-1 probably doesn’t have much of a role in humans

IL-6
Explains systemic manifestations of inflammation
 Acute-phase response (CRP, sed-rate)  Hypergammaglobulinemia (“protein gap”)
 Anemia (induces hepcidin)  Hypoalbuminemia

Amplification mechanisms
Mechanism
One mediator with multiple effects
One mediator induces production of another
One mediator activates / inactivates another
Two mediators synergize with one another
Example in RA
Example in RA TNF receptors exist on most cells
TNF induces IL-1 and itself; same for IL-1
TNF/IL-1 induce collagenase & inhibit collagen synthesis
↑ TNF + ↑ IL-1  ↑↑↑↑ biological response

Pathogenesis of RA: Summary

Proinflammatory > Anti-inflammatory

This is probably a good level of detail to understand
For Tx: either ↓ pro-inflammatory or ↑ anti-inflammatory

Other factors that affect outcome in RA

 Treatment  Health behaviors (adherence to meds, wt management, exercise)
 SES  Other comorbid illnesses
 Depression
Treatment of RA
Bench-to-bedside approach: represents a good example of success in evolution of treatment

Classes of treatment strategies

Anti-inflammatory drugs
Immunosuppressives
Biologic (targeted) therapies
Toxicities (steroids, NSAIDs)
Mechanism unknown (e.g. MTX); use in small amounts
Directed against a single key molecule that contributes to pathogenesis
Mix & match to get good control
44
Biologic therapy approaches
Strategy Implementation
 Give soluble TNF receptor  bind TNF
Neutralize cytokines
 mAb against TNF
 mAb against receptor
Block receptors
 Receptor antagonists
↑ anti-inflammatory
Harder to do
pathways

Current therapies
Soluble mediators TNF, IL-6 ≫ IL-1 (TNF probably most important)
 T-cell – can inhibit co-stimulation of T-cells (Ab against CTLA4)
Cell membrane molecules
 B-cell – can deplete peripheral B-cells (Ab against CD20 -rituximab)

TNF inhibitors: game-changers

 1st rational / biological based therapy for RA
 Proof of concept that a single cytokine (TNFα) plays critical role in RA pathogenesis
 Disease modifying; alternative to MTX failures

New directions:
 Target signal transduction or gene transcription regulators, or new cytokines
 Move away from protein drugs? Oral bioavailability?

45
 Spondyloarthritis
A group of diseases
 Ankylosing spondylitis  Enteropathic / inflammatory bowel disease arthritis
 Psoriatic arthritis (PsA)  Juvenile spondyloarthropathy
 Reactive arthritis (ReA)  Others

Clinical Characteristics of Spondyloarthritis

Characteristic Notes
Spondyloarthropathy Involvement of spine (especially sacroiliac joint) – vs. RA, which spares spine
Seronegative No autoantibodies identified (RF-, CCP-)
Typically asymmetric (vs symmetric RA)
Oligoarticular Typically <5 joints (vs polyarticular RA)
Enthesitis / enthesopathy Inflammation at tendon / ligament insertions into bone
New bone formation & periostitis

Enthesopathy / Enthesitis (inflammation /

Sacroilitis – Inflammation  effacement of joint!
erosion of tendon ligament insertion into bone)

Ankylosing Spondylitis (AS)

Clinical features
 Men > women (5:1); onset typically in 20s-30s
Epidemiology
 Prevalence ≈ 500k in USA

Genetics HLA-B27 in 90%

 Morning accentuation of low back pain & stiffness
 Eventual limitation of spinal mobility
Presentation
 Extraarticular / systemic manifestations too (see below)
 Progressive (80% lose mobility w/in 10 yrs)
Sacroilitis* is hallmark, usually bilateral
Joint involvement  Arthritis of girdle joints (hips / shoulders) axial skeleton common
 May have associated peripheral arthritis, enthesopathy
 X-ray: erosions, sclerosis, syndesmophytes bridging vertebrae (BAMBOO SPINE)
Radiography  CT: erosions, sclerosis
 MRI (e.g. STIR, suppresses fat signal): bone marrow edema (not a specific finding)
*note: sacroilitis is NOT SPECIFIC for AS; also seen in other forms of spondyloarthritis

46
Plain radiographs: Erosion, sclerosis (L);
syndesmophytes bridging vertebrae (R):
“bamboo spine”
STIR MRI (removes fat signal) – see
CT: erosions (R) and sclerosis (L)
bone marrow edema

Systemic Features of AS

Feature Prevalence Description

Anterior uveitis & iritis
Inflammatory bowel disease (Asx)
Lung involvement
Cardiovascular involvement
25-30%  Unilateral, blurred vision, pain, photophobia, infection
up to 60%  Rarely develop typical IBD symptoms
 Costovertebral joint fusion  ↓ chest expansion  restrictive lung dz
 Pulmonary fibrosis can develop too
≈ 5% long-  Valvular insufficiency (esp. aortic)
standing AS  Variable degrees of AV block

Anterior Uveitis

Psoriatic Arthritis
Inflammatory arthritis associated with

 Skin psoriasis
o Silvery, scaly lesions over knees / joints most commonly
o but arthritis before skin disease in at least 10%
 Nail changes (onycholysis, nail pits)
 Can be rapidly destructive (over a few years!)

Epidemiology Psoriasis: scaly, silvery

 Male ≈ Female lesions; knees / joints mostly
 Prevalence ≈ 1% population; arthritis in up to 30% pts with psoriasis
 Other musculoskeletal manifestations (e.g. enthesitis) may be even more frequent

Arthritis mutilans (can be

Nail pitting “Sausage digits” Nail involvement, DIPs
destructive, just like RA)
47
Joints affected:
Joint / pattern Notes
DIPs frequently (like OA, usually spared in RA)
Radial / “ray” pattern see MCP, PIP, DIP joint of single digit
“Sausage digits” swollen, puffed out
± spondylitis sometimes seen
One subset (may be hybrid – HLA-DR4) mimics RA

Inflammatory enthesopathy
 Inflammation of tendonous insertion 
 Subchondral bone inflammation & resorption
 Periosteal new bone formation

Achilles Tendinitis: clockwise, Periostitis:

X-ray: joint destruction
from UR: swollen tendon; new new bone
Ensethopathy – note inflammation all (arrowheads) but also bone
bone formation (X-ray, then U/S); formation
around ligamentous insertion formation (arrows) at insertion
↑ vascularity with Doppler (arrow) @
points
(marker of new bone formation) insertion

Psoriatic vs Rheumatoid Arthritis (KNOW THIS)

Feature Psoriatic Rheumatoid
Gender (M:F) 1:1 1:3
Rheumatoid Factor <10% 80%
DIP joints 30-50% Extremely rare
Asymmetric Symmetric
Pattern of Joint Involvement
“Ray” pattern “Row” pattern
SI joint/axial spine 35%--any level Cervical spine in late disease
Other musculoskeletal Enthesitis, dactylitis
Extra-articular Skin, nails, uveitis Nodules, Sicca, vasculitis, scleritis
Radiology Erosions, periostitis, bony proliferation Erosions, periarticular osteopenia

Reactive Arthritis
Sterile joint inflammation that typically develops 1-2 wks after infection (not infection of joint, but reaction!)

 Infection sites involve mucosal compartments

o Urogenital: urethritis, prostatitis, cervicitis, balanitis, vulvovaginitis
o GI: colitis, enteritis

 Agents: Chlamydia trachomatis, Salmonella typhimurium, Yersinia, Campylobacter sp, Shigella flexneri

48
Clinical Presentation
Epidemiology: Typically younger adults, M=F, 30-40/100k; Worldwide distribution, but infectious agents vary
Genetics: ≈50% associated with HLA-B27

Arthritis: Typically weight-bearing joint; oligoarticular

Enthesopathy, dactylitis, tenosynovitis common

Extra-articular features:
Ocular inflammation
Skin lesions
Cardiac involvement
Classic “Reiter’s Syndrome”
Conjunctivitis, uveitis
Keratoderma, balanitis
Aortitis
Arthritis, urethritis, conjunctivitis

Keratoderma blennorhhagica: Skin lesions on palms,

Circinate balanitis: Skin
soles, can spread; vesiculo-pustular waxy lesions with
inflammation around tip of penis
yellow-brown color; can join together  plaques

Prognosis: Usually good, but 30-70% continue to have symptoms

Sample case: arthritis after salmonella outbreak (contaminated alfalfa) in Finland – 45% affected were HLA-B27+

Inflammatory Bowel Disease & Enteropathic Arthritis

Seen with
 IBD (UC/CD)
 Celiac disease
 Intestinal bypass sugery
 Infectious enteritis (Salmonella, Shigella, Yersinia, Campylobacter)
 Whipple’s disease

Associated with HLA-B27

Clinical Presentation
 Monoarthritis is common (weight bearing lower-extremity joints typical: knees, ankles, feet)
 Sacroilitis, spondylitis seen too, also enthesitis
 Arthritis often accompanies flare of gut symptoms; but may also persist when GI disease quiescent

49
 Pathogenesis of Spondyloarthritis

Remember: MHC I  CD8; MHC II  CD4

HLA-B27
 MHC class I molecule (involved in presenting antigens to CD8+ T-cells)

Epidemiology: involved but not the only factor

 Present in 90% pts with ankylosing spondylitis, but also 8% healthy Caucasians
 ↓ in Asians / Africans, but AS in those pops as well

+ +
2% all HLA-B27 individuals develop dz, but 25% of B27 relatives of AS pts develop dz
 also only 50-75% MZ twin concordance (13-15% DZ)
 Other genes besides B27 also important!

Gorillas: 20% gorillas have AS; Gogo-B0101 is similar to HLA-B27 in “B” pocket
 Similar Ag-binding pocket  would present similar peptides?

Disease associations for HLA-B27:

 Associated with ankylosing spondylitis (90% caucasians, 50% AA)
 Also reactive arthritis, IBD arthritis, psoriatic arthritis with spondylitis (all around 50%)
 But in 7-8% healthy Caucasians, 4% healthy AA as well

Animal models:
 Rats with human HLA-B27 spontaneously develop chronic inflammatory lesions
 But also require CD4+ T-cells (not just CD8) and exposure to bacteria! What’s going on?

Normal signaling
 Remember that class I peptide loading takes place in
ER, then presented on the cell surface
 Maybe this process is disturbed in HLA-B27 pts?

HLA-B27
 Slow to assemble, tends to misfold / self-associate /
dimerize on cell surface

HLA-B27: a PARTIAL explanation

Classical model:
 Ag presented on HLA-B27 (bacterial antigen or self-
arithrogenic peptide that mimics foreign antigen)
 T-cells activate & proliferate, make cytokines, damage
 But CD4, NOT CD8 cells are predominant in human & animal dz!

New model #1:

 Maybe HLA-B27 is directly antigenic
o misfolded HLA-B27 seen as “foreign”, or broken down, presented as new peptide antigen
 Could then activate MHC type II  generate CD4+ response

New model #2:

 Maybe misfolded HLA-B27 accumulates inside ER, causes ER stress response
 ER stress response  ↑ proinflammatory cytokines  ↑ CD4+ proliferation
50
New model #3:
 Maybe HLA-B27 dimerizes on cell surface
 Dimer somehow directly activates T/NK cells in an antigen-independent manner  activates CD4+ T-cells?

The Gut & Spondyloarthritis

The gut might be involved in pathogenesis of spondyloarthritis:
 Clinical evidence: Enteropathic reactive arthritis, also IBD / whipple’s dz / celiac / intestinal bypass arthritis
 Animal models: HLA-B27 transgenic rats (need bacterial exposure)

Final Pathways: common with RA?

 T-lymphocytes at the enthesis
 CD68+ activated Mϕ involved
 TNF (Mϕ cytokine), and T-cell cytokines seen in affected joints!

Brand New Stuff

Aberrant antigen processing, IL-23/TH17 cells, and disordered bone formation may be involved in AS
Most of this data from GWAS: IL-1 receptor, other loci identified too

Aberrant Antigen Processing

GWAS: Endoplasmic reticulum aminopeptidase (ERAP-1)
 Remember theory that ER might be involved? ER stress?
 ERAP shapes the peptide repertoire displayed by class I MHC
 Affects shedding of TNF-R, IL6-R, IL1-R (natural cytokine antagonists)

IL-23 and TH17 cells

GWAS: IL-23 Receptor
 Important in TH17 cell differentiation
 Also implicated as susceptibility gene in psoriasis & IBD
 IL12/23 antagonist is effective in psoriasis

TH-17 cells
 ↑ in AS/PsA pts; IL-17↑ in serum too
 TH17 cells important in psoriasis & IBD
 Active role in bone resorption / remodeling –
remember that in AS, both resorption & remodeling!
IL-17
 Made by TH17 cells
 Pleiotropic role (osteoblasts/ chondrocytes, ↑ fibroblast / Mϕ expression, ↑ RANKL expression)

Therapeutic implications
 IL-6 induces TH17 cells, IL-6 inhibitor effective in RA
 IL-12/23 antagonist effective in Psoriasis & IBD
 Anti-IL-17 in clinical development

51
Disordered bone formation
Wnt signaling pathways in bone formation
 Wnt proteins involved in bone homeostasis & new bone formation
o Signal to promote osteoblast differentiation

 Dickkopf-1 (DKK1) and sclerostin (SOST) inhibit Wnt pathway, and therefore inhibitors of bone formation
o Maybe dysregulated in AS (↓ inhibitors  ↑ new bone formation)

 May be link between SA & OA (both involve new bone formation)

Treatment
Look for commonalities – what causes inflammation & what causes damage

 Similar to RA treatment: NSAIDs, TNF antagonists, methotrexate

 TNF antagonists: good responses (radiography, etc) - ± slowing bone formation

 Also target specific etiologies where possible

o Psoriatic arthritis: maybe IL12/23 antagonists?
o Reactive arthritis: Abx for infection
o IBD-associated arthritis: careful with NSAIDs; treat underlying IBD

Key Points
• Spondyloarthritis is a continuum of diseases affecting joints as well as other sites (skin, eye, gut).

• Potential clinical involvement of sacroiliac joints and spine is a common feature

• Frequent occurrence of enthesopathy

• Characterized by inflammation, joint destruction, and new bone formation

• Driven by autoreactive T-cells at disease sites
• HLA-B27 is a contributing factor but the precise mechanisms are still unclear
• TNF is an important cytokine in disease-related symptoms

• Recent genetic studies suggest aberrant antigen processing, IL23, and TH17 cells may be important
• Recent clinical studies suggest that abnormalities in pathways of osteoblastic new bone formation (Wnt, DKK-1,
Sclerostin) may be important

• Infectious trigger is suggested for some forms of spondyloarthritis

• Treatment usually requires immunomodulatory therapies

52
 Autoantibodies
Just normal antibodies, but against self antigens!
Display all the hallmarks of an adaptive, T-cell driven response:
Class switching Somatic hypermutation Affinity maturation

Detecting Autoantibodies
Don’t need to memorize these
For all: need antigens, Ab, solid support, washing, detection systems

 ELISA / immunofluorescence more commonly used clinically

 Immunofluorescence: put cells down, add antibodies, add fluorophore-conjugated 2° Ab to visualize
o If Ag are present in cell, you’ll see them light up
o Just tells you that there’s something there & where it is – but not what it is
 ELISA: coat tube with Ag, add your Ab, wash off the non-adherent ones, add enzyme-conj 2° Ab to visualize
o Very commonly used, but can be too sensitive (false positives!)
 Immunoprecipitation: use Ab conjugated to beads; add radiolabeled lysate, then spin down & get Ab-Ag
 Western blot: same idea, just use Ag to probe an electrophoresis gel (just tells you the size of Ag)

 Future: moving towards multiplex assays

Used clinically

Mainly for research

53
 Autoantibody Systems
Tissue-specific antigens expressed only in a limited number of tissues (usually the target tissue)
expressed in every nucleated cell
Ubiquitously expressed antigens
frequently associated with specific phenotype
Auto-Ab:
 may participate directly in tissue damage or dysfunction, or
 may be markers of what other immune components are recognizing.

Auto-ab are a pretty random group:

Not unified by subcellular site, molecular structure, function
Are unified by being targets of an adaptive immune response
 Driven by self-antigen, T-cell dependent!
 Specific for a given disease
o Anti-CCP is associated with RA, not SLE or scleroderma (for example)
o Few exceptions (e.g. Ro/La in SLE & Sjogren’s)
o Probably tells us something about initiating sites / mechanisms of disease!

Disease Associated autoantibodies

Rheumatoid arthritis Anti-CCP, RF
SLE Nucleosome, U1-RNP, Sm, Ro/La, PARP, NuMA, anti-phospholipid
Scleroderma Topoisomerase I, fibrillarin, RNApol, CENPs A, B,C, B23
Myositis Mi-2, SRP-72kDa, PM-SCI, tRNA synthetases, U1-RNP
Sjogren’s Ro/La, α,β-Fodrin, Ku/DNA-PK, Golgins, PARP, M3-R, NuMA, ICA69

Autoantibody Patterns
Key point: many autoantibodies are associated with specific phenotypic presentations within a disease

Scleroderma
Ab  nuclear staining, @ centromere or nucleolus (anti-topo I): staining pattern correlates tightly w/ phenotype!

AutoAb Nuclear staining Phenotype

Anti-CENP

Centromere Ischemic digit loss, pulmonary HTN

Anti-topo I

Nucleolus Pulmonary fibrosis, diffuse skin disease, cancer

More rare: Anti-RNApol III (renal crisis, diffuse skin dz); Anti-B23/fibrillarin (IPAH)
54
Lupus
Making anti-nuclear Ab (anti-DNA, or anti-histone, etc)

Staining

“Homogeneous” “Speckled”
Auto-Ab Anti-DNA Against ribonuclear proteins

Myositis

Anti-cytoplasmic antibodies: Ab against tRNA synthetases

 tRNA synthetases in cytoplasm, so…
 intense cytoplasmic staining

What’s the relationship between autoantibodies & the disease

Key (unanswered) questions:
 Why would a specific immune response arise to an ubiquitously expressed “housekeeping” protein
 If proteins are ubiquitously expressed, how can there be a phenotype-specific auto-Ab response?

The Adaptive Immune Response

For an immune response (normal or autoimmune), you need:
1. Non-tolerized structure as your Ag
2. Supra-threshold concentration of Ag
3. Pro-immune context (both signal 1 & signal 2, the co-stimulatory signal

So how does an autoimmune response get generated? Possible Answer:

 Dominance & crypticity
 Molecular mimicry
 Feed-forward property of the auto-Ag themselves (e.g. DNA / RNA-associated autoantigens)

Dominance & Crypticity

Remember that MHC class I / II present peptides (bits of peptide) to the immune system
 But only a very limited repertoire of antigen (self or foreign) are usually presented on MHC class II
o “immunodominant” epitopes are those presented more frequently
o “cryptic” epitopes are presented rarely
 Dominance is influenced by protein structure / folding

With self-antigens, tolerance is only induced to dominant but not cryptic epitopes
 So T-cells recognizing cryptic self-Ag aren’t deleted, so they persist
 Altering a molecules processing / presentation  can reveal previously cryptic epitopes
 E.g. novel proteolysis, high affinity binding to Ab / another protein, post-translational modification, alternative splicing

Example: tyrosinase splice variants in mice – give a mouse a tumor; certain splice variants in tumor associated with ↑ rejection (↑
immune response) – different cryptic self-Ag detected

55
CD8+ cells: may play a role in revealing cryptic epitopes

 Remember: if lots of pro-inflammatory cytokines are

around, CTLs insert perforins, then granzymes to kill cells

 Autoantigens tend to be cleaved by granzyme B

 Maybe part of how cryptic epitopes get exposed? Get

cleaved by granzyme B  novel presentation? Lupus Ag
cluster on apoptotic cell surfaces  maybe apoptosis involved?

Auto-Antigens: pro-inflammatory?

Auto-Ag may be able to influence their own immune fate

 Can act as chemoattractant to APCs, lymphocytes (e.g. tRNA synthetases in myositis)
 Can ligate receptors of innate immune system (nucleic-acid-containing Ag in SLE)

Theory for selection of a self-molecule as a target for auto-Ab response

 May be a consequence of the pro-inflammatory properties of the molecule itself ?!
 If more inflammation around, more opportunity for presentation in an immune-response-provoking context?

Timing of Auto-Antibodies
Auto-Ab in some diseases can show up years before the disease itself!
 Since diseases often only recognizable after development of the diagnostic phenotype, tendency is to interpret findings at
diagnosis as findings present at “initiation”. Largely incorrect – autoimmunity often precedes development of phenotype

Different groups of auto-Ab may mark distinct events in the development of auto-immune dz
 Markers of disease initiation for some
 Markers of disease propagation for othres
o Ag at this phase probably function in propagation, e.g. pro-inflammatory / adjuvant function

Summary
• Specific autoantibodies are frequently associated with distinct phenotypes
– Such specificity may be of diagnostic and prognostic relevance

• Autoantibody specificity may provide important insights into disease mechanism

– feed-forward properties of the antigens themselves
– immune effector pathways that change antigen structure
– pathways in tissues which provide unique forms of antigens not previously seen by the immune system

• Various assays are available; New multiparameter assays are in the future

• Autoantibodies are markers of various processes which alter the structure and expression of antigens in tissues

• Dominance and Crypticity & acquisition of adjuvant properties are of mechanistic importance
• Autoimmunity occurs in multiple phases
– some autoantibodies are associated with initiation,
– others with propagation

56
 Systemic Lupus Erythematosus
Introduction & Epidemiology
 The prototype of a systemic autoimmune disease: multiple systems are involved
 Female > Male (9:1) - like many autoimmune diseases
 Affects up to 0.1% of the population
 Mean age in 30s
Clinical Presentations
Disease Course
 Starts with constitutional symptoms in initial flare
o Subacute onset usually
o Fevers, fatigue, weight loss, flu-like symptoms

 Recurrent flares with organ involvement

o Often mimetic (same organs for a pt)
o Can “add-on” new organs too

Manifestations
CNS dz (35%)

 Photosensitivity (30%)
Skin dz (70%)  Butterfly rash (40%)
 Discoid lesions

Glomerulonephritis (50%)

Arthritis (80%) Non-erosive

Raynaud’s (25%)
 Anemia (55%)
Cytopenias  Leukopenia (45%)
 Thrombocytopenia (20%)
 Fevers (60%)
Constitutional symptoms
 Wt loss (50%)
Lymphadenopathy (30%)
Mucosal ulcers (15%)

Specific Findings: More detail

Photosensitivity Butterfly rash Subacute cutaneous lupus

Slightly raised rash over bridge of Often with drug-induced lupus

From UV exposure nose, typically in acute flares Interface dermatitis: aggregation of lymphocytes between
Spares nasolabial fold dermis & epidermis (“Lupus band”)
57
 Serositis Arthritis

Similar to RA, but non-erosive - Subluxation w/o joint destruction

 Still can get get ulnar deviation
Can affect lungs, or manifest as ascites
Jaccoud’s subluxation – reducible subluxation with no joint space narrowing

Ab  C’ depositing in glomerulus
 Hypercellularity
 Loss of capillaries
Glomerulonephritis  IG deposition
 “Full-house staining”

Proteinuria, RBC/WBC casts in urine

Classification criteria for SLE

Need 4/11 – and 9/11 are clinical criteria (immune system not represented well!)
1. Malar rash 5. Arthritis 9. Hematologic disorder
2. Discoid rash 6. Serositis 10. Immunologic disorder
3. Photosensitivity 7. Renal disorders 11. Antinuclear antibody
4. Oral ulcers 8. Neurologic disorders

Abnormal Immune Response in SLE

↑ ↑↑ production of IgG antibodies
 Hypergammaglobulinemia
 Enlarged 2° lymphoid organs (really active)
o Lymphadenopathy & splenomegaly!
 Nectrotizing inflammatory response
 hyperplasia of germinal centers

Autoantibodies in Lupus

Initial discovery: LE cells LE = (lupus erythematosis)

 PMNs that have ingested nuclear material, but chromatin still intact

 Found that SLE pts’ IgGs were binding nuclear material 

o Fix C’  PMNs started phagocytosing it up

 This is how anti-nuclear antibodies (anti-DNA & anti-

deoxyribonucleoprotein Ab) were discovered

58
Autoantigens in SLE
 Naming is arbitrary & confused
 Based on patient name (Ro, La, Sm), disease association (SS-A/Ro), organelles (antinuclear, antiribosomal), or actual
molecule targeted (nucleosome, etc)
 Don’t need to memorize these specific Ab! / Ag / phenotypes / whatever!

Antibody specificities in SLE – what are they targeting?

Proteins binding RNA / Membrane-bound
dsDNA Nucleosomes
DNA phospholipids

Most specific antinuclear Anti-histone, Anti-dsDNA, etc Small nuclear

Exposed during apoptosis
Ab in SLE Pretty specific & sensitive riboproteins (snRNPs)

What antibodies bind to which antigens?

Location Target structure Associated Ab in SLE
Nucleosomes: The nucleosome consists of a core of histone surrounded by double- Anti-Histone
stranded DNA. It forms the basic subunit of the high order organization of DNA. Anti-dsDNA
Nuclear Small nuclear ribonucleoproteins (snRNPs): Multiple proteins associated with
Anti-Sm
uridine-rich nuclear RNAs that mediate splicing of pre-mRNA to mRNA by the removal of
Anti U1-snRNP
introns
The Ro proteins are complexed with small cytoplasmic RNAs (hYRNAs). Anti-Ro
Cytoplasmic
The La protein appears to bind any RNA with a polyuridine 3’ end. Anti-La
Membrane- Acidic phospholipids in association with phospholipids-binding serum proteins, e.g. b2
Anti- Phospholipids
bound glycoprotein 1, Annexin V.

Auto-Ab associated with specific clinical phenotypes – but not absolute (still pretty heterogeneous between pts
Antibody specificity Clinical phenotype
Anti-double stranded DNA glomerulonephritis
Anti-Sm glomerulonephritis
Anti-ribosomal P CNS disease
Anti-Ro Neonatal heart block and neonatal dermatitis, subacute cutaneous lupus, photosensitivity
Anti-La Protection from renal disease
Anti-phospholipid antibodies Thrombosis, thrombocytopenia, livedo reticularis

Direct antibody binding to target tissue
Antibodies can bind to target tissue  initiate tissue damage themselves!
SLE involvement
Neonatal disease
Anti-erythrocyte or anti-platelet Ab
Anti-ribosomal P Ab
Anti-phospholipid Ab
Mechanisms of Pathogenesis
Mechanism / Results
 Maternal IgG cross the placenta 
 bind apoptotic cells in developing AV node, irradiated keratinocytes
 Hemolytic anemia, thrombocytopenia
 Cross blood-brain barrier  bind neuronal surface P antigen
 Maybe involved in psychiatric complications?
 Bind phospholipids exposed on trophoblast Fetal loss

59
Immune-complex-mediated damage
Immune complexes in lupus (from ↑ antibody production) can fix C’ or activate Fc receptors
 Probably causes majority of pathology in SLE
 ↑↑ IgG  overwhelm non-inflammatory clearance mechanisms

Complement:
 Classical pathway (immune complexes with aggregated IgG, apoptotic cells  trigger C1q/s/r, etc.)
o Involved in normal clearance of apoptotic cells – we all have low levels of immune complexes

 If you have a complement deficiency in classical pathway – can get lupus! (can’t clear complexes!)
 If you have normal complement & lupus – still can get ↓ complement (deplete components)  Sx
o Can use C’ levels to monitor flares of lupus!

 Other pathways: Lectin pathway (terminal mannose groups on bacteria); Alternative pathway (bacteria, viruses, , etc)
 All go through C3 to activate all kinds of stuff

Fc receptors:
 Mast cells & phagocytes (PMNs, etc) have Fc receptors  When triggered, get ↑ pro-inflammatory cytokines
 Usually have pretty low affinity – don’t want to be spitting out these cytokines every time you see an Ab
 But in lupus, have immune complexes – can bind multiple Fc receptors at once (↑ avidity)  activate!
o Proinflammatory cytokines get secreted (TNF-α, IFN-γ, etc)
o Bind / internalize antigen  shuttles to inside of cells  engages specialized receptors  ↑ response

The complement system (L) and Fc-receptor mediated damage (R)

Changes in Immunological Parameters during Flares

 ↑ titers of autoantibodies  Circulating immune complexes
 Isotype switching  Hypocomplementemia

Disease Evolution
Susceptibility  Initiation  Transition Propogation
Susceptibility: genetic (MZ ≫ DZ concordance)
 Genes in pathways that regulate non-inflammatory clearance of self structures that could be inflammatory

60
 Disease Initiation
How does all this get started?
Some autoantibodies present years before diagnosis – and some Ab tend to present earlier than others
 From study analyzing banked serum samples from military

Environmental triggers
The cells that are involved are probably not normal
 maybe these environmental triggers  abnormal cells  abnormal processing, etc.
 UV-B radiation (photosensitivity), infections, toxins,drugs, trauma all proposed to have a role

Molecular mimicry
Basic idea: foreign pathogen  get immune response to Ag
 Classic idea: Similar host protein can get hit in crossfire (more rare)
 “epitope spreading” is probably more common mechanism
o Over time, the Ab specificity becomes “more promiscuous”

Apoptosis
Apoptotic cells are the most likely source of autoantigens in lupus

Normally: Apoptosis promotes tolerogenic immune response

 nuclear, cytoplasmic, membrane components packed up into blebs; cleared quickly (tissue Mϕ)
 These Mϕ secrete IL-10, TGFβ (promote tolerance in immune response)
 APCs pick up apoptotic fragments in non-inflammatory context  ↑ tolerance too!

How is this response messed up in lupus?

 Neoautoantigen generation: If apoptotic cells not

cleared right away  can be processed in unusual
ways or not processed at all (explode), and new
epitopes end up being exposed

 Clearance defects: SLE proteins are often found on

cell surface in small blebs, apoptotic bodies – if
apoptotic cells hang around too long, ↑ chance of
generating immune response

Example: C1q deficiency: can’t clear apoptotic cells correctly  develop lupus!

End result: instead of a tolerogenic effect, start producing type I IFNs  inflammatory response

Normal immune response to apoptotic cell  tolerance SLE response: ↑ type I IFN production

61
 Disease Transition & Propogation
The initial immune response described above can precede the phenotype by years
 The transition stage can eventually lead to disease propogation

Innate Immunity, TLRs, and Transition

Toll-like receptors: recognize LPS, ssRNA, CpG DNA, blah blah blah
 TLR 7: recognizes ssRNA, TLR 9: recognizes CpG DNA, Both are inside the cell

Remember that lupus antibodies recognize nucleic acids – and so do these guys
 Lupus immune complex binds DNA, internalized into cell, engages TLRs
 Cell then gets activated (esp. plasmocytoid dendritic cells)  produce type I IFNs
 Type I IFNs  ↑ B-cell maturation & proliferation  FEED FORWARD LOOP!

“Type I IFN signature” in the blood results

 ↑↑ Type I IFN expression
 maybe dx test in future?

Summary: Evolution of SLE & a Model for Pathogenesis

1. Initiation
a. Accumulation of apoptotic cells (via any number of defects) 
b. cleared in a pro-immune (not tolerogenic way)  autoimmunity develops
i. Ab against apoptotic cell suface peptides, other nuclear autoantigens, can’t ligate TLRs
c. At this stage, patients are asymptomatic

2. Transition: from asx; auto-Ab+ pts to amplifying, clinical phenotype

a. Apoptotic events with ↑ TLR signaling  ↑ immune responses (e.g. vs ribonucleoproteins)
b. New autoAb  ↑ response (by triggering TLR signaling)  type I IFN production
i. ↑ Type I IFN  ↑ target cell killing, ↑ CTL effectors, ↑ MHC I expression, ↑ APC activity, etc
ii. Perpetuates immune response

3. Propagation:
a. Previous changes induce more apoptosis  ↑ autoantigen load  self-sustaining cycle (feed-forward)
b. Disease flares from exposure to something that increases apoptotic cell death
i. sunlight, viral infection, drug exposure can trigger
c. Disease manifestations: from tissue damage
i. Immune complex formation / deposition (skin, joints, kidney, blood vessel wall)  fix C’
ii. Tissue damage  more apoptotic material  ↑ immune response to autoantigen!

Treatment
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 Prediction, Prevention Target of research
 Plaquenil (anti-malarial agent) / anti-TNR
Initiation / Transition
 Anti-IFN?
 Immunosuppression (↓ apoptosis, ↓ response)
 Moderate C’ pathway (heparin?)
Propagation
 Anti-IFN (but don’t want to totally take out type I IFN function)
 Stop pro-immune antigen presentation (Plaquenil)

Summary
 SLE is a multisystem disease
o Often subacute onset
o Chronic course with periods of flares

 Involvement of adaptive & innate immune response

 Production of diverse specific autoantibodies
 Damage in target tissue by antibodies & immune complexes; important roles of complement & Fc receptors
 Importance of innate immune response (TLRs, type I IFN production)

63
 Autoimmune Myopathies
Terminology:
 Autoimmune myopathy ≈ Myositis ≈ Acquired inflammatory myopathy ≈ Idiopathic inflammatory myopathy

Classification
Inherited myopathies Acquired myopathies
 Muscular dystrophies (e.g., Duchenne)  Toxic (e.g., statins)
 Metabolic myopathies (e.g., McArdle’s)  Infectious
 Glycogen storage (e.g., Pompe’s)  Autoimmune myopathies (i.e., myositis)
 Mitochondrial myopathies
May have FHx (although often recessive)
Usually acute or subacute onset
Usually slowly progressive

Inflammatory myopathies (*=can be associated with other connective tissue disease)

 Polymyositis (PM)*
 Dermatomyositis (DM)*
 Inclusion body myositis (IBM) – may or may not be autoimmune, and he pretty much ignored it

Epidemiology of DM & PM
 Childhood / adult onset, peak in 4 -6th decades
th

 Incidence: roughly 1/100k

 Sex predominance varies
o F>M (2:1) for PM/DM
o F=M for childhood & malignancy-associated
o F≫M (10:1) for connective tissue-disease associated
Some genetic associations, but rare familial associations (generally think inherited myopathy if strong family history)

Clinical Features of DM & PM

• Symmetric proximal limb weakness
o difficulty washing/combing hair, rising from a seated position, climbing stairs, lifting head off pillow
• Pharyngeal and diaphragmatic weakness
• No facial weakness, sparing of ocular muscles (unlike inherited forms)
• Often painless (>75%) – but can have myalgias
• Subacute presentation (weeks/months)
• Associated with cancer (DM > PM)

64
Unique Skin Findings in Dermatomyositis

Finding Description Picture

Around eyelids
Heliotrope rash
Looks different in pts with different skin colors

Periorbital edema

On MCP, PIP, DIP but spare skin between

 Can be on feet too
Gottron’s Papules
 DDx vs Lupus (upper left pic) –
which spares joints

Oncholysis Can see in scleroderma too

Other rashes in dermatomyositis

Gottron’s sign V-sign Shawl sign

Generally on extensor surfaces of

Like V-neck shirt Back of neck
fingers, but here on elbows too

Histology: See interface dermatitis (can also see in discoid lupus)

 WBC attacking the basal layer of epidermis 
 vacuolar change in the basal cells or necrosis of basal keratinocytes

Calcinosis in juvenile DM – calcium deposition outside the bone

 Can be really painful

65
MRI
Generally use T1 or STIR
 Can distinguish between acute / chronic

Acute DM: See hyperintensity on STIR (edema)

Inclusion body myositis (chronic)

 see fatty replacement of muscle
 what muscle is left is bright

Cancer & DM/PM

Dermatomyositis: 3.0 standardized increased risk (SIR) – more strongly associated

 ↑ ovarian, lung, pancreatic, breast, colorectal, stomach cancers; lymphomas, many others
 Adeno > squamous > lymphoids

Polymyositis: ≈ 1.5 SIR (less strongly associated)

 ↑ lung, NHL, bladder cancers

BIGGEST RISK in 2 years prior to Dx, 1 year afterwards - Still a risk even 5 years out

Histology
Polymyositis
Normal muscle Polymyositis

Primary inflammation: see

See evenly sized bundles, good ↑ MHC-1 expression –
normal myofiber surrounded by
spacing even distant from areas of inflammation!
CD8+ T-cells

Possible mechanism: CD8+ T-cells are key

 Think that CD8 CTLs coming right up to muscle cells, inserting perforin
/ granzymes  damage, apoptosis, lysis
 Many of the myositis autoantigens are cleaved by granzyme B 
immunogenic fragments?

↑ MHC1 expression
 Even distant from areas of inflammation
 Mice with over-expression of MHC-I results in muscle inflammation, auto-Ab, ER stress response – may be pathogenic!
66
Dermatomyositis
Key findings (not just polymyositis with a skin rash!):
 Perifasicular atrophy
 Perivascular inflammation (CD4+ T-cells & plasma cells) - what you see in skin too!
o Many of these CD4 cells are actually plasmacytoid dendritic cells – potent cytokine producers

Perifasicular atrophy – smaller muscle fibers @ edges of

Perivascular inflammation
fascicles; basically pathognomonic for dermatomyositis

Pathogenesis?
 C’ deposition on endothelial cells
Perifasicular capillary depletion  ↓ # perifasicular capillaries
 Perifasicular atrophy from hypoxia?
 CD4+ cells are actually plasmacytoid dendritic cells
IFN-α/β
 Maybe pouring out lots of IFN α/β & causing damage?

Autoantibodies in Myositis
Myositis-specific autoantibodies
Myositis-associated autoantibodies
Synthetase Non-synthetase
Anti-Jo-1, others SRP, Mi-2 Tons (PM-Scl, U1RNP, Ro/SSA, etc)

Myositis-specific antibodies: Anti-tRNA synthetase antibodies

Anti-tRNA synthetase antibodies are classic; Jo-1 is the classic example
 Associated with a specific classic antisynthetase syndrome phenotype

Antisynthetase syndrome phenotype (e.g. Jo-1)

Nonerosive arthritis Mechanic’s hands Interstitial lung disease Raynaud’s phenomenon

 Jo-1 titers correlate with disease activity (CK, arthritis, lung measures!)
o Suggests that these are useful markers – and maybe pathogenic?
o Mouse models: immunize with Jo-1, get similar disease

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Myositis-specific antibodies: Non-synthetase
Name Antigen Clinical Manifestations
SRP Signal recognition particle Severe, acute, tx resistant; necrotizing myopathy
Mi-2 Chromatin remodeling enzyme DM>>PM

Anti-SRP (anti signal-recognition particle)

 Complex of proteins / RNA that recognizes AA sequence to target to ER
o Found in all cells! No idea why just some are targeted

 Anti-SRP syndrome
o About 5% of myositis patients
o Rapidly progressive severe weakness
o Early muscle atrophy
o Dysphagia common
o Very high CK levels (often 5,000-30,000)
o Difficult to treat
o Necrotizing myopathy (minimal inflammation)

 Pathogenesis unknown – not much inflammation inside the tissue itself!

o See C’ deposition on SRP capillaries & muscle fibers

Anti-Mi-2
Strongly associated with dermatomyositis (10-30% DM pts)
 More fulminant cutaneous manifestations
 But better response to steroid therapy
 ↓ malignancy incidence vs other DM pts

UV exposure & Dermatomyositis

In some cities, DM > PM; in others, PM > DM!
 ↑ dermatomyositis (and ↑ anti-Mi-2 Ab) in cities with ↑ UV exposure!

So what’s the relationship?

 No definitive answer
 ↑ UV exposure  ↑ anti-Mi-2 Ab incidence; in skin cultures, ↑ anti-Mi-Ab production with UV exposure
 Anti-Mi-2 Ab pts are more often photosensitive
 Anti-Mi-2Ab may be pathogenic?

Pathogenesis
Clue #1: autoantigen expression ↑ in myositis muscle
 See local increase in expression of autoantigens (Mi2 in DM, Jo -1in PM, etc)

Clue #2: ↑ autoantigen levels in regenerating cells

 Normal muscle regeneration: Damage  satellite cells proliferate
 myoblasts  myotubes
 Myogenin is a marker for these regenerating cells: ↑ staining

Clue #3: ↑ autoantigen levels in cancer tissue

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Putting it all together:
• Normal muscle expresses low levels of autoantigens
• Regenerating muscle expresses high levels of autoantigens
• Tumors express high levels of autoantigens
• Myositis is associated with increased cancer risk

Possible mechanism:
 Immune system tries to mount a response against a tumor
o Maybe often can actually eradicate the tumor – why all
DM / PM pts don’t have tumors!
 Normally no effect on muscle (expressing low levels of autoantigens)
 But if muscle damaged, see ↑ autoantigen expression
 Immune response can be directed against muscle now
 Immune response damages muscle  ↑ autoAg expression  feed-forward loop!

Summary
Inflammatory myopathies
• Polymyositis (PM)
• Dermatomyositis (DM)
• Inclusion body myositis (IBM)

Clinical features
• Symmetric proximal weakness • Subacute presentation (weeks/months)
• Pharyngeal and diaphragmatic weakness • Associated with cancer (DM > PM)
• Sparing of facial and ocular muscles

DM skin features: Gottron’s sign, heliotrope rash, V-sign, shawl sign

Pathology:
 PM: Normal myofiber with CD8+ T-cells surrounding it (primary inflammation)
 DM: perifasicular atrophy & perivascular inflammation (CD4+ T-cells & plasma cells)

Specific phenotypes for myositis-specific autoAb

 Antisynthetases (e.g. Jo-1): myositis, arthritis, mechanic’s hands, ILD, Raynaud’s
 Anti-SRP: severe necrotizing myopathy
 Anti-Mi-2: dermatomyositis

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 Vasculitis
Definition: A clinicopathologic process characterized by inflammation of blood vessels

Results in:
 occlusion or destruction of the vessel
 ischemia of the tissues supplied by that vessel

BAD STUFF HAPPENS! – need clinical manifestations to have the disease

 You need vasculitis to have vasculitis

Pathology
Inflammatory destruction of blood vessel
 Infiltration of vessel wall with inflammatory cells
 Fibrinoid necrosis of the vessel wall
 Endothelial proliferation
 Thrombosis, occlusion, ischemia
 Aneurysm formation (wall weakens)
 Rupture, hemorrhage

Leukocytoclasis: the presence of inflammatory cells (PMNs) in the vessel wall with…
 Stuck (suspended animation = clasis); Degranulating onto blood vessel wall (bad)
 Leukocytoclastic vasculitis is not a disease – e.g. after PCN allergy – need to find the cause!

Leukocytoclasis Blood vessel occlusion

L: medium-sized muscular artery, but occluding process walled off.

PMNs in vessel wall
R: total occlusion ( ischemia, etc)

Aneuyrism Tissue infarction

Aneuyrism of the popliteal artery. Testicular infarction. Not cool.

Diagnostic Approach
General clues
 Subacute onset
 Generalized systemic inflammation (vessels everywhere): ↑ ESR, CRP, platelets, other acute-phase reactants
 Multisystem involvement
 PAIN is prominent (arthralgia, myalgia, neuralgia)  “Vasculitis is a hurting disease” (from ischemia!)

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 31 yo F with ulcers, foot slap, pain 31 yo M, ulcers, feels fine
The woman probably has vasculitis – she’s in PAIN
(the guy was pouring acid on himself – also no vessels follow that pattern)

Vasculitis can mimic things that cause terminal tissue ischemia

• Endocarditis • Cholesterol Emboli • Antiphospholipid syndrome
• Malignancy • Scurvy • Scleroderma
• Thromboemboli • Atrial Myxoma • Factitious
Vasculitis is rare – consider these!

Vasculitis is not a disease – it’s a process

 Temporal arteritis, Kawasaki’s disease, Churg-Strauss syndrome, etc. are the diseases!
 Look for the syndrome – what clinical company does it keep?

Classifying vasculitis
What size of blood vessel is involved?
SIZE DESCRIPTION EXAMPLES
Large > 150 mm; not in skin. Aorta & main branches
50 – 150 mm; Some visualized.
Medium The other named vessels
Muscular walls.
< 50 mm; can’t see them. E.g. vessels that you notice if you cut when
Small
Capillaries, venules, arterioles you’re shaving (no pulse)

Look at the pattern!

 Tell rheum: “it’s probably a small vessel vasculitis”

Current system based on vessel size, shared clinical features

 NOT based on underlying pathophysiology or etiology
 Has problems!
– Significant overlap
– Wide range of phenotypes even within a single classified
disease (eg. WG, CSS, GCA)
– Many patients cannot be classified
– Single organ vasculitis
– Not all vascular beds of similar size are affected in all organs (ie. thyroid, pancreas)
– Skin, lung, kidney, GI tract particularly vulnerable

New insights from embryology, vascular biology, immunology

 Some vessel beds seem to have more TLRs, for instance  maybe ↑ predilection for vasculitis!

Treatment: always treat the process, even if you don’t have the classification perfect

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 Examples of Vasculitis
Small Vessel Vasculitis
Purpura can be a helpful finding
 non-blanchable punctuate skin rash caused by vasculitic involvement of small vessels of skin
 Bx: shows leukocytoclasis (activated, dying PMNs in blood vessel wall) + extravasated blood

Other organs with small vessels:

 Kidney  Glomerulonephritis – the glomerulus is full of small vessels!
 Lung full of small vessels  can look like pneumonia!

Purpura: indicates small vessel disease if vasculitis Glomerulonephritis

Medium vessel vasculitis

Mononeuritis multiplex: can be a helpful finding
 sensorimotor neuropathy of “named nerves” (e.g. radial, ulnar, common peroneal, anterior tibial, etc.)
 Caused by vasculitis of medium sized vessels that supply the nerve bundle
 Highly specific for vasculitis (if trauma, diabetes absent)

Mononeuritis multiplex  involvement of named nerve Medium sized vessel (muscular wall)
(e.g. radial neuropathy here) but way too many inflammatory cells

Polyarteritis nodosa: probably the closest thing to a pure medium-vessel vasculitis

 Medium vessel disease: need more than just a surface biopsy  need to get to medium vessels!
 Big, deep ulcers: probably a medium vessel process
 Can get aneurysms of GI tract (small mesenteric vessels, big splenic / hepatic artery aneyurisms, etc)!

Big ulcers Need deep biopsy of skin! Mesenteric aneurysms

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Large Vessel Vasculitis
Involves the aorta and its main branches

• Giant cell arteritis (Temporal arteritis) • (Cogan’s syndrome)

• Takayasu’s arteritis • (Relapsing polychondritis)
• Idiopathic aortitis

Diagnosis: often need to image (can’t really biopsy these big vessels)

Occlusions on MRI Thickened aorta (way too thick)

Distinguishing size of vessels involve

Medium vessel occlusion: could be vasculitis (inflammation) or vasculopathiy (e.g. scleroderma – no inflammation!)
 Need to see what else is going on
 Could also have both processes at once!

Medium vessel: note range affected, multiple digits Small vessel (splinter) overlaid on medium vessel process!

Mechanisms of Pathogenesis

Mechanism #1: Immune Complex Deposition

 Need Ab, Ag, C’ for immune complexes;
 Fc receptors, C’ receptors for effects

E.g. hepatitis C-related cryoglobulinemic vasculitis

 See membranoproliferative glomerulonephritis (below)
 viral particle  immune activation

73
 HCV-related vaculitis (small vessel  purpura); Purpura with immune complex
pt needed bilateral amputations deposition in skin

Kinetics are key in immune complex formation

Inject antigen  takes around a week for immune complexes to form
 If pt says: “A week ago I took a medicine,” might be causing vasculitis.
 If pt says: “Two hours ago…” – not the cause!

What makes immune complexes pathogenic?

 ↑ Antigen load (serum sickness, rxn to abx, viruses)  RES efficacy (C’)
 ↑ Antibody response  Physical properties of blood vessels

 Physical properties of immune system (e.g. solubility – not a fixed property; affected by Ag:Ab ratio)
o “Goldielocks” model – need a “just right” amount – otherwise more easily cleared
o Immune complexes develop in environments of SLIGHT ANTIGEN EXCESS!

Therapeutic implications
45 yo IV drug user who presents with rapidly progressive kidney failure, purpura, and wrist drop
 Probably hepatitis C vasculitis  with small & medium (wrist drop) vessel involvement

Steroids ↓ acute inflammation

Rx: Plasmapheresis remove ICs
Antivirals ↓ HCV load

Mechanism #2: ANCA-associated diseases (anti-neutrophil cytoplasmic antibody)

Probably a marker (but controversial)

Examples
• Wegener’s granulomatosis • Churg-Strauss syndrome
• Microscopic polyangiitis • Drug-induced AAV

Wegener’s: Classic triad of necrotizing granulomatous infection

1. Upper respiratory structures (sinus)

• Saddle nose from destruction of cartilage
2. Lower respiratory (lungs)
3. Severe kidney glomerulonephritis
 C-ANCA is highly specific!

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 ANCA patterns (KNOW THESE)
C-ANCA P-ANCA
Pattern
(cytoplasmic) (perinuclear)

Antigen

Antigen Proteinase-3 Myeloperoxidase

MPA, Churg-Strauss, Drug-
Disease(s) Wegeners (specific)
induced, IBD (not too specific)

ANCA titers do NOT reliably PREDICT disease activity or risk of flares in Wegener’s
(although they do for some individual pts)

Are ANCA pathogenic?

 Paradox: ANCA highly associated with specific types of vasculitis: but little to no ICs in these diseases!
 Evidence for role: ANCA can activate primed PMNs in vitro; two models reveal that pANCA transfer can cause vasculitis-like
illness (but cANCA does not!), eliminating B-cells improves WG in some pts;
 Evidence against: removing immune complexes can ameliorate severe dz symptoms (IC related?), ANCA titers don’t
correlate with activity / prognosis of dz

Mechanism #3: T-cell mediated inflammation in large vessel vasculitis (e.g. GIANT CELL ARTERITIS)

Giant cell arteritis: Inflammatory dz of aorta & main branches (muscular arteries with own blood supply)
 Older pts: very rare in patients under 50 years old
 Clinical manifestation: temporal arteritis usually
o Headache, jaw claudication, diplopia, prominent temporal arteries, polymyalgia rheumatica
o ESR is typically ↑
 Pathology:
o see medial smooth muscle hyperplasia + intimal hypertrophy + adventitial inflammation
o Luminal occlusion  ischemia  Sx!
o GIANT CELLS (forming granulomas

Prominent temporal arteries Pathology: note occluded lumen Disruption of internal elastic lamina

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What’s going on?
 Basic idea is that immune stuff is happening out in the adventitia
(via the vasa vasora)
 Obliteration happens from outsidein!
o This is for large-vessel diseases
o (vs. immune complexes, “inside-out” in small vessel dz)

More in-depth look

 T-cells enter vasa vasora, interact with resident dendritic cells (TLRs?)
 DCs activate, mature, release cytokines  Mϕ recruited
 Medial Mϕ release factors  ↑ myofibroblast differentiation
 Intimal expansion, microvessel formation (via IFN-γ)
 End result: vessel occlusion

Treatment: “One Size Fits All”

• Steroids
• Immunosuppression
• Role for biologics? TNF Inhibitors, B Cell depletion, Co-stimulatory blockade, Other anti-cytokine Rx?
– Age of “rational Rx” for vasculitis has not yet arrived
Summary
• Vasculitis is a clinicopathologic process involving inflammation and necrosis of blood vessels

• General clues to vasculitis: subacute onset, inflammation, multisystem, pain

• Specific clues to vasculitis: skin lesions, mononeuritis multiplex, pulselessness

Pathogenesis
 Explains how vasculitis affects many organs
Immune Complex Deposition Model
 Importance of Ag load, Ag:Ab ratio, solubility
 Novel autoantibody but few ICs
ANCA-associated Model
 ANCA/neutrophil interactions might be important
 Adaptive immune response that likely progresses from the “outside-in”
T cell-mediated model in GCA
 Putative antigens are unknown; IFN-γ mediated

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 Scleroderma
Epidemiology
 20M / yr; prevalence 200-300/million
 F>M (3:1), onset usually 40-50 y/o
 All races
 Chronic duration / supportive treatment

Classification of Scleroderma

Scleroderma = “hard skin”

 Localized: affects the skin only
 Systemic: has internal organ involvement!
o Limited (internal organs + limited skin)
o Diffuse (internal organs + diffuse skin)

Localized Scleroderma (Morphea)

Circumscribed Generalized Linear “En Coup de Sabre”

Linear lesion of the

One patch Multiple patches Linear limb involvement forehead; resembling a
“sabre wound”

Note that if early onset, can have growth abnormalities! – e.g. leg, skull, etc.

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Systemic Sclerosis
Limited Diffuse

Classification debated – still systemic Entire body, back usually spared

E.g. CREST syndrome – here sclerodactyly Whole body affected

Don’t confuse limited with localized scleroderma! LIMITED still has INTERNAL ORGAN INVOLVEMENT

Facial & Skin Features of Scleroderma

Facial Features

Thinning of upper lip, protruding teeth, shrinking / tightening of oral aperture

Facial Features “Salt & pepper” / “vitiligo-like” skin lesions

Thickened folds of neck

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 Pathogenesis of Scleroderma
Hallmarks:
 Immune activation
 Fibrosis
 Vascular injury

Autoantibodies in Scleroderma
 General autoimmunity (95% positive for ANA)
 Scleroderma-specific Ab (only in SSc; specific phenotypes)
 Scleroderma-pathogenic Ab (possibly pathogenesic?)

NO EVIDENCE OF IMMUNOCOMPLEX FORMATION in scleroderma!

Scleroderma-specific Ab:
Antibody Phenotype Associated skin involvement
Anti-centromere CREST, PAH Limited
Anti-topoisomerase Lung fibrosis Diffuse

Immune Activation
Cellular immune responses
General
Pro-fibrotic phenotype
T-cell cytotoxic function
T-cell response (auto)-antigen-specific
Early infiltration of activated mononuclear cells, Mϕ in target tissues
 precedes fibrosis!
T cells exhibit TH2 polarization
 Direct cell-mediated damage (to endothelium, alveoli),
 Propagates autoimmune response
 Oligoclonal T-cell repertoire
 Autoreactive T-cells (topo-I)

Shift to fibrotic response comes from shift in balance of T-cells

Inflammation early on becomes fibrosis later
Th2 cells predominate  profibrotic!

79
 Autoantigens presented by APC  activate T-cell Really complicated. Basic idea: immune response hurts stuff, turns
response against endothelial cells  apoptosis, fibrotic because of the cytokine mileu. Hypoxia leads to propogation.
generation of more autoantigens – and release of New evidence: immune response might also be directly targeting
profibrotic cytokines (IFNγ, IL-4, IL-13) vessels, activating fibroblasts

Putting it all together: a model for scleroderma

Fibrosis, vascular injury, and immune activation are always active; predominant pathogenesis changes with time though!
 Pre-clinical phase: Immune response is prominent (↑ immune activation)
 Onset of symptoms: Fibrosis & vascular injury become more prominent (symptoms!)
 Late phase: Vascular injury plays biggest role (hypoxia  more damage  perpetuation!)

Normally: once stimulus removed, healing takes place

Scleroderma: persistent stimulus  ↑ Mϕ , lymphs

 ↑ growth factors (activate fibrogenic cells) In scleroderma, the STIMULI are abnormal
 ↑ pro-inflammatory cytokines (↑ collagen synth)  The rest of this response is normal & healthy!
 ↓ metalloproteinase activity (↓ ECM degradation)

End result: FIBROSIS

Molecular mediators of fibrosis: promote collagen synthesis, ECM secretion, ↓ MMPs, etc
Signal through lots of complicated pathways via cell-surface receptors
 TGFβ (transforming growth factor β) - from platelets, monocytes, Mϕ, T-cells, fibroblasts
 PDGF (platelet-derived growth factor) – from platelets, Mϕ, endothelial cells, fibroblasts
 CTGF (connective tissue growth factor) – from fibroblasts, epithelium, endothelium, vascular SMC
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 End Organ Effects: Fibrosis in Scleroderma

Basic idea:
 Tons of ECM, collagen made via above mechanisms
 Normal architecture of tissues disrupted
 Loss of organ function  organ failure!

Skin
Fibrotic, tight, hard skin – both clinically & histologically

Lungs
 Can develop interstitial lung disease  a big deal clinically!
 Fibrosing alveolitis: like idiopathic pulmonary fibrosis, but not idiopathic (scarring / thickening of lungs)

Interstitial lung disease (Xray) CT: ground glass at onset  really bad! Fibrosing alveolitis

GI Tract
 Fibrosis can involve muscle layers  hypomotility
 Esophageal dysmotility = “E” in “CREST” syndrome

Upper GI Lower GI
 Dysmotility
 Swallowing difficulties  Constipation/ diarrhea
 Acid reflux  Bacterial overgrowth
 Delayed gastric emptying  Malabsorption
 Dyspepsia  Malnutrition / wt loss

Pic: barium enema: sacculation of

Pic: esophageal dysmotility terminal ileum, bunching of folds

81
 Vascular Disease in Scleroderma
Progressive impairment of MICROVASCULAR bed leading to ↓ blood supply  tissue / organ chronic ischemia
Microvascular = capillaries, arterioles; macrovascular = medium/large arteries

Triggers (infections, immune activation, ischema / reperfusion – like Raynaud’s) lead to endothelial dysfunction
 Response: Apoptosis, ↑ adhesion molecules, ↑ vascular smooth muscle cells, vasoconstriction
 All these things lead to vessel occlusion  chronic ischemia, which damages things even more
 The end result? A vicious cycle of damage  dysfunction  response  ischemia  damage!

Note: this isn’t a dramatic inflammation like vasculitis

 Vascular smooth muscle cells, fibroblasts migrating into the intima, depositing collagen
 Not tons of mononuclear cells, etc. like in vasculitis

Molecular mediators in scleroderma vascular dysfunction: ↓ vasodilators, ↑ vasoconstrictors

Molecule Function Levels in SSc
Endothelin-1 Vasoconstriction, VSMC proliferation, fibroblast activation ↑
Nitric oxide SMC relaxation, vasodilatation, anti-inflammatory, ↓ VSMC, etc. ↓
Prostacyclin vasodilatation, ↓ platelet aggregation, ↓ VSMC, etc. ↓

Clinical manifestations of vascular dysfunction

 Note that most are microvascular in nature
 But macrovascular complications too!

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 Telangiectasias (“T” in CREST)
Abnormal nailfold capillaries  Digital capillary microscopy
 Bundles of capillaries reorganize
 Good early findings; can check here (almost 100% SSc have them)
 Create small lakes of blood
 Progression (LR: normal  dilated capillaries  “dropout”)
 Prone to bleeding!

Raynaud’s Phenomenon
The “R” in CREST
 Common; NOT SPECIFIC for scleroderma (≈ 5% of population!)

Episodic ischemic events

 in response to cold or emotional stress
 with typical color changes in fingers & toes
o Pallor (white) or
o Cyanosis (blue)

Affects distal arteries (constrict  discoloration)

Pathogenesis:
 Normally, cold  shut down external capillaries (get blood to important parts)
 Raynaud’s is an exaggeration of this normal response (total occlusion) in response to a trigger

Phases:
White (pallor) Blue (cyanosis) Red (blushed)
Vasospasm Venostasis Reactive hyperemia
(no blood in fingers) (blood stuck behind; Hb gets oxidized) (fresh blood flowing in)

Primary Raynaud’s: condition starts on its own – just an aberrant vasomotor regulation

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Consequences in scleroderma
 In scleroderma, it’s a 2° Raynaud’s phenomenon

 Combo of causes - together, make it more likely to happen!

o Vasospasm = reversible
o Small blood clots can occlude (permanent!)
o Vessel fibrosis from scleroderma  narrowing

Can end up with:

 Obstructive vasculopathy – lose circulation to fingers!
 Ischemic digital ulcers
o A big RED FLAG – typical spastic Raynaud’s won’t give you ulcers!
o Can be really painful!

Obstructive vasculopathy Ischemic digital ulcers

Calcinosis
The “C” in CREST
 Get calcium deposits under skin
 Can rupture  ↑ ulcers, etc

Macrovascular Disease in Scleroderma

Macrovascular involvement  digital gangrene / digit loss; renal crisis, pulmonary arterial hypertension
Digital Gangrene & Finger loss
 If bigger vessels are involved, can get big-time ischemia to digits  may have to amputate!

ulnar artery involved here Digital gangrene  finger / toe loss

Scleroderma Renal Crisis

 If bigger vessels involved  clog big arteries of kidney  quick onset of ACUTE RENAL FAILURE
 Can very quickly become dialysis-dependent; only 50% recover (really bad sign)
 ACEi are an effective therapy – but need to catch it early!

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 Renal arteriogram: “pruned” appearance in Histology : note thickened vessel walls, occluded lumen.
scleroderma (compromised blood flow) Gross : renal infarcts

Pulmonary Arterial Hypertension

 A big deal when it develops 
 PARTICULARLY POOR PROGNOSIS

Pathogenesis:
 Environmental factors / genetics 
 Endothelial injury 
 Vasoconstriction, remodeling 
 In situ thrombosis 
 pulmonary hypertension  more injury!

Histopathology: Immune activation, Fibrosis, Obliteration X-ray: see large but “pruned” pulmonary arteries
maybe immunosuppressive drugs could help? (vs. CHF, etc  would see dilation whole way out)

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 Treatment Options for Scleroderma
To treat… You can use… Type of treatment
• Vasodilator therapy
Raynaud’s phenomenon • Calcium channel blockers Supportive
• Phosphodiesterase inhibitors
• Antacids
Gastrointestinal dysmotility Supportive
• Pro-kinetic agents
Immunosuppression
Diffuse skin disease (active)
• Cyclophosphamide Non-selective
Fibrosing alveolitis (early)
• Mofetil Mycophenolate (Cellcept)
Scleroderma Renal Crisis  ACE inhibitors Targeted
• Prostaglandins
Targeted
Pulmonary Hypertension • Endothelin-1 inhibitor
• Phosphodiesterase inhibitors Disease-modifying

Fibrosis • Thyrosine kinase inhibitors Targeted

(lungs, skin, gut, heart, kidneys, vessels) • TGF- inhibitors Disease-modifying
Note: there’s no direct anti-fibrotic treatment available right now!

Review: CREST

C R E S T
Calcinosis Raynaud’s Esophageal dysmotility Sclerodactyly Telangectasia

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 Pharmacology:
Immuno / Rheum
Drug Hypersensitivity..................................................................................................................................................2
Pharmacologic Manipulation of the Immune System ....................................................................................................7
Immunopharmacology of Transplantation..................................................................................................................13
NSAIDs.....................................................................................................................................................................17

1
 Drug Hypersensitivity
Classification of Adverse Drug Reactions
Adverse reactions occurring in normal patients Adverse reactions occurring in susceptible patients
 Overdose
 Intolerance
 Side effects
 Idiosyncrasy (pharmacogenetics)
 2° or indirect effects
 Allergy or hypersensitivity
 Drug interactions
Immunogenicity & Drug Reactions

Drug hypersensitivity
 Idiosyncratic reactions = non-immunologic
 Allergic reactions = immunologic

Immunogenicity: For drug to provoke antibody production from B cells, you need two signals
 Signal from T-helper cell
 Cross-linking of BCR by epitope

Need multivalent epitope presentation for cross-linking – but most drugs are small!
 Complete allergens (multi-valent themselves – need to be big enough!)
 Direct haptenation allergens (they themselves can act as haptens)
 Metabolite hapten allergens (metabolites act as haptens

Complete drug allergens
Need to be big enough! Think proteins!
 Insulin, other hormones
 Enzymes, protamine
 Antisera
 Recombinant proteins (rarely)
 Vaccines
 Multivalent chemicals (succinylcholine,
quaternary NH4 compounds)
Don’t need to memorize all of this!
Direct hapten drug allergens Metabolite hapten drug allergens
 β-lactam antibiotics
 Sulfa drugs (hydroxylamine)
 Quinidine
 Phenacetin (hydroxylamine)
 Cis-platinum
 Acetaminophen (quinine imine)
 Barbituates
 Phenytoin (arene oxide)
 Penicillamine
 Procainamide (hydroxylamine)
 Anti-thyroid drugs
 Heavy metals (gold)
 Halothane (radicals, acyl halide)

Complete Drug allergens

Succinylcholine: neuromuscular blocking agent; used in anesthesia

 Quaternary NH4 can be recognized by immune system
 Has two groups on either end – just large enough to be multivalent
 Other neuromuscular blocking agents have the same quaternary NH4  immunogenic!

Direct Haptenation
Drug binds covalently & irreversibly to a large macromolecule,
 which then presents itself as an allergen to the immune system
 Macromolecule can be either covalent or circulating

Metabolite hapten allergens

Metabolism (e.g. by CYP in liver) generates highly reactive metabolite,
 which can then act as a hapten on macromolecules

2
 Allergenicity
Similarly to immunogenicity, need multivalent presentation to mast cell / basophil to generate allergic response

Whole spectrum of immunopathologic reactions can occur with drug exposure!

Type (Gell-Coombs) Description Example of allergic drug reactions
I Anaphylaxis (IgE-mediated reactions) Acute anaphylaxis, urticaria
II C’ dependent cytolysis Hemolytic anemia, thrombocytopenia, interstitial nephritis
III Immune complex damage Serum sickness, drug fever
IV Delayed or cellular hypersensitivity Contact dermatitis, delayed r ashes

Penicillin Allergy
 Responsible for 50% of all allergic skin reactions to drugs

Prevalence: ↑ with exposure

 8% of outpatients
 10% of acute medical inpatients
 25% in surgical ICU

Manifestations
 35% urticaria (hives)*
 20% exanthem*
 7% anaphylaxis*
 29% other, 9% uncertain
*urticaria, anaphylaxis, and probably some of the rashes are IgE mediated via hapten pathway

Mechanism:
 Penicilloyl-protein intermediate is major antigenic determinant
o Penicillin reacting with proteins  hapten
o Doesn’t require any enzymes

 Minor antigenic determinants can be made from protein coupling by

isomer of penicillin (penicillenic acid)

Skin Testing for Penicillin

In ≈ 15 min, these agents will do their thing (hapten generation, etc.)

If IgE present  mast cells degranulate, etc!  get a wheal & flare
 Major determinant = use PPL (penicilloyl-polylysine)
 Minor determinant = use MDM (minor determinant mixture of penicillin-G, penicilloate, penilloate)

Prevalence of + penicillin skin tests

 About 2 % of population have negative history but positive skin test (risk for unexpected serious allergic reactions)
 Only 7.1% of pts with any positive history will have a positive skin test
 Only 13.2% of pts with history of anaphylaxis or urticaria have a positive skin test!

3
So are these tests no good, or are these patients no longer allergic? Skin test results % acute allergic rxn
 Patients with (+)Hx but (-)test challenged with PCN  no higher risk! PPL positive 50
 PENICILLIN ALLERGIES are NOT FOREVER! MDM positive 70
Both negative 2-15*
*and almost all minor (a little itching, etc)
Take-home: penicillin allergies are not forever!
 You can give penicillin to an “allergic patient” if needed, if skin testing OK

Non-IgE Drug-induced Immunopathology

Cytotoxic (type II) and Immune complex (type II) reactions
 Usually after prolonged high-dose therapy
 Drug IgG may be present in high titer
 Risk factors: immune responsiveness & cumulative dose

Type IV
 Usually dermatitis or hepatitis
 Rare except for occupational exposure (e.g. making up penicillin by hand in old days)
 Examples: hepatitis from analeptics, antithyroid drugs, TB drugs

 Lymphocyte transform ation test

o Idea is to see how lymphocytes react when exposed to allergen; Not very useful (many clinical false positives)

Other β-lactams & Cross-reactivity with Penicillins

Penicillins & cephalosporins
 Experimental cross-reactivity is very high (expected – very similar structure)
 Clinical cross-reactivity is variable
 Skin testing: 30-50% cross-reactivity

Individual risk of having reaction (if penicillin skin tests positive)

 Penicillin = 50-70%
 Cephalosporins = 15-25%

Other β-lactams
 Similar reactivity except for monobactams
 Once ring opened, monobactams don’t have the “core structure” to generate immunogenicity

Risk Factors for Drug Allergy

 Immune recognition
 Persistence of IgE antibody (usually lose with age, but some persist)
 Constiutional component
o need something else: not everybody has rxn with + skin test! Atopy, etc. may be involved
 ↑ age (may be related to ↑ cumulative exposure with age)
 High dose and/or parenteral administration (more likely to both sensitize & elicit response)

4
 Drugs that cause reactions
Good list to know for clinical practice
Idiosyncratic Immunologic
 Primacrine sensitivity (G6PD deficiency)
 Isoniazide (acetylator status)  Penicillins
 Phenophthalein
 Halothane, succinylcholine (malignant hyperthermia)  Cephalosporins
 Anti-TB drugs
 Succinylcholine (pseudocholinesteraes)  Sulfonamides
 Anti-thyroid drugs
 Barbituates (acute intermittent porphyria)  Quinine / quinidine
 Cis-platinum
 Aspirin, N SAIDs  Muscle relaxants
 Anticonvulsants
 Radiocontrast media (quaternary NH4 compounds)
 Local anesthetics (most)

Idiosyncratic Reactions
Not immunologic, but look like allergic reactions in a clinical sense
 Can happen with first exposure (don’t need to be sensitized!)

Aspirin Sensitivity
 NSAIDs very similar too
 Not actually “allergic” to aspirin – no Ab!

Clinical features: all look like IgE-mediated symptoms but none around!)
 Bronchospasm  Urticaria  Anaphylaxis
 Nasoocular Sx (red eyes, etc)  Angioedema

Aspirin sensitivity in asthmatics

 Prevalence 10-30%; onset > age 30 (adult-onset asthmatics)
 Typically non-atopic females
 Associated conditions:
o Perennial rhinitis (non-allergic, not seasonal),
o Chronic sinusitis, Nasal polyps
o Steroid-dependent asthma (some, not al)

Pathogenesis: evidence for idiosyncrasy, not allergy

 Aspirin is really small
 ASA acetylated proteins are poorly immunogenic
 Cross-reactivity with NSAIDs with unrelated structures (probably not Ab-mediated)
 Common functional property of NSAIDs = inhibit prostaglandin synthetase

Theory:
 Aspirin blocks COX
 Shunts arachidonic acid pathway towards leukotrienes
 Leukotrines can be causing these reactions

Evidence:
 LTs ↑ with aspirin in these pts
 LT receptor antagonists block ASA asthma
 Doesn’t explain ↑ airway sensitivity to leukotrines, cellular source,
or basic defect (why doesn’t this happen in everybody?)

5
Why is it important to distinguish between allergenic & idiosyncratic reactions? Changes the way you treat the patient!

 Don’t use NSAIDs in an ASA-sensitive patient

o cross-reactive based on functional similarity, although structure different

 Can use various agents that have similar structures - not Ab-dependent!
o Sailcylate salts, salasate, propoxyphene, phenylbutazone, acetaminophen, corticosteroids all OK!

Summary

Allergy vs idiosyncratic rxns

Allergic Idiosyncratic
Example Penicillin Aspirin
↑ risk of allergic drug reactions in general Yes No
Persistence of risk in specific reactions dissipates with time Variable
Cross-reactivity patterns Common structure Common function
Manifestation Bronchospasm, urticaria, anaphylaxis

6
 Pharmacologic Manipulation of the Immune System
Introduction
Used in: immunodeficiency disorders, cancer, infectious diseases, pregnancy, autoimmune diseases
Challenges: complexity, redundancy, & interconnectedness of immune system
 Example: T-cell & APC interacting in the LN: multiple receptors = multiple targets
o TCR matching MHC + peptide, costimulatory receptors leading to activation or anergy, etc
o Targets can be general (all T-cells) or specific (subtypes)

Colony Stimulating Factors

Small proteins that drive the production of hematopoetic cells
 Multilineage factors (e.g. IL-3; differentiation of all these cell types)
 Lineage-specific factors (e.g. EPO, only in generation of RBC)

Structure: range of sizes, disulfide bonds maintain structure

Signaling:
 bind surface receptor
 signal through ras/raf/MAPK or JAK/STAT pathways

Note that multiple types of cells are capable of producing CSFs

 endothelial cells, fibroblasts, T-helper cells, etc
 Recombinant CSFs must be made in eukaryotic cell cultures

Sources Major targets

IL-3 T-helper cells Granulocytes, eos, basos, monos, RBCs, megakaryocytes
GM-CSF Fibroblasts, endothelial cells, T-helper cells, monos, Mϕ Granulocytes, RBCs, eos, megakaryocytes, monos
G-CSF Fibroblasts, monos, Mϕ, endothelial cells Granulocytes (others at high concentration)
EPO Renal peritubular cells RBCs
M-CSF Monos, Mϕ, endothelial cells, fibroblasts Monos, Mϕ

The G-CSF receptor:

 Contains 4 cytoplasmic non-receptor TKs that are rapidly P-lated, mediate downstream effects
 Expressed on PMNs & precursors
o Also on endothelial cells including umbilical cord & coronary artery cells
o Also on CNS neurons & progenitors; other cell types too (activated T-cells, cardiac myocytes, others)

Clinical applications of CSFs

 Basic use is stimulation of production of mature, functional PMNs
o Used both for acquired (transplantation) & congenital (agranulocytosis) neutropenic states
 Stimulate Mϕ & PMN functions (migration, phagocytosis, ADCC, oxidative metabolism, factor secretion)
 Also found to have use in myocardial infarcts

Clinical benefits of CSFs

1. Higher neutrophil count at the nadir (lowpoint)
2. Shortened nadir duration
3. ↓ serious infections
4. ↓ treatment delays (e.g. chemotherapy)
5. ↓ days of hospitalization

Recombinant G-CSF (filgrastim) Approved for treatment of neutropenia following standard dose chemo
Recombinant GM-CSF (sargramostim) Approved for treatment of chemo-induced neutropenia in BMT

7
Pharmacokinetics
 IV – big, r apid rise in plasma concentration (to 5x higher than needed
clinically), then rapid drop to almost undetectable levels, with β-phase of
elimination over hours

 Subcut aneous – slow rise over 2-3 hrs to more modest concentration,
sustained for 10-12h, then elimination over 10-12h

 SUSTAINED concentration is MORE EFFECTIVE, so give it SUB-Q (or IM)

Other Effects

G-CSF for MI?

 G-CSF receptors on myocytes: if you give G-CSF in a rat model of MI, see
better survival of animals & heart mm
 Protect heart muscle from irreversible death from ischemia
o Mixed results in humans, but do induce release of appropria te
progenitor cells into bloodstream, LV function ↑?

Interferons
Discovered as small proteins that “interfere with” ability of viruses to replicate

Induced by various stimuli

 Foreign cells
 Foreign nucleic acids
 Foreign antigens

Types of Interferons
Immune interferons Type I interferons
Examples IFN-γ IFN-α (leukocyte), β (fibroblast)
Production Antigen-MHC complexes,
Viruses, other microorganisms
stimulated by activating NK cell ligands, IL-12, TLRs
Produced by NK cells, T-cells All nucleated cells
Receptors All nucleated cells All nucleated cells
# Types Just one Multiple types per species
Expression of class II / II MHC, tumor Ag, cytokine receptors,
Expression of MHC-I, tumor Ag, cytokine
Stimulates adhesion molecules, FC receptors , ADCC activity, PMN / Mϕ
receptors, ADCC activity
chemotaxis / activation, phagocytosis, free radical generation
Virus attachment, uncoating, early
transcription, translocation, virus budding
Inhibits Virus replication & tumor cell growth
Tumor cell growth, oncogene induction
IL-4-induced IgE synthesis, collagen synthesis

Signaling
 Bind receptor, JAK-STAT signaling
o P-lated STAT dimers go to nucleus, affect gene expression

 Pleotropic effects mediated through gene expression

Study: knock out the IFN-receptor (easier than knocking out all IFNs ), ↑ viral infections in mice

8
Pharmacokinetics
Data for IFN-α, applies to other interferons
 IV: see rapid spike, drop-off (slower than CSFs)
 IM: quick onset, sustained concentration
 Subcut aneous: slightly slower onset, sustained concentration
 MORE EFFECTIVE WITH SUSTAINED CONCENTRATIONS:
o GIVE IM OR SUB-Q

Pegylation
 Add PEG (polyethylene glycol) to reactive lysine residues on IFN ( can add in straight chains or branches)

 Dramatically changes pharmacokinetics!

o Graph to right: for IV IFN: half life from a few hours to DAYS!
o ↑ peak, ↓ clearance  ↑ t1/2 , ↑ sustained duration

o Basically making a “sarcophagus” of PEG around the protein – PEG prevents

catabolism by receptor-mediated uptake / br eakdown by RES
o There is a ↓ effect on binding to receptors, but still enough to signal!
o Net balance ↑ signaling!

o Pegasys (PEG40kD IFN) can be given once weekly

Clinical Applications
Agents Used in
IFN-α + ribavirin Chronic hepatitis C - standard of care (3x weekly)
Ribavirin Broad-spectrum anti-viral drug (purine nucleoside analogue)
Pegylated IFN (Pegasys or PEG Intron) + ribavirin Chronic hepatitis C (widely used)
Pegylated IFN In testing for other infectious / malignant disease

Immunoglobulins

Make good drug candidates: Long half-life (21d for IgG); high specificity, limited side effects (if human)

Standards for IVIg

 Clinical utility started with simple goal: provide IgG to pts who don’t have them
 Initial preparations crude, administered IM
o aggregates formed, cross-linked Fc receptors  C’ activation  vascular collapse!

WHO criteria (1981)

1. Wide spectrum of Ab 5. Pyrogen-free
2. Half life should be ≈ normal IgG 6. Low IgA levels (some pts born without IgA!)
3. All IgG subclasses should be present 7. Should be sterile, stable, inexpensive
4. No aggregates present (all IgG monomeric)

Seven IVIgG preps licensed for use in USA (all pretty much meet WHO criteria)
 NO DOCUMENTED CASES of DISEASE TRANSMISSION!

9
Clinical Applications
Primary Secondary
Autoimmune diseases
immunodeficiency immunodeficiency
Fc-receptor blockade
Ab replacement Ab replacement Anti-idiotype Abs
Immune modulation?
Severe burns (lose proteins) Protein-losing enteropathy ITP
Hypogammaglobulinemia
CLL AIDS Chronic idiopathic neutropenia
XLA, etc
Nephrotic syndrome BMT recipients Kawasaki syndrome

Pharmacokinetics
 Wide interpatient variation in IgG catabolism
 Lot-to-lot variation of preparations (depends on donors)
 Half-life are equivalent to normal IgG (21d)

Adverse effects
Most related to infusion rate: myalgias, fevers, muscle aches, headaches
 NO DOCUMENTED CASES OF HBV/HIV/DISEASE TRANSMISSION

Monoclonal Abs
Drug potential based on:
 Exquisite specificity for a single epitope
 Wide range of Ag to which mAb can be prepared (any macromolecule – lipid, protein, whatever)
 Unlimited availability
 Very high batch-to-batch consistency (affinity, purity)
 Relatively long half life (range 1-3d for murine, 21d for humanized)

How to make an mAb:

 Traditional approach: i mmuni ze mouse with Ag; remove spleen, fuse to myeloma cells; hybridoma cells selected wi th appropria te
drug, coned  propoga ted in cul ture / animals, purify Abs
 Phage display libraries (now method of choice): Insert Ig Fv (va riable sequence pa rts of genes , from libra ry) genes into
ba cteria , infect with phage  infected ba cteria produce phases displa ying Fv  pha ges s creened for binding to Ag; genes from selecti ve
phages put back into bacteria  Ab fragments produced in mass quani ti tes (or ba ck into human backbone to make whole IgG)

“Designer antibodies” – neutralizing Abs

 All use IgG heavy chain backbone

 Take a recognition area of receptor (e.g. CD4) & put in light chain area
o Theory – should bind to HIV (which normally binds CD4), neutralize!
o In this case, turned out you were actually priming GP120 to bind chemokine receptor

 Goals of designer antibodies (vs just recombinant protein)

o Improve avidity (two binding sites), even if you don’t improve the affinity
o Improve half-life (much longer than if you just inject protein alone)

Mouse vs. Humanized mAbs

 Major limitation to use of mouse mAbs is formation of anti-mouse Ig (HAMA – human anti-mouse Ab)
o Could only use 2-3 courses of treatment for mouse Abs
o HAMA can cause anaphylactic shock 2° to immune complex formation if mAb readministered
o HAMA can also bind mAb & limit therapeutic effect

 Progression: chimeric  humanized  fully human

10
 Only specific binding parts
Fc, Fab both from humans Mouse Fab, human Fc All human
of Fab from mouse

Current Status
 Now 23 mAb approved for human use; several await FDA approval (two conjugated to r adioisotopes for cancer!)
o All kinds of targets! Transplant rejection, clotting, NHL, breast cancer, RA/crohn’s, RSV, leukemia, CLL
 Actually cheaper to produce as drugs ($2M to get ready for for human trials, vs $20M for traditional drugs)!
 Remarkably safe / non-toxic

In the Genomics Era

 Most Mabs now used are humanized by “brute force” – splice mouse Mab into human Ab backbones
 Numerous problems – altered affinities, altered specificity, length, trial & error – or computerized modeling
 Two companies: genomics era approach (have produced mice with human immunoglobulin genes!)
o When immunized, these animals make normal Ab responses with HUMAN Abs
o These companies license mice to other companies; get royalties (HuMAb mouse, Xenomouse)

Limitations & Solutions

 Not enough capacity (bioreactors) to make enough proteins (need 20-30 more to make that many)
o Maybe use transgenic plants?
 Tobacco? produce for as little as $1/gram (vs $300/g in bioreactors)? Corn? Ab end up in corn oil !
o Goats / cows & get Ab in milk?

Rheumatoid Arthritis & TNF-α

RA is a systemic disorder characterized by chronic inflammation
 associated with autoimmunity (T-cells / Abs)
 Effects localized mainly to joints
 Associated with ↑ levels cytokines, adhesion molecules in synovium of joints
 Affec ts 0.5-1% of population

TNF-α is really involved in RA: if you can target TNF-α, you can ↓ production of other pro-inflammatory cytokines
 An “alarm signal” – but can have both pro-inflammatory & anti-inflammatory effects
 Lots of drug companies started making Ab against TNF-α (human Ab, humanized, chimeric, pegylated Fab, etc)
 Good response (block granulocyte migration into joints; also ↓ joint swelling, subjective assessment of Sx)
o Also lowers circulating VEGF levels

STANDARD OF CARE is now to give Ab agent in RA

Remicade (infliximab) chimeric anti-TNFα Ab mouse mAb Fv fused to human IgG1 Fc
Enbrel (etanercept) chimeric “designer antibody” p75 TNFα receptor domains fused to human IgG Fc
new player, made from transgenic mice
Simponi (golimumab) human anti-TNFα Ab
 2 wk half life –self-injection q1m!

11
Progressive Multifocal Leukoencephalopathy (PML)
Rapidly degenerative neurological condition; most often seen in AIDS pts; also seen in other immunosuppressed pts

Caused by JC virus (polyomavirus) – very common in US; usually harmless

 Reactivated in immunocompromised patients (demyleinization  severe neuro problems  often death)
 Also see in people taking mAb drugs that BLOCK T-CELL FUNCTION (migration into brain)
o Raptiva (anti-LFA-1) and Tysabri (anti-VLA4) – e.g. MS
o Withdrawn from market (until method developed to determine basis for susceptibility to PML)

Plasmapheresis
Plasmapheresis is a kind of apheresis
 Whole blood separated into components (usually by centrifugation)
 Component(s) removed / stuff put in
 Blood put back in

Plasmapheresis: the removal & retention of plasma

 = “plasma exchange”
 Purpose is to remove offending agent in plasma
 Large volumes must be exchanged for clinical benefit

Uses
Immune complexes (SLE)
Autoantibodies, alloantibodies
Ab causing hyperviscosity (Waldenstrom’s macroglobulinemia)
Inflammatory mediators (fibrinogen, C’)
Ab blocking immune system fxn
Protein-bound toxins (barbiturate poisoning)
Lipoproteins (cholesterolemia)
Platelet aggregating factors

Technique: Run plasma through affinity column / filter

Absorbent Substance removed Clinical application

Activated Charcoal Bile acids Cholestatic diseases
A/B antigens Anti-A & B Abs Transplantation
Anti-LDL, heparin LDL Hypercholesterolemia
DNA Anti-DNA Abs, ICs SLE
Protein A (staph), protein G (strep) IgG, ICs ITP, cancer, hemolytic syndromes

Clinical Use
Benefit affected by several factors
 Synthesis / catabolism of offending agent (is it still being made?)
 Distribution of agent between intravascular / extravascular space
Ab Characteristics Plasmapheresis
IgM Intravascular, slow synthesis very effective
Equal distribution in intravascular / extravascular space
IgG not good (re-equilibrates back to blood)
Synthesized more rapidly

Special considerations
 IgG removal induces increased Ab synthesis (rebound effect)
 So IgG plasmapheresis should be combined with immunosuppressive drugs
12
 Immunopharmacology of Transplantation
Take-Home Messages
 T-cell response is responsible for organ rejection
 Inhibition of CD4 T-cells’ activation is a major strategy to block organ rejection
 Calcineurin is the major signal transducer of calcium signaling in peripheral tissues
 CsA, FK506, and rapamycin represent a novel type of drug:
o Work by bringing two proteins together to block the function of the target protein

The Molecular Basis of Organ Rejection

Remember:
 MHC I (lots of cell types, present intracellular Ag)  CD8
 MHC II (APC mostly, present extracellular Ag)  CD4

CD4 T-cells activate CD8 T-cells

 Leads to robust immune response  rejection

B-cells activated too (Ab, plasma cells)

 less important in rejection

Classic mouse experiment

 If syngenic: no rejection
st
 If allogenic – rapid 1 set rejection (different MHCs)
nd
o Second graft – faster 2 set rejection
 If you sensitize a mouse, then transfer T-cells to a
nd
new mouse & give graft – see fast 2 set rejection!

So T-cells are necessary & sufficient for rejection

Signaling involved in CD4+ T-cell Activation

These are targets for therapeutics!

 TCR interaction with MHC II-peptide complex

o Intracellular signal transduction (TCR to nucleus, via Ca+2 )
o activates cytokine production

 T-cell surface receptor interaction with cytokines

o IL-2: signaling  T-cell proliferation, clonal expansion
o Intracellular signal transduction pathways from
cytokine receptors can be target too

 General T-cell proliferation

13
 Classes of Immunosuppressive agents
Inhibitors of MHC/peptide-TCR interaction
Need APC/T-cell interaction (MHCII-peptide / TCR) interaction to activate T-cells – so develop Ab against TCR

Mechanism of Action: Ab against TCR: made from animals (horse, rabbit, sheep, goat)
with human thymocytes as antigens
antithymocyte
Effects: blocks TCR / MHC-peptide interaction (can't activate T-cells!)
globulin
Indications: used to prevent acute rejections
Toxicity: MAJOR - serum sickness, nephritis (from immune response to animal Ab)

Mechanism of Action: anti-CD3 Ab

 prevents T-cell activation by MHC-peptide complex & rapidly depletes circulating T-cells

Indications: help prevent transplant rejection

anti-CD3 Ab
Selective Toxicity: Can be humanized (prevent immune response to antibodies themselves)
(Orthoclone OKT3)
Toxicity: Also can bind bivalently & act as agonists of TCR!
 Leads to secretion of cytokines & side effects
 "cytokine release syndrome" - mild flu-like illness or severe shock-like reaction; can be lethal!

Inhibitors of TCR-mediated intracellular signal transduction

Steps in signaling
1. MHCII-peptide complex binds TCR
2. Activation signal transmitted into cytosol, then nucleus of T-cells – transmission requires calcium!
3. In nucleus  ↑ transcription of cytokine genes

Calcineurin’s normal action

Calcium, calmodulin-dependent protein phosphatase, which transduces Ca signal into nucleus
 ↑ Ca  calmodulin activated, binds calcineurin
 Activated calcineurin dephosphorylates NFAT (nuclear factor of activated T-cells)
 NFAT binds enhancer regions of cytokine genes  ↑ transcription (↑ IL-2 production)
 IL-12, other cytokines promote T-cell activation (autocrine signaling)

Mechanism of Action of CsA & FK506: block T-cell activation via calcineurin inhibition
 CsA / FK506 enter cell Bind to a protein called an immunophilin: cyclophilin for CsA, FKBP for FK506
 CsA-cyclophilin or FK506-FKBP complexes bind calcineurin (protein phosphatase 2B)
 Inhibit calcineurin’s activity  NFAT stays in cytosol
(even when TCR engaged with MHCII-peptide)
o No secretion of IL-2  no T-cell activation!

14
 Mechanism of Action: Inhibitor of the TCR-mediated intracellular signaling pathway.
 more in depth: cyclosporine A recruits cyclophilin (an immunophilin protein receptor); the complex
inhibits calcineurin, which can't deP-lateNFAT, so p-lated NFAT is stuck in the cytosol (needs to be
de-p-lated to translocate to the nucleus & bind enhancer reginos of cytokine genes).

Effects: Blocks calcium-mediated signaling, which would normally leads to gene transcription
modulation & cytokine production by CD4+ T-cells.
 No IL-2 / other cytokine secretion means no T-cell activation!

Indications: frontline therapy to prevent rejection

cyclosporine A  has changed the game for organ transplantation (can give long-term)
(CsA, Sandimmune)
Administration: IV and oral; oral now more popular (new formulations)
Pharmacokinetics: peak [plasma] within a few hours.
 over 50% sequestered in RBC (serve as reservoir for drug)

Metabolism: extensively metabolized in the liver (CYP450 A3) to over 30 metabolites.

 Excreted mostly bile to feces, small fraction to urine
Toxicity: nephrotoxicity (same mechanism as immunosuppression ) - don't use in kidney transplants

Other: fungal metabolite; a hydrophobic cyclic peptide

Mechanism of Action: Inhibitor of the TCR-mediated intracellular signaling pathway.

 more in depth: FK506 recruits FKBP (immunophilin); rest same as CsA

Effects: like CsA

 Specific to FK506: Actually stimulates hepatocyte growth. 10x more potent than CsA.

FK506 Indications: Alternative & sometiems complementary option to CsA for organ transplant patients.
 Widely used in liver transplants (actuallystimulate hepatocyte growth)
Administration: IV, oral
Pharmacokinetics: peak [plasma] in a few hours (like CsA)
Metabolism: Also extensively metabolized in the liver
Toxicity: Mainly nephrotoxicity (like CsA) - don't use in kidney transplants
Other: Polyketide of bacterial orgiin - discovered by bioassay (offspring of CsA)

Inhibitor of cytokine – receptor interaction

 IL-2 is one of the most important signals to stimulate T-cell proliferation
 mAb against the IL-2 receptor blocks T-cell proliferation - used in the clinic to prevent organ rejection

15
Inhibitors of cytokine receptor-mediated signal transduction
Binding of IL-2 to IL-2 receptor leads to signal transduction cascade  ↑ proliferation (cell cycle progression) of T-cells
 Inhibit this signaling pathway  blocks T-cell activation

Rapamycin (=sirolimus/SRL) structurally similar to FK506, binds FKBP

 But complex doesn’t affect calcineurin

 instead, inhibits mTOR (molecular target of rapamycin)
o mTOR = FRAP (FKBP-rapamycin associated protein) = RAFT
(rapamycin & FKBP target)

 mTOR is a phospholipid kinase: regulates both transcription &

translation of T-cell proliferation genes, so ↓ proliferation

Mechanism of Action: Inhibits cytokine receptor mediated signal transduction, preventing T-cell
proliferation. See above for details
Effects: ALLOWS FOR INDUCTION OF TOLERANCE (an extra advantage)
rapamycin /  blocking proliferation, not activation pathway, so TCR-MHC pathway intact
sirolimus  can induce anergic / Treg pathway diff if strong TCR binding but no costimulatory molecules!

Indications: immunosuppression, synergistic with CsA & FK506.

Toxicity: Reduces dose of CsA or FK506 needed, so less toxicity

Inhibitor of T-cell proliferation

Mechanism of Action: (selective) inhibitor of T-cell proliferation.
 Prodrug for mycophenolic acid (ester cleaved), which inhibits inosine monophosphate
dehydrogenase, required for de novo purine biosynthesis
Effects: Leads to cell cycle arrest of proliferating T/B cells in G1
mycophenolate
mofetil Selective Toxicity: T/B cells rely on de novo purine biosynthesis (don't have hypoxanthine-guanine
phosphoribosyl transferase salvage pathway), so selectively sensitive to de novo pathway inhibition

Indications: Used primarily in renal transplant.

 Has anti-angiogenic activity too (endothelial cells rely on de novo pathway exclusively too!)

Other Inhibitors
 Steroids: Still use glucocorticoids as immunosuppressants (inhibit T-cell activation)
 Cytotoxic drugs
o T-cells susceptible to non-specific inhibition by cytotoxic drugs (anti-neoplastic products)
o Asathioprine, cyclophosphamide – have severe side effects, have been mostly replaced by CsA / FK506

16
 NSAIDs
Aspirin is the only irreversible inhibitor of this class!
History
 Willow bark  salicylic acid (not well tolerated)  acetylated (aspirin = acetylsalicylic acid): Bayer: Hoffman/Dreiser (1899)
 Traditional N SAIDs (Anti-inflammatory); “aspirin like”, found to inhibit enzymatic production of prostaglandins
 COX-2 selective (1999, problems)
 Today: 3-9% prescriptions worldwide; 80B tablets / yr consumed

Classes of NSAIDs

Agent Inhibition Examples

Aspirin Irreversible, non-selective
 Ibuprofen (Advil, Motrin, Nuprin, Medipren)
Traditional NSAIDs Reversible, non-selective  Naproxen (Aleve, Anaprox, Naprosyn)
 Also: indomethacin, diclofenac, ketorolac, ketoprofen, tolmetin,
piroxicam, meclofenamate, flurbiprofen, oxaprozin, nabumetone
COX-2 inhibitors Reversible, selective celecoxib, rofecoxib, valdecoxib

NSAID effects
Desired Undesired
 Analgesia  GI: ulcers, bleeding, perforation
 Anti-pyresis  Cardiovascular
 Anti-inflammatory  Renal

Desired effects
 Effective against pain of low-to-moderate intensity
Analgesic
 Lack unwanted effects of opiods
Anti-pyretic Reduces body temperature in febrile states, not in exercise
Provides symptomatic relief from inflammation
Anti-inflammatory
 Acetaminophen ≪ NSAIDs < Immunomodulators

Mechanism of Action
NSAIDs inhibit prostaglandin synthesis! – All of these blocked!
Inflammation
Erythema From vasodilation PGE2, prostacyclin (PGI2)  erythema, ↑ local blood flow
Edema From vascular permeability PGE2 can cause edema and ↑ bradykinin/histamine effect
WBC migration Prostaglandins promote leukocyte migration by ↑ blood flow
All of these blocked when ↓ prostaglandins!
Pain & fever
Pain PGE2, PGI2  hyperalgesia
Fever PGE2  tells hypothalamus to ↑ body temperature (↑ heat generation, ↓ heat loss)
Both of these blocked when ↓ prostaglandins!

17
How do NSAIDs work?

 Steroids block Phospholipase A2

 NSAIDs block cyclooxygenase
o Prostaglandins have both “housekeeping” (good) & occasional (inflammation / pain / fever) roles
o COX-1 = “housekeeping” ; COX-2 = “occasional”

COX-1 COX-2
Ubiquitous Limited distribution
Inducible? Constitutive expression Inducible expression
Stimulated by cytokines, mitogens,
Stimuli? Slight increase with stimuli
growth factors
 Homeostasis  Inflammation
Functions  Physiology  Immune reactions
 Hemostasis  Mitogenesis
Steric block (prevents binding of Retains COX activity (although reaction
Acetylation by asprin
arachadonic acid @ active site) produces a novel product)

Structure

Big side pocket –

Selective inhibitors Can’t fit methyl group of COX-2 inhibitors! can accommodate bulkier COX-2 selective
inhibitors’ methyl groups

18
 Aspirin
Aspirin: irreversibly acetylates COX @ a serine residue

Acetylation by aspirin:
 Covalent: duration of effect is related to rate of synthesis of new COX in target tissues
o COX-1: Steric block in CO (prevents arachadonic acid binding @ hydrophobic active site)
o COX-2: retains COX activity
 Salicylate = weaker, reversible inhibitor

COX-1 vs COX-2 inhibitors

 Celexocib, other COX-2 inhibitors do selectively inhibit COX-2 ≫ COX-1
o Big, bulky side / groups (e.g. CH3) can fit into “side pocket” of COX-2, not COX-1
 Indomethacin, other traditional NSAIDs, inhibit both about the same (reversibly)

Desired effects
Celecoxib = traditional NSAIDs (naproxen, diclofenac) for all desired effects (e.g. RA - # pain / tender join ts, swelling, etc.)

Undesired effects: Gastrointestinal Effects

Mechanism: Inhibition of gastric mucosal protection (↓ COX-activity in GI mucosa).

 ↑ risk of GI effects: ↑ age, ↑ NSAID dosage, Hx of GI problems, concomitant corticosteroids or anticoagulants
 COX-1 but NOT COX-2 constitutively expressed in stomach – so COX-2 should ↓ incidence

Symptoms ↓ in COX-2?
 Heartburn / dyspepsia
Nuisance symptoms  Nausea / vomiting Yes
 Abdominal pains
Mucosal lesions on endoscopy YES! ↓ ulcers
 Bleeding
Serious complications  Perforation YES: significant reduction (VIGOR)!
 Strictures

19
Undesired effects: Cardiovascular Effects
↑ risk with COX-2 inhibitors (VIGOR – rofecoxib vs placebo)

Possible mechanism: platelet function?

Thromboxane A 2 (TxA2) Prostacyclin (PGI2)
 released by activated platelets  produced by COX in macrovascular endothelium
 serves as platelet agonist , potent vasoconstrictor  inhibits aggregation of platelets, vascular tone
Inhibit = antithrombotic Inhibit = prothrombotic

 Irreversible acetylation of COX-1 in platelets

(anuclear, can’t synthesize COX-1)
 1 dose aspirin inhibits platelet COX-1 for life of platelet
Aspirin
 Less effect on antagonistic PGI2 (COX-2-mediated) in
endothelial cells (synthetically capable)
End result: antithrombotic

 Minimal inhibition of platelet function (COX-1)

COX-2  ↓ prostacyclin effects; leads to unopposed TxA2
inhibitors
(coxibs)
End result: prothrombotic

NSAIDs (non-selective) – some may resemble pro-thrombotic effects of coxib

Postlude:
 Rofecoxib, valdecoxib  ↑ CV risk; rofecoxib (Vioxx) withdrawn; valdexocib (Bextra) probably soon
 Celebrex (celexocib) – adding boxed warning, medication guide (still used for select pts)

Undesired effects: Renal Effects

Normally, prostaglandins don’t play a big role in basal renal function

If renal hemodynamics compromised, prostaglandins start to have big role

 Help maintain renal perfusion, GFR (vasodilatory)
 In these cases, NSAID inhibition  ↓ prostaglandins
 Can result in acute renal failure!

At risk for acute vasomotor renal failure:

 Volume depletion  Hepatic cirrhosis  Diabetes mellitus
 Anesthesia  Nephrotic syndrome  Advanced Age
 Congestive heart failure  Sepsis  Renal insufficiency

20
 Pharmacokinetics
Traditional NSAIDs
Absorption Excellent
Distribution Highly protein bound
Mostly renal & hepatic (CYP450)
Metabolism / elimination  Short t1/2 (<5h): ibuprofen, indomethacin, diclofenac, fenoprofen, ketoprofen, tolmetin
 Long t1/2 (> 5h): naproxen, diflunisal, piroxicam, sulindac

Aspirin
Complex pharmacokinetics of elimination!
 Two saturable major pathways
 Three apparently 1st-order minor pathways

End result: DOSE-DEPENDENT HALF-LIFE

 The “half-life” increases with increasing doses (technically half-life = 1st order only)
 Example:
o 2.4h “half-life” for 0.25g
o 19h “half-life for 10-20g!

THIS IS A PROBLEM: even small increases in dose can result in disproportional increases in plasma [salicylate]!

Clinical Use & Side Effects: A Comparison

Non-selective NSAIDs COX-2 selective

Efficacy
Osteoarthritis  
Rheumatoid arthritis  
Acute pain  
Toxicity
GI XX X
Renal X X
Cardiovascular X* X
*varies by individual drug

21
 Pathophysiology: Pain
Definition of pain: an unpleasant sensory & emotional experience which we primarily:
 Associate with tissue damage
 Describe in terms of tissue damage (burning, stabbing, etc)
 Or both

Pain has a dual nature – both “sensory discriminative” & “affective”

 Intrinsic emotional content distinguishes pain

Pain is subjective, but it’s a bounded subjectivity (we can set constraints on what we know)
 It’s an important concomitant of illness (think chest pain)
 Pain is measurable, scalable, reproducible, responsive to treatment, and causes a dramatic ↓ in QOL

How do we describe pain?

Pain scores
NRS (numerical rating scale) – line from 1-10; tick marks for each integer
 The big way that we measure pain these days
 A change of ≈ 2 is considered significant
 Ratings are reproducible

Alternatives: make sure you’re using an appropriate scale

All of these converted to 10 point scales
 VAS (visual analog scale) – a line without tick marks (earlier)
 Faces (for kids > 7; non-verbal self-report)
 Behavior scales (very young children, non-verbal populations)

Characterization of Pain
 By experience: dull, pricking, aching, throbbing burning, stabbing, shock-like, boring
 By phenomenon: tissue, visceral, joint, cancer, nerve injury
 By mechanism: nociceptive, inflammatory or neuropathic
o Noiceptive: from surgery / trauma
o Inflammatory: from abcesses / sunburns
o Neuropathic: from neuropathies or spinal cord injury

These overlap: Back pain after injury can include all three aspects: trauma, inflammation, nerve root

Psychophysics of pain
 Standardized measurements of pain make an S-shaped curve
 As you ↑ intensity of stimulus, perception of pain increases in S-shape
 Pain threshold = minimum stimulus that can be perceived
 Peoples curves are different – shifted to left or right!

Injury shifts the curve to the left (e.g. after sunburn, light touch painful)
 Allodynia: pain due to a non-nociceptive stimulus (normally non-painful)
 Hyperalgesia: ↑ pain sensitivity (↑ response to a normally painful stimulus)
 Chronic opioid use shifts the curve to the left too! ↑ pain!

1
Where does pain come from?
 Noiciceptive: Normal sensing of painful stimuli
 Inflammatory: Sensitized responses due to inflammation (sunburn, steam burn)
 Neuropathic: Abnormalities in pain system (peripheral neuropathy, radiculopathy, MS/TM, stroke)

Nociception (the perception of painful stimuli)

Very few pain-privileged spaces (e.g. nucleus pulposus of disc) – almost everywhere has pain sensing fibers

Four main processes: Transduction, Transmission, Modulation, Perception

Transduction
Happens in skin, muscle, bone, discs, other target organs
 Occurs by production of a graded generator potential
 Aδ-fiber nociceptors signal sharp pain to punctuate stimulation (1st pain) - Get that hand off of the stove!
 C-fibers account for dull, poorly localized heat pain (2nd pain) - motivational centers – don’t do that again!

Transmission
Happens in nerves, ganglia, roots, higher-order neurons, etc. via all-or-none action potentials
 Use excitatory neurotransmitters (e.g. glutamate)
o Some are peptidergic, use substance P & CGRP as neurotransmitters
o Some are non-peptidergic (have purinergic receptors)
 Peripheral terminals are sensitized by inflammatory mediators (NGF, H+)

Peripheral nerve notes: anatomy is central

 Carpal tunnel: from compression of the median nerve of hand
 Tarsal tunnel: can lead to pain / numbness of forefoot
 Remember that the ulnar nerve doesn’t run through the carpal tunnel – mostly from compression @ arm

Peripheral nerve: axons & nerve coverings (perineurium, epineurium)

 Nociceptive fibers small, consist of:
o Aδ fibers (thin, myelinated) – sharp-sensing
o C-fibers (unmyelinated; multiple axons bound together) – heat pain

Neuropathic pain: Generally don’t respond to NSAIDs! Distal peripheral nerves carpal tunnel syndrome
Need to use anticonvulsants, tricyclics, even opiods! Proximal peripheral nerve sciatica
Plexus brachial neuritis
 Sciatic / plexus lesions are disorders of pain transmission
Nerve roots herniated disc radiculopathy
 Dorsal roots / ganglia part of transmission
 Cervical / lumbar disc herniation can cause severe pain
 Pain / weakness in a root distribution is a hallmark of bradiculopathy

Wiring
 Transmission to the pain-localizing somatosensory cortex system via:
o the lateral STT (oligocynaptic) to ventral thalamus (3rd order neuron)
 Transmission to the pain affective limbic/ hypothalamus system is polysynaptic
 Transmission at dorsal horn & higher levels is subject to sensitization

Dorsal horn  medial thalamus  Detailed characteristics of pain

Lateral pain pathway
Medial pain pathway
Other pain pathways too
primary sensory cortex (quality,regional location, severity, timing)
Dorsal horn  medial thalamic nuclei → Emotional effects of pain
limbic cortex (distress, unhappiness, anger, frustration
Projections to basal ganglia, etc. Modulate behaviors / postures?

2
Modulation
The dorsal horn: 1st synapse, subject to sensitization / modulation
 Different drugs start to work here
 For antidepressants: need to have norepi efficacy! (e.g. SNRIs)

Nociceptive primary afferents converge on second-order neurons in the dorsal horn

 Generally use excitatory neurotransmitters (glutamate, aspartate)
 Subset use peptidergic co-neurotransmitters (e.g. substance P, CGRP)

Dorsal horn 2nd order neurons have descending inhibition (via NE, DA, 5-HT)
 Also subject to descending facilitation
 Local interneurons also synapse on 2nd order neurons in the dorsal horn (use GABA, enkephalin, glycine)
Periaqueductal gray: A major site of pain modulation
A major site for descending inhibition and facilitation
Raphe nucleus magnus (NRM)
Located in the rostro-ventral medulla on the midline
Locus Coeruleus: An important role in descending pain modulation

ACC = anterior cingulate cortex (limbic system, emotion)

NRM = nucleus raphe magnus

 descending facilitation / inhibition

PAG = periaqueductal gray (also involved in descending regulation)

Diseases of the spine (cord injury, transverse myelitis, MS) are frequently painful

Perception
Happens at the level of the cortex; has the reproducible psychophysical properties discussed above
 Even a small stroke can produce a central pain syndrome, often resistant to treatment
o E.g. Dejerine-Roussy syndrome (due to thalamic stroke)

S1 (somatosensory cortex) Localizes pain & defines its quality

Controls emotional component of pain
Limbic system (hypothalamus, anterior cingulated cortex)
Controls autonomic responses to pain

Review table: Somatosensory Pathway

Peripheral 2nd order 3rd order

Tract tract 4th order neuron
axons neuron neuron
II/IV Lateral spino- VPL Internal capsule, post-central gyrus 3b
Pain / temp Lamina I, II
(slow!) thalamic thalamus posterior limb & limbic cortex

Take-home messages
“Strange” pain pattern? Think about all possible explanations before dismissing patient & their complaint

There are many pain patterns that have a biological basis:

Dermatomes, Named nerves, diffuse patterns (neuropathy / myopathy), Myotomes, Sclerotomes, Viscerotomes
3
 Pharmacology: Opiates
Intro
 Treating pain is a big part of medicine
 Opium: from poppies; relaxed euphoria used for thousands of years; no drugs as effective as opiates
o Goal: try to develop less-addicting opiates

The Receptor Concept

Opiate receptors are highly specific & selective
 Yes, Virginia, there is an opioid receptor:
o Different potencies for different opiates
o act sterospecifically
o selective antagonists exist
 Pharmacologic activity / binding correlation determined w/ intestines (organ bath)

Structural features:
 Ring structures
 Tyrosine-like motifs (left circle) – like enkephalin!
 N-allyl or N-cyclopropyl (right circle, instead of N-methyl) = antagonists

How do they work? Details still a mystery.

 Basic idea: inhibit release of lots of neurotransmitters
o Work via GPCRs 
o ↓ adenylate cyclase, open K channels, close Ca channels
o Less calcium release  less neuronal signaling!

 Classic antagonists: bind  conformational change  block other binding

 But mixed agonist / antagonists exist for opiates, and no good chemical way of predicting which will be which!

Agonist vs antagonist vs mixed

 Agonist / antagonist difference happens at level of receptor & G-protein!
 Mixed agonist / antagonist = less addicting
o Good for clinical use, but some have psychotomimetic effects (probably from kappa stimulation)
o Probably bind half the time in an antagonist conformation and the other half as agonists
 Need CONTINUOUS OCCUPANCY for agonist activity

Opiate Receptor Subtypes

Mu, Delta, and Kappa are the three big ones for clinical purposes
 Mu is most relevant for clinical effects of morphine
o Mouse knockout – no response to morphine; but normal pain sensitivity
o Suggests that endogenous opioid system is inactive under basal conditions
 Kappa produces less respiratory depression but agonists produce dysphoria & psychotomimetic effects

Enkephalins (“endogenous opiates”) & receptor localization

Enkephalins (endogenous morphine-like peptide neurotransmitters), found in same distribution as opiate receptor
 Two forms: met-enkephalin & leu-enkephalin (terminal AA); both have tyrosine @ start
 Mimic morphine @ opiate receptor binding sites, smooth muscle, caues analgesia, tolerance, dependence

β-endorphin, dynorphin are larger peptides with same activity

 but distribution doesn’t follow opiate receptors as well – so enkephalins are probably the #1 endogenous ligand

1
Receptor Sites
Receptor site Effects?
Explains analgesic effects of opiates in pain perception in body / head
 Enkephalin found in small interneurons in dorsal SC (layers I & II) w/ opiate receptors
Spinal cord &
 Sensory pain fibers terminate in this area; use peptide transmitters (e.g. substance P)
brain stem
 Opiates inhibit substance P release  “spinal level” of analgesia
 For the head, similar – lower brain stem (substantia gelatinosa of spinal tract of CN V)
Explains autonomic effects – e.g. respiratory depression
Vagal nucleus
 Nuclei of solitary tract, nucleus commissuralis, nucleus ambiguus!
Brain stem & Maybe emotional, euphoric effects?
Limbic system  Brainstem: locus coeruleus, parabrachial nucleus; limbic: amygdale, stria terminalis
Brain stem & lat. geniculate Miosis (pretectal area, superior colliculus)
Thalamic nuclei Block “affective” component of pain perception

Effects of Opiates
Effect Targets & descriptions
Supraspinal
 Classic description: “pain is still there, but it doesn’t bother me!”
↓ pain appreciation
 Thalamus is major way-station for pain; mostly lateral nuclei (& ↑↑ opiate receptors)
 Periaqueductal gray plays a role too
↓ release of “pain neurotransmitters” (like substance P)
↑ pain threshold
 Classic: just ↓ appreciation, not ↑ threshold – but turns out ↑ threshold too!
Various areas that mediate emotional behavior involved
Euphoria  Various limbic areas (amygdala, others)
 Locus coeruleus (cells use NE as neurotransmitter; inhibited by opiates)
Lateral geniculate & midbrain sites (medial /lateral optic nuclei)
Pupillary
 Pupils continue to constrict even if pt is tolerant to opiate actions!
constriction
 Addicts  “pinpoint pupils” (used by the 5-0)
Area postrema (component of chemoreceptor trigger zone)
Nausea
 One of the main impediments to the use of opiates for Rx of moderate pain
GI opiate receptors in myenteric plexus  ↓ acetylcholine release
 ↓ propulsive contractions, ↑ nonpropulsive contractions
 ↑ sphincter tone too (biliary, ileocecal, others)
 Also ↓ hypersecretion of fluid / ions
Constipation
Can be side effect or therapeutic:
 Loperamide for diarrhea (hydrophobic), stays in gut, can’t formulate for IV not abusable
 Codeine, paregoric (tincture of opium) also effective, cheap, only moderately abusable
Coughing often treated with dextromethorphan
 Coughing mediated by vagal afferents relaying bronchial irritation
↓ coughing
 DM: inactive D-isomer; sold OTC, active ingredient in cough syrups, Influences electrical
activity of brain stem cough centers but probably not via conventional opiate receptors

2
 Vagal nuclei in brain stem (esp. solitary tract nucleus) have ↑ opiate receptor density
 VERY SENSITIVE to very low doses  resp ↓ even with low doses
 Can still elicit respiratory depression after chronic use, even if already tolerant to analgesic effects

Respiratory
RESPIRATORY DEPRESSION CAN KILL!
depression
 Lose sensitivity to CO2 to stimulate breathing, but retain hypoxic drive for respiration
 So DON’T GIVE O2 to a patient with ↓ RR from opioid OD
o You’d knock out hypoxic drive  can cause total cessation of respiration
 Can still breathe voluntarily – so tell the patient to breathe!

Specific Drugs

 Gold standard, drug of choice for severe pain (esp. in post-op patients)
morphine  Poor oral bioavailability - generally given by injection
 "Patient-controlled analgesia" (PCA) - pt controls the pump

Structurally, morphine with a methyl group instead of a hydroxyl

 needs to be demethylated by CYP450s in liver to restore the enkephalin-tyrosine-like motif.
 Morphine (from demethylation) enters bloodstream slowly
o less euphoria, which needs rapid effect, so less abuse liability
codeine
Good oral bioavailability (2/3 as potent by mouth as by injection)
Used for moderate pain, bad coughs

Oxycodone, hydrocodone are derivatives

All frequently formulated with acetaminophen (potentiate each other, but watch out for toxicity!)

 Weak agonist at mu opiate receptors; may have other actions too (naloxone only partially blocks)
tramadol o Inhibits NE/serotonin uptake (maybe relevant)
(Ultram)  Side effects like other opiates but less respiratory depression
 Introduced recently, widely used; same spectrum as codeine-acetaminophen (for moderate pain)

pentazocine  First widely employed mixed agonist - antagonist: less addicting and effective analgesic
(Talwin)  Downside: psychotomimetic effects (probably from kappa receptors)

Diacetyl morphine; needs deacetylation from phenol ring for activity

 Acetyl group can readily dissociate in brain or other tissue even without enzyme activity!
 So opposite PK from codeine:
o easy access to brain (acetyl groups) + fast metabolism = euphoriant rush
heroin
High abuse potential (rush)
 Short-acting (2-3h high) with rapid offset (withdrawal; need constant injections)

Introduced by Bayer, 1898

3
 Full agonist, just as intrinsically addicting as morphine
Principal treatment for heroin addiction
 Orally available & long-acting (daily dosing); gradual entry into brain so less euphoria
methadone
Can help pt get rehabilitated, quit drug culture, stop criminal activity, function normally / hold job

LAM (L-acetyl-methadol) = longer-acting form (q3d)

Mixed agonist-antagonist of Mu receptors, not psychotomimetic (not Kappa agonist)

 Less addicting then methadone and longer-acting, but not totally nonaddicting
 Schedule III (moderate potential for abuse) - methadone = schedule II (high potential)
buprenorphine
o Can dispense at retail pharmacies

Works by mouth (conventional pills or sublingual, e.g. as suboxone)

First widely used opiate antagonist

Used to treat opiate overdose (IV injection can reverse coma in minutes!)

naloxone Not active orally, short-acting - limited to OD treatment

(Narcan) Give repeated administrations (short half-life)

Experimental use: are various phenomena mediated by endogenous opioid systems?

Acupuncture, anesthesia, placebo-induced anesthesia blocked by naloxone

Orally active pure antagonist; related to naloxone in structure

naltrexone Theory: use for treatment for opioid addicts (but they have to take it, and they don't - no euphoria)
(Trean)  Implantable naltrexone can last for a month

Also effective in alcoholism (mechanism unknown)

4
 Opioid Medications: A to Z
Treating Pain
Options
 Non-pharmacological (heat/cold/massaged/acupuncture/etc) – but tailor to patient!
 Simple analgesics (acetaminophen, NSAIDs)
 Local anesthetics (soft tissue infiltration, spinal / topical, nerve blocks, IT pumps)

“Adjuvant” medications (implies that 1° analgesics are first-line – but these meds are often first-line for chronic pain)
 Typical: antidepressants, AEDs, muscle relaxants, sedative-hypnotics
 Exotic: anti-arrhythmics, α2 adrenergic agents, NMDA antagonists
 Topical: either compounded or commercially available
 Misc: cannabinoids, antihistamines, adenosine, others

Opioids (in general)

Opioids: friend or foe?

Good Bad
 Potent analgesics  Sedation, constipation, other AEs
 Quick onset of action  Risk of dependency, addiction, abuse, diversion
 No ceiling effect with many agents  Lack of anti-inflammatory effect
 Effective in variety of pain syndromes  Tolerance, neuroadaptation
 No risk of GI bleeds or renal / hepatotoxicity  External scrutiny for use (DEA #, etc)

What affects responsiveness?

 Type of pain  Progression of disease
 Temporal pattern of pain  Individual patient factors
 Tolerance  Drug specificity (metabolites, route of administration, interactions)

Receptors
 Mu receptors are the big ones that most of these drugs target
 Kappa receptors can produce psychotomimetic effects; may contribute to differentially ↑ response in females
 Delta, sigma, epsilon are less clinically relevant

Mechanism of action
Opioid receptor activation: ↓ presynaptic release, post-synaptic response to excitatory neurotransmitters
 (e.g. substance P) from nociceptive neurons
 mimicking activity of enkephalins & endorphins in central descending pathways of pain perception
 Overall: ↓ nerve impulse transmission

On the cellular level

 Alter Ca, K ion conductance  influx of potassium, hyperpolarization
 Coupled to G-proteins  ↓ formation of intracellular cAMP  ↓ calcium channel P-lation
 So: ↓ calcium entry  ↓ neurotransmitter release

Classified in various ways (phenanthrenes, phenylpiperidines, diphenylheptanes) chemically

5
Tolerance
 Genetically determined, seen with first dose
Innate tolerance
 Based on the subunit composition of the Mu receptor
 Pharmacokinetic (receptor desensitization)
Acquired tolerance  Pharmacodynamic (↓ concentration of drug at receptor by various mechanisms)
 Learned (reinforcement of drug effect)

Opioid-induced Hyperalgesia
Remember hyperalgesia = ↑ perception of a normally painful stimulus (vs allodynia)

Hypothesis: NMDA receptor activation  sensitization of pronocioceptive pathways

 Happening at the DRG, 2 order neurons  cranking up all the natural processes involved in transmitting pain
nd

 Think: pt who once responded to opioids and in spite of being on a stable dose, now have ↑ pain sensitivity

OIH: ↑ sensitivity to pain, aggravation of pre-existing pain, expression of novel pain symptoms
 ↑reg of pain-facilitating neuronal pathways at multiple levels of
OIH1: opioid maintenance therapy the central / peripheral nervous system
 Stimulation of excitatory AA neurotransmitter system
 Usually high doses of morphine, hydromorphone
 Severe allodynia + myoclonus
OIH2: very high, escalating opioid doses
 From metabolites inhibiting glycinergic inhibition @ spinal cord level
 strychnine-like excitatory intoxication

Immediate-release, short-acting opioids

Short half-lives  peaks & troughs in drug concentration

 Too high (peak)  CNS side effects

 Too low (trough)  pain returns

Made long-acting opioids a desired goal for research!

Mechanism of Action: Weak mu-opioid receptor agonist (6000x less than morphine)
 Also inhibits NE / serotonin uptake.
Metabolism:
tramadol  Short-acting (onset < 1h, peak 2-4h, duration 6h)
 Ok oral bioavailability (70%: 100% absorbed; 20-30% 1st pass).
 Chief metabolite is also an analgesic (2-4x activity of tramadol)
Indications: Better analgesic than codeine, hydrocodone, propoxyphene)

Mechanism of Action: Classic opioid, widely prescribed.

Kinetics: Rapid absorption & short duration (onset 30-60m, duration 3-8h)
 so significant abuse potential (sched III)
hydrocodone
Administration: dosed q3-6h.
 Often combined with acetaminophen (as Vicodin) or ibuprofen - better analgesic effect

Toxicity: High doses may lead to deafness. Hepatic if with acetaminophen, renal if with ibuprofen

6
 Long-acting opioids
Consistent pain control is the goal!
 Can help prevent unwanted pain behaviors
o If analgesia inadequate, can lead to aberrant opioid-seeking behavior
o About 50% of people on chronic opioids do something “bad”; only about 10% of those are “addicted”

 Consistent pain control can help reduce:

o Need for dose escalation
o Breakthrough pain & need for rescue medication (pts may just start taking breakthrough meds all the time)

 Sustained-release / controlled-release opioids: ↑ compliance, pain control, ↓ psychoactive effect

More opioids
Mechanism of Action: opioid, classic mu agonist
Indications: Most widely used opioid analgesic
 but stigmatized ("addiction", for "cancer/dying") for chronic use

Administration: IM:oral potency around 1:6; 1:2-3 with repeat administration, round-the-clock dosing.
 PO has onset 15-60m, available in extended release (duration up to 24h).
 Also SC/IM (30-60m onset); IV (peak 20 min)

Toxicity: constipation is #1 - maybe a greater incidence with morphine?

morphine
 Also transient nausea, dizziness, sedation.

Metabolites can be a problem too:

 M-3-G (morphine-3-glucuronide) is major metabolite; not an analgesic (may be anti-analgesic, may
have hyperalgesic or allodynic effect, maybe stimulant for N/V, CNS excitatory agent - myoclonus,
hyperalgesia, behavioral excitation?)

 M-6-G too (morphone-6-glucuronide), potent analgesic (maybe the main component of morphine's
analgesic effect?) and may be powerful respiratory depressant.

Mechanism of Action: Semi-synthetic opioid analgesic

 mostly a kappa opioid receptor agonist via an active metabolite (oxymorphone)

Administration: Available in lots of oral formulations: Immediate release (onset 15-60m, duration 4-6h) or
controlled-release (onset < 1h, duration 8-12h).
 Lower dose in females (25% higher plasma concentration).
oxycodone  Can be given with acetaminophen as Percocet

Metabolism: 60-80% lower bioavailability (first-pass metabolism)

Toxicity: High abuse potential. Serotonin syndrome with coadministration of oxycodone / sertraline

Other: metabolites play less of a role therapeutically

7
 Mechanism of Action: synthetic mu-agonist opioid.
 Racemic mix of R/S-methadone in USA. R form (a.k.a. "l-form") accounts for analgesic effects.
 Also non-competitive NMDA receptor blockade

Indications: Generally used for MMT / treatment of opiate addiction.

Administration: oral

Pharmacokinetics: Important!
 Long, variable half-life (~40h), good, variable bioavailability (~75%), highly protein-bound
Toxicity:
methadone  associated with torsades, but only with ↑↑ doses or drugs that prolong QT / induce torsades.
 Lots of drug interactions (CYP450 3A4, 2D6 metabolism).
o Inhibiting 3A4/2D6  ↑ [methadone] with increased risk of respiratory depression
 3A4 inhibitors: amitryptiline, cipro, fluconazole, sertraline
 2D6 inhibitors: fluoxetine, paroxetine, sertraline).
o Inducing 3A4/2D6 decreases [methadone], risk of withdrawal
 e.g. HIV meds induce 3A4, also rifampin, spironolactone).
 careful with textbook methadone conversions! (see below)

Other: Not necessarily any "stronger" or "weaker" than other opioids in the "strong" class. "Cheap" to buy
compared to pharma-designed long-acting opioids; not perceived to be associated with abuse stigma.

Textbook conversions & methadone

 Many textbooks underestimate potency of methadone; often don’t apply to repeat opioid dosing
 As ↑ dose morphine / other opioids, ↑ relative potency of methadone
 Conversion ratios are NOT bi-directional, and there’s LARGE INTERPATIENT VARIABILITY
 Pts who have been on large & INEFFECTIVE doses of morphine / other opioids may need ↑↑ ratio of
methadone vs patients who have been on large & EFFECTIVE doses of other opioids

Mechanism of Action: opioid, mainly a mu agonist with minimal kappa effects

Administration:
 Most often as transdermal patch (difficult to abuse) because it's very lipophilic .
 Can also give IV (really potent - 50-100x morphine!, rapid onset - lipophilic!)

fentanyl Toxicity:
 Drug interactions (metabolized by CYP3A4).
 May cause less constipation than morphine for equivalent doses.

Other: Delivery affected by body fat, temperature, edema, placement - but absorption doesn't really vary
between chest / abdomen / thigh

Mechanism of Action: Mu agonist, derived from morphine

Indications: Efficacy comparable to morphine although more potent than morphine!
hydromorphone Metabolism: H-3-G (metabolite) has neuroexcitatory effects.
Administration: Oral (IR; 30-60m onset, 4-6h duration) or parenteral (5m onset/ < 20m peak)
Toxicity: H-3-G accumulates in renal impairment

8
 Mechanism of Action: mu and delta agonist opioid
Administration: Poor oral bioavaility, but better with food.
 Can give PO, immediate release or extended release.
oxymorphone
Toxicity:CYP-based drug interactions.
 Has much better absorption when taken with alcohol (so be careful!)

Mechanism of Action: Partial mu agonist and kappa antagonist opioid at high doses
Metabolism:
 semisynthetic, highly lipophilic opioid
 has very tight binding & is slow to disperse (degree of analgesia not related to plasma []!)
Indications:
 Can cause "blockade effect" to other opioids that can last >24h;
buprenorphine
 FDA approved for induction of withdrawal (but can be legally prescribed for pain too)

Administration: For pain: TID/QID.

 low oral bioavailability (1st pass effect), so give sublingually.
 Suboxone when given with naloxone
Toxicity: Contraindicated in opioid-dependent patients (can precipitate withdrawal)

Mechanism of Action: mu and kappa agonist opioid; also NMDA receptor antagonist
Indications: Very potent (5x greater than IV morphine)
levorphanol
Kinetics: has very long half-life (12-16h), so long duration of analgesic effect (6-8h)
Toxicity: Can accumulate (2-3d of continuous administration)!

Side Effects
Effect notes
CNS toxicities dysphoria, euphoria, agitation, disorientation, sedation
GI nausea, vomiting, constipation
Respiratory depression Dangerous but readily reversible
Hypersensitivity, itching Can be really severe
Urinary retention
Myoclonus
Hormonal changes
Immune system modulation

Sedation
 Many pts with regularly-scheduled long-acting opioids build up tolerance to sedation (1-2 wks)
o If using short-acting opioids, can change to long-acting (minimize “peak effect” sedation)
o Severe sedation, ↓ RR may signal impending opioid toxicity

More common in opioid-naïve pts & during periods of dose escalation

 Other patient factors: advanced cancer, tumor burden, MOF, dehydration
 Other drug factors: bolus effect (short-acting drugs), metabolite accumulation (morphine), polypharmacy, ↓ renal function

Approach:
 Rule out other causes, discontinue non-essential adjuvant meds
 Allow for tolerance to develop (slow escalation), ↓ dose by 25% if pain still controlled
 Add psychostimulating agent, consider opioid rotation, consider alternative analgesic method

9
Nausea / vomiting
 Differentiate opioid / non-opioid causes
o Opioid causes: action on CTZ, vestibular effects, direct GI irritation
o Non-opioid causes: meds (NSAIDs, Fe, K, abx), metabolic (hyperCa, hypoNa), motility (constipation / obstruction)

 Take a proactive approach with anti-emetic medications, combo therapy when appropriate

Treatment Use if N/V from… Examples

Dopamine antagonists
Histamine antagonists
Acetylcholine antagonists
Serotonin antagonists
Prokinetic agents
Antacids
Opioids, liver mets, radiation tx
Movement / dizziness
Motion, opioids
Chemo, radiation, post-anesthesia,
emesis refractory to other Rx
Constipation or partial obstruction
Medication irritation of GI tract
(e.g. codeine, NSAIDs)
haloperidol, prochlorperazine, thiethylperazine,
promethazine, metoclopromide
diphenhydramine, meclizine, hydroxyzine
scopolamine, diphenhydramine
odansetron, dolasetron
metoclopramide (Reglan)
Antacids, H2-blockers (cimetidine, ranitidine), PPI
(omeprazole)

Constipation from opioids

 Happens to some degree with all opioids
o Opioids act at multiple sites in GI tract, spinal cord  ↓ intestinal secretions, peristalsis
o Tolerance developed slowly or not at all
 Dietary interventions alone usually AREN’T sufficient!
 Avoid bulk-forming agents in debilitated patients

First line: usually combo stimulant / softeners / osmotic agents (Senna + docusate sodium, senna = lactulose, miralax)
 Other options: prokinetics, colchicines, methylnaltrexone

Hormonal changes from opioids

Affect hypothalamic – pituitary – adrenal and –gonadal axes
 Can cause strong, progressive ↓ in plasma cortisol level in adults
 Modulate hormonal release:
o ↑ prolactin; ↓ LH, FSH, T, E

Immune modulation
May affect immunity through neuroendocrine effects or maybe via direct effects on immune system
 Minimal studies in long-term opioid pts (chronic pain); some evidence in HIV pts
 Pain itself can impair immune system
 Methadone may be less immunosuppressive than morphine

10
 Geriatric Pathophysiology
What is aging, and why do we all do it?
Introduction
Aging is something that happens to an individual patient; lifespan is a characteristic of a species

Aging resembles being sedentary: ↓ bone mass, muscle strength, cardiovascular reserve, ↑ glucose & lipids
 Also highly confounded by being sedentary (↓ activity!)

Highly confounded by disease, and risk factor for disease too (vascular disease, almost all cancers, death)

Aging is Hard to Study

What is “normal” in an older patient? Hard to define!
 “No rmal” heart over 90 years beats ≈ 3 billion times - wha t happens?
 What happens to a “normal” brain, or a “normal” mini-men tal?
 How can we subtract out diseases that are beco ming more prevalent to study th ese things?

“Normal” can mean: average in a population, and not associated with disease
 But is the 90-year old who’s completely free of disease “normal?”

Research problems
 Cross sectional studies: often inadequate (hard to compare old to young people)
o Height: people are getting taller
o Intelligence: ↑ education
o Miami: People dying are Jewish; people being born are Cuban - but aging doesn’t make you Jewish!
 Longitudinal studies: period effects are confounders
o Cholesterol: awareness ↑ in 1980s, so ↓ cholesterol – but doesn’t mean cholesterol ↓ with aging!

Baltimore Longitudinal Study on Aging

Studying people who don’t have disease
 ↓ in almost everything: cardiac index, GFR, vital capacity, standard renal plasma flow, etc
 Something about aging is a deterioration

Theories about aging

 Programmed – in an intergenerational sense (wear & tear  ↑ advantage for younger generations?)
 Antagonistic pleitropy – the same things that wer e advantageous early for reproduction= bad later (e.g. T levels)
 Cumulative error – we’re a complicated organism; as errors ↑, ↓ survivability

Frailty
 It’s hard to imagine somebody who’s old and really buff (think of a 100-year-old)
 Is that “normal” or a “disease”?

A brief history of death

 All multicellular organisms age & die (vs. amoeba, etc – which can replicate indefinitely)
 Human fibroblasts: will eventually die after dividing a number of times
o Elderly people s’ fibroblasts die more rapidly than younger peoples’
o Cancer cells can live perpetually (e.g. HeLa)
o Telomeres?

1
 Life Span
 Species-specific relationship
 Time is lethal, and there’s a dose-response relationship
o Bell-shaped curve – some in the species die young, some die early!

The Demographic Imperative

 Trying to limit early mortality
 The Baby Boom is coming!
o Surgeons will be routinely be operating on nonagenarians
o Almost all specialties will be dealing primarily with elderly patients

“Hey doc – how long do I have left to live” (Life expectancy)

For an individual patient (life-span for the species)
 Caloric restriction is the #1 intervention that replicably ↑ life expectancy

In developed countries, death / life expectancy is associated with aging

 Not always true in the past / other countries – death may b e mo re co mmon from o ther fo rms (trauma, disease, etc)
 Can divide it down by quartile & project (though nobody can tell the future)
o Life expec tancy for an 80 year old woman in the top quartile for health is 13 years‼
o If you’re healthy & 95, expect to live to be 100!
 Men have much lower life expectancies than women

Function is a key determinant

 E.g. admissions to hospital: function really determines survival
 Lower “points” predictive (like golf – want a lower score)
o Get points for being male, CHF, renal failure
o Except for metastatic cancer, total ADL dependency is the worst predictor for survival

ADLs: eat, bathe, dress, toilet, transfer; If you’re unable to do any of these  really bad 1 year survival

Mortality & Age: the Gompertz Function

↓ survival with older age
 Studied POWs, living in Austria during WWII, etc. – with ↑ age, people have ↓ survival
 Everest: ↓ chance of making the summit, and risk of death tripled for people > 60 (even in a very elite group)

Clinical applications
For the doctor, the elderly patient is more likely…
 To die soon
 To depend on others
 To be chronically ill
 To be harmed by medical intervention
 To be under-represented in clinical trials (no RCT data on diabetes control in an 80 year old!)

These are the most vulnerable patients in an adult patient

 Requires tremendous judgment (mor e knowledge needed not to do a bronchoscopy than to do one)

2
 Caring for Older Patients
General Principles
1. The hospital gown adds 10 years
2. Occam’s Razor gets dull with age
3. Older people haven’t read your textbooks
4. If you’ve seen one 80-year old… you’ve see one eighty year old
5. Older people think they go to the hospital to get well… but we know differently

The Hospital Gown adds 10 years

 Understand that people exist outside of the hospital – and they might be doing better when at home
 Hospitals are inhospitable to older people (in general, home is better, and patients are not at best when sick)
 If you aspirate once in 80 years, you’re doing pretty good

Occam’s Razor gets dull with age

 The medical model (linear disease  Sx) applies to less than half of older adults presenting with symptoms
o The single unifying diagnosis is rare
 Alternate models apply (synergistic or causal) in older patients
o E.g. in continence: a little fro m being slo w, a little from d etrusor muscle problems, etc.

Older people haven’t read your textbooks

 Atypical presentations of common diseases are just as common as “classic” presentations for older pts!
o Thyroid disorders, depression that’s not sad, MI without angina, infection w/o fever, etc.
 DDx for delirium, falls, and fatigue includes everything

If you’ve seen one 80-year old… you’ve see one eighty year old
Aging is a heterogeneous process
 Use patient-centered goals of care (& know their baseline)
 Vulnerable to over / under-treatment (& no good studies for treatment)
 Diseases can be muted, subtle, or non-specific

Older people think they go to the hospital to get well… but we know differently
 “Usual” aging / disease may not produce disability in ordinary circumstances

 Hospitalization is stressful - exhausts

the patient’s low reserves (↓
homeostatic mechanisms)

 Despite the “cure”, you may leave

more disabled

Often results from cascade of effects

Often leave
 confused,
 weaker / more disabled,
 sicker (DVT, pressure ulcers,
infections, injuries)

≈ 40% don’t recover function at 3 months!

3
 Specific Syndromes / Hazards
Delirium, immobility, falls, & infections

Delirium
Need to assess every day for older patients!

1. Acute onset / fluctuating course

2. Inattention
3. Disorganized thinking Need 1 AND 2 + EITHER (3 or 4)
4. Altered level of consciousness

Pathophysiology poorly understood: cholinergic deficiency? DA excess? Cytokines? Chronic stress?

Precipitating factors
Restraints, dehydration, meds,
infection, iatrogenic events Functional decline
Dementia
DELIRIUM Falls / injuries
Vulnerabilities DEATH
Visual impairment, severe
illness, cognitive impairment
events
Meds involved in 40%, usually those with psychoactive effects, and especially with ↑ # total drugs!
 Sedatives / hypnotics, narcotics (esp. benzos), antihistamines, heterocyclic antidepressants, neuroleptics
 Digoxin & NSAIDs too

Simple interventions can be helpful in preventing delirium & ↓ length of stay

 Have the patient’s family bring in glasses, be around at mealtime (to help consistent feedings), etc.

Things med students can do to recognize / prevent delirium

Know patient’s baseline assess on admission & check with family to compare to home
Recheck daily months backwards, digit span, serial 7s
Pay attention to order sets automatic drugs / sleep disruptors
Adequate pain control
Frequent reorientation remind them where they are and what’s going on
Others: Sleep at night with activity during day, facilitate sensory input, minimize transfer of rooms, Involve family

Immobility
Deconditioning is a common problem while in the nursing home
 Often put on bedrest or minimal activity! 72% older patients don’t ambulate in halls at all
 OR ↑ for ADL decline, institutionalization, death
Bed rest has very little benefit for your average patient (except for certain conditions: ICU, BP problems, big fall risk, etc)
 No outcomes improve but some outcomes get worse for bedrest, both after medical procedure or as 1° Tx

How fast does this happen?

st
 Lose 5% strength / day (big if you’re already weak), 50% strength in 1 3 weeks
o Leg > arm strength affec ted  ↓ independenc e!
 Bone loss 0.9% / wk; ↓ cartilage smoothness in 1 wk (↑ arthritis sx)
 Diaphragm atrophies quickly on ventilators!
 CO effects from long-term recumbency: ↓↓ CO, ↑↑ HR, ↓↓ CO, ↑PVR, ↓ BP  ↑ falls
(along with ↓ baroreceptor reflex)
4
Falls
 3-10 falls / month in a 25 bed ward! 6.6% result in Fx, soft tissue injury, dislocation

↑ risk with:
 age  need for ambulatory assistance  visual impairment
 delirium / agit ation / etc  urinary frequency  comorbidity
 unstable gait

Prevention strategies:
 Eliminate environmental hazards
 Use appropriate assistive devices
 Avoid deconditioning (get out of bed & walk!)
 Avoid delirium & watch closely if delirious
 AVOID RESTRAINTS
 Don’t encourage elimination at night (IVF, diuretics, or bowel preps) – don’t want them to go to the bathroom!

Things you can do

 Identify who’s at risk (watch them walk)
 Know functional status
 Write appropriate activity orders (exercise is good, beds are for sleeping – don’t eat in bed!)
 Avoid dangerous drugs
 Avoid tethers (Foley = “single point restraint”)
 Water & feed

Pressure ulcers can be a big problem – be careful about back, feet, wherever weight is!

Infections
Iatrogenic infections: more people die from hospital-acquired infections than auto-accidents & homicides combined!

Most common
UTI
Mostly all secondary to catheter > 72h
Wound infection #2 – in certain surgeries, need prophylactic abx
#3 – but most lethal
 Attributable mortalily 72%
Pneumona
 Best predictors: difficulty with oropharyngeal secretions, presence on NGT
 Prevent with deep breathing, OOB, avoid H2RA / oversedation

Indications for catheter use (only four!)

1. Inability to void
2. Incontinence AND something that would make incontinence dangerous
a. Open wounds needing protection
b. Terminal illness / palliative care
3. Monitor urine output AND patient unable to assist / comply
4. After anesthesia (short-term only)

5
 Geriatric Pharmacology
Basics: How to Avoid Making Your Patients Wobbly and Wacky
Challenges when prescribing for older adults:
 Multiple chronic medical problems  Adherence / cost
 Multiple meds / prescribers  Supplements, herbals, OTC drugs
 Different metabolism / responses
Physiologic changes associated with usual aging (know this)
 ↓ water (↓ volume of distribution for water-soluble drugs)
 ↓ muscle mass
 ↑ fat (esp. central)
 Slowed hepatic metabolism
 ↓ renal excretion
 ↓ baroreceptor reflex (responsiveness & sensitivity)

Pharmacokinetics
Absorption
not affected by the normal aging process
 Can be affected by drug interactions (antacids, iron)
 Can be affected by disease (↓ IF  ↓ B12 absorption, or delayed gastric emptying)
Distribution
Change Effect on volume of distribution Result
↓ water ↓ ↑ concentration of water soluble drugs
 prolonged actions of fat-soluble drugs
↑ fat ↑
 ↓ peak concentrations
↓ lean body mass ↓ ↑ concentration of muscle-bound drugs
↓ serum proteins (e.g. albumin) ↑ concentration of unbound (free / active) drugs

Metabolism
 ↓ hepatic blood flow, mass
 ↑ risk drug interactions (↑ # of drugs!)
Phase I (CYP450s) Slowed Oxidation, reduction, dealkylation
Phase II Essentially unchanged Conjugation, acetylation, methylation

Excretion (Renal)
Renal
 Renal clearance may be reduced (↓ ≈ 1% per year after age 40)
 SCr is not an accurate reflection of renal clearance in elderly pts (↓ lean body mass)
o A “nor mal” serum Cr does not mean a normal GFR
o Calculate estimated GFR using Cockcroft-Gault or modified MDRD for old pts!
 Active drug metabolites can accumulate (long therapeutic action, adverse effects)

Pharmacodynamics
 Alterations in receptor #, affinity, 2nd messenger function, cell/nuclear responses
 Patients can be “more sensitive” or “less sensitive” to an agent
o ↓ responsiveness to β-adrenergic drugs
o ↑ CNS effects from anticholinergic drugs
o Blunted baroreceptor effects
 Remember that PKs are messed up too – so different levels and different effects!

1
Physiologic Changes associated with disease states
 ↓ cardiac output (↓ absorption, metabolism, clearance)
Cardiac disease
 ↑ susceptibility to cardiac adverse effects
Kidney / liver disease  ↓ drug clearance
 ↓ neurotransmitter levels
Neurological diseases  ↓ cerebral bloodflow
 ↑ sensitivity to neuro effects

Polypharmacy, Adverse drug reactions, and Events

Lots of meds and little evidence
 2/3 older adults on regular meds, but frequently not included in clinical trials
 Makes it hard to predict drug metabolism or adverse effects

Gaps in our understanding

 Not well studied (often exclude older / on multiple meds from RCTs)
 Multiple concomitant meds adversely affect safety / effectiveness of individual meds
 Multiple medical problems can also affect outcomes of pharmacotherapy

Polypharmacy
 Concomitant use of multiple meds; other definitions
 ↑ risk of bad stuff (adverse effects, etc) with ↑ number of meds

Adverse drug reactions (ADRs) & Events (ADEs)

 Adverse drug reaction (ADR) – any undesirable / noxious drug effect at standard drug treatment doses
 Adverse drug event (ADE) – ADRs + errors in drug administration
 Also adverse symptoms, adverse pt outcomes, etc.

Risk factors for ADEs: ↑ chronic diseases, ↑ doses/day, ≥ 9 medications, low BMI, older, ↓ ClCr, Hx of prior ADE
 Very common (esp. in primary care) – causes lots of geriatric admissions, etc.

Which meds cause most ADEs?

 Cardiovascular medications  Anticoagulants
 Psychotropic medications  Non-opioid analgesics (NSAIDS)
 Antibiotics  Anti-seizure medications

Often results from cascade

 Come in for knee pain, and then high BP gets picked up
 Prescribe BP drug, then get side effects
 Prescribe another drug for knee pain, etc.

Interactions
Drug-drug interactions are more common
Drug-disease interactions are more common too!
Benzos, anticholinergics ↑ confusion
Anticholinergics, TCAs, antispasmotics, antihistamines ↑ bladder outlet obstruction / incontinence
NSAIDs ↑ renal failure, heart failure, PUD
Anticholinergics, TCAs, Ca-channel blockers ↑ constipation
TCAs, benzos, SSRIs, antiHTN ↑ falls

2
 Thoughtful Prescribing
Four key principles
1. Less is more (keep the drug list short) 3. Start low & go slow
2. Think drugs (before making a new diagnosis) 4. Address adherence

1. Less is More
Keep the med list short
 Question need for new meds; stop whenever possible, prioritize treatments (risk/benefit)
 But avoid undertreating older pts, especially for:
o Pain, systolic hypertension (stroke, renal failure,CVD), anticoagulation / A-fib (stroke prevention)

2. Think drugs
 Every time you see a new symptom, think about ADEs
o Establish diagnosis (urinary retention can be an ADE!)
o Stop / reduce offending meds (including OTCs & herbals)
 Try to avoid the “drug cascade” (prescribing even more drugs to treat an ADE)

The “Beers Criteria” - avoid potentially dangerous drugs

 Consensus-based list of potentially inappropriate meds for older adults; can look it up
 Includes anticholinergics, decongestants (HTN / bladder outflow obstruction), meperidine, benzos

3. Start low & go slow

 Start one med at a time, low dose  increase gradually
 Monitor for response, anticipate adverse effects, address adherence with regimen

4. Address adherence before changing drugs

 Multiple meds / doses can be complicated; Sensory, physical, memory impairment can interfere
 Language / health literacy might be lower ; cost might be a factor (fixed income); QOL effects may ↓ adherence

Things that help: short med list, once daily meds, using a pillbox, review bottles of meds, write indications on Rx

A Case Study
83yo M, Hx of BPH +HTN; developed viral URI; took decongestant / diphenhydramine. Now unable to urinate; BP 190/80
Urinary retention, hypertension
 PNS mediates detrusor muscle contraction; blocked by anticholinergic meds like diphenhydramine
 SNS: α-adrenergic activity causes sphincter to contract (retains urine); ↑ SVR (↑ BP)
o pseudoephedrine, phenylephrine are α-adreneric agonists
Prescribed terazosin (α-1-adrenergic agonist) to help with urinary retention / BP; then falls on way to bathroom
Orthostatic hypotension & hip failure
 ↓ baroreceptor sensitivity with age
 α-adrenergic blockade can worsen postural hypotension  ↑ risk falls  ↑ morbidity / mortality
Nervous in ED  given Demerol for pain + diazepam for anxiety, then becomes confused & somnolent
Drug-induced delirium
 Meperidine & its active metabolites can cause confusion, esp. in older adults with ↓ renal clearance
 Diazepam (long acting benzo, lipophilic)  ↑ half/life in elderly, ↑ risk falls / fractures

Slow recover after hip Fx, still has so me hip pain  acetaminophen + low-dose opioids fo r break-through pain along with laxatives to
avoid opioid-induced constipation. Deliriu m slowly clea rs; can go home after rehab (meds reviewed)

3
 Big Pharma & the Risk to Older Adults
Vulnerability
 A general short-hand for “old”
 Reduced homeostatic reserves – can be “normal” at baseline, but worse with perturbation
o Serum sodium, glucose, temperature, infection  all harder to maintain baseline if older!

Specific Drugs
Gapapentin
 Supposed to be good for uncomfortable generalized peripheral neuropathy, priapism, hiccups, etc
 Fraudulent! $500M fine (biggest in FDA history), but 90% off-label; The same shenanigans are afoot with Lyrica

Cholinesterase Inhibitors
What’s a legit goal for Rx of Alzheimer disease? How do we define AD?
 What do we want? pt’s life better, caregiver’s life better, better behavior, less institutionalization, ↓ cost, ↑ life
 Donepezil vs placebo – no differences for
o 1° outcomes (institutionalizations, progression of disability) 2° outcomes (behavior / psych, costs, etc).
o MMSE 0.8 points better, statistically significant but meaningless for the patient!
4 canards about AChEis
 No “catastrophic reaction” if you stop cholinesterase inhibitors
 Not “unethical” to not give cholinesterase activities
 Not a “stabilization” technique
 Not the “standard of care” (although it’s permeating the literature)
Toxicity: ↑ cholinergic transmission
 ↑ syncope, pacers, hip fractures

Drugs for overactive bladder

 Whole industry has grown up around these – cost ≈ $100/mo
 Enablex, Vesicare vs placebo:
o ↓ urinations (one per day), ↓ incontinence (by one q3d), ↑ voided volume (2tbsps) - not big effects!

PPIs and GERD

Same as “indigestion”, “dyspepsia”, “stomachache”, “heartburn”, “upset stomach”, “stomachache”, but GERD sells PPIs!
 Gastric acid conserved throughout evolution (all vertebrates) – except for in humans taking PPIs
PPIs: no longer sterilizing what’s going through the GI tract
 ↑ pneumonia (1.9x RR), ↑ C. diff diarrhea (2.9x RR), ↑ hip fractures (2.7x RR)
 Also stop PPI if using clopidogrel (enzyme interaction, not acid-relation)

Sedative-Hypnotics & Insomnia

What are goals of sleeping pills?
 ↑ sleep quality, ↑ next-day alertness /problem solving/performance, ↑ “feeling alert”?
 People tend to overreport insomnia (underestimate length of sleep, overestimate nocturnal awakenings)
Sedative-hypnotics  ↑ 25m total sleep time, awakening ↓ 0.63x/night, sleep quality ↑ 0.11
 But ↑ adverse cognitive effects (4.8x), ↑ psychomotor effects (2.6x), ↑ daytime fatigue (3.8x)
 The “primary benefit” of sedatives: render the patient unconscious for an interval that you & pt agree on
The “Z-drugs”: not really different from short-acting benzos
 Choose the cheapest (“z’s” about $100; oxazepam about $9)
 Use only for temporary extreme sleep disturbance (e.g. extreme grief, etc)

4
 Shock: Pathology & Pathophysiology
Definitions
Shock
 Critical decrease in global tissue perfusion resulting in diffuse cellular hypoxia & organ dysfunction

Hypovolemic Cardiogenic Obstructive Distributive

Myocardial disease Pulmonary embolus
Hemorrhage Sepsis
Valvular disease Aortic aneurysm
Dehydration Anaphylaxis
Arrythmia Tamponade

Sepsis
SIRS (Systemic inflammatory response syndrome):
 2+ of : abnormal temp, tachycardia, tachypnea, altered WBC ct

Sepsis: SIRS 2° to infection

 Severe sepsis: associated organ dysfunction
 Septic shock: severe sepsis with hypotension despite fluid resuscitation

Epidemiology of sepsis: 750k cases annually, 210k deaths, incidence increasing:

 ↑ immunosuppressives (tumors, transplants, inflammatory diseases),
 ↑ age with comorbidities, ↑ use of invasive devices

Pathogenesis of septic shock: Noninfectious or infectious trigger causes release of mediators, which causes shock!
 Tons of mediators (TNF / ILs / IFNγ / etc, etc, etc.) – no single answer (reductionist approach is limited)
 Proinflammatory or anti-inflammatory balance is key

Inducible product of variety of cell types

TNFα
TNF infusion  sepsis-like syndrome ( humans); TNF blockers  attenuates sepsis in animals
Generated in various different ways (neuronal / endothelial / inducible), effects on cGMP, Hb, proteins, etc.
NO
In shock: ↑↑ NO; vasoplegia 2° to NO from smooth muscle (↓ vessel response to norepi, restored with NOS inhibitors)
Ceramide A phospholipid, TNFα / sphingomyelin  ceramide pathway linked, produced in response of LPS

Hyperinflammation & sepsis?

Former idea: just lots of inflammation in sepsis  pathogenesis – but probably not that simple
 Cytokines: doses in animal studies “excessive”
 Can’t usually detect TNF, IL-1 levels in humans?

 Defective immune function seen in septic patients

o ↓ monocyte cytokine production
o ↓ B-cells / CD4 cells in spleen with long sepsis
o ↑ IL-10 (anti-inflammatory) in sepsis; ↑ levels predict mortality (even
though it’s anti-inflammatory)

 The pro-inflammatory / anti-inflammatory balance may be key

PRRs / innate immune probably kicking it all off, triggering cytokine production
 And then the pro-inflammatory / anti-inflammatory balance comes into play
 The balance can be perturbed in lots of ways
Lots of details known, but no real good way to actually translate it into patient care!

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Pathology of Sepsis
Shock: severe hemodynamic / metabolic disturbance resulting from inadequate blood flow to vital organs
 Organ changes due primarily to anoxic / hypoxic cell injury
 Individual organ changes aren’t specific for shock, but constellation of changes in multiple organs is

Organs / organ systems affected in shock (in most common organ of failure)
 Lungs > Kidneys > liver / intestines > heart / brain / adrenals / pancreas / hematologic)
 But this can change with comorbid disease states

Shock & the Cardiovascular System

Trigger  mediators  cardiovascular  shock
In septic shock, primary defects are vascular (tone, permeability, volume)
 SVR: gets at vascular tone (peripheral resistance), TPR is similar

MARKED REDUCTION IN SVR IS THE HALLMARK OF SEPTIC SHOCK

Oxygen delivery
 Normally, VO2 is independent of O2 delivery down to really low levels of delivery
o O2 extraction varies to maintain VO2 in a “supply dependent” phase
o Keep tissues oxygenated!

 “Pathologic supply dependency” in sepsis?

o Altered microvascular vasomotor regulation &
vascular plugging might be playing a role

o O2 consumption elevated at baseline

o smaller decrease in O2 transport leads to
coupling of supply & consumption!

 ↓ survival with ↑ lactate

Cardiac manifestations
Remember: HR x SV = CO (SV determined by preload, contractility, & afterload)

Cardiac index:
 In isolation (e.g. animal models), if you look at a muscle strip, ↓ contractility with exposure to mediators
 But for patients: ↑ cardiac index with sepsis, and ↑↑ CI  BAD PROGNOSIS
o ↓ contractility, but ↓↓ afterload (from ↓SVR!)

Pathology: Contraction Bands & Subendocardial Hemorrhages

Contraction band necrosis:

 bright, eosinophilic bands crossing fibers
o accentuated with trichrome stain
 From ↑ calcium release  hypercontraction
 EM: sarcomeres aligned & hypertrophied

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 Normal (left) vs contraction band necrosis Trichrome accentuates
Subendocardial hemorrhages
(right, lots of contraction bands) contraction bands

EM: sarcomeres hypertrophied, aligned Residual scarring after recovery

Hemodynamics
PCWP* CO SVR
Cardiogenic ↑ ↓ ↑
Hypovolemic ↓ ↓ ↓
Obstructive ↑/↓ ↓ ↑
Distributive** ↓/nl ↑ ↓
*reflects loading of LV
**note that in septic / distributive shock, ↓ SVR is hallmark – and ↑ CO as a result

The Lung in Septic Shock

 ↑ metabolic demand (↑ O2 consumption / ↑ CO2 production)  ↑ VE (minute ventilation)
 ↑ permeability of circulation  ↑ interstitial edema  ↓ compliance (disrupt surfactant)

Both of these processes contribute to ↑ WORK OF BREATHING

 If you can’t keep up with the work of breathing, you need a ventilator!
o Diaphragm affected too (septic shock)
 Redistributed blood flow with ↑ work of breathing  need to get more blood to respiratory muscles
o This exacerbates the lack of blood going to other tissues!

Hypoxemia results (from altered V/Q matching & shunt)

Pulmonary hypertension in animal models
Treg cells may be involved in recovery?

Adult respiratory distress syndrome (ARDS)

1. Acute onset
2. Diffuse infiltrates
3. Hypoxemia
4. Noncardiogenic pulmonary edema
Sepsis is #1 cause of ARDS, and ARDS occurs in 20-40% of septic shock cases
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Pathology: DAD / ARDS
DAD is pathology, ARDS is clinical finding (difficulties in gas exchange!)

Pathogenesis
1. Endothelial cell injury
2. Leakage of protein-rich fluid (exudates) & inflammatory cells
(mostly PMNs) into interstitium
3. Injury to alveolar lining cells (type I pneumocytes) 
leakage of fluid, some inflammatory cells into alveoli
4. Sloughing of type I pneumocytes into alveoli,
proliferation of type II pneumocytes to replace them
5. Hyaline membranes: come from
a. Deposition of protein (exudates)
b. Deposition of fibrin
c. Cellular debris (sloughed type I pneumocytes, inflammatory cells on top of type II pneumocytes)

Normal lung (L) vs ARDS: widened septae, Proliferating type II pneumocytes

ARDS: wet, heavy lungs
RBC / debris / fibrin in alveoli, thrombi if DIC (arrowhead), hyaline membrane (arrow)

Proliferating type II pneumocytes

Diffuse hyaline membranes Hyaline membranes (close-up)
(arrowhead); cell debris (arrow)

The Kidney in Septic Shock

 Oliguria, azotemia are common findings
 Contributors are prerenal / renal / postrenal (prerenal most important early in sepsis)

Remember the glomerulus: interplay between afferent / efferent arteriolar tone regulates pressure gradient
 many of the mediators in shock affect afferent / efferent arterioles

Prerenal ARF is frequent early in sepsis

 MAP < 80 mm Hg  start to lose the ability to autoregulate
 Impaired autoregulation in sepsis from mediators
 Vasoconstriction (endogenous / exogenous – endotoxin, COXi, radiocontrast can play a role)
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“Renal” ARF: from acute tubular necrosis (tubular / obstructive)
 Caused by ischemia, sepsis / cytokines, oxidants, nephrotoxins
 Cellular events: disordered transport (from ↓ ATP, loss of epithelial polarity)
 Obstruction  ↑ tubular pressure  ↓ GFR

Acidosis can be exacerbated

 if low pH, pressors are less effective & SMC contractility decreases

Pathology: ischemic acute tubular necrosis + oliguric renal failure

 PCT, medullary thick ascending limb (same zone) are particularly susceptible to ischemia

Histology:
 Flattening of proximal tubular epithelium  apparent dilatation of tubular lumens
 Necrosis, sloughing of individual proximal tubular epithelial cells
o Widespread tubule cell necrosis is more typical of toxic ATN
 Granular casts in distal / collecting tubules, sometimes with brownish pigmentation
 Regenerative changes of tubular epithelium
 Interstitial edema often present, but without prominent interstitial inflammation
 Nucleated cells (WBCs) in vasa recta on biopsy (nonspecific on autopsy)
 Glomeruli unremarkable (unless underlying renal disease)

Normal tubules (L) vs necrosis (R):

single cell necrosis, flattened / reactive cells,
Gross: congested Flattening of cells  dilated lumen
epithelial-mesynchemal transition, loss of
polarity / transport functions

EM: Normal (L): mitochondria stacked up

Congestion if more advanced: Proliferative changes if even
along brush border (Na/K ATPase needs
endothelial injury; sludging of RBC (+ more advanced  big nuclei,
ATP). Shock (R): less infoldings, loss of
thrombi if DIC) into lumen reactive cells, trying to restore
brush border (↓ reabsorptive capacity)

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 The Brain in Septic Shock
 Altered mental status is early, frequent
 CNS disturbances is multifactorial (hypoperfusion, metabolic abnormalities, etc)
 May contribute independently to respiratory alkalosis?

Some study results: both in the hospital and long term

 Delirium means you spend longer in the hospital & have lower survival
 For those who survive ARDS, many have psych sequelae (survival of “pathophysiologic storm”
 ↓ muscle strength in general (still 50% at 1 yr!)

Pathology: watershed infarcts & laminar necrosis

Ischemic injury to the brain from hypoperfusion in vulnerable areas

Watershed infarcts (e.g. ACA/MCA watershed)

Relative ↓ circulation
Laminar necrosis: deep gray matter (supplied by small penetrating arteries)
↑ sensitivity of cells Purkinje cells of cerebellum, particular area of hippocampus – cells are particularly sensitive

Vulnerable areas:
Watershed, laminar necrosis
Purkinje cells, part of hippocampus
Laminar necrosis (note thin line in deep
ACA/MCA watershed infarct
gray matter). Histology on right

The GI Tract in Septic Shock

 Limited ability to augment O2 extraction
 Mucosal barrier compromise  can sustain trigger / mediator response  ↑ MOF
 Ileus (obstruction) can complicate fluid balance
 Exacerbation of acidosis can result

Liver
 Intrahepatic cholestasis common
o (↑ BILIRUBIN, ↑ alk-phos, transaminases a bit too)
 ↓ reticularendothelial clearance
 Cytokine / acute phase reactant expression altered
 ↓ synthesis of coagulation pathway factors

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Pathology: centrilobular necrosis
Area around central vein especially sensitive to hypoxic injury

Degenerative & some

Centrilobular necrosis (around CV) Normal (L) vs centrilobular necrosis (R)
reactive changes

Hematology in Septic Shock

 Leukocytosis or leukopenia
 Thrombocytopenia common
 Altered balance of clotting / fibrinolysis

↑ fibrin  generation of fibrinogen / split products (e.g. D-dimers)

 Series of effect: pro-clot formation (↑ TNF, etc)

DIC (disseminated intravascular coagulation)

 Widespread deposition of fibrin; microvascular thrombosis
 Consuming feedback inhibitors  more clotting
 Consumption of clotting factors eventually leads to bleeding!

BIG PROBLEM: patients transition from clotting  bleeding!

Pathology: DIC
 Can see in glomerular capillary bed (really fine capillary)
 Adrenal cortical hemorrhage & lipid depletion too
o Waterhouse – Friderichsen syndrome (adrenal hemorrhage classically a/w meningococcus)
o ACUTE ADRENAL FAILURE (not cool)

Clotting in glomerular capillaries Normal adrenal (L) vs W-F hemorrhage (R) Lipid depletion

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 Summary of Septic Shock
↑ mortality with ↑ # of organ failures (Intuitive, but important when considering what to do with a patient)

Septic shock
 Can be seen as response to all categories of infection; similar with non-infectious stimuli
 Critical decrease in tissue perfusion, cellular oxygenation
 Reduction in SVR is hallmark, likely NO-mediated
 Multiple organs are affected, and in turn affect other organs

Pathology
Organ system Path manifestations
 Contraction bands
Heart
 Subendocardial hemorrhages
 DAD (diffuse alveolar damage)
Lungs
 ARDS (adult respiratory distress syndrome)
 Ischemic acute tubular necrosis
Kidneys
 Oliguric acute renal failure
 Watershed infarcts
Brain
 Laminar necrosis
 Ischemic bowel disease
GI tract  Gastrointestinal hemorrhage
 Superficial necrosis
Liver  Centrilobular necrosis
 Disseminated intravascular coagulation
Other organs  Adrenal cortical hemorrhages & lipid depletion
 Acute pancreatitis

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 Shock: Pharmacology
Introduction
Shock: alteration in perfusion leading to diffuse cellular hypoxia & end-organ dysfunction
 NOT synonymous with hypotension!
 Can have shock w/o hypotension or hypotension without shock (e.g. cyanide – can’t use O2)

Most organs regulate blood flow over a wide range of MAP

This curve can be shifted to the right:

 may need a higher blood pressure to maintain blood flow
 (e.g. partially treated HTN)

Causes of shock: (generally all of these active in septic shock)

 Inadequate blood pressure  Impaired vascular tone
 Impaired cardiac function  Impaired cellular function
Hemodynamic parameters of distributive shock
 ↓ SVR  ↑ CO (in other types of shock, ↓ CO  ↑ SVR)
 ↓ filling pressure (PCWP), ↓ central venous pressure
Goals of therapy: Optimize end organ delivery
 Cardiac output
 Hemoglobin
 Oxygen delivery (cardiac index x arterial oxygen content; Hb / SaO2 drive arterial oxygen content)
 Blood pressure (but ↓ CO with many things we give to maintain BP!)

ABCs too: Supplemental oxygen, establish airway; Vascular access, provide adequate volume; Support BP / CO

Treatment of septic shock: Overview

Strategy
Establish likely diagnosis
Give appropriate early abx
Volume resuscitation
Vasopressors
(& consider inotropes)
Measure surrogates of organ
perfusion / pressure
Move patient to monitored area
DO NOT HARM
Notes
 Use Hx, clinical exam (urine output, peripheral exam, mentation)
 Consider pulmonary artery cath in rare circumstances
Send Cx 1st, but don’t wait for cultures to come back (start empiric therapy)
 door-to-abx time is important!
 ↑ mortality with ↑ delay in antibiotic delivery - make sure the pt gets them!
 Your other measures are just stabilizing to buy time for abx to work
Empiric coverage:
 most likely organisms (nursing home / community / etc)
 local resistance patterns
Maintain organ perfusion
Support organ perfusion
Capillary refill, urine output, mentation
 MAP 65 mm Hg, CVP 8-12 mm Hg, urine output 0.5 cc/kg/hr
Consider early measurement of lactate / venous O2 sat
Get pt to where trained personnel can manage them
Avoid nosocomial complications (cath infections, vent-assisted pneumonia, etc)

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 Vasoactive Medications for Shock
Volume resuscitation in shock
Prior to starting vasoactive medications, ENSURE ADEQUATE INTRAVASCULAR VOLUME
 You need lots of volume (these patients are leaky!) – MAKE SURE YOU FILL THE TANK FIRST
 Give LOTS (e.g. 3L immediately, 6L in 6h, 8-9L over 24h)

CRYSTALLOID IS THE BEST, & GIVE A LOT OF IT!

0.9% NS
Crystalloids  Easily accessible, cheap
Ringer’s Lactate
 Potential rapid distribution into extravascular compartments
Less volume needed
Theory: ↑ oncotic pressure w/ ↓ distribution to extravascular compartments
Albumin
More expensive
Colloids Gelatin
Meta-analysis does NOT support routine use of colloids
Pentastarches
 Albumin isn’t better than NS
 Pentastarch  less fluid, but ↑ mortality (don’t use!)
Theoretically best (can carry oxygen)
Blood products But no routine value in non-hemorrhagic shock
 Doesn’t increase O2 uptake

When to give vasopressors

 When preload is adequate (adequate volume resuscitation), but patient still hypotensive
 Patient moribund (e.g. SBP 40)  can give volume + vasopressors concomitantly
 Don’t start prematurely: you’re increasing afterload (PVR  ↑ cardiac workload)

Vasopressor overview
Drugs that raise blood pressure (not synonymous with catecholamines, but many are)
 Norepinephrine  Phenylephrine  Dopamine
 Epinephrine  Vasopressin

Most are catecholamines (dopamine, dobutamine, NE, E, isoproterenol, dopexamine)

 CV effects via adrenergic receptors (complex group of glycoproteins, use G-proteins to mediate action)
 Remember that they have multiple organ effects too – need to recognize these effects!

Types of adrenergic receptors involved in blood pressure

α-adrenergic β-adrenergic Dopaminergic
In peripheral vascular In cardiac muscle
Vasoconstriction ↑ inotropy / chronotropy
Endogenous catecholamine response
 SNS response; try to preserve homeostasis in face of shock / other stretches
 Norepi from sympathetic nerves (modulated by pH, adenosine concentration, PGE2)
 Epi primarily from adrenal gland; some contribution from other chromaffin tissue
o Circulating hormone; small changes in [epi]  big hemodynamic effects!

Exogenous catecholamines
 Pts with shock have ↑ catecholamine levels (endogenous)
 But inadequate or inadequate end-organ response?
 Treatment – give exogenous catecholamines (or other vasoactive meds) for shock pts

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Specific vasopressors
Low doses: works on splanchnic circulation only (just dopaminergic receptors)
High doses: works on alpha (vasoconstrict), beta receptors (ionotropic & chronotropic effects) more
dopamine
End result: increased HR & BP
Limitation: increases HR (not great for patients with already highish HRs)

Works on alpha > beta receptors, but both

norepinephrine Has less chronotropy than dopamine but more alpha-adrenergic activity (better at maintaining BP)
Maybe better than dopamine for patients with higher heart rates

Really potent in high doses (both alpha & beta effects)

epinephrine
Used for anaphylaxis mostly

Beta effects: powerful inotrope & chronotrope

isoproterenol No alpha effects - not a pressor, so you can't use it alone for shock
Rarely used in general

Beta effects: inotrope & chronotrope (a lttle less powerful than isoproterenol)
dobutamine
No alpha effects (can't use alone for shock - not a pressor)

Big alpha effects (good pressor)

No beta effects (not a chronotrope / inotrope) - like the opposite of dobutamine
phenylephrine
Good for, say, a young patient with a good heart rate - want to increase BP w/o affecting HR
But bad if the cardiac output is down (would just increase afterload & knock down CO even more!)

Catecholamines vs “Pressors” vs “Inotropes”

Pressors have α effects
 Catecholamines that aren’t pressors: dobutamine & isoproterenol
(CAN’T USE ALONE FOR SHOCK!)

Inotropes have β effects; may or may not have α effects

 Inotropes that aren’t pressors: dobutamine, milronone/amrinone, isoproterenol
(CAN’T USE ALONE FOR SHOCK!)

Pressors that aren’t inotropes (or catecholamines)

 Phenylephrine, vasopressin, angiotensin,

Choosing a vasopressor
Generally dopamine or norepinephrine (pressors & inotropes)
First line
 No good data to say one vs the other (see recent NEJM though)
Excessive tachycardia Phenylephrine, norepinephrine are 2nd choices
Inadequate control of hypotension Norepinephrine
Anaphylaxis Epinephrine

Renal splanchnic blood flow – theoretically low-dose dopamine should increase splanchnic / renal blood flow
 May increase urine output, but doesn’t increase solute clearance
 Take-home: don’t use dopamine for kidney failure (no evidence of benefit)
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 Adjunctive Therapies in Septic Shock
Goal-directed therapy
Oxygen delivery in sepsis
 May have a pathologic supply dependency
 Would mean that you need ↑ O2 delivery?

But no benefit to increasing oxygen delivery with Rx

 ↑ CO or ↑ venous output – but also ↑ consumption
 Doesn’t help outcomes

May be a benefit to early goal-directed therapy in the treatment of severe sepsis, septic shock
 Use complicated algorithm
 For instance, try to maintain venous O2 sat measured via central venous line; keep above 70%

Immunomodulation
 Really complicated pathophysiology of sepsis
 No good way to target single immune mediators to change outcomes

Vasopressin
 Patients in septic shock have less arginine vasopressin
 Give vasopressin in septic shock  can ↓ need for exogenous catecholamines
o But multicenter trial: NE + vasopressin  no better outcomes, but no worse either
o Occasionally used if pt has complications from NE (can decrease dose of NE!)

NO synthase inhibitors
 Blocking NO synthase  ↓ NO  ↑ blood pressure
 But ↑ risk of refractory shock, cardiac death  ↑ patient mortality (DON’T GIVE THIS

Glucocortocoids
 Lots of trials: maybe giving glucocortcoids can make end organs more responsive to catecholamines?
o High doses in early sepsis – didn’t really work; ↑ infectious compliations
o Lower doses in really sick patients (↑ lactate, ↓ SBP, even with vasopressors) – maybe some benefit
o No effect in less sick patients with low doses
 Take home: really sick patients with refractory hypotension may benefit; most patients don’t

Coagulation
 Lots of interest in blocking prothrombin  thrombin conversion (e.g. antithrombin III, TFPi)
 AT III & TFPi didn’t work, but activated protein C improves outcomes for some patients in some trials

Activated protein C
 Really expensive & ↑ intercranial bleeding is a big problem!
 Use rarely (only ≈ 1/20 pts you think about will meet the criteria)
 Can’t use in ESRD / end-stage liver dz

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 Summary: Therapy of Sepsis
Therapy
Give appropriate antibiotics early & empirically
Use adequate fluids
Crystalloids best for fluid resuscitation
Use blood for sepsis infrequently
Vasopressors to support MAP
Steroids
Goal-directed therapy with venous O2sat
Activated protein C (APC)
Vasopressin
Notes
Within 1h of hypotension
Lots! Up to 9L in 1st 24h
No benefit to giving albumin
Primarily as part of early goal-directed therapy (hgb < 10)
 No benefit in established shock
Choose based on physiologic effect, side effect profile
Only if hypotensive for <1h and risk of steroids < benefit
Reasonable in early septic shock (1st 6 h)
Don’t use after 48h
For patients who meet PROWESS criteria
 Need APACHE II > 25, low risk of bleeding
Not first line
 Consider to ↓ NE dose on pts already on NE