Protocol 1

Cellular responses to stress and toxic insults: Adaptation, injury and death. Accumulation in cell
and matrix

Types of responses

 Adaptation (hypertrophy, hyperplasia, atrophy, metaplasia)

 Injury (reversible; cellular swelling and fatty change)
 Death (irreversible; necrosis, apoptosis, autophagy)
Accumulations:
 Intracellular and extracellular
 Lipids, proteins, hyaline, glycogen, exogenous and endogenous pigments

1. Dystrophia parenhymatosa renis (acute tubular injury)

E/ hypoxia, ischemia, Hg and Pb poisoning, renal disease
PG/ oxygen deficit-> low ATP-> Na+/K+ ATPase dysfunction ->
high intracellular Na+ -> diffusion of water into the cell-> cellular
swelling
Gross/ kidney is pale, enlarged, ‘boiled’
Histo/
 Proximal tubules are lined with bigger cells
 Narrowed lumen
 Granular cytoplasm
 Nuclei not visible but exist
 Distal tubules unaffected, glomeruli look bigger

Most often this process occurs in the epithelial cells of proximal

convoluted tubules of the kidney. Boundaries between cells are not
visible. Ducts are enlarged, their lumens are irregular because of
swollen epithelial cells that are intensely stained pink. Tubules thicker-
swollen due to increased cytoplasmic volume.
2. Dystophia adipose hepatis (steatosis hepatis)
(fatty liver; fatty liver disease)
Terminology:
 Steatosis- lipid deposition in the cytosol of parenchymal cells
 Lipomatosis- local lipid deposition in mesenchymal cells
 Obesitas- diffuse lipid deposition in mesencyhmal cells
E/ alcohol abuse, DM, obesity, some drugs and mushrooms

PG/ 1. Diet high in lipids

2. increased lipogensis
3. increased mobilization of lipids from fat depots
4. Decreased lipid outflow in the form of lipoprotein complexes
5. decreased degradation of lipids via beta oxidation-> accumulation of TAG in hepatocytes->
90% in cytoplasm-> decreased liver function

Gross/ liver is enlarged, soft, yellowish-brown colour

Histo/ 2 types- macrovesicular and microvesicular

NB! Lipids get extracted by the alcohols used during slide preparation and in their place
empty spaces (vacuoles) are seen. If stained by Sudan III they appear orange.
Pericentral hepatocytes are dystrophic. Periportal hepatocytes are unaffected.
If condition progresses (toxic factor persists)-> liver cirrhosis
Think of empty bubbles everywhere and nucleus pushed to the side

Sudan III;
3. Athermoatosis aortae (H&E, Sudan III)- atherosclerosis of the aorta
E/ smoking, hyperlipidemia, DM, arterial hypertension, decreased physical activity, genetic
factor

PG/ cholesterol enters subendothelial space -> chronic inflammatory healing response ->
intimal cellular proliferation. Lesion progression: fatty streaks -> plaques-> complicated
plaques

Gross/ wall of abdominal aorta is thickened, with a yellowish luminal surface (lipid streak);
dense, egg-shell-like, cracked protrusions (atherosclerotic plaque). If plaque is circular, the
vessel looks like raw pasta

Complications/
1. Rupture, ulceration, erosion
2. Thrombosis (-> downstream ischemia)
3. Hemorrhage into the plaque (contained hematoma, aortic dissection)
4. Atheroembolism
5. Aneurysm formation (due to medial atrophy)

Histo/
1. Pink amorphous necrotic core with optically empty inclusions in the place of the extracted
cholesterol crystals (in the empty box of right picture below) and lipids
2. foam cells – macrophages (lipophages) and smooth muscle cells at edge of plaque, filled
with cholesterol esters; they appear lighter, with vacuolated cytoplasm and indistinct
borders
3. Intimal thickening with dense deposits of collagen (fibrous cap)
4. Ca2+ crystals may be present

Sudan
III;
 4. Anthracosis pulmonis
E/ inhalation of coal dust

PG/ alveolar macrophages pick up the pigment -> ‘coniophage’-> transport to interstitium of lung
and regional lymph nodes

Gross/ black lines on lung surface

Histo/ resin-black pigment in interstitium (perivascular, perialveolar, peribronchial space)

NB! The anthracotic pigment isn’t harmful but if mixed with Si-> silicosis and lung induration

 This is an example of exogenous pigment deposition in the lung (coal dust)

 Inhaled particle of dust overcome the tracheobronchial tree and reach the alveoli where
they are phagocytosed by alveolar macrophages-> coniophage (cytoplasm contains black
powder inclusions)
 After death of coniophage, pigment is deposited in interstitial of CT

Think BLACK!! When looking at the slide as a whole in microscope-> n/w of empty holes
 5. Icterus renis

E/ obstructive (post-hepatic) jaundice

Jaundice: when equilibrium of BR production and clearance is disturbed

Mechanisms:
1. Excessive extrahepatic production of BR
2. Reduced hepatocyte uptake
3. Impaired conjugation (note 1-3= uncongj. Hyper BR)
4. Decreased hepatocellular excretion
5. Impaired bile flow (note 4-5= conj. Hyper BR)

PG/ conjugated hyperbilirubinemia -> BR passes the glomerular membrane and enters
epithelial lining of proximal tubules and LOH. When reaches distal tubules -> BR cylinders
NB! Only conjuagated BR can pass through the glomerulus, because it is water soluble and
isn’t strongly bounded to albumin

Gross/ yellowish, normal sized kidney

Hist/ BR in proximal tubule epithelium- orange-yellow-brown granules in cytoplasm, no

nuclei. BR cylinders in lumen of distal tubules

We are interested in the

tubules! – bright Red-orange
Inside (BR bile Cast)= solid
Balls inside tubules (BR and
Cell debris)
6. Atrophia fusca hepatis

E/ age, free radicals

PG/ lipofuscin (a.k.a wear-and-tear pigment)- peroxidised membrane lipids and

phospholipids (mitochondria and lysosomes). It is particularly found around nuclei
(perinuclear) of myocardiocytes and centrilobular hepatocytes of aging patients.
Result of free radical injury
Basically, old people, old cells and old tissue- dead organelles within cells- accumulate
‘trash’

Gross/ liver is smaller, brown, firm, sharp edge, Glisson’s capsule is wrinkled

Histo/ Brown-yellow perinuclear pigment of lipofuscin in centrilobular hepatocytes,

shrunken lobules
7. Naevus pigmentosus (mole, melanocytic nevus)
Congenital or acquired benign neoplasm originating from dendritic melanocytes
localized in the basal layer of epidermis.
E/ sun exposure, increased ACTH (Adison’s disease)

PG/ in the skin: Tyrosine-> DOPA-> melanin

In adison’s= decreased production of corticosteroids leads to > stimulation of pituitary->
proopiomelanocortin (POMC) converted to ACTH, MSH and beta-endorphine.

Gross/ hyperpigmented (brown) macule (flat) or papule (elevated) of the skin, small
(<6mm), round, well-defined borders

Histo/ nests of round nevus cells, usually containing melanin

Types of nevi:
Junctional: at dermoepidermal junction, flat, young nevi
Compound: junctional nevis that grows into underlying dermis
Intradermal: nests only in dermis
NOTE: the lower into the dermis nevis cells sink, the more mature the become

Melanocytes proliferate and shaped in nestes in epidermis and usually contain brown
granules of melanin (may not be evident). Nests are composed of uniform round or
polygonal cell with slightly granular cytoplasm and round oval nucleus.
Nevus can give rise to early malignant pigmented tumours- malignant melanoma
 Protocol 2

Mesenchymal degenrations. Accumulations in cells and matrix

Hyaline- homogenous glassy pink appearance; consists mainly of proteins with some lipids and
CHO’s. 3 patterns of accumulation:
1. Extracellular (CT)- white bodies in ovary
2. Vascular (insudational)- arteriolar hyalinization of kidney
3. Intracellular (Russel bodies, malory bodies, reabsorption droplets)

Fibrinoid- homogenous dark pink appearance; consists of albumins, globulins, fibrin; only
extracellular; causes inflammation.

Amyloid – abnormal protein matter associated with different pathological processes; consists of
different proteins with identical secondary structure- beta-sheet;
On microscopy:
- HE- pink
- MV (methylviolet)- tissue is dark blue and amyloid is purple-violet via metachromasia-
colouring of a tissue constituent in a colour different from that of dye applied
- Congo red- amyloid is orange-red with apple-green under polarized light
Types of amyloid:
- AL = multiple myeloma and other monoclonal gammopathies
- AA= chronic inflammation
- AE= hereditary
 1. Corpus albican ovarii

An example of physiologic hyalinosis, extracelluar type- doesn’t lead to inflammation.

Gross/ ovarian surface is uneven, on cut surface; wavy or oval white bodies- macroscopic deposition
of hyaline. White bodies are final phase in evolution of Graafian follicle.

Histo/ oval light pink bodies with wavy borders and thicker stroma surrounding them. Among the
homogenous pink material- atrophic fibrocytes

homogenous pink colour, bodies

are well-demarcated from the
surrounding tissue folded in the
form of swag border.
 2. Hyalinosis arteriolarum renis

An example of vascular hyaline

E/ Benign arterial hypertension, DM

PG/ inusdation- high luminal tension forces blood proteins into vessel wall where they become
tightly packed-> reduction of lumen-> partial ischemia-> hyalinisation of some glomeruli

Gross/ both kidneys reduced in size, firmer; surface is finely granular- hyalinised glomeruli pull the
tissue inwards, while affected glomeruli become hypertrophic (to compensate loss of function) and
push the surface upwards/

Histo/ 1. Thickening of arteriolar walls (mostly vasa afferentia)

2.Hyalinisation of some glomeruli
3.pericapsular fibrosis
 3. Amyloidosis renis (HE, Congo red)
E/ chronic inflammation, malignant neoplasms

PG/ elevated SAA (serum Amyloid A protein, produced in liver during inflammation) + enzyme deficit
degradation= deposition of AA in tissues

Gross/ kidney is enlarged, pale, waxy consistency

Histo/ all glomeruli englarged, amyloid accumulates extracellularly in basement membranes.

Congo red- amyloid is orange red

Congo red stain below;

4. Amyloidosis lienis (HE,MV)
Gross / 2 types:
- Amyloid deposition in white pulp (localized type) -> sago spleen
- Amyloid deposition in red pulp (diffuse type)-> lardaceous spleen

Histo/
- Localised type= deposition of amyloid in the walls of the arterioles in the white pulp
- Diffuse type= deposition in sinuses, sparing follicles
- Deposition of amyloid is spleen; homogenous pink-coloured follicles. Centrally located
follicular arteries are homogenized and thickened with pink coloured walls;
HE staining – on top left picture

Amyloidsis MV stain(bottom 3)- lymph follicles and

central arteries amyloid is red, other tissure are
blue-violet. This method is used for proof of
amyloidosis in differential diagnosis with other
processes;
 Protocol 3

Tissue and cell death (necrosis)

3 types of cell death- necrosis, apoptosis and autolysis

Necrosis vs. Cell injury- in necrosis there is nuclear damage-> irreversible;

- Karyopynkosis= smaller hyperchromic wrinkled nucleus, chromatin condensation
- Karyolysis= leakage of chromatin into the cytoplasm
- Karyorhhexis= fragmentation of nucleus
Necrosis Apoptosis
Definition Local tissue death in living Progressive self-destruction of
organism that leads to impaired cells. Programmed cell death
function
Types of processes Physiologic or pathologic-> leads to Physiologic-> no inflammation
inflammation
Location Physiologic- blood cells, epidermis, In embryogenesis
GI tract epithelium, resp. Epithel.

Types of necrosis:
 1. Necrosis renis (infarctus anemicus renis)

An example of coagulative necrosis [note: coagulative necrosis everywhere but brain, pink, lose
nuclei]
E/ ischemia, *atherosclerosis of renal arteries
Gross/ pale, soft protruding sections

PG/ anemic infarction of the kidney develops and blockage of some of the branches of renal arteries-
> embolism-> ischemia-> necrosis of renal parenchyma

Histo/ lack of nuclei , granular pink cytoplasm

- Ill-defined cell borders (glomeruli and tubules look like shadows)
- Leukocytes and vasodilation (inflammation)-> hyperaemia and reddening= hyperaemic-
hemorrhagic zone
- Line of demarcation- zone of inflammatory reaction separating diseased area and healthy
tissue
- around the area of necrosis- area consisting of dilated blood vessels and bleeding. Near it
there is leukocytes which may be missing in early stages.
 2. Necrois myocardii (AMI) (infarctus anemiucs myocardii)
Another example of coagulative necrosis in myocardium as a result of stopping the blood
flow, mostly due to blockage of coronary artery by clot or prolonged vasoconstriction.

E/ - atherosclerosis of coronary arteries

-emboli
-aterial spasm

Histo/ lack of nuclei on damaged site

- Lack of the striate appearance
- Dilated or collapsed capillaries
- Cicatrices and hypertrophic cardiomyocytes around damaged site
- Wavy and fragmented cardiomyocytes
- Line of demarcation (inflammation)
 3. Necrosis lymphonodi
An example of caseous necrosis. Develops during tuberculosis infection (specific inflammation with
mycobacterium tuberculosis)

Histo/ caseating necrosis- eosinophillic acellular homogenous matter

-complete destruction and vanishment of organ structure (no shadows)
-at periphery- epithelioid cells and giant cells ‘langhans’ (specific to TB)
- numerous lymph (lymphocytes)

Lymphoid follicles
circular lighter areas in
the node
Giant cells= pink dots
(prominent)
 4. Necrosis cerebri (encephalomalacia= cerebral softening) (stroke)

An example of liquefactive necrosis

E/ occlusion of cerebral artery

PG/ ischemia
- Phase 1= Ischemic phase (0-2 days); edema, break down of myeling sheaths, degeneration of
cells
- Phase 2= resorption (2-14 days); phagocytosis of broken down myelin sheaths (lipids) by
microglia-> foam cells (lipophages)
- Phase 3= pseudocyst formation; after 2 weeks- empty space in place of the central necrotic
tissue
NB! True cysts have epithelium lining their walls. Pseudocysts don’t have epithelial lining

Gross/
Phase 1= lighter zone in brain tissue
Phase 2= tissue softening
Phase 3= pseudocyst formation

Histo/
Phase 1= interstitial edema around perivascular and pericellular
space (empty halos; cytoplasm appears loose)
Phase 2- foam cells
Phase 3- central empty space (pseudocyst) surrounded by glial cicatrix (cyst wall)
The area of necrosis is seen as a stretch of pale pink coloured, homogenous, structure less granular
matter.

Pseudocyst- no epithelial lining (cyst- epithelial lining). Look out for lighter areas (absence of tissue),
bubbles around cells= Edema
 Protocol 4
Hemodynamic disorders
1.Iduratio fusca pulmonis (local deposition of hemosiderin in lungs)
E/ left-sided chronic heart failure

PG/ chronic hypoxia in alveolar capillaries endothelial dysfunction increased vascular

permeability erythrocytes pass into the alveoli and phagocytosed by alveolar macrophages (dust
cells) haemoglobin-> ferritin-> hemosiderin siderophages (hemosiderin-containing
macrophages= heart failure cells)
- Chronic hypoxia in the lung  proliferation of fibroblasts collagen synthesis and
deposition  thickening and hardening (induration) of interalveolar septa

Gross/ lungs smaller, firm, reddish-brown in colour

Histo/ siderophages and extracellular hemosiderin (brown pigment)

-thick alveolar septa
- small intra-alveolar haemorrhages (from rupture of conjested capillaries)
-partial edema

Special stain for Fe2= Prussian blue stain- hemosiderin appears blue.
2. Edema pulmonis

E/ > hydrostatic pressure (acute L-heart failure)

- < oncotic pressure
- > vascular permeability
- Blocked lymph drainage

PG/ depends on etiologic factor, end result is extravascular accumulation of fluid

Swelling in alveolar walls walls expand, interstitial edema develops after accumulation of fluid in
interstitial lung (leakage of transudate into alveoli)

Gross/ lungs enlarged, heavy, on cut surface= pink foamy liquid oozes (air and bubbles, edema fluid
and RBCs)

Histo/
-alveoli with light-pink homogenous protein rich-fluid-> fills alveoli and moves bronchi and
bronchioles
-congested vessels (dilated and filled with blood)
- between alveolar spaces= thick
3.Cyanosis hepatis (brief stagnation of blood in venous system of liver)

E/ acute R-heart failure

PG/ acute R-heart failure venous hyperaemia in vena cava, hepatic veins and central veins of liver
lobules (cause brief stagnation of blood in venous system of liver)

Gross/ liver in enlarges, painful

Histo/ central vein (severe central hypoxia may produce centriobular necrosis) and liver sinusoids
are dilated and congested
-liver sinusoids appear wavy
4.Hepar moschatum (congestive hepatopathy) (nutmeg liver)

E/ chronic R-heart failure due to prolonged venous stasis in central vein

PG/ persistent blood stagnation hypoxia centrilobular dystrophy and atrophy of hepatocytes

Gross/ liver is reduced in size, cyanotic; central parts of lobules are dark-violet and surrounded by a
yellowish periphery (nutmeg liver); on cut surface- large amount of venous blood leaks out

Histo/
-centrilobular part= conjested, atrophic hepatocytes
-intermediate part- dystrophic hepatocytes (steatosis)
-peripheral part- unaffected

NB! Condition could progress- the atrophic tissue grows and becomes replaced by fibrosis cardiac
cirrhosis
5.Haemorrhagia punctatae cerebri (pinpoint haemorrhages in the brain with damage to small blood
vessels)

E/ shock, DIC syndrome, trauma, increased permeability, hypoxia, poisons

PG/ haemorrhage= extravasation of blood by:

- Heamorrhagia per diapedesin- passive RBS pass through vessel wall due to increased
permeability/hypoxia/stagnation/increased pressure (endothelial damage)
- Haemorrhagia per rhexin- by rupture of vessel wall (trauma, ulcers)
- Haemorrhagia per diabrosin- by ulceration or tumour invasion

Histo/
- Free collection of RBCs in brain tissue; could be circular or annular
- Edema (perivascular, pericellular) and necrosis of surrounding brain tissue
 Protocol 5
Hemodynamic disorders. Thrombosis. Part 2
1.Thrombus mixtus
A laminated thrombus consists of thrombocytes, fibrin, erytorocytes, leukocytes and plasma
proteins.

PG/ Virchrow’s triad

1) Endothelial injury
2) Hemodynamic changes (stasis- varicose veins; turbulence- atherosclerotic plaques)
3) Hypercoagulability (causes= inherited diseases, polycythemia, contraceptives, some
tumours)
Types of thrombi:
1) Venous (coagulative)- in veins with stasis: mainly Er, little fibrin, few Throm (red thrombus)
2) Arterial (aglutinational)- in Arteries (coronary, cerebral, femoral)
-over atherosclerotic plaques; endothelial injury= throm adhesion and aggregation+ fibrin+
Leu (White thrombus)
3) Mixed thrombus- ‘white’ head and ‘red’ tail
4) postmorten clots- no fibrin, unattached, gelatinous

Gross/ crumbly, variegated (lines of Zahn), attached to tunica media and its shape follow shape of
vessel lumen

Histo/
-pink fibrin meshwork and Throm
- layers with dark-blue coloured leu (by haematoxylin)
-Layers with orange-red coloured Er (by eosin)

Fate of thrombus:
1) Propagation- accumulation of more Throm and fibrin
2) Embolization- parts of thrombys break off, travel and occlude a smaller distant blood vessel
3) Dissolution (fibrinolysis
4) Organisation and recanalization
Wall of aorta, fibrin mesh, RBCs, platelets
2. Thrombus organisatus and recanalisatus

 Favourable outcome of vascular thrombosis

 Organisation- the development of granulation tissue in the thrombus.
 Granulation tissue consists of young mesenchymal cells and neovascularisation.
 Formation begins at attachment site of thrombus and gradually advances toward the centre
 Over time, some newly formed capillaries are replaced by collagen (fibrous CT). The rest of
the capillaries grow in diameter and their walls thicken- adequately functioning blood
vessels= restoring blood flow (recanalization) small vessels appear inside thrombus
 Thrombi most commonly form over atherosclerotic plaques, these plaques are found in the
obturated vessel
wall

Red part=small blood

vessels formed inside the
blood clot
3.Infarctus haemorrhagicus pulmonis

 Infarction= an area of ischemic necrosis caused by an acute occlusion of arterial

supply or venous drainage
 Type according to colour:
1) Anemic (white) infarction= solid, compact organs usually caused by arterial
obstruction (due to thrombus or embolus)- heart, kidneys, spleen, liver
2) Heamorrhagic (red) infarction= in organs with dual circulation- lungs, small
bowels; in organs with a single different efferent vein, cause is usually venous
thrombus- testes, ovary

E/ leading cause for red infarction= pulmonary embolism; the emboli originate from DVT in lower
extremities

- Clinical pulmonary embolism presentation depends on size/number of emboli:

1) Big solitary emboli could block lungs or its bifurcation (saddle embolus) acute R heart
failure and sudden death
2) Many small emboli <60%  clinically silent
3) Many small emboli that obstruct >60% of pulmonary circulation sudden death
4) Medium-sized emboli that obstruct medium-sized arteries- usually don’t lead to
infarction (due to dual circulation of lungs), but can cause onset of chronic L heart
failure red infarction

PG/ lungs have dual artery supply; a.pulmonalis (02-poor blood) and a.bronchialis (02 rich blood).
Occlusion of one of these arteries leads to ischemic infarction of the supplied tissue and the
uninterrupted flow through the other allows blood to leak into the necrotic area.

Gross/ Wedge-shaped, soft, dark redish-brown zone

Histo/ -alveolar spaces and interstitium filled with RBCs

-alveolar cells have no nuclei
-siderophages +/- brown induration in surrounding tissues
-lots of homogenous pink areas
-necrosis of alveolar walls-no walls or structures defined
4.Infarctus anamicus renis (necrosis renis) (protocol 3)

- Anemic infarction of kidney- blockage of some branches of renal arteries due to embolism
usually.
- Coagulation necrosis
- Homogenous cytoplasm (intense pink coloured) and cells lacking nuclei in tubules
- Delineated cell borders
- Around area of necrosis= area consisting of dilated blood vessels and bleeding

5. Infarctus anaemicus myocardii (necrosis myocardii) (protocol 3)

- Ischemic/anemic/coagulation necrosis as a result of stopping of blood flow (mostly due to
blockage of coronary artery by clot or prolonged vasoconstriction)
- Well homogenized limited area of cardiomyocytes
- Nuclei not clearly visible
-Hyperaemic hemorrhagic zone=purpley