Pathology Quick Review And MCQs, 3rd Edition

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PATHOLOGYQuick Review and MCQsBased onTextbook of Pathology6th EditionFor free online Web Images and Web Tables cited in the text,access on www.jaypeeonline.inScratch pin number available in the main textbook.

PATHOLOGYQuick Review and MCQsTHIRD EDITIONBased onTextbook of Pathology6th EditionHarsh Mohan MD, MNAMS, FICPath, FUICCProfessor & HeadDepartment of PathologyGovernment Medical CollegeSector-32 A, Chandigarh-160 031INDIAE-mail: [email protected] JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTDSt Louis (USA) Panama City (Panama) New Delhi Ahmedabad BengaluruChennai Hyderabad Kochi Kolkata Lucknow Mumbai Nagpur

Published byJitendar P VijJaypee Brothers Medical Publishers (P) LtdCorporate Office4838/24 Ansari Road, Daryaganj, New Delhi 110 002, India, Phone: 91-11-43574357,Fax: 91-11-43574314Registered OfficeB-3 EMCA House, 23/23B Ansari Road, Daryaganj, New Delhi 110 002, IndiaPhones: 91-11-23272143, 91-11-23272703, 91-11-23282021, 91-11-23245672Rel: 91-11-32558559 Fax: 91-11-23276490, 91-11-23245683e-mail: [email protected], Website: www.jaypeebrothers.comBranches 2/B, Akruti Society, Jodhpur Gam Road SatelliteAhmedabad 380 015 Phones: 91-79-26926233, Rel: 91-79-32988717Fax: 91-79-26927094 e-mail: [email protected] 202 Batavia Chambers, 8 Kumara Krupa Road, Kumara Park EastBengaluru 560 001 Phones: 91-80-22285971, 91-80-22382956, 91-80 22372664Rel: 91-80-32714073 Fax: 91-80-22281761 e-mail: [email protected] 282 IIIrd Floor, Khaleel Shirazi Estate, Fountain Plaza, Pantheon RoadChennai 600 008 Phones: 91-44-28193265, 91-44-28194897, Rel: 91-44-32972089Fax: 91-44-28193231 e-mail: [email protected] 4-2-1067/1-3, 1st Floor, Balaji Building, Ramkote Cross RoadHyderabad 500 095 Phones: 91-40-66610020, 91-40-24758498, Rel: 91-40-32940929Fax: 91-40-24758499, e-mail: [email protected] No. 41/3098, B & B1, Kuruvi Building, St. Vincent RoadKochi 682 018, Kerala Phones: 91-484-4036109, 91-484-2395739, 91-484-2395740e-mail: [email protected] 1-A Indian Mirror Street, Wellington SquareKolkata 700 013 Phones: 91-33-22651926, 91-33-22276404, 91-33-22276415Fax: 91-33-22656075, e-mail: [email protected] Lekhraj Market III, B-2, Sector-4, Faizabad Road, Indira NagarLucknow 226 016 Phones: 91-522-3040553, 91-522-3040554e-mail: [email protected] 106 Amit Industrial Estate, 61 Dr SS Rao Road, Near MGM Hospital, ParelMumbai 400 012 Phones: 91-22-24124863, 91-22-24104532,Rel: 91-22-32926896 Fax: 91-22-24160828, e-mail: [email protected] “KAMALPUSHPA” 38, Reshimbag, Opp. Mohota Science College, Umred RoadNagpur 440 009 (MS) Phone: Rel: 91-712-3245220Fax: 91-712-2704275 e-mail: [email protected] America Office1745, Pheasant Run Drive, Maryland Heights (Missouri), MO 63043, USA, Ph: 001-636-6279734e-mail: [email protected], [email protected] America OfficeJaypee-Highlights Medical Publishers Inc., City of Knowledge, Bld. 237, Clayton,Panama City, Panama, Ph: 507-317-0160Pathology Quick Review and MCQs 2010, Harsh MohanAll rights reserved. No part of this publication should be reproduced, stored in a retrieval system, ortransmitted in any form or by any means: electronic, mechanical, photocopying, recording, orotherwise, without the prior written permission of the author and the publisher.This book has been published in good faith that the material provided by author is original.Every effort is made to ensure accuracy of material, but the publisher, printer and author will notbe held responsible for any inadvertent error(s). In case of any dispute, all legal matters are tobe settled under Delhi jurisdiction only.First Edition : 2000Second Edition : 2005Third Edition : 2010Assistant Editors: Praveen Mohan, Tanya Mohan, Sugandha MohanISBN: 978-81-8448-778-7Typeset at JPBMP typesetting unitPrinted at Ajanta Press

He whose deeds are virtuous,is rewarded with purity and knowledge. Theactionsdonewithpassioncausemisery, while he whose deeds are dark is cursed with ignorance. (The Bhagvadgita, Chapter XIV: Verse 16) To all those who matter so much to me:My family—wife Praveen anddaughters Tanya, SugandhaandAll students and colleagues—former and present,with whom I had occasion to share and interact.

PrefaceThe release of the Third Revised Edition of Pathology QuickReview and MCQs simultaneous to the release of the SixthEdition of its parent book, Textbook of Pathology, marks thecompletion of 10 years since its first launch. The satisfiedusers of this ancillary handy learning material during thedecade have surely encouraged me and the publisher tocontinue the convention of providing the baby-book as apackage with the mother-book. Besides, with this edition, athird learning resource has been added for the benefit ofusers—the buyer of the package now gets free access to thehighly useful website containing all the images and tablesincluded in the main textbook which can be used as anadditional learning tool by the students for self-assessmentand quick review of the subject while teachers may use thedownloadable figures and tables for inclusion in theirlectures.The companion book is the abridged version of sixthrevised edition of my textbook and has been aimed to servethe following twin purposes as before:For beginner students of Pathology who have undertakenan in-depth study of the main book earlier may like to revisethe subject in a relatively short time from this book and mayalso undertake self-test on the MCQs given at the end ofeach chapter.For senior students and interns preparing for theirpostgraduate and other entrance examinations who areconfronted with revision of all medical subjects besidespathology in a limited time, this book is expected to act asthe main source material for quick revision and also exposethem to MCQs based on essential pathology.Pathology Quick Review book has the same 30 chaptersdivided into sections as in the main textbook—Section I:Chapters 1-11 (General Pathology and Basic Techniques),Section II: Chapters 12-14 (Haematology and Lymphoreticular Tissues), Section III: Chapters 15-30 (SystemicPathology) and an Appendix containing essential NormalValues. Each major heading in the small book has crossreferences of page numbers of the 6th edition of my textbookso that an avid and inquisitive reader interested insimultaneous consultation of the topic or for clarification ofa doubt, may refer to it conveniently. Self-Assessment byMCQs given at the end of every chapter which keeps thisbook apart from other similar books, has over 100 new

viiiPathology Quick Reviewquestions raising their number to over 700 MCQs in therevised edition, besides modifying many old ones. Whilemuch more knowledge has been condensed in the babybook from the added material in the main textbook, efforthas been made not to significantly increase the volume ofthis book. It is hoped that the book with enhanced andupdated contents continues to be user-friendly in learningthe essential aspects of pathology, while at the same time,retaining the ease with which it can be conveniently carriedby the users in the pocket of their white coats.Preparation of this little book necessitated selection fromenhanced information contained in the revised edition ofmy textbook and therefore, required application of mydiscretion, combined with generous suggestions fromcolleagues and users of earlier edition. In particular, valuablesuggestions and help came from Drs Shailja and Tanvi,Senior Residents in the department, which is gratefullyacknowledged.I thank profusely the entire staff of M/s Jaypee BrothersMedical Publishers (P) Ltd. for their ever smiling supportand cooperation in completion of this book in a relativelyshort time, just after we had finished the mammoth task ofrevision work of sixth edition of the main textbook.Finally, although sincere effort has been made to be asaccurate as possible, element of human error is still likely; Ishall humbly request users to continue giving their valuablesuggestions directed at further improvements of its contents.Government Medical CollegeHarsh MohanSector-32 AMD, MNAMS, FICPath, FUICCChandigarh-160 031Professor and HeadINDIADepartment of PathologyE-mail: [email protected]

ContentsSECTION I: GENERAL PATHOLOGY ANDBASIC TECHNIQUES1. to Pathology . 01Techniques for the Study of Pathology . 06Cell Injury and Cellular Adaptations . 14Immunopathology Including Amyloidosis . 41Derangements of Homeostasis andHaemodynamics . 63Inflammation and Healing . 92Infectious and Parasitic Diseases . 131Neoplasia . 145Environmental and Nutritional Diseases . 185Genetic and Paediatric Diseases . 203Basic Diagnostic Cytology . 212SECTION II: HAEMATOLOGY ANDLYMPHORETICULAR TISSUES12. Introduction to Haematopoietic System andDisorders of Erythroid Series . 22613. Disorders of Platelets, Bleeding Disorders andBasic Transfusion Medicine . 26614. Disorders of Leucocytes andLymphoreticular Tissues . 281SECTION III: SYSTEMIC .29.30.The Blood Vessels and Lymphatics .The Heart .The Respiratory System .The Eye, ENT and Neck .The Oral Cavity and Salivary Glands .The Gastrointestinal Tract .The Liver, Biliary Tract and Exocrine Pancreas .The Kidney and Lower Urinary Tract .The Male Reproductive System and Prostate .The Female Genital Tract .The Breast .The Skin .The Endocrine System .The Musculoskeletal System .Soft Tissue Tumours .The Nervous System PPENDIX: Normal Values . 750Index . 757

Abbreviations UsedThroughout the book following abbreviations have been used:G/Afor Gross Appearance.M/Efor Microscopic Examination.EMfor Electron Microscopy.IFfor Immunofluorescence Microscopy.

Chapter11Introduction to PathologyLesions are the characteristic changes in tissues and cells produced bydisease in an individual or experimental animal.Pathologic changes or morphology consist of examination of diseasedtissues.Pathologic changes can be recognised with the naked eye (gross ormacroscopic changes) or studied by microscopic examination of tissues.Causal factors responsible for the lesions are included in etiology ofdisease (i.e. ‘why’ of disease).Mechanism by which the lesions are produced is termed pathogenesis ofdisease (i.e. ‘how’ of disease).Functional implications of the lesion felt by the patient are symptoms andthose discovered by the clinician are the physical signs.EVOLUTION OF PATHOLOGY (p. 1)Pathology as the scientific study of disease processes has its deep roots inmedical history. Since the beginning of mankind, there has been desire as wellas need to know more about the causes, mechanisms and nature of diseases.The answers to these questions have evolved over the centuries—fromsupernatural beliefs to the present state of our knowledge of modern pathology. FROM RELIGIOUS BELIEFS AND MAGIC TO RATIONAL APPROACH(PREHISTORIC TIME TO AD 1500) (p. 2)Present-day knowledge of primitive culture prevalent in the world in prehistorictimes reveals that religion, magic and medical treatment were quite linked toeach other in those times. The earliest concept of disease understood by thepatient and the healer was the religious belief that disease was the outcome of‘curse from God’ or the belief in magic that the affliction had supernatural originfrom ‘evil eye of spirits.’ To ward them off, priests through prayers andsacrifices, and magicians by magic power used to act as faith-healers andinvoke supernatural powers and please the gods. Remnants of ancientsuperstitions still exist in some parts of the world.Introduction to PathologyPatient is the person affected by disease.Chapter 1STUDY OF DISEASES (p. 1)The word ‘Pathology’ is derived from two Greek words—pathos meaningsuffering, and logos meaning study. Pathology is, thus, scientific study ofstructure and function of the body in disease; or in other words, pathologyconsists of the abnormalities that occur in normal anatomy (including histology)and physiology owing to disease. Knowledge and understanding of pathologyis essential for all would-be doctors, general medical practitioners andspecialists. Remember the prophetic words of one of the eminent founders ofmodern medicine in late 19th and early 20th century, Sir William Osler, “Yourpractice of medicine will be as good as your understanding of pathology.”Since pathology is the study of disease, then what is disease? In simplelanguage, disease is opposite of health i.e. what is not healthy is disease.Health may be defined as a condition when the individual is in complete accordwith the surroundings, while disease is loss of ease (or comfort) to the body(i.e. dis-ease).It is important for a beginner in pathology to be familiar with the languageused in pathology:

2Section IGeneral Pathology and Basic TechniquesBut the real practice of medicine began with Hippocrates (460–370 BC),the great Greek clinical genius of all times and regarded as ‘the father ofmedicine’ (Web Image 1.1). Hippocrates followed rational and ethical attitudesin practice and teaching of medicine as expressed in the collection of writingsof that era. He firmly believed in study of patient’s symptoms and describedmethods of diagnosis.Hippocrates introduced ethical concepts in the practice of medicine and isrevered by the medical profession by taking ‘Hippocratic oath’ at the time ofentry into practice of medicine.Hippocratic teaching was propagated in Rome by Roman physicians,notably by Cornelius Celsus (53 BC-7 AD) and Cladius Galen (130–200 AD).Celsus first described four cardinal signs of inflammation—rubor (redness),tumor (swelling), calor (heat), and dolor (pain). Galen postulated humoraltheory, later called Galenic theory.The hypothesis of disequilibrium of four elements constituting the body(Dhatus) similar to Hippocratic doctrine finds mention in ancient Indian medicinebooks compiled about 200 AD—Charaka Samhita and Sushruta Samhita. FROM HUMAN ANATOMY TO ERA OF GROSS PATHOLOGY(AD 1500 TO 1800) (p. 3)The backwardness of Medieval period was followed by the Renaissanceperiod i.e. revival of leaning. Dissection of human body was started byVesalius (1514–1564) on executed criminals. His pupils, Gabriel Fallopius(1523–1562) who described human oviducts (Fallopian tubes) and Fabriciuswho discovered lymphoid tissue around the intestine of birds (bursa of Fabricius)further popularised the practice of human anatomic dissection for whichspecial postmortem amphitheatres came in to existence in various parts ofancient Europe (Web Image 1.2).Antony van Leeuwenhoek (1632–1723), a cloth merchant by profession inHolland, during his spare time invented the first ever microscope.The credit for beginning of the study of morbid anatomy (pathologicanatomy), however, goes to Italian anatomist-pathologist, Giovanni B. Morgagni(1682–1771). He laid the foundations of clinicopathologic methodology in thestudy of disease and introduced the concept of clinicopathologic correlation(CPC), establishing a coherent sequence of cause, lesions, symptoms, andoutcome of disease (Web Image 1.3).Sir Percival Pott (1714–1788), famous surgeon in England, identified thefirst ever occupational cancer in the chimney sweeps in 1775 and discoveredchimney soot as the first carcinogenic agent. However, the study of anatomyin England during the latter part of 18th Century was dominated by the twoHunter brothers: John Hunter (1728–1793), a student of Sir Percival Pott,rose to become greatest surgeon-anatomist of all times and he, together withhis elder brother William Hunter (1718–1788) who was a reputed anatomistobstetrician (or man-midwife), started the first ever museum of pathologicanatomy (Web Image 1.4).R.T.H. Laennec (1781–1826), a French physician, dominated the earlypart of 19th century by his numerous discoveries. He described several lungdiseases (tubercles, caseous lesions, miliary lesions, pleural effusion,bronchiectasis), chronic sclerotic liver disease (later called Laennec’s cirrhosis)and invented stethoscope.Morbid anatomy attained its zenith with appearance of Carl F. vonRokitansky (1804–1878), self-taught German pathologist who performed nearly30,000 autopsies himself. ERA OF TECHNOLOGY DEVELOPMENT ANDCELLULAR PATHOLOGY (AD 1800 TO 1950s) (p. 4)Pathology started developing as a diagnostic discipline in later half of the 19thcentury with the evolution of cellular pathology which was closely linked to

3Chapter 1Introduction to Pathologytechnology advancements in machinery manufacture for cutting thin sectionsof tissue, improvement in microscope, and development of chemical industryand dyes for staining.The discovery of existence of disease-causing micro-organisms wasmade by French chemist Louis Pasteur (1822–1895). Subsequently, G.H.A.Hansen (1841–1912) in Germany identified Hansen’s bacillus as causativeagent for leprosy (Hansen’s disease) in 1873.Developments in chemical industry helped in switch over from earlierdyes of plant and animal origin to synthetic dyes. The impetus for theflourishing and successful dye industry came from the works of numerouspioneers as under:Paul Ehrlich (1854–1915), described Ehrlich’s test for urobilinogen usingEhrlich’s aldehyde reagent, staining techniques of cells and bacteria, and laidthe foundations of clinical pathology (Web Image 1.5).Christian Gram, who developed bacteriologic staining by crystal violet.D.L. Romanowsky, Russian physician, who developed stain for peripheralblood film using eosin and methylene blue derivatives.Robert Koch, German bacteriologist who, besides Koch’s postulate andKoch’s phenomena, developed techniques of fixation and staining foridentification of bacteria, discovered tubercle bacilli in 1882 and cholera vibrioorganism in 1883.May-Grunwald and Giemsa developed blood stains.Sir William Leishman described Leishman’s stain for blood films.Robert Feulgen described Feulgen reaction for DNA staining.Until the end of the 19th century, the study of morbid anatomy hadremained largely autopsy-based and thus had remained a retrospective science.Rudolf Virchow (1821–1905) in Germany is credited with the beginning ofmicroscopic examination of diseased tissue at cellular level and thus beganhistopathology as a method of investigation. Virchow gave two majorhypotheses:All cells come from other cells.Disease is an alteration of normal structure and function of these cells.Virchow came to be referred as Pope in pathology in Europe and is aptlykn

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