Ch 5: pp. 161-173, 177-198, 207-209

see also Junqueira Ch. 14, pp. 226-235 for an overview of the immune response

Slide 50 [DigitalScope]

A 19-year-old student presented to the campus health service complaining of transient knee and hip joint pains of one week’s duration. He had become febrile 2 days prior to seeking medical attention. Physical examination revealed swollen knee joints and small painless subcutaneous swellings located in the scalp and over the elbows. One week later, a heart murmur thought to be due to mitral regurgitation was detected. Congestive heart failure soon developed and the patient succumbed despite aggressive medical treatment. Slide 50 is prepared from the autopsy material.

• Note the fibrinopurulent inflammation of the epicardium (i.e. epicarditis/pericarditis) [example].


• Note the valvular endocardial fibrin deposits (excrescences) are present in the slide (i.e. endocarditis) [example].


• Note also the focal, granulomatous areas of inflammation and necrosis (hints: also known as "Aschoff bodies" with "Anitschkow cells") in the myocardium (i.e. myocarditis) [example].

1. Based on the history, presentation, and histological findings, what do you think is the best diagnosis for this case?

2. While the disease was triggered by a bacterial infection, much of the symptoms are actually due to an autoimmune reaction. What general class of hypersensitivity reaction is this?

1. Type I
2. Type II
3. Type III
4. Type IV

UMich Slide 178 [DigitalScope]

History: A 35-year-old man was clearing a path in the woods. When he returned home, he noticed an intensely pruritic linear vesicular eruption on his extensor forearms. A skin biopsy was taken.

Histologic features: There is pronounced spongiosis (intercellular edema) within the epidermis resulting in intraepidermal vesicles. Exocytosis of lymphocytes (lymphocytic spongiosis) may be seen in the epidermis. There is a superficial perivascular lymphocytic infiltrate.

1. Based on the history, presentation, and histological findings, what do you think is the best diagnosis for this case?

2. What type (I, II, III, or IV) of hypersensitivity reaction is this?

1. Type I
2. Type II
3. Type III
4. Type IV

CASE NUMBER 26
[DigitalScope]

Clinical History: This 48-year-old male with a history of Hepatitis B infection was admitted with a history of weight loss (approximately 20 pounds in the last 4 months) chills, fever, and pain in the right upper quadrant. He was diagnosed with cholecystitis and cholangitis (inflammtion of the gallbladder and bile duct) and the gallbladder was resected. Grossly, the walls of the gallbladder were thickened. The mucosa of the gallbladder was intact and numerous gallstones were present.

Microscopically, the gallbladder had an unexpected finding. The small arteries in the wall are involved in a necrotizing and inflammatory process which appears to be in all stages of development, resolution, and healing. The earliest change seen is an acute fibrinoid necrosis of the wall of the artery, which appears in the innermost third of the media, frequently involves the wall in an eccentric arrangement, and finally involves the entire thickness of the wall. Many of these arteries are markedly dilated with the formation of aneurysmal-like sacs. There is a marked exudation of inflammatory cells both within the wall of the artery and surrounding the artery. These cells are made up of eosinophils, neutrophils, macrophages and lymphocytes [example]. In some of the vessels, the process appears to be in a healing phase with the site of artery represented by fibrous scar surrounded by a chronic inflammatory exudate. Arterioles, capillaries, and veins are relatively spared.

1. In light of these findings, it is likely that he has more a widespread "arteritis" (inflammation of the arteries) that is probably affecting other organs as well. Research the various types of arteritis and provide your best opinion as to which diagnosis is appropriate in this case.

2. What type (I, II, III, or IV) of hypersensitivity reaction is this?

1. Type I
2. Type II
3. Type III
4. Type IV

Slide 268 [DigitalScope] (large airways)

Slide 68alt [DigitalScope] (small airways and lung)

Clinical History: A 24-year-old man is brought into the emergency department after a motor vehicle crash resulting from having sudden onset of dyspnea and loss of consciousness while driving. His family is notified and they report he had a long-standing history of episodic dyspnea, cough, and wheezing, usually triggered or exacerbated by exposure to cold air, physical activity, and exposure to cats and birds. His wheezing was notable during both inhalation and exhalation and was usually relieved upon administration of inhaled albuterol.

The patient is hypotensive, tachycardic, and non-responsive. Pupils are fixed and dliated and adbdominal ultrasound indicates the presence of significant internal bleeding from a ruptured aorta. Despite efforts to stabilize the patient for emergency surgery, he progresses into asytole and is pronounced dead in the resucitation bay of the emergency department. An autopsy is performed from which the specimens from the patient's lungs are provided.

Starting in Slide 268 in the lumen of one of the bronchi [example], note:

• very thick mucus layer on the surface of the epithelium and/or mucus "plugs" that fill the lumen (due to hypersecretion from goblet cells and seromucous glands)
• goblet cell hyperplasia (response to cytokines produced in the inflammatory response)
• basement membrane thickening (due to epithelial cell proliferation)
• marked increase in eosinophils and fibrosis in underlying connective tissue [example]
• bronchial smooth muscle hypertrophy and hyperplasia [example]
• increase in submucosal glands [example]

Slide 68 shows changes in the smaller airways (bronchioles) and the lung interstitium.

In a bronchiole [example] there are features that are obstructive in nature:

• very thick mucus layer on the surface of the epithelium and/or mucus "plugs" that fill the lumen (due to hypersecretion from goblet cells)
• metaplastic changes to the epithelium such that it contains goblet cells --usually bronchiole contain only a few goblets and will have club cells instead.
• basement membrane thickening
• smooth muscle hypertrophy and hyperplasia
• chronic lymphocytic inflammation and thickening of the adventitia

1. Based on the history, presentation, and histological findings, what do you think is the best diagnosis for this case?

2. The symptoms of episodic wheezing and dyspnea upon exposure to certain environmental factors are due to an autoimmune reaction. What general class of hypersensitivity reaction is this?

1. Type I
2. Type II
3. Type III
4. Type IV

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