Highlights of 5 edition th

The overwhelming response by the students and 100% Pathology (including many Medicines, Pediatrics) MCQs from AIIMS, PGI,
JIPMER and NEET entrance exams from this book made it a roaring sensation in the market. It gives us immense pleasure to bring it
you the fifth edition of Complete Review of Pathology & Hematology with fully revised content, most recent updates, recent questions,
high yield points and annexures.

ƒƒ Pretexts: Detailed yet concise, pointwise overview of the entire topic. High yielding MCQs and repeated MCQs have been
highlighted.

ƒƒ Flow charts: Flow diagrams have been added wherever necessary for easy understanding including most updated points from
recent editions of books. A new chapter on “Diseases of Muscle and Tumors of Bones and Joints” has been added. Over 80
new labelled and explained images have been added for proper explanation of texts and better understanding of Image-Based
Questions.

ƒƒ Recent updates: All additions and changes are according to latest Robbin’s 10th edition and are highlighted separately, so that
students are updated with recent advances in relevant topics. These are potential MCQs in upcoming PGMEEs.

ƒƒ MCQs: All MCQs of NBE pattern up to January 2019, AIIMS up to November 2018, PGI up to December 2018 and JIPMER up to
November 2018 have been included, and the recent Qs have been highlighted separately. MCQs have been arranged chronologically
with recent ones coming earlier, so that more stress is put on recent pattern questions. Repeated MCQs have been clubbed together
to avoid unnecessary duplication and time wastage.

ƒƒ AIIMS new pattern 2019 model questions: Since you all must be aware that AIIMS PG exam has announced new patterns of
MCQs from this session onwards, we have added many new pattern Qs including “match the following, arrange in sequence,
reason and assertion and concept-based multiple answers” in the current edition to benefit the aspiring students.

ƒƒ Image-based MCQs: As PGMEEs have shifted to online CBT exams, there has been an increase in image-based questions. We
have included potential image-based MCQs at the end of every topic to familiarize the students with the same. Students can learn
identification points of images from the pretext and then quickly answer Image-based Questions for strong hold in subject.

ƒƒ Video-based questions have been added to cater recent AIIMS pattern.

ƒƒ Authentic explanations: Explanations from standard and recent edition textbooks have been provided for each answer. Difficult
and controversial MCQs have been explained in detail discussing each option and excluding the incorrect ones. This will help a
student to develop his/her analytical skills.

ƒƒ Annexures: A new Annexure on Autoimmune Antibodies have been added for quick revision.

Though utmost care has been taken to avoid all possible errors, some minor errors might have crept in inadvertently. We request the
readers to kindly point out the same and give their valuable suggestions or feedback on the address provided in About the Authors
page.

We wish you all the very best for your upcoming exams and for your bright future!
 Contents
Preface............................................................................................................................................................................................ V
Acknowledgements......................................................................................................................................................................... VII
AIIMS New Pattern 2019 Model Questions.................................................................................................................................... XV
Recent Pattern Questions 2019 ...................................................................................................................................................... XXVIII
Sample Video Questions ................................................................................................................................................................. XXIX

ANNEXURES

1. Important Special Stains and Fixatives XXX

2. Important Fixatives XXXI
3. Cytokines and Cytokine Receptors XXXII
4. Type of Modified Macrophages XXXIII
5. Types of Giant Cells XXXIII
6. Important Translocations XXXIV
7. Important Genes & Chromosome XXXIV
8. Chromosomal Abnormality XXXV
9. Cancer Predisposition Syndromes and Associated Gene XXXVI
10. CD Markers Used for Hematolymphoid Neoplasms, Location/Characteristics XXXVII
11. Features of the Peripheral Blood Smear XXXIX
12. Blood-Clotting Factors XL
13. Crystals in Urine XL
14. Different Types of Urinary Casts XLI
15. Rosettes XLII
16. Familial Cancer Syndromes with Cutaneous Manifestations XLIII
17. Relationship Between Proteins and Neurodegenerative Diseases XLIII
18. Pattern of Injury and Associated Agents XLIV
19. Morphological Differentiation of Malaria Parasites XLV
20. Autoantibodies in Autoimmune Disease XLVI

1. CELL AS A UNIT OF HEALTH AND DISEASE

Theory................................................................................................................................................................................................................................. 1
Multiple Choice Questions........................................................................................................................................................................................... 11
Answers and Explanations.......................................................................................................................................................................................... 14

2. CELL ADAPTATION, INJURY AND DEATH

Theory............................................................................................................................................................................................................................... 19
Image-Based Questions............................................................................................................................................................................................... 36
Multiple Choice Questions........................................................................................................................................................................................... 38
Answers and Explanations.......................................................................................................................................................................................... 44
 3. INFLAMMATION AND REPAIR

Theory............................................................................................................................................................................................................................... 51
X
Image-Based Questions............................................................................................................................................................................................... 69
Multiple Choice Questions........................................................................................................................................................................................... 71
Answers and Explanations.......................................................................................................................................................................................... 78
Complete Review of Pathology

4. HEMODYNAMICS
Theory............................................................................................................................................................................................................................... 87
Image-Based Questions............................................................................................................................................................................................... 95
Multiple Choice Questions........................................................................................................................................................................................... 97
Answers and Explanations.......................................................................................................................................................................................... 99

5. GENETIC DISORDERS

Theory.............................................................................................................................................................................................................................101
Image-Based Questions.............................................................................................................................................................................................114
Multiple Choice Questions.........................................................................................................................................................................................117
Answers and Explanations........................................................................................................................................................................................125

6. DISEASES OF THE IMMUNE SYSTEM

Theory.............................................................................................................................................................................................................................135
Image-Based Question...............................................................................................................................................................................................157
Multiple Choice Questions.........................................................................................................................................................................................158
Answers and Explanations........................................................................................................................................................................................169

7. NEOPLASIA
Theory.............................................................................................................................................................................................................................183
Image-Based Questions.............................................................................................................................................................................................197
Multiple Choice Questions.........................................................................................................................................................................................199
Answers and Explanations........................................................................................................................................................................................208

8. DISEASES OF INFANCY AND CHILDHOOD

Theory.............................................................................................................................................................................................................................221
Image-Based Questions.............................................................................................................................................................................................226
Multiple Choice Questions.........................................................................................................................................................................................227
Answers and Explanations........................................................................................................................................................................................230

9. WHITE BLOOD CELLS AND ITS DISORDERS

Theory.............................................................................................................................................................................................................................233
Image-Based Questions.............................................................................................................................................................................................254
Multiple Choice Questions.........................................................................................................................................................................................257
Answers and Explanations........................................................................................................................................................................................270
 10. RED BLOOD CELLS AND ITS DISORDERS

Theory.............................................................................................................................................................................................................................285
XI
Image-Based Questions.............................................................................................................................................................................................300
Multiple Choice Questions.........................................................................................................................................................................................302
Answers and Explanations........................................................................................................................................................................................314

Complete Review of Pathology

11. BLEEDING AND COAGULATION DISORDERS

Theory.............................................................................................................................................................................................................................329
Image-Based Question...............................................................................................................................................................................................340
Multiple Choice Questions.........................................................................................................................................................................................341
Answers and Explanations........................................................................................................................................................................................348

12. CARDIOVASCULAR SYSTEM AND ITS DISORDERS

Theory.............................................................................................................................................................................................................................357
Image-Based Questions.............................................................................................................................................................................................382
Multiple Choice Questions.........................................................................................................................................................................................384
Answers and Explanations........................................................................................................................................................................................392

13. RESPIRATORY SYSTEM AND ITS DISORDERS

Theory.............................................................................................................................................................................................................................401
Image-Based Questions.............................................................................................................................................................................................417
Multiple Choice Questions.........................................................................................................................................................................................420
Answers and Explanations........................................................................................................................................................................................427

14. GASTROINTESTINAL TRACT AND ITS DISORDERS

Theory.............................................................................................................................................................................................................................435
Image-Based Questions.............................................................................................................................................................................................458
Multiple Choice Questions.........................................................................................................................................................................................460
Answers and Explanations........................................................................................................................................................................................466

15. LIVER, GALLBLADDER, PANCREAS AND ITS DISORDERS

Theory.............................................................................................................................................................................................................................473
Image-Based Questions.............................................................................................................................................................................................490
Multiple Choice Questions.........................................................................................................................................................................................493
Answers and Explanations........................................................................................................................................................................................501

16. RENAL SYSTEM AND ITS DISORDERS

Theory.............................................................................................................................................................................................................................511
Image-Based Questions.............................................................................................................................................................................................529
Multiple Choice Questions.........................................................................................................................................................................................531
Answers and Explanations........................................................................................................................................................................................540
 17. MALE AND FEMALE GENITOURINARY TRACT

Theory.............................................................................................................................................................................................................................549
XII
Image-Based Questions.............................................................................................................................................................................................567
Multiple Choice Questions.........................................................................................................................................................................................568
Answers and Explanations........................................................................................................................................................................................572
Complete Review of Pathology

18. BREAST (New Chapter)

Theory.............................................................................................................................................................................................................................577
Multiple Choice Questions.........................................................................................................................................................................................585
Answers and Explanations........................................................................................................................................................................................587

19. ENDOCRINE SYSTEM AND ITS DISORDERS

Theory.............................................................................................................................................................................................................................589
Image-Based Questions.............................................................................................................................................................................................601
Multiple Choice Questions.........................................................................................................................................................................................604
Answers and Explanations........................................................................................................................................................................................608

20. SKIN AND ITS DISORDERS

Theory.............................................................................................................................................................................................................................615
Image-Based Questions.............................................................................................................................................................................................625
Multiple Choice Questions.........................................................................................................................................................................................627
Answers and Explanations........................................................................................................................................................................................629

21. CENTRAL NERVOUS SYSTEM AND ITS DISORDERS

Theory.............................................................................................................................................................................................................................631
Image-Based Questions.............................................................................................................................................................................................647
Multiple Choice Questions.........................................................................................................................................................................................649
Answers and Explanations........................................................................................................................................................................................653

22. BLOOD BANKING AND TRANSFUSION MEDICINE

Theory.............................................................................................................................................................................................................................659
Image-Based Questions.............................................................................................................................................................................................664
Multiple Choice Questions.........................................................................................................................................................................................666
Answers and Explanations........................................................................................................................................................................................668

23. TUMORS OF SOFT TISSUE & HEAD & NECK

Theory.............................................................................................................................................................................................................................671
Multiple Choice Questions.........................................................................................................................................................................................676
Answers and Explanations........................................................................................................................................................................................678
 24. DISEASES OF MUSCLES (New Chapter)

Theory.............................................................................................................................................................................................................................681
XIII
Image-Based Questions.............................................................................................................................................................................................684
Multiple Choice Questions.........................................................................................................................................................................................685
Answers and Explanations........................................................................................................................................................................................685

25.

Complete Review of Pathology

TUMORS OF BONE AND JOINTS (New Chapter)

Theory ............................................................................................................................................................................................................................687
Image-Based Questions.............................................................................................................................................................................................692

26. RECENT TECHNIQUES IN PATHOLOGY

Theory.............................................................................................................................................................................................................................693
Image-Based Questions.............................................................................................................................................................................................698

27. STAINS AND FIXATIVES

Multiple Choice Questions ........................................................................................................................................................................................699

Answers and Explanations........................................................................................................................................................................................703
 AIIMS NEW PATTERN
2019 MODEL QUESTIONS
 GENERAL PATHOLOGY a. A-5, B-1, C-2, D-4 b. A-5, B-1, C-2, D-6
c. A-5, B-1, C-6, D-4 d. A-5, B-6, C-2, D-4
PATTERN 1: MULTIPLE TRUE /FALSE TYPE
XVI 1. In an experiment, a cell line derived from a human
Ans. (a)  A-5, B-1, C-2, D-4

malignant neoplasm is grown in culture. A human

4. A. c-abl 1. Small cell carcinoma of the lung
IgG antibody is added to the culture, and the tumor
cells become coated by the antibody, but they do not B. L-myc 2. Neuroblastoma
Complete Review of Pathology

undergo lysis. Next, human cells are added that are C. N-myc 3. Breast cancer
negative for CD3, CD19, and surface immunoglobulin, D. c-myc 4. Burkitt’s lymphoma
but are positive for CD16 and CD56. The tumor cells
are observed to undergo lysis. Which of the following 5. Chronic myelocytic leukemia (CML)
statement denotes correctly about the cell types most 6. Squamous cell carcinoma of the lung
likely to have killed the tumor cells?
a. A-5,B-1,C-2,D-4 b. A-5,B-1,C-2,D-6
1. B cells have surface immunoglobulin and can lyse the
c. A-5,B-1,C-6,D-4 d. A-5,B-6,C-2,D-4
tumor cells
2. CD8+ cell are positive for CD16 and can lyse the tumor
Ans. (a)  A-5,B-1,C-2,D-4
cells
3. Dendritic cells can lyse the tumor cells
5. A. CD8 1. Helper T cells,
4. Macrophage express MHC II and can lyse the tumor
cells B. CD4 2. Pan T cell marker
5. Natural killer cells show ADCC and can lyse the tumor C. CD3 3. T cell receptor
cells
D. CD2 4. Receptor for sheep erythrocyte (E rosette)
a. Option 1, 3, 4 are true
b. Option 2 and 5 are true 5. Cytotoxic T cells
c. Option 5 is true, all others are false 6. Receptor for Fc portion of IgG
d. All options are false
a. A-5,B-1,C-2,D-4 b. A-5,B-1,C-2,D-6
Ans. (c)  Option 5 is true, all others are false c. A-5,B-1,C-6,D-4 d. A-5,B-6,C-2,D-4
CD8 + CELL is not positive for CD16 ans c
Ans. (a)  A-5,B-1,C-2,D-4
2. Which of the following are true about deficiencies in
complement pathway
6. A. Centromere 1. Smith (SLE),
1. Deficiency of decay-accelerating factor → paroxysmal
nocturnal hemoglobinuria B. Speckled (non-DNA 2. Double-stranded
2. Deficiency of C6 and C7 → recurrent pyogenic bacterial extractable nuclear proteins) DNA (SLE)
infections C. Rim (peripheral) 3. T cell receptor
3. Deficiency of C1 esterase inhibitor → hereditary
D. Nucleolar (RNA) 4. Progressive
angioedema
systemic sclerosis
4. Deficiency of C3 and C5 → recurrent pyogenic bacterial
infections 5. CREST syndrome
5. Deficiency of C6, C7, and C8 →recurrent infections with 6. Histones
Neisseria species
a. A-5,B-1,C-2,D-4 b. A-5,B-1,C-2,D-6
a. Option 1, 3, 4 are true
b. Option 2 and 5 are true c. A-5,B-1,C-6,D-4 d. A-5,B-6,C-2,D-4
c. Option 5 is true, all others are false
Ans. (a)  A-5,B-1,C-2,D-4
d. All options are false
7. Based on tumor and their respective IHC marker match
Ans. (a)  Option 1, 3, 4 are true the following
A. Carcinoma 1. CD 45
PATTERN 2 : MATCH THE FOLLOWING B. Lymphoma 2. NSE
C. Sarcoma 3. Vimentin
3. A. Mast cells 1. Granulomatous response
D. Melanoma 4. CK
B. Langhans giant cells 2. Cytotoxic lymphocytes
E. Neuroendocrine Tumor 5. HMB45
C. CD8 + cells 3. Humoral immunity
D. Dendritic cells 4. Elaborate type I interferons a. A-5, B-1,C-2, D-3, E-4 b. A-4, B-1,C-3, D-5, E-2
c. A-3, B-2,C-4, D-1, E-5 d. A-1, B-2,C-3, D-4, E-5
5. Surface-bound IgE
6. Express MHC 1 Ans. (b)  A-4, B-1,C-3, D-5, E-2
 Sample Video Questions
1. Identify the technique? 4. What is this way of taking samples called:

a. Bone marrow aspiration b. CSF aspirate

a. Order of draw b. Collection sample order
c. Blood culture d. Pleural tap
c. Universal protocol d. None
2. Identify the technique?
5. What is the solution used when there is blood spill

Ans.

1. a
2. b
3. a
4. a
5. a

a. Bone marrow aspirate b. FNAC

c. Blood culture d. Pleural tap
a. Hypochlorite
3. What is this brush used for
b. H2SO4
c. HCl
d. Formalin

For video, scan this QR Code

a. Liquid based cytology b. Conventional cytology

c. CSF needle d. Pleural tapping
 Annexures
Annexure 1
1.  Important Special Stains and Fixatives
Name of stain Elements stained
For Microorganisms
Ziehl-Neelsen stain, Kinyoun stain Acid-Fast Organism
May - Grünwald Giemsa Stain Bacteria, blood elements
Gram stain Bacteria
Toluidine Method, Steiner method Helicobacter pylori (stained black)
Grocott‘s methenamine silver method, PAS Fungi
Macchiavello stain Rickettsia and viral inclusions
Shikata‘s orcein stain Hepatitis B Antigen
Mucicarmine Cryptococcus
Warthin – Starry method Spirochetes
Gomori Methenamine silver Fungus (stained black)
Calcofluor white Acanthamoeba (stained white)
For Connective tissue and lipids
Hematoxylin & Eosin stain (H&E) All tissues (most commonly used stain)
Trichrome Stain Collagen
Verhoeff - Van Gieson‘s stain (Best for Elastin) Elastic fibers
Luna stain Elastin & Mast cells
Silver Methenamine stain Reticulin
Oil red O stain (on Fresh specimen/Frozen section) Fat
Sudan black (on fixed specimen)
Mallory’s PTAH stain Muscle striations
MSB (martius scarlet blue) (1st stain to stain fibrin in various stages) Fibrin
PAS, Silver Methenamine stain Basement membrane
Bielschowsky (silver stain) Neurofibrillary tangles, Senile plaques
Luxol fast blue Myelin
Papanicolau stain Cervical Exfoliative cytology
For Carbohydrates
PAS Glycogen/neutral mucin or mucoprotein
Alcian blue Differentiates Acid & neutral mucopolysaccharides
(at pH 2.5: positive for acid mucopolysaccharides)
Mucicarmine stain (specific) Acidic epithelial Mucin
Alcian blue at pH 1 Highly acidic mucins (sulphated mucins)
 Annexure 11
XLV
19.  Morphological Differentiation of Malaria Parasites
P. falciparum P. vivax P. ovale P. malariae
Infected red cells Normal size, Maurer's
a
Enlarged; Schuffner's dots c
Enlarged; oval and Normal or microcytic;

 Annexures
cleftsb fimbriated; Schuffner‘s stippling not usually seen
dotsc
Ring forms (early Delicate; frequently 2 or Large, thick; usually single Thick compact rings Very small, compact rings
trophozoites) more; accole forms;d small (occasionally 2 in cell;
chromatin dot large chromatin dot)

Vivax Trophozoite
Falciparum Ring forms

Later trophozoites Compact, vacuolated; Amoeboid; central Smaller than P. Vivax, Band across cell; deep
sometimes 2 chromatin vacuole; light blue slightly amoeboid blue cytoplasm
dots cytoplasm
Schizonts 18-24 merozoites filling 12-24 merozoites, 8-12 merozoites filling 3/4 6-12 merozoites in daisy-
2/3 of cell irregularly arranged of cell head around central mass
of pigment
Pigment Dark to black clumped Fine granular; yellow Coarse light brown Dark, prominent at all
mass brown stages

Gametocytes Crescent of sausage- Spherical compact, almost Oval, fills 3/4 of cell; Round; fills 1/2 to 2/3
shaped; diffuse chromatin; fills cell; single nucleus similar to but smaller than of cell; similar to P. vivax
single nucleus P. vivax but smaller, with no
Schuffner‘s dots

Falciparum gametocyte
 THE HUMAN GENOME
ƒƒ Human genome contains 3.2 billion DNA base pairs.Q
ƒƒ 20,000 protein-encoding genesQ, comprising only 1.5% of the genome.Q
2
ƒƒ Function of these protein encoding genes: enzymes, structural components, and signaling molecules and to assemble and
maintain all cells in the body.

Noncoding DNA
Complete Review of Pathology

ƒƒ It refers to the 98.5% of human genome that does not encode proteins
ƒƒ The amount of noncoding DNA varies greatly among species. E.g. In bacteria, only 2% of genome is noncoding DNA
ƒƒ Noncoding DNA is also transcribed into functional noncoding RNA molecules (e.g. transfer RNA, ribosomal RNA, and
regulatory RNAs)

/3
R9th Latest Update

5
ENCODE (ENCyclopedia of DNA Elements) project: 2007

y,
•• This project has systematically mapped regions of transcription, transcription factor association, chromatin structure and histone
modification.

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•• Striking conclusion: 80% of the human genome, even the noncoding regions either binds proteins or regulate gene expression
Major classes of functional nonprotein-coding sequences:

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Nonprotein coding sequences Characteristics
Promoter & enhancer regionsQ Provide binding sites for transcription factors

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Binding sites for factors Organize and maintain higher order chromatin structures
Noncoding regulatory RNAs Regulate gene expression: miRNAs and long noncoding RNAs
Pa
Mobile genetic elementsQ (transposons/“jumping genes”) Segments that move around the genome, exhibiting wide
variation in number and positioning;
Role in gene regulation and chromatin organization
of

Special structural regions of DNA Chromosome ends (Telomeres) and “tethers” (centromeres)
s
ge

POLYMORPHISM Role of SNPs

Any two individuals share greater than 99.5% of their DNA ƒƒ SNPs located in noncoding regions are regulatory elementsQ
Pa

sequences.Q So what is the reason of genetic variations? in the genome

The most common forms of DNA variation in the human genome ƒƒ They alter gene expressionQ and have direct influence on
is shown in Flowchart 1. disease susceptibility
e

Flowchart 1: DNA variation in human genome ƒƒ Even if any SNP has no effect on gene function (Neutral SNP)Q,
it may be coinherited with the “actual disease causing gene,” if
pl

located close to that gene → “Linkage disequilibrium”Q

m

ƒƒ May act as markers of multigenic complex diseases, E.g.

Diabetes, Hypertension.
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Epigenetics
ƒƒ Definition
{{ Heritable changesQ in gene expression, not caused by
alterations in DNA sequence.Q
ƒƒ Epigenetic factors
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{{ Histones and histone-modifying factors
H yy Histone methylation, Histone acetylation, Histone
E phosphorylation, DNA methylation, Chromatin orga-
O nizing factors

R
Y
ƒƒ Significance Flowchart 2: Generation of MicroRNA (miRNA) and
{{ Epigenetic Dysregulation → central role in malignancy their mode of action
{{ Many other diseases are associated with inherited or
acquired epigenetic alterations. E.g. Genomic imprinting 3
in Prader Willi syndrome
{{ Epigenetic alterations like histone acetylation and DNA

methylation are reversible and are responsive to drugs;

Chapter 1   Cell as a Unit of Health and Disease

So, HDAC inhibitors and DNA methylation inhibitors
are being tested in the treatment of cancer
ƒƒ Diagnosis
{{ Sequencing

/3
{{ Chip on chip (Microarray technology)

{{ Using Methylation specific primers in Polymerase chain

5
reaction (PCR)
{{ Bisulphite method: Bisulphite converts unmethylated

y,
cytosine to uracil, which acts like thymine in downstream
reactions. The unmethylated (modified) DNA is detected

og
by sequence analysis.

High Yield Facts

ol
• SNP is the most common type of DNA polymorphismQ

th
• SNP can be detected by SNP Cytogenomic Array. Small Interfering RNAs (siRNAs)
• Linkage analysis can be used to detect SNPs with profound •• miRNA introduced experimentally into cells and inhibit them
Pa
effects and high penetrance.Q •• So-called “knockdown technology”
• Linkage analysis is used to identify unknown genesQ •• Possible therapeutic agents to silence pathogenic genes,
associated with a disease such as oncogenes involved in neoplastic transformation.
• GWAS can be used to identify unknown genes NOT in ‘Linkage
of

disequilibrium’Q B. Long Noncoding RNA (lncRNA or long ncRNAs): Nonprotein

• The 2 types of genetic polymorphisms most useful for linkage coding transcripts longer than 200 nucleotidesQ
analysis are SNPs and repeat length polymorphismsQ lncRNAs modulate gene expression in following ways:
s

• Repeat length polymorphisms can be mini-satellite (1-3 kb)Q

ge

or Micro-satellite repeats (< 1 kb)Q Mechanism Characteristics

• Genome-wide association study (GWAS) refers to ‘Genome
Wide Association Studies’Q Gene activation Can facilitate transcription factor
Pa

• In GWAS, entire genome of large number of individuals with binding → promote gene activation
and without a disease are examined for common genetic vari- Gene suppression Can preemptively bind transcription
ants or polymorphisms that are over represented in patients factors → prevent gene transcription.
with the disease.
e

Histone & DNA Bind to and direct acetylases/

modification methylases (or deacetylases /
pl

demethylases) 
NONCODING REGULATORY RNA
m

Assembly of protein Act as scaffolding to stabilize secondary/

A. Micro-RNA (miRNA): Small noncoding RNA molecule complexes tertiary structures and/or multi-subunit
Sa

(22 nucleotides) which causes RNA silencing and post- complexes influencing chromatin
transcriptional regulation of gene expression. architecture or gene activity
ƒƒ Generation and mode of action of miRNA is shown in Repressive function Example: XIST → role in physiologic X
Flowchart 2. chromosome inactivation

High Yield Facts

T
• lncRNAs have been found to have link with diseases like atherosclerosis & cancer.
H
• XIST refers to ‘X-inactive specific transcript’Q E
• XIST is a RNA gene (17 kb) on the X chromosome that acts as major effector of the X inactivation process.
O
• XIST is expressed on the inactive X chromosome and not on the active one.
R
Y
 MULTIPLE CHOICE QUESTIONS

1. Integrin binds to?  (AIIMS Nov 18) 11. The term pathology was coined by? 11
a. Fibronectin b. Vitronectin  (APPGMEE 2015)
c. Collagen d. Laminin a. Robert Kochs b. Rudolf Virchow
2. The small inner circles in the given image of EM signifies c. Lois Pasteur d. Gregor Mendal

Chapter 1   Cell as a Unit of Health and Disease

which of the following?  (AIIMS May 18) 12. Which Collagen is typical of basement membrane?
 (AIIMS May 2015)
a. Type I b. Type V
c. Type IV d. Type III
13. Which of the following function is done by RNAi in a

/3
gene?  (AIIMS May 2015)
a. Knock in b. Knock out

5
c. Knock down d. Knock up
14. All of the following are Intermediate filament except?

y,
 (Recent Question 2016)
a. Lamin b. Cadherin

og
c. Vimentin d. Desmin
15. Tight junction consists of all except?
 (Recent Question 2016)

ol
a. Neuro transmitter b. Neurosecretory granules a. Occludin b. Claudin
c. Zonulin d. Cadherin

th
c. Collagen fibril d. Microtubules
3. False about micro satellites is?  (JIPMER 18) 16. Titin protein mutated in? (Recent Question 2016)
a. DCM b. HOCM
Pa
a. Repeat size more than 10 to 15 nucleotides
b. More prone to variation c. RCM
c. Found in colonic carcinoma d. Non functional cardiomyopathy
d. DNA repeats present 17. Peripheral protein in cell membrane are attached by?
of

4. Type 1 collagen is present in all except? (AIIMS May 18)  (Recent Question 2016)
a. Bone b. Cartilage a. GpI b. Desmosome
c. Ligament d. Aponeurosis c. Catenins d. Cadherins
s

5. Which among the following is not seen in disorder to 18. Bridging fibrosis in large wounds is due to
ge

deficiency in elastin production?  (AIIMS May 18) (Recent Question 2015)

a. Aortic dissection a. Keratinocyte growth factor
b. Lens subluxation b. Epidermal growth factor
Pa

c. Ligament hyperlaxity c. Platelet derived growth factor

d. bone fracture d. Transforming growth factor-b
6. Which Vitamin increases iron Absorption? 19. Major cytokine involved in fibrosis
 (AIIMS May 18) a. Transforming growth factor-a (Recent Question 2015)
e

a. Vitamin C b. Biotin b. Transforming growth factor-b

pl

c. Vitamin B6 d. Vitamin E c. Fibroblast growth factor

7. Which of the following plays a role in gene editing? d. Epidermal growth factor
m

(AIIMS MAY 2017) 20. Types of collage playing important role in wound
a. Gene Xper b. CRISPR healing  (Recent Question 2015)
Sa

c. Health care apps d. Big data a. I and III b. II and V

8. Cell to cell permeability occurs through c. III and IV d. V and IX
 (Recent Question 2016-17) 21. Oval stem cells are located in (Recent Question 2015)
a. Occludin b. Zona adherens a. Canal of schlemm b. Canal of herring
c. Connexins d. Zonulin c. Space of disse d. Basal lamina of myotubules
9. Tensile strength of tendon depends on 22. Stem cells are present in? (Recent Question 2015)
a. Cornea b. Base of crypts
 (Recent Question 2016-17)
c. Bile duct of liver d. Mesonephros
a. Fibrillin b. Collagen
c. Fibronectin d. Elastin 23. Human genome contains  (Recent Question 2015)
10. Which of the following mechanism is mainly involved in a. 3.2 billion DNA base pairs
Genomic imprinting?  (AIIMS Nov 2015) b. 2.3 billion DNA base pairs
a. Methylation b. Acetylation c. 3.2 million DNA base pairs M
c. Deamination d. Phosphorylation d. 2.3 million DNA base pairs C
Qs
 ANSWERS AND EXPLANATIONS

14 1. Ans. (d)  Laminin > Fibronectin 11. Ans. (b)  Rudolf Virchow (Ref: Robbins 9th/preface)
Integrins localised in the plasma membrane are the major Pathology (from the Ancient Greek roots of pathos,
adhesion receptors connecting cells with components of meaning "experience" or "suffering", and -logia, "an
the extracellular matrix. Integrins interact directly with account of") is a significant component of the causal
Complete Review of Pathology

laminin, fibronectin present in the basal lamina and study of disease and a major field in modern medicine
intracellularly contact actin through intermediate proteins, and diagnosis. The term cellular pathology was coined
such as alpha-actinin, vinculin,and talin. by Rudolf Virchow.

2. Ans. (b)  Neurosecretory granules

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12. Ans. (c)  Type IV (Ref: Robbins 9th/pg 20-23)
Neurosecretion is the storage, synthesis and release of

5
hormones from neurons. These neurohormones, produced 13. Ans. (c)  Knock down (Ref: Robbins 9th/pg 3-4)
by neurosecretory cells, are normally secreted from nerve Small interfering RNAs (siRNAs)

y,
cells in the brain that then circulate into the blood. •• Short RNA sequences introduced experimentally into
cells

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3. Ans. (a)  Repeat size more than 10 to 15 nucleotides
•• Their action is similar to endogenous miRNAs.
•• Synthetic siRNAs targeted against specific mRNA have
4. Ans. (b)  Cartilage
become useful laboratory tools to study gene function

ol
Please refer Explanation of Q.20 (so-called “knockdown technology”)

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5. Ans. (d)  Bone fracture Pa 14. Ans. (b)  Cadherin (Ref: Robbins 9th/pg 21-24)
Intermediate filaments are 10-nm diameter fibrils which
6. Ans. (a)  Vitamin C
provide tensile strength to a cell.
Cadherins are cell-cell desmosomal junctions are
7. Ans. (b)  CRISPR (Ref. R 9th/p 5-6)
formed by homotypic association of transmembrane
of

CRISPR-Cas9 is a genome editing tool essential in adaptive glycoproteins.

immunity in select bacteria enabling the organisms to
respond to and eliminate invading genetic material 15. Ans. (d)  Cadherin (Ref: Robbins 9th/pg 21-24)
s

Ans. (c)  Connexins (Ref: Robbins 9th/ pg 11)

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8. Occluding junctions (Tight junctions)

•• Communicating junctions (Gap junctions): mediate the •• Seal adjacent cells together to create a continuous
passage of chemical or electrical signals from one cell to barrier that restrictsQ the paracellular (between cells)
Pa

another. movement of ions and other molecules.

•• Consists of pores called connexions and formed by •• Proteins involved are Occludin, Claudin, Zonulin and
hexamers of transmembrane proteins called connexins Catenin
e

9. Ans. (b)  Collagen (Ref: Robbins 9th/ pg 12-13) 16. Ans. (a)  DCM (Ref: Robbins 9th/pg 21-24)
pl

Fibrous structural proteins like Collagens confer tensile

Mutations in TTN, a gene on chr 2q31 that encodes titin (so-
E strength and & elastins provide recoil to the tension
m

called because it is the largest protein expressed in humans)

X 10. Ans. (a)  Methylation (Ref: Robbins 9th/pg 3-4)
causes 20% of all cases of Dilated Cardiomyopathy (DCM)
Sa

P •• Genomic imprinting selectively inactivates either the 17. Ans. (a)  GpI (Ref: Robbins 9th/pg 21-24)
maternal or paternal allele.
L Proteins are linked to cell via glycophosphatidylinositol
•• Occurs in the ovum or the sperm, before fertilization,
A and then is stably transmitted to all somatic cells (GPI) structures.

N through mitosis
18. Ans. (d)  Transforming growth factor-β (Ref: R 9th/pg 20
A Mechanisms
Functions of TGFβ are:
T •• Histones and histone modifying factors
•• Histone methylation •• Anti-inflammatory, fibrosis, tumor suppressor gene,
I ƒƒ Histone acetylation angiogenesis
O ƒƒ Histone phosphorylation
19. Ans. (b)  Transforming growth factor-β (Ref: R 9th/pg 20)
•• DNA methylation
N •• Chromatin organizing factors
20. Ans. (a)  I and III (Ref: Robbins 9th/pg 20-23)
S
 CELL ADAPTATIONS yy Compensatory increase after damage or resection, e.g.
Liver regeneration after partial hepatectomyQ
Hypertrophy {{ Pathologic hyperplasia

20 ƒƒ Increase in the size of cellsQ Excessive action of hormones or growth factors acting on
ƒƒ Seen in: Nondividing cells.Q target cells.
ƒƒ Stimulus: Increased workloadQ (Most common) yy Endometrial hyperplasia
ƒƒ Mechanism: Increased production of cellular proteins.Q yy Benign prostatic hyperplasia
Examples yy Skin warts-by viral infections such as HPVQ
Complete Review of Pathology

ƒƒ
{{ Uterus during pregnancy.Q ƒƒ Outcome: Constitutes a fertile soil in which cancerous
{{ Bulging muscles of body builders. proliferations may eventually arise
{{ Hypertension or faulty valves → heart hypertrophy
{{ Breast in lactationQ

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ƒƒ Outcome
{{ Reversible process; Does not predispose to malignancyQ

5
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Normal endometrium

th
Pa
Normal uterus Hypertrophied uterus
of

↑number
of glands
s
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Normal muscle Endometrial hyperplasia

Pa

R10th Latest Update

• Combined hypertrophy + hyperplasia: uterus in pregnancyQ
e

• Hypertrophy: Breast in lactationQ

pl

• Atrophy: Breast at menopauseQ

Hypertrophied smooth muscle
m

Atrophy
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Hyperplasia ƒƒ Reduction in the size of an organ or tissue due to a decrease

in cell size and numberQ
ƒƒ Increase in number of cells in an organ or tissue in response
to a stimulus.Q ƒƒ Mechanism: Decreased protein synthesisQ and increased
ƒƒ Seen in: Dividing cells.Q protein degradation in cells.
ƒƒ Mechanism: ƒƒ Types with examples
T ƒƒ Growth factor-driven proliferationQ of mature cells {{ Physiologic atrophy:
ƒƒ Increased output of new cells from tissue stem cells (rare) yy During normal development e.g notochord and
H ƒƒ Types with examples thyro­glossal ductQ
{{ Physiologic hyperplasia:
E yy Decrease in size of uterus after parturitionQ
yy Action of hormones or growth factors in hormone Pathologic atrophy
O responsive organs
{{

yy Disuse atrophy: Most common due to decreased

R {{ Breast in pregnancy and during puberty
workload
yy Bone marrowQ in response to deficiency of terminally
Y differentiated blood cells.
 Pigments

32
Complete Review of Pathology

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Black carbon pigment

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inside the cytoplasm of
the macrophages in the
alveolar wall
Pa
of
s
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Mic: Perinuclear pigment Hemosiderin Laden

Pa

Macrophages in Lung Alveoli

Melanin
e
pl
m

Melanin in basal layer

(Electron microscopy Perls stain showing
Sa

or epidermis
showing perinuclear hemosiderin pigment
pigment)

High Yield Facts

Stains
•• The pigments do not usually evoke any inflammatory
•• Masson Fontana-melanin
T response.Q
•• Iron is normally carried with transferrin in circulation.Q •• Remember Masson trichrome is not for pigment, it
H •• In cells, it is stored in association with a protein, apoferritin, distinguishes collagen from muscle
E to form ferritin micellesQ •• Long ZN stain for Lipofuscin
•• Whenever there is a local or systemic excess of iron, ferritin •• Perls Prussian blue for hemosiderin (Fe3+)
O forms hemosiderin granulesQ •• The tissue-bound ferric ions subsequently are visualized
R •• Hemosiderin is considered as a degraded and oxidized form by treatment with potassium ferrocyanide to form bright
of ferritin.Q blue deposits of ferric ferrocyanide or Prussian blue.
Y •• Ferritin is soluble while hemosiderin is insoluble.Q •• Lillie’s method is used for picking up ferrous iron
 Image-Based Questions
36
1. 45 year old male had history of hepatitis B infection. 3. 50 year old female comes with history of discharge per
On liver biopsy, multiple councilman bodies were seen. vaginum. On examination, her squamo-columnar junction
Electrophoresis was done to pick up whether he was of cervix appears erythematous. She underwent cervical
Complete Review of Pathology

undergoing apoptosis or necrosis. Identify the pattern in biopsy which showed following findings. Describe the
lane 2 and diagnosis change marked by arrow.

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a. Step ladder pattern, apoptosis a.
Squamous metaplasia 
b. Smeared pattern, necrosis b.
Columnar metaplasia

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c. Step ladder pattern, necrosis c.
Transitional metaplasia
d. Smeared pattern, apoptosis d.
None
Pa
2. Earliest morphological change seen in reversible cellular 4. 60 year old asymptomatic female shows following change
injury is? Inset shows normal hepatocytes as control. in tunica media of blood vessels. Diagnosis?
of
s
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e

a.
Hydropic change b. Fatty change a.
Medial calcification b. Medial fibrosis
c.
Necrosis d. None c.
Amyloidosis d. None
pl
m

5. 50 year old female underwent cholecystectomy on examination, the lamina

propria of gall bladder was seen infiltrated by foam cells. Diagnosis?
Sa

I
B a.
Cholestrolosis b.
Atherosclerosis
c.
Steatosis d. None
Qs
Answers of Image-Based Questions
37
1. Ans. (a) Step ladder pattern, apoptosis
•• This is step ladder pattern which is typically seen in apoptosis, its also called DNA laddering characterized by the activation of
endogenous endonucleases with subsequent cleavage of chromatin DNA into internucleosomal fragments of roughly 180-200 base
pairs (bp).

Chapter 2   Cell Adaptation, Injury and Death

•• Smear pattern is seen in necrosis.
2. Ans. (a) Hydropic change
•• Cellular swelling is the first manifestation of almost all forms of injury to cells. Cellular swelling appears whenever cells are incapable
of maintaining ionic and fluid homeostasis and is the result of failure of energy-dependent ion pumps in the plasma membrane. It

/3
is reversible.
•• On microscopic examination, small clear vacuoles may be seen within the cytoplasm; these represent distended and pinched-off

5
segments of the ER. This pattern of nonlethal injury is sometimes called hydropic change or vacuolar degeneration.
•• This is a case of hydropic change in hepatocytes (control normal hepatocytes are seen in inset).

y,
3. Ans. (a) Squamous metaplasia

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•• Here we are seeing endocervix lined by columnar epithelium. And underlying stroma shows endocervical glands. Here columnar
epithelium is being changed to squamous epithelium suggestive of squamous metaplasia. Inciting cause for this metaplasia is
chronic cervicitis.

ol
4. Ans. (a) Medial calcification
•• Medial artery calcification (MAC) is also known as Mönckeberg's arteriosclerosis, is a nonobstructive condition leading to reduced

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arterial compliance that is commonly considered as a nonsignificant finding.
•• With the H&E stain, calcium appear deep blue-purple.
Pa
5. Ans. (a) Cholesterolosis of the gallbladder
•• Here we are seeing accumulation of foam cells in lamina propria of gallbladder suggestive of cholestrolosis
of
s
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Pa
e
pl
m
Sa

I
B
Qs
 Adhesion
ƒƒ Firm attachment of the leukocytes to the endothelial cells
ƒƒ Mediated by heterodimeric leukocyte surface proteins called integrins.
54
Integrin Molecule of Integrin Ligand on endothelium
b1-integrins VLA molecules (VLA-4 (CD49a/CD29) or a4B7 (CD49D/CD29) VCAM-1Q.
b2-integrins LFA-1 or Mac-1(CD11a/CD18) ICAM-1Q
Complete Review of Pathology

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High Yield Facts Outside the Lumen
• Pavementing: Endothelium appears to be lined by white cells. Migration in the Tissues toward a
of

This is due to margination. Chemotactic Stimulus: Chemotaxis

• Endothelial cell expression of E-selectin is a hallmark of acute ƒƒ Unidirectional movementQ of the leukocytes towards site of
cytokine-mediated inflammation.Q
s

injury along a chemical gradient.

• P Selectin is stored in Endothelium weibel palade bodiesQ ƒƒ Bind to G-protein coupled receptorsQ on the surface of
ge

and Platelets α granulesQ leukocyte

• L-selectin helps in Lymphocytes homing to high endothelial ƒƒ Causes actin polymerization and all movements.
venulesQ
Pa

Integrins are transmembrane receptors that are the bridges for Chemotactic Agents
cell-cell and cell-extracellular matrix (ECM) interactions. Few
ligands for integrins:
• VCAM & ICAM – on the endothelium
e

• GPIIbIIIa, an integrin on the surface of blood platelets

pl

• Fibronectin, vitronectin, collagen, and laminin.

m
Sa

Across the Lumen

Leukocyte Migration through Endothelium:
Transmigration or diapedesisQ
ƒƒ Occurs mainly in postcapillary venules.Q
ƒƒ Most important molecule: PECAM-1 (platelet endothelial
cell adhesion molecule) or CD31.Q
PHAGOCYTOSIS AND CLEARANCE OF
T ƒƒ After traversing the endothelium, leukocytes pierce basement THE OFFENDING AGENT
H membrane, probably by secreting collagenases,Q and enter
Phagocytosis involves following three sequential steps
extravascular tissue.
E
O
R
Y
 INCLUSIONS IN GRANULOMAS

64
Complete Review of Pathology

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The details about lymphocytes, formation of a granuloma is discussed later in the chapter of ‘immunity’.

ol
SPECIAL TYPES OF GRANULOMA Palisaded granuloma

th
ƒƒ Rheumatoid nodule
Granuloma morphology ƒƒ Wegeneres granulomatosis
Pa
ƒƒ Caseating epithelioid cell granuloma (Caseous necrosis
(green arrow) and Langhans cell (yellow arrow)
of
s
ge
Pa

Stellate granuloma
ƒƒ Stellate granuloma-follicular hyperplasia with central
stellate necrosis with neutrophils, surrounded by palisading
e

histiocytes.
pl

ƒƒ Most commonly found in children

ƒƒ Foreign body granuloma: (Refractile FB seenwith polarized
ƒƒ Benign infectious disease caused by the bacterium Bartonella
m

light shown by arrows) henselae.

ƒƒ Seen in cat scratch disease
Sa

T
H
E
O
R
Y
 MULTIPLE CHOICE QUESTIONS

ACUTE INFLAMMATION AND MECHANISMS 7. Vasodilation in acute inflammation is first shown by 71

(Recent Question 2015)
1. Identify the arrow marked cell in the given condition
a. Venules b. Arterioles
below? (AIIMS May 16)
c. Capillaries d. Vein
8. Cellular infiltrate seen in late pseudomonas infection is

Chapter 3   Inflammation and Repair

formed mainly by (Recent Question 2014-15)
a. Neutrophils b. Lymphocytes
c. Monocytes d. Plasma cells
9. Which of the following is the mechanism of “late

/3
appearing sunburn”?  (Recent Question 2015)
a. Leucocyte mediated injury

5
b. Delayed prolonged leakage
c. Early prolonged leakage

y,
d. Delayed transient leakage
10. Increased permeability in acute inflammation is due to-

og
(Recent Question 2014)
a. Histamine b. IL-2
c. TGFβ d. FGF

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11. Sequence of events in acute inflammation-
a. Macrophage b. Lymphocyte a. Vasodilatation → Stasis → Transient vasoconstriction
c. Plasma cell d. Eosinophil → Increased permeability

th
(Recent Question 2014)
2. Which of the following cells will increase in case of b. Transient vasoconstriction → Increased permeability
parasite infection?  (AIIMS May 16) → Stasis → Vasodilatation →
Pa
c. Transient vasoconstriction → Vasodilatation → Stasis
→ Increased permeability
d. Transient vasoconstriction → Vasodilatation →
Increased permeability → Stasis
of

12. The following is not an adhesion molecule?

a. Spectrin (JIPMER 2014)
s

b. Integrins
c. Selectins d. Cadherin
ge

PATHOPHYSIOLOGY OF ACUTE INFLAMMATION

Pa

13. The RBCs with schizonts of P. Falciparum are not visible

on peripheral blood smear due to which of the following
reason?  (AIIMS Nov 16)
a. A b. B a. Capillary adherence or sequestration of parasitized
e

c. C d. D RBCs
pl

3. Vasoconstricttion in acute inflammation shown by b. ADCC mediated RBC destruction

 (WBPGMEE 2016, Recent Question 2016) c. Selective hemolysis of affected RBCs in spleen
m

a. Venules b. Arterioles d. Cellular lysis due to hemozoin produced by the

c. Capillaries d. Vein parasites Erythrocyte Changes in Malaria
Sa

4. SIRS diagnostic criteria.. Wrong statement is 14. Amino acid which is useful in Neutrophil extracellular traps
 (Recent Question 2016) (NETs) as to causes lysis of chromatin is?  (JIPMER 2016)
a. Band>10% a. Arginine b. Alanine
b. Leucocyte>12000 cells/mm3 c. Phenyl alanine d. Valine
c. Respi. rate>20 15. The following statements are true regarding neutrophil
d. Band <5% extracellular trap  (Recent Question 2015)
5. Eosinophillia is found in? (Recent Question 2016) a. Produced by neutrophils in response to infectious
a. Cryptococcus b. HPV pathogens and inflammatory mediators
c. Stronglyloides d. Typhoid b. Provide a high concentration of antimicrobial
6. Severe infection will increase if absolute neutrophil substances at sites of infection
count will become? (Recent Question 2015) c. Prevent the spread of the microbes by trapping them in
a. <500 b. Less than 800 the fibrils M
c. Less than 1000 d. Less than 2000 d. All the above
C
Qs
 ANSWERS AND EXPLANATIONS

78 1. Ans. (c)  Plasma cell •• Moderate neutropenia (500 ≥ ANC < 1000): moderate
risk of infection
(Ref: Wintrobes 13ed / pg 303; Wintrobes Atlas)
•• Severe neutropenia (ANC < 500): severe risk of infection.
Plasma cells are spherical or ellipsoid and range from 5
•• Agranulocytosis refers to a virtual absence of neutrophils
Complete Review of Pathology

to 30 μm in size. The cytoplasm is abundant, always is

in peripheral blood. It is usually applied to cases in
basophilic, and usually is deep blue; it may have a granular
char- acter. Plasma cells have a well-defined perinuclear which the ANC is lower than 100/μL
clear zone that contains the Golgi apparatus.
7. Ans. (b)  Arterioles (Ref: Robbins 9th/pg 74; 8th/pg 47)

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2. Ans. (c)  C (Ref: Wintrobes 13th ed. Pg. 303; Wintrobes Atlas) Vasodilation first involves the arterioles and then leads to
   Key to the figure: opening of new capillary beds in the area.

5
   A: Lymphocyte, B: Neutrophil, C: Eosinophil, D: Basophil The result is increased blood flow, which is the cause of heat
and redness (erythema) at the site of inflammation.

y,
3. Ans. (b)  Arterioles
(Ref: Essentials of Rubins Pathology 5th ed pg 19) 8. Ans. (a)  Neutrophils (Ref: 9th/pg 71; 8th/pg 44)

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Transient vasoconstriction of arterioles at the site of injury
is the earliest event in acute inflammation. It is usually 9. Ans. (b)  Delayed prolonged leakage (Ref: R 9th/pg 74)

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mediated by neurogenic and chemical mediators and
Mechanism of increased vascular permeability:
usually resolves within seconds.

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Mechanism Caused by Blood vessels Type of
4. Ans. (d)  Band <5%
affected response
Pa
(Ref: http://www.clevelandclinicmeded.com/ •• Thermal
medicalpubs/diseasemanagement/infectious-disease/ and
sepsis) Mild radiation Reversible,
Venules and
endothelial injuryQ Delayed &
of

The term systemic inflammatory response syndrome capillaries

(SIRS) describes the host response to a critical illness of damage •• Late- prolonged
infectious or non-infectious cause appearing
s

Evidence of a systemic inflammatory response is indicated SunburnQ

ge

by at least two of the following:

•• Fever or hypothermia: core body temperature 38° C or 10. Ans. (a)  Histamine (Ref: Robbins 9th/pg 74; 8th/pg 47)
higher or 36° C or lower
Pa

•• Tachypnea: 20 breaths/min or more, or need for Increased vascular permeability

mechanical ventilation for an acute process •• Formation of endothelial gaps (Immediate transient
•• Tachycardia: heart rate 90 beats/min or more, unless the response) is the most common mechanismQ for
patient has a preexisting tachycardia increased permeability.
e

•• White blood cell count:12,000 cells/mm3 or higher, •• Most important immediate mediator responsible for
pl

4,000 cells/mm3 or less, or more than 10% bands on

Immediate transient responseQ is histamineQ
E differential
•• Other immediate mediators: bradykinin, leukotriene,
m

X 5. Ans. (c)  Stronglyloides substance P

Sa

•• Somewhat delayed mediators: TNF, IL-1,1FN-γ

P (Ref: dacie and lewis practical ematology, 11th ed, pg 102)
Option b: IL2: IL-2 is known to activate T-cells, especially
L Moderate eosinophilia occurs in allergic conditions; more
CD4+ T-helper cells. Other minor function of IL2 are:
severe eosinophilia (20–50 × 109/L) may be seen in parasitic
A infections IL2 can activate lipoxygenase pathway with release of
lipoxygenase metabolites which play a role in pulmonary
N 6. Ans. (a)  <500 (Ref: Robbins 9th/pg 582) vascular permeability. (Cytokines and Inflammation By
A Neutropenia is denoted as ANC (absolute neutrophil Edward S. Kimball, pg 215)
T count) Option c and d: are mediators of chronic inflammation
(%neutrophils + %bands) × (WBC) Here the answer is definitely histamine >> IL2
I ANC =
100
O 11. Ans. (d)  Transient vasoconstriction → Vasodilatation
•• Mild neutropenia (1000 ≥ ANC < 1500): minimal risk of
→ Increased permeability → Stasis (Ref: R 9th/pg 73-74)
N infection

S
 89

Chapter 4  Hemodynamics
A

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A B

5
Fig. 1 A. Normal lung; B. Microscopy showing heart failure cells

y,
B
s/o chronic pulmonary congestion
Fig. 2 Chronic passive hepatic congestion. A. Gross appearance:

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Liver shows dilated congested centrilobular regions s/o nutmeg liver
B. Microscopic preparation shows centrilobular hepatic necrosis.

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HEMOSTASIS

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Explained in detail in Chapter Bleeding and its disorders (Chapter 11)
Pa
THROMBOSIS
ƒƒ Pathologic formation of intravascular thrombus
of

ƒƒ Virchow’s triad is required for thrombus formation.Q

Explained in detail in Chapter 11
Types
s

There are three types of thrombosis

ge

Thrombosis
Pa

Mural thrombosis Arterial thrombosis Venous thrombosis

•• Mural thrombi: arterial thrombus •• Occurs in rapidly flowing blood of
Q •• Occurs in slow moving bloodQ in
e

originate in heart or aorta & adhere to arteries & heartQ veinsQ

•• Sites: Phlebothrombosis (lower
pl

wall of underlying structure. •• Sites: Coronary > cerebral > femoral

arteriesQ extremities M.C)
ƒƒ Upper limbs, periprostatic plexus,
m

•• Cause: AtherosclerosisQ is a major

cause ovarian and periuterine veins
•• Cause: StasisQ
Sa

•• Ulcerated atherosclerotic plaque

•• Propagation: Extend in the directionQ
and aneurysmal dilationQ are the
of blood flow (i.e., toward the heart).
precursors of aortic thrombiQ
•• Occlusion: Almost always occlusiveQ
•• Propagation: RetrogradeQ direction
•• Gross: Red, or stasis, thrombi.Q
from the point of attachment
•• Microscopy: Contain more
•• Occlusion: Usually mural, does not
erythrocytesQ
occludeQ the lumen completely
•• Gross: White thrombi.Q
•• Embolization: More commonQ T
Gross appearance of heart showing •• Microscopy: Contain more plateletsQ H
mural thrombi •• Embolization: Less commonQ
E
O
R
Y
 •• Thrombi on heart valves are called vegetations: seen in Rheumatic heart disease, infective endocarditis; nonbacterial thrombotic
endocarditis and verrucous (Libman-Sacks) endocarditisQ (Fig. 3).
•• Thrombus has a firm attachmentQ to underlying vessel or heart wall, which is not seen in clotQ
90 •• Thrombi (both arterial & venous)Q have laminations, called line of ZahnQ
•• Line of Zahn are due to alternate pale layers of platelets with fibrin & darker layers with more RBCs (Fig. 4). These lines distinguish
antemortem clots from the bland non-laminated clots postmortemQ clots
•• Postmortem clot: Gelatinous & not attachedQ to the underlying wall (in contrast to thrombusQ), Dark red dependent portion where
red cells have settled by gravity and yellow “chicken fat”Q upper portion (Fig. 5).
Complete Review of Pathology

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Fig. 3  Vegetations on heart valves Fig. 4 Line of Zahn Fig. 5 Postmortem clot

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Fate of the Thrombus Pulmonary Emboli (Fig. 6)

th
Thrombus undergoes four events in the ensuing days to weeks: ƒƒ Most common form of thromboembolic disease.Q
Pa
possible fates DOPE:Q ƒƒ Most arise in the deep leg veins above the level of knees.Q
ƒƒ Dissolution-is the result of fibrinolysis ƒƒ 80% are clinically silentQ because of dual circulation and
ƒƒ Organization & repair-in older thrombi; by ingrowth of small size
fibroblasts, endothelial & smooth muscle cells ƒƒ Multiple emboli over time cause pulmonary hypertension
of

ƒƒ Propagation-by accumulation of additional platelets and and right ventricular failureQ

fibrin ƒƒ >60% obstruction in pulmonary circulation → sudden death
ƒƒ Embolization-Thrombi dislodge and travel to other sites in or corpulmonale
s

the vasculature ƒƒ Paradoxical embolusQ can pass through interatrial/inter-

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ventricular defect, thus entering the systemic circulation.Q

DISSEMINATED INTRAVASCULAR
Pa

COAGULATION (DIC) / CONSUMPTION

COAGULOPATHY
e

Discussed in chapter-11
pl

EMBOLISM
m

ƒƒ ‘Embolus’ is a detached intravascular solid, liquid, or

Sa

gaseous mass that is carried by the blood from its point of

origin to a distant siteQ,
ƒƒ The vast majority of emboli are dislodged thrombi, hence
the term thromboembolism.Q

T Fig. 6 Pulmonary emboli : Gross appearance

H
E
O
R
Y
D or IV Medium : Acrocentric 13-15
E or V Small : Metacentric/ Submetacentric 16-18
F or VI Small : Metacentric 19-20 113
G or VII Smallest : Acrocentric 21, 22 and Y

Chapter 5   Genetic Disorders

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 DEVELOPMENT OF RBCs
Bone marrow Peripheral blood
286
Complete Review of Pathology

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� Reticulocytes takes 4–5 days (1–3 days in bone marrow and 1–2 days in peripheral circulation)Q to mature into RBCs
� Ferritin molecules can be seen at proerythroblast stageQ by electron microscopy

5
� Hemoglobin can be first visualized at polychromatic (Intermediate) erythroblastQ stage

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REGULATION OF ERYTHROPOIESIS

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Hypoxia → Kidney → Erythropoietin → Bone marrow → Manufactures and releases RBCs

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RBC INDICES

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Mean Cell Volume Mean Cell Hemoglobin (MCH) 30 ± 3 (pg) Mean Cell Hemoglobin Concentration Red Cell Distribution
(MCV) 80–100 m (fl) (MCHC) 34 ± 2 (g/d) Width (RDW) 12–16
Pa
Average volume of a Average content (mass) of hemoglobin per Average concentration of hemoglobin Coefficient of
red cell red cell, MCH = Hb/RBC countQ in a given volume of packed red cells, variation of red cell
MCHC = Hb/MCVQ volumeQ
of

� Hematocrit or Packed cell volume: ratio of the volume of RBCs to total volume of blood
� Hct or PCV = MCV × RBC concentration
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ge
Pa
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pl
m
Sa

Hematocrit Wintrobe’s tube for ESR measurement

T ESR
H
� Definition:
E � Measurement of sedimentation of RBCs in diluted blood (EDTA or Citrate) after standing for 1 hr in an open-ended glass tube
O of 30 cm length mounted vertically on a stand.

R
Y
� Characteristics:
� It is slower to respond to acute disease activity
� It is insensitive to small changes in disease activity.
� It is less specific than CRP because it is influenced by
287
immunoglobulins & Anemia.
� Stages of sedimentation:
� Formation of rouleaux
� Period of fast settling

Chapter 10   Red Blood Cells and its Disorders

� Period of packing of the rouleaux at the bottom of the tube Anemia Due to Blood Loss
� Normal value: Acute Blood loss
� Men: < 15 mm/hr

� Very low ESR: � Etiology:

/3
(0–1 mm) � External (trauma, or obstetric hemorrhage)
� Polycythemia, hypo- or afibrinogenemia, congestive cardiac � Internal (e.g., from bleeding in the gastrointestinal tract,

5
failure & abnormalities of red cells such as poikilocytosis, rupture of the spleen, rupture of an ectopic pregnancy,
spherocytosis, or sickle cells. subarachnoid hemorrhage)

y,
� Very high ESR � Pathophysiology:
(>100 mm) � Loss of intravascular volume → Intravascular shift of water

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� Tuberculosis, Hodgkin’s disease, multiple myeloma, chronic from the interstitial fluid compartment → Hemodilution
infective or inflammatory conditions → Lowering of hematocrit
� Factors influencing ESR � Features:

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� Early recovery is marked by thrombocytosisQ
Increased ESR Lower ESR

th
� On day 5- reticulocytosis startsQ
•• Old age •• Extreme leucocytosis
� Massive bleeding- granulocytosis (leukocytosis)Q
•• Female •• Polycythemia
Pa
� Day 7: reticulocytosis (10–15%)Q
•• Pregnancy •• Spherocytosis,
� MCV increasesQ as newly produced RBC’s are larger
•• Anemia microcytosis
•• Paraprotein •• Hyperviscosity
(Multiple Myeloma) •• Low Protein; fibrinogen, Chronic Blood Loss
of

•• Hypergammaglobulinemia gammaglobulins Anemia is the only manifestation

•• Macrocytosis •• Technical factors;
s

•• Elevated fibrinogen (infection, dilution, clotted sample Hemolytic Anemias: Due to increased RBC
•• Afibrinogenemia
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inflammation malignancy) destruction

•• Technical factors: dilution, high No effect Characterized by:
temperature
•• Obesity
Pa

� Shortened RBC life spanQ (normal = 120 days)Q

•• Body temperature � Increase in erythropoiesisQ
•• Recent meal � Accumulation of hemoglobin degradationQ products
•• Aspirin, NSAIDs
e

Erythrocyte Sedimentation Rate is zero in Afibrinogenemia

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ANEMIA
m

Definition: Functionally defined as an insufficient RBC mass to

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adequately deliver oxygen to peripheral tissues

WHO Criteria
Category Hb (g/d)Q cut-off for Mean Normal Hb
Anemia (g/d)
Adult male < 13 14.5 T
B
Adult female < 12 13.5 H
Pregnant female < 11 12.5 PS of hemolytic anemia E
A. Fragmented RBC; B. nRBC
Child < 6 yr < 11 12
O
R
Y