Hands of patient with Rheumatoid Arthritis at autopsy

Note the swollen joints and deforming arthritis

Joint capsule surrounding metacarpal joints of patient with Rheumatoid Arthritis

Note the thickening of the capsule and the focal accumulation of inflammatory cells surrounding a central area of fibrinoid necrosis (arrow)

Joint capsule with another granuloma surrounding a central area of fibrinoid necrosis (arrow)

Foot of same RA patient

Note the subcutaneous nodule on the medial aspect of the foot (arrow)

Micrograph of the subcutaneous nodule from this RA patient

Subcutaneous nodule from RA patient

Granulomatous lesion with a necrotic center and a peripheral rim of macrophages, fibroblasts, and occasional lymphocytes. In the necrotic center of the granuloma there is some mineralization (basophilic material).

Subcutaneous nodule

Demonstrates necrotic center and peripheral rim of macrophages, fibroblasts, and occasional lymphocytes. There are focal accumulations of hyaline material (fibrinoid material) within the granuloma.

Illustrates the palisading nuclei of the monocytes which are located at the periphery of the central necrotic region (1)

Mononuclear cells surrounding the central necrotic area

The focal accumulations of fibrinoid material are clearly visible. Lymphocytes are present in the extreme right.

Another region with macrophages (right), fibrocytes (left), and occasional lymphocytes throughout the lesion

Thyroid gland from patient with Graves’ Disease.

Note the gland is enlarged and dark red.

A normal thyroid weighs 25 g, this one weighed 45 g.

Thyroid gland from patient with Graves’

Very cellular and very little colloid

Thyroid gland from patient with Graves’

Note the cellularity of the tissue with marked infolding of the epithelial tissue.

Thyroid gland from patient with nodular goiter

Closer view of cut surface of thyroid from patient with nodular goiter

Note the multilobular appearance of the tissue.

Thyroid gland of patient with Hashimoto’s Thyroiditis, picture taken at autopsy

Only slightly enlarged, very firm texture

Thyroid gland from this case

More cellular than expected. There does not appear to be normal colloid-filled blue spaces in this gland.

Note the large number of blue-staining inflammatory cells in this tissue. These cells appear to be forming germinal centers. Some residual thyroid gland tissue can be seen in this section (arrows).

Inflammatory cells forming germinal centers

Inflammatory cells and residual thyroid tissue

Inflammatory cells infiltrating into residual thyroid tissue (arrows)

Lymphocytes and plasma cells surrounding the thyroid gland epithelium

Lymphocytes and plasma cells surrounding the thyroid gland epithelium.

Large, eosinophilic, degenerating thyroid gland cells (Hurthle cells) can be seen in this section (arrows).

Angiogram of abdominal viscera demonstrating numerous aneurysms throughout the mesenteric circulation (arrows)

Angiogram of the liver demonstrating numerous aneurysms throughout the hepatic circulation (arrows)

Angiogram of the kidneys demonstrating numerous aneurysmal dilations in the renal circulation (arrows)

A mesenteric vessel from this case of polyarteritis nodosa (arrow)

The vessel is completely occluded by thrombotic material and the vessel wall is infiltrated with inflammatory cells.

Mesenteric vesselNote the thrombotic material occluding the vessel (arrows) and the inflammatory cell infiltrate in the wall of the vessel and in the surrounding adventitia.

Mesenteric Artery

Marked inflammatory cell response

1: Fresh hemorrhage 2: Thrombotic material

Vessel wall

There is hemorrhage and infiltration with inflammatory cells, primarily neutrophils (arrows).

Small vessel with a rim of fibrinoid necrosis (arrow)

There is an area of necrosis in the adrenal gland (1) and an affected vessel adjacent to the gland (2).

Affected vessel from previous image

The vessel wall is infiltrated with inflammatory cells and the vessel lumen is completely occluded (arrow).

Heart with areas of fibrosis in the myocardium (arrows)

Note that the large epicardial coronary artery is normal.

Affected vessels in the heart (arrows)

There are areas of fibrosis (old infarcts) in the myocardium adjacent to these affected vessels.

Affected vessel in the heart

The lumen is completely occluded.

Cut section of lungs from patient with scleroderma

Note extensive fibrosis of the lung parenchyma.

Cut section of one lung from patient with sclerodermaNote extensive fibrosis of the lower lobe (arrows).

Cut section of one lung from patient with sclerodermaNote extensive fibrosis and the severe emphysematous changes.

Cut section of one lung from patient with sclerodermaNote extensive fibrosis and the severe emphysematous changes.

Heart from this case

There is thickening of the left ventricular wall and some thickening of the right ventricle as well.

Lung

Apical lesion representing an old healed lesion from Mycobacterium tuberculosis infection

Lung tissue with multiple circumscribed nodules- granulomas (arrows)

Tb granuloma

Note the eosinophilic material in the center (caseous necrosis) and the epothelioid macrophages and giant cells around the periphery.

Tb granulomaCaseous necrosis is on the left-hand side of the image. There are multinucleated giant cells and epithelioid macrophages throughout the remainder of this tissue.

Acid-fast stain

Mycobacterium tuberculosis bacilli stain red.

Saggital section of end stage chronic glomerulonephritis (GN)

Note the marked thinning of the cortex (arrow).

Hyalinized glomeruli (arrows) and glomeruli with thick basement membranes

1: Hyalinized glomeruli

2: Glomeruli with thickened basement membranes

Interstitial and vascular lesions in end stage renal disease

Granular membranous immunofloursecence (immune complex disease)

The antibody used was specific for IgG.

Electron micrograph of subepithelial electron dense deposits (arrows) which correspond to the granular immunofloursecence in the previous image.

Acute poststreptococcal glomerulonephritis

In this case the immune complex glomerular disease is ongoing with necrosis and accumulation of neutrophils in the glomerulus.

Immunoflourescent pictomicrograph of a glomerulus from a case of acute poststreptococcal glomerulonephritis; shows a granular immunoflourescence pattern consistent with immune complex disease

The antibody used was specific for IgG, but antibody for complement would show a similar pattern.

Electron micrograph demonstrating scattered subepithelial dense deposits (arrows) and a polymorphonuclear leukocyte in the lumen.

Immunoflourescent pictomicrograph of a glomerulus from a patient with Goodpasture’s syndromeThe linear immunoflourescene (arrows) is characteristic of Goodpasture’s.

Acute rejection

Note the kidney is swollen (edema and inflammation) and there are areas of hemorrhage throughout the kidney.

Acute rejection: Kidney

Focal accumulations of cells; diffuse cellular infiltrate (blue dots) throughout the parenchyma

Acute rejection: KidneyNote cellular infiltrates

Cellular infiltrates in kidney undergoing acute rejectionNote that in addition to the diffuse cellularity, the focal accumulations of cells seemed to be focused around blood vessels.

Kidney undergoing acute rejectionCellular infiltrate within the interstitium and around the small blood vessel in the center of the image

Kidney undergoing acute rejectionCellular infiltrate within the interstitiumThere is some degeneration (coagulative necrosis) of tubules and glomeruli.

Cellular infiltrate within the interstitium and in the wall of the blood vessel on the left

Acute Rejection: Kidney

1: Cellular infiltrate within the interstitium

2: In the wall of the blood vessel

Acute Rejection: Kidney

Cells infiltrating the wall of the blood vessel

Acute Rejection: Kidney

Cellular infiltrate within the interstitium and cells within the renal tubules

Acute Rejection: Kidney

Chronic Rejection: Kidney

Note the focal areas of hemorrhage and inflammatory cell infiltrate

Chronic Rejection: KidneyKidney containing a section of blood vessel that demonstrates a marked neointimal proliferative response (1). In this case the lumen is obliterated. Also note the cellular infiltrate in the interstitium of the kidney (2) and the paucity of the tubules.

Chronic Rejection: KidneyKidney with a focal area of hemorrhage around a small blood vessel (left) and congestion of the glomeruli. Note that there is a marked loss of renal tubules throughout this section with replacement by fibrous connective tissue. Also note the cellularity of the glomeruli.

1: Fibrosis2: Focus of inflammatory cells indicating that despite the chronic nature of this lesion, there is still ongoing acute rejection and renal damageNote the loss of renal tubules throughout the section.

Chronic Rejection: Kidney1: Congestion2: Glomerulus that is almost completely obliterated or sclerosedNote the increased cellularity of the glomeruli with mesangial expansion

Rejected kidney with a focus of cellular infiltrate (left) and a small artery with neointimal proliferation and stenosis (arrow)

Chronic Rejection: KidneyGlomerulus with a mild cellular infiltrate (left)There is extensive interstitial fibrosis (1), loss of renal tubules, and the remaining tubules contain protein (2) indicating severe damage.

Chronic Rejection: KidneyRenal cortex with cellular infiltrate and few remaining renal tubulesThe cellular infiltrate comprises macrophages, activated (large) lymphocytes, and a few neutrophils and plasma cells.

Chronic Rejection: KidneyDamaged glomerulusNote the loss of normal capillary structure, the mesangial expansion, and the infiltration of large mononuclear cells.

Extensive damage to the kidney due to chronic rejection (loss of tubules and glomerular lesions)In addition, this kidney was removed during an episode of acute rejection. The marked cellular infiltrate indicates acute rejection in a case of chronic transplant rejection.

Acute rejection in a case of chronic rejection: KidneyCellular infiltrate is composed of lymphocytes, macrophages, plasma cells, and a few neutrophils.

Acute rejection in a case of chronic rejection: KidneyNote the cellular infiltrate around a small blood vessel (right) and neutrophils within renal tubules (arrow).

Mediastinal mass; encapsulated and contains cellular areas (blue) and areas of pale red material

Multiple Myeloma with Amyloid

Junction between an amorphous hylaine-appearing area (amyloid) on the right and cellular areas (plasmacytoid cells) on the left

Multiple Myeloma with Amyloid

Demonstrates the cells that make up the tissue: resemble plasma cells and are the malignant cell of multiple myeloma

Vertebral column at autopsy

1: Collapsed vertebra

2: Multiple variably-sized nodules within the bone marrow; these are accumulations of malignant plasma cells in this case of multiple myeloma

Liver with amyloidosis

Note the pale, swollen appearance of the liver.

Liver with amyloidosisCut surfaceThe liver tissue is firm and has a waxy appearance.

Arrows: The pale waxy material can be seen within hepatic tissue.

Liver with amyloidosis

Eosinophilic hyaline material (1) present within and between hepatic tissue (2)

There is marked distortion of the lobular architecture by the amyloid.

Amyloid deposits (1) between hepatocytes (2)

Liver with amyloidosis

Congo red stain reacts with amyloid, giving it an orange color (arrows).

Liver with amyloidosis

Congo red stain

The orange amyloid tissue is clearly seen between liver parenchymal cells.

Liver with amyloidosis

Congo red stain, partially polarized light

Congo red stained amyloid viewed through polarized light should give off a classic “apple green” birefringence (arrows). Not demonstrated well here.

Kidney with amyloidosis

Note the pale yellow material within the cortex (arrows). This is indicative of amyloid within the cortex and the glomeruli. Also note there are multiple red spots in the cortex. They represent congested glomeruli due to the vascular compromise produced by the amyloid.

Amyloid deposits within glomeruli (arrows)

Tongue with extensive amyloid deposits (1) separating the skeletal muscle fibers of the tongue. In many cases the amyloid encircles the muscle fibers (2) and these muscle fibers are atrophied.

Heart: Senile Amyloidosis

This tissue was firm and had a waxy texture.

If you use your imagination, you can see pale yellow areas within this tissue which represent the amyloid deposits.

Heart: Senile Amyloidosis

At this magnification the structure looks relatively normal.

Heart: Senile Amyloidosis

1: Amyloid deposition throughout the myocardium

2: Deposition in the wall of the blood vessel

Heart: Senile Amyloidosis

1: Extracellular amyloid

2: Deposition in the vessel wall

Heart: Senile Amyloidosis

Special stain for amyloid, demonstrating the amyloid (1) and fibrosis (2) in the myocardium. The amyloid is darker purple/magenta and tends to be more amorphous. The fibrosis is pink and more fibrillar.