Clinical vignette

A 56 year old man complains of transient attacks of blurred vision in his left eye lasting a few minutes each time. Examination of the eye revealed no abnormality. However, a bruit was heard over the left carotid artery.

Cerebral angiography showed an ulcerated atherosclerotic lesion at the bifurcation of the left common carotid artery with stenosis of the internal carotid and reduction of the lumen to 1 mm.

A carotid endarterectomy was performed, with relief of symptoms.

Discussion topics:

1. What are the risk factors for developing atherosclerotic arterial disease?
2. What are the major complications of atherosclerosis?
3. What is the cause of the visual disturbance in this patient?
4. What other organs might be affected?

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Clinical vignette

A 65 year old white male with a long history of hypertension presented to the Emergency room complaining of dull pain in the lower abdomen. Physical examination revealed a palpable, pulsatile mass in the abdomen. A plain x-ray of the abdomen revealed irregular calcifications in the mid-line. An ultrasound examination confirmed the clinical diagnosis of a large aneurysm of the lower abdominal aorta. While in the ER, the patient developed severe pain and tenderness and became hypotensive. After initial supportive measures, the patient was taken to the operating room for emergency surgery to repair his aneurysm which had ruptured.

Discussion topics

1. What is the cause of this aneurysm? What are the complications that may occur?
2. What are the other types of aneurysms? What is the most likely location, and pathological features of each type?

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Clinical vignette

A 50 year old female complained of fever, weakness and myalgia for the previous 6 months. Initial work-up revealed that she was hypertensive, her sedimentation rate was elevated and she had microscopic hematuria. After preliminary investigations to exclude a neoplasm arising in the urinary tract, a renal biopsy was performed which showed changes of polyarteritis nodosa. She was treated with steroids and with anti-hypertensive drugs and improved remarkably.

Discussion topics

1. What are the classical vascular changes in polyarteritis nodosa?
2. What organ systems are commonly involved?
3. What is the relationship of this disease to Hepatitis B?
4. Name 3 other types of vasculitis and describe briefly the clinical and pathological changes in each.

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Clinical vignette

A 35 year old homosexual male who tested positive for HIV developed flat purpura-like lesions on the face that became papular over several days. His CD4 count was low; he developed multiple opportunistic infections including Pneumocystis carinii pneumonitis, to which he ultimately succumbed. At autopsy, in addition to numerous infections, he had lesions of Kaposi sarcoma in numerous lymph nodes, the GI tract, and the skin.

Discussion topics

1. What are the microscopic features of Kaposi sarcoma? What are some of the other lesions it may be confused with, especially in a patient with AIDS?
2. Discuss the epidemiology of Kaposi sarcoma. What is the pathogenesis and prognosis?
3. Describe some of the other tumors of blood vessels, including clinical and pathologic features.

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Clinical vignette 5

A 50 year old male is found to have a blood pressure of 160/100 at his annual medical check-up. He admits to having frequent headaches with occasional "dizzy spells" and palpitations which he had attributed to stress in the workplace. Other than being somewhat overweight, the rest of his physical examination was normal. After appropriate follow-up and lab studies, a diagnosis of essential hypertension was made.

Discussion topics

1. Discuss the regulatory mechanisms of normal blood pressure.
2. What are the causes of secondary hypertension? Name some of the screening tests/procedures used to exclude these?
3. What are some of the factors thought to be involved in the pathogenesis of essential hypertension?
4. Discuss the pathological changes that occur in the blood vessels in hypertension.

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