Ed Friedlander, M.D., Pathologist

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Welcome to Ed's Pathology Notes, placed here originally for the convenience of medical students at my school. You need to check the accuracy of any information, from any source, against other credible sources. I cannot diagnose or treat over the web, I cannot comment on the health care you have already received, and these notes cannot substitute for your own doctor's care. I am good at helping people find resources and answers. If you need me, send me an E-mail at Your confidentiality is completely respected. No texting or chat messages, please. Ordinary e-mails are welcome.

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Freely have you received, give freely With one of four large boxes of "Pathguy" replies.

I'm still doing my best to answer everybody. Sometimes I get backlogged, sometimes my E-mail crashes, and sometimes my literature search software crashes. If you've not heard from me in a week, post me again. I send my most challenging questions to the medical student pathology interest group, minus the name, but with your E-mail where you can receive a reply.

Numbers in {curly braces} are from the magnificent Slice of Life videodisk. No medical student should be without access to this wonderful resource.

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Freely have you received, freely give. -- Matthew 10:8. My site receiver(an enormous amount of traffic, and I'm still handling dozens of requests for information weekly, all as a public service.

Pathology's modern founder, Rudolf Virchow M.D., left a legacy of realism and social conscience for the discipline. I am a mainstream Christian, a man of science, and a proponent of common sense and common kindness. I am an outspoken enemy of all the make-believe and bunk that interfere with peoples' health, reasonable freedom, and happiness. I talk and write straight, and without apology.

Throughout these notes, I am speaking only for myself, and not for any employer, organization, or associate.

Special thanks to my friend and colleague, Charles Wheeler M.D., pathologist and former Kansas City mayor. Thanks also to the real Patch Adams M.D., who wrote me encouragement when we were both beginning our unusual medical careers.

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Especially if you're looking for information on a disease with a name that you know, here are a couple of great places for you to go right now and use Medline, which will allow you to find every relevant current scientific publication. You owe it to yourself to learn to use this invaluable internet resource. Not only will you find some information immediately, but you'll have references to journal articles that you can obtain by interlibrary loan, plus the names of the world's foremost experts and their institutions.

Alternative (complementary) medicine has made real progress since my generally-unfavorable 1983 review. If you are interested in complementary medicine, then I would urge you to visit my new Alternative Medicine page. If you are looking for something on complementary medicine, please go first to the American Association of Naturopathic Physicians. And for your enjoyment... here are some of my old pathology exams for medical school undergraduates.

I cannot examine every claim that my correspondents share with me. Sometimes the independent thinkers prove to be correct, and paradigms shift as a result. You also know that extraordinary claims require extraordinary evidence. When a discovery proves to square with the observable world, scientists make reputations by confirming it, and corporations are soon making profits from it. When a decades-old claim by a "persecuted genius" finds no acceptance from mainstream science, it probably failed some basic experimental tests designed to eliminate self-deception. If you ask me about something like this, I will simply invite you to do some tests yourself, perhaps as a high-school science project. Who knows? Perhaps it'll be you who makes the next great discovery!

Our world is full of people who have found peace, fulfillment, and friendship by suspending their own reasoning and simply accepting a single authority that seems wise and good. I've learned that they leave the movements when, and only when, they discover they have been maliciously deceived. In the meantime, nothing that I can say or do will convince such people that I am a decent human being. I no longer answer my crank mail.

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During the eighteen years my site has been online, it's proved to be one of the most popular of all internet sites for undergraduate physician and allied-health education. It is so well-known that I'm not worried about borrowers. I never refuse requests from colleagues for permission to adapt or duplicate it for their own courses... and many do. So, fellow-teachers, help yourselves. Don't sell it for a profit, don't use it for a bad purpose, and at some time in your course, mention me as author and William Carey as my institution. Drop me a note about your successes. And special thanks to everyone who's helped and encouraged me, and especially the people at William Carey for making it still possible, and my teaching assistants over the years.

Whatever you're looking for on the web, I hope you find it, here or elsewhere. Health and friendship!


More of Ed's Notes: Ed's Medical Terminology Page

Perspectives on Disease
Cell Injury and Death
Accumulations and Deposits
What is Cancer?
Cancer: Causes and Effects
Immune Injury
Other Immune
HIV infections
The Anti-Immunization Activists
Infancy and Childhood
Environmental Lung Disease
Violence, Accidents, Poisoning
Red Cells
White Cells
Oral Cavity
GI Tract
Pancreas (including Diabetes)
Adrenal and Thymus
Nervous System
Lab Profiling
Blood Component Therapy
Serum Proteins
Renal Function Tests
Adrenal Testing
Arthritis Labs
Glucose Testing
Liver Testing
Spinal Fluid
Lab Problem
Alternative Medicine (current)
Preventing "F"'s: For Teachers!
Medical Dictionary

Courtesy of CancerWEB

Learning Objectives

Describe some theoretical mechanisms of autoimmune disease. Give examples of known or suspected triggers for autoimmune disease.

List the common autoimmune diseases -- both those included in this lecture, and related disorders.

Give the predisposing factors, typical symptoms, signs, laboratory findings (especially autoantibodies), and pathologic anatomy for each of the following:

Give the distinguishing features for each of the following:

Recognize the following using the microscope:

Recognize lupus as today's "great imposter", and keep a high index of suspicion for all the common autoimmune diseases.

Immune Disease
Iowa Virtual Microscopy
Have fun

Immuno Pathology
Photos, explanations, and quiz
Indiana U.

From Chile
In Spanish

KCUMB Students
"Big Robbins" -- Immuno
Lectures follow Textbook



familial hemochromatosis (gene is in this and some other alleles

B8 & DR3

autoimmune Addisonism
myasthenia gravis


ankylosing spondylitis
Reiter's syndrome
enteropathic arthropathy
autoimmune uveitis




psoriatic arthritis




21-hydroxylase deficiency (gene is in the allele)


common psoriasis


multiple sclerosis


celiac sprue / dermatitis herpetiformis
lupoid hepatitis
lupus (weak)

DR3, DR4

autoimmune diabetes


rheumatoid arthritis (the DR4 alleles with the "shared antigen")


autoimmune pernicious anemia
Hashimoto's autoimmune thyroiditis

THE AUTOANTIBODIES (Am. J. Med. 100(2A): 16S, 1996)

RIM PATTERN Probably anti-dsDNA. Your patient probably has SYSTEMIC LUPUS.

HOMOGENEOUS PATTERN Probably anti-histones. Your patient probably has DRUG-INDUCED LUPUS.

SPECKLED PATTERN Could be anti-Sm and/or anti-Ro/SSA and/or anti-La/SSB and/or anti-U1snRNP and/or any of several others. You'll certainly want to continue your workup!

CENTROMERE PATTERN An especially fine speckling with little background staining. This is anti-centromere, the marker for CREST / pulmonary hypertension.

NUCLEOLAR PATTERN anti-Th/To or anti-fibrillarin / anti-U3snRNP or anti-U17RNP. Think of SCLERODERMA, though most scleroderma patients don't show the nucleolar pattern.

anti-dsDNA Anti-double stranded DNA. A misnomer, of course. Your patient has systemic lupus. About half of lupus patients have these antibodies.

anti-ssDNA Anti-single stranded DNA. Think of drug-induced lupus.

anti-histone Think of drug-induced lupus.

anti-Sm Anti-Smith. Your patient has systemic lupus. About a third of lupus patients have these antibodies.

anti-Ro/SSA Lupus, Sjogren's, neonatal lupus, or some mix of these.

anti-La/SSB Lupus, Sjogren's, or some mix of these

anti-U1snRNP Anti-ribonucleoprotein. When this is the main autoantibody, your patient has mixed connective tissue disease.

Anti-Scl70 Anti-topoisomerase I. Your patient has the bad kind of scleroderma. A large minority of people with the bad kind of scleroderma have this autoantibody.

Anti-centromere Sensitive and specific for CREST, the limited scleroderma variant.

Anti-Jo Antibody against transfer-RNA synthetase. Your patient probably has polymyositis. About half of these patients have this autoantibody.

SYSTEMIC LUPUS ERYTHEMATOSUS (SLE, "the red wolf"; update on what we know and how much more we don't Nat. Med. 18: 871, 2012).

From Chile
In Spanish

{08403} lupus immune complexes (green) trapped in the glomerulus
{28142} discoid lupus on the face (what features do you see?)

{08394} LE cell; Giemsa stained preparation
{29440} LE cells, Papanicolaou stain

Lupus glomerulonephritis
The dark pink is immune complexes
WebPath photo

Lupus glomerulonephritis
Lots of immune complexes
WebPath photo

Lupus glomerulonephritis
Lots of immune complexes
WebPath photo

Systemic lupus
Butterfly rash
KU Collection

Butterfly rash
WebPath photo

Butterfly rash
WebPath photo

{08388} butterfly rash
{12273} butterfly rash
{12274} butterfly rash
{25551} butterfly rash
{33208} lupus butterfly

{14316} discoid lupus
{08376} discoid rash of lupus, histology (nice local hydropic change in basal layer)
{11985} discoid lupus
{28868} discoid lupus
{28877} discoid lupus (good plugs)
{28880} discoid lupus (good atrophy / hyperkeratosis of epidermis)

{08385} positive lupus band test (granules along basement membrane are immune complexes)
{33205} positive lupus band test, better example

Positive lupus band test
WebPath photo

Positive lupus band test
WebPath photo

{06962} Libman-Sacks endocarditis in lupus

SJOGREN'S SYNDROME (Mikulicz's disease, "autoimmune exocrinopathy", "autoimmune epithelitis", etc. Review Br. J. Rheum. 35: 204, 1996.

{35591} Sjogren's histology, minor salivary gland, fibrosis and lymphocytes
{35594} Sjogren's histology
{35597} Sjogren's histology; note lots and lots of lymphocytes

WebPath photo

Minor salivary gland
Wikimedia Commons

SCLERODERMA ("[Progressive] Systemic Sclerosis"): NEJM 360: 1989, 2009.

{33248} anti-nuclear antibody preparation in scleroderma, with each of the thousand points of light a different nucleolus

{08466} onion-skinning of intima of small artery in scleroderma
{08469} intimal proliferation in scleroderma (elastic stain, kidney)
{24854} intimal proliferation in scleroderma demonstrated with PAS stain
{33259} intimal proliferation in small artery of the scleroderma kidney; the tubules are atrophic because of the longstanding lack of blood flow
{17124} kidney vascular changes in scleroderma

From Chile
In Spanish

Note the sclerodactyly and facial changes
WebPath photo

Malnutrition or physical effect?
You decide. Webpath.

Intimal onionskinning
WebPath photo

{14335} scleroderma, hands (notice calcium in knuckles)
{14336} scleroderma, finger (notice that the thin epidermis makes the skin shiny, and that the vessels are bunched at the nail root)
{25460} scleroderma, acrosclerosis
{24626} scleroderma, hands
{24917} scleroderma, histology of skin
{08460} scleroderma, histology of skin

Skin changes
WebPath photo

Skin changes
WebPath photo

{33274} scleroderma lung; trichrome stain shows collagen/scar blue

{12187} morphea
{14333} morphea
{15358} morphea

Morphea (localized scleroderma)
Prize photograph
Institute of Medical Illustrators

POLYMYOSITIS and DERMATOMYOSITIS: Lancet 355: 53, 2000; immunology review from Harvard Neurology 69: 2008, 2007).

{13120} Gottron's sign
{14342} heliotrope eyelids
{14338} Gottron's sign (easier to see on the left hand than on the right hand)
{14339} Gottron's sign
{14340} Gottron's sign
{15346} butterfly rash (closely resembles lupus)

Muscle biopsy in dermatomyositis
Text and photomicrographs
Dr. Warnock's Collection

{05780} dermatomyositis, histology; note the lymphocytes in this particular case
{05789} dermatomyositis, late, trichrome stain; muscle cells (red) are largely replaced by scar tissue (blue)
{09039} polymyositis, histology in muscle; note lymphocytes
{14358} polymyositis, histology; good perifascicular atrophy
{29501} polymyositis; find a few examples each of muscle fibers undergoing necrosis, atrophy, and regeneration


Weird bowel lesion
Pittsburgh Pathology Cases

Pittsburgh Pathology Cases

Mixed Connective Tissue Disease
Pittsburgh Illustrated Case

Anti-nuclear antibodies
Homogeneous pattern
WebPath photo

Anti-nuclear antibodies
Homogeneous pattern
WebPath photo

Anti-nuclear antibodies
Peripheral pattern
WebPath photo

Anti-nuclear antibodies
Speckled pattern
WebPath photo

Anti-nuclear antibodies
Nucleolar pattern
WebPath photo

Anti-nuclear antibodies
Nucleolar pattern
WebPath photo

* FIBROMYALGIA SYNDROME ("allodynia", "fibrositis", "rheumatic pain modulation disorder"; "muscular rheumatism", not an autoimmune disease: Big current review Ann. Int. Med. 146: 726, 2007.

* Reminder: You will study osteoarthritis ("wear and tear arthritis"), rheumatoid arthritis, the enthesopathies, and rheumatic fever later in the course. Another important cause of multi-joint arthritis is iron overload -- fairly common, and very preventable.



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