Enumerate and describe the types of Reed Sternberg cells with well labelled diagram 2nd yr mbbs refer harsh mohan
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Reed Sternberg cells types Hodgkin lymphoma
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lymphocytic histiocytic L&H popcorn cells lymphocyte predominance Hodgkin
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Excellent! I now have the key textbook figure (Fig. 13.25 from Robbins) and all the information needed. Let me now compile a comprehensive, exam-ready answer for a 2nd year MBBS student in the style of Harsh Mohan's Textbook of Pathology.
Reed-Sternberg (RS) Cells — Types and Descriptions
(Reference: Harsh Mohan, Textbook of Pathology, 8th ed.; Robbins & Cotran Pathologic Basis of Disease)
What is a Reed-Sternberg Cell?
Reed-Sternberg (RS) cells are the pathognomonic neoplastic cells of Hodgkin Lymphoma (HL). They are derived from germinal centre B lymphocytes (confirmed by clonal IGH gene rearrangements and somatic hypermutation).
Basic features of classic RS cells:
- Large cells (~45 μm in diameter)
- Binucleated or bilobed nucleus, with mirror-image appearance
- Each nucleus contains a large, eosinophilic, inclusion-like nucleolus (5–7 μm — size of a small lymphocyte)
- Surrounded by a clear halo → "Owl-eye appearance" (the hallmark)
- Abundant pale cytoplasm
- Set against a background of lymphocytes, eosinophils, plasma cells, and macrophages
Immunophenotype (classic HL): CD30⁺, CD15⁺, PAX5 (weak)+, CD45⁻, CD20⁻
Types / Variants of Reed-Sternberg Cells
Fig. 13.25 (Robbins) — RS cells and variants. (A) Diagnostic RS cell (owl-eye, binucleate). (B) Mononuclear variant. (C) Lacunar variant (cell sitting in empty space/lacuna). (D) Lymphohistiocytic (L&H / popcorn) variants with multilobated nuclei and small nucleoli.
1. Classic (Diagnostic) RS Cell
| Feature | Detail |
|---|---|
| Nucleus | Binucleate or bilobed; mirror-image |
| Nucleolus | Large, prominent, eosinophilic — "inclusion-like" (5–7 μm); one per lobe → "Owl-eye" appearance |
| Cytoplasm | Abundant, pale eosinophilic |
| Size | ~45 μm |
| Background | Lymphocytes, eosinophils, plasma cells, macrophages |
| Subtype | Required for diagnosis in all classic HL subtypes |
| IHC | CD15⁺, CD30⁺, PAX5 weak+, CD45⁻ |
Key fact (Harsh Mohan): The classic RS cell is the sine qua non for diagnosing Hodgkin lymphoma. Its identification in an appropriate cellular background is mandatory for diagnosis.
2. Mononuclear Variant (Hodgkin Cell)
| Feature | Detail |
|---|---|
| Nucleus | Single nucleus (instead of two) |
| Nucleolus | One large, prominent, eosinophilic, inclusion-like nucleolus |
| Cytoplasm | Abundant |
| Morphology | Essentially half of a classic RS cell |
| Subtype | Common in Mixed Cellularity and Lymphocyte-Rich subtypes |
| Note | Also called "Hodgkin cell" |
3. Lacunar Variant
| Feature | Detail |
|---|---|
| Nucleus | Multilobated/folded; delicate nuclear membranes |
| Nucleolus | Small to inconspicuous (multiple small ones) |
| Cytoplasm | Abundant pale cytoplasm that retracts during formalin fixation, leaving the nucleus in an empty clear space = lacuna |
| Artifact | The "lacuna" (empty space) is a fixation artifact — NOT seen in B5-fixed specimens |
| Subtype | Characteristic of Nodular Sclerosis HL (most common subtype, 65–70%) |
| IHC | CD15⁺, CD30⁺ |
Mnemnonic tip: "Lacunar = Nodular Sclerosis" — the lacunar cell + collagen bands = nodular sclerosis pattern.
4. Lymphohistiocytic (L&H) Variant — "Popcorn Cell"
| Feature | Detail |
|---|---|
| Nucleus | Multilobated, polypoid/folded — resembles popcorn |
| Nucleolus | Multiple, small, basophilic (not the large eosinophilic nucleolus of classic RS) |
| Chromatin | Fine, vesicular |
| Cytoplasm | Moderately abundant, pale |
| Subtype | Characteristic of Nodular Lymphocyte-Predominant HL (NLPHL) |
| IHC | CD20⁺, CD45⁺, CD15⁻, CD30⁻ (opposite to classic HL!) |
| Background | B-cell rich nodules with follicular dendritic cells; T cells form rosettes around LP cells |
Key distinction: L&H cells express B-cell markers (CD20+) and are CD15⁻/CD30⁻, unlike all other RS variants. NLPHL has an indolent course and excellent prognosis.
5. "Mummified" (Pyknotic) RS Cell
| Feature | Detail |
|---|---|
| Nucleus | Pyknotic, shrunken, condensed chromatin |
| Cytoplasm | Deeply eosinophilic |
| Mechanism | A peculiar form of cell death seen in classic HL subtypes |
| Significance | Seen especially in Lymphocyte-Depleted HL |
Summary Table
| RS Cell Variant | Also Called | Nucleus | Nucleolus | Associated HL Subtype | CD15 | CD30 | CD20 |
|---|---|---|---|---|---|---|---|
| Classic RS cell | Diagnostic RS cell | Binucleate, owl-eye | Large, eosinophilic (×2) | All classic HL subtypes | ⊕ | ⊕ | ⊖ |
| Mononuclear | Hodgkin cell | Single nucleus | Large, eosinophilic (×1) | Mixed Cellularity, Lymphocyte-Rich | ⊕ | ⊕ | ⊖ |
| Lacunar | — | Multilobated, folded | Small/multiple | Nodular Sclerosis | ⊕ | ⊕ | ⊖ |
| L&H / Popcorn | Lymphohistiocytic | Polypoid, multifolded | Small, basophilic | Nodular Lymphocyte-Predominant | ⊖ | ⊖ | ⊕ |
| Mummified | Pyknotic RS cell | Pyknotic, condensed | Absent | Lymphocyte-Depleted | ⊕ | ⊕ | ⊖ |
Diagnostic Rule (Harsh Mohan)
Classic RS cells are necessary but NOT sufficient for diagnosis. They must be found in an appropriate reactive cellular background (lymphocytes, eosinophils, plasma cells). RS-like cells occur in:
- Infectious mononucleosis
- Non-Hodgkin lymphomas (especially ALCL)
- Solid tissue carcinomas (mimics)
Immunohistochemistry (CD15, CD30, CD20, CD45, PAX5) is used to confirm when morphology is uncertain.
Sources: Robbins, Cotran & Kumar — Pathologic Basis of Disease, Fig. 13.25 & Table 13.8 (corresponds to Harsh Mohan's classification of RS cell types in the Lymph Nodes chapter).
Splenomegaly
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splenomegaly gross pathology enlarged spleen
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I now have comprehensive data from Robbins, Goldman-Cecil, and Harrison's. Let me compile the full, exam-ready answer in Harsh Mohan style.
Splenomegaly — Complete Overview
(Refs: Harsh Mohan Textbook of Pathology; Robbins & Cotran Pathologic Basis of Disease; Goldman-Cecil Medicine; Harrison's Principles of Internal Medicine)
Definition
Splenomegaly = enlargement of the spleen beyond its normal weight (>250 g in adults; normal 150 g). The spleen is the largest lymphoid organ in the body and functions as a filter, immune organ, and blood reservoir.
Normal Spleen at a Glance
| Parameter | Normal |
|---|---|
| Weight | ~150 g (range 100–250 g) |
| Size (USG) | < 13 cm length, < 5 cm thickness |
| Enlarged on USG | ≥13 cm length OR ≥5 cm thickness |
Classification / Causes of Splenomegaly
Splenomegaly can be classified by mechanism (as per Harsh Mohan) or by aetiology:
A. By Mechanism
| Mechanism | Examples |
|---|---|
| 1. Hyperplasia of lymphoid/phagocytic cells | Infections, haemolytic anaemias, immune disorders |
| 2. Congestion (vascular) | Portal hypertension (cirrhosis), cardiac failure, portal/splenic vein thrombosis |
| 3. Infiltration | Leukaemia, lymphoma, myeloproliferative disorders, storage diseases |
| 4. Extramedullary haematopoiesis | Myelofibrosis, thalassaemia major |
| 5. Space-occupying lesions | Cysts, abscesses, haemangiomas |
B. By Aetiology (Table — Robbins Table 13.12 / Goldman-Cecil Table 154-5)
🔴 Infections
| Category | Specific Causes |
|---|---|
| Bacterial | Infective endocarditis, typhoid fever, brucellosis, tuberculosis, syphilis |
| Viral | Infectious mononucleosis (EBV) ← most common acute cause in young adults; CMV, HIV |
| Parasitic | Malaria ← most common cause worldwide; Kala-azar (Leishmaniasis) ← massive splenomegaly; schistosomiasis, trypanosomiasis, toxoplasmosis |
| Fungal | Histoplasmosis |
🔵 Congestive (Portal Hypertension)
- Cirrhosis of liver ← commonest cause of massive congestive splenomegaly (Banti's syndrome)
- Portal vein thrombosis / pylephlebitis
- Splenic vein thrombosis (carcinoma stomach/pancreas)
- Cardiac failure (tricuspid/pulmonary valve disease, cor pulmonale)
- Schistosomiasis ("pipestem" hepatic fibrosis)
🟡 Lympho-haematogenous Disorders
- Hodgkin lymphoma, Non-Hodgkin lymphomas
- CLL, CML, ALL, AML
- Hairy cell leukaemia
- Multiple myeloma
- Myeloproliferative neoplasms (polycythaemia vera, essential thrombocythaemia, myelofibrosis — classically massive)
- Haemolytic anaemias: hereditary spherocytosis, sickle cell disease (early), thalassaemia
🟢 Immune-mediated / Autoimmune
- Rheumatoid arthritis (Felty syndrome)
- SLE
- Autoimmune haemolytic anaemia
- Drug reaction (e.g. phenytoin)
🟣 Storage & Infiltrative Disorders
- Gaucher disease ← most common storage disorder causing splenomegaly
- Niemann-Pick disease
- Amyloidosis
- Sarcoidosis
- Thyrotoxicosis
⚫ Other / Structural
- Splenic cysts (primary/echinococcal)
- Haemangioma (most common primary splenic tumour)
Grades of Splenomegaly (Clinical / Harsh Mohan)
| Grade | Palpability | Common Causes |
|---|---|---|
| Mild | Just palpable to 4 cm below costal margin | Infections (EBV, typhoid), cardiac failure |
| Moderate | 4–8 cm below costal margin | Cirrhosis, haematological disorders |
| Massive (Giant) | Crossing midline / into pelvis | Kala-azar, CML, Myelofibrosis, Malaria (hyperreactive), Gaucher disease, Schistosomiasis |
Massive splenomegaly mnemonic — "KMMGS": Kala-azar, Malaria (tropical/hyperreactive), Myelofibrosis, Gaucher disease, Schistosomiasis (+ CML, thalassaemia major)
Pathology / Morphology
1. Nonspecific Acute Splenitis (Infections)
- Gross: Enlarged (200–400 g), soft, congested (tense capsule)
- Micro: Acute congestion of red pulp; encroachment on white pulp follicles; neutrophils, plasma cells, eosinophils; rarely abscess formation
- Can occur with any blood-borne infection
2. Congestive Splenomegaly (Banti's Syndrome)
- Gross: Markedly enlarged (1000–5000 g); firm; thickened fibrous capsule
- Micro (early): Red pulp congestion
- Micro (late): Progressive fibrosis; collagen deposited in sinusoidal walls; sinusoids appear dilated and rigid; Gamma-Gandy bodies (haemosiderin + calcium + fibrous tissue deposits = "siderotic nodules") — characteristic
- Prolonged exposure of blood cells to macrophages → hypersplenism
3. Splenic Infarcts
- Pale, wedge-shaped, subcapsular infarcts
- Overlying fibrinous capsular exudate
- Septic infarcts (suppurative necrosis) in infective endocarditis
Clinical Features
| Symptom/Sign | Mechanism |
|---|---|
| Dragging sensation / LUQ discomfort | Direct mass effect |
| Early satiety | Gastric compression |
| Left shoulder pain | Diaphragmatic irritation (splenic infarct / perisplenitis) |
| Anaemia, leucopenia, thrombocytopenia | Hypersplenism (sequestration + phagocytosis) |
| Spontaneous rupture | Massive enlargement (CML, EBV mononucleosis) |
| Palpable mass — LUQ | Enlarges downward and medially, notch palpable |
Distinguishing Splenic Mass from Other Masses
- Enlarges downward and to the right (toward right iliac fossa)
- Has a notch on medial/inferior border
- Cannot get above the mass (not bimanually palpable like kidney)
- Moves with respiration
- Dull to percussion (unlike retroperitoneal masses)
Hypersplenism
A clinical syndrome that may complicate any cause of splenomegaly:
| Criteria (all 4 required) |
|---|
| 1. Splenomegaly |
| 2. Cytopenia (anaemia ± thrombocytopenia ± leucopenia) |
| 3. Compensatory bone marrow hyperplasia |
| 4. Correction after splenectomy |
Mechanism: Sequestration + prolonged red pulp transit → phagocytosis of formed elements by macrophages.
Investigations
| Investigation | Purpose |
|---|---|
| USG abdomen | First-line; measures size; ≥13 cm = enlarged |
| CT abdomen | Detailed anatomy; detects diffuse vs nodular enlargement; portal vein assessment |
| CBC + peripheral smear | Cytopenias (hypersplenism); abnormal lymphocytes (lymphoma/leukaemia); malarial parasites; Howell-Jolly bodies (splenic dysfunction) |
| LFTs + coagulation profile | Liver disease / portal hypertension |
| Bone marrow biopsy | Haematological malignancies, myelofibrosis, storage diseases |
| Flow cytometry | Lymphoma/leukaemia immunophenotyping |
| Serology / cultures | Infectious causes (EBV, Leishmania, malaria thick smear) |
| LDH, uric acid | Lymphoma (Burkitt's, DLBCL) |
| FDG-PET | Limited role — does NOT distinguish causes |
| Splenic biopsy / splenectomy | Last resort (high bleeding risk) |
Summary Box (Exam-Ready)
| Feature | Detail |
|---|---|
| Normal weight | 150 g |
| Enlarged | >250 g (USG: >13 cm) |
| Commonest worldwide | Malaria |
| Commonest in India | Malaria / Kala-azar |
| Massive splenomegaly | Kala-azar, CML, Myelofibrosis, Gaucher, Schistosomiasis, Malaria |
| Congestive — #1 cause | Cirrhosis (Banti's syndrome) |
| Characteristic micro finding in congestion | Gamma-Gandy bodies (siderotic nodules) |
| Complication of any splenomegaly | Hypersplenism → pancytopenia |
| Acute splenitis weight | 200–400 g, soft |
| Massive congestive splenomegaly weight | 1000–5000 g, firm |
Sources: Robbins & Cotran Pathologic Basis of Disease, Table 13.12, pp. 573–574; Goldman-Cecil Medicine, Table 154-5; Harrison's Principles of Internal Medicine, 22e; Harsh Mohan — Textbook of Pathology, Chapter on Lymph Nodes and Spleen.
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