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More people would learn from their mistakes if they weren't so busy denying them. -Harold J. Smith
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
CPC4.3.2 – Molly. ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
CPC4.3.2 – Molly. ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
CPC4.3.2 – Molly. ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Diagnostic points (for DM type) ? ,[object Object],[object Object],[object Object],[object Object],[object Object]
?Pathogenesis: “ recurrent multisite infections” ,[object Object],[object Object],[object Object],[object Object],[object Object]
Miss ML: Most likely diagnosis: ,[object Object],[object Object],[object Object],[object Object],[object Object]
?Pathogenesis:  Whitish vaginal discharge.  ,[object Object],[object Object],[object Object],[object Object],[object Object]
Most likely .. What type of DM ?  ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
In this world,  Be like the tongue in the midst of the teeth, carefully, confidently & courageously going about its task, without getting bitten..!  - Baba  Divine Discourse on the Bhagavad Gita, 1984
“ Nothing great in the world has ever been accomplished without  passion” - - CHRISTIAN FRIEDRICH HEBBEL
Pathology of  Diabetes Dr. Venkatesh M. Shashidhar Assoc. Prof. & Head of Pathology
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Introduction ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
World Statistics:
Diabetes Mellitus - Definition ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Criteria for the Diagnosis of Diabetes ,[object Object],[object Object],[object Object],[object Object]
Pancreas Normal Anatomy:
Normal Pancreas:
Normal Pancreas: Islet of Langerhans (Endocrine Pancreas) Pancreatic acini (Exocrine Pancreas) Duct
Normal Pancreatic Islet: (ipx stain) α   cells  20%   (Glucagon)   ß cells  70%   (Insulin) δ  cells  (Somatostatin)  pp Cells  (pan prot) ß α
Blood Glucose & Hormones ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Maintained within  3.5-6.5  mmol/l .
Normal Insulin secretion:
Insulin -  Anabolic  Steroid ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Insulin Functions:
Cellular Glucose Uptake ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Diabetes Classification :  (not a single disease) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Metabolic Syndrome (X) -  IDF criteria ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
LADA: Late onset Autoimmune DM ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Your life should rest on morality and truth. Base your life on truth & love for all.  - Sai - Summer Showers, 1973 Money and goes but morality comes and grows.
Pathogenesis of Type I DM Genetic  HLA-DR3/4 Environment Viral infe..? Insulin deficiency Autoimmune Insulitis Ab to ß cells/insulin  ß cell  Destruction ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Secondary DM Inflammation,  Tumor,  Infection Trauma Pancreatitis Antibodies: Islet cell Ab -  ICA Insulin Auto Ab -  IAA Glut. Acid Decarb -  GAD65
Insulitis – Type I Lymphocytes.
DM1 Course:
Progression of Type II Years ..
Pathogenesis of Type II DM Relative  Insulin Def. ß cell  Exhaustion (IDDM)
DM2 Islets:   Normal early    amyloid late:    Normal. Loss of ß cells ( only in late stage ) replaced by Amyloid protein deposit (hyalinization).
Type-I  Type-II ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Type-I  Type-II Insulitis: Lymphocytic infiltrate within islets. Islet Hyalinization: Central hyaline deposits replacing dead beta cells
Diagnosis: (WHO)
New in DM: Incretins. ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Being true human is maintaining complete harmony between thought, word and deed. Divergence between thought, word and deed is the  cause of all our problems…! - BABA.
DM Complications:  ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Diabetes Complications: ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Pathogenesis of complications: ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
 
DM: Complications:
The best gift of Nature  to man is the briefness of his life…!   Latin quote
Microangiopathy Pathogenesis: ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Diabetic Microangiopathy Normal Diabetic ,[object Object],[object Object],[object Object],[object Object]
Neuropathy ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
DM-Neuropathy – Myelin stain Myelin loss in nerve Normal
Neuropathic ulcer ,[object Object],[object Object],[object Object],[object Object]
Neuropathic ulcers FEATURES: Painless, surrounded by callus  At pressure points.  associated with good foot pulses May not be associated with gangrene
Neuropathic Arthropathy:  Charcot’s foot. ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Normal Charcot
DM Amyotrophy  - Painful muscle wasting ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Chronic Polyneuropathy ,[object Object],[object Object],[object Object],[object Object],[object Object],Claw foot – Dermopathy & Neuropathy
Diabetic Amyotrophy ,[object Object],[object Object],[object Object],[object Object]
Nephropathy ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Diabetic Nephropathy ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Nodular Glomerulosclerosis – KW lesion.
Diabetic Glomerulosclerosis B A
Diabetic Glomerulosclerosis B A
 
Diabetic Glomerulosclerosis Hyaline nodule
Nephropathy – Progression:
Nephropathy Classes: I - IV
DM with Infarction: Papillary necrosis
Retinopathy: ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Non Proliferative Retinopathy ,[object Object],[object Object],[object Object],[object Object]
Proliferative Retinopathy ,[object Object],[object Object],[object Object],[object Object]
Normal Retina
Diabetic Retinopathy
Diabetic Retinopathy Fluorescein angiogram of the eye of a diabetic patient.  Note the numerous, small, dot-like capillary microaneurysms.
Diabetic Retinopathy Pre retinal Hemorrhage - detachment
Label the diagram. ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Retina  ? diagnosis
You must learn to distinguish between good and bad, truth and untruth. You must use your education for the purpose of serving community.  - Sai - Summer Showers, 1973.
Macroangiopathy Atherosclerosis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Atherosclerosis:
Fungal infections: Candidiasis
Macrosomia With Polycythemia
Blood vessel calcification: In digital arteries in DM Amputated Toe Calcified BV
Cataract –  Sorbitol.. Polyol..osmotic.. Lens epithelium (Insulin independent) is exposed to Hyperglycaemia, excessive flux of glucose to sorbitol by the polyol pathway. The accumulation of intracellular sorbitol exerts osmoprotection and prevents cell shrinkage. The excessive accumulation of sorbitol, causes an increased osmotic load within the lens causing swelling, fibre breakdown, and opacification (the osmotic hypothesis). Other mechanisms, including glycation and oxidative stress, may also be responsible for lens opacification.
Acanthosis Nigricans ,[object Object]
Pathogenesis of Infections in DM: ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Laboratory Diagnosis: ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
“ It's not that I'm so smart, it's just that I stay with problems longer”…! --Albert Einstein
CPC-3.2– END–DM2 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Case 1 ,[object Object],[object Object]
Pathologic mechanism? ,[object Object],[object Object],[object Object],[object Object],[object Object]
50y, male DM2, kidney biopsy. Likely nature of feature shown by arrow? ,[object Object],[object Object],[object Object],[object Object],[object Object]
47y F, DM2 - foot ulcer: ? Diagnosis ,[object Object],[object Object],[object Object],[object Object],[object Object]
Thickening of small BV in this patient is most likely related which pathologic mechansim? ,[object Object],[object Object],[object Object],[object Object],[object Object]
57y M, DM2: Gross Kidney- arrow ? feature ,[object Object],[object Object],[object Object],[object Object],[object Object]
DM– Pancreatic Islet- ? Feature shown by arrow? ,[object Object],[object Object],[object Object],[object Object],[object Object]
47y F, DM2 – Kidney- arrow ? feature ,[object Object],[object Object],[object Object],[object Object],[object Object]
DM– Pancreatic Islet- ? Feature shown by arrow? ,[object Object],[object Object],[object Object],[object Object],[object Object]
DM Kidney.Microscopy. ? Feature Arrow B ,[object Object],[object Object],[object Object],[object Object],[object Object],B A
DM Kidney.Microscopy. ? Feature Arrow A ,[object Object],[object Object],[object Object],[object Object],[object Object],B A
57y M, DM2 – Kidney- arrow ? feature ,[object Object],[object Object],[object Object],[object Object],[object Object]
57y M, DM2 – Eye ? Pathogenesis ,[object Object],[object Object],[object Object],[object Object],[object Object]
47y F, DM2 - foot ulcer: ? Diagnosis ,[object Object],[object Object],[object Object],[object Object],[object Object]
56y Fem, Anterior wall MI. 3+ proteinuria & FBG 19mmol/L. Image shows her pancreas.  What complication she may develop? ,[object Object],[object Object],[object Object],[object Object],[object Object]
Label the diagram. ,[object Object],[object Object],[object Object],[object Object],Capillary Nodule – AGE Bowman cap. Hyaline arteriolo sclerosis in arteriole.
It is a matter of great satisfaction if you are educated on the right lines, become an example to others and accept positions of responsibility. In all these things, always keep “ Truth & Love for all ” as your goal. Then only you will get the Grace of God….! - Sai - Summer Showers, 1973.
Case 2 – 58y Fem Asymptomatic. ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
CPC-3.2– KFP Questions: ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Summary ,[object Object],[object Object],[object Object],[object Object]
Points to remember/review: ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Questions.. ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
56y woman,  nocturia ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Site of action of Anti DM drugs:
Metabolic (short term) complications:
Diagnostic criteria for DM, IFG, and IGT
DECODE: increased 2-hour glucose is associated with increased mortality rate (adjusted for age, center, and gender).
Cumulative incidence of diabetes mellitus (based on American Diabetes Association criteria) according to study group in the DPP.   * The incidence of diabetes differed significantly among the 3 groups (p <0.001 for each comparison. Reprinted with permission from Knowler et al. 13
Endocrinology Other :  (Brief notes) ,[object Object],[object Object],[object Object],[object Object],[object Object]
GAME-PLAN for DM2:
Diabetic Retinopathy Neovascularization  Cotton wool spots
Diabetic Retinopathy Cotton wool Dot hem Blot hem Neovascul.  Cotton wool
Diabetic Retinopathy Advanced fibrous plaques
Diabetic Retinopathy - Proliferative
Diabetic Retinopathy - Proliferative
Normal Retina:
Progression of Type I
 
DM - Clinical Examination:
Daily changes in hormone…
Gestational DM:
MODY: Maturity Onset DM of Youth.

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