Fa: Respiratory - Pathology - 1

Front 1

What is the term for the obstruction of sinus drainage into the nasal cavity, leading to inflammation and pain over the affected area? What is the most likely affected area?

Back 1

Rhinosinusitis
- Often in maxillary sinuses in adults (yellow arrows)

Front 2

What happens in Rhinosinusitis? What is the most common cause?

Back 2

- Obstruction of sinus drainage into the nasal cavity, leading to inflammation and pain over the affected area (usually maxillary sinuses in adults)
- Most common acute cause is VIRAL URI, may cause superimposed bacterial infection (S. pneumoniae, H. influenzae, M. catarrhalis)

Front 3

What is the most common acute cause of rhinosinusitis?

Back 3

Viral URI

Front 4

What are the most common causes of superimposed bacterial infection on rhinosinusitis?

Back 4

- S. pneumoniae
- H. influenzae
- M. catarrhalis

Front 5

What predisposes to a deep venous thrombosis?

Back 5

Virchow's Triad:
- Stasis
- Hypercoagulability
- Endothelial damage

Front 6

What can cause hypercoagulability? What is this a component of?

Back 6

- Eg, defect in coagulation cascade proteins, most commonly Factor V Leiden
- Component of Virchow's triad

Front 7

What are the characteristics of endothelial damage that is a component of Virchow's triad?

Back 7

Exposed collagen triggers clotting cascade

Front 8

What is the most likely location for pulmonary emboli to arise from?

Back 8

Deep leg veins

Front 9

What is the Homan sign?

Back 9

Dorsiflexion of the foot → calf pain

Front 10

What drug can be used to prevent deep vein thrombosis?

Back 10

Heparin

Front 11

What drug can be used for acute management of deep vein thrombosis?

Back 11

Heparin

Front 12

What drug can be used for long-term prevention of deep vein thrombosis recurrence?

Back 12

Warfarin

Front 13

What are the signs / symptoms of Pulmonary Embolism?

Back 13

- V/Q mismatch → hypoxemia → respiratory alkalosis
- Sudden-onset dyspnea
- Chest pain
- Tachypnea
- May present as sudden death

Front 14

What are the types of Pulmonary Emboli?

Back 14

"An embolus moves like a FAT BAT"
- Fat
- Air
- Thrombus
- Bacteria
- Amniotic fluid
- Tumor

Front 15

What are fat pulmonary emboli associated with?

Back 15

Associated with long bone fractures and liposuction

Front 16

What is the classic triad of fat emboli?

Back 16

- Hypoxemia
- Neurologic abnormalities
- Petechial rash

Front 17

What can an amniotic fluid emboli lead to?

Back 17

Can lead to DIC, especially post-partum

Front 18

Who is likely to get gas emboli? How do you treat them?

Back 18

Nitrogen bubbles can precipitate in ascending divers; treat with hyperbaric oxygen

Front 19

What is the best way to image a patient you think has a pulmonary embolism? What do you look for?

Back 19

CT pulmonary angiography (look for filling defects)

Front 20

What is this gross image of?

Back 20

Pulmonary Embolism
- Note large embolus (arrows) in the pulmonary artery

Front 21

What does this image show?

Back 21

Pulmonary Thromboembolus
- Lines of Zahn are interdigitating areas of pink (platelets, fibrin) and red (RBCs) found only in thrombi formed BEFORE death
- Helps distinguish pre- and post-mortem thrombi

Front 22

What can you look for to determine whether a thrombus formed pre-mortem or post-mortem?

Back 22

Lines of Zahn are interdigitating areas of pink (platelets, fibrin) and red (RBCs) found only in thrombi formed BEFORE death

Front 23

What are the consequences of obstructive lung diseases?

Back 23

- Leads to air trapping in the lungs
- Airways close prematurely at high lung volumes → ↑ RV and ↓ FVC
- PFTs: ↓↓ FEV1, ↓ FVC → ↓ FEV1/FVC ratio
- V/Q mismatch

Front 24

What can chronic, hypoxic pulmonary vasoconstriction lead to?

Back 24

Cor Pulmonale

Front 25

What are the types of obstructive lung diseases?

Back 25

- Chronic Bronchitis ("blue bloater")
- Emphysema ("pink puffer", barrel-shaped chest)
- Asthma
- Bronchiectasis

Front 26

What happens to the pulmonary function tests in patients with obstructive lung disease?

Back 26

- ↓↓ FEV1
- ↓ FVC
- ↓ FEV1/FVC ratio

Front 27

What are the types of COPD?

Back 27

- Chronic Bronchitis
- Emphysema

Front 28

What happens pathologically in patients with Chronic Bronchitis?

Back 28

Hyperplasia of mucus-secreting glands in the bronchi → Reid index >50%

Front 29

What is the Reid Index? Utility?

Back 29

Ratio of thickness of gland layer / total thickness of bronchial wall

>50% is supportive of Chronic Bronchitis

Front 30

What are the diagnostic criteria for Chronic Bronchitis?

Back 30

Productive cough for >3 months / year (not necessarily consecutive) for >2 years

Front 31

Chronic bronchitis is a disease of what airways?

Back 31

Small airways

Front 32

What signs and symptoms does a patient with Chronic Bronchitis have?

Back 32

- Wheezing
- Crackles
- Cyanosis (early onset hypoxemia due to shunting)
- Late onset dyspnea
- CO2 retention

Front 33

What happens pathologically in patients with Emphysema?

Back 33

- Enlargement of air spaces
- ↓ Elastic recoil
- ↑ Compliance
- ↓ DLCO resulting from destruction of alveolar walls

Front 34

What are the types of emphysema? What is each associated with?

Back 34

- Centriacinar: associated with smoking
- Panacinar: associated with α1-antitrypsin deficiency

Front 35

What causes increased lung compliance in patients with emphysema?

Back 35

↑ Elastase activity → loss of elastic fibers → ↑ lung compliance

Front 36

How do patients with emphysema breathe?

Back 36

Exhale through pursed lips to increase airway pressure and prevent airway collapse during respiration

Front 37

What is the pathology responsible for asthma?

Back 37

Bronchial hyperresponsiveness causes reversible bronchoconstriction

Front 38

What are the histologic findings of asthma?

Back 38

- Smooth muscle hypertrophy
- Curschmann spirals (shed epithelium forms mucus plugs)
- Charcot-Leyden crystals (formed from breakdown of eosinophils in sputum)

Front 39

What is the term for shed epithelium that forms mucus plugs? What pathology is it a sign of?

Back 39

Curschman Spirals - sign of asthma

Front 40

What is the term for the crystals formed by the breakdown of eosinophils in the sputum? What pathology is it a sign of?

Back 40

Charcot-Leyden crystals - sign of asthma

Front 41

What can trigger asthma?

Back 41

- Viral URIs
- Allergens
- Stress

Front 42

What test can you use to diagnose asthma?

Back 42

Methacholine challenge

Front 43

What are the findings of asthma?

Back 43

- Cough
- Wheezing
- Tachypnea
- Dyspnea
- Hypoxemia
- ↓ I/E ratio
- Pulsus paradoxus
- Mucus plugging

Front 44

What pathology is seen in Bronchiectasis?

Back 44

Chronic necrotizing infection of bronchi → permanently dilated airways, purulent sputum, recurrent infections, and hemoptysis

Front 45

What part of the respiratory tract is affected by bronchiectasis? How is it affected?

Back 45

Bronchi: chronic necrotizing infection
- Permanently dilates the airways
- Forms purulent sputum
- Recurrent infections
- Hemoptysis

Front 46

What is bronchiectasis associated with?

Back 46

- Bronchial obstruction
- Poor ciliary motility (smoking)
- Kartagener syndrome (primary ciliary dyskinesia)
- Cystic fibrosis
- Allergic bronchopulmonary aspergillosis

Front 47

What are the characteristics of all restrictive lung diseases?

Back 47

Restricted lung expansion causes:
- ↓ Lung volumes (↓ FVC and TLC)
- PFTs: FEV1/FVC ratio ≥ 80%

Front 48

What are the types of restrictive lung disease?

Back 48

- Restrictive lung disease due to poor breathing mechanics

- Restrictive lung disease due to interstitial lung disease

Front 49

What are the characteristics of restrictive lung diseases due to poor breathing mechanics? Causes?

Back 49

- Extrapulmonary, peripheral hypoventilation, normal A-a gradient

Causes:
- Poor muscular effort: polio and myasthenia gravis
- Poor structural apparatus: scoliosis and morbid obesity

Front 50

What are the characteristics of interstitial lung diseases?

Back 50

- Pulmonary ↓ diffusing capacity
- ↑ A-a gradient

Front 51

What are the types of interstitial lung diseases?

Back 51

- Acute Respiratory Distress Syndrome (ARDS)
- Neonatal Respiratory Distress Syndrome
- Pneumoconioses
- Sarcoidosis
- Idiopathic pulmonary fibrosis
- Goodpasture syndrome
- Granulomatosis with Polyangiitis (Wegener)
- Langerhans cell Histiocytosis
- Hypersensitivity Pneumonitis
- Drug toxicity

Front 52

What histologic finding is characteristic of neonatal respiratory distress syndrome?

Back 52

Hyaline membrane (disease)

Front 53

What are the findings in Sarcoidosis that affects the lungs?

Back 53

Restrictive lung disease
- Bilateral hilar lymphadenopathy
- Non-caseating granuloma
- ↑ ACE and Ca2+

Front 54

What are the characteristics of idiopathic pulmonary fibrosis?

Back 54

Restrictive lung disease
- Repeated cycles of lung injury and wound healing with increased collagen deposition

Front 55

What kind of granulomas occur in Langerhans Cell Histiocytosis?

Back 55

Eosinophilic Granulomas

Front 56

What drugs can cause restrictive lung disease?

Back 56

- Bleomycin
- Busulfan
- Amiodarone
- Methotrexate

Front 57

What type of reaction causes hypersensitivity pneumonitis?

Back 57

Mixed type III/IV hypersensitivity reaction to environmental antigens

Front 58

Which symptoms occur in hypersensitivity pneumonitis?

Back 58

- Dyspnea
- Cough
- Chest tightness
- Headache

Front 59

Who is most likely to get hypersensitivity pneumonitis?

Back 59

- Farmers
- Those exposed to birds

Front 60

What are the types of pneumoconioses?

Back 60

- Asbestosis
- Coal Workers' Pneumoconiosis
- Silicosis

Front 61

What do Coal Workers' Pneumoconiosis, Silicosis, and Asbestosis increase the risk for?

Back 61

- Cor pulmonale
- Caplan syndrome (rheumatoid arthritis and pneumoconioses with intrapulmonary nodules)

Front 62

What is Caplan Syndrome?

Back 62

Rheumatoid Arthritis and Pneumonconioses with Intrapulmonary Nodules

Front 63

What lung pathology is associated with shipbuilding, roofing, and plumbing?

Back 63

Asbestosis

Front 64

What are the characteristic findings on imaging of asbestosis?

Back 64

"Ivory white" calcified pleural plaques are pathognomonic of asbestos exposure, but they are not precancerous

Front 65

What are these findings associated with?

Back 65

Asbestosis:
- Associated with increased risk of bronchogenic carcinoma and mesothelioma

Front 66

What part of the lungs are affected by asbestosis?

Back 66

Affects lower lungs:
"Asbestos is from the roof (common in insulation), but affects the base (lower lobes)"

Front 67

What is the appearance of asbestos histologically?

Back 67

Asbestos (ferruginous) bodies are golden-brown fusiform rods resembling dumbbells

Front 68

What part of the lungs are affected by silicosis?

Back 68

Affects upper lobes:
"Silica is from the base (earth), but affect the roof (upper lobes)"

Front 69

What part of the lungs are affected by coal?

Back 69

Affects upper lobes:
"Coal is from the base (earth), but affect the roof (upper lobes)"

Front 70

What is the other name for "black lung disease"?

Back 70

Coal Workers' Pneumoconiosis

Front 71

What happens if someone has prolonged exposure to coal dust?

Back 71

Macrophages become laden with carbon → inflammation and fibrosis → Coal Workers' Pneumoconiosis

Front 72

What condition is found in many urban dwellers exposed to sooty air? Symptoms?

Back 72

Anthracosis - asymptomatic

Front 73

What is associated with foundries, sandblasting, and mines?

Back 73

Silicosis

Front 74

What happens if someone has exposure to silica?

Back 74

- Macrophages respond to silica and release fibrogenic factors → fibrosis → Silicosis
- Silica may disrupt phagolysosomes and impair macrophages, increasing susceptibility to TB

Front 75

What is there increased risk of in patients with Silicosis?

Back 75

- Increased susceptibility to TB
- Bronchogenic carcinoma

Front 76

What is the characteristic appearance of silicosis?

Back 76

"Eggshell" calcification of hilar lymph nodes