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115 Cards in this Set

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responsible for 1/6 of all deaths in the US
What are the host defense mechanisms that filter out inhaled particulates and contaminated air?
1. mucociliary clearance
2. macro. engulfment with help of complement
3. humoral IgA neutralization of bacteria and viruses
What happens if you have a deficient humoral immune system in the pulm. system?
leads to increased incidence of extracellular bacterial infection
What happens if you ahve a deficient cellular immune system in the pulm. system?
leads to increased incidence of intracellular viral and mycobacterial infection
Community Acquired Pneumonia
usually bacterial
-strep. pneumoniae
-haemophilus influenzae
-moraxella catarrhalis
What groups and at increased risk for developing pneumonia?
1. elderly
2. sickle cell anemia
3. COPD patients
4. diabetic patients
5. AIDs patients
usually aspiration of pharyngeal flora causes bronchopeumonia or lobar pneumonia
*RML and lower obes affected most
What are the three types of pneumonia?
1. lobar pneumonia
2. bronchopneumonia
3. hematogenous disemination of infection (infection some place else in body)
What are the 4 phases in lobar pneumonia?
1. congestion- boggy red lung w/ vascular congestion and prteinaceous fluid in the alveoli
2. red hepatizaiton- liver like consistency w/ the alveoli packed w/ neutrophils, red cells and fibrin
3. gray hepatization- dry, gray, and firm with fibrinous exudate persisting and lysis of red cells
4. resolution- exudates ingested by macro., resorbed and or expectorated
-inflamm. patches seen throughout one or several lobes
-well developed lesions appear as 3-4cm, yellow-whate and discrete
What is the treatment for pneumococcal pneumonia?
1. penicillin- except when resistant
2. clarithromycin- macrolide capable of concentrating the lung
3. cephalosporins- for resistant infections
What is the prevention for pneumococcal pneumonia?
vaccination for elderly and immune suppressed containing 23 common serotypes
What are 4 complications from pulmonary infections?
1. abscess formation with extension to the pleura
2. empyema- pleural space extension of abscess
3. organgization may convert the lung into solid fibrous tissue
4. bacterial dissemination leading to meningitis, arthritis, infective endo., bacteremia and resultant sepsis
Haemophilus influenzae
-both encapsulated and unencapsulated form cause CAP
-encapuslated type B H. influenzae have been eradicated with pediatric vaccination- caused epiglottitis
Moraxella catarrhalis
-cause pneumonia in elderly
-*2nd most common cause of pneumonia in adults with COPD
-cuase of otitis media infection w/ the other 3 CAP assoc.. bacteria
Staph. aureus
-important cause of secondary bacterial pneumonia in children follwoing viral pneumonia
-assoc. w/ abscess form and empyema
-more of a nosocomial pathogen
Klebsiella pneumoniae
-*most frequent g- bacterial pneumonia affecting malnourished, debilitated patients and alcoholics
-characterized by thick gelatinous (currant jelly) sputum from the exopolysaccharide capsule of the bacteria
Pseudomonas aeruginose
-assoc. w/ pneumonia of cystic fibrosis patients (more noscomial)
-common in patients who are neutropenic or burn patients
-more likely to go in bld stream w/ invasion of BV causing necrosis of lung parenchyma
Legionella pneumophilia
-Legionaire's disease causing fulminant pneumonia w/ a fatality rate of 30-50%
-affects elderly w/ chronic conditions and transplant patients
-natural in stagnant water where it attacks amoeba, but can be found in air ducts
Pontiac Fever
Legionella pneumophila infection in immunocompetent host
What are the 4 community acquired atypical pneumonias?
1. Mycoplasma pneumoniae
2. Chlamydiae pneumoniae
3. Coxiella burnetti (Q fever)
4. Viruses: RSV, parainfluenza virus, adenovirus, etc.
Atypical CAP
-most agents cause mild upper respiratory symptoms in children, adolescents, and young adults
-spread by airborn route in closed quarters
-usually self limited w/ life long immunity for that particular serotype (not commong in elderly
What is the treatment for atypical CAP?
-most mycoplasma treated w/ azithromycin
-sypmtomatic treatment
-isolation form work, school, etc.
-communicable, airborne disease causing caseating granulomas of the lung by mycobacterium tuberculosis
*leading cause of death worldwide
What are the tuberculosis risk factors? (9)
1. low socioeconomic status
2. diabetes mellitus
3. Hodgkin's Disease
4. HIV
5. chronic lung disease
6. chronic renal failure
7. malnutrition
8. alcoholism
9. immunosuppression
What kind of immunitiy is vital to suppressing TB infection?
T cell mediated immunity
What is the pathogenesis of TB?
1. inoculation from the environment
2. walling off of infection within the lung
3. dormancy of the mycobacteria
PPD Test
-TB leads to delayed hypersensitivity of the tuberculin antigen with peak induration, erythema, and itching in 48-72hrs
-immunosuppression may lead to a false negative test
What is the etiology of TB?
-acid fast slender rods w/ complex lipid shell w/ humans serving as the only natural resorvoir
-contraction is by direct airborne inoculum w/ active TB aerosol
What is the pathogenisis of TB in an immunocompetent patient?
-infection fo the lung parenchyma by the tubercle bacillus w/ form. or a single caseating granulom and adjacent calcified lymph node
-host repsone is to wall of teh infectiong and hypersinsitivity to the tuberculing Ag signfies acquisition of immunuity
-TB dorman for the remainder of life in host
What is the Ghon Complex?
calcified lymph nodes that occur with TB in immunocompetent host
natural resistance assoc. macro. protein 1 gene polymorphisms especially amog black may have decreased microbicidal activity
Primary TB
TB in an unsensitized individual- elderly and immune-suppressed can lose their sensitized responses and develop primary TB more than once
Ghon Focus
lung parenchyma with caseous necrotic center
Ghon Complex
fibrotic lung parenchymal lesion with affected hilar lymph nodes
Ranke Complex
calcified lung parenchymal lesion w/ affected lymph nodes
Secondary TB
reactivation of TB arising in a sensitized host usually in the apical lobes b/c of high oxygen tension
Progressive pulmonary TB
erosion of lung parenchyma, vessels, and airways
Miliary TB
organisms drain into lymphatic channels w/ dissemination into thoracic duct and bld. stream producing diffuse abscesses in distant organs
What is the clinical course of TB?
asymptomatic to cachexia, dyspnea, malaise ad low grade fever and hemoptysis w/ erosion into BV and plerotic painw/ extension into pleura
Plott's disease
miliary TB of he spinal vertebral bodies with paraplegia if untreated
How do you diagnose TB?
-PCR amp. of TB DNA w/ as few as 10 organisms
-AFB pos. sputum
-cuture: 4-6 wks slow growth on 7H11 agar
What is the treatment for TB?
-regimen of 3 drugs for nonresistant types insoniazid, pyrazinamide, rifampin
-4 drugs for resistant isoiazid, pyrazinamide, rifampin, and ethambutol with other meds
Atypical Mycobacteria
1. mycobacterium avium-intracellular
2. mycobacterium kansasii
3. mycobacterium chelonae-abscessus
-affect immunocompromised and treated w/ larger drug regimens
Fungal Infections
-classified as yeasts (budding) and molds (hyphal)
-all fungi can infect the lungs depending on host immune status
What categories are fungal infections divided into? (4)
1. superficial
2. subcutaneous
3. deep seated
4. opportunistic infections
*most frequent disease causing fungus, normally in GI tract and vagina
-has yeast and pseudohyphae in tissue
-may be diplayed in tissue with silver stains
What is the most frequent disease causing fungus?
-superficial infection of the oral cavity in people taking inhaled steroids, HIV and antibiotics
candida especially in diabetics
candida; hemtolymphoid malignancies and HIV patients
Cutaneous Candida Infections
nail (onychomycosis), nail folds (paronychia), hair follicles (folliculitis), fingers and toe webs spaes (intertrigo), ad penile skin (balanitis)
Chronic Mucocutaneous Candidiasis
refractory disease affecting mucous membranes, hair, skin, and nails assoc. with autoimmune polyglandular syndrome (endocrinopathies) and iis rare
Invasive Candidiasis
bloodborne disease with dissemination to various organs with abscesses to multiple organs found in immunodeficient patients
-pulmonary disease in immunocopetent patients- usually self limited
-meningitis in HIV/AIDs patients
What is the morphology of cryptococcus?
-5-10microns yeast in tissue that has a thick gelatinous capsule and reproduces by buding with no pseudohyphal form seen
-diagnosed with India Ink and PAS stains in tissue and cryptococcal Ag test in fluids
What kind of reaction does cryptococcosis have in tisse?
-creates a granulomatous reaction in tissues
-in immunosuppressed forms "soap bubble" lesions seen in the spaces of the sulci in the brain and perivascular virchow-robin space
How is cryptococcosis transmitted?
-it is inhaled from bird droppings and evades host via capsular polysaccharide, resistance to macro. killing and production of phenol oxidase enzyme that consumes epinephrine to protect form protective oxidative reactions
-mainly in lung and can causec granulomatous chronic inflammatory reactions
-gets into CNS and grows meninges
-opportunistic mold in diabetic patients and other immunocompromised
Pulmonary Mucormycosis
localizeddisease may present radiologically as miliary pattern
Rhinocerebral Mucormycosis
colonize nasal tact and invade into the brain parenchyma (surgical emergency)
-opportunistic mold in immunosuppressed producing a necrotizing pneumonia with systemic dissemination
Allergic bronchopulmonary aspergilosis
patients who develop asthma may develop type I hypersensitivity to noninvasive aspergillosis growing in the bronchi and haveperipheral eosinophilia
occurs with colonization of preexisting pulmonar cavities (bronchiectasis or post-tuberculous cavities) that grow as balls and obstruct the bronchus with no tissue invasion
Dimorphic Fungal Infections (3)
seen in immunocompetent individuals found in endemic areas
1. histoplasma capsulatum
2. coccidioides immitis
3. blastomyces dermatitidis
Histoplasma capsulatum
intracellular 2-5 microns yeast form in vivo
Coccidioides immitis
thick walled nonbudding spherules 20-60 microns filled with small endospores in vivo
Blasomyces dermatitidis
oval 5-15 micron extracellular broad based budding yeast in vivo
Where is H. capsulatum found?
in the warm soil admixed with bird droppings in the Ohio and Mississippi rive valleys along the Appalachian mountains and southeast
Where is C. immitis found?
in the southwest paritcularly the San Joaquin valley in the soil
Where is B. dermatitidis found?
overlaps the Ohio and Mississippi river valleys where histoplasmosis is found
Acute Pulmonary Infection
resembles in most cases a flu like syndrome, self limited
Chronic cavitary pulmonary disease
cavitary lung disease with upper lobe involvement with cough, hemoptysis and chest pain
Disseminated miliary disease
infants, HIV patients takes the form of multiorgan disease witha minority of cases causing mouth and tongue lesions, cutaneous form iwht Bastomycosis mistaken for squamous cell carcinoma
How do we diagnose dimorphic funal infections?
1. skin test analogous to tuberculin hypersensitivity test
2. Histoplasmin, Coccidioidin PPD; o skin test exists for Blastomycosis
3. capsular Ag test for histoplasmin form the urin available
Pneumocystis pneumonia (PCP)
-opportunistic funal infection
-Pneumocystis jiroveci is causative org.
-serologic evidence of panexposure, however infection remains latent
-reactivation in the immunocompromised
-infection confined to lung producing hypoxia and interstitial pneumonitis with bibasilar infiltrates seen on CXR
What is the histology of pneumocystis pneumonia?
-intraalveolar foamy pink staining exudate with HandE stain
-GMS stain shows sup shaped org. (5-8microns) in alveoli
How do we diagnose pneumocystis pneumonia?
-mainly histology
-PCR based tests
member of herpesviridae
How is CMV transmitted? (5)
1. transplacental
2. perinatal infection through breast milk
3. preschool years asymptomatic to CMV mononucleosis
4. after 15yo verneral route
5. blood transfusions
What is CMV produced from in the immunocopromised?
-latent reactivated CMV due to depressed immune system
-CMV seroconversion from positive donor
What does CMV produce?
-pnumonitis developing into ARDS
-CMV retinitis
What is the histology of CMV?
parenchymal epithelial cells infected- produces "owls eye" nuclear changes
How is CMV diagnosed?
-Rising Ab titer- serology
-PCR based tests for CMV from DNA
What is the number one cause of cancer related death in the US in both men and women?
-carcinoma of the lung, rising in women
Carcinoma of the lung
-peak incidence 55-65
-at time of diagnosis 50% have metastasis w/ small cell at diagnoses 100% metastasis
-for all stages, 5yr survival = 14%
Bronchogenic Carcinoma
-non-small cell and small cell carcinoma
Non-small cell carcinoma
-amenable to surger, chemo and radiation
-squamous cell carcinoma
-large cell adenocarcinoma
What is the most common primary tumor in women smakers and in patients <45yo?
Small cell carcinoma
-not amenable to surgery, treated with chemo and radiation therapy
-may be combination of histological types
Bronchogenic Carcinoma Mutations
-early events: inactivation of tumor suppressor genes on 3p- found in normal epi cells exposed to carcinogens
-late events: TP53 mutations and K-RAS oncogene stimulation
What percent of lung cancers is smoking assoc. with?
What carcinomas show the stongest association with tobacco exposure? (2)
1. squamous cell carcinoma
2. small cell carcinoma
What is the pathology of carcinomas?
-pseudostratified columnar epi
-squamous metaplasia
-may have central cavitation and necrosis of tumor
-form large bulky mass pushing into adjacent lungparenchyma, blood vessels and bronchi
Squamous Cell Carcinoma
-more common in men and tend to rise centrally from bronchus
-disseminate later than other histo. types
-transform from squamous metaplasia to dysplasia/carcinoma in situ to frank invasive carcinoma
Keratinizing type of squamous cell carcinoma
show keratin pearls and intercellular bridges (well differentiated) to poorly differentiated neoplasms with no squamous features
Non-keratinizing type of squamous cell carcinoma
-similar cells, no extracellular keratin
-intercelluar bridges
-more common in women and tend to arise peripherally from lung scars
-metastasize widely at presentation
Which lung tumor has the weakest association with smoking?
What is the histopathology of adenocarcinoma?
shows intracellular mucin with vacuoloation indicating glandular differentiation to solid growth patterns
Atypical Adenomatous Hyperplasia
precursor lesion of the adenocarcinoma with cuboidal cells resembling Clara cells or type II pneumocytes and may be multifocal
Bronchioalveolar Carcinoma
subtype of adenocarcinoma with usually wideshpread involvement of the lung with growth along alveolar ducts that preserves alveolar architecture (can be multifocal)
Large Cell Adenocarcinoma
group of neoplasms which lackcytologic differentiation and represent squamous and adenocarcinomas
What is the histopathology of large cell adenocarcinoma?
may have osteoclast type giant cells (multinucleated) or sarcomatous type cells (spindle cells)
Small Cell Carcinoma
-appear as pale gray centrally located mass with extension into lung parenchyma and spreads beneath bronchi
-early involvement of the hilar and mediastinal nodes
-100% metastasis at presentation
What is the histopathology of small cell carcinoma?
-2-3X larger than lymphocytes
-monotonous appearance with high nuclear to cytoplasmic ratios and are derived from Kulchitsky cells (neuroendocrine cells)
-necrosis and mitotic figures
-nuclear molding
What is nuclear molding?
close apposition of tumor cells that makes nuclei appear to push each other (seen in small cell carcinoma)
Malignant Mesothelioma
-arise from parietal or visceral pleura with most cases occupational exposue to asbestos (25-40yrs after exposure)
-lifetime risk does not decrease with removal from asbestos exposure
Combination of smoking and asbestos exposure increases the risk of ___________ but not ______________
bronchogenic carcinoma
malignant mesothelioma
What are the genetic mutations in malignant mesothelioma? (3)
1. somatic mutations to p16/CDKN2A on chromosome 9p
2. neurofibromatosis gene 2 (NF2) on chromosome 22q
3. recently Simian virus 40 has been isolated in 60-80% malignant mesotheliomas
Is surgery an option for malignant mesothelioma?
-no because tumor is almost always unresectable
-chemo and radiation tried with little success
What is the five year survival rate for malignant mesothelioma?
What is the progression of malignant mesothelioma?
1. exposure to asbestos manifests as pleural fibrosis and plaque formation
2. lung ensheathed in a yelow-white firm tumor that obliterates the pleural space
3. invades the chest wall and subpleural lung tissue
What is the histopathology of malignant mesothelioma?
-normal mesothelial cells are biphasic giving rise to pleural lining cells and underlying fibrous tissue
What are the three patterns that malignant cells confom to?
1. epitheloid-line tubular and microcystic spaces with budding
2. sarcomatoid- spindle and fibroblastic appearing cells grow in nondistinctive sheets
3. biphasic- having both patterns