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43 Cards in this Set

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Conditions that cause hemoptysis
•TB
•Carcinoma
•Left heart failure
Causes for atelectasis in adults
•Obstruction (resorption): asthma, chronic bronchitis, aspiration
•Compression- pleural fluid, air
(pneumothorax)
•Contraction- fibrosis of lung
•Microatelectasis (small collapse)
Pneumonia Symptoms
•Fever
•Cough
•Dyspnea
•Chest pain
Difference between primary and secondary pneumonia
Primary is in healthy people and involves a virulent organism (S. pneumonia, L. pneumophilia). Secondary involves the immunocompromised.
Define Bronchiectasis in One Line!
Permanent dilation of bronchi by destroying elastic muscle due to chronic necrotizing infections
Features of atypical pneumonia?
•Moderate sputum
•No consolidation
•Lack of alveolar exudate

Organisms:
•Mycoplasma
•Chlamydia
•Viral (Influenza)
•Rickettsiae
•Herpes, CMV in the immunocompromised

Affects alveolar wall (interstitial). Note that it is virus OR something thats obligate intracellular!
Organisms in Acute pneumonia?
•S. pneumoniae
•H. influenzae
•Moraxella catarrhalis
•Legionella
Organisms in nosocomial pneumonia?
•Klebsiella
•E. coli
•Pseudomonas
•Staph
Stages in Pneumonia
Acute Congestion
• heavy red boggy lungs
• Vascular congestion
• bacteria multiply in alveoli, dilated alveolar capillaries, early fluid exudation
• early PMNs + early red cells

Red Hepatization
• consistency liver like
• lining alveolar cells lost
• Alveoli packed with PMNs, fibrin, red cells ± Pleuritis
• infection controlled

Grey Hepatization
• dry, gray, firm (red cells have been lysed)
• exudation and hyperemia stop
• Fibrino suppurative exudate persists in the alveoli

Resolution
• Removal of exudate by enzymatic
degradation- granular semifluid debris- reabsorbed, engulfed by macrophages or coughed out
• complete resolution can occur because structure of alveoli not damaged in lobar pneumonia
• Bronchopneumonia has structural damage
Complications of Pneumonia
•Abscess - local collection of pus. Think staph aureus, gram (-) bacteria or type 3 pneumococci. Would see foul smelling sputum

•Fibrosis - scar tissue

•Empyema - collection of pus in pleural space

•Bacteremia - bacteria in blood. Would see meningitis, arthritis, infective endocarditis
Clinical Features of Pneumonia
• Abrupt high fever, cough, rusty
purulent sputum
• Chest pain, pleural rub (if there is
pleuritis)
• ↓ air entry, consolidation, X- ray
• Microbe - sputum, blood
Organisms in Community Acquired Pneumonia?
•Strep pneumoniae
•Hemophilus influenzae
•Moraxella Catarrhalis
•Staph aureus
•Klebsiella pneumoniae
•Pseudomonas aerogenosa
•Legionella pneumophila
H. influenzae causes...
•Pneumonia in COPD
•Bronchiectasis
•Infection in cystic fibrosis
Moxarella catarrhalis causes...
•Pneumonia in elderly
•Second most common cause of pneumonia in elderly
•Also causes otitis media in kids
Staph aureus pneumonia factoids...
• After viral respiratory illness – secondary (measles in children, influenza in adults)
• Hospitalized patients – primary (nosocomial)
• Abscess formation, empyema
• I/V drug abusers- endocarditis right side
• Penicillin resistance
Properties of Klebsiella pneumonia
• Most frequent gram negative bacterial pneumonia
• Debilitated and malnourished
• Chronic alcoholics
• Thick gelatinous sputum ( viscid
capsular material)
• Extensive destruction
Properties of pseudomonas aeroginosa pneumonia?
• Progressive necrotizing pneumonia
• Nosocomial, neutropenic patients,
burns
• Vasculitis and vascular spread
• Extensive destruction, abscess
formation
• Empyema
• Progressive necrotizing pneumonia
• Nosocomial, neutropenic patients,
burns
• Can also cause disease in patients with cystic fibrosis- community acquired
Legionella pneumonia properties?
• Sporadic, epidemic pneumonia
• Unlike Pontiac fever -> self limited URI without pneumonia
• Artificial water pools- tubing, cooling towers
• Inhalation of aerosolized organisms or aspiration of contaminated drinking water
• In chronically ill patients, post transplant
• High fatality
Clinical Features of Interstitial pneumonias?
• Variable
• Mild illness usually
• Fever, cough- nonproductive, dyspnea (sometimes out of proportion to chest signs and radiology) diffuse alveolar damage
• Very few clinical signs
• Reticular shadows on chest X- ray
• Organisms difficult to demonstrate, check antibody titers
Types of people pneumonia of Mycoplasma pneumoniae tends to affect?
• Children, young adults
Causes of lung abscesses?
1. Aspiration of infected material- caries from teeth, gastric contents
2. Sequela of acute suppurative
pneumonia (Staph. Aureus, Klebsiella, Pseudomonas)
3. Bronchial obstruction - foreign body (inhalation, aspiration), tumor
4. Bronchiectasis
5. Secondary infection on tuberculous cavity
6. Septic embolus from infective
endocarditis right heart
Clinical Features of Lung Abcesses
• Cough with copious, foul sputum, hemoptysis, spiking fever, malaise
• Clubbing of fingers, weight loss, anemia
• Complications – bronchopleural fistula, empyema, septicemia (meningitis, brain abscess), amyloidosis
CMV Pneumonia Morpholgoy and Demographics
Morphology:

• Large cells-large nuclei, large amount of cytoplasm, large basophilic nuclear inclusion with halo around it- owl eye, smaller basophilic cytoplasmic inclusions

Demographics:
• Neonates, immune compromised, AIDS, BM transplant
Morphology and Etiology of Pneumocystis jiroveci Pneumonia
•Reactivation in immune compromised (AIDS-CD4 < 200)

• Interstitial pneumonia
• Intra alveolar foamy pink exudate-cotton candy
• Alveolar septa thickened-edematous, minimal mononuclear infiltrate
• Silver stain shows cup shaped cyst walls in alveolar exudate
• Sputum if it can be induced or BAL- Giemsa or methylene blue- shows trophozoites
• Can also do immunofluorescence or PCR
If Pneumonia is not responding to treatment it could be....
•Brochiectasis
•Lung Abscess
•Lung tumor causing hilar obstruction or bronchioalveolar carcinoma
•Vasculitis
Morphology of ARDS
Acute Stage:
•Lungs are dark red, firm, airless, heavy
•Capillary congestion
•Necrosis of alveolar epithelial cells
•Hyaline membrane formation
•Hemorrhage
•Interstital and intraalveolar edema
Clinical Features of ARDS
• Respiratory difficulty- acute
• Gasping for breath
• Severe hypoxemia, cyanosis
• Refractory to oxygen therapy
• Bilateral infiltrates on chest X-ray
• Absence of clinical features of left ventricular failure
• Leads to multisystem organ failure
• Predisposes to infections
• High mortality
Clinical Features and Morphology of Pulmonary Infarct
• Clinically resembles myocardial infarction: chest pain, dyspnea, shock

Gross:
•Wedge shaped
•hemorrhagic infarct
•may be multiple
•Occurs in lower lobes
•apex of infarct towards hilum, •raised red blue area
•pleura has fibrinous exudate

• Micro: coagulation necrosis, hemorrhage. Later on may see hemosiderin, fibrosis
Morphology of Pulmonary Hypertension
• Large elastic arteries - atheromas
• Medium sized muscular – proliferation of myointimal cells and smooth muscle cells -> medial and intimal thickening and narrowing of lumen
• Smaller arteries and arterioles- marked thickening, medial hypertrophy, elastic reduplication
• Capillaries burst, lead to necrosis

• Plexogenic changes in severe
varieties only (primary)
• Necrosis of wall (fibrinoid)
• Thrombosis
• Rupture, bleed
• Dilation lesions, angiomatoid lesions (tufts of thin walled capillaries)
• Hemosiderin
Clinical Features of Primary Pulmonary Hypertension
• Younger persons, more in females
• Symptoms appear late
• Fatigue, dyspnea
• Syncope on exercise (fainting)
• Chest pain
• Respiratory insufficiency, cyanosis
• Cor pulmonale
• Death in 2-5 years
• Treat with vasodilators, antithrombotic agents and eventually lung transplantation
Clinical Features and Morphology of Goodpasture syndrome
Clinical Features
•Hemoptysis
•Hematuria
•Oliguria
•Hemorrhagic interstital pneumonia

Morphology
• Gross: lungs heavy, red brown, areas of consolidation
• Micro: focal necrosis of alveolar walls, intra alveolar hemorrhages, fibrous thickening of alveolar septa,
hemosiderin
Clinical Features and Morphology of Wegener's Granulomatosis
Morphology:
• Pulmonary angiitis and granulomatosis
• Necrotizing vasculitis (fibrinoid necrosis), parenchymal granulomas, vessels may also show necrotizing granulomas

Clinical Features:
• Upper respiratory tract- chronic sinusitis, epistaxis, nasal polyps, ulcers over the nose
• Lower respiratory tract- cough, hemoptysis, chest pain
• c-ANCA positivity- specific
Morphology of Idiopathic Pulmonary Fibrosis
• Gross- Cobble stone appearance due to retraction by the scars in the septa, cut surface firm, rubbery, white (fibrosis), lower lobe more affected, patchy involvement, subpleural areas and interlobular septa

• Micro- Patchy interstitial fibrosis, mixture of early (fibroblastic) and late (fibrosis) lesions- temporal heterogeneity- (not seen in other cases of nonspecific interstitial pneumonia), collapse of alveolar walls, cystic spaces lined by proliferating pneumocytes or bronchiolar epithelium- honey comb fibrosis, patchy interstitial infiltrate- lymphocytes, plasma cells, mast cells, eosinophils, secondary pulmonary hypertension
Clinical Features of Idiopathic Pulmonary Fibrosis
• Insiduous onset, nonproductive cough with dry crackles during inspiration
• Progressive dyspnea, hypoxia, cyanosis, pulmonary hypertension
• Bilateral basal lesions
• Diagnosis- Take proper social and occupational history
• X-ray- small nodules, irregular lines, ground glass opacities
• CT- early detection of IPF, exclude other causes of pulmonary fibrosis
Morphology of nonspecific interstital pneumonia
• Either cellular pattern- Diffuse or patchy chronic interstitial inflammatory infiltrate- Lymphocytes, a few plasma cells
• Or fibrosing pattern- diffuse or patchy interstitial fibrosis (no temporal heterogeneity like in UIP)
Morphology of Sarcoidosis
•Intraalveolar and interstitial accumulation of CD4 cells
•Anergy to Candida skin tests
•Polyclonal hypergammaglobulinema
•Noncaseating epitheliod granulomas
•Asteroid bodies
•Schaumann bodies

CXR:
•Linear shadows
•Hilar lymph nodes
Hypersensitivity Pneumonitis
•BAL - CD4 and CD8 cells
•Granulomas in alverolar walls

• Patchy interstitial mononuclear infiltrate
• Characteristic peribronchiolar accentuation
• Lymphocytes, plasma cells, epithelioid cells
• Noncaseating granulomas
• Eventually may develop DIF

•History shows exposure to things like farmer's hay, pigeon droppings, sugar cane
Clinical Features of Goodpasture's syndrome
•Oliguria
•Hematuria
•Hypertension
•Right heart failure
•Progressive dyspnea
•Glomerulonephritis
Difference between panacinar and centriacinar emphysema
Panacinar is symptomatic
Morphology of Emphysema
•Alveoli large
•Wall thin, destroyed
•No fibrosis
•Adjecent alveoli are confluent - large spaces
Clinical Features of Emphysema
• Symptoms appear late (earleir if coexistent chronic bronchitis)
• Barrel chest, dyspnea, prolonged expiration (because it is active)
• Sitting in a forward hunched position trying to squeeze air out of the lungs
• X- ray flat domes of diaphragm
• Hyperventilation → blood gases normal till late
• “Pink Puffers”
• Late stage - hypoxia, respiratory acidosis
Mediastinal Emphysema
• Air escapes in to the connective tissue of lung stroma, mediastinum and subcutaneous tissue
• Spontaneously with sudden increase in intra alveolar pressure
• violent cough, vomiting, whooping cough, trauma- perforating injury to the ribs
• usually with some obstruction to the bronchial passage- eg mucus plug
• tear in the interstitium

• Patient bloats suddenly like a balloon including chest head and neck
• Crackling crepitations over chest
wall
• Recovers spontaneously after the
defect is sealed
Chronic bronchitis and bronchiolitis
Bronchitis:
• hypertrophy and hyperplasia of
mucous glands
• (Reid Index > 0.5)
• Goblet cells in the surface epithelium
• Squamous metaplasia

Bronchiolitis
• Goblet cell metaplasia
• Mucus plugging (obstruction)
• Inflammation-mononuclear and some PMN
• Peribronchiolar fibrosis (collapse in expiration)
• smooth muscle hyperplasia
• Coexistent emphysema
• +/- secondary infection- inflammation exacerbates the symptoms
• Rarely fibrous occlusion of bronchioles- bronchiolitis obliterans