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53 Cards in this Set

  • Front
  • Back
Newborn lungs with hyaline membrane disease (respiratory distress syndrome)
RDS is due to a deficiency of surfactant, which normally reduces surface tension and keeps the airways from collapsing on expiration. Note the collapsed alveoli throughout all lung fields. The ventilation defect related to massive atelectasis results in intrapulmonary shunting of blood and severe hypoxemia. The pink staining hyaline membranes are due to necrotic type II pneumocytes and fibrin from fibrinogen.
EM: type II pneumocyte with lamellar bodies
Note the concentric, lamellar bodies in the cytosol. These contain surfactant. The type II pneumocyte is also the repair cell of the lungs. When destroyed, as in RDS and ARDS, they contribute to the formation of hyaline membranes in both conditions.
Gram stain of sputum with Streptococcus pneumoniae
Note the gram positive, lancet shaped diplococci. S. pneumoniae is the MCC of typical, community acquired pneumonia and is treated with penicillin G
Lung: bronchopneumonia
Note the yellow white patches scattered throughout the lower lobe. These represent foci of consolidation in a patient with S. pneumoniae bronchopneumonia.
Lung: lobar pneumonia
Note the pale consolidation of the entire upper lobe. This is lobar pneumonia, which is also most commonly caused by S. pneumonia
Chest x-ray: right upper lobe lobar pneumonia
Note the consolidation in the right upper lobe. Grossly, it would have looked like the previous slide.
Gram stain of sputum in a cardiac transplant patient with pneumonia: Nocardiosis
Note the branched, gram positive, aerobic bacteria within the inflammatory infiltrate. These organisms are partially acid fast, unlike Actinomyces, which is a gram positive strict anaerobe.
X-ray of lateral neck: thumbprint sign of acute epiglottitis due to Hemophilus influenzae
Note the "thumbprint" appearance of the swollen epiglottis. Inspiratory stridor was present in this child.
Cavitary lesion in the right upper lobe: reactivation tuberculosis
Note the cavitary lesion lined by caseous material. The apex has the highest oxygen content, which explains why TB, a strict aerobe, enjoys this location. Cavitation occurs, since the patient has previously been exposed to TB, which causes an intense inflammatory reaction involving T cells and their cytokines.
Acid fast stain in TB
Mycolic acid in the cell wall is responsible for acid-fastness in TB.
Chest x-ray with miliary tuberculosis
Careful observation reveals small densities throughout both lung fields representing miliary spread. This could have been due to a caseous focus extending into a bronchus or into the pulmonary artery.
Spherule with endospores: Coccidioides immitis
Coccidioides is indigenous in the southwestern states. Arthrospores are inhaled in dust
Macrophage with phagocytosed Histoplasma capsulatum
Note the yeast forms of Histoplasma in this macrophage in the bone marrow. Histoplasma is indigenous in the Ohio-Tennessee valley. Starlings, bats, and caves are the key words to remember.
Macrophage with phagocytosed Histoplasma capsulatum
Note the yeast forms of Histoplasma in this alveolar macrophage in the lung.
Verrucous skin lesion on the face: Blastomyces dermatitidis
Note the raised, wart-like lesion on the face. This is characteristic of blastomycosis.
Broad based bud of Blastomyces dermatitidis
Blastomycosis frequents the southern states
Chest x-ray: bilateral apical cavities containing the fungus ball of Aspergillus fumigatus
Note the fuzzy appearance within the apical cavities (old abandoned TB cavities). These represent the fungus balls of Aspergillus. Massive hemoptysis is a potential complication.
PAS stain of Aspergillus
Note the classic corona of Aspergillus. The hyphae are septate and have narrow angles. Aspergillus is a vessel invader.
PAS stain of Mucor
Note the non-septate, wide angled hyphae of Mucor. Mucor is a vessel invader.
Section of lung with Pneumocystis carinii
Note the foamy exudate in the alveoli. This is the MC AIDS defining infection. Pneumocystis is a fungus.
Silver stain of Pneumocystis carinii
Note the round and crushed cysts in the lavage specimen from the lungs of a patient with AIDS. TMP/SMX is the Rx of choice.
Superior segment of the right lower lobe: lung abscess
Note the cystic cavity lined by purulent material (liquefactive necrosis). The patient was an alcoholic who aspirated oropharyngeal material while sleeping on his back. Mixed aerobe/anaerobe organisms were present in culture.
Schematic of pulmonary embolus
Pulmonary emboli can be large leading to occlusion of the pulmonary artery orifices (saddle embolus) or small, the latter resulting in wedge shaped hemorrhagic infarctions (coagulation necrosis). Most emboli do not cause infarction unless the patient has preexisting lung disease. The majority of pulmonary emboli come from the femoral vein.
Pulmonary artery: saddle embolus
Note the large embolus essentially occluding the entire lumen of the PA. This produces sudden death due to acute right heart strain. There is no time for infarction.
Ventilation perfusion scan in a patient with a pulmonary embolus to the right lower lobe (RLL)
The right lung is on your left. A ventilation scan is on the top and shows uptake of the scan material in both lungs, however, note the slightly fuzzy appearance at the base of the RLL. The perfusion scan is on the bottom and it clearly shows a lack of perfusion in the RLL. A V/P scan is the initial test of choice to screen for a PE.
Histologic section of a thickened pulmonary vessel in a patient with pulmonary hypertension (PH)
Note the small calibre lumen of the vessel (space with RBCs). The vessel wall is thickened owing to hyperplasia and hypertrophy of smooth muscle cells.
Normal heart on the right and heart with right ventricular hypertrophy (RVH) on the left in a patient with PH
Note the thick right ventricular wall on your left compared to the normal right ventricular wall on your right. It is thickened because of the afterload it had to contract against in the pulmonary vessel. The combination of PH and RVH is called cor pulmonale, if the PH is secondary to primary lung disease or a primary pulmonary artery hypertension. PH secondary to cardiovascular disease does not qualify.
Coal worker's pneumoconiosis (restrictive lung disease)
The black pigment is anthracotic pigment. The dilated spaces represent centrilobular emphysema. There is an increase in fibrous tissue throughout the lungs (progressive massive fibrosis) in between the areas of emphysema. CWP is primarily a restrictive type of lung disease, however, there is a small component of emphysema, which is obstructive. Patients are susceptible to TB but not cancer.
Silicotic nodule in the lungs in a patient with silicosis (restrictive lung disease)
Note the solid areas of fibrous tissue. If this was polarized, it would reveal silica crystals throughout the nodule. This disease commonly occurs in sandblasters. Patients are susceptible to TB but not cancer.
Section of lung with asbestos fibers (ferruginous bodies, restrictive lung disease)
Note the rusty colored, dumbbell shaped bodies in the lung tissue. These represent asbestos fibers coated by iron. Benign pleural plaques are the MC manifestation of asbestos exposure. Primary lung cancer is more common than mesothelioma. Smoking + asbestos exposure has a synergistic effect on increasing risk for lung cancer rather than a mesothelioma.
Mesothelioma (restrictive lung disease)
Note that the entire lung is encased by thickened pleura. This is characteristic of a mesothelioma, which is a highly malignant tumor. It requires at least 20-40 years for these to develop, unlike primary lung cancer, which explains why the latter is more common. There is no smoking relationship with mesotheliomas
Hamman Rich lung (restrictive lung disease)
HR lungs are the end result of an alveolitis. Note the cystic spaces resembling a honeycomb along the outer portions of the lung. Alveolar fibrosis leads to proximal dilatation of the small airways
Chest x-ray in a patient with sarcoidosis (restrictive lung disease)
Note the markedly enlarged hilar lymph nodes ("potato nodes"). Along both lung bases there is a very fine reticulonodular pattern representing interstitial fibrosis.
Non-caseating granuloma in a hilar lymph node in a patient with sarcoidosis (restrictive lung disease)
Note the multinucleated giant cells and the pink staining epithelioid cells representing activated macrophages.
Pink puffer (left) and blue bloater (right): obstructive lung disease
Pink puffers predominantly have emphysema, which involves the respiratory unit, while blue bloaters have chronic bronchitis, which primarily obstructs the more proximal terminal bronchioles, hence the greater trapping of CO2 leading to respiratory acidosis, hypoxemia, and cyanosis (note facial discoloration).
Schematic of centrilobular emphysema (obstructive lung disease)
The respiratory bronchiole is the primary site of destruction in this type of emphysema. It is most commonly due to smoking and less commonly to CWP. The upper lobes are primarily involved.
Schematic of panacinar emphysema (obstructive lung disease)
The entire respiratory unit is destroyed in this type of emphysema, which is due to a deficiency of AAT. It may be acquired in smokers and inherited as an AR disease. The lower lobes are primarily involved.
Serum protein electrophoresis in a patient with hereditary AAT deficiency (obstructive lung disease)
The top SPE pattern labeled C is normal. Compare this to the lower SPE labeled P. Note that the a1 globulin component is missing. This is due to lack of liver synthesis of the protein.
Bronchiectasis (obstructive lung disease)
Note the dilated, pus-filled bronchi extending to the pleural surface of the lung. Obstruction and infection weaken the bronchi causing them to dilate. Cystic fibrosis is the MCC in this country and TB in other countries.
Main-stem bronchus cancer associated with bronchiectasis (obstructive lung disease)
At the top of the slide there is a white colored mass that has completely obstructed the main-stem bronchus. Behind the obstruction dilated, pus filled bronchi extend to the pleural surface.
Patient with bronchial asthma (obstructive lung disease)
Note the increased anteroposterior diameter in the patient. This is due to air trapping behind the inflamed terminal bronchioles.
Sputum with Charcot-Leyden crystals in a patient with bronchial asthma (obstructive lung disease)
Note the spear-head shaped crystals representing crystalline material derived from degenerated eosinophils.
Chest x-rays: left x-ray with a primary peripheral adenocarcinoma, right x-ray with primary centrally located cancer
Adenocarcinoma has replaced squamous cancer as the MC primary cancer. They are usually (not always) peripherally located. There are different variants of adenocarcinoma, some of which have no smoking relationship. Centrally located cancers include squamous cancer and small cell cancer.
Primary main-stem bronchus cancer
Toothpicks are necessary to keep the lumen open. Note the white material encircling and invading into the lumen of the main-stem bronchi. This could be either a squamous or small cell cancer.
Well differentiated squamous cell carcinoma of lungs
Note the concentric areas of eosinophilic staining cells on the lower margin of the side. These are malignant squamous cells with keratin formation (called squamous pearls).
Pap smear of sputum with squamous cancer
Keratin stains bright red with a Papanicolaou stain. Note the malignant cells in each of the frames and the intense staining of the keratin. Squamous cancers may ectopically secrete PTH-like peptide leading to hypercalcemia.
Pap smear with a malignant squamous pearl
Note the concentric appearance of this malignant cell containing keratin.
Lung biopsy in a patient with a small cell carcinoma
Note the diffuse infiltrate of small, dark cells throughout the tissue. Small cell cancers are of neural crest origin (neurosecretory tumors) and ectopically secrete ADH or ACTH in some cases.
Pap smear of small cell cancer in sputum
The small cells resemble lymphocytes, hence they are frequently missed in sputum cytology.
Lung with metastatic disease
Note the multifocal nature of metastasis. Primary lung cancers are usually solitary. Breast cancer is the MC malignancy metastasizing to lungs.
Lung with metastatic disease along the visceral pleural surface
Note the white nodular masses lining the pleura on your left.
Lung with metastatic disease in lymphatics surrounding airways
Note the white tumor encircling small airways throughout the lungs. This produces intense dyspnea in the patient.
Patient with Horner's syndrome
The patient has a Pancoast tumor (superior sulcus tumor), which is most often due to a primary squamous cancer at the lung apex involving the brachial plexus and superior cervical ganglion. Destruction of the superior cervical ganglion, located in the posterior mediastinum, produces Horner's syndrome. Horner's syndrome includes ipsilateral lid lag (drooped right eyelid), miosis (look hard and note that the right pupil is constricted compared to the left), and anhydrosis (absence of sweating)