Pulm Vascular Disease, Acute Lung injury, & Infections - Gupta

Question 1

Usual source of PE (location?)

Answer 1

DVT from lower extremity

Question 2

Virchows triad?

Answer 2

hypercoaguable state, stasis, endothelial injury

Question 3

Consequence of PE depends on what 2 factors?

Answer 3

size of embolus, status of circulation (adequate vs inadequate)

Question 4

Adequate circulation preventing severe consequence from PE refers to?

Answer 4

Bronchial arterial supply sufficient enough to sustain lung tissue distal to small peripheral emboli

Question 5

Infarcted lung tissue distal to site of PE has what characteristic features?

Answer 5

alveolar hemorrhage, coagulative necrosis of alveolar septa

Question 6

Resolving pulmonary infarction has what characteristic features?

Answer 6

After 48 hours, infarcted lung tissue begins to organizing and becomes a paler red–brown due to the conversion of hemorrhage into hemosiderin by macrophages and will eventually form a contracted scar

Question 7

Examples of non-thrombotic emboli?

Answer 7

air, fat, amniotic fluid, foreign material (i.e. IV drug abuse)

Question 8

Pulmonary circulation is (what fraction) of systemic pressure?

Answer 8

1/8

Question 9

Primary pulmonary HTN: predominantly seen in what epidemiologic make up?

Answer 9

young female (3rd to 5th decade)

Question 10

What inactivating mutation is seen in primary pulmonary HTN? cause of this mutation?

Answer 10

BMPR2 (bone morphogenetic protein receptor type 2, leads to proliferation of vascular smooth muscle

Question 11

Primary pulmonary HTN genetics?

Answer 11

Autosomal dominant

Question 12

Secondary causes of pulmonary HTN?

Answer 12

• Chronic obstructive or interstitial lung diseases
• Cardiac disease (congenital or acquired)
• Recurrent thromboemboli

Question 13

What cardiac disease can cause secondary pulmonary HTN? Mechanism?

Answer 13

Mitral stenosis

- elevated left atrial pressure causes increased pulmonary venous and arterial pressure

Question 14

Regardless of etiology, all forms of pulmonary HTN are associated with what 3 outcomes?

Answer 14

1. medial hypertrophy of the pulmonary muscular and elastic arteries
2. pulmonary arterial atherosclerosis
3. right ventricular hypertrophy

Question 15

Microscopic appearance of pulmonary HTN?

Answer 15

plexogenic lesions

Question 16

3 examples of diffuse pulmonary hemorrhage syndromes (pulmonary vascular diseases)

Answer 16

• goodpasture
• idiopathic pulmonary hemosiderosis
• vasculitis - associated hemorrhage (SLE, Wegener’s)

Question 17

Goodpasture = autoimmune disorder with circulating antibodies towards ___?

Answer 17

alpha-3 chain of collagen IV

Question 18

Goodpasture is characterized by destruction of (what) in what organ(s)?

Answer 18

destruction of basement membrane in kidney glomeruli and lung alveoli

Question 19

Good pasture epidemiology?

Answer 19

men in teens-20s, smokers

Question 20

Microscopic appearance of goodpasture?

Answer 20

Alveolar basement membrane destruction evidenced by:

• necrosis of alveolar walls
• intra-alveolar hemorrhage

Question 21

pulmonary edema due to what 2 primary factors?

Answer 21

hemodynamic edema (increased hydrostatic pressure, decreased oncotic pressure)
edema due to microvascular injury

Question 22

Increased hydrostatic pressure resulting in pulmonary edema most commonly associated with what disease?

Answer 22

left heart failure

Question 23

Left heart failure resulting in pulmonary edema worst in what part of lungs? why?

Answer 23

at bases of lungs, hydrostatic pressure greatest here

Question 24

Decreased oncotic pressure resulting in pulmonary edema due to what disease?

Answer 24

liver disease (hypoalbuminemia)

Question 25

Common ways in which patient can develop edema due to microvascular injury?

Answer 25

infections, inhaled smoke and other gases, shock

Question 26

Microscopic appearance of pulmonary edema?

Answer 26

engorged alveolar capillaries and intraalveolar granules and precipitate

Question 27

Chronic pulmonary edema microscopic apperance?

Answer 27

alveolar microhemorrhages and resulting hemosiderin–laden macrophages (“heart failure cells”) may be seen

Question 28

ARDS (acute respiratory distress syndrome) characterized by ? (referring to alveolar capillaries)

Answer 28

diffuse alveolar capillary damage

Question 29

Onset of ARDS?

Answer 29

rapid

Question 30

ARDS manifests histologically as ?

Answer 30

diffuse alveolar damage (DAD)

Question 31

ARDS histologic findings are similar to __?

Answer 31

preterm infants with deficient surfactant (neonatal RDS)

Question 32

Pathophysiology of Acute lung injury?

Answer 32

Capillary damage ⇒ Activates macrophages ⇒ Activates neutrophils ⇒ Neutrophils release PAF, leukotrienes, proteases ⇒ These attack and kill Type II (and Type I) pneumocytes. Type II are in charge of surfactant production and stem cells for production of further pneumocytes ⇒ TGF-beta moves in causing fibrosis. At the end of all this, protein rich fluid+necrotic epithelial cells will produce the hyaline membrane (BIG POINT)

Question 33

Fibrin+necrotic epithelial cells leads to production of what in acute lung injury?

Answer 33

hyaline membrane within alveolar walls

Question 34

During organizing stage of acute lung injury, what happens to the hyaline membrane?

Answer 34

resorbed and replaced with plugs of intraalveolar organizing fibroconnective tissue

Question 35

Pneumonia most likely to occur in what subset of patients (think general)?

Answer 35

those with chronic disease, immunologic deficiency, on immunosuppressants

Question 36

Three patterns of pneumonia? Which are more likely bacterial vs viral

Answer 36

More likely bacterial: bronchopneumonia, lobar pneumonia | More likely viral: interstitial (atypical) pneumonia

Question 37

CAP (community acquired pneumonia) most common bacteria?

Answer 37

streptococcus pneumoniae

Question 38

Gross geographic feature of bronchopneumonia?

Answer 38

patchy distribution in lungs

Question 39

Gross geographic feature of lobar pneumonia?

Answer 39

entire lobe or large portion of lobe

Question 40

Stages of inflammatory response in pneumonia?

Answer 40

Congestion ⇒ Red Hepatization ⇒ Gray Hepatization ⇒ Resolution

Question 41

Stages of inflammatory response. Congestion features?

Answer 41

Numerous bacteria, few neutrophils, vascular engorgement and edema

Question 42

Stages of inflammatory response. Red Hepatization features?

Answer 42

Massive congestion, lots of neutrophils

Question 43

Stages of inflammatory response. Gray Hepatization features?

Answer 43

Disintegration of RBCs, macrophages. Fibronopurulent exudate

Question 44

Stages of inflammatory response. Resolution features?

Answer 44

Enzymatic digestion, resorption by macrophages

Question 45

Pneumonia. Elderly with acute COPD exacerbation. What bug?

Answer 45

Moraxella catarrhalis

Question 46

Pneumonia. IV drug abusers. What bug?

Answer 46

Staph aureus

Question 47

Pneumonia. debilitated, malnourished, alcoholics. What bug?

Answer 47

Klebsiella pneumoniae

Question 48

Pneumonia. CF patients. What bug?

Answer 48

Pseudomonas aeruginosa

Question 49

Pneumonia. Water towers and smokers. What bug?

Answer 49

Legionella pneumophila

Question 50

Main complications of pneumonia?

Answer 50

abscess, empyema (spread to pleural cavity), dissemination to other organs (meningitis)

Question 51

Necrotizing pneumonia (abscess) are most likely due to what bugs?

Answer 51

streptococcus, klebsiella

Question 52

Atypical pneumonia main distinguishing feature?

Answer 52

lack of neutrophil infiltration, predominantly lymphocytes instead

Question 53

Microscopic appearance of atypical pneumonia?

Answer 53

lymphocytic inflammation of the interstitium. Type II Pneumocyte hyperplasia

Question 54

Primary TB occurs in previously ___?

Answer 54

unexposed patients

Question 55

T/F. Over 10% of newly infected patients (TB) develop clinical disease.

Answer 55

False, only 5% of newly infected actually develop TB disease

Question 56

Secondary (reactivation) of TB typically occurs in what part of lung?

Answer 56

Apex

Question 57

Gross appearance of primary TB. What complex is seen? What is the definition of this complex?

Answer 57

Ghon complex = calcified parenchymal focus + caseous hilar lymph nodes

Question 58

Microscopic appearance of TB?

Answer 58

granulomatous inflammation w/ central necrosis, surrounded by rim of macrophages

Question 59

Secondary TB gross appearance?

Answer 59

Confluent areas of caseous necrosis and cavitation, found primarily in upper lobes (site of highest O2 tension)

Question 60

Gross appearance of miliary TB?

Answer 60

Lymphohematogenous dissemination of mycobacteria results in multiple 2-4 mm foci (look like millet seeds, hence the name) of granulomatous inflammation.

Question 61

Fungal pneumonia primarily due to what fungus?

Answer 61

histoplasma capsulatum

Question 62

Classic cause of fungal pneumonia? (Histoplasmosis common with exposure to what?)

Answer 62

inhalation of dust contaminated with bird/bat droppings that contain spores

Question 63

Fungal pneumonia microscopic appearance?

Answer 63

granulomatous inflammation, typically necrotizing

Question 64

Besides histoplasma capsulatum, what other 3 fungi can cause fungal pneumonia?

Answer 64

Blastomyces dermatidis, cryptococcus neoformans, coccidioides immitis

Question 65

BIG, broad-based buds. Name that fungus.

Answer 65

Blastomyces. Think alliteration. BIGGG, broad-based buds. Gupta thinks they look like snowmen...or snow-women #genderequality #allmysingleladies

Question 66

Pigeon droppings. What fungus most likely?

Answer 66

Cryptococcus neoformans

Question 67

Coccidioides immitis endemic to what geographic region in US?

Answer 67

Southwest and western U.S. (San Joaquin Valley)

Question 68

Main staining feature seen with cryptococcus?

Answer 68

large anti-phagocytic capsule is easily stained

Question 69

Main microscopic feature of coccidioidomycosis?

Answer 69

Thick walled, nonbudding large sphere, filled with small endospores

Question 70

Pneumonia in immunocompromised host usually due to what bugs?

Answer 70

CMV, pneumocystis jiroveci, mycobacterium avium-intracellulare, invasive aspergillosis, mucormycosis, candidiasis

Question 71

CMV pneumonia microscopic appearance?

Answer 71

enlarged cell w/ cytoplasmic and intranuclear (OWL EYES) viral inclusion

Question 72

Granular alveolar exudate with central umbilications. Seen in what form of immunocompromised pneumonia?

Answer 72

Pneumocystis pneumonia

Question 73

Pulmonary aspergillosis pneumonia characterized by what feature?

Answer 73

angioinvasion of regular septate hyphae with progressive acute-angle branching

Question 74

Main dif between aspergillosis and mucormycosis.

Answer 74

Also angioinvasive, however produces wide angle "ribbons" with non-septate hyphae