Pulmo Part 3 Flashcards by Denisse Tiangco

Most common opportunistic CMV disease

retinitis

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Fungi causing pneumonia in AIDS <200 CD4 count

Foamy acellular exudate
Cup-shaped round cyst within exudate

P jiroveci

P carinii

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Intraalveolar foamy pink staining exudate with h & e (cotton candy)
Round to cup shaped cyst 4-10um dm with intracystic body without budding

P jiroveci

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P jiroveci dx

Sputum or BAL immunofluorescence

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Most common disease causing fungus

Candida albicans

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Yeast like form (blastoconidia)
pseudohyphae, true hyphae

Budding yeast joined end to end at constrictions simulating true fungal hyphae

Stain:

C albicans

Pseudohyphae

Gomori methenaminesilver
Periodic acid Schiff

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Gray white
Dirty looking pseudomembrane
Matted organism and inflammatory debris
Mucosal hyperemia, inflammation

Oral thrush

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Candidal infection on nail fold

Paronychia

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Candida assoc disease

Hypoparathyroidism
Addison disease
Autoantibodies

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Mutation affecting TH17 Rendering px highly susceptible to severe mucocutaneous candidiasis

Job syndrome

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5-10 um yeast with thick gelatinous capsule, buds
No pseudohyphae true hyphae
Capsule is invaluable to diagnosis
Halo seen in india ink and periodic acid Schiff staining
Capsular polysaccharide antigen substrate for latex agglutination assay

C neoformans

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C neoformans grow in meninges and perivascular Virchow Robin spaces producing

soap bubble lesion

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Zygomycetes
Nonseptate hyphae branching at right angle
Common to hematolymphoid malig, neutropenia and corticosteroid therapy allogeneic stem cell

Mucormycosis

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Septate and branched hyphae at acute angles

Aspergillus

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Nondistinctive suppurative granulomatous reaction with predilection for invading blood vessel wall causing necrosis and infarction (3)

Rhizopus
Mucormycosis
Aspergillus

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Colonizes nasal cavity and sinuses spreading into brain, orbit
DKA
localized pulmonary disease with diffuse miliary involvement

Rhinocerebral mucormycosis

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Immunosupressed

Localizing in lung manifesting as necrotizing pneumoniae

Invasive aspergillosis

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Asthma caused by type I hypersensitivity against fungus growing in bronchi

Allergic bronchopulmo aspergillosis

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Fungus ball
Colonization of preexisting pulmo cavity
Act as ball valves

Aspergilloma

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Most common benign lung lesion 3-4cn
Coin lesion
mature cartilage admixed with fat, fibrous tissue and blood vessel

hamartoma

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Carcinoma with strongest association with smoking

Squamous cell

Small cell

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Most common primary lung tumor

esp in women
never smokers
less than 45
metastasize at early stage

Adenocarcinoma

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Two broad lung ca

bec

1 small cell
2 non small cell (adeno, squamous and large)

all small cell have metastasized by time of diagnosis, not curable by surgery

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Small cell lung ca best tx

chemotherapy

with or without radiation

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Lung CA pathogenesis

inactivating TSG on short arm of ch 3p TP53 mutation activation of KRAS oncogene “field effect” seen even in lungs of smokers without lung cancer

Adenocarcinoma in nonsmoking women is due to mutation of

EGFR epidermal growth factor receptor KRAS EML4-ALK cMET

Heavy smokers exposed to asbestos inc risk of lung cancer

55 times greater

SCCs are common in smoking men and arise in

central major bronchi | large lesions undergo central necrosis giving rise to cavitation

SCCs are preceded by

squamous metaplasia or dysplasia in bronchial epithelium -> carcinoma in situ

SCCs histologically are seen as

Keratin pearls and | intercellular bridged

Adenocarcinomas are located

peripherally with central scar

Adenocarcinoma on histology

Acinar gland forming Papillary Mucinous Solid with intracellular mucin

Putative precursor for adenocarcinoma

atypical adenomatous hyperplasia cuboidal -> low columnar with atypia

Peripheral part of lung occuring as single nodule diameter of 3cm or less, growth along preexisting structure and preservation of alveolar architecture

Adenocarcinoma in situ | Bronchioalveolar carcinoma

Undifferentiated malignant epithelial tumor lacking cytologic features of small cell carcinoma without glandular or squamous differentiation

Large cell carcinoma

Pale gray centrally located masses with extension into lung parenchyma and involvement of hilar mediastinal nodes Round fusiform shape, scant cytoplasm and finely granular chromatin “Crush artifact” in small biopsy Neuroendrocine expression

Small cell lung carcinoma

Left supraclavicular node involvement in lung ca

Virchow node

Destruction of first and second rib Invasion of brachial or cervical sympathetic plexus causing severe pain in ulnar nerve or Horner’s (ipsi enopthalmos, ptosis, miosis abd anhidrosis)

Pancoast tumor

Basophilic staining of vascular wall due to encrustation of DNA from necrotic tumor cell in small cell carcinoma

Azzopardi effect

``` Scant cytoplasm Small hyperchromatic nuclei with fine chromatin Indistinct nucleoli Diffuse sheet of cell Neuroendocrine marker + (chromogranin, enolase, synaptophysin) Absent Mucin ACTH, ADH, Gastrin and calcitonin 3p deletion, rb mutation and p54 mut Complete response to chemo and radio ```

Small cell lung carcinoma

``` Abundant cytoplasm Pleomorphic nuclei with coarse chromatin Prominent nucleoli Glandular or squamous architecture Absent neuroendocrine Present epithelial marker (CEA, cytokeratin) Mucin in adenoCa PTh-rp in SCC 3p deletion KRAS mut in adenoCa EGFR in adeno, nonsmoker, women ALK rearrangement in adeno, non, signet ring ```

Non small cell lung carcinoma

Lung CA common mets

brain liver bone

Better prognosis

NSCL P

Paraneoplastic syndromes

1 hypercalcemia from PTH 2 Cushing syndrome 3 SIADH 4 neuromusc MG 5 clubbing and hypertrophic pulmonary osteoarthropathy 6 coagulation abno (migratory thrombo), nonbacterial endo

Hypercalcemia is associated with

Squamous cell

Hematologic syndromes are assoc with

adenocarcinoma

Tumors 3cm or less charac by pure growth along preexisting structures (lepidic pattern) without stromal invasion are called

adenocarcinoma

Paraneoplastic syndromes are caused by

SCLC

Carcinoid patterns

1 obstructing polypoid, spherical, intraluminal mass | 2 mucosal plaque penetrating bronchial wall to fan out in peribronchial tissue (collar-button)

Nests of uniform cell with regular round nuclei Salt and pepper chromatin Absent or rare mitosis

Typical carcinoid

Higher mitotic rate Focal necrosis High incidence of lymph node and distant metastasis TP53 mutation

Atypical carcinoid

Represent continuum of inc histologic aggressiveness and malignant potential withib spectrum of pulmo neuroendocrine neoplasm

Typical, atypical, small cell

Attacks of diarrhea Flushing Cyanosis

Carcinoid syndrome

Transudate

hydrothorax

Protein content greater than 2.9gm/dl | Inflammatory cell

Exudate

Cause of pleural exudate

1 microbe invasion(suppurative pleuritis, empyema) 2 cancer 3 pulmonary infarct 4 viral pleuritis

Rare cancer of mesothelial cell in parietal and visceral pleura, peritoneum, pericardium Related to asbestos exposure

Malignant mesothelioma

Extensive pleural fibrosis and plaque formation Ensheathed by yellow-white, firm, gelatinous layer of tumor Distant metastasis rare 3 patterns:

Mesothelioma Epithelial (most common), Sarcomatous (spindled, fibroblastic) Biphasic (sarcomatous and epithelial)

Mesotheliomas are associated with mutations in

p16/CDKN2A at ch9p21 | NF2 at ch22q12

Smooth, hemispherical protrusion less than 0.5cm on true vocal cords Singer’s nodule, heavy smoker

Vocal cord nodule

Benign neoplasm on true vocal cord Soft raspberrylike excrescence more than 1cm Multiple slender fingerlike projection by central fibrovascular cores

Laryngeal papilloma | Squamous papilloma

Recur after excision Multiple in children Recurrent respiratory papillomatosis are caused by

HPV 6 and 11 regress after puberty from vertical transmission

2% of all ca 40 yrs, M Smokers, alcoholics and asbestos HPV SCC on vocal cord (glottic 60-75%), above and below Pearly gray plaques on mucosa ulcerating, fungating Hoarseness

Carcinoma of larynx Location has bearing on prognosia since 90% located on larnyx without dense lymphatic supply vs supraglottic which metastasize into cervical LN

Cause of death in laryngeal ca

Infection of distal respi passages | Metastases, cachexia

Acute bacterial epiglottitis is causes by

H influenzae

Diptheritic laryngitis is caused by

Corynebacterium diptheriae dirty gray pseudomembrane

Most common cause of laryngotracheobronchitis or croup

Parainfluenza stridor