Pulmonary pathology

Question 1

Rhinositus

Answer 1

Obstruction of sinus drainage into nasal cavity

Typically maxillary sinuses –> that drain into middle nasal meatus

Common causes: S. pneumo, H influenza

Question 2

Epistaxis

Answer 2

Nose bleed

Generally occurs in anterior segment of nostril

Can be life threatening if in posterior segment (sphenopalatine a.- part of maxillary a)

Tx: cauterization (often of nasal septum) –> highly vascularized

Question 3

Head and neck ca

Answer 3

Most often Squamous cell ca

Generally in oral cavity

Question 4

Deep venous thrombosis

Answer 4

Virchow triad: SHE
Stasis
Hypercoagulability
Endothelial damage

S&S: Homan sign- pain with dorsiflexion of foot

Tx: unfractionated heparin or LMWH (enoxaparin) --> prophylaxis and acute management
Oral anticoags (like warfarin or riveroxaban for long term tx)

Imaging: compression US

Question 5

Pulmonary emboli

Answer 5

V/Q mismatch; causes increase A-a gradient –> hypoxemia –> respiratory alkalosis (because of hyperventilation)

Lines of Zahn: pink and red; tells you that emboli formed right before death

Can be caused by FAT BAT (fat, air (nitrogen bubbles in ascending divers), thrombus, bacteria, amniotic fluid (fetal squamous cells seen in pulmonary vasculature), and tumor)

Question 6

Obstructive lung diseases

Answer 6

Main characteristics: increased TLC, but decreased FEV1/FVC (<0.8)

Causes: Chronic bronchitis, emphysema, asthma, bronchiectasis

Question 7

Chronic bronchitis

Answer 7

Hyperplasia of mucus secreting glands

Productive cough (for > 2 years- not necessary consecutive)

Can cause pulmonary HTN and for pulmonale

Question 8

Emphysema

Answer 8

Enlargement of air spaces, decreased diffusion capacity, increased compliance

Centriacinar- smoking
Panacinar- alpha-1 antitrypsin

Barrel shaped chest, exhale through pursed lips (to increase airway back pressure and prevent airway collapse

Question 9

Asthma

Answer 9

Smooth muscle hypertrophy; Curschmann spirals (whorled mucus plugs); Charcot-Leyden crystals (eosinophilic, hexagonal crystals)

Dx: methacholine challenge –> muscarinic agonist –> increases bronchial tone

Question 10

Bronchiectasis

Answer 10

Necrotizing infection of bronchi –> causes permanently dilated airways, digital clubbing

Can happen with allergic bronchopulmonary aspergillosis

Question 11

Restrictive lung disease

Answer 11

Decreased FVC and TLC; increased FEV1/FVC; decreased DLCO

Types can be muscular or lung-related

Question 12

Muscular/ mechanical causes

Answer 12

Weakened intercostal muscles: Polio, ALS, MG, Guillian-Barre

Poor structural apparatus: scoliosis, obesity

Question 13

Intersitial lung disease

Answer 13

Sarcoidosis
Fibrosis (idiopathic): see honeycombing (on S-ray) and clubbing
ARDS/ NRDS
Goodpasture
Wegener- granulomatosis with polyangiitis
Drug toxicity (bleomycin, amiodarone, busulfan, methotrexate)

Question 14

Flow volume loops

Answer 14

Right shift: Restrictive

Left shift: obstructive

Question 15

Hypersensitivity pneumonitis

Answer 15

Mixed type III/IV HS reaction

Seen in farmer exposed to birds

Question 16

Pneumoconiosis

Answer 16

Increased risk of cor pulmonate, cancer and Caplan syndrome (RA and pneumoconiosis w/ nodules)

Types: Asbestosis, beryllosis, coal workers, silicosis

Question 17

Asbestosis

Answer 17

Ferruginous bodies (via Prussian blue stain)- brown rods resembling dumbbells

Shipbuilding, roofing, plumbing

White plaques in pleura

Bronchogenic carcinoma (esp. if smoker) > Mesothelioma

Lower lobes

Question 18

Berylliosis

Answer 18

Aerospace and manufacturing industries

Granulomatous; steroids may help

Upper lobes

Question 19

Coal workers

Answer 19

Black lung disease

Macrophages with carbon –> Cause inflammation and fibrosis

Upper lobes

Anthracosis: asymptomatic; found in urban dwellars

Question 20

Silicosis

Answer 20

Foundries (metal factory), sandblasting, mines (not to be confused with coal workers)

Macrophages respond to silica –> causes fibrosis; may also increase susceptibility to TB

Upper lobes

Eggshell calcifications of hilar lymph nodes

Question 21

General trends of pneumoconiosis

Answer 21

Asbestos is from the roof (insulation/ ceiling), but affects the base (lower lung)

All the others affect the upper lungs (and are metals/ coal that are found in the ground)

Question 22

ARDS

Answer 22

Endothelial damage (neutrophils release toxic factors) –> causes increased alveolar capillary permeability –> protein leaks into alveoli –> diffuse alveolar damage

Causes formation of intra-alvelolar hyaline membrane

Characterized by bilateral lung opacities without evidence of fluid overload or HF

Can be due to SPARTAS: sepsis, pancreatitis, aspiration, uRemia, trauma, amniotic fluid embolism, shock

Tx: mechanical ventilation with low tidal volumes

Question 23

Sleep apnea

Answer 23

Cessation of breathing for > 10 seconds during sleep; normal Pa_O2 during the day

Can cause pulm HTN

Question 24

Obstructive sleep apnea

Answer 24

Assoc with obesity, excess tissue/ tonsils in airway

Tx: weight loss, CPAP, and surgery

Question 25

Central sleep apnea

Answer 25

CNS injury/ toxicity causes lack of respiratory effort (opioids, HF)

Question 26

Obesity hypoventilation volume

Answer 26

Obesity causes hypoventilation--> causes decreased PaO2 and increased PaCO2 at NIGHT AND increased PaCO2 during the DAY

Question 27

Lobar

Answer 27

S.pneumo, Legionella, Klebs

Question 28

Bronchopneumonia (patchy- acute inflammatory infiltrate)

Answer 28

S.pneumo, S. aureus, H. influenzae, Klebsiella

Question 29

Interstitial (atypical)

Answer 29

Mucoplasma, Chlamydia, Legionella, virus (RSV, CMV< influenza, adenovirus) Slower course, diffuse, patchy infiltrate

Question 30

Lung abscess

Answer 30

Collection of pus within parenchyma Causes: aspiration, bronchial obstruction (cancer) S&S: air-fluid levels Tx: Clindamycin (because infection generally caused by anaerobes- e.g. B. fragilis)

Question 31

Mesothelioma

Answer 31

Malignancy of the pleura Associated with asbestosis; psammoma bodies on histology CYTOKERATIN and CALRETININ + Smoking not a RF

Question 32

Pancoast tumor

Answer 32

Carcinoma of the apex of the lung Hoarseness --> recurrent laryngeal nerve Horner (ptsosis, anhidrosis, miosis) --> sympathetic chain Superior vena cava --> SVC syndrome Sensorimotor deficit

Question 33

SVC syndrome

Answer 33

JVD and upper extremity edema caused by tumor pressing on SVC or thrombosis from indwelling catheters Obstruction of right brachiocephalic vein will present similarly BUT only right side will be affected

Question 34

Lung cancer

Answer 34

LEADING CAUSE OF DEATH S&S: cough, hemoptysis, brochial obstruction, wheexing, coin lesion on CXR Can met to adrenals, brain, bone, liver Mets are more common to the lung than primary lung tumors (often from breast, colon, bladder, prostate)

Question 35

Central

Answer 35

Squamous and Small cell are CENTRAL and caused by SMOKING

Question 36

Small cell lung ca

Answer 36

May secrete ACTH, SIADH, or Antibodies (against presynaptic Ca2+ channel or neurons) Associated with myc oncogenes Histology: neoplasm of neuroendocrine cells (Kulchitsky) --> small dark blue cells Chromogranin A + Enolase +

Question 37

Squamous cell carcinoma

Answer 37

Also central Cavitation, hyperCalcemia (produces PTHrP), and Cigarettes Keratin pearls

Question 38

Adenocarcinoma

Answer 38

Peripheral; most common lung ca in nonsmokers Associated with mutations in KRAS, EGFR, and ALK Can see clubbing Generally mucin + Bronchioloalveloar subtype --> looks thickening of alveolar walls (better prognosis) --> looks like hazy infiltrates in CXR

Question 39

Large cell

Answer 39

Anaplastic, undifferentiated; poor prognosis Pleomorphic giant cells; can secrete beta-hCG

Question 40

Bronchial carcinoid tumor

Answer 40

Good prognosis, mets rare carcinoid syndrome symptoms (flushing, diarrhea, wheezing) Chromogranin A +