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Pathoma > Respiratory Tract Pathology > Flashcards

Respiratory Tract Pathology Flashcards

1
Q

Rhinitis

A

Inflammation of the nasal mucosa –> rhinovirus is the most common cause
- presents with sneezing, congestion and runny nose (common cold)

Allergic rhinitis is a subtype of rhinitis –> due to type I hypersensitivity reaction (e.g. to pollen)

  • characterized by an inflammatory infiltrate with eosinophils
  • associated with asthma and eczema
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2
Q

Nasal polyp

A

Protrusion of edematous, inflamed nasal mucosa

  • usually secondary to repeated bouts of rhinitis; also occurs in CF and aspirin-intolerant asthma
  • aspirin intolerant asthma –> characterized by the triad of asthma, aspirin induced bronchospasms, and nasal polyps
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3
Q

Angiofibroma

A

Benign tumor of nasal mucosa composed of large blood vessels and fibrous tissue

  • classically seen in adolescent males
  • presents with profuse epistaxis
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4
Q

Nasopharyngeal carcinoma

A

Malignant tumor of nasopharyngeal epithelium

  • associated with EBV –> classically seen in african children and chinese adults
  • biopsy usually reveals pleomorphic keratin positive epithelial cells (poorly differentiated squamous cell carcinoma) in a background of lymphocytes

Often presents with involvement of cervical lymph nodes

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5
Q

Acute epiglottitis

A

Inflammation of the epiglottis
- H. influenza type b is the most common cause, especially in non-immunized children

Presents with high fever, sore throat, drooling with dysphagia, muffled voice, and inspiratory stridor –> risk of airway obstruction

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6
Q

Laryngotraceobronchitis (croup)

A

Inflammation of the upper airway
- parainfluenza virus is the most common cause

Presents with a hoarse, barking cough and inspiratory stridor

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7
Q

Vocal cord nodule

A

Nodule that arises on the true vocal cord

  • due to excessive use of vocal cords
  • usually bilateral
  • composed of degenerative (myxoid) connective tissue

Presents with hoarseness; resolves with resting of voice

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8
Q

Laryngeal papilloma

A

Benign papillary tumor of the vocal cord

  • due to HPV 6 +11
  • papillomas are usually single in adults and multiple in children

Presents with hoarseness

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9
Q

Laryngeal carcinoma

A

Squamous cell carcinoma usually arising from the epithelial lining of the vocal cord

Risk factors:

  • alcohol
  • tobacco
  • can rarely arise from a laryngeal papilloma

Presents with hoarseness
- other signs include cough + stridor

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10
Q

Pneumonia

A

Infection of the lung parenchyma
- occurs when normal defenses are impaired (e.g. impaired cough reflex, damage to mucociliary escalator, or mucus plugging)

Clinical features

  • fever and chills
  • productive cough with yellow-green (pus) or rusty (bloody) sputum
  • tachypean with pleuritic chest pain
  • decreased breath sounds
  • dullness to percussion
  • elevated WBC count

Diagnosis –> made by chest x ray, sputum gram stain + culture, and blood cultures

3 patterns classically seen on chest x ray:

  1. lobal pneumonia
  2. bronchopneumonia
  3. interstitial pneumonia
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11
Q

Lobar pneumonia

A

Characterized by consolidation of an entire lobe of the lung
- usually bacterial –> most common causes are streptococcus pneumoniae (95%) + Klebsiella pneumoniae (5%)

Classic gross phases of lobar pneumoina:

  1. congestion –> due to congested vessels and edema
  2. red hepatization –> due to exudate, neutrophils and hemorrhage filling the alveolar air spaces, giving the normally spongy lung a solid consistency
  3. grey hepatization –> due to degradation of red cells within the exudate
  4. resolution
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12
Q

Bronchopneumonia

A

Characterized by scattered patchy consolidation centered around bronchioles

  • often multifocal and bilateral
  • caused by a variety of bacterial organisms
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13
Q

Interstitial (atypical) pneumonia

A

Characterized by diffuse interstitial infiltrates

  • presents with relatively mild upper respiratory symptoms –> minimal sputum and low fever = atypical presentation
  • caused by bacteria or viruses
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14
Q

Aspiration pneumonia

A

Seen in patients at risk for aspiration –> alcoholics + comatose patients

  • most often due to anaerobic bacteria in the oropharynx –> bacteroides, fusobacterium + peptococcus
  • classically results in a right lower lobe abscess –> anatomically, the right main stem bronchus branches at a less acute angle than the left
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15
Q

Causes of lobar pneumonia

A
  1. Strep pneumo –> most common cause of CA pneumonia and secondary pneumonia (bacterial pneumonia superimposed on a viral upper respiratory tract infection)
    - usually seen in middle aged adults and the elderly
  2. Klebsiella pneumoniae –> part of enteric flora that is aspirated, affects malnourished and debilitated individuals, especially elderly in nursing homes, alcoholics and diabetics
    - thick mucoid capsule results in gelatinous sputum = currant jelly
    - often complicated by abscess
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16
Q

Causes of bronchopneumonia

A
  1. Staph aureus –> 2nd most common cause of secondary pneumonia; often complicated by abscess or empyema
  2. Haemophilus influenzae –> common cause of secondary pneumonia and pneumonia superimposed on COPD (leads to exacerbation of COPD)
  3. Moraxella catarrhalis –> CA pneumonia and pneumonia superimposed on COPD (leads to exacerbation of COPD)
  4. Llegionella pneumophilia –> CA pneumonia, pneumonia superimposed on COPD, or pneumonia in immunocompromised states
    - transmitted from water source
    - intracellular organism that is best visualized by silver stain
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17
Q

Causes of interstitial/atypical pneumonia

A
  1. Mycoplasma pneumoniae –> most common cause of atypical pneumonia, usually affects young adults
    - complications include autoimmune hemolytic anemia (IgM against I antigen on RBCs causes cold hemoltyic anemia) + erythema multiforme
    - not visible on gram stain due to lack of cell wall
  2. Chlamydia pneumoniae –> second most common cause of atypical pneumonia in young adults
  3. Respiratory syncytial virus (RSV) –> most common cause of atypical pneumonia in infants
  4. CMV –> atypical pneumonia with post transplant immunosuppressive therapy
  5. Influenza virus –> atypical pneumonia in the elderly, immunocompromised, and those with pre-existing lung disease
    - also increases the risk for superimposed S. aureus or H. flu bacterial pneumonia
  6. Coxeilla burnetti –> atypical pneumonia with high fever (Q fever), seen in farmers and vets
    - coxiella spores are deposited on cattle by ticks or are present in cattle placentas
    - coxiella is a rickettsial organism, but distinct from most rickettsiea because it…
    - –> causes pneumonia
    - –> does not require arthropod vector for transmission (survives as highly heat resistant endospores)
    - —> does not produce a skin rash
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18
Q

Tuberculosis

- primary TB

A

Due to inhalation of aerozolized mycobacterium tuberculosis

Primary TB arises with initial exposure –> results in focal, caseating necrosis in the lower lobe of the lung and hilar lymph nodes that undergoes fibrosis and calcification, forming a Ghon complex

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19
Q

Secondary TB

A

Arises with reactivation of mycobacterium tuberculosis

  • reactivation is commonly due to AIDS, may also be seen with aging
  • occurs at apex of lung –> relatively poor lymphatic drainage + high oxygen tension
  • forms cavitary foxi of vaseous necrosis, may also lead to miliary pulmonary TB or tuberculous bronchopneumonia

Clinical features

  • fevers
  • night sweats
  • cough with hemoptysis
  • weight loss

Biopsy revelas caseating granulomas; AFB stain reveals acid fast bacilli

Systemic spread often occurs and can involve any tissue –> common sites:

  • meninges –> meningitis
  • cervical lymph nodes
  • kidneys –> sterile pyuriva
  • lumbar vertebrae –> Pott disease
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20
Q

Basic principles of COPD

A

Group of diseases characterized by airway obstruction –> lung does not empty, and air is trapped

  • volume of air that can be forcefully expired is decreased (decreased FVC), especially during the first second of expiration (very decreased FEV1) –> results in decreased FEV1: FVC ratio
  • total lung capacity is usually increased due to air trapping
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21
Q

Chronic bronchitis

A

Chronic productive cough lasting at least 3 months over a minimum of 2 years –> highly associated with smoking

Characterized by hypertrophy of bronchial mucinous glands –> leads to increased thickness of mucus glands relative to bronchial wall thickness

  • Reid index increases to >50%, normal is mucus plugs trap CO2 = increased PaCO2 + decreased PaO2
  • increased risk of infection and cor pulmonale
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22
Q

Emphysema

A

Destruction of alveolar air sacs –> loss of elastic recoil and collapse of airway during exhalation results in obstruction and air trapping

Due to imbalance of protease and antiproteases

  • inflammation in the lung normally leads to release of proteases by neutrophils and macrophages
  • alpha1 antitrypsin (A1AT) neutralizes proteases
  • excessive inflammation of lack of A1AT –> leads to destruction of the alveolar air sacs

Smoking is the most common cause of emphysema

  • pollutants in smoke lead to excessive inflammation and protease mediated damage
  • results in centriacinar emphysema that is most severe in the upper lobes
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23
Q

A1AT deficiency

A

A rare cause of emphysema

  • lack of antiprotease leaves the air sacs vulnerable to protease-mediated damage
  • results in panacinar emphysema that is most severe in the lower lobes
  • liver cirrhosis may also be present
  • –> A1AT deficiency is due to misfolding of the mutated protein
  • –> mutated A1AT accumulates in the ER of hpatocytes, resulting in liver damage
  • –> biopsy reveals pink, PAS-positive globules in hepatocytes

Disease severity is based on the degree of A1AT deficiency

  1. PiM = normal allele –> two copies are usually expressed
  2. PiZ = most common clinically relevant mutation –> results in significantly low levels of circulating A1AT
  3. PiMZ = heterozygotes are usually asymptomatic with decreased circulating levels of A1AT –> significant risk for emphysema with smoking exists
  4. PiZZ homozygotes –> significant risk for panacinar emphysema and cirrhosis
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24
Q

Clinical features of emphysema

A
  • dyspnea and cough with minimal sputum
  • prolonged expiration with pursed lips
  • weight loss
  • increased anterior-posterior diameter of chest (barrel chest)
  • hypoxemia (due to destruction of capillaries in the alveolar sac) and cor pulmonale are late complications
25
Q

Asthma

A

Reversible airway bronchoconstriction, most often due to allergic stimuli (atopic asthma)
- presents in childhood –> often associated with allergic rhinitis, eczema, and a family history of atopy

Pathogenesis = type I hypersensitivity

  1. allergens induce TH2 phenotype in CD4 T cells of genetically susceptible individuals
  2. TH2 cells secrete…
    - –> IL4 = mediates class switch to IgE
    - –> IL5 = attracts eosinophils
    - –> IL10 = stimulates TH2 cells and inhibits TH1
  3. reexposure to allergen leads to IgE-mediated activation of mast cells –> release of preformed histamine granules and generation of leukotrienes C4, D4 + E4 lead to bronchoconstriction, inflammation and edema (early phase reaction)
    - inflammation, especially major basic protein derived from eosinophils, damages cells and perpetuates bronchoconstriction (late phase reaction)

Asthma may also arise from nonallergic causes (non-atopic asthma) such as exercise, viral infection, aspirin, and occupational exposures

26
Q

Cliniical features of asthma

A

Episodic and related to allergen exposure

  • dyspnea and wheezing
  • productive cough, classically with spiral shaped mucus plugs (Curschmann spirals) and eosinophil derived crystals (Charcot-leyden crystals)
  • severe, unrelenting attack can result in status asthmaticus and death
27
Q

Bronchiectasis

A

Permanent dilation of bronchioles and bronchi –> loss of airway tone results in air trapping

Due to necrotizing inflammation with damage to airway walls –> causes:

  1. CF
  2. Kartagener syndrome –> inherited defect of the dynein arm, whichis necessary for ciliary movement
    - –> associated with sinusitis, infertility (poor motility of sperm), and situs inversus (position of major organs is reversed)
  3. tumor or foreign body
  4. necrotizing infection
  5. allergic bronchopulmonary aspergillosis –> hypersensitivity reaction to aspergillus leads to chronic inflammatory damage
    - –> usually seen in individuals with asthma or CF
28
Q

Clinical features of bronchiectasis

A
  • cough, dyspnea, and foul smelling sputum
  • complications incude hypoxemia with cor pulmonale and secondary amyloidosis (AA) –> due to deposition of acute phase reactants
29
Q

Basic principles of restrictive lung disease

A

Characterized by restricted filling of the lung

  • decreased TLC, decreased FEV1, and extremely decreased FVC
  • FEV1: FVC ratio is increased

Most commonly due to interstitial disease of the lung
- may also arise with chest wall abnormalities (e.g. massive obesity)

30
Q

Idiopathic pulmonary fibrosis

A

Fibrosis of lung interstitium

  • etiology is unknown –> likely related to cyclical lung injury; TFG-beta from injured pneumocytes induces fibrosis
  • secondary causes of interstitial fibrosis such as drugs (bleomycin and amiodarone) and radiation therapy must be excluded

Clinical features:

  • progressive dyspnea and cough
  • fibrosis on lung CT –> initially seen in subpleural patches, but eventually results in diffuse fibrosis with end stage “honeycomb” lung

Treatment –> lung transplant

31
Q

Pneumoconioses

A

Interstitial fibrosis due to occupational exposure; requires chronic exposure to small particles that are fibrogenic
- alveolar macrophages engulf foreign particles and induce fibrosis

Types of pneumoconioses

  1. Coal workers’
  2. Silicosis
  3. Berylliosis
  4. Asbestosis
32
Q

Coal workers’ pneumoconiosis

A

Exposure: Carbon dust –> seen in coal miners

Pathologic findings: Massive exposure leads to diffuse fibrosis (‘black lung’); associated with rheumatoid arthritis (Caplan syndrome)

Comments:
- mild exposure to carbon (e.g. pollution) results in anthracosis = collections of carbon laden macrophages –> not clinically significant

33
Q

Silicosis

A

Exposure: Silica –>seen in sandblasters and silica miners

Pathologic findings: Fibrotic nodules in upper lobes of the lung

Comments:
- Increased risk for TB –> silica impairs phagolysosome formation by macrophages

34
Q

Berylliosis

A

Exposure: Beryllium –> seen in beryllium miners and workers in the aerospace industry

Pathologic findings: Noncaseating granulomas in the lung, hilar lymph nodes, and systemic organs

Comments: Increased risk for lung cancer

35
Q

Asbestosis

A

Exposure: Asbestos fibers –> seen in construction workers, plumbers, and shipyard workers

Pathologic findings: Fibrosis of lung and pleura (plaques) with increased risk for lung carcinoma and mesothelioma
- lung carcinoma is more common than mesothelioma in exposed individuals

Comments:
- lesions may contain long, golden brown fibers with associated iron (asbestos bodies) –> confirm exposure to asbestos

36
Q

Sarcoidosis

A

Systemic disease characterized by noncaseating granulomas in multiple organs
- classically seen in african american females

Etiology is unknown –> likely due to CD4+ helper T cell response to an unknown antigen

Granulomas most commonly involve the hilar lymph nodes and lung, leading to restrictive lung disease
- characteristic stellate inclusions (“asteroid bodies”) are often seen within gian cells of the granulomas

Other commonly involved tissues include

  • uvea = uveitis
  • skin = cutaneous nodules or erythema nodosum
  • salivary and lacrimal glands = mimics sjogren syndrome
  • almost any tissue can be involved
37
Q

Clinical features and treatment of sarcoidosis

A

Clinical features

  • dyspnea or cough –> most common presenting symptom
  • elevated serum ACE
  • hypercalcemia –> 1 alpha hydroxylase activity of epitheliod histiocytes converts vit D to its active form

Treatment is steroids –> often resolves spontaneously without treatment

38
Q

Hypersensitivity pneumonitis

A

Granulomatous reaction to inhaled organic antigens (e.g. pigeon breeders lung)

  • presents with fever, cough, and dyspnea hours after exposure; resolves with removal of the exposure
  • chronic exposure leads to interstitial fibrosis
39
Q

Basic principles of pulmonary hypertension

A

High pressure in the pulmonary circuit (mean arterial pressure > 25 mm HG, normal is 10 mm Hg)

Characterized by atherosclerosis of the pulmonary trunk, smooth muscle hypertrophy of pulmonary arteries, and intimal fibrosis
- plexiform lesions are seen with severe, long standing disease

Leads to right ventricular hypertrophy with eventual cor pulmonale
- presents with exertional dyspnea or right sided heart failure

Subclassified as primary or secondary based on etiology

40
Q

Primary pulmonary hypertension

A

Classically seen in young adult females

Etiology is unknown –> some familial forms are related to inactivating mutations of BMPR2, leading to proliferation of vascular smooth muscle

41
Q

Secondary pulmonary hypertension

A
  • due to hypoxemia –> COPD and interstitial lung disease
  • increased volume in the pulmonary circuit –> e.g. congenital heart disease
  • recurrent pulmonary embolism
42
Q

Acute respiratory distress syndrome

A

Diffuse damage to the alveolar capillary interface (diffuse alveolar damage)
- leakage of protein rich fluid leads to edema that combines with necrotic epithelial cells to form hyaline membranes in alveoli

Occurs secondary to a variety of disease processes

  • sepsis
  • infection
  • shock
  • trauma
  • aspiration
  • pancreatitis
  • DIC
  • hypersensitivity reactions
  • drugs
  • –> activation of neutrophils induces protease and free radical mediated damage of type I and type II pneumocytes
43
Q

Clinical features and treatment of ARDS

A

Clinical features

  • hypoxemia and cyanosis with respiratory distress - due to thickened diffusion barrier and collapse of air sacs (increased surface tension)
  • white out on chest x ray

Treatment

  • address underlying cause
  • ventilation with positive end expiratory pressure (PEEP)
  • recovery may be complicated by interstitial fibrosis –> damage and loss of type II pneumocytes leads to scarring and fibrosis
44
Q

Neonatal respiratory distress syndrome

A

Respiratory distress due to inadequate surfactant levels

  • surfactant is made by type II pneumocytes –> phosphatidylcholine (lecithin) is the major component
  • surfactant decreased surface tension in the lung, preventing collapse of alveolar air sacs after expiration
  • lack of surfactant leads to collapse of air sacs and formation of hyaline membranes
45
Q

What is neonatal respiratory distress syndrome associated with?

A
  1. Prematurity –> surfactant production begins at 28 weeks; adequate levels are not reached until 34 weeks
    - amniotic fluid lecithin to sphingomyelin ratio is used to screen for lung maturity
    - phosphatidylcholine (lecithin) levels increase as surfactant is produced; sphingomyelin remains constant
    - a ration >2 indicates adequate surfactant production
  2. C section delivery –> due to lack of stress induced steroids; steroids increase synthesis of surfactant
  3. Maternal diabetes –> insulin decreases surfactant production
46
Q

Clinical features and complications of neonatal respiratory distress syndrome

A

Clinical features

  • increasing respiratory effort after birth
  • tachypnea with use of accessory muscles
  • grunting

Complications

  • Hypoxemia increases the risk for persistence of PDA and necrotizing enterocolitis
  • supplemental Ox increases the risk for free radical injury
  • –> retinal injury leads to blindness
  • –> lung damage leads to bronchopulmonary dysplasia
47
Q

Basic principles of lung cancer

A

Most common cause of cancer mortality in the US
- average age of presentation is 60 years

Key risk factors are cigarette smoke, radon, and asbestos

  1. cigarette smoke contains over 60 carcinogens; 85% of lung cancer occurs in smokers
    - polycyclic aromatic hydrocarbons and arsenic are particularly mutagenic
    - cancer risk is directly related to the duration and amount of smoking (“pack years”)
  2. radon is formed by radioactive decay of uranium, which is present in soil
    - accumulates in closed spaces such as basements
    - responsible for most of the public exposure to ionizing radiation; second most frequent cause of lung carcinoma in the US
    - increased risk of lung cancer is also seen in uranium miners
48
Q

Presenting symptoms of lung cancer

A

Non specific –> cough, weight loss, hemoptysis, and postobstructive pneumonia

Imaging often reveals a solitary nodule (“coin lesion”) –> biopsy is necessary for diagnosis of cancer

Benign lesions, which often occur in younger patients, can also produce a coin lesion

  • granuloma –> often due to TB of fungus
  • bronchial hamartoma –> benign tumor composed of lung tissue and cartilage; often calcified on imaging
49
Q

Categories of lung carcinoma

A

Small cell carcinoma = 15%
- usually not amenable to surgical resection –> treated with chemo

Non-small cell carcinoma = 85% –> treated upfront with surgical resection, does not respond well to chemo

  • adenocarcinoma = 40%
  • squamous cell carcinoma = 30%
  • large cell carcinoma = 10%
  • carcinoid tumor = 5%
50
Q

Small cell carcinoma

A

Poorly differentiated small cells –> arises from neuroendocrine (Kulchitsky) cells

  • male smokers
  • centrally located
  • rapid growth and early metastasis
  • may produce ADH of ACTH or cause eaton lambert syndrome
51
Q

Squamous cell carcinoma

A

Characteristic histology –> keratin pearls or intercellular bridges

  • most common tumor in male smokers
  • centrally located
  • may produce PTHrP = hypercalcemia
52
Q

Adenocarcinoma

A

Characteristic histology –> glands or mucin

  • most common tumor in nonsmokers and female smokers
  • peripherally located
53
Q

Large cell carcinoma

A

Poorly differentiated large cells –> no keratin pears, intercellular bridges, glands, or mucin

  • associated with smoking
  • central or peripheral location
  • poor prognosis
54
Q

Bronhioloalveolar carcinoma

A

Columnar cells that grow along preexisting bronchioles and alveoli –> arises from clara cells

  • not related to smoking
  • peripherally located
  • may present with pneumonia-like consolidation on imaging
  • excellent prognosis
55
Q

Carcinoid tumor

A

Well differentiated neuroendocrine cells –> chromogranin positive

  • not related to smoking
  • central or peripheral location –> when central, classically forms a polyp like mass in the bronchus
  • low grade malignancy
  • rarely, can cause carcinoid syndrome
56
Q

Metastasis to the lung

A

Most common sources are breast and colon carcinoma

  • multiple cannon ball like nodules on imaging
  • more common than primary tumors
57
Q

TMN staging

A

T - tumor size and local extension

  • pleural involvement is classically seen with adenocarcinoma
  • obstruction of the SVC leads to distended head and neck veins with edema and blue discoloration of arms and face (SVC syndrome)
  • involvement of recurrent laryngeal nerve can leads to hoarseness or phrenic nerve can cause diaphragmatic paralysis
  • compression of sympathetic chain leads to horner syndrome –> ptosis (drooping eyelid),d miosis (pinpoint pupil) and anhidrosis (no sweating) –> usually due to an apical tumor (pancoast)

N - spread to regional lymph nodes (hilar and mediastinal)

M - unique site of distant metastasis is the adrenal gland
- also brain

Overall, 15% 5 years survival
- often presents late due to absence of an effective screening method

58
Q

Pneumothorax

A

Accumulation of air in the pleural space

Spontaneous pnuemothorax –> due to rupture of an emphysematous bleb, seen in young adults
- results in collapse of a portion of the lung –> trachea shifts to the side of collapse

Tension pneumothorax –> arises with penetrating chest wall injury

  • air enters the pleural space, but cannot exit –> trachea is pushed opposite to the side of injury
  • medical emergency –> treated with insertion of a chest tube
59
Q

Mesotheolioma

A

Malignant neoplasm of mesothelial cells –> highly associated with occupational exposure to asbestos

  • presents with recurrent pleural effusions, dyspnea, and chest pain
  • tumor encases the lung

Pathoma (16 decks)

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