19. Pulmonary Path 2 Flashcards
Restrictive lung disease is commonly interchangable with chronic INTERSTITIAL lung disease. Idopathic pulmonary fibrosis makes up about 20% of ILD (interstitial lung disease), including what three diseases?
idiopathic pulomonary fibrosis (IPF)
Non specific interstitial pneumoina (NSIP)
Cryptogenic organizing pneumonia (COP)
What is a heterogenous group of disorders with inflammation and fibrosis of the pulmonary interstitium?
Chronic interstitial lung disease
What disease refers to a clinicopathologic syndrome marked by progressive interstitial pulmonary fibrosis and respiratory failure with unknown cause?
idiopathic pulmonary fibrosis (IPF)
idiopathic pulmonary fibrosis (IPF) damages pulmonary tissues in waves of inflammation injury leading to fibrosis. A patient will usually present with dyspnea, tachypnea, crackles (velcro like), restrictive pattern on PFTs (dec. DLco,FVC) and what on CXR?*2
Bilateral basilar infiltrates Honeycomb lung (end stage)
NOTE: ground glass shadows indicated interstitial fibrosis
There are thought to be many contributing factors to IPF including urban areas (industrialized societies) and SMOKING. What other 2 are common factors?
increasing age (>50) - older pts Genetic factors (in family): *MUC5B, telomerase/surfactant mutations
When all the predisposing factors (age, smoking, genetics) add up, causing persistant alveolar epithelial injury/activation releasing profibrogenic factors, activated fibroblasts lead to increase PI3K/AKT signaling causing?
synthesis and depositition of collagen = interstitial fibrosis & resp failure
The histological pattern of fibrosis in IPF is referred to as ?
Usual interstitial pneumonia (UIP) (more pronounced in subpleural regions and along interlobular septa)
Post pulmonary bx for IPF, once can see UIP, which presents as normal areas, inflammation, fibroblast foci (patchy interstitial fibrosis) and?
peripheral honeycombing - will see all four patterns together
What has dense fibrosis and cystic spaces lined with hyperplastic type II pneumocytes or bronchiolar epithelium?
IPF - honeycomb lung!
IPF is becoming more common and has a progressive course, with most patients expiring from resp disease in 3-5 years. Medications to arrest fibrosis such as tyrosine kinase inhibitors and TGF-B inhibitors may work minimally, but the best therapy for IPF is?
lung transplatation
What disease has diffuse fibrosis of unknown etiology whose lung biopsies lack the diagnostic features of any other intersitial lung dz, but has very unique histology to differentiate it from other fibrosing diseases?
Non specfici interstitial pneumonia (NSIP)
Non specfici interstitial pneumonia (NSIP) histologically has uniform infiltrates and fibrosis, no heterogeneity, no fibroblast foci, no granulomata and a better prognosis than?
usual interstitial pneumonia UIP
*no honeycombing
NSIP has diffuse uniform pattern on inflammation/fibrosis, which are all of the same stage*. Clinically NSIP presents as chronic dyspnea and cough for several?
months
NOTE: cellular pattern patients tend to be younger than those with fibrosing and have even better prognosis
What dz is formerly known as bronchiolitis obliterans organizing pneumonia (BOOP) with a unknown etiology, usually presenting with cough and dyspnea?
Cryptogenic organizing pneumonia (COP)
Cryptogenic organizing pneumonia (COP) presents as a pneumonia like consolidation in patients in their 50-60s, commonly have a past URI. Histologically what is characteristic of this dz?
Fibroblast foci called Masson bodies* which are polypoid plugs/swirls of loose CT within alveoli
Cryptogenic organizing pneumonia (COP) is diagnosed via exclusion( not infection, drug or toxin induced, or related to a connective tissue DO). What is the prognosis and tx?
Good prognosis and patients recovery fully from oral steroids
diffuse interstitial lung fibrosis gives rise to restrictive lung disease characterized by reduced lung compliance and reduced forced vital capacity. the ratio FEV1to FVC is?
NORMAL (because both decrease)
Autoimmune/CT disease can manifest as ILD, including SLE, systemic sclerosis (NSIP more common) and?
rheumatoid arthritis
If ILD occurs as a manifestation of these conditions, they are not diagnosed as pure disease, prognosis is linked to?
the severity of the underlying condition
What is a multi-system granulomatous disease of unknown etiology that can involve several organs and tissues, lung involvement or bilater hilar lymphadenopathy in 90% of cases?
Sarcoidosis
With sarcoidosis, you will see granulomatous inflammation with epithelioid histiocytes, mø, giant cells, WITHOUT what?
necrosis!
sarcoidosis manifests as non-caseating, non-necrotizing granulomata
Clinically it presents as dyspnea or more commonly incidental abnormal radiograph. There are 4 stages of sarcoidosis, 1 including only hilar lypmhadenopathy, stage 2 hilar lymphadenopathy and pulm infiltration, stage 3 is pulm infiltration only, and stage 4?
Fibrosis
most common is stage 1 NOTE: stages are not in order- people can jump around
sarcoidosis has granuloma inclusions such as laminated concretions composed of calcim and proteins known as Schaumann bodies and also have stellate inclusions known as?
Asteroid bodies (both these are found within giant cells 60% of the time)
Patients with sarcoidosis tend to be under the age of 40 years, and commonly involve lungs, lymph nodes, anyplace. There is a 10x increased risk in?
African americans
Again, sarcoidisis will present as dyspnea or incidental finding on radiology, likely to be immune related etiology with possible genetic predispostition. What serum levels will be elevated?
Serum angiotensin converting enzyme ACE
20% of patients have progressive lung disease with sarcoidosis, death may occur from pulmonary, cardiac or ?
neurologic involvement
Along with the lung disease, sarcoidosis pts may have spleen/liver involvments, lesions of bone resorption on phalangeals, subcutaneous nodules/red plaques, mucus membane lesions, iridocyclitis (corneal opacities, glaucoma), and what syndrome which is bilateral sarcoidosis of the major salivary gland?
Mikulicz syndrome
note: sarcoidosis is diagnosed via biopsy with noncaseating granulomas
What dz is a spectrum of immunologically mediated interstitial disorders due to inhaled organic antigens, primarily affecting the alveoli = extrinsic alveolar alveolitis?
Hypersensitivity pneumonoitis
Hypersensitivity pneumonoitis can be seen histologically with chronic inflammation and almost no normal parynchema at all along with granulomatous inflammation. What are the 3 different types of immune reaction to inhaled antigen?
Pigeon breeders lung (protein from bird poo) Farmers lung (actinomycetic spores in hay) Hot tub (rxn to mycobacterium avium complex MAC)
Hypersensitivity pneumonoitis is an airway centered granulomata reaction with associated lympochytes. What is a very important part of the dx of this dz?
THE HISTORY
Noncaseating granulomas present in 2/3 of the patients with Hypersensitivity pneumonoitis, T cell mediated type 4 HS. Clinically it is variable: recurring fever, dyspnea, cough. Pulmonary tests indicate what?
restrictive lung dz (FEV1/FVC is normal)
What is a past or present smokers disease seen with larger patchy collections of smokers macrophages in alveoli of a current or former smoker?
DSIP (Desquamative interstitial pneumonia)
DSIP (Desquamative interstitial pneumonia) occurs in smokers in their 40-50s and have restrictive lung disease presentation with histology showing VERY characteristic ‘stuffed’?
alveolar spaces full of macrophages
alveolar septa are thickened by inflam infiltrate of lymphcytes, plasma cells, sometimes eosinophils
DSIP (Desquamative interstitial pneumonia) has a good prognosis - greater than 95% survival rate at 5 years, and be treated in what two ways?
STOP SMOKING
corticosteroids
(excellent response)
What dz is part of a spectrum with DSIP but less symptomatic and has an earlier presentation of 30-40s and is smoking related?
Respiratory bronchiolitis-Interstitial lung disease (RB-ILD)
Respiratory bronchiolitis-Interstitial lung disease (RB-ILD) can be diagnosed via chest CT which would prompt for a?
biopsy
Respiratory bronchiolitis-Interstitial lung disease (RB-ILD) histologically you can see macrophages present to a lesser extent (smokers macrophages like DSIP), may have mild peribronchiolar fibrosis and ?
peribronchiolar metaplasia (abnormally located ciliary cells
Respiratory bronchiolitis-Interstitial lung disease (RB-ILD) is often reversible if?
smoking is stopped early
What is a rare disease of young adult smokers, with most cases resolving with smoking cessation suggesting that the lesions are reactive inflammatory process?
Pulmonary langerhans cell histiocytosis (LCH)
Pulmonary langerhans cell histiocytosis (LCH) has progressive scarring leading to cysts which can rupture and cause?
pneumothorax
histologically, Pulmonary langerhans cell histiocytosis (LCH) has eosinophils, nodules with langerhans cells (immature dendritic cells w grooved nuclei) and varying fibrosis/cysts.. What is a characteristic of this dz?
Stellate (star) lung lesions
Pulmonary langerhans cell histiocytosis (LCH) has eosinophils (pink tinge throughout langerhans) and will also test positive for ? 2
S100
CD1A
What is a rare entity characterized by surfactant accumulation in alveoli and bronchioles due to defects related to GM-CSF (granulocyte macrophage colony stimulating factor) or pulmonary macrophage dysfunction?
Pulmonary alveolar proteinosis (PAP)
There are 3 types of Pulmonary alveolar proteinosis (PAP), including autoimmune (most common >90%), secondary and hereditary (least common-neonates fatal). Typically is middle aged female and due to impaired metabolism of surfactant = too much, how can it be tx?
GM-CSF subcutaneously
Pulmonary alveolar proteinosis (PAP) is characterized by granular pink proteinaceous collection filled in alveolar spaces. If a lung lavage is done, what does it show?
COPIOUS amounts of milk fluid (so much surfactant)
Pulmonary alveolar proteinosis (PAP) is periodic acid schiff (PAS) positive, with MARKED increase in size and weight of the lung, clinically pts present with cough with abundant sputum containing chunks of?
gelatinous material - pathognomonic
What is common in bedridden pts or those with hypercoagublability, such as severe burns, trauma, frature pts, with DVT causing 95% of the cases?
Pulmonary embolism
Pulmonary embolism occurs in pts predisposed to clotting such as cardiac issues prolonged imobilization, hip frature, hypercoagulability (factor V leiden), obesity, IV lines and what in women?
Oral contraceptives/pregnancy
Emboli can cause hemorrhage or infarct, infarcts occuring in the lower lobes, causing what shaped lesions due to radiating pattern vessels?
wedge shaped infarcts
What should one look for on autopsy to know of the embolism was post mortem or ante mortem?
Lines of Zahn = ante-mortem
An pulmonary infarct over time is classically hemorrhagic and appears red-blue in early stages with the apposed pleural surface covered by a fibrinous exudate overlying fibrinous pleuritis which can form a ?
pleural friction rub
Large (saddle) pulmonary embolism causes instantaneous death due to electromechanical dissociation (no pulse cause no blood). Does the patient die d/t heart or lung problems?
HEART! right heart failure/cor pulmonale
no pulmonary infarcts are seen
Emboli present as transient chest pain, hemoptysis, cough and fever and on CXR a wedge shaped infiltrate 12-36hrs after.. DVTs are diagnosed via?
duplex ultrasound
Bone marrow embolisms are seen in trauma (breaking ribs when doing CPR) and are usually accompanied by fat embolism. What can be seen in IVDU on histology, seen as irridescent and shiny lesions, which under polarized light looks refractile?
Talc Embolism
What can cause nodules in IVDU, which come off of heart valves and cause neutrophilic inflammation leading to infection with abscesses/cysts?
Septic Emboli from vegetations usually off the tricuspid valve
Septic emboli are bloodborne infective material and may occur in endocarditis where valve vegetations break off and manifest in other sites. What are 3 common symptoms/ presentations?
Skin microemboli seen as Janeway lesions
Retinal microemboli: Roth spots
Vascular dam in nail bed: Splinter hemorrhage
What is known as the mean pulmonary artery pressure (PAP) of being greater than 25mmhg at rest?
Pulmonary HTN
There are five world health organization subgroups of pulm HTN including:
1) PAH (pulmonary arterial hypertension-primary vascular disease)
2) Secondary to heart failure
3) Secondary to chron pulm parenchymal dz
4) secondary to thromboembolic pulm dz
5)
multifactorial
NOTE 2/3 are most common
How does one measure pulmonary artery pressure PAP?
via a catheter into the lungs
(primary) Familial pulmonary HTN is due to a mutation in bone morphogenetic protein receptor type 2 which in mutations inhibit proliferation and favor apoptosis, What is the gene associated?
BMPR2
All forms of pulmonary hypertension are associated with medial hypertrophy of the pulmonary muscular and elastic arteries, pulm arterial atherosclerosis and RV hypertrophy. What is medial hypertrophy?
smooth muscle in small arteries in medial layer in lung is thickened
What is an extreme spectrum of pathologic change which is very characteristic of pulmonary hypertension and can give a better diagnosis?
Plexiform lesions which is a tangled tuft/knot of capillary formations, producing a network or web that spans the lumens of vessels.
What is a dramatic complication of some interestitial lung disorders which include goodpasture, granulomatosis with polyangitis and idiopathic pulmonary hemosiderosis?
Pulmonary hemorrhage syndromes
With pulmonary hemorrhage syndromes, you tend to see bright red hemoptysis, be anemic and have hemorrhage, can also see what in the alveoli?
blood
What syndrome is caused by autoantibodies agains the noncallagenous domain of collagen IV a3 chain- anti-basement membrane?
Goodpasture syndrome
Goodpasture syndrome can be seen in teens to late 20s in males and common in active smokers. What can be seen on immunofluorescense?
LINEAR pattern of deposition due to anti basement membrane antibodies with pulmonary hemorrhage
Clinical disease results from ab-mediated damage to basement membranes in lung/ renal with MASSIVE hemoptysis- what type of HS reaction?
Type 2 since the IF is linear meaning no complexes
in goodpasture, the lungs are heavy with areas of red-brown consolidation, alveoli contain intraalveolar hemorrhage and what type of mø?
hemosiderin laden macrophages
What has an unknown etiology, a disease of children with intermittent diffuse alveolar hemorrhage and present with cough and hemoptysis?
Idiopathic pulmonary hemosiderosis IPH
Idiopathic pulmonary hemosiderosis IPH is similar to goodpasture but there are no?
anti basmenet membrane antibodies in the serum
What dz is PR3-ANCA positive, autoimmune disease present with hemoptysis including the Upper resp. tract and or lungs?
Granulomatosis with polyangitis (wegners)
Granulomatosis with polyangitis (wegners) will have capillaritis and scattered, poorly formed granulomas (sarcoidosis is well defined), the granulomas will have?
necrosis and cause cavitations with coagulated blood within
Pulmonary infections- pneumonia is the second MCC of hospital admissions, worlds leading cause of death under 5, half of all nonimmunocompromised adults hospitalized for penumonia 18-64s, 1/2 deaths from pneumococcal penumonia occur in 18-64y/o. Pneumonia is the MCC of septic shock and?
Sepsis
Pneumonia can be classified by clinical setting such as community acquired pneumonia, healt care associated, hospital acquired, aspiration, chronic, or pneumonia in an?
immunocompromised host
*what kind of bacterial/virus depends on the setting
Pneumonia can also be classified by anatomical location such as bronchopneumonia or?
lobar pneumonia
What does lobar pneumonia mean?
that there is a strict distribution of inflammation and pneumonia only in one lobe, restricted by the fissures
Lobar pneumonia can be clinically diagnosed with characteristic radiographic appearance (horizontal line where fissure is). Pathologic sequence offers insight to the course of the?
disease process
There are four stages of lobar pneumonia inflammatory response, the first stage is congestion (1-2days) in which the lung is heavy, boggy and red, characterized by?
vascular engorgement*, intra alveolar fluid with few neutrophils and numerous bacteria
After the first stage of lobar pneumonia, the second stage (2-4days) is what, which is characterized by massive neutrophilic exudation with RBCs and fibrin that fill the alveolar spaces- red firm, and airless with a liver like consistency?
Red hepatization
After red hepatization, the third stage (4-8days) is grey hepatization which is a sequale of red hepatization and characterized by progressive disintegration of red cells and persistence of fibrinosuppurative exudate that leads to?
grey-brown color (debris)
The last stage after grey hepatization is resolution (1-3weeks), which is characterized by fibrosis and debris that is ingested by?
macrophages (clean-up) or organized by fibroblast growing into it
(RBC are gone)
Lobar pneumonia is dangerous, always caused by bacterial organisms, leading to consolidation of a lobe complications includ *asbcess formation, and what other two?
empyema: intrapleural pus
Bacteremia (sepsis)
Community acquired bacterial pneumonia is MOST commonly caused by what bacteria, which is characterized as lancet shaped, gram positive diplococci in pairs and chains?
Streptococcus pneumoniae (lobar distribution)
Vaccination for Strep pneumo is recommended for infants and patients older than 65, and in?
respiratory disease/smokers
What bacteria is the most common bacterial cause of acute exacerbation of COPD, and also a very virulent pneumonia in children with a recommened vax for type B for children 5 and under?
Haemophilus influenzae
pediatric emergency w high mortality rate, but is decreasing d/t vax
Staphylococcus aureus is a common secondary bacterial pneumonia in children and adults post-viral respiratory illness (measles/flu)… What are two demographics of staph areus?
Seen in IVDU
abscess formation
What organism is the most frequent cause of gram negative bacterial pneumonia, especially in CHRONIC alcoholics, who present with a thick mucoid sputum or currant jelly sputum?
Klebsiella pneumoniae (-)
What organism is the MCC of nosocmial infection, commonly seen in CF, burn patients and pts with neutropenia? (copper rust green)
Pseudomonas aeruginosa
Typical bacterial pneumonia has a more abrupt onset, resp sx dominate, consolidation on CXR, and more commonly in older adults or young children. What about atypical or walking pneumonia?
Slower onset Systemic sx predominate PATCHY infiltrates on CXR Young adults/teens/older children Have no resp sx, commonly see fever/HA
Typical bacterial pneumonia is lobar and consolidated while what can be seen on CXR for atypical or walking pneumonia?
patchy infiltrates with fine lines pattern
Atypical pneumonia is caused by legionella pneuomophila, chlamydia pneumonia, chlamydia psittaci and what, which is the MCC and is neither gram neg or pos?
Mycoplasma Pneumoniae (tx with way diff abx like macrolide)
Mycoplasma pneumoniae is the smallest free living, self preplicating microorganism common in young children and military camps- what does the organism lack?
A CELL WALL (hard to tx)
cold agglutinants & bullous myringitis - tympanic membrane in eardrum infxn
What bacterial organism is unsual in the fact that it spreads like a virus and affected many people via water contamination or aerosolization? It is a gream negative bacillus which grows in warm freshwater (misters/Hot tubs/AC units)
Legionella pneumophila
dx with culture, antigens in urine- grown on chocolate agar use a silver stain to detect
Community acquired viral pneumonia can see patchy/lobar areas of congestion without* consolidation, interstitial pneumonitis occurs with widened , edematous alveolar walls and mononuclear inflammation, and WHAT forms due to diffuse alveolar damage?
Hyaline membranes
What are the three most common causes of community acquired viral pneumonia?
H1N1 influenza
SARS
Respiratory Syncytial Virus
Comm. accquired viral pneumonia - influenza virus is classified by 2 proteins, hemagglutinin and neuraminidase, which do what?
hemagglutinin: attaches virus to cell
neuraminidase: allows release of replicated virus from host cell (cleaves HA anchoring the viron to the host, the virion is released to infect other body cells)
What is the MOA of tamiflu?
It inhibits neuraminidase function, not allow the virus to spread to other cells to replicate
The major signs/sx of influenza include an abrupt onset, fever for 3-4 days, severe aches, chills, fatigue and ?
Headache is common along with chest discomfort and cough
What occurs due to mutation in hemagluttinin and neuraminidase proteins that create new viral strains which elude antibodies produced to prior exposure to other strains?
Localized epidemic or Antigenic DRIFT
similar enough to originial virus allowing for immunity in some
What occurs when hemagluttinin and neuraminidase genes are replaced due to recombination of influenza virus with animal influenza viruses?
Antigenic SHIFT or Pandemics (major)
What influenza type was responsible for pandemics from 1918-1919 in the spanish flu, causing more than 30million deaths worldwide?
Influenza H1N1 (avian(bird) gave H1N1 to humans)
In 1957 the asian infuenza had a high mortality rate a combination of avian (H2N2) and human (h1n1) viruses. in 1968, hong kong influenza was due to avian H3 virus combining with?
H2N2 human virus
in 2009 in mexico, swine flu killed 200,000 people. The avion H1N1 combine with human flu and was harboured in pigs. Pigs transmitted it to humans via inhaling viral particles and human to human via same route. What were the sx?5
high fever coughin sneezing breathing difficulties loss of appetite
Severe acute respiratory syndrome SARS is a common cold virus named? It originated in china and there was a world outbreak in 2002-2004 which infects the lower resp tree and spreads systematically. uncommon for a patient to have this- has animal reservior
Coronavirus
Pneumonia in children varies by age. In newborns/neonatal the most common infection is from MOM, and includes listeria, gram negative bacilli and?
group B strep
In children older than 1 month there are both viral and bacterial, viral include parainfluenza virus, influenza A/B, adenovirus, rhinovirus, and which most important one?
respiratory syncytial virus (RSV)
In children older than 1 month, there are common bacterial pneumonia including S. pneumoniae, H. influenzae, M. catarrhalis and?
S. Aureus
In older children and adolescents we see what type of pneumonia, induce by M. pneumoniae and C. pneumoniae?
Atypical/Walking pneumonia
Respiratory syncytial virus (RSV) is a collection of nuclei within a cell. Patients present with rhinorrhea and cough, wheezing and dyspnea, tachypnea and cyanosis… What is the organism that causes this?
paramyxovirus
RSV is associated with excess mucus and inflammed small bronchiole walls which causes?
the symptoms associated with RSV
Human Metapneumovirus MPV is a paramyxoviurs associated with upper and lower respiratory infections, causes bronchiolitis and pneumonia in young, old and immunocompromised- INDISTINGUISIBLE from those caused by RSV. Which is more common?
RSV is Number 1
MVP is number 2
(occurs in early childhood and reinfection is common throughout life)
What are three important vaccinations to become immune to?
measles
pertusis
diphtheria
What is the main difference between the histology of pneumonia in bacterial vs viral patients?
bacterial will be inflammed with RBCs filled in the alveolar spaces, spread with no boundaries (besides fissures)
Viral will STAY in the interstitum ***
What is the difference between bact and viral pneomonia presentations? Bacterial Abrupset onset Not associated w epidemics (besides elgionella/pertussis) May have associated bacteremia HIGH GRADE FEVER crackles on lung exam Lobar or consildated appearance*** may involve pleura Responds quick to Abx Viral?
Viral gradual onset Epidemics are COMMON not associated with viremia no fever or have low grade fevers wheezes on lung exam DIFFUSE infiltrates on CXR Not typically involve pleura No response to abx but is self limiting
What are the most common pneomonias associated with health care (nursing home/ hospital)?
Methicillin resistant Staphylococcus Aureus (MRSA) and pseudomonas aeruginosa
Long term hospital acquired pneumonia is commonly cause by gram + cocci (staph aureus/strep pneumonia, gram - rods: enterobacteriaceae/pseudomnonas and gram - bacilli =
ventilator associated pneumonia
What type of cells are seen in bacterial infection vs viral infection?
bacterial = neutrophils viral = lymphocytes
What type of pneumonia occurs in markedly debilitated patients with abnormal gag and swallowing reflexes, caused by aerobs more than anaerobes, seen also in chronic alcoholics and elderly patients post stroke causing LUNG ABSCESSES?
Aspirtation pneumonia which leads to tissue necorsis and abscess formation
Lung abscesses are a local suppurative necrosis of lung tissue- airfluid levels are very characteristic, who can get these?
Complications of pneumonia (S aureus and K pneumoniae) Aspiration of (food?)
The location of lung abscesses depend on cause: aspiration based are more common on the right side and single. Pneumonia based abscesses are typically located?
basally and are found in multiples
Lung abscesses histologically **(cardinal) have suppurative destruction of the lung parenchyma with central area of cavitation, clinically presents as cough, fever, chest pain and COPIOUS amounts of foul smelling?
purulent or sanguineous sputum (bronchiectasis and lung abscess = foul smelling sputum)
Tb symptoms are commonly due to secondary or reactivated Tb. primary infxn occurs causing caseation in lymph nodes and lung tissue and will either heal (not common) or become?
Latent lesions
From latent lesions after primary infection, there may be a reactivation and secondary Tb occurs, which is bad. Causing localized caseating destructive lesions in the lungs and kidneys and can progress causing what?
massive hematogenous dissemintation = MILIARY Tb deadly once in blood - can see lesions in liver and spleen too
A primary (Ghon) complex is formed, consisting of a granuloma, typically in the middle or lower zones of the lung in combination with?
hilar lymphnodes + caseating tb = ghon complex
What is localized inflammation in immunocompetent patients without regional lymph node involvement, usually fulminant and widespread lasting for months?
Chronic pneumonia
There are 3 fungal organisms known to lead to chronic pneumonia, including histoplasma, blastomycosis and coccidiomycosis. Where can each be found geographically?
histoplasma- midwest
blastomycosis midwest w snail face
coccidiomycosis- desert valley- southwest
Which fungus is endemc in the midwest and carribean, which is typically a subclinical infection with granulomatous response w/ **calcifications or coin* lesions on CXR?
Histoplasma Capsulatum
Histoplasma can become fulminant disseminated histoplasmosis in immunocompromised pts with a agressive course. Buzz word tree bark appearance on histo and have characteristic yeast forms showing?
Pumpkin seed morphology
What dimorphic fungus is soil dwelling and occurs in central and southeast USA among other areas, which in the lung yeilds a granulomatous resopnse?
Blastomyces Dermatitides
Blastomyces usually involves upper lobe and will see lovar consolidation and can also infect skin and rarely causing a disseminated infection. What is the characteristic yeast form seen?
Broad Based Budding
BBBB- Blastomyces BBB) (two balls kissing eachother -Thick double-contoured cell wall with visible nuclei**
What fungus causing chronic pneumonia is found in southwest usa (arizona/mexico), spread by inhalaing spores which block fusion of phagosome and lysosome in the mø and resist intracellular killing?
Coccidiodes immitis (Valley fever-asymptomatic)
Coccidiodes in the lungs is uncommon, but yields a granulomatous response with EOSINOPHILS, often subclinical and self-limited unless you are?
Immunocompromised = disseminated infection
Coccidiodes histologically will be able to see within mø, the fungus is seen as a thick wall NONBUDDING what?
spherules filled with ENDOSPORES*** characteristic
What is an opportunistic fungal infection that is an AIDS-defining illness which can be diffuse or focal, and has characteristic CUP SHAPED yeast forms?
Pneumocystic jiroveci (carinii)
What is a bacterial organism in the immunocompromised or elderly patients with thin mycobacteria seen as slender RED forms on acid-fast staining?
Mycobacterium avium complex (MAc)
What is extremely important to remember when trying to label an organism to pneumonia?
The method of acquisition of pneumonia will impact the differential for the causative organism :)
Lung transplants are indicated for emphysema (not blue bloaters), IPF (end stage honeycomb), cystic fibrosis, prim pulm HTN, usually one single lung is tranplanted. What is needed to determine the difference between infections and rejections?
Lung biopsy (either infections and rejections will show bilateral lung infiltrates with fever 5 days post transplant)
Lung rejection will show mononuclear infiltrates around the vessels (acute rejection), infection is most common with fungal zygomycosis or CMV (opportunistic infections)… How would one treat rejection compared to infection?
Treating rejecting would involve increasing immunosuppression
Treating infection would involve decreasing immunosuppression
