Chapter 9 Flashcards
1
Q
What is the most common cause of rhinitis (sneezing, congestion, and runny nose)?
A
Rhinovirus
2
Q
What causea allergic rhinitis?
A
Type I hypersensitivity (e.g. to pollen) characterized by an inflammatory infiltrate with eosinophils
3
Q
What are the most common causes of nasal polyps?
A
Usually secondary to repeated bouts of rhinitis,
also occur in cystic fibrosis and aspirin-intolerant asthma
4
Q
What is the classic triad of aspirin-intolerant asthma?
A
asthma, aspirin-induced bronchospasm, and nasla polyps
5
Q
What is this?
A
Benign tumor of nasal mucosa composed of large blood vessels and fibrous tissue; classically seen in adolescent males
Presents with profuse epistaxis (nosebleeds)
6
Q
What is nasopharyngeal carcinoma?
A
A MALIGNANT tumor of nasopharyngeal epithelium associated with EBV
7
Q
Who commonly gets nasopharyngeal carcinomas?
A
Chinese adults and African children
8
Q
Describe the histo of a nasopharyngeal carcinoma
A
Pleomorphic keratin-positive epithelial cells in a background of LYMPHOCYTES
9
Q
What is the most common cause of epiglottitis?
A
H. influenzae type B (esp. in nonimmunized children)
10
Q
How does epiglottitis present?
A
High fever
sore throat, drooling with dysphagia, muffled voice
inspiratory stridor
11
Q
What is the most common cause of laryngotracheobronchitis (croup)?
A
Parainflunzae virus
12
Q
What is the most common cause of laryngotracheobronchitis (croup)?
A
Parainflunzae virus
13
Q
How does croup present?
A
Hoarse, ‘barking’ cough and inpiratory stridor
14
Q
What is this?
A
Vocal cord nodules (usually bilateral)- due to excessive use of the vocal cords and presents on the TRUE vocal cords
Composed of myxoid CT
15
Q
What is this?
A
Laryngeal papilloma- a BENIGN papillary tumor of the vocal cord due to HPV 6 and 11 (single in adults and multiple in children)
Presents with hoarseness
16
Q
What are laryngeal carcinomas?
A
Squamous cell carcinoma usually arising from the epithelial lining of the vocal cords
17
Q
What are the risk factors for laryngeal carcinomas?
A
alcohol and tobacco- can rarely arise from a laryngeal papilloma
Presents with hoarseness, cough, and stridor
18
Q
What is pneumonia?
A
Infection of the lung parenchyma that typically occurs when normal defense mechanisms are impaired (e.g. impaired cough reflex, damage to the epithelium)
19
Q
How does pneumonia present?
A
Fever and chills, productive cough with yellow-green or rusty (bloody) sputum, tachypnea with plueritic chest pain, decreased breath sounds, dullness to percussion, and elevated WBC count
20
Q
What are the major patterns of pneumonia?
A
Lobar, bronchopneumonia, and interstitial
21
Q
What is lobar pneumonia?
A
Marked by consolidation of an entire love of the lung
22
Q
What are the most common causes of lobar pneumonia?
A
Usually bacterial, most commonly Strep. pneumoniae (95%) and Klebsiella
23
Q
What are the histologic phases of lobar pneumonia?
A
- Congestion- due to congested vessels and edema
- Red hepatization- due to exudate, neutrophils, and hemorrhage filling the alveolar spaces
- Grey hepatization- due to degradation of red cells within the exudate
- Resolution
24
Q
What stage of lobar pneumonia is this?
A
Red hepatization
25
What stage of lobar pneumonia is this?
grey hepatization- macrophages
26
Lobar pneumonia
Lobar pneumonia
27
Describe bronchopneumonia
Marked by scattered patchy consolidation centered around bronchioles, often multifocal and BILATERAL
28
What are the most common causes of aspiration pneumonia?
Anaerobes in the oropharynx such as Bacteriodes, Fusobacterium, and Peptococcus
29
What is the most common cause of community-acquired pneumonia and secondary pneumonia superimposed on a viral URTI?
S. pneumoniae
30
Who gets Klebsiella pneumoniae?
This is an enteric flora that is aspirated commonly in malnourished and debilitated individuals, especially elderly, alcoholics, and diabetics.
**Red currant jelly** sputum
31
What are the major causes of bronchopneumonia?
Staph aureus
Haemophilus influenzae
Pseudomonas aeruginosa
Moraxella catarrhalis
Legionella pneumophilia (water sources)
32
Who gets Haemophilus influenzae or Moraxella catarrhalis pneumonia?
communtiy-acquired and pneumonia **superimposed on COPD**
33
Describe interstitial pneumonia (atypical)
Marked by diffuse interstitial infiltartes and presents with a relatively mild URTI (low feveer)
34
What are the most common causes of interstitial pneumonia?
Mycoplasma pneumoniae (classic in young adults, classically military recruits or dorm students
Chamydia pneumoniae
RSV (most common atypical in infants)
CMV (posttransplant pts. on immunosuppression)
Influenza virus
Coxiella burnetii
35
What are the major complications of Mycoplasma pneumoniae?
Autoimmune hemolytic anemia (IgM against I antigen on RBCs cause cold hemolytic anemia)
## Footnote
**Erythema multiforme**
36
Again, who gets CMV pneumoniae?
pts. on posttransplant immunosuppressive therapy
37
Who gets influenzae virus pneumoniae?
Atypical pneumonia in the elderly, immunocompromised, and those with preexisting lung disease.
## Footnote
**Also increases the risk for superimposed S. aureus or H influenzae bacterial pneumonia**
38
Coxiella is a rickettsial organism but it is distinct from most rickettsia. How?
1) It causes pneumonia
2) does not require qrthropod vector for transmission (survives as highly heat-resistant endospores)
3) Does not produce a skin rash
39
Aspiration pneumonia classically results in abscess where?
right lower lobe becase the right main stem branches at a less acute angle than the left
40
Tuberculosis is due to inhalation of aerosolized M. tb. How does primary TB present?
Results in a focal, caseating granuloma formation in the LOWER lobe and hilar lymph nodes that undergoes fibrosis and calcification, form a **Ghon complex**
Generally asymptomatic, but WILL result in a positive PPD
41
Describe secondary TB
Commonly seen with immunosuppresion and goes on to infect the UPPER lobes (high O2 content and low lymph drainage)
Clinical features include the **classic fever, night sweats, cough with hemoptysis, and weight loss**
42
What is COPD?
A group of diseases marked by airway obstruction and a lung that does not EMPTY causing air to become trapped
43
What are the PFT findings of COPD?
decreased FVC, and a decreased FEV1:FVC ratio (expiration during the first second)
Total lung capacity is usually increased due to air trapping
44
What are the two parts of COPD?
Chronic bronchitis and emphysema
45
What is chronic bronchitis?
Chronic productive cough lasting at least 3months over a minimum of 2 yrs (highly associated with smoking)
46
A main microscopic diagnostic factor for chronic bronchitis is:
Reid index (thickness of mucus glands to the bronchial wall thickness) over 50% (normal less than 40%)
47
What is emphysema?
Destruction of alveolar air sacs due to loss of elastic recoil and collapse of airways during EXHALATION (results in air trapping)
48
What causes emphysema?
Due to imbalance of proteases and antiproteases. Inflammation normally leads to release of proteases by neutrophils and macrophages, which are neutralized by a1-antitrypsin. Excessive protease activity or A1AT deficiency leads to emphysema
49
What is the most common cause of emphysema?
Smoking- leads to excessive inflammation
50
Smoking related emphysema presents where?
CENTRIACINAR emphysema in the UPPER lobe
51
A1AT deficiency results in what?
**Panacinar emphysema** that is most severe in the LOWER LOBES
52
How else might A1At deficiency present?
Liver cirrhosis because the misfolded A1At gets stuck in the **ER of hepatocytes**, resulting in liver damage
Liver biopsy reveals: **Pink, PAS+ globules in hepatocytes** (below)
53
Disease severity is based on the degree of A1AT deficiency. Explain.
PiM is the normal allele and two copies are usually expressed
PiZ is the most common clinically relevant mutation and PiMZ heterozyotes are usually asymptomatic with decreased circulating levels of A1AT (but significant emphysema may become clinical with smoking)
54
What are the clinical signs of emphysema?
1. Dyspnea and cough with minimal sputum
2. Prolonged expiration with pursed liods
3. Weight loss
4. **Barrel-chest** (below)
5. Hypoxemia
55
What is asthma?
REVERSIBLE airway bronchoconstriction, most often due to allergic stimulti (atopic asthma)
56
What is the basis of asthma?
Allergens induce Th2 phenotype in CD4 T cells of genetically susceptible individuals which secrete IL-4 (mediates class switch to IgE), IL-5 (attracts eosinophils), and IL-10 (stimulates Th2 and inhibits Th1)
Rexposure to allergen leads to IgE-mediated activation of mst cells causing release of preformed granules and generation of leukotrienes (C4-E4) leading to bronchoconstriction, inflammation, and edema (early phase rxn)
Inflammation, especially major basic protein derived from eosinophils damages cells and perpetuates bronchoconstriction (late-phase rxn)
57
What are the main findings of asthma?
Dyspnea and wheezing
Productive cough, classically with spiral-shaped mucus plugs (**Curschmann spirals**) and eosinophil-derived cystrals (Charcot-Lyeden crystals)
58
What is bronchiectasis?
Permanent dilation of bronchioles and bronchi causing loss of airway tone resulting in air trapping
59
What causes bronchiectasis?
Necrotizing inflammation with damage to airway walls. Causes include:
Cystic fibrosis
Kartagener syndrome (inherited defect of the dynein arm, which is needed for ciliary movement)
Tumor, Necrotizing Infection, or Allergic bronchopulmonary aspergillosis
60
Kartagener syndrome is also associated with?
sinusitis, infertility and situs inversus
61
How does restrictive disease present?
Marked by restricted filling of the lung: Decreased TLC, FEV1, and greatly decreased FVC
the FEV1:FVC ratio is increased
62
What is the most common cause of restrictive disease?
Interstitial lung diseases or chest wall abnormalities (e.g. massive obesity)
63
What causes idiopathic pulmonary fibrosis?
Unknown but likely related to cyclical lung injury i which **TGF-B from injured pneumocytes induces fibrosis**
Secondayr causes include bleomycin and miodarone and radiation therapy
64
How does idiopathic pulmonary fibrosis present?
Progressive dyspnea and cough
Fibrosis on lung CT initially seen in subpleural patches but eventually results in diffuse fibrosis with end-stage honeycomb lung
Tx is lung transplant
65
What are pneumoconioses?
Interstitial lung fibrosis due to occupational exposure (requires chronic exposure to small particles that are fibrogenic)
Alveolar macrophages engulf foreign particles nd induce fibrosis
66
What are the major pneumoconioses?
- Coal Workers Pneumoconiosis
- Sillicosis
Berylliosis
-Asbestosis
67
What causes Coal Workers Pneumoconiosis?
massive exposure to carbon dust seen in **coal miners** causes diffuse fibrosis (black lung)
68
What is the major association of Coal Workers Pneumoconiosis?
Rheumatoid arthritis (Caplan syndrome)
69
Note that a mild exposure to carbon (e.g. pollution) results in \_\_\_\_\_\_\_\_
**anthracosis-** collections of carbon-laden macrophages (not clinically significant)
70
Sillcosis is classically seen in who?
Sandblasters and silica miners
71
How does Sillcosis present?
Fibrotic nodules in **upper** lobes the lung
72
Sillcosis carries an increased risk of what?
Increased risk of TB (silica impairs phagolysosome formation by macrophages)
73
Berylliosis is classically seen in who?
Workers in aerospace industry and beryllium miners
74
How does Berylliosis present histologically?
Noncaseating granulomas in the lung, hilar lymph nodes, and systemic organs (increased risk of LUNG CANCER)
75
Who gets asbestosis?
**Asbestos fibers** seen in construction workers, plumbers, and shipyard workers
76
What is the most common sequelae of asbestosis?
Lung carcinoma over mesothelioma
77
What is this?
78
What is sarcoidosis?
Systemic disease marked by noncaseating granulomas in multiple organs (classically seen in AA females)
79
What causes sarcoidosis?
Etiology unknown but likely due to CD4+ Helper T cells to an unknown antigen
80
How does sarcoidosis present?
Granulomas most commonly involve the hilar lymph nodes and lung leading to restrictive lung disease
81
What is the classic histo finding of sarcoidosis?
**Stellate inclusions** ('asteroid bodies')
82
What other tissues are commonly involved in sarcoidosis?
Uvea (uveitis), skin (**cutaneous nodules**), and salivary and lacrimal glands (mimics Sjogren syndrome)
83
What are the clinical features of sarcoidosis?
Dyspnea or cough (most common)
Elevated serum ACE
Hypercalcemia (1-alpha hydroxylase activity of epitheliod histiocytes converts vitD)
84
How is sarcoidosis tx?
Steroids (often resolves without tx)
85
What is hypersensitivity pneumonitis?
Granulomatous rxn to inhaled organic antigens (e.g. pigeon breeder's lung) presenting with fever, cough, and dyspnea hours after exposure
86
How is pulmonary HTN defined?
pulmonary pressure over 25 mm Hg (normal: 10 mm Hg)
87
What are the classic findings of pulmonary HTN?
atherosclerosis of the pulmonary trunk, smooth muscle hypertrophy or pulmonary arteries and intimal fibrosis
**plexiform lesions** (below) are seen with long-standing disease
88
What causes PRIMARY pulmonary HTN?
Classically seen in young adult females and familial forms are related to inactivating **mutations of BMPR2**, leading to proliferation of vascular smooth muscle
89
What causes 2ndary pulmonary HTN?
Due to hypoxemia (e.g. COPD and interstitial lung disease) or icnreased volume in the pulmonary circuit (e.g. CHF) or with recurrent pulmonary embolism
90
What is ARDS?
Diffuse damage to the alveolar-capillary interface (diffuse alveolar damage) causes leakage of protein-rich fluid leading to edema that combines with necrotic epithelial cells to form **hyaline membranes**
91
How does ARDS present?
Hypoxemia and cyanosis with respiratory distress due to thickened diffusion barrier and collapse of air sacs due to increased surface tension
## Footnote
**White Out seen on CXR**
92
What are some common causes of ARDS?
2ndary to a variety of disease processes including sepsis, infection, shock, trauma, aspiration, pancreatitis, DIC, and drugs
93
What causes neonatal respiratory distress syndrome?
Lack of surfactant (in preemies) leading to collapse of air sacs (surfactant is made by type II pneumocytes with lecithin being the major component)
94
What are the most common causes of NRDS?
1. Prematurity- surfactant production begins at 28 weeks and adequate levels are not reached until 34 weeks (Amniotic fluid lecithin to sphingomyelin ratio is used to screen for lung maturity and a ratio of 2+ indicated adequate surfactant production)
2. C-section- due to lack of stress induced steroids
3. Maternal diabetes- Insulin decreases surfactant production
95
What are the main complications of NRDS?
1. Hypoxemia increases the risk for persistence of PDA and necrotizing entercolitis
2. Supplemental oxygen increases the risk for free radical injury with could cause retinal damage
96
What is the 2nd most common cause of lung cancer in the US (behind smoking)?
Radon (formed by the radioactive decay of uranium, which is present in soil and tends to accumulate in closed spaces like basements)
97
Imaging of lung cancer often reveals \_\_\_\_\_\_\_\_\_
a **solitary nodule (coin lesion)**
Biopsy needed for diagnosis
98
Other things to keep on the DDx for coin lesions?
**Granulomas** often due to TB or fungus (esp. Histoplasma in the Midwest)
## Footnote
**Bronchial hamartoma**
99
Lung carcinoma is classically divided into 2 categories, namely:
1. Small cell carcinoma (15%)- ususlly not amenable to surgical resection (tx with chemo)
2. Non-small cell carcinoma (85%)- tx upfront with surgical resection (does not respond well to chemo)
100
What are the subtypes of Non-small cell carcinoma?
Adenocarcinoma (40%)
Squamous cell carcinoma (30%)
Large cell carcinoma (10%)
Carcinoid tumor (5%)
101
What is this?
Small cell carcinoma, a poorly differentiated cancer arising from neuroendocrine cells (Kulchitsky cells)
common in male SMOKERS
Centrally located
102
What are some small cell carcinoma findings?
Rapid growth and early METS
may produce ADH or ACTH or cause **Eaton-Lambert syndrome**
103
Squamous cell carcinoma findings
Common findingL keratin pearls or intercellular bridges (most common tumor in male smokers)
CENTRAL location
104
Squamous cell carcinoma may produce \_\_\_\_
PTHrP
105
Large cell carcinoma- could be central or peripheral (poor prognosis)
106
How does adenocarcinoma present?
Gland or mucin production
Most common tumor in nonsmokers and female smokers
Peripheral location
107
Bronchoalverolar carcinoma
Columnar cells that grow along preexisting bronchioles and alveoli; arises from CLARA cells (excellent prognosis)
Not related to smoking
PERIPHERAL location
108
Carcinoid tumor
Well differentiated neuroendocrine cells (**chromogranin positive**)
Not related to smoking
Central or peripheral location with the central form presenting as a polyp-like mass on the bronchus
109
What are most common sources of METs to the lung?
Breast and colon carcinoma (more common than primary tumors)
110
Plerual involvment is classically seen in \_\_\_\_\_\_\_\_\_\_\_
adenocarcinoma
111
What are some possible presentations of lung carcinoma?
1. Obstruction of SVC leads to distended head and neck veins with edea and blue discoloration of arms and face (SVC syndrome)
2. Involvement of recurrent laryngeal (hoarseness) or phrenic nerve
3. Compression of the sympathetic chain leads to Horner syndrome marked by ptosis (drooping eyelid), miosis, and anhidrosis
112
Pneumothorax is the accumulation of air in the pleural space. What are some forms?
1. Spontaneous pneumothorax- due to rupture of an emphysematous bled; seen in young adults (trachea shifts TOWARD to the side of the collapse)
2. Tension pneumothorax (trachea shifts to the OPPOSITE side of the collapse)
113
Mesothelioma tumors encases the lung
