Lecture 65_66 - Occupational Lung Disease, Sarcoidosis + related patholgy

Question 1

what three factors determine the toxicity of a foreign material ?

Answer 1

Size – the smaller the particle (<5 microns) can get into the alveoli; (2.5 microns can also get into the blood stream) –

Solubility – airway is moist; mucus is water based
If soluble – absorbed into mucus membranes
If less water soluble – will travel deeper into lungs

Surface Area – -more spherical form – more potential for toxicity

Question 2

Constrictive Bronchiolitis
aka
- what kind of exposures? 
- PFT pattern/ 
- pathologic changes? \

classic cases

Answer 2

Bronchiolitis Obliterans

○ Inhalation of large dose of toxic, typically less water-soluble gases/vapors

Sulfur and nitrogen oxides; Diacetyl

PFTs: irreversible obstruction; decreases in DLCO

	○ Leads to peribronchiolar fibrosis, which constricts & scars bronchioles

cases: Diacetyl exposure in popcorn factory; Zamboni drivers

Question 3

Pneumoconioses:

• exposure to what particles?

Answer 3

inorganics

asbestos, silica, coal, beryllium

Question 4

• Asbestos –

possible exposures (past and present)

Answer 4

§ Exposure potential in the past: Mechanics, construction works, shipyard workers, military personnel
□ Secondary exposures — the family of such workers
§ Current Exposures – Construction/demolition workers (brake pads); people in homes with friable materials; environmental exposure to Erionite (rocks with asbestos)

Question 5

Asbestos

non malignant related lung disease

Answer 5

□ Benign Asbestos pleural effusion
□ Rounded Atlectasis
Pleural Plaque
Asbestosis

Question 6

what are pleural plaques? – what are the only two things that can cause them? what is seen on CT?

Absteosis – predilection for which lobes?
timeline of onset

Answer 6

□ Pleural Plaque (calcification of a thickened pleura) – only etiologies are asbestos exposure or surgical complication

Lower lobes; lung fibrosis
onset long time after initial expsoure

Question 7

Asbestos

malignant related lung disease

Answer 7

Mesothelium – malignancy of the pleura

increased risk of lung carcinomas

Question 8

Asbestos – what is the pathognomonic histological/stain finding ?

Answer 8

Fe Stain – Asbestos bodies.

golden brown rods of iron

Question 9

Silica –

what is its mechanism of harm?
pathognomonic occupation associated with exposure?
other occupations

Answer 9

Surface characteristics — redox potential –

Sandblasting/silica mining
Agriculture, glass, ceramics

Question 10

Silicosis – affects which lobes

three types of silicosis

Answer 10

upper lobes

Acute Silicosis
Accelerated Silicosis
Chronic Simple Silicosis –

Question 11

Chronic Simple Silicosis –

Symptoms?
timeline of onset?
Primary complication?

CT for chronic simple silicosis and how it differs from its primary complications

Answer 11

® Latency > 10 years (typically ?20-30 years)
® Symptoms: progressive SOB and cough; crakcles; may be asymptomatic

Progressive Massive Fibrosis (PMF)

CT Findings:
CSS: diffuse little gray nodules

PMF: Conglomerate mass formation from the nodules; tends to occur closer to the hilum

Question 12

Histopathological findings of silicosis?

Answer 12

Silicoanthrotic nodules

Question 13

Coal workers Pneumoconiosis –

aka? 
Mechanims of injury? 
Predilection for which lobes?
time line of onset? 
CT and CXR? 
Tx? 
what is seen on histo/macro pathology ?

Answer 13

the Black lung

Mechanism: direct heavy metal toxicity (free radicals) of coal; activation of oxidant production by alveolar macro phages

Upper Lobes

Decades long progression

CT/CXR – similar to silicosis

Histo/macro Path – Antrhacosis

Tx – Supportive and remove from exposure

Question 14

Beryllium

exposures:
Berylliosis – histopath finding
Blood test

Answer 14

Sources: Fluorescent Light bulbs; associated with aerospace and manufacturing industries, high tech electronics

Berylliosis – chronic granulomatous lung disease

Blood test – Berrylium lymphocyte proliferation test:

-Glu69 Substitution in HLA : indicative of susceptibility to berrylium; mount larger T cel response

Question 15

Hypersensitivity Pneumonitis

• aka
• exposure to what? where?
• Imaging findings ?

Triad of pathology?

Tx

Answer 15

bird fancier’s lung; farmer’s lung

Organic antigens – Bacteria, fungi, animal protein (bird poop),

hot tubs, humidifiers, agriculture, farm animals, birds,

CT: Ground glass –> centrilobular nodularity

Path: Interstitial inflammation, Poorly formed Granulomas, bronchiolar inflammation

Tx – removal from exposure

Question 16

Sarcoidosis:

• what is it?
• who is most susceptible by race ?

Possible presenations

Answer 16

Systemic granulomatous disease of unknown origin – persons who are genetically susceptible – activation of macrophages

• African americans, Scandinavians

- Multi-organ presenation -- can be anything: 
Resp: SOB, CP, cough
LAD, organomegaly 
Arthralgias
Erythema nodosoum, Uveitis

Question 17

whats the pathology behind kidney stones in sarcoid patients

Answer 17

§ Granulomas – Higher Levels of Enzyme activating Vitamin D – leading to more calcium absorption from the diet —> Hypercalcema –> stones

Question 18

Sarcoid – predilection for which lobes?

Answer 18

○ Usually in the Upper lobes

Question 19

Scadding Staging for Sarcoid:

Answer 19

○ 1 – just hilar nodes
○ 2 – Hilar LAD + parenchymal infiltrates
○ 3 – Parenchymal infiltrates; no LAD
○ 4 – pulmonary fibrosis

Question 20

Treatment for sarcoid:

limited involvement
mild pulmonary involvment
worse pulm involvment or extra-lung involvement

if brain / heart involved?

Answer 20

Limited; Observe

mild pulm ; inhalded CST

more pulm: prednisome

HeartBrain: MTX, azathiprime (immunomodulators)

Question 21

Complication of Sarcoid in the lungs:

Answer 21

PAH

core pulmonale

Question 22

Drug related interstitial lung disease:

• what drug commonly?
  histolopathology?

Answer 22

Amiodarone

“bubbly” macrophages and pneumocytes

Question 23

Pulmonary Alveolar Proteinosis:

• what is it?
• what is the difference between acquired PAP and secondary PAP?

Histopathology ?

Treatment?

Answer 23

• Accumulation of acellular surfactant in alveolar spaces

Acquired – antibody to CM CSF

Secondary – associated with hematopoietic disorders, malignancy, immunodef, acute silicosis

Histo: VERY PINK with clefts of cholesterol

Tx: CM CSF, whole BAL