Midterm Flashcards
What is the pathological hallmark of sarcoidosis?
Noncaseating granuloma
What chest xray findings are highly suggestive of sarcoidosis?
Combination of diffuse interstitial infiltrates in the lung fields and hilar lymphadenopathy
What looks like sarcoid?
Beryllium disease
Asbestosis classic lesion
calcified parietal pleural plaque
Zileuton
Asthma med
5-lipoxygenase pathway inhibitor
(leukotriene modifying)
Omalizumab
Asthma med
anti IgE antibody
Cromolyn sodium
Asthma med
stabilizes mast cells (inhibits degranulation), interferes with chloride channel function
nebulizer only, no MDI
very safe, but not sure how effective it actually is
Theophylline
Asthma med
class of xanthine derivatives
Phosphodiesterase inhibitor
What drug decreases clearance of theophylline?
Ciprofloxacin!
inhibits the cytochrome p450 enzyme
Which disease causes the lung to grossly resemble cirrhosis?
UIP
With what type of lung cancer could you see a cushings syndrome?
Small cell carcinoma
What type of cancer might you see eaton-lambert syndrome in?
small cell carcinoma
Brush cells
1 of the 5 cell types of respiratory epithelium
Has microvilli
Neurons seen in relation to them, suggesting they may have a sensory function
Basal (short) cells
1 of the 5 cell types of respiratory epithelium
= progenitor cells of other cell types in the respiratory epithelium
Small granule cell
1 of the 5 cell types of the respiratory epithelium
Secretes polypeptide hormones
May function to control serous & mucous secretion in the respiratory system
related to enteroendocrine cells of the GI system
What are the 3 cell types of the olfactory epithelium?
olfactory cell
sustentacular cell
basal cell
Sustentacular cell
1 of 3 cell types that make up the olfactory epithelium
a columnar cell with many microvilli
provides support, nourishment, and electrical insulation for the olfactory cells
Bowman’s glands
mucoserous glands within the lamina propria underlying the olfactory epithelium
keep the olfactory surface moist
BOOP
granulation tissue plugs project into lumen of distal bronchioles & air sacs
prognosis generally excellent
Stellate shaped nodules (w/ area of central cavitation)
pulmonary eosinophilic granuloma
The one with langerhans cells (histiocytes)
pulmonary eosinophilic granuloma
“crazy-paving”
Pulmonary alveolar proteinosis
Montelukast (singulair)
Asthma med
leukotriene receptor antagonist
zafirlukast (accolade)
Asthma med
leukotriene receptor antagonist
What do you see an increased Reid index in?
chronic bronchitis
acetazolamide
carbonic anhydrase inhibitor
for acute mountain sickness
Molecular defects in lung cancer
K-ras (adenocarcinoma)
p53 & Rb (50-60% NSCLC, and > 90% SCLC)
chr 3p deletion all types
SCLC staging
limited - extensive disease
NSCLC staging
stage I - small tumor, 65-85% 5yr
stage II - extension to chest wall/pleura, 40%
stage III - LN, 20%
stage IV - metastatic, 0%
Most common lung cancer in women & nonsmokers
adenocarcinoma
keratin pearls
Squamous cell lung cancer
treatment of SCLC
NO surgery
“oat cell” lung cancer
SCLC
nests of uniform cells
carcinoid tumor of lung
Lung cancers related to & not related to smoking
smoking:
SCLC, squamous cell lung cancer, large cell lung cancer
non-smoking:
adenocarcinoma, carcinoid tumor
popcorn lesion on xray
pulmonary hamartoma
most common tumors that metastasize to lung
solid tumors –> breast, colon, sarcomas
ferruginous bodies
asbestos
apneustic breathing
problem switching from inspiration to expiration, so pause at end of inspiration
Biot’s breathing
apnea in the middle of normal breathing
Kussmaul breathing
deep & fast
indoor cooking with fossil fuels in underdeveloped countries is a risk factor for what?
Obstructive lung disease
paraseptal emphysema associated with what?
spontaneous pneumothorax of young men
strongest predisposing factor for asthma
atopy
Factors for predicted normal PFTs
height, age, sex
central to the management of COPD
inhaled bronchodilators
what determines risk assessment in asthma
of exacerbations
head & neck cancer risk factors
tobacco & alcohol (betel nut w/ chewing tobacco in india), genetic factors (nasopharyneal in southern china), mate (tea from south america), asbestos, hardwood dust (nasal & sinus tumors), HPV (oropharyngeal)
erythroplasia
premalignant lesion
high incidence of carcinoma in situ
leukoplasia
premalignant lesion
more common & less likely to become malignant than erythroplasia
Head & Neck cancer - molecular progression
heterozygosity, p53, p16
Isoretinoin
reduces incidence of 2nd primaries in H&N cancer
EGFR inhibitors
given in conjunction with XRT to treat H&N cancers
EGFR is overexpressed in these cancers
Cetuximab (erbitux)
IgG monoclonal antibody against the binding domain in EGFR
an EGFR drug to be used in H & N cancer
Which type of cancer is associated with HPV?
oropharyngeal
Which type of cancer has high incidence in southern China?
nasopharyngeal
Which type of cancer is associated with epstein barr virus?
nasopharyngeal
nasopharyngeal tumor presentation
blockage of eustachian tube (hearing loss, sensation of fluid in ears), headache, nose bleeds, double vision, proptosis & other cranial nerve symptoms
metastatic spread to posterior cervical chain
what is the most common head & neck tumor?
laryngeal
Treatment of early laryngeal tumors
radiation, vocal cord stripping, laser therapy, partial laryngectomy (not chemo)
prophylactic cranial radiation
used for both limited & extensive SCLC stages as long as there’s response to tumor
NOT of any benefit for NSCLC
SCLC treatment
limited: chemo + chest radiation
Extensive: chemo
PCI for both stages
NO surgery
NSCLC treatment
Stage I/II = surgery (adjuvent chemo for stage II & radiation for high risk pts)
Stage III = chemoradiation
Stage IV = palliative chemo (sx curative if isolated brain or adrenal mets with stage I in lung)
no benefit of PCI
Bevucizumab
intravenous mAb against VEGF
used in combo with chemotherapy for NSCLC
associated w/ hypertension, GI perforation/wound healing problems
contraindicated in squamous type
EGFR tyrosine kinase mutations in NSCLC
prognostic of better survival outcomes in general
exon 19 deletion or L858R mutation predictive biomarker of tretment response to EGFR TKIs such as erlotinib
found in adenocarcinomas, with higher prevalence among non-smokers
Erlotinib
Oral EGFR tyrosine kinase inhibitor (TKI)
used alone (no proven benefit in combo with chemo)
common toxicities: skin rash & diarrhea
EML4-ALK translocation
3-5% of adenocarcinomas
younger, never smokers
Crizotinib
oral inhibitor of ALK
effective against adenocarnimomas with ALK transformation
Oncogenic drive mutations in squamous cell lung cancer
FGFR1 amplification
DDR2 mutation
where does repiratory epithelium become columnar?
respiratory bronchiole
swell bodies
venous plexuses in the lamina propria of the concha
direct the flow of ambient air to the opposite side
what muscle is the vocalis muscle a part of?
thyroarytenoid muscle
neuroepithelial bodies
in the bronchioles
groups of 80-100 cells containing secretory granules which receive cholinergic nerve endings
clara/bronchiolar cell
lack cilia
secrete a surfactant like material
produce a clara cell secretory protein the decreases lung injury
divide to regenerate the bronchiolar epithelium
structures in the hilum
artery is superior
bronchus in middle
vein is inverior
secondary lobules of miller
contain terminal bronchioles, & respiratory bronchioles, alveolar ducts & alveoli
knob
a single smooth muscle cell that guards the opening to each alveolus as it branches from an alveolar duct
type II pneumocytes are aka
greater alveolar cells
septal cells
Gold stages of COPD
1 mild >80
2 moderate 50-80
3 severe 30-50
4 very severe >30
noncaseating v. caseating granuloma
non caseating has center with intact viable cells
caseating has necrosis in center
What infection in CF is pathognomonic?
culture positive presence of pseudomonas, esp the mucoid strain, in the lung of a child with chronic pulmonary disease
intercellular bridges
desmosome attachments
in squamous cell carcinoma
when would you see a central softening or cavitation in a tumor due to necrosis?
squamous cell carcinoma
which is the most aggressive lung tumor?
small cell carcinoma
BOOP xray
patchy air spaces
UIP aka
UIP = usual interstitial pneumonia
IPF = idiopathic pulmonary fibrosis
Cryptogenic fibrosing alveolitis
simple nodular silicosis
2-4mm lesions w/ microscopic whorled appearance
needle shaped silica crystals in nodules
hilar lymph nodes enlarged w/ egg shell calcification
xray diagnosis, no respiratory dysfunction or symptoms
what do asbestos bodies look like?
central colorless fiber core & beaded protein coat
“dumbbell in macrophage”
asbestosis
asbestos bodies & diffuse interstitial fibrosis
inc risk of lung cancer & mesothelioma
hypersensitivity pneumonitis aka
extrinsic allergic alveolitis
UIP
peripheral SUBPLEURAL areas of honeycombing
**variation in age of lesions
fibroblast foci
poor prog
DIP v. RBILD micro
DIP has widespread alveolar macrophage infiltrate
RBILD macrophage infiltrate is predominantly peribronchiolar
pulmonary eosinophilic granuloma aka
histiocytosis X
langerhans cell granulomatosis
idiopathic pulmonary hemosiderosis (IPH)
similar to goodpastures but no renal failure or cytotoxic Abs
intraalveolar hemorrhage and hemosiderin filled macrophages
hyperplasia of type II pneumocytes and variable interstitial septal fibrosis
4 things that stimulate contraction pathway:
M3 muscarinic
Cysteinyl leukotriene 1
histamine H1
endothelin A/B
Contraction pathway
Gq receptors –> phospholipase C –> IP3 –> Ca release from SR –> Contraction
Methacholine
nonspecific M2-M3 agonist
Methacholine challenge test
dose at which FEV1 falls by 20% or more
measure of airway hyperresponsiveness
Ipratroprium
nonspecific M2-M3 antagonist
contraction at low doses, relaxation at high doses
More M2 in central airways so helps with tracheomalacia
Tiotroprum
M3 specific antagonist
C fiber endings
release substance P & neurokinin A
cause contraction
Relaxation pathway
Gs coupled receptors –> adenylate cyclase –> cAMP –> protein kinase A –> phosphorylates 4 things –> causing dec Ca release (among other things) –> Relaxation
Things that stimulate the relaxation pathway:
Epi inhaled B2 agonists prostacyclin PGE2 VIP adenosine NO
Factors favoring Th1 phenotype
= protective immunity presence of older sibling early exposure to day care tuberculosis, measles, or hep A infection rural environment
Factors favoring Th2 phenotype
= allergic diseases including asthma widespread use of antibiotics western lifestyle urban environment diet sensitization to house-dust mites & cockroaches
work exacerbated asthma
preexisting asthma made worse by employment
occupational asthma
precipitated by a particular occupational enviroment and not by stimuli outside the workplace
irritant induced asthma
follows exposure to workplace irritants
reactive airways dysfunction syndrome
suden inhalation of a large dose of highly irritating substance causing asthma symptoms
Asthma - impairment v. risk
impairment = immediate manifestations of the disease risk = potential for exacerbations or decreased lung function
Salmeterol v. formoterol
salmeterol 10-20 min onset of action
formoterol 1-3 min onset of action
lower lipophilicity of formoterol
theophylline/aminophylline adverse effects
N/V, headache, insomnia, palpitations, tachycardia, convulsions, arrhythmias
metabolized in liver, so inc half life in liver disease
Candidates for omalizumab therapy
adolescent (12 and up) & adult pts moderate to severe persistent asthma perennial allergy IgE bw 30-700 IU/mL symptoms not well controlled with ICS or ICS + LABA pts not elligible for immunotherapy
Infections in CF
staph aureus when young
pseudomonas when older
Also MRSA, cepacia complex, stenotrophomonas, atypical myocbacteria, fungi
What was the causative agent with popcorn workers lung?
diacetyl - a butter flavored ketone
Well controlled asthma - action
maintain current step
consider step down if well controlled at least 3 months
Not well controlled asthma - action:
step up 1 step
re-evaluate in 2-6 weeks
Very poorly controlled asthma - action:
consider oral steroids
step up 1-2 steps & re-evaluate in 2 weeks
normal anion gap
12 +/- 4
Numbers for calculating compensation in acid base cases
met acid: 1.5 & 8
met alk: 0.9 and 16
resp acid: 1 and 3.5
resp alk 2 and 4
PFT used to determine severity in obstructive disease
FEV1 (% pred)
PFT used to determine severity in restrictive disease
TLC
Decreased DLCO
obstructive lung disease
parenchyma disease
pulmonary vascular disease
anemia
Increased DLCO
pulmonary hemorrhage
polycythemia
L –> R shunt
tree in bud sign
bronchiolitis
