Pulm 3 Shea

Question 1

• Diffuse interstitial PNA in immunocompromised patients
• Characteristics of both fungus and protozoan parasite
• Transmission?
• # 1 cause of PNA in AIDS patients, leading cause of death in these patients

Answer 1

• Pneumocystis jiroveci
• Inhalation, does not cause disease in healthy patients

Question 3

• Cup or boat shaped cysts in alveoli induces inflammatory response –> results in frothy, eosinophilic, edema fluid which blocks O2 exchange.

Answer 3

Pneumocystic jiroveci

Question 4

• Sudden onset fever, cough, dyspnea, tachypnea
• Bilateral rales/rhonchi
• Chest x-ray reveals diffuse interstitial PNA
• Isolates to lungs only

Answer 4

Pneumocystic jiroveci

Question 5

What type of stain is used to see the boat/ cup like appearance of pneumocystis jiroveci?

Answer 5

Silver Stain (GMS) for Cyst Organsims

Question 6

A chronic, bacterial infectious disease caused by Mycobacterium

Answer 6

Tuberculosis

Question 7

• TB is more common in which patients and which population?
• How is it treated?

Answer 7

• AIDS patiens
• Homeless population (crowding in small areas in the cold)

Question 8

• Rod shaped bacterium w/ waxy capsule
• Acid fast
• Neither gram neg or gram pos
• DOES NOT stain w/ gram stain dyes
• Obligate aerobe

Answer 8

M. tuberculosis

Question 9

M. tuberculosis has a cell wall which contains what?

Answer 9

Mycolic acid (a complex lipid) which is antiphagocytic

Question 10

• Which organism stains “magenta?”
• What is the shape?

Answer 10

• TB on an acid fast stain
• Beaded rod

Question 11

How is TB transmitted?

Answer 11

Person to person w/ respiratory aerosols

Question 12

Where is the initial site of infection of TB?

Answer 12

Lungs

Question 13

• Bacterial infection which is not acute
• Does not attract PMNs
• Not marked by acute purulent lesions
• Encapsulated bacteria form granulomas which contain stimulated macrophages, which transform into –> multi-nucleated giant cells w/ central caseous necrosis

Answer 13

TB

Question 14

Why do we need to use 3 drugs to kill TB?

Answer 14

Because just one drug would not be enough to penetrate the necrosis

Question 15

Where does the TB organism multiply in the lungs after being inhaled? Why?

Answer 15

In the alveoli, bc/ alveolar macrophages can’t kill it

Question 16

Where does the initial infection of TB usually occur within the lungs?

Answer 16

Lower lobes

Question 17

Consists of:

• peripheral parenchymal granuloma
• prominent infected draining mediastinal (hilar) lymph node w/ *caseous necrosis - looks like mozarella chz*

Answer 17

Ghon Complex associated w/ initial infection of TB

Question 18

What part of the lungs is there higher oxygen levels?

Answer 18

Lower lobes

Question 19

Grossly, is well circumscribed w/ central necrosis and later on the lesion is fibrotic and calcified

Answer 19

Healed, subpleural Ghon nodule

Question 20

• How do patients w/ primary TB infection present clinically?
• Where is the organism?

Answer 20

• 90-95% (majority) are asymptomatic, lesion remains localized, heals w/ calcification that can be seen on CXR. (coin lesion)
• Calcified primary lesion within the caseous necrosis (organism visualized on AFB stain

Question 21

The initial lesion enlarges rapidly and there is erosion of bronchi or bronchioles by the necrotic central liquefaction. Which 2 groups does this most often occur in?

(Primary TB typically does not remain limited and heal, it usually spreads to other parts of lungs)

Answer 21

Progressive Primary TB

• Children
• Immunosuppressed

Question 22

Represents a reactivation of dormant primary infection

Answer 22

Secondary Infection of TB

(Reactivation)

Question 23

• Bacteria spreads to apex of lungs
• Causes granulomatous PNAs
• Hemoptysis from erosion into pulmonary blood vessels

Answer 23

Secondary TB / Reactivation

Question 24

What is the main complication of the Secondary Stage of TB?

Answer 24

Miliary Spread which is a result of tissue destruction and erosions

Question 25

Multiple, small tuberculous granulomas in many organs which have well oxygenated sites

Answer 25

Miliary Spread

Question 26

Where are the 4 oxygenated sites of miliary spread?

Answer 26

* **If swallowed:** GI tract (small intestines) * **Via eroded bloodstream:** kidneys, brain, or bones

Question 27

What are complications of miliary spread?

Answer 27

* contralateral PNA * pleuritis w/ effusion * pleural granulomas * TB laryngitis * intestinal TB (from swallowing) * hemoptysis (from erosion of small pulm arteries in wall of cavity) * Scrofula * TB meningitis * Osteoarthritis

Question 28

* Lymphatic spread to the hilar lymph nodes w/ infection to the neck area causing enlarged supraclavicular lymph nodes * Unilateral cervical adenitis (swollen non-tender nodes)

Answer 28

Scrofula (complication of Miliary Spread of TB)

Question 29

Where does TB tend to go in the CNS?

Answer 29

Meninges (base of brainstem/pons)

Question 30

* TB eroding the body of vertebrae, can involve the disc as well as the bone. * A miliary form of TB

Answer 30

Pott's disease | (vertebral osteoarthritis)

Question 31

Expectorated acid-fast bacilli (TB) may cause infection of what?

Answer 31

Larynx, causing laryngitis

Question 32

What is the initial diagnostic test for TB?

Answer 32

Acid-Fast Staining of sputum or other specimens

Question 33

Slowest growing organism

Answer 33

Acid-fast bacilli (TB)

Question 34

Where is a tuberculoma located?

Answer 34

Brainstem

Question 35

What is the #1 cancer in men and #1 cause of death from cancer in the U.S.?

Answer 35

Carcinoma of the Lung

Question 36

* Subtype of adenocarcinoma that grows along preexisting alveolar walls. * Accounts for 1-5 % of all invasive lung tumors. * Copious mucin in the sputum * Grossly, may appear as a single peripheral nodule or coin lesion (over 50% of cases), multiplenodules or a diffuse infiltrate **_indisting-uishible from a lobar pneumonia._**

Answer 36

Bronchioloalveolar Carcinoma

Question 37

Which 3 cancers to 90% are centrally located?

Answer 37

* Squamous Cell Carcinoma * Small Cell Carcinoma

Question 38

* **_\*\*Which cancer to 90% is peripherally located?_** * often associated with scars which can result in puckering of the pleural. * Slight association with smoking. * Appear as irregular masses, which on cut section appear gray-white in color, soft and _glistening,_ depending on the amount of mucus.

Answer 38

Adenocarcinoma

Question 39

* Previously called “oat cell carcinoma”. * A highly malignant epithelial tumor that exhibits neuroendocrine features. * Accounts for 20% of all lung cancers and is strongly associated with cigarette smoking.

Answer 39

Small Cell Carcinoma

Question 40

* Produces a variety of Paraneoplastic Syndromes, including Diabetes Insipidus, due to ADH production, ectopic ACTH (corticotropin) or Parathormone production.

Answer 40

Small Cell Carcinoma

Question 41

* Usually appears as a perihilar (central) mass * Extensive lymph node metastases. * On cut section, it is soft and white, but with extensive hemorrhage and necrosis.

Answer 41

Small Cell Carcinoma

Question 42

This type of lung cancer is the only tumor that is sensitive to radiotherapy.\*\*\*

Answer 42

Small Cell Carcinoma

Question 43

* Histologically, they consist of _sheets of small, round, oval or spindle-shaped cells._ * The tumor cells display _scant cytoplasm with finely granular nuclear chromatin._ * By EM (electron microscopy) many of the cells contain _secretory neuroendocrine granules_

Answer 43

Small Cell Carcinoma

Question 44

* Diagnosis of exclusion in a poorly undifferentiated non-small cell carcinoma * Does not show features of squamous or glandular differentiation. * Cells are large and irregular and exhibit ample cytoplasm. The nuclei frequently show prominent nucleoli and vesicular chromatin.

Answer 44

Large Cell Carcinoma

Question 45

* Where is the most common extranodal site/extranodal metastasis? * 3 most common sites of metastatic disease

Answer 45

* Adrenal gland * Brain, bone, liver