Resp Pathology Flashcards
Type of respiraotyr epithelium?
- 45M presents with renal colic, his second presentation in the last month
- Previously healthy, never smoker • Owns an autobody shop
- Mostly office stuff now, used to do lots of body work • No meds/allergies
• Tachycardic, Hypertensive,
other Vitals normal • No H&N adenopathy • Normal Resp exam • Normal CV exam • No abdominal
organomegaly, tenderness at
right CV angle
- CBC
- Hgb 140 (N Indices), Platelets 200, WBC 12.5 (N Diff)
- Electrolytes/Renal Function
- Na 135, K 4.0, Cl 95, HCO3 25, Creatinine 95 (eGFR 55) • Calcium 3.35mmol/L, Intact PTH 5ng/L, 1,25-Vit D 300pmol/L
- Liver Function Tests
- ALT 25, Bili 12, Albumin 40
I see bilateral hilar enlargement. could be lymphoma, sarcoidosis, environmental factors could point to nodules from silicosis or something.
• 45M presents with renal colic, his second presentation in the
last month
Profile
• Previously healthy, never smoker
• Owns an autobody shop
Xray shows bilateral hilar enlargement, and biopsy shows this:
Sarcoidosis presents with non-necrotizing granulomas
causes of non-nectrotizing Granulomatous Inflammation
75M with progressive dyspnea/cough for 6 months
• Hypertension, 20pack-yr ex-smoker
• No history of CTD/malignancies/cardiac disease
• Retired librarian
• Meds: HCTZ. No allergies
Vitals normal • No H&N adenopathy • Resp exam: bibasilar crackles • Normal CV exam, clubbing on fingers.
• No signs hypervolemia
• Hgb 190 (N Indices), Platelets 185, WBC 8.0 (N Diff)
• Electrolytes/Renal Function
• Na 135, K 4.0, Cl 95, HCO3 25, Creatinine 70 (eGFR 75) • Calcium 2.35
• Liver Function Tests
• ALT 25, Bili 12, Albumin 40
- lower lobe bilateral haziness.
- silhouette sign
- peripheral fibrosis is seen.
- possible bronchiectasis– lots of dilation
- honey combing on the periphery suggests interstitial lung disease– UIP!!
75M with progressive dyspnea/cough for 6 months
• Hypertension, 20pack-yr ex-smoker
• No history of CTD/malignancies/cardiac disease
• Retired librarian
• Meds: HCTZ. No allergies
Vitals normal • No H&N adenopathy • Resp exam: bibasilar crackles • Normal CV exam, clubbing on fingers.
• No signs hypervolemia
• Hgb 190 (N Indices), Platelets 185, WBC 8.0 (N Diff)
• Electrolytes/Renal Function
• Na 135, K 4.0, Cl 95, HCO3 25, Creatinine 70 (eGFR 75) • Calcium 2.35
• Liver Function Tests
• ALT 25, Bili 12, Albumin 40
thick fibrosis on the periphery of the lung.
- this is different from sarcoid and hypersensitivity pneumonitis because those two affect all parts of the lung.
- peripheral nodules on the subpleural zones, with temporal heterogeneity is classic UIP.
• ILD encompass a complex group of diseases
• Idiopathic Pulmonary Fibrosis
characteristic clinical/radiological presentation • New drugs available! (a disease with a poor prognosis)
Correct Diagnosis of ILD very Important (usually requires Path)
• Most common ILD • Characteristic pathology can confirm the diagnosis
• Some cases can be diagnosed with a very
distribution of honeycomb lung for UIP
UIP encompasses which diseases
- idiopathic pulmonary fibrosis
- manifestiation of CVD
- chronic hypersensitivity pneumonities (less chronic presentations look more like sarcoidosis– granulomatous inflammation)
- asbestosis.
• 60F with small-volume hemoptysis for 2 weeks, has had a
worsened headache for the last week • Profile
• Current 40pack-yr smoker • Current waitress • Meds/Allergies: none
• Vitals normal • ?Left supraclavicular
lymphadenopathy • Resp exam: hyperinflation • Normal CV exam • No abdo organomegaly
• CBC
• Hgb 150 (N Indices), Platelets 285, WBC 9.0 (N Diff)
• Electrolytes/Renal Function
• Na 133, K 4.0, Cl 95, HCO3 28, Creatinine 80 (eGFR 75) • Calcium 2.35
• Liver Function Tests
• ALT 55, Bili 18, Albumin 30
Mild Liver Enzyme Abnormalities
ddx?
tuberculosis with tuberoma
- lung cancer– lung cancers associated with smoking is small cell lung caracinoma and squamous cell carcinoma.
- there is haziness, hilar enlargement.
• 60F with small-volume hemoptysis for 2 weeks, has had a
worsened headache for the last week • Profile
• Current 40pack-yr smoker • Current waitress • Meds/Allergies: none
• Vitals normal • ?Left supraclavicular
lymphadenopathy • Resp exam: hyperinflation• Normal CV exam • No abdo organomegaly
• CBC
• Hgb 150 (N Indices), Platelets 285, WBC 9.0 (N Diff)
• Electrolytes/Renal Function
• Na 133, K 4.0, Cl 95, HCO3 28, Creatinine 80 (eGFR 75) • Calcium 2.35
• Liver Function Tests
• ALT 55, Bili 18, Albumin 30
Mild Liver Enzyme Abnormalities
what type of cancer?
Squamous cell carcinoma
- more likely to affect airways than adenocarcinoma (more liekly to affect lung parenchyma)
- M>F
- metastasizes outside thorax only late
- likely to have paraneoplastic syndrome– hypercalcemia
Squamous cell carcinoma
Adenocarcinoma
F>M
- more likely to infiltrate the lung parenchyma rather than the main airways
what is being depicted in this slide
hyalination and white blood cell s
conditions associated with ards
3 stages of ARDS
- exudatiev
- proliferative
- fibrotic– hyalization
phase of ARDS?
- proliferation type II cells
- fibroblast proliferation
- hyaline membrane deposit
honey comb lung, usually indicates ILD– fibrosis
65yo f
- productive cough for last decade
- worse in the morning– clear to white sputum
- increasing SOB with exertion over the past 2 years, where now she is breathless upon minimal exertion
- pulmonary function stuies show TLC 6.5 (expected 6L), FVC 4.5, and FEV1 2.5L. $
- see increased pulmonary markings for sure
- ct shows dilation
- EMPHYSEMA: abnormal permanent enlargemnet of the airspaces distal to the terminal bronchioles accompanied by destruction of the alveolar wall and without obvious fibrosis.
- part of COPD
main risk factors associated with emphysema
- smoking
- alpha 1 antitrypsin deficiency
- intravenous injection of methlphenidate
there are three morphologic subtypes of emphysema based on their relationship to the secondary pulmonary lobule. what are they?
- centriacinar emphysema: most common, affects proximal respiratory bronchioles and upper lobes predominate. strongly associated with smoking
2. panlobular (emphysema); affects entire secondary pulmonary lobule. most pronounces in the lower zones. associated with alpha 1 antitrypsin deficiney.
3. paraseptal emphysema; usually located adjacent to the pleural surfaces (including pleural fissues)– aka a more peripheral emphysema. associated with smoking and can lead to the formation of a sub pleural bullae and spontaneous pneumothorax
type of peripheral emphysema. associated with smoking and can lead to the formation of a sub pleural bullae and spontaneous pneumothorax
paraseptal emphysema. look at the peripheral dilation
this person has jaundice, reduced coagulaiton protein synthesis and cirrhosis. she also has this on her lung biopsy
Panlobular (opanacinar) emphysema
affects entire secondary pulmonary lobule
most pronounced in lower zones, matching areas of maximal blood flow
assoc with alpha-1-antitrypsin deficiency, IV injection of methylphenidate (Ritalin lung)
this person smokes like s chimney. this was a biopsy of the upper lobe left lung
CENTRILOBULAR EMPHYSEMA
MOST COMMON
AFFECTS PROXIMAL RESPIRATORY
BRONCHIOLES
UPPER LOBES PREDOMINANT
STRONGLY ASSOCIATED WITH
SMOKING IN A DOSE-DEPENDENT WAY
location difference in panlobular, centriacinar and paraseptal emphysema
panlobular; affects lower zones of the lhng
centriacinar; affects upper lobes of the lung
paraseptal; affects peripheral parts of the secondary pulmonary lobule
centriacinar is cloistered in the middle of the lub, but panacinar has uniform dilations everywhere too.
in emphysema, there is a realease of proteolytic enzymes which digest the elastin framework of the alveoli causing airspaces to break down and enlarge.
- this results in an ___ in lung volume, loss of surface area for gas exchange, and incresaed compliance.
- emphysema causes airway obsrtuction due to loss of alveolar attachments to the bronchial walls
- this results in collapse of the airways durign expiration with consequent airway obstruction
30 yo runner had surgery on achilles tendon. 2 days later he noticed his leg was more swoollen than the other. pt suddenly coded in cardiorespiratory arrest. code was ran for an hour until he was pronounced dead.
30 yo runner had surgery on achilles tendon. 2 days later he noticed his leg was more swoollen than the other. pt suddenly coded in cardiorespiratory arrest. code was ran for an hour until he was pronounced dead.
evident thrombus with characteristic lines of blood and fibrin
factors that can lead to PE
virchows triad
- hypercoaguability
- vascular damage
- stasis
- 78 year old man with severe respiratory dysfunction and overall impairment
- worked as a carpenter and had substantial exposure to asbestos
- died and an autopsy was performed to reveal:
- peripheral fibrosis; characteristic UIP
UIP has a peripheral predominant process with white around the periphery. also may have honeycombing cysts and more likely to affect lower zones (which this one did)
UIP is most likely to be:
- idiopathic pulmonary fibrosis
- manifestion of CVD
- chronic hypersensitivity pneumonitis
- ASBESTOSIS
usual interstitial pneumonia covers which diseases
UIP is most likely to be:
- idiopathic pulmonary fibrosis
- manifestion of CVD
- chronic hypersensitivity pneumonitis
- ASBESTOSIS
- 78 year old man with severe respiratory dysfunction and overall impairment
- worked as a carpenter and had substantial exposure to asbestos
- died and an autopsy was performed to reveal:
asbestos fibers is a group of ___ ___ fibers that can induce ___ ancer
group of magnesium silicate fibers that can form mesotheliomas
- 78 year old man with severe respiratory dysfunction and overall impairment
- worked as a carpenter and had substantial exposure to asbestos
- died and an autopsy was performed to reveal:
mesothelioma
- 30 yo female with peutz-jeghers syndrome with 2x prior bowel resection
- never smoker
- mother also has PJS and died of lung cancer
- baseline CT imaging done as part of genetic counselling.
an evident nodule on the left lung. little dilations in both lungs. the lung cancer most likely to affect lung parencyhma and nonsmokers is adenocarcionma.
- need a bronchoscopy biopsy
- 30 yo female with peutz-jeghers syndrome with 2x prior bowel resection
- never smoker
- mother also has PJS and died of lung cancer
- baseline CT imaging done as part of genetic counselling.
- noduels were seen in lung and this is what the biopsy shows:
this lesion shows obvious glandular tissue with large atypical cells with abundant apical mucin and basally oriented nuceli lining the alveolar walls.
this is consistent with primary pulmonary adenocarcinoma
classic emphysema– breakdown of alveolar walls
COPD chronic bronchitis
aka PARASEPTAL
ILD
honeycombing. the fact that this is a lower cut section indicates that it might be UIP going on. Really indicates severity of disease
68 yo F lifetime non-smoker, previously well
HPI: 2 days increasing SOB, cough PMHx: GERD
Meds: Lansoprazole, Nitrofurantoin x past 9 days
Exposures: None
Labs: WBC/PMNs/ALP/ALT/LDH elevated
Room air ABG: 7.47/34/48/25
A-a gradient: 40
EKG: sinus tachy
DRUG INDUCED PNEUMONITIS!! (type of ILD)
- if you discontinue the macrobid they might feel better
38 yo M – smokes 1 ppd
Cough and Dyspnea on exertion x 6 months
Weight loss x 10 pounds
Previously well No meds, no allergies No HP exposures, No CTD
Works in a Foundry making metal castings
68 yo M
Never smoker
2-3 years progressive dyspnea on exertion
PMHx: HIV - normal CD4, undetectable VL
Medications: ART, ASA 81
NKDA
Velcro-crackles to lower lobes bilaterally Inspiratory squawks/squeaks upper lobes Loud P2, RV heave, pedal edema, JVP 4 cm ASA
FEV 1 /FVC 0.79
DLCO33% predicted
FVC 49% predicted DL
Has a backyard aviary x 30 years >100 pigeons 3 parrots, 4 parakeets, 2 parrotlets – in his home
Hypersensitivity Pneumonitis (HP)
Which of these is NOT a cause of HP?
1. Farming 2. Birds 3. Hot tubs 4. Cats 5. Wind Instruments
cats do not cause hypersensitivity pneumonitis
62 yo F with 2 years SOBOE and dry cough PMHx: HTN, ex-smoker (30 pk-yrs), GERD Meds: ACEI/HCTZ, PPI NKDA SHx: Manages a construction company, wood-
working and painting as hobbies FHx: No ILD, CTD ROS: No symptoms of CTD, angina, CHF
Normal Vitals: Sp02 = 94% r/a Finger Clubbing Velcro-like crackles to bases bilaterally CBC: Hgb = 165 ANA, RF, ENA, anti-CCP Ab all negative/normal
this is classic UIP; fibrosis in the periphery of the lung, preferring the bottom portion of the lung.
UIP is mainly caused by idiopathic pulmonary fibrosis, chronic hypersensitivity pneumonitis or asbestosis (or as CVD)
huge bronchiole dilations– bronchiectasis
2 classic findings that indicate bronchiectasis
1`. signet ring
- tram tracks
