Respiratory/lungs Flashcards
__________is the most common cause of community acquired pneumonia in patients over 40
Clinical Presentation: Fever, productive cough, Infiltrates on CXR
Hemoptysis is frequent and is characteristically “rusty”
Pneumococcus
Gram +
alpha hemolytic
A sputum cytology specimen shows Curschmann spirals, Charcot-Leyden crystals, and acute inflammatory cells in a background of abundant mucus. Many of the inflammatory cells are eosinophils. Which of the following lung diseases is the patient with such a specimen most likely to have?
Bronchiectasis Foreign body aspiration Atopic asthma Centrilobular emphysema Chronic bronchitis
Asthma:
Clinical Features: Chest tightness, a nonproductive cough, inspiratory and expiratory wheezes, tachypnea, dyspnea, prolonged expiratory phase
Histologic Features: Mucus-containing Curschmann spirals, eosinophils and Charcot-Leyden crystals
Treatment: Short acting β2-agonists (albuterol), Long acting β2-agonists (salmeterol), Anticholinergics (ipratropium), Inhaled steroids (Budesonide, Fluticasone), Oral Steroids (prednisone)
63-year-old male worked for 20 years in the sandblasting business, and he used no respiratory precautions during that time. He now has increasing dyspnea without fever, cough, or chest pain. Which of the following inflammatory cell types is most crucial to the development of his underlying disease?
Plasma cell Mast cell Eosinophil Macrophage Natural killer cell
Macrophage
History of work as a Sandblaster = Silicosis (silica is a major component of sand)
Silica particles are ingested by alveolar macrophages
Dead macrophages release free silica particles and fibrogenic factors
The released silica is then re-ingested by macrophages and the process is amplified
Increased risk for TB
_______ causes plexiform lesions and are seen with severe, long standing disease
Pulmonary HTN
Leadss to right vent hypertrophy and cor pulmonale
What disease process is being descrubed?
Neutrophils are activated by acute insult and release enzymes, which damage pulmonary capillary endothelium-Type I and II pneumocytes
Histologic appearance: Hyaline membranes
Radiographic Appearance: Bilateral infiltrates progressing to “white out”, ICU sign = if you’re given a CXR with numerous lines and tubes on a test, think ARDS
Acute Respiratory Distress Syndrome (ARDS) AKA diffuse alveolar damange (DAD)
What disease is being described?
Triad of diffuse alveolar hemorrhage, glomerulonephritis and a circulating autoantibody to a component of basement membranes…linear deposit of IgG on immunoflueoresence
Goodpasture’s Syndrome:
Renal failure AND alveolar destruction
A 70-year-old female is referred to an ophthalmologist for right eye problems. The findings include enophthalmos, miosis, anhidrosis, and ptosis. She also has pain in the right upper chest region that radiates down her right arm. A chest radiograph is shown below. Which of the following conditions is she most likely to have?
Bronchopneumonia Bronchiectasis Squamous cell carcinoma Sarcoidosis Tuberculosis
Squamous cell carcinoma
This is a pancoast tumor (most often squamous)…may extend into the cervical sympathetic chain causing horners syndrome (enopthalmous, miosis, anhydrosis)
Mixed type III/IV hypersensitivity reaction to environmental antigen causing dyspnea, cough, chest
tightness, headache. Often seen in farmers and those exposed to birds.
A lung biopsy shows interstitial infiltrates of lymphocytes and plasma cells, minimal interstitial fibrosis. and small granulomas.
Hypersensitivity pneumonitis
Improves with removal of exposure
Chronic exposure (often in farmers) lead to interstitial fibrosis
A 49-year-old male is found to have an elevated serum calcium concentration
A chest radiograph reveals a 7-cm right hilar lung mass. A chest CT shows prominent central necrosis in this mass. Which of the following neoplasms is most likely to be associated with these findings?
Metastatic colonic adenocarcinoma
Small cell carcinoma
Bronchioloalveolar carcinoma
Squamous cell carcinoma
Large cell carcinoma
Squamous cell carcinoma-may produce parathyroid-like hormone–> produces calcium as a paraneoplastic syndrome
Metastatic will present with multiple lung masses
Small cell may produce endocrine (ACTH) or nervous system (lamber eaton) paraneoplastic syndrome
A 78-year-old male increasing dyspnea over the past 4 months.
CT scan shows a dense, bright, right pleural mass encasing most of the right lung, and a pleural biopsy shows spindle cells that invade adipose tissue.
Inhalation of which of the following materials is probably an important factor in development of this mass?
Asbestos Bird dust Silica Cotton fibers Coal dust
Mesothelioma:
Complication of asbestos exposure, neoplasm of mesothelial cells, most common in the pleura
Histologic Appearance: Glands and tubules admixed with sheets of spindle cells
Encasing the lung is characteristic of mesothelioma
What disease process is being described?
Irreversible Dilation of Bronchi Caused by Destruction of Bronchial Walls
Due to prolonged/recurrent infections or prolonged atelectasis (tumor, pneumonia, ect.)
Clinical Presentation: Chronic cough with copious production of mucopurulent sputum (often described as several cups full of sputum), Hemoptysis
Radiographic Appearance: dilated bronchi with thickened walls
Bronchiectasis
Due to necrotizing inflammation with damage to airway walls
Causes include Cystic Fibrosis (most common cause)
Kartagener syndrome (inherited defect in dyenin arm)
Tumor or foreign body
Necrotizing infection (described above)
Damage to the bronchial mucosa by major basic protein of eosinophils is characteristic of what respiratory condition?
Asthma
Unopposed action of neutrophil-derived elastase resulting fomr A1AT deficeincy is characteristic of what respiratory condition?
COPD/emphysema
A 45-year-old female who is not a smoker is found to have the PiZZ phenotype of α1- antitrypsin deficiency. She suffers from increasing respiratory difficulty that limits her activities. What condition is probably present in her lungs?
Sarcoidosis Bronchiectasis Interstitial fibrosis Centrilobular emphysema Panacinar emphysema
Empysema:
Panacinar = due to A1AT deficiency, worse in lower lobes (increased blood flow = increased presence of neutrophils + elastase)
Cenrtilobular = due to cigarette smoking, worse in upper lobes (think of smoke rising)
Is emphysema worse in upper or lower parts of lung?
Typically centrilobular worse in upper lobes if cause is smoking (smoke rises)
It will be panacinar that is more severe in lower lobes is caused by A1AT deficiency (PiZZ homozygous is worst risk)
Which type of lung cancer can mimic pneumonia…something like pleuritic chest pain, 3-weel hx of cough, month of abx treatment but no relief.
- Kaposi sarcoma
- Bronchial carcinoid
- Hamartoma
- Bronchoiloavlveolar carcinoma
Bronchioloalveolar Carcinoma:
Distinctive subtype of adenocarcinoma that grows purely along preexisting alveolar walls (lepidic growth)
Clinical Presentation: Peripheral tumor that may mimic pneumonia
Good prognosis: 100% survival at 5 years
What is the most common primary lung malignancy in women and non-smokers?
adenocarcinoma
Tends to arise in the periphery and is often associated with pleural fibrosis and subpleural scars
Decent prognosis: 5 year survival after excision of stage I tumor = 50-80%
An abnormality that inhibits the normal functioning of the ATPase- containing dynein arms of cilia is most likely to produce:
Asthma Bronchiectasis Cirrhosis Emphysema Steatosis
Bronchiectasis
Dyskinesia of cilia leads to ineffective mucocilliary clearance and thus recurrent pulmonary infections that cause bronchiectasis
Kartagener Syndrome: ciliary dyskinesia, dextrocardia (with or without situs inversus), bronchiectasis and sinusitis
Cilia are deficient throughout the body –> sperm (infertility)
Typical patient in test questions = young African American female, cough, dyspnea, uveitis, erythema nodosum, Hypercalemia (due to macrophages in granulomas converting vitamin D to its active form)
Radiologic Appearance: bilateral hilar adenopathy, with or without interstitial pulmonary infiltrates.
Sarcoidosis
Histologic Appearance: Non-caseating granulomas
Treatment: Steroids
Asteroid body
Diffuse fibrosis and “Honeycomb lung” on x-ray or CT is indicative of what respiratory condition?
Usual intersitital pneumonia (UIP)
Fibrosis of lung interstitium. Etiology is unknown
What respiratory condition is described?
Histologic Appearance: Polypoid plugs of loose fibrous tissue fill the bronchiolar lumen and surrounding alveolar spaces
BOOP
Bronchiolitis obliterans with organizing pneumonia
Clinical dx is called cryptogenic organizing pneumonia
“coin” lesions discovered incidentally on chest radiographs
Histologic Appearance: cartilage, fibromyxoid connective tissue, fat, or bone interspersed with clefts lined by respiratory epithelium
Pulmonary Hamartoma: solitary nodule
Good prognosis, benign
What is the characteristic pathologic change seen in the lung in bacterial pneumonia: A. Chronic inflammation in the interstitium B. Acute inflammation in the interstitium C. Cytopathic changes in type II pneumocytes D. Acute inflammation in the alveolar spaces
D. Acute inflammation in the
alveolar spaces
What is the histologic feature characteristic of an adenocarcinoma? A. Keratin formation B. Intercellular bridges C. Presence of necrosis D. Gland formation
D. Gland formation
Keratin and Intercellular bridges: Squamous cell carcinoma
Diffuse alveolar damage is characterized by: A. Masson bodies B. Acute inflammation in the alveolar lumen C. Hyalin membranes D. Chronic inflammation in the interstitium
C. Hyalin membranes
Bronchiolitis obliterans organizing pneumonia:
A. Always follows a bacterial pneumonia
B. Has a very bad prognosis
C. When idiopathic is referred to as cryptogenic organizing pneumonia
D. Morphologically shows hyalin membranes in the lung
C. When idiopathic is referred to as cryptogenic organizing pneumonia
What is the most common cause of community aquired pneumonia?
Most common hospital aquired?
CA: Strep pneumo (gram +)
Hospital: Pseudomonas or Klebsiella
What respiratory condition is being described:
Neutrophils within alveoli are replaced by plugs of proliferating fibroblasts
Fibroblast plugs = “Masson bodies”
Organization (organizing pneumonia/BOOP)
which lung cancer is a neoplasm of neuroendocrine Kulchitsky cells (chromogranin A stain positive) that is poorly differentiated?
Where is it located?
Small cell carcinoma
Located central involving the mainstem, lobar, or segmental bronchi
• More commonly present as a cavitary mass than other histologic types due to necrosis
• Wheezing, hemotypsis more common
• Paraneoplastic syndrome (hypercalcemia – PTHrP)
Which lung cancer type has acinar growth and is the most common lung carcinoma in never-smokers
and females?
where is it located?
adenocarcinoma
Located peripherally
Glandular pattern that may stain mucin
Mutations in KRAS, EGFR, and ALK are associated with which type of lung cancer?
Adenocarcinoma (NSCLC)
What type of lung cancer presents with a polyp-like mass in bronchus and stains postitive for chromogranin (neuroendocrine)
Carcinoid tumor
“salt and pepper” chromatin
NOT related to smoking
Mostly occurs in younger patients
EGFR, ALK, ROS1, and BRAF mutations are most likely to be detected in what type of lung cancer? A. Squamous cell carcinoma B. Adenocarcinoma C. Small cell carcinoma D. Large cell neuroendocrine carcinoma E. Carcinoid tumor
B. Adenocarcinoma
All of the following can present as a central (hilar) mass except… A. Squamous cell carcinoma B. Adenocarcinoma C. Small cell carcinoma D. Carcinoid tumor E. Malignant mesothelioma
B. Adenocarcinoma (more likely in the periphery)
E. Malignant mesothelioma
The most common lung cancer in smokers or those with a smoking history is ? A. Squamous cell carcinoma B. Adenocarcinoma C. Small cell carcinoma D. Large cell neuroendocrine carcinoma E. Carcinoid tumor
B. Adenocarcinoma (regardless of smoking type)
Large cell carcinomas are easily diagnosed in cytology or biopsy specimens by their lack of squamous or glandular differentiation ?
A. True
B. False
B. False
You need to make the dx based on resection of tissue
The most common lung cancer in neversmokers? A. Squamous cell carcinoma B. Adenocarcinoma C. Small cell carcinoma D. Large cell neuroendocrine carcinoma E. Carcinoid tumor
B. Adenocarcinoma
A 56-year-old man with a history of cigarette smoking presents with difficulty swallowing and a muffled voice. Laryngoscopy reveals a 2-cm laryngeal mass. If this mass is a malignant neoplasm, which of the following is the most likely histologic diagnosis? A. Adenocarcinoma B. Leiomyosarcoma C. Small cell carcinoma D. Squamous cell carcinoma E. Transitional cell carcinoma
Squamous Cell
The vast majority of laryngeal cancers are squamous
The three most common tumors that locate more central are what?
Squamous cell
small cell
large cell
A 68-year-old man complains of shortness of breath, hoarseness, productive cough, and bloody sputum of 2 weeks in duration. He admits to smoking two packs a day for 45 years and drinks occasionally. Recently, he has
experienced a significant loss of appetite and weight loss. Physical examination shows pallor, cachexia, clubbing of the fingers, and barrelshaped chest. A chest X-ray reveals a mass at the right lung apex. Histologic examination of a transbronchial biopsy is shown in the image. What is the appropriate histologic diagnosis?
A. Adenocarcinoma
B. Mesothelioma
C. Metastatic adenocarcinoma
D. Small cell carcinoma
E. Squamous cell carcinoma
All markers are negative, indicating a poorly dfferentied tumor: large cell carcinoma
P63: squamous marker
TTF-1: adeno
Chromogranin: neuroendocrine
A 55-year-old man presents with increasing chest pain, bloody sputum, and weight loss over the past 3 months. A high resolution CT scan reveals a mass circumscribing the right main bronchus, extending into its lumen.
Histologic examination of an open-lung biopsy is shown in the image. Immunohistochemistry shows the tumor cells are positive for chromogranin and synaptophysin. What is the appropriate diagnosis?
A. Adenocarcinoma
B. Large cell neuroendocrine carcinoma
C. Carcinoid tumor
D. Large cell carcinoma
E. Squamous cell carcinoma
Carcinoid tumor
Mass extending into lumen
synaptophysin: stains neuroendocrine
chromogranin: stains neuroendocrine
