Respiratory Pathology Flashcards
1
Q
What causes rhinosinusitis?
A
Obstruction of sinus drainage into the nasal cavity leading to inflammation and pain over the affected area
2
Q
What is the most common site of inflammation causing rhinosinusitis?
A
Maxillary Sinuses (because the drainage orifice is superiorly placed near the roof, which impedes drainage)
3
Q
What is the most common cause of acute rhinosinusitis?
A
Viral URI
a viral URI can lead to a superimposed bacterial infection
4
Q
What are the three most common bugs associated with rhinosinusitis?
A
- S. pneumoniae
- H. influenzae
- M. catarrhalis
5
Q
What is epistaxis?
A
Nose bleed
6
Q
What is the most common site of epistaxis (nose bleed)?
A
Anterior Segment of nostril (Kiesselbach plexus, where 4 arteries anastomose)
7
Q
Where do life-threatening hemorrhages in the nostril occur?
A
Posterior Segment (sphenopalatine artery, a branch of the maxillary artery)
8
Q
What are the three components of Virchow’s Triad that predispose patients to DVTs?
A
Virchow Triad (SHE):
- Stasis (Venous)
- Hypercoaguability (e.g. defect in coagulation cascade proteins, such as factor V leiden)
- Endothelial Damage (exposed collagen triggers clotting cascade)
9
Q
What is Homan’s sign?
A
Calf pain with passive stretching (i.e. dorsiflexion of foot)
10
Q
What is a Deep Venous Thrombosis (DVT)?
A
Blood clot within a deep vein causing swelling, redness, warmth and pain
11
Q
How do you treat a Deep Venous Thrombosis (DVT)?
A
Use fractionated heparin or low-molecular weight heparins (eg. enoxaparin) for prophylaxis and acute management
Use oral anticoagulants (eg. warfarin, rivaroxaban) for treatment (long-term prevention)
12
Q
What patient populations are predisposed to DVTs?
A
- ortho trauma
- immoblization
- pregnant/post-pardum
- Cancer patients
- Older patients
- Patients taking long plane rides or car rides
- Women on birth control pills
- Lupus (hypercoaguability)
13
Q
What are the signs of a pulmonary emboli (PE)?
A
Sudden onset dyspnea, chest pain, tachypnea, tachycardia (may present as sudden death)
14
Q
What is the imaging test of choice for evaluating a pulmonary emboli (PE)?
A
CT pulmonary angiography (look for filling defects)
15
Q
What histological finding helps to distinguish pre and postmortem thrombi?
A
Lines of Zahn, which are interdigitating areas of pink (platelets, fibrin) and RBCs (light pink then darker pink/red then light pink again, layers are alternating). This is only found in thrombi formed before death.
16
Q
What are the different types of pulmonary emboli (PE)?
A
FAT BAT
Fat Air Thrombus Bacteria Amniotic Fluid Tumor
17
Q
What are the two associations with forming fat emboli and what is the classic triad of symptoms for fat emboli?
A
Associated with long bone fractures and liposuction
Triad:
- Hypoxemia
- Neurologic Abnormalities
- Petechial Rash
18
Q
What is the most common sequelae associated with Amniotic emboli?
A
Can lead to DIC (widespread activation of the clotting cascade, leading to bleeding, bruising, and kidney failure) especially post pardum
See shistocytes and helmet cells in peripheral smear in DIC
Classic boards tip off to DIC: blood oozing from all IV sites
19
Q
What can lead to air emboli and how is it treated?
A
Nitrogen bubbles precipitate in ascending divers
Treat with hyperbaric O2
20
Q
Where is the most common site of origin for pulmonary emboli?
A
Femoral Vein
even though the most common site of DVT is the calf
21
Q
What is the result of obstructive lung disease and what are some examples?
A
Obstruction of air flow resulting in air trapping in lungs
Ex: Chronic Bronchitis, Emphysema, Asthma, Bronchiectasis
22
Q
What happens to RV in obstructive lung disease?
A
RV increases
23
Q
What happens to FEV1 in obstructive lung disease?
A
FEV1 decreases
24
Q
What happens to FVC in obstructive lung disease?
A
FVC decreases
25
What happens to the FEV1/FVC ratio in obstructive lung disease?
FEV1/FVC ratio decreases (hallmark of obstructive lung disease)
26
What are the common sequelae of obstructive lung disease?
V/Q mismatch leads to chronic, hypoxic pulmonary vasoconstriction, which can lead to cor pulmonale
27
What is the classic presentation of Chronic Bronchitis?
"Blue Bloater"
Productive cough for > 3 months (not necessarily consecutive) for > 2 years
Findings: wheezing, crackles, cyanosis (early onset hypoxemia due to shunting), late-onset dyspnea, CO2 retention ( hypercapnia), 2° polycythemia (body tries to compensate for poor oxygenation)
28
What is the pathology of chronic bronchitis?
Hypertrophy/Hyperplasia of mucus glands
29
What is the Reid index and what is the value of the Reid Index in chronic bronchitis?
Thickness of gland layer/total thickness of bronchial wall
> 50 in chronic bronchitis
30
What is the pathology of emphysema?
Enlargement of air spaces, decreased recoil, increased compliance, and decreased diffusing capacity resulting from destruction of alveolar walls
31
What are the two types of emphysema and what are each type associated with?
1. Centriacinar - associated with smoking
2. Panacinar - associated with alpha 1 antitrypsin deficiency (inhibits neutrophil elastase from breaking down, w/ mutation increased elastase activity, causes loss of elastic fibers and increases lung compliance; look for a young patient with liver problems and lung problems)
32
What is the classic presentation of a patient with emphysema?
"Pink Puffer" who is barrel chested and breathing through pursed lips (exhalation through pursed lips causes an increase in airway pressure and prevents airway collapse during respiration)
33
What is the pathology of asthma?
Bronchial hyperresponsiveness causes reversible bronchoconstriction
(Type 1 Hypersensitivity reaction)
34
What are common triggers of asthma?
Viral URIs, allergens, stress
35
What are the findings associated with asthma?
Nighttime cough, wheezing, tachypnea, dyspnea, hypoxemia, decreased inspiratory/expiratory ratio, pulsus paradoxes and mucous plugging
36
What are common histological findings for asthma?
1. Smooth muscle hypertrophy
2. Curschmann spirals (shed epithelium forms whorled mucus plugs)
3. Charcot-Leyden crystals (eosinophilic hexagonal, double pointed, needle-like crystals formed from the breakdown of eosinophils in the sputum)
4. Eosinophils (release major basic protein)
5. Creola Bodies
37
What cytokines are triggered in asthma?
Th2 cytokines (IL-4, IL-5, IL-10, IL-13)
38
What test do you do to rule asthma in or out?
Methacholine challenge
39
What is the pathology of bronchiectasis?
Chronic necrotizing infection of bronchi:
- permanently dilated airways
- purulent sputum
- recurrent infections
- hemoptysis
40
What are common associations for bronchiectasis?
Associated with:
- bronchial obstruction
- poor ciliary motility (e.g. smoking, Kartangener syndrome)
- cystic fibrosis
- allergic bronchopulmonary aspergillosis
- Klebsiella
41
What are the histological findings associated with bronchiectasis?
1. mucoid exudate
2. goblet cell metaplasia
3. epithelial basement
4. membrane thickening
42
What is the pathology of restrictive lung disease?
Restricted lung expansion causes a decrease in lung volumes (decreased FVC and TLC)
43
In restrictive lung disease is the FEV1/FVC ratio increased or decreased?
FEV1/FVC ratio > or = 80%
It is either preserved or increased
44
What are the two types/causes of restrictive lung disease?
1. Poor Breathing mechanics (extra pulmonary, peripheral hypoventilation, normal A-a gradient)
- poor muscular effort (polio, myasthenia gravis)
- poor structural apparatus (scoliosis, morbid obesity)
2. Interstitial Lung Diseases (decreased diffusion capacity, increased A-a gradient)
45
What are some examples of interstitial lung diseases?
1. Acute Respiratory Distress Syndrome (ARDS)
2. Neonatal Respiratory Distress Syndrome (NRDS; hyaline membrane disease)
3. Pneumoconioses (e.g. anthracosis, silicosis, asbestosis)
4. Sarcoidosis: bilateral hilar lymphadenopathy, noncaseating granuloma: increased ACE and Ca2+
5. Idiopathic pulmonary fibrosis (repeated cycles of lung injury and wound healing with collagen deposition)
6. Goodpasture Syndrome
7. Granulomatous with polyangitis (Wegener)
8. Langerhands cell histiocytosis (eosinophilic granuloma)
9. Hypersensitivity Pneumonitis
10. Drug Toxicity (bleomycin, busulfan, amiodarone, methotrexate)
46
How are lung volume changes different in restrictive vs. obstructive lung diseases?
Restrictive: lung volumes normal
47
How does FEV1 and FVC change in restrictive vs. obstructive lung diseases?
Reduced in BOTH restrictive and obstructive
In obstructive, FEV1 is more dramatically reduced compared to FVC resulting in a DECREASE FEV1/FVC ratio
48
What hypersensitivity is involved in Hypersensitivity Pneumonitis?
Mixed Type III and Type IV hypersensitivity reaction to environmental antigen
IgG Ab = Type III
CD8+ = Type IV
49
When and how does Hypersensitivity Pneumonitis present?
4-6 hours after mold or droppings exposure (Aspergillus and Actinomyces). Often seen in farmers and those exposed to birds.
Symptoms: dyspnea, cough, chest tightness, and headache
50
What are two risks associated with Pneumoconioses (coal worker's pneumoconiosis, silicosis and asbestosis)?
1. Increased risk of cor pulmonale
| 2. Caplan Syndrome (rheumatoid arthritis and pneumoconiosis with intrapulmonary nodules)
51
What findings are pathonomonic of asbestosis?
"Ivory white" calcified pleural plaques
Asbestos (ferruginous) bodies are golden brown fusiform rods resembling dumbbells (found in alveolar septum)
52
What are jobs associated with asbestos exposure?
shipbuilding, roofing, plumbing
53
What are the risks associated with asbestos?
Increased risk of lung cancer (bronchogenic carcinoma > mesothelioma)
54
Which pneumoconioses affects the lower lobes of the lung?
Asbestosis
Asbestos is from the roof (was common in insulation), but affects the base (lower lungs)
Silica and Coal are from the base (earth), but affect the roof (upper lungs)
55
Which industries are associated with Berylliosis?
Aerospace and manufacturing
56
What is the histology associated with Berylliosis?
Granulomatous, and therefore, occasionally responsive to steroids
(affects upper lobes)
57
What is Anthracosis?
Asymptomatic condition found in many urban dwellers exposed to sooty air
58
What is the pathology of Coal worker's pneumoconiosis?
Prolonged coal dust exposure leads to macrophages laden with carbon leading to inflammation and fibrosis
(affects upper lobes)
59
What industries are associated with Silicosis?
Associated with foundries, sandblasting, mines
60
What is the pathology of Silicosis?
H2O2 production damages tissue, macrophages respond to silica and release fibrogenic factors + release of cytokines (TNF, IL-1, LTB4)
(affects upper lobes)
61
Silicosis increases someone's risk for which two conditions?
1. Tuberculosis
| 2. Bronchogenic Carcinoma
62
What finding is pathonomonic of silicosis?
"Eggshell" calcification of hilar lymph nodes
63
What is the pathology of Neonatal Respiratory Distress Syndrome?
Surfactant deficiency leads to increased surface tension leads to decreased compliance and increased work of breathing
Increased surface tension can cause alveolar collapse ("ground glass" appearance of lung fields)
64
What lecithin/sphingomyelin ratio in the amniotic fluid is predictive of NRDS?
is low risk)
65
What are risk factors for NRDS?
1. Prematurity
2. Maternal Diabetes (due to increased fetal insulin)
3. C-section delivery (decreased release of fetal glucocorticoids)
66
What are complications associated with NRDS?
1. metabolic acidosis
2. PDA (persistently low O2 tension)
3. Necrotizing enterocolitis
67
What is the treatment for NRDS?
Maternal steroids before birth
or
Artificial surfactant for infants
68
What are the risks associated with therapeutic supplemental O2?
RIB:
Retinopathy of prematurity
Intraventricular hemorrhage
Bronchopulmonary dysplasia
69
What is Acute Respiratory Distress Syndrome (ARDS) and what are some potential causes?
Clinical syndrome characterized by acute onset respiratory failure, bilateral lung opacities, decreased PaO2/FiO2, no HF
May be caused by trauma, sepsis, shock, gastric aspiration, uremia, acute pancreatitis, amniotic fluid embolism
70
What is the pathology of Acute Respiratory Distress Syndrome (ARDS)?
Initial damage is due to release of neutrophilic substances toxic to the alveolar wall, activation of coagulation cascade, and oxygen derived free radicals.
Diffuse alveolar damage leads to increased alveolar capillary permeability and protein leakage into alveoli and noncardiogenic pulmonary edema (normal PCWP)
71
What is the common histological finding associated with ARDS?
Intra-alveolar hyaline membranes
72
What is the management for ARDS?
Mechanical ventilation with low tidal volumes
73
What is sleep apnea?
Repeated cessation of breathing > 10 seconds during sleep
Normal PaO2 during the day
74
What are the classic signs/complaints indicating sleep apnea?
disrupted sleep & daytime somnolence
75
What are potential sequelae of sleep apnea/nocturnal hypoxia?
systemic/pulmonary hypertension, arrhythmias (atrial fibrillation/flutter), sudden death
76
What is Obstructive Sleep Apnea?
Respiratory effort against airway obstruction. Caused by excess parapharyngeal tissue in adults and adenotonsillar hypertrophy in children.
It is associated with obesity and loud snoring.
77
What is the treatment for Obstructive Sleep Apnea?
Weight loss, CPAP, surgery
78
What is Central Sleep Apnea?
No respiratory effort (due to CNS injury/toxicity)
| Narcotics, HF, Renal Failure, Rapid Ascent to High Altitudes
79
What is Obesity Hypoventilation Syndrome?
Obesity (BMI > 30 kg/m2)
Hypoventilation (decreased respiratory rate) with decreased PaO2 and increased PaCO2 during sleep
Increased PaCO2 during waking hours too (daytime hypercapnia is the way to distinguish this from OSA)
80
What are the long term sequelae of pulmonary hypertension?
Cor pulmonale and right ventricular failure
81
What is normal mean pulmonary artery pressure and at what value are you concerned about pulmonary hypertension?
Normal PA pressure = 10-14 mm Hg
Pulmonary Hypertension > 25 mm Hg at rest
82
What is the gene involved in heritable pulmonary arterial hypertension (PAH)?
Due to an inactivating mutation in BMPR2 gene (normally inhibits vascular smooth muscle proliferation); poor prognosis
83
On examination, what do bilateral dullness to percussion and decreased breath sounds at the lung bases suggest?
Pleural Effusion
84
On examination, what does hyper resonant percussion suggest?
Pneumothorax
85
On examination, what does increased tactile fremitus, bronchial breath sounds and late inspiratory crackles suggest?
Consolidation (pneumonia or pulmonary edema)
86
What is a pleural effusion?
Excess accumulation of fluid between pleural layers (restricted lung expansion during inspiration)
87
How can a pleural effusion be treated?
thoracocentesis to remove the fluid
88
What is a transudate pleural effusion and what causes it?
decreased protein content
due to increased hydrostatic pressure or decreased oncotic pressure (eg. HF, nephrotic syndrome, hepatic cirrhosis)
serum/fluid protein ratio
89
What is a exudate pleural effusion and what causes it?
increased protein content, cloudy
due to malignancy, pneumonia, collagen vascular disease, trauma (occurs in states of increased vascular permeability)
**must be drained due to risk of infection
serum/fluid protein ratio > 0.5
serum/ fluid LDL > 0.6
90
What is a lymphatic pleural effusion (chylothorax) and what causes it?
Milky-appearing fluid; increased triglycerides
Due to thoracic duct injury from trauma or malignancy
91
What is a pneumothorax?
Accumulation of air in pleural space
92
What are the clinical signs of a pneumothorax?
Unilateral chest pain and dyspnea, unilateral chest expansion, decreased tactile fremitus, HYPERRESONANCE, diminished breath sounds all on the affected side
93
What is the cause of primary spontaneous pneumothorax and who gets this?
Due to rupture of apical blebs or cysts
Occurs most frequently in tall, thin, young males
94
What is the cause of secondary spontaneous pneumothorax and who gets this?
Due to a diseased lung (eg. bullae in emphysema, infections), mechanical ventilation with use of high pressures (barotrauma)
95
What is the cause of traumatic pneumothorax and who gets this?
Caused by blunt trauma (rib fracture) or penetrating trauma (gun shot or needle puncture)
96
What is a tension pneumothorax?
Air enters the pleural space and cannot exit
(increased trapped air = tension pneumothorax)
EMERGENCY, must do a needle decompression before a scan
97
Which way does the trachea deviate in a tension pneumothorax?
Away from the side of the lesion
98
Which way does the trachea deviate in atelectasis (bronchial obstruction)?
Toward the side of the lesion
99
What organisms cause lobar pneumonia?
S. pneumoniae most frequently, also Legionella and Klebsiella
100
What are the characteristics of a lobar pneumonia?
Intra-alveolar exudate / consolidaton
May involve entire lobe or lung
101
What organisms cause bronchopneumonia?
1. S. pneumoniae
2. S. aureus
3. H. influenzae
4. Klebsiella
102
What are the characteristics of a bronchopneumonia?
Patchy distribution involving 1 or more lobes
Acute inflammatory infiltrates from bronchioles into adjacent alveoli
103
What organisms cause interstitial pneumonia?
Viruses (influenza, CMV, RSV, adenoviruses)
Mycoplasma, Legionella, Chlamydia
104
What are the characteristics of an interstitial pneumonia?
Diffuse patchy inflammation localized to interstitial areas at the alveolar walls
involving 1 or more lobes
generally follows a more indolent course ("walking pneumonia")
105
What is a lung abscess?
Localized collection of pus within parenchyma
106
What causes lung abscesses?
Aspiration of oropharyngeal contents (especially in patents predisposed to loss of consciousness, e.g. alcoholics or epileptics)
or
Bronchial obstruction (cancer)
107
What is the CXR finding for lung abscesses?
air-fluid levels (common in cavities, suggests cavitation)
108
What organisms cause lung abscesses?
Anaerobes (eg. Bacteroides, Fusobacterium, Peptostreptococcus) or S. Aureus
109
What is the treatment for lung abscesses?
Clindamycin
110
What is mesothelioma?
Malignancy of the pleura; associated with asbestos (smoking makes it worse, but is not an independent risk factor)
May result in hemorrhagic pleural effusion (exudative) and pleural thickening
111
What histological finding is associated with mesothelioma?
Psammoma bodies (laminated calcifications)
112
Where are pan coast tumors located?
Also called Superior Sulcus Tumors
Located in the apex of the lung
113
What are the sequelae of pan coast tumors and what syndromes do they cause?
May cause Pancoast Syndrome by invading the cervical sympathetic chain, which causes Horner's Syndrome (ipsilateral ptosis, mitosis, anhidrosis), SVC syndrome, sensorimotor deficits and hoarseness
114
What is SVC syndrome?
An obstruction of the SVC that impairs blood drainage from the head
Signs include:
- facial plethora
- JVD
- Edema in the upper extremities
Commonly caused by malignancy (pan coast tumor) and thrombosis from indwelling catheters
It's a medical emergency bc it can raise intracranial pressure (look for headaches, dizziness, increased risk of aneurysm/rupture of cranial arteries)
115
What is the presentation of lung cancer?
Cough, hemoptysis, bronchial obstruction, wheezing, pneumonic "coin lesion" on CXR or non-calcified nodule on CT
116
What are the sites of metastases of lung cancer?
Adrenals, brain, bone (pathologic fracture), liver (jaundice, hepatomegaly)
117
In the lung, what are more common, metastases or primary neoplasms?
Metastases (usually multiple lesions) are more common than primary neoplasms
Most often breast, colon, prostate and bladder cancer
118
What are the sequelae of lung cancer?
SPHERE
```
SVC Syndrome
Pancoast tumor
Horner syndrome
Endocrine (paraneoplastic)
Recurrent laryngeal nerve compression (hoarseness)
Effusions (pleural and pericardial)
```
119
What are the risk factors for lung cancer?
smoking, second hand smoke, radon, asbestos, family history
120
What is the most common type of lung cancer?
Adenocarcinoma is the most common lung cancer in non-smokers and overall (except for metastases)
121
Where does adenocarcinoma of the lung occur?
Periphery
122
What mutations should you expect in adenocarcinoma of the lung?
Activating mutations in KRAS, EGFR, and ALK
123
What physical finding is associated with adenocarcinoma of the lung?
Hypertrophic osteoarthropathy (clubbing)
124
What is the histology associated with adenocarcinoma of the lung?
Glandular pattern on histology; often stains with mucin
| clara cells + type 2 pneumocytes
125
What is the prognosis for adenocarcinoma of the lung?
excellent prognosis
126
What is are the CXR and histological findings of the bronchioalveolar subtype of adenocarcinoma of the lung?
CXR shows hazy infiltrates similar to pneumonia
Histology: grows along alveolar septae and see thickening of alveolar walls
127
Where does squamous cell carcinoma of the lung occur?
Central (hilar mass arising from the bronchus)
128
What finding is associated with squamous cell carcinoma of the lung?
Hypercalcemia (mass can produce PTHrp)
129
What is the major risk factor for developing squamous cell carcinoma of the lung?
Smoking
130
What histological finding is associated with squamous cell carcinoma of the lung?
Keratin Pearls and intercellular bridges
131
What is the prognosis for small cell carcinoma of the lung?
undifferentiated tumors; very aggressive
| worst 5 year prognosis
132
Where does small cell carcinoma of the lung occur?
Central
133
What small molecules can small cell carcinoma of the lung produce and what syndromes do these cause?
1. ACTH (Cushing syndrome)
2. ADH (SIADH leads to fluid retention and hyponatremia)
3. Antibodies against presynaptic Ca2+ channels (Lambert-Eaton myasthenia syndrome)
4. neurons (paraneoplastic myelitis/encephalitis)
134
What genetic mutation is common in small cell carcinoma of the lung?
Amplification of myc oncogenes
135
What are the histological findings associated with small cell carcinoma of the lung?
Neoplasm of neuroendocrine Kulchitsky cells, which are small dark blue cells on histology
Chromogranin A +
136
What is the treatment for small cell carcinoma of the lung?
Inoperable; treat with chemotherapy
137
Where does large cell carcinoma of the lung occur?
Peripheral
138
What is the prognosis of large cell carcinoma of the lung?
Highly anapestic undifferentiated tumors; poor prognosis
139
What can large cell carcinoma of the lung secrete?
Beta-hCG
140
What histological finding is associated with large cell carcinoma of the lung?
Pleomorphic giant cells
141
What is the treatment for large cell carcinoma of the lung?
Less responsive to chemotherapy; remove surgically
142
What is the prognosis for bronchial carcinoid tumors?
Excellent prognosis; grow slowly and metastasis is rare
143
How do bronchial carcinoid tumors present?
Symptoms are usually due to the mass effect: bronchial obstruction, hemoptysis, coughing
144
What syndrome can be associated with bronchial carcinoid tumor and what hormone causes it?
Carcinoid Syndrome (serotonin/5-HT secretion)
leads to flushing, diarrhea, wheezing (sometimes right heart failure)
145
What are the histological findings of bronchial carcinoid tumors?
Nests of neuroendocrine cells
Chromogranin A +
