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USMLE > Respiratory - Pathology > Flashcards

Respiratory - Pathology Flashcards

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USMLE® Step 1 flashcards
1
Q

Rhinitis: Mechanism and Presentation

A

Inflammation of nasal mucosa

Sneezing, congestion, runny nose

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2
Q

What is the most common cause of rhinitis?

A

Adenovirus

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3
Q

Allergic Rhinitis: Mechanism. What type of hypersensitivity?

A

Type I hypersensitivity (e.g. to pollen) Subtype of rhinitis

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4
Q

Allergic Rhinitis: Histology

A

Inflammatory infiltrate with eosinophils

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5
Q

What is allergic rhinitis associated with?

A

Asthma and eczema

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6
Q

Nasal polyp: Mechanism and Causes

A

Protrussion of edematous, inflamed nasal mucosa

Repeated rhinitis, cystic fibrosis and aspirin-intolerant asthma

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7
Q

What is the triad of aspirin-intolerant asthma?

A

Asthma, Aspirin-induced bronchospasm, nasal polyps

Seen in 10% of asthmatic adults

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8
Q

What is a nasopharynx angiofibroma?

A

benign tumor of nasal mucosa of large blood vessels and fibrous tissues, classically seen in adolescent males Present with profuse epistaxis

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9
Q

Nasopharyngeal carcinoma

A

malignant tumor of nasopharyngeal epithelium often involves cervical lymph nodes

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10
Q

What is nasopharyngeal carcinoma associated with? Which population?

A

EBV African children and Chinese adults

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11
Q

Nasopharyngeal carcinoma: biopsy

A

pleomorphic keratin-positive epithelial cells (poorly differentiated SCC) in background of lymphocytes

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12
Q

Acute epiglottis: Presentation

A

Inflammation of epiglottis

Fever, sore throat, drooling with dysphagia, muffled voice, inspiratory stridor, risk of airway obstruction

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13
Q

What is the most common cause of acute epiglottis?

A

H. flu type b Especially in nonimmunized children

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14
Q

Laryngotracheobronchitis (Croup)

A

Inflammation of upper airway

Presents with hoarse, “barking” cough and inspiratory stridor

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15
Q

What is the most common cause of laryngotracheobronchitis?

A

Parainfluenza virus

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16
Q

What is a singer’s nodule?

A

Vocal cord nodule - arise on true vocal cord

Presents with hoarseness; resolves with resting of voice

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17
Q

What is the cause of a vocal cord nodule?

A

Excessive use of vocal cord, usually bilateral

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18
Q

Vocal cord nodule: histology

A

degenerative (myxoid) connective tissue

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19
Q

Laryngeal papilloma

A

Benign papillary tumor of vocal cord Presents with hoarseness

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20
Q

What is the common cause of laryngeal papilloma?

A

HPV 6 and 11

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21
Q

How are laryngeal papillomas presented in children vs adults?

A

Children - multiple Adults - single

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22
Q

Laryngeal carcinoma

A

Squamous cell carcinoma usually from epithelial lining of vocal cord

Presents with hoarseness, other sings include cough and stridor

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23
Q

Risk factors for laryngeal carcinoma

A

alcohol and tobacco

Rarely arise from laryngeal papilloma

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24
Q

What is choanal atresia?

A

Unilateral or bilateral bony septum between nose and pharynx

Newborn cannot breath through nose; cyanosis when breast-feeding and pink up after crying

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25
Q

What is the most common polyp in adults?

A

Allergic polyp

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26
Q

What test to order when a child has nasal polyps?

A

Sweat test to rule out cystic fibrosis

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27
Q

Obstructive sleep apnea: laboratory findings

A

Respiratory acidosis and hypoxemia

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28
Q

Obstructive sleep apnea: complications

A

Risk for developing cor pulmonale

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29
Q

Diagnosis for Obstructive Sleep Apnea

A

Polysomnography: confirmatory test that documents period of apnea during sleep

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30
Q

What is the most common sinus infection in adults?

A

maxillary sinusitis

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31
Q

What is the most common sinus infection in children?

A
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32
Q

What is the most common cause of sinusitis?

A

viral

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33
Q

What is the most common bacterial pathogen causing sinusitis?

A

Streptococcus pneumoniae

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34
Q

What is the most sensitive test for sinusitis?

A

CT

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35
Q

What is pneumonia?

A

Infection of lung parenchyma

Occurs when normal defences are impaired (cough reflex, damage to mucociliary escalator, mucus plugging)

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36
Q

Presentation of Pneumonia

A

Fever and chills, productive cough with yellow green (pus) or rusty (bloody) sputum
Tachypnea with pleuritic chest pain, elevated WBC count

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37
Q

How is pneumonia diagnosed?

A

chest x-ray
sputum gram stain and culture
blood culture

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38
Q

What are the three patterns classically seen on chest x-ray for pneumonia?

A

lobar pneumonia
bronchopneumonia
interstitial pneumonia

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39
Q

What is lobar pneumonia?

A

Consolidation of entire lobe on lung

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40
Q

Causes of lobar pneumonia

A

Usually bacterial
Most common: strep pneumo (95%) and klebsiella pneumoniae

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41
Q

What is the classic gross phases of lobar pneumonia?

A
  1. congestion (congested vessels and edema)
  2. Red hepatization (exudates, neutrophils, hemorrhage filling alveolar air space, giving normally spongy lung a solid consistency)
  3. Gray hepatization (degradation of red cells within exudate)
  4. Resolution
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42
Q

What is bronchopneumonia? What is it caused by?

A

Scattered patchy consolidation centered around bronchioles; often multifocal and bilateral

Caused by a variety of bacterial organisms

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43
Q

What is interstitial (atypical) pneumonia?

A

Diffuse interstitial infiltrates

Relatively mild upper respiratory symptoms (minimal sputum and low fever)

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44
Q

What is aspiration pneumonia?

A

Seen in patients at risk for aspiration (alcoholics and comatose)

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45
Q

What are the most common causes (5) of bronchopneumonia?

A

S. aureus
H. flu
Pseudomonas aeruginosa
Moraxella catarrhalis
Legionella pneumophila

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46
Q

What are the most common causes (6) of atypical pneumonia?

A

Mycoplasma pneumoniae (most common)
Chlamydia pneumoniae
RSV
CMV
Influenza
Coxiella burnetii

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47
Q

What usually results from an aspirated pneumonia?

A

Right lower lobe abscess - right main stem bronchus at less acute angle than left

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48
Q

What are the two water loving bacterias

A

Pseudomonas aeruginosa
Legionella pneumophila

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49
Q

What is a Ghon complex?

A

Focal, caseating necrosis in lower lobe of lung and hilar lymph nodes that undergoes fibrosis and calcification

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50
Q

What is form in secondary TB?

A

cavitary foci of caseous necrosis; may lead to miliary pulmonary TB or tuberculosis bronchopneumonia

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51
Q

Wht are common sites of TB systemic spread?

A

Meninges (meningitis)
Cervical lymph nodes
Kidneys (sterile pyruia)
lumbar vertebrae (pott disease)

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52
Q

What is the virulence factor of TB?

A

Cord factor

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53
Q

What is the most common extrapulmonary site of TB?

A

Kidneys

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54
Q

What is the most common TB in AIDS?

A

Mycobacterium avium - intracellulare (MAC) Complex

CD4 Th cells fall below 50 cells/mm3

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55
Q

What is the most common cause of lung abscess?

A

Aspiration of oropharyngeal material

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56
Q

What does chest x-ray shows for lung abscesses?

A

cavitation and fluid level

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57
Q

Define COPD

A

Group of disease characterized by airway obstruction
Lung does not empty; air is trapped

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58
Q

COPD: Typical lung volume changes (FVC, FEV, FEV1/FVC ratio, TLC)

A

Decreased FVC
Decreased FEV1 (more than FVC)
Decreased FEV1/FVC ratio

Increased TLC (due to air trapping)

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59
Q

What are the 4 COPDs?

A

Chronic bronchitis
Emphysema
Asthma
Bronchietasis

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60
Q

Chronic Bronchitis

A

Productive cough lasting at least 3 months over minimum of 2 years
Highly associated with smoking

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61
Q

Chronic bronchitis: histology

A

Hypertrophy of bronchial mucinous glands
Increased thickness of mucus glands relative to overall bronchial wall thickness (Reid index increases > 50% - normaly is 40%)

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62
Q

Chronic bronchitis: Presentation

A

Productive cough due to excessive mucus production
Cyanosis (blue boaters) - mucus plugs trap CO2; increased PaCO2 and decreased PaO2

Increased risk of infection and cor pulmonale

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63
Q

What is the most common cause of bronchiectasis?

A

Smoking

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64
Q

Emphysema

A

Destruction of alveolar air sac from loss of elastic recoil and collapse of airways during exhalation

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65
Q

Describe how inbalance of proteases/antiproteases contribute to emphysema

A

Inflammation leads to release of proteases by neutrophils and macrophages
alpha1-antitrypsin neutrlizes proteases

excessive inflammation or lack of antitrypsin leads to destruction of alveolar air sacs

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66
Q

What is the most common cause of emphysema?

A

Smoking (pollutants in smoke lead to excessive inflammation and protease-mediated damage)

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67
Q

Where is smoking-associated emphysema located?

A

Centriacinar emphysema in upper lobes

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68
Q

What is A1AT deficiency?

A

Alpha-1 antitrypsin deficiency - rare cause of emphysema
Lack of antiprotease leaves air sacs vulnerable to protease-mediated damage

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69
Q

Where is A1AT-associated emphysema?

A

panacinar emphysema in lower lobes

70
Q

What other organ besides the lungs can A1AT deficiency affect? Why?

A

Liver cirrhosis
misfolding of mutated protein - accumulates in ER of hepatocytes leading to damage

pink, PAS-positive globules in hepatocytes

71
Q

How is A1AT inherited?

A

PiM is normal allele; two copies are expressed
PiZ is common clinically relevant mutation - significantly lowers circulating A1AT

72
Q

What is the genotype of individual with heterozygous and homozygous A1AT deficiency? Do they have the same risk for developing disease?

A

Heterozygote: PiMZ: usually asymptomatic but significantly increased risk with smoking
Homozygote: PiZZ significant risk for panacinar emphysema and liver cirrhosis

73
Q

Emphysema: Presentation

A

dyspnea and cough with minimal sputum
prolonged expiration with pursed lips (pink-puffer)
weight loss
increased AP diameter (barrel-chested)

hypoxemia and cor pulmonale as late complications

74
Q

What poses a risk for spontaneous pneumothorax?

A

paraseptal emphysema (subpleural location)

75
Q

Asthma

A

Reversible airway bronchoconstriction, most often due to allergic stimuli (Type I hypersensitivity)

76
Q

Describe pathogenesis of asthma

A 
Allergens induce Th2 phenotype in CD4+
 Th2 cells secrete IL-4 (IgE class switch), IL-5 (attract eosinophils), IL-10 (stimulate Th2 and inhibits Th1)

Rexposure leads to IgE mediated activation of mast cells

77
Q

Describe the early-phase reaction in asthma

A

Release of preformed histamine granules
Generation of leukotrienes C4, D4, E4

Leads to bronchoconstriction, inflammation, edema

78
Q

Describe the late-phase reaction in asthma

A

Inflammation, especially major basic protein derived from eosinophils, damages cells and perpetuates bronchoconstriction

79
Q

Asthma: Presentations

A

Episodic and related to allergen exposure

dyspnea, wheezing; productive cough

80
Q

Asthma: histology of sputum

A

Spiral-shaped mucus plugs (Curschmann spirals) and eosinophil-derived crystals (Charcot-Leyden crystals)

81
Q

Non allergic causes of asthma

A

Exercise, viral infection, aspirin, occupational exposures

82
Q

Diagnostic test for asthma

A

methacholine challenge

83
Q

Bronchiectasis

A

Permanent dilation of bronchioles and bronchi; loss of airway tone results in air trapping

84
Q

Causes (5) of bronchiectasis

A
  1. cystic fibrosis
  2. kartagener syndrome
  3. tumor or foreign body
  4. necrotizing infection
  5. allergic bronchopulmonary aspergillosis
85
Q

Bronchiectasis: Presentation

A

cough, dyspnea, foul-smelling sputum
comlications include hypoxemia with cor pulmonale and secondary (AA) amyloidosis

86
Q

Describe lab values for restrictive lung diseases (TLC, FVC, FEV1: FVC)

A

Decreased TLC
Decreased FVC

Increased FEV1/FVC ratio

87
Q

What are the two broad categories of restrictive lung diseases?

A
  1. Interstitial disease of lung (most common)
  2. chest wall abnormalities
    Poor muscular - polio, MG,
    Poor structural - scoliosis, obesity
88
Q

Idiopathic pulmonary fibrosis

A

Fibrosis of lung interstitium
Unknown etiology; likely related to cyclical lung injury; TGF-beta from injured pneumocytes induces fibrosis

89
Q

What are secondary causes of interstitial lung fibrosis?

A

Drugs (Bleomycin, amiodarone)
Radiation therapy

90
Q

Idiopathic pulmonary fibrosis: presentation

A

Progressive dyspnea and cough
Fibrosis on lung seen in subpleural patches (CT), but eventually results in diffuse fibrosis with end-stage “honeycomb” lung

91
Q

Idiopathic pulmonary fibrosis: Histology

A

honeycomb lung

92
Q

Idiopathic pulmonary fibrosis: treatment

A

lung transplantation

93
Q

Pneumoconioses: 4 types

A

Coal Worker’s Pneumoconiosis
Silicosis
Berylliosis
Asbestosis

94
Q

What is the basic mechanism of pneumoconioses?

A

Alveolar macrophages engulf foreign particles and induce fibrosis

95
Q

Coal Worker’s Pneumoconiosis:
Exposure, Finding

A 
Carbon dust (coal miners)
 Diffuse fibrosis (black lung)

No increased risk for TB or cancer

96
Q

Caplan syndrome

A

Coal Worker’s Pneumoconiosis with Rheumatoi arthritis (cavitating rheumatoid nodules)

97
Q

Anthracosis

A

mild exposure to carbon (e.g. pollution) results in collections of carbon-laden macrophages in upper lobes

98
Q

Silicosis: Exposure, Finding

A

Silica (sandblasters, foundries and silica miners)

Fibrotic nodules in upper lobes of lung; “egg shell calcifications” of hilar lymph nodes
Contains collagen and quartz

99
Q

Which pneumoconiosis is associated with TB? Why

A

Silicosis
Silica disrupts phagolysosomes and impair macrophages
Increasing susceptibility to TB

100
Q

What are the complications of silicosis exposure?

A

Silicosis pneumoconiosis
TB
bronchogenic carcinoma

101
Q

Berylliosis: Exposure and finding

A

Beryllium (beryllium miners, aerospace industry)

Noncaseating granulomas in the lung, hilar lymph nodes and systemic organs
Resembles sarcoidosis

102
Q

What are the complications of beryllium exposure?

A

Berryliosis
Increased risk for lung cancer

103
Q

Asbestosis: Exposure and finding

A

Asbestos fibers (construction workers, roofing, plumbers, shipyard workers)

Fibrosis of lung and pleura (plaques); “ivory white”, calcified pleural plaque pathognomonic (not precancerous)
Long, golden-brown fibers with associated iron resembling dumbbells(asbestos bodies)

Affects lower lobes

104
Q

What are the complications of asbestosis exposure?

A

Increased risk for bronchogenic carcinoma and mesothelioma

105
Q

What is the most common occupational disease?

A

Silicosis

106
Q

Where does malignant mesothelioma arise from?

A

Serosa of pleura; encases the lung

107
Q

Sarcoidosis

A

Systemic disease characterized by noncaseating granulomas in multiple organs; African American females
Unknown etiology; likely due to CD4+ helper T cell response

Granulomas most commonly involve hilar lymph nodes and lung

108
Q

Sarcoidosis: Histology

A

Stellate inclusions (asteroid bodies) within giant cell of granulomas

109
Q

What tissues are involved in Sarcoidosis in addition to the lungs?

A

Uvea (uveitis)
Skin (cutaneous nodules, erythema nodosum)
Salivary and lacrimal glands (mimic Sjogren)

110
Q

Sarcoidosis: Presentation

A

Dyspnea or cough
Elevated ACE
Hypercalcemia (1-alpha hydroxylase of epithelioid histiocytes)

111
Q

Sarcoidosis: Treatment

A

steroids; often resolves spontaneously without treatment

112
Q

Sarcoidosis Skin nodules: biopsy

A

granulomas

113
Q

What is the most common noninfectious granulomatous disease of the liver?

A

Sarcoidosis

114
Q

Sarcoidosis causes what lab abnormalities?

A

Increased ACE, Hypercalcemia (hypervitaminosis D)

115
Q

Hypersensitivity pneumonitis

A

Granulomatous reaction to inhaled organic antigens
Presents as fever, cough, dyspnea after exposure; resolves with removal of exposure

Chronic exposure can lead to interstitial fibrosis

116
Q

What are some collagen vascular diseases with interstitial fibrosis?

A

Systemic sclerosis
SLE
RA

117
Q

What disease to suspect for pleural effusion in young woman?

A

SLE

Any unexplained pleural effusion in a young woman is SLE until proven otherwise
Pleural fluid contains inflammatory infiltrate, lupus erythematosus cells; presence of serositis

118
Q

Farmer’s lung

A

Hypersensitivity pneumonitis
Exposure to Saccharopolyspora rectivirgula (thermophilic actinomyces) in moldy hay

119
Q

What type of hypersensitivity is Farmer’s lung?

A

Type 3 and 4

120
Q

Silo filler’s disease

A

Inhalation of gases (oxides of nitrogen) from plant material
Immediate hypersensitivity associated with dyspnea

121
Q

Byssinosis

A

Contact with cotton, linen, hemp products
“Monday morning blues”

122
Q

Acute Respiratory Distress Syndrome

A

Diffuse damage to alveolar-capillary interface (diffuse alveolar damage)
Leakage of protein-rich fluid leads to edema and formation of hyaline membranes in alveoli

123
Q

ARDS: Clinical features and X-Ray

A

hypoxemia and cyanosis with respiratory distress - thickened diffusion barrier and collapse of air sacs (increased surface tension
White-out on chest x-ray

124
Q

Causes of ARDS

A

Sepsis, infection, shock, trauma, aspiration, pancreatitis, DIC, hypersensitivity reactions, drugs

Activation of neutrophils induces protease-mediated and free radical damage of type I and II pneumocytes

125
Q

ARDS: treatment

A

address underlying cause
PEEP

Recovery may be complicated by interstitial fibrosis (damage and loss of type II pneumocytes lead to fibrosis and scarring)

126
Q

Neonatal respiratory distress syndrome

A

Inadequate surfactant levels
Lack of surfactant leads to collapse of air sacs and formation of hyaline membranes

127
Q

What are some of the associations/causes of neonatal respiratory distress syndrome?

A

Prematurity (surfactant begins production at week 28)
C-section (lack of stress-induced steroids)
Maternal diabetes (insulin decreases surfactant production)

128
Q

Neonatal respiratory distress syndrome: clinical features

A

increasing respiratory effort after birth; tachypnea with use of accessory muscles and grunting
hypoxemia with cyanosis
diffuse granularity of the lung (ground glass appearance) on x ray

129
Q

Neonatal respiratory distress syndrome: complications

A

hypoxemia increases risk of persistant patent ductus arteriosus and necrotizing enterocolitis
Supplemental O2 increases risk for free radical injury - blindness, bronchopulmonary dysplasia

130
Q

What is retinopathy of prematurity?

A

Inappropriate proliferation of vessels in inner layers of retina - increased VEGF

131
Q

What is the most common cause of cancer mortality in US?

A

Lung (age 60)

132
Q

Key risk factors for lung cancer

A

smoking (85% of lung cancer), radon asbestos

133
Q

What is the second most common cause of lung cancer in US?

A

Radon exposure
Radioactive decay of uranium (in soil) - closed spaces such as basements
Responsible for most public exposure to ionizing radiation; also seen in uranium miners

134
Q

Symptoms of lung cancer

A

not specific - cough, weight loss, hemoptysis, postobstructive pneumonia

135
Q

Lung cancer: imaging

A

coin-lesion (solitary nodule) - biopsy necessary for diagnosis

136
Q

What are some examples of benign “coin-lesions” in the lung?

A 
Granulomas (TB, fungus)
 Bronchial hamartoma (benign tuor of lung and cartilage)
137
Q

What are the two major categories of lung carcinoma?

A

Small cell 15% - not amenable to surgical resection

Non small cell (85%) - surgical resection

138
Q

Describe TNM staging for lung carcinoma

A

T = tumor size and local extension
Pleural involvement; obstruction of SVC; recurrent laryngeal or phrenic; horner’s syndrome

N=spread of regional lymph nodes (hilar and mediatinal)

M = unique site of distant metastasis (adrenal gland)

139
Q

Which organ does lung carcinoma spread to?

A

Adrenal gland

140
Q

Small cell carcinoma: histology

A

poorly differentiated small cells from neuroendocrine (Kulchitsky) cells

141
Q

Small cell carcinoma: association and location?

A

Male smokers
Central

142
Q

Small cell carcinoma: Paraneoplastic syndromes?

A

ADH
ACTH

Eaton-Lambert syndrome

143
Q

Small cell carcinoma: prognosis and metastasis

A

rapid growth and early metastasis

144
Q

Squamous cell carcinoma of lung: histology

A

keratin pearls or intracellular bridges

145
Q

Squamous cell carcinoma of lung: Association and location

A

Most common tumor in male smokers
Central

146
Q

Squamous cell carcinoma of lung: Secretion?

A

PTHrP

147
Q

Adenocarcinoma of lung: histology

A

glands or mucin

148
Q

Adenocarcinoma of lung: Association and location

A

Most common in nonsmokers and female smokers
Peripheral

149
Q

Large cell carcinoma of lung: histology

A

poorly differentiated large cells (no keratin pearls, intercellular bridges, glands or mucin)

150
Q

Large cell carcinoma of lung: Association and location

A

Smoking
Central or peripheral

151
Q

Large cell carcinoma of lung: Prognosis

A

Poor

152
Q

Bronchioalveolar carcinoma: Histology

A

Columnar cells that grow along preexisting bronchioles and alveoli
Arise from Clara cells

153
Q

Bronchioalveolar carcinoma: Association and location

A

Not related to smoking
Peripheral

154
Q

Bronchioalveolar carcinoma: imaging and prognosis

A

Pneumonia-like consolidation
Excellent prognosis

155
Q

Carcinoid tumor of the lung: Histology

A

Well differentiated neuroendocrine cells; chromogranin positive

156
Q

Carcinoid tumor of the lung: association and location

A

Not related to smoking
Central or peripheral; classically forms a polyp-like mass in bronchus

157
Q

Carcinoid tumor of the lung: Prognosis

A

Low-grade
Rarely, can cause carcinoid syndrome

158
Q

What are the most common metastasis to the lung?

A

Breast and colon

159
Q

Lung metastasis: x-ray

A

multiple cannon ball nodules on imaging

160
Q

What is the most common tumor of the lung?

A

metastasis

161
Q

What mutation is common in adenocarcinoma?

A

K-ras

162
Q

Definition of pulmonary hypertension

A

>25 mmHg; normal is 10 mmHg
Atherosclerosis of pulmonary trunk, smooth muscle hypertrophy of pulmonary arteries and intimal fibrosis

163
Q

Histology of severe, long-standing pulmonary hypertension

A

Plexiform lesions

164
Q

Pneumothorax

A

accumulation of air in pleural spaace

165
Q

What are the two types of pneumothorax?

A

Spontaneous and tension

166
Q

Spontaneous pneumothorax

A

Rupture of emphysematous bleb, in young adults
Collapse of portion of lung

167
Q

Does the trachea deviates to or away from spontaneous pneumothorax

A

Shifts to the side of collapse

168
Q

Tension pneumothorax

A

Penetrating chest wall injury
Air enters pleural space, but cannot exit

169
Q

Does trachea deviates to or away from trachea of tension pneumothorax?

A

Opposite side

170
Q

Tension pneumothorax: treatment

A

insertion of chest tube

171
Q

Mesothelioma

A

malignant neoplasm of mesothelial cells; high associated with occupationl exposure
Recurrent pleural effusions, dyspnea, chest pain; tumor encases the lung

172
Q
A

USMLE (13 decks)

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