The Lung and Pleura

Question 1

Loss of lung volume cause by inadequate expansion of airspaces, resulting in shunting of inadequately oxygenated blood from pulmonary arteries into veins; can be resorption (obstruction that prevents air reaching distal air spaces), compression (pleural fluid or mass compressing the lung), and contraction (pleural fibrosis impeding expansion of lungs).

Answer 1

Atelectasis

Question 2

Abrupt onset of significant hypoxemia and bilateral infiltrates WITHOUT heart failure.

Answer 2

Acute lung injury (ALI)

Question 3

Severe manifestation of ALI; lungs are dark red, firm, airless and heavy; there is capillary congestion, necrosis of alveolar epithelial cells, interstitial and intra-alveolar edema and hemorrhage and neutrophils in capillaries; hyaline membrane is also characteristic, lining the alveolar ducts.

Answer 3

Acute respiratory distress syndrome (ARDS)

Question 4

Most common causes of ARDS.

Answer 4

Sepsis, diffuse pulmonary infections, Gastric aspiration

Question 5

Class A recommendation for management of ARDS.

Answer 5

Low Tidal Volume ventilation: 6cc/Kg PREDICTED Body weight Early neuromuscular blockade: Cisatracurium besylate for 48 hours

Question 6

Diffuse pulmonary disease characterized by limitation of airflow, usually resulting from an increase in resistance caused by partial or complete obstruction at any level; spirometry findings: markedly decreased FEV1, decreased FVC, decreased FEV1/FVC; examples: Bronchial asthma, Emphysema, Chronic bronchitis and Bronchiectasis

Answer 6

Obstructive lung diseases

Question 7

Characterized by abnormal permanent enlargement of the airspaces distal to the terminal bronchioles accompanied by destruction of their walls without obvious fibrosis; there is thinning of the alveolar walls and loss of elastic tissue; can be centriacinar (respiratory bronchioles only; associated with smoking), panacinar (associated with a-1-antitrypsin deficiency, distal acinar (most commonly seen in adults with spontaneous pneumothorax), and irregular (most common).

Answer 7

Emphysema (Pink puffers)

Question 8

Defined as persistent productive cough for at least 3 consecutive months in at least 2 consecutive years; morphologically, mucosal lining of the larger airways is usually hyperemic and swollen with edema fluid, often covered by a layer of mucinous or mucopurulent secretions; trachea and bronchi have enlarged mucus-secreting glands.

Answer 8

Chronic bronchitis (Blue bloaters)

Question 9

Triad of: 1. Intermittent and reversible airway obstruction; 2. Chronic bronchial inflammation with eosinophils; and 3. Bronchial smooth muscle cell hypertrophy and hyperreactivity; morphologically characterized by thick, tenacious mucus plugs with Curschmann spirals (whorls of shed epithelium found in mucus plugs) and Charcot-Leyden crystals (collections of crystalloids made up of eosinophil protein).

Answer 9

Bronchial asthma

Question 10

Criteria for reversibility of airway obstruction diagnostic of bronchial asthma.

Answer 10

FEV1 increase of >12% or 200 mL post bronchodilator

Question 11

Permanent dilation of bronchi and bronchioles caused by destruction of the muscle and elastic supporting tissue, resulting from chronic necrotizing infections; morphologically, there is intense acute and chronic inflammatory exudate within the walls, with mixed flora often cultured; there is also peribronchiolar fibrosis in chronic cases.

Answer 11

Bronchiectasis

Question 12

Thickening of airway wall; sub-basement membrane fibrosis; increased vascularity in submucosa; increase in size of the submucosal glands and goblet cell metaplasia of the airway epithelium; hypertrophy and/or hyperplasia of the bronchial muscle; are collectively called:

Answer 12

Airway remodeling

Question 13

Diffuse pulmonary disease characterized by reduced expansion of lung parenchyma accompanied by decreased total lung capacity; spirometry findings: decreased FEV1, markedly decreased FVC, normal or increased FEV1/FVC; examples: Chronic interstitial lung diseases

Answer 13

Restrictive lung diseases

Question 14

Heterogeneous group of disorders characterized predominantly by inflammation and fibrosis of the pulmonary interstitium; follows restrictive lung disease pattern; complications include cor pulmonale and honeycomb lung; examples: Usual interstitial pneumonia (Idiopathic pulmonary fibrosis), Pneumoconiosis, and Sarcoidosis.

Answer 14

Chronic interstitial lung diseases

Question 15

Pneumonia with a patchy distribution of inflammation involving more than one lobe.

Answer 15

Bronchopneumonia

Question 16

Pattern of pneumonia observed in pneumococcal pneumonia; has four phases of evolution, from congestion, red hepatization, gray hepatization and resolution.

Answer 16

Lobar pneumonia

Question 17

Inflammatory reaction is largely confined within the walls of the alveoli; septa widened and edematous, with mononuclear infiltrates of lymphocytes, histiocytes and plasma cells; alveolar spaces are free of cellular exudate. This morphology points more to:

Answer 17

Atypical pneumonia

Question 18

A localized area of suppurative necrosis within the pulmonary parenchyma, resulting in the formation of one or more large cavities; most commonly occurs in the right side, particularly in the posterior segment of the upper lobe and apical segments of the lower lobe; most common isolates are anaerobic bacteria.

Answer 18

Lung abscess

Question 19

Form of tuberculosis that develops in a previously unexposed, unsensitized person.

Answer 19

Primary tuberculosis

Question 20

Implantation of the inhaled M. tuberculosis bacilli in the distal airspaces of the lungs, causes the formation of this 1-1.5 cm area of gray-white inflammatory consolidation.

Answer 20

Ghon focus

Question 21

Ghon focus with involvement of the hilar lymph nodes is called:

Answer 21

Ghon complex

Question 22

Radiographically detectable calcified Ghon complex is called:

Answer 22

Ranke complex

Question 23

Pattern of disease that arises in previously sensitized host to M. tuberculosis.

Answer 23

Secondary or reactivation TB

Question 24

Occurs when TB bacilli drain through the lymphatics into lymphatic ducts, which eventually empty into the right side of the heart and into pulmonary circulation; individual lesions are small, visible foci of yellow-white consolidation scattered through the parenchyma.

Answer 24

Miliary tuberculosis

Question 25

Type of necrosis seen in tuberculosis.

Answer 25

Caseous

Question 26

Type of inflammation seen in tuberculosis.

Answer 26

Chronic granulomatous

Question 27

Type of hypersensitivity reaction in tuberculosis (including TST).

Answer 27

Type IV (Cell-mediated/Delayed)

Question 28

Cytokine responsible for formation of granulomas in tuberculosis.

Answer 28

IFN-g

Question 29

Histologic appearance of tuberculosis infection in the absence of an intact cell-mediated immunity.

Answer 29

Macrophages filled with bacilli

Question 30

Most common form of extrapulmonary TB.

Answer 30

Tuberculous lymphadenitis (scrofula)

Question 31

Most common affected segment in gastrointestinal TB (Note: GITB is rare, due to decrease in consumption of infected milk).

Answer 31

Ileum

Question 32

One of the two most common histologic types of lung cancer associated with smoking; centrally located in major bronchi; may range from poorly differentiated to well-differentiated with keratin pearl formation; associated in general with hypercalcemia, due to production of PTH related peptide (PTHrp). Immunostains: p63, p40.

Answer 32

Squamous cell carcinoma

Question 33

The most common histologic type of lung cancer; most commonly seen in nonsmokers; peripherally located; histologically, may show acinar (glandular), papillary, mucinous, and solid types. Immunostains: TTF-1 and napsin A.

Answer 33

Adenocarcinoma

Question 34

Most common histologic type of lung cancer associated with smoking; centrally located; with early nodal involvement; histologically, small, round to fusiform cells with scant cytoplasm and finely granular chromatin with numerous mitotic figures are present; most associated with paraneoplastic syndromes, such as Cushing syndrome (ectopic ACTH), Lambert-Eaton myasthenic syndrome, and SIADH, among others; only type not amenable to surgery; Immunostains: chromogranin, synaptophysin, CD57 and BCL2.

Answer 34

Small cell (Oat cell) carcinoma

Question 35

Lung carcinoma that typically has large, prominent nucleoli, and a moderate amount of cytoplasm, with minimal glandular or squamous differentiation. Diagnosed when immunostains for known histologic types of lung cancer are negative.

Answer 35

Large cell carcinoma

Question 36

A rare cancer seen in patients who work in shipyards, miners and insulators; presents as lung ensheathed by a yellow-white, firm or gelatinous layer of tumor that obliterates the pleural space; lesion is preceeded by extensive pleural fibrosis and plaque formation; may be epithelial, sarcomatoid or biphasic in morphology.

Answer 36

Malignant mesothelioma

Question 37

Immunostains: Epithelioid and Sarcomatoid

Answer 37

Immunostains: Epithelioid: Keratin, calretinin, WT-1, CK5,6, D2-40; Sarcomatoid: usually Keratin(+) only.