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LUNGS www.freelivedoctor.com
LUNG <ul><li>“ Degenerative” </li></ul><ul><li>Inflammatory </li></ul><ul><li>Neoplastic and Pleura </li></ul><ul><li>LAB:...
OVERVIEW <ul><li>Normal Anatomy and Histology </li></ul><ul><li>Pathology </li></ul><ul><ul><li>Congenital </li></ul></ul>...
OVERVIEW <ul><li>INFECTIONS </li></ul><ul><li>NEOPLASMS   and PLEURA (effusions, pneumothorax, tumors) </li></ul>www.freel...
WEIGHT LOBES SEGMENTS BRONCHI ARTERIES, pulmonary ARTERIES, bronchial VEINS PLEURA, visceral PLEURA, parietal NERVES www.f...
Bronchi Bronchioles Terminal bronchioles Alveolar ducts Alveoli Type 1 pneumocytes Type 2 pneumocytes Macrophages Capillar...
www.freelivedoctor.com
www.freelivedoctor.com
www.freelivedoctor.com NORMAL” chest X-Ray [CXR]
<ul><li>Pathology </li></ul><ul><ul><li>CONGENITAL </li></ul></ul><ul><ul><li>Atalectasis </li></ul></ul><ul><ul><li>Acute...
CONGENITAL <ul><li>Agenesis/Hypoplasia </li></ul><ul><li>Tracheal/bronchial anomalies, i.e., Tracheo-Esophageal (TE) fistu...
www.freelivedoctor.com
OVERVIEW <ul><li>Pathology </li></ul><ul><ul><li>Congenital </li></ul></ul><ul><ul><li>ATALECTASIS </li></ul></ul><ul><ul>...
ATALECTASIS <ul><li>INCOMPLETE EXPANSION </li></ul><ul><li>COLLAPSE </li></ul>www.freelivedoctor.com
OVERVIEW <ul><li>Pathology </li></ul><ul><ul><li>Congenital </li></ul></ul><ul><ul><li>Atalectasis </li></ul></ul><ul><ul>...
PULMONARY EDEMA <ul><li>IN-creased venous pressure </li></ul><ul><li>DE-creased oncotic pressure </li></ul><ul><li>Lymphat...
ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS or D.A.D., i.e., Diffuse Alveolar damage) (aka, “SHOCK” lung) <ul><li>NON-specif...
ARDS www.freelivedoctor.com
ACUTE INTERSTITIAL PNEUMONIA <ul><li>Think of it as ARDS with NO known etiology! </li></ul>www.freelivedoctor.com
OVERVIEW <ul><li>Pathology </li></ul><ul><ul><li>Congenital </li></ul></ul><ul><ul><li>Atalectasis </li></ul></ul><ul><ul>...
OBSTRUCTION v. RESTRICTION <ul><li>OBSTRUCTION </li></ul><ul><li>Air or blood? </li></ul><ul><li>Large or small? </li></ul...
OVERVIEW <ul><li>Pathology </li></ul><ul><ul><li>Congenital </li></ul></ul><ul><ul><li>Atalectasis </li></ul></ul><ul><ul>...
OBSTRUCTION (cOPD) <ul><li>EMPHYSEMA  (almost always chronic) </li></ul><ul><li>CHRONIC BRONCHITIS   emphysema </li></ul>...
EMPHYSEMA <ul><li>COPD, or “END-STAGE” lung disease </li></ul><ul><li>Centri-acinar, Pan-acinar, Paraseptal, Irregular </l...
CENTRO-acinar PAN-acinar www.freelivedoctor.com
www.freelivedoctor.com Bullae, or “peripheral blebs” are hallmarks of chronic obstructive lung disease, COPD.
<ul><li>HYPER-expansion  2) “flattened” diaphragms (blunted),  </li></ul><ul><li>3) “bullae”  4) increased lucency </li></...
CHRONIC BRONCHITIS <ul><li>INHALANTS, POLLUTION, CIGARETTES </li></ul><ul><li>CHRONIC COUGH </li></ul><ul><li>CAN OFTEN PR...
ASTHMA <ul><li>Similar to chronic bronchitis but: </li></ul><ul><ul><li>Wheezing is hallmark (bronchospasm, i.e. “wheezing...
www.freelivedoctor.com Note the heavy inflammatory cell infiltrate around bronchioles and small bronchi.
What are the 4 classical histologic findings in bronchial asthma? www.freelivedoctor.com
BRONCHIECTASIS <ul><li>DILATATION of the BRONCHUS, associated with, often, necrotizing inflammation </li></ul><ul><ul><li>...
BRONCHIECTASIS www.freelivedoctor.com
OVERVIEW <ul><li>Pathology </li></ul><ul><ul><li>Congenital </li></ul></ul><ul><ul><li>Atalectasis </li></ul></ul><ul><ul>...
RESTRICTIVE (INFILTRATIVE) <ul><li>REDUCED COMPLIANCE, reduced gas exchange) </li></ul><ul><li>Are also DIFFUSE </li></ul>...
FIBROSING <ul><li>“ IDIOPATHIC” PULMONARY FIBROSIS (IPF) </li></ul><ul><li>NONSPECIFIC INTERSTITIAL FIBROSIS </li></ul><ul...
IPF (UIP) <ul><li>IDIOPATHIC, i.e., not from any usual caused, like lupus, scleroderma </li></ul><ul><li>FIBROSIS </li></u...
NON-SPECIFIC INTERSTITIAL PNEUMONIA <ul><li>WASTEBASKET DIAGNOSIS, of ANY pneumonia (pneumonitis) of any known or unknown ...
CRYPTOGENIC ORGANIZING PNEUMONIA (COP) <ul><li>IDIOPATHIC </li></ul><ul><li>“ BRONCHIOLITIS OBLITERANS” </li></ul>www.free...
“ COLLAGEN” VASCULAR DISEASES <ul><li>Rheumatoid Arthritis </li></ul><ul><li>SLE (“Lupus”) </li></ul><ul><li>Progressive S...
PNEUMOCONIOSES <ul><li>“ OCCUPATIONAL” </li></ul><ul><li>“ COAL MINERS LUNG” </li></ul><ul><li>DUST OR CHEMICALS OR ORGANI...
GRANULOMATOUS <ul><li>SARCOIDOSIS , i.e., NON-caseating granulomas (IDIOPATHIC) </li></ul><ul><li>HYPERSENSITIVITY  (DUSTS...
SARCOIDOSIS <ul><li>Mainly LUNG, but eye, skin or ANYWHERE </li></ul><ul><li>UNKNOWN ETIOLOGY </li></ul><ul><li>IMMUNE, GE...
NON-Caseating Granulomas are the RULE “ Asteroid” bodies within these granulomas are virtually diagnostic www.freelivedoct...
www.freelivedoctor.com
SMOKING RELATED <ul><li>DIP (Desquamative Interstitial Pneumonia) </li></ul><ul><ul><li>M>>F </li></ul></ul><ul><ul><li>CI...
PAP (Pulmonary Alveolar Proteinosis) <ul><li>Very RARE, usually acquired </li></ul><ul><li>Proteinaceous Material in Alveo...
OVERVIEW <ul><li>Pathology </li></ul><ul><ul><li>Congenital </li></ul></ul><ul><ul><li>Atalectasis </li></ul></ul><ul><ul>...
VASCULAR PULMONARY DISEASES <ul><li>PULMONARY EMBOLISM  (with or usually WITHOUT infarction) </li></ul><ul><li>PULMONARY H...
P.E. <ul><li>Usually secondary to debilitated states with immobilization, or following surgery </li></ul><ul><li>Usually d...
PULMONARY HYPERTENSION <ul><li>COPD, C”I”PD (vicious cycle) </li></ul><ul><li>CHD (Congenital HD, increased left atrial pr...
VERY thickened arteriole in pulmonary hypertension NORMAL pulmonary arteriole www.freelivedoctor.com
HEMORRHAGIC SYNDROMES <ul><li>GOODPASTURE Syndrome: Ab’s to the alpha-3 chains of collagen IV, GBM deposits too! </li></ul...
CHF,  CHRONIC IDIOPATHIC PULMONARY HEMOSIDEROSIS www.freelivedoctor.com
PNEUMONIA www.freelivedoctor.com
  COMM UNITY-ACQUIRED BACTERIAL ACUTE PNEUMONIAS Streptococcus Pneumoniae Haemophilus Influenzae Moraxella Catarrhalis Sta...
BASIC CONSIDERATIONS <ul><li>PNEUMONIA vs. PNEUMONITIS </li></ul><ul><li>DIFFERENTIATION from INJURIES, OBSTRUCTIVE DISEAS...
PREDISPOSING FACTORS <ul><li>LOSS OF COUGH REFLEX </li></ul><ul><li>DIMINISHED MUCIN or CILIA FUNCTION </li></ul><ul><li>A...
Although pneumonia is one of the most common causes of death, it usually does  NOT  occur in healthy people spontaneously ...
Classifications of PNEUMONIAS <ul><li>COMMUNITY ACQUIRED </li></ul><ul><li>COMMUNITY ACQUIRED, ATYPICAL </li></ul><ul><li>...
Classifications of PNEUMONIAS <ul><li>COMMUNITY ACQUIRED </li></ul><ul><li>COMMUNITY ACQUIRED, ATYPICAL </li></ul><ul><li>...
COMMUNITY ACQUIRED <ul><li>STREPTOCOCCUS PNEUMONIAE (i.e., “diplococcus”) </li></ul><ul><li>HAEMOPHILUS INFLUENZAE (“H-Flu...
STREPTOCOCCUS <ul><li>The classic LOBAR pneumonia </li></ul><ul><li>Normal flora in 20% of adults </li></ul><ul><li>Only 2...
HAEMOPHILUS PNEUMONIA <ul><li>Commonest in CHILDREN <2, with otitis, URI, meningitis, cellulitis, osteomyelitis </li></ul>...
MORAXELLA CATARRHALIS <ul><li>2nd most common COPD pneumonia, after haemophilus </li></ul><ul><li>Gram NEGATIVE coccobacil...
STAPH aureus <ul><li>Most common pneumonia following viral pneumonias </li></ul><ul><li>M.R.S.A., of course, is usually NO...
KLEBSIELLA PNEUMONIAE <ul><li>DEBILITATED MALNOURISHED PEOPLE </li></ul><ul><li>ALCOHOLICS  with pneumonia are often thoug...
PSEUDOMONAS Aeruginosa <ul><li>Usually NOT community acquired but nosocomial </li></ul><ul><li>CYSTIC FIBROSIS patients wi...
LEGIONELLA  (pneumophila) <ul><li>Often in OUTBREAKS </li></ul><ul><li>Often LOBAR </li></ul><ul><li>Spread by water “drop...
Although pneumonia is one of the most common causes of death, it usually does  NOT  occur in healthy people spontaneously ...
MORPHOLOGY <ul><li>ACUTE </li></ul><ul><li>ORGANIZING </li></ul><ul><li>CHRONIC </li></ul><ul><li>FIBROSIS vs. FULL RESOLU...
Classifications of PNEUMONIAS <ul><li>COMMUNITY ACQUIRED </li></ul><ul><li>COMMUNITY ACQUIRED,   ATYPICAL </li></ul><ul><l...
COMMUNITY ACQUIRED , (atypical) <ul><li>VIRAL (INFLUENZA) </li></ul><ul><li>MYCOPLASMAL (MYCOPLASMA PNEUMONIAE (obligate i...
VIRAL PNEUMONIAS <ul><li>Frequently “interstitial”, NOT alveolar </li></ul>www.freelivedoctor.com
INFLUENZA VIRUS <ul><li>A,B,C </li></ul><ul><li>1915, 1918, PAN-demics, type A </li></ul><ul><li>Has MUTATED throughout hi...
www.freelivedoctor.com
SARS   (Severe Acute Respiratry Syndrome) <ul><li>CORONA-VIRUS </li></ul><ul><li>2002 China outbreak </li></ul><ul><li>Spr...
S A R S www.freelivedoctor.com
Classifications of PNEUMONIAS <ul><li>COMMUNITY ACQUIRED </li></ul><ul><li>COMMUNITY ACQUIRED,   ATYPICAL </li></ul><ul><l...
NOSOCOMIAL <ul><li>Acquired in HOSPITALS, also called “hospital acquired”, versus “community acquired” pneumonias. </li></...
Classifications of PNEUMONIAS <ul><li>COMMUNITY ACQUIRED </li></ul><ul><li>COMMUNITY ACQUIRED,   ATYPICAL </li></ul><ul><l...
ASPIRATION PNEUMONIAS <ul><li>UNCONSCIOUS PATIENTS </li></ul><ul><li>PATIENTS IN PROLONGED BEDREST </li></ul><ul><li>LACK ...
www.freelivedoctor.com
LUNG ABSCESSES <ul><li>ASPIRATION </li></ul><ul><li>SEPTIC EMBOLIZATION </li></ul><ul><li>NEOPLASIA </li></ul><ul><li>From...
www.freelivedoctor.com
Classifications of PNEUMONIAS <ul><li>COMMUNITY ACQUIRED </li></ul><ul><li>COMMUNITY ACQUIRED,   ATYPICAL </li></ul><ul><l...
CHRONIC Pneumonias <ul><li>USUALLY NOT persistences of the community or nosocomial bacterial infections, but CAN BE, at le...
CHRONIC Pneumonias <ul><li>TB </li></ul><ul><li>HISTO-PLASMOSIS </li></ul><ul><li>BLASTO-MYCOSIS </li></ul><ul><li>COCCIDI...
HISTOPLASMOSIS <ul><li>Spores in bird or bat droppings </li></ul><ul><li>Mimics TB  </li></ul><ul><li>Histoplasma CAPSULAT...
www.freelivedoctor.com
BLASTOMYCOSIS <ul><li>Spores in soil </li></ul><ul><li>Mimics TB, like ALL the granulomatous lung dideases do.  </li></ul>...
COCCIDIOMYCOSIS <ul><li>Spores in soil </li></ul><ul><li>Mimics TB  </li></ul><ul><li>Coccidioides IMMITIS </li></ul><ul><...
GRANULOMA www.freelivedoctor.com
COMPROMISED HOSTS <ul><li>PNEUMOCYSTIS CARINII </li></ul><ul><li>CYTOMEGALOVIRUS (CMV) </li></ul><ul><li>FUNGI </li></ul>w...
PCP www.freelivedoctor.com
Methenamine SILVER stain for Pneumocystis Carinii www.freelivedoctor.com
LUNG TRANSPLANTATION <ul><li>EMPHYSEMA </li></ul><ul><li>Pulmonary Fibrosis </li></ul><ul><li>Cystic Fibrosis </li></ul><u...
Lung Transplant Pathology  <ul><li>Infections (immunocompromised patients) </li></ul><ul><ul><li>Bacterial </li></ul></ul>...
www.freelivedoctor.com
LUNG TUMORS <ul><li>Benign, malignant, epithelial, mesenchymal, but 90% are CARCINOMAS </li></ul><ul><li>BIGGEST USA kille...
PATHOGENESIS <ul><li>NORMAL BRONCHIAL MUCOSA </li></ul><ul><li>METAPLASTIC/DYSPLASTIC MUCOSA </li></ul><ul><li>CARCINOMA-I...
TWO TYPES <ul><li>NON-SMALL CELL </li></ul><ul><ul><li>SQUAMOUS CELL CARCINOMA </li></ul></ul><ul><ul><li>ADENOCARCINOMA <...
The BIG list <ul><li>Squamous cell carcinoma </li></ul><ul><li>Small cell carcinoma </li></ul><ul><li>Combined small cell ...
OTHER TUMORS www.freelivedoctor.com
www.freelivedoctor.com
TNM, Lung www.freelivedoctor.com T1 Tumor <3 cm without pleural or main stem bronchus involvement T2 Tumor >3 cm or involv...
LOCAL effects of LUNG CANCER www.freelivedoctor.com Clinical Feature Pathologic Basis Pneumonia, abscess, lobar collapse T...
SYSTEMIC effects of LUNG CANCER (PARA-NEOPLASTIC SYNDROMES)~ 5% ADH (hyponatremia) ACTH (Cushing) PTH (Hyper-CA) CALCITONI...
OTHER TUMORS www.freelivedoctor.com
METASTATIC TUMORS <ul><li>LUNG is the  MOST COMMON  site for all metastatic tumors, regardless of site of origin </li></ul...
PLEURA <ul><li>PLEURITIS </li></ul><ul><li>PNEUMOTHORAX </li></ul><ul><li>EFFUSIONS </li></ul><ul><ul><li>HYDRO-THORAX (Pe...
PLEURITIS <ul><li>Usual bacteria, viruses, etc. </li></ul><ul><li>Infarcts </li></ul><ul><li>Lung abscesses, empyema </li>...
PNEUMOTHORAX <ul><li>SPONTANEOUS, TRAUMATIC, THERAPEUTIC </li></ul><ul><li>OPEN or CLOSED </li></ul><ul><li>“ TENSION” pne...
EFFUSIONS <ul><li>TRANSUDATE (HYDROTHORAX) </li></ul><ul><li>EXUDATE (HYDROTHORAX) </li></ul><ul><li>BLOOD (HEMOTHORAX) </...
MESOTHELIOMAS <ul><li>“ Benign” vs. “Malignant” differentiation does not matter, but a self limited localized nodule can b...
www.freelivedoctor.com
   EM H&E, IMMUNOCHEMISTRY www.freelivedoctor.com
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Pulmonary pathology

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Pulmonary pathology

  1. 1. LUNGS www.freelivedoctor.com
  2. 2. LUNG <ul><li>“ Degenerative” </li></ul><ul><li>Inflammatory </li></ul><ul><li>Neoplastic and Pleura </li></ul><ul><li>LAB: (Review, Cases, and/or Virtual Microscopy) </li></ul>www.freelivedoctor.com
  3. 3. OVERVIEW <ul><li>Normal Anatomy and Histology </li></ul><ul><li>Pathology </li></ul><ul><ul><li>Congenital </li></ul></ul><ul><ul><li>Atalectasis </li></ul></ul><ul><ul><li>Acute Pulmonary Injury </li></ul></ul><ul><ul><li>Obstructive vs. Restrictive (infiltrative) concepts </li></ul></ul><ul><ul><li>O bstructive P ulmonary D isease (C OPD ) </li></ul></ul><ul><ul><li>Restrictive (Infiltrative) Pulmonary Disease </li></ul></ul><ul><ul><li>Vascular Pulmonary Diseases </li></ul></ul>www.freelivedoctor.com
  4. 4. OVERVIEW <ul><li>INFECTIONS </li></ul><ul><li>NEOPLASMS and PLEURA (effusions, pneumothorax, tumors) </li></ul>www.freelivedoctor.com
  5. 5. WEIGHT LOBES SEGMENTS BRONCHI ARTERIES, pulmonary ARTERIES, bronchial VEINS PLEURA, visceral PLEURA, parietal NERVES www.freelivedoctor.com
  6. 6. Bronchi Bronchioles Terminal bronchioles Alveolar ducts Alveoli Type 1 pneumocytes Type 2 pneumocytes Macrophages Capillaries www.freelivedoctor.com
  7. 7. www.freelivedoctor.com
  8. 8. www.freelivedoctor.com
  9. 9. www.freelivedoctor.com NORMAL” chest X-Ray [CXR]
  10. 10. <ul><li>Pathology </li></ul><ul><ul><li>CONGENITAL </li></ul></ul><ul><ul><li>Atalectasis </li></ul></ul><ul><ul><li>Acute Pulmonary Injury </li></ul></ul><ul><ul><li>Obstructive vs. Restrictive (infiltrative) concepts </li></ul></ul><ul><ul><li>O bstructive P ulmonary D isease (C OPD ) </li></ul></ul><ul><ul><li>Restrictive (Infiltrative) Pulmonary Disease </li></ul></ul><ul><ul><li>Vascular Pulmonary Diseases </li></ul></ul>www.freelivedoctor.com
  11. 11. CONGENITAL <ul><li>Agenesis/Hypoplasia </li></ul><ul><li>Tracheal/bronchial anomalies, i.e., Tracheo-Esophageal (TE) fistula </li></ul><ul><li>Vascular anomalies </li></ul><ul><li>Congenital Emphysema </li></ul><ul><li>Foregut cysts </li></ul><ul><li>Pulmonary Artery Malformations (CPAM) </li></ul><ul><li>Sequestration (no connection to airways) </li></ul>www.freelivedoctor.com
  12. 12. www.freelivedoctor.com
  13. 13. OVERVIEW <ul><li>Pathology </li></ul><ul><ul><li>Congenital </li></ul></ul><ul><ul><li>ATALECTASIS </li></ul></ul><ul><ul><li>Acute Pulmonary Injury </li></ul></ul><ul><ul><li>Obstructive vs. Restrictive (infiltrative) concepts </li></ul></ul><ul><ul><li>O bstructive P ulmonary D isease (C OPD ) </li></ul></ul><ul><ul><li>Restrictive Pulmonary Disease </li></ul></ul><ul><ul><li>Vascular Pulmonary Diseases </li></ul></ul>www.freelivedoctor.com
  14. 14. ATALECTASIS <ul><li>INCOMPLETE EXPANSION </li></ul><ul><li>COLLAPSE </li></ul>www.freelivedoctor.com
  15. 15. OVERVIEW <ul><li>Pathology </li></ul><ul><ul><li>Congenital </li></ul></ul><ul><ul><li>Atalectasis </li></ul></ul><ul><ul><li>ACUTE PULMONARY INJURY </li></ul></ul><ul><ul><ul><li>Pulmonary Edema </li></ul></ul></ul><ul><ul><ul><li>ARDS ( D iffuse A lveolar D amage) </li></ul></ul></ul><ul><ul><ul><li>Acute Interstitial Pneumonia </li></ul></ul></ul><ul><ul><li>Obstructive vs. Restrictive (infiltrative) concepts </li></ul></ul><ul><ul><li>O bstructive P ulmonary D isease (C OPD ) </li></ul></ul><ul><ul><li>Restrictive (Infiltrative) Pulmonary Disease </li></ul></ul><ul><ul><li>Vascular Pulmonary Diseases </li></ul></ul>www.freelivedoctor.com
  16. 16. PULMONARY EDEMA <ul><li>IN-creased venous pressure </li></ul><ul><li>DE-creased oncotic pressure </li></ul><ul><li>Lymphatic obstruction </li></ul><ul><li>Alveolar injury </li></ul>www.freelivedoctor.com
  17. 17. ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS or D.A.D., i.e., Diffuse Alveolar damage) (aka, “SHOCK” lung) <ul><li>NON-specific pattern of lung injury </li></ul><ul><li>INFECTION </li></ul><ul><li>PHYSICAL INJURY </li></ul><ul><li>TOXIC </li></ul><ul><li>CHEMICAL </li></ul><ul><li>DIC </li></ul><ul><li>ETC </li></ul>www.freelivedoctor.com
  18. 18. ARDS www.freelivedoctor.com
  19. 19. ACUTE INTERSTITIAL PNEUMONIA <ul><li>Think of it as ARDS with NO known etiology! </li></ul>www.freelivedoctor.com
  20. 20. OVERVIEW <ul><li>Pathology </li></ul><ul><ul><li>Congenital </li></ul></ul><ul><ul><li>Atalectasis </li></ul></ul><ul><ul><li>Acute Pulmonary Injury </li></ul></ul><ul><ul><li>OBSTRUCTION vs. RESTRICTION </li></ul></ul><ul><ul><li>O bstructive P ulmonary D isease (C OPD ) </li></ul></ul><ul><ul><li>Restrictive (Infiltrative) Pulmonary Disease </li></ul></ul><ul><ul><li>Vascular Pulmonary Diseases </li></ul></ul>www.freelivedoctor.com
  21. 21. OBSTRUCTION v. RESTRICTION <ul><li>OBSTRUCTION </li></ul><ul><li>Air or blood? </li></ul><ul><li>Large or small? </li></ul><ul><li>Inspiration or Expiration? </li></ul><ul><li>Obstruction is SMALL AIRWAY EXPIRATION obstruction, i.e., wheezing </li></ul><ul><li>HYPEREXPANSION on CXR </li></ul><ul><li>RESTRICTION </li></ul><ul><li>“ Compliance” </li></ul><ul><li>“ Infiltrative” </li></ul><ul><li>REDUCED lung VOLUME, DYSPNEA, CYANOSIS </li></ul><ul><li>REDUCED GAS TRANSFER </li></ul><ul><li>“ GROUND GLASS” on CXR </li></ul>www.freelivedoctor.com
  22. 22. OVERVIEW <ul><li>Pathology </li></ul><ul><ul><li>Congenital </li></ul></ul><ul><ul><li>Atalectasis </li></ul></ul><ul><ul><li>Acute Pulmonary Injury </li></ul></ul><ul><ul><li>Obstruction vs. Restriction </li></ul></ul><ul><ul><li>OBSTRUCTIVE Pulmonary Diseases (COPD) </li></ul></ul><ul><ul><li>Restrictive (Infiltrative) Pulmonary Disease </li></ul></ul><ul><ul><li>Vascular Pulmonary Diseases </li></ul></ul>www.freelivedoctor.com
  23. 23. OBSTRUCTION (cOPD) <ul><li>EMPHYSEMA (almost always chronic) </li></ul><ul><li>CHRONIC BRONCHITIS  emphysema </li></ul><ul><li>ASTHMA </li></ul><ul><li>BRONCHIECTASIS </li></ul>www.freelivedoctor.com
  24. 24. EMPHYSEMA <ul><li>COPD, or “END-STAGE” lung disease </li></ul><ul><li>Centri-acinar, Pan-acinar, Paraseptal, Irregular </li></ul><ul><li>Like cirrhosis, thought of as END-STAGE of multiple chronic small airway obstructive etiologies </li></ul><ul><li>NON-specific </li></ul><ul><li>IN-creased crepitance, BULLAE (BLEBS) </li></ul><ul><li>Clinically linked to recurrent pneumonias, and progressive failure </li></ul>www.freelivedoctor.com
  25. 25. CENTRO-acinar PAN-acinar www.freelivedoctor.com
  26. 26. www.freelivedoctor.com Bullae, or “peripheral blebs” are hallmarks of chronic obstructive lung disease, COPD.
  27. 27. <ul><li>HYPER-expansion 2) “flattened” diaphragms (blunted), </li></ul><ul><li>3) “bullae” 4) increased lucency </li></ul>www.freelivedoctor.com
  28. 28. CHRONIC BRONCHITIS <ul><li>INHALANTS, POLLUTION, CIGARETTES </li></ul><ul><li>CHRONIC COUGH </li></ul><ul><li>CAN OFTEN PROGRESS TO EMPHYSEMA </li></ul><ul><li>MUCUS hypersecretion, early, i.e. goblet cell increase </li></ul><ul><li>CHRONIC bronchial inflammatory infiltrate </li></ul>www.freelivedoctor.com
  29. 29. ASTHMA <ul><li>Similar to chronic bronchitis but: </li></ul><ul><ul><li>Wheezing is hallmark (bronchospasm, i.e. “wheezing”) </li></ul></ul><ul><ul><li>STRONG allergic role, i.e., eosinophils, IgE, allergens </li></ul></ul><ul><ul><li>Often starting in CHILDHOOD </li></ul></ul><ul><ul><li>ATOPIC (allergic) or NON-ATOPIC (infection) </li></ul></ul><ul><ul><li>Chronic small airway obstruction and infection </li></ul></ul><ul><ul><li>1) Mucus hypersecretion with plugging, 2) lymphocytes/eosinophils, 3) lumen narrowing, 4) smooth muscle hypertrophy </li></ul></ul>www.freelivedoctor.com
  30. 30. www.freelivedoctor.com Note the heavy inflammatory cell infiltrate around bronchioles and small bronchi.
  31. 31. What are the 4 classical histologic findings in bronchial asthma? www.freelivedoctor.com
  32. 32. BRONCHIECTASIS <ul><li>DILATATION of the BRONCHUS, associated with, often, necrotizing inflammation </li></ul><ul><ul><li>CONGENITAL </li></ul></ul><ul><ul><li>TB , other bacteria, many viruses </li></ul></ul><ul><ul><li>BRONCHIAL OBSTRUCTION (i.e., LARGE AIRWAY, NOT SMALL AIRWAY) </li></ul></ul><ul><ul><li>Rheumatoid Arthritis, SLE, IBD (Inflammatory Bowel Disease) </li></ul></ul>www.freelivedoctor.com
  33. 33. BRONCHIECTASIS www.freelivedoctor.com
  34. 34. OVERVIEW <ul><li>Pathology </li></ul><ul><ul><li>Congenital </li></ul></ul><ul><ul><li>Atalectasis </li></ul></ul><ul><ul><li>Acute Pulmonary Injury </li></ul></ul><ul><ul><li>Obstruction vs. Restriction </li></ul></ul><ul><ul><li>Obstructive Pulmonary Diseases (COPD) </li></ul></ul><ul><ul><li>RESTRICTIVE (INFILTRATIVE) PULMONARY DISEASES </li></ul></ul><ul><ul><li>Vascular Pulmonary Diseases </li></ul></ul>www.freelivedoctor.com
  35. 35. RESTRICTIVE (INFILTRATIVE) <ul><li>REDUCED COMPLIANCE, reduced gas exchange) </li></ul><ul><li>Are also DIFFUSE </li></ul><ul><li>HETEROGENEOUS </li></ul><ul><li>FIBROSING </li></ul><ul><li>GRANULOMATOUS </li></ul><ul><li>EOSINOPHILIC </li></ul><ul><li>SMOKING RELATED </li></ul><ul><li>PAP [Pulmonary Alveolar Proteinosis] </li></ul>www.freelivedoctor.com
  36. 36. FIBROSING <ul><li>“ IDIOPATHIC” PULMONARY FIBROSIS (IPF) </li></ul><ul><li>NONSPECIFIC INTERSTITIAL FIBROSIS </li></ul><ul><li>“ CRYPTOGENIC” ORGANIZING PNEUMONIA </li></ul><ul><li>“ COLLAGEN” VASCULAR DISEASES </li></ul><ul><li>PNEUMOCONIOSES </li></ul><ul><li>DRUG REACTIONS </li></ul><ul><li>RADIATION CHANGES </li></ul>www.freelivedoctor.com
  37. 37. IPF (UIP) <ul><li>IDIOPATHIC, i.e., not from any usual caused, like lupus, scleroderma </li></ul><ul><li>FIBROSIS </li></ul>www.freelivedoctor.com
  38. 38. NON-SPECIFIC INTERSTITIAL PNEUMONIA <ul><li>WASTEBASKET DIAGNOSIS, of ANY pneumonia (pneumonitis) of any known or unknown etiology </li></ul><ul><ul><li>FIBROSIS </li></ul></ul><ul><ul><li>CELLULAR INFILTRATE (LYMPHS & PLASMA CELLS) </li></ul></ul>www.freelivedoctor.com
  39. 39. CRYPTOGENIC ORGANIZING PNEUMONIA (COP) <ul><li>IDIOPATHIC </li></ul><ul><li>“ BRONCHIOLITIS OBLITERANS” </li></ul>www.freelivedoctor.com
  40. 40. “ COLLAGEN” VASCULAR DISEASES <ul><li>Rheumatoid Arthritis </li></ul><ul><li>SLE (“Lupus”) </li></ul><ul><li>Progressive Systemic Sclerosis (Scleroderma) </li></ul>www.freelivedoctor.com
  41. 41. PNEUMOCONIOSES <ul><li>“ OCCUPATIONAL” </li></ul><ul><li>“ COAL MINERS LUNG” </li></ul><ul><li>DUST OR CHEMICALS OR ORGANIC MATERIALS </li></ul><ul><ul><li>Coal (anthracosis) </li></ul></ul><ul><ul><li>Silica </li></ul></ul><ul><ul><li>Asbestos </li></ul></ul><ul><ul><li>Be, FeO, BaSO4, CHEMO </li></ul></ul><ul><ul><li>HAY, FLAX, BAGASSE, INSECTICIDES, etc. </li></ul></ul>www.freelivedoctor.com
  42. 42. GRANULOMATOUS <ul><li>SARCOIDOSIS , i.e., NON-caseating granulomas (IDIOPATHIC) </li></ul><ul><li>HYPERSENSITIVITY (DUSTS, bacteria, fungi, Farmer’s Lung, Pigeon Breeder’s Lung) </li></ul>www.freelivedoctor.com
  43. 43. SARCOIDOSIS <ul><li>Mainly LUNG, but eye, skin or ANYWHERE </li></ul><ul><li>UNKNOWN ETIOLOGY </li></ul><ul><li>IMMUNE, GENETIC factors </li></ul><ul><li>F>>M </li></ul><ul><li>B>>W </li></ul><ul><li>YOUNG ADULT BLACK WOMEN </li></ul>www.freelivedoctor.com
  44. 44. NON-Caseating Granulomas are the RULE “ Asteroid” bodies within these granulomas are virtually diagnostic www.freelivedoctor.com
  45. 45. www.freelivedoctor.com
  46. 46. SMOKING RELATED <ul><li>DIP (Desquamative Interstitial Pneumonia) </li></ul><ul><ul><li>M>>F </li></ul></ul><ul><ul><li>CIGARETTES </li></ul></ul><ul><ul><li>100% Survival </li></ul></ul>Alveolar Macrophages www.freelivedoctor.com
  47. 47. PAP (Pulmonary Alveolar Proteinosis) <ul><li>Very RARE, usually acquired </li></ul><ul><li>Proteinaceous Material in Alveoli </li></ul><ul><li>MINIMAL cellular infiltrate </li></ul><ul><li>Like Pulmonary Edema, but MUCH Protein </li></ul>www.freelivedoctor.com
  48. 48. OVERVIEW <ul><li>Pathology </li></ul><ul><ul><li>Congenital </li></ul></ul><ul><ul><li>Atalectasis </li></ul></ul><ul><ul><li>Acute Pulmonary Injury </li></ul></ul><ul><ul><li>Obstruction vs. Restriction </li></ul></ul><ul><ul><li>Obstructive Pulmonary Diseases (COPD) </li></ul></ul><ul><ul><li>Restrictive (Infiltrative) Pulmonary Diseases </li></ul></ul><ul><ul><li>VASCULAR PULMONARY DISEASES </li></ul></ul>www.freelivedoctor.com
  49. 49. VASCULAR PULMONARY DISEASES <ul><li>PULMONARY EMBOLISM (with or usually WITHOUT infarction) </li></ul><ul><li>PULMONARY HYPERTENSION , leading to cor pulmonale </li></ul><ul><li>HEMORRHAGIC SYNDROMES </li></ul><ul><ul><li>GOODPASTURE SYNDROME </li></ul></ul><ul><ul><li>HEMOSIDEROSIS , idiopathic </li></ul></ul><ul><ul><li>WEGENER GRANULOMATOSIS </li></ul></ul>www.freelivedoctor.com
  50. 50. P.E. <ul><li>Usually secondary to debilitated states with immobilization, or following surgery </li></ul><ul><li>Usually deep leg and deep pelvic veins (DVT), NOT superficial veins </li></ul><ul><li>Follows Virchow’s triad, i.e., 1) flow problems, 2) endothelial disruption, 3) hypercoagulabilty </li></ul><ul><li>Usually do NOT infarct, usually ventilate </li></ul><ul><li>When they DO infarct, the infarct is hemorrhagic </li></ul><ul><li>Decreased PO2, acute chest pain, V/Q MIS-match </li></ul><ul><li>DX: Chest CT, V/Q scan, angiogram </li></ul><ul><li>RX: short term heparin, then long term coumadin </li></ul>www.freelivedoctor.com
  51. 51. PULMONARY HYPERTENSION <ul><li>COPD, C”I”PD (vicious cycle) </li></ul><ul><li>CHD (Congenital HD, increased left atrial pressure) </li></ul><ul><li>Recurrent PEs </li></ul><ul><li>Autoimmune, e.g., PSS (Scleroderma), i.e., fibrotic pulmonary vasculature </li></ul>www.freelivedoctor.com
  52. 52. VERY thickened arteriole in pulmonary hypertension NORMAL pulmonary arteriole www.freelivedoctor.com
  53. 53. HEMORRHAGIC SYNDROMES <ul><li>GOODPASTURE Syndrome: Ab’s to the alpha-3 chains of collagen IV, GBM deposits too! </li></ul><ul><li>IDIOPATHIC PULMONARY HEMOSIDEROSIS, to be differentiated from chronic CHF </li></ul><ul><li>WEGENER GRANULOMATOSIS </li></ul>www.freelivedoctor.com
  54. 54. CHF, CHRONIC IDIOPATHIC PULMONARY HEMOSIDEROSIS www.freelivedoctor.com
  55. 55. PNEUMONIA www.freelivedoctor.com
  56. 56.   COMM UNITY-ACQUIRED BACTERIAL ACUTE PNEUMONIAS Streptococcus Pneumoniae Haemophilus Influenzae Moraxella Catarrhalis Staphylococcus Aureus Klebsiella Pneumoniae Pseudomonas Aeruginosa Legionella Pneumophila COMMUNITY-ACQUIRED ATYPICAL (VIRAL AND MYCOPLASMAL) PNEUMONIAS Morphology. Clinical Course. Influenza Infections Severe Acute Respiratory Syndrome (SARS) NOSOCOMIAL PNEUMONIA ASPIRATION PNEUMONIA LUNG ABSCESS Etiology and Pathogenesis. CHRONIC PNEUMONIA Histoplasmosis, Morphology Blastomycosis, Morphology Coccidioidomycosis, Morphology PNEUMONIA IN THE IMMUNOCOMPROMISED HOST PULMONARY DISEASE IN HUMAN IMMUNODEFICIENCY VIRUS INFECTION PULMONARY INFECTIONS www.freelivedoctor.com
  57. 57. BASIC CONSIDERATIONS <ul><li>PNEUMONIA vs. PNEUMONITIS </li></ul><ul><li>DIFFERENTIATION from INJURIES, OBSTRUCTIVE DISEASES, RESTRICTIVE DISEASES, VASCULAR DISEASES </li></ul><ul><li>DIFFERENTIATION FROM NEOPLASMS </li></ul><ul><li>CLASSICAL STAGES of INFLAMMATION </li></ul><ul><li>LOBAR- vs. BRONCHO- </li></ul><ul><li>INTERSTITIAL vs. ALVEOLAR </li></ul><ul><li>COMMUNITY vs. NOSOCOMIAL </li></ul><ul><li>ETIOLOGIC AGENTS vs. HOST IMMUNITY </li></ul><ul><li>2 PRESENTING SYMPTOMS </li></ul><ul><li>2 DIAGNOSTIC METHODS </li></ul><ul><li>ANY ORGANISM CAN CAUSE PNEUMONIA!!! </li></ul>www.freelivedoctor.com
  58. 58. PREDISPOSING FACTORS <ul><li>LOSS OF COUGH REFLEX </li></ul><ul><li>DIMINISHED MUCIN or CILIA FUNCTION </li></ul><ul><li>ALVEOLAR MACROPHAGE INTERFERENCE </li></ul><ul><li>VASCULAR FLOW IMPAIRMENTS </li></ul><ul><li>BRONCHIAL FLOW IMPAIRMENTS </li></ul>www.freelivedoctor.com
  59. 59. Although pneumonia is one of the most common causes of death, it usually does NOT occur in healthy people spontaneously www.freelivedoctor.com
  60. 60. Classifications of PNEUMONIAS <ul><li>COMMUNITY ACQUIRED </li></ul><ul><li>COMMUNITY ACQUIRED, ATYPICAL </li></ul><ul><li>NOSOCOMIAL </li></ul><ul><li>ASPIRATION </li></ul><ul><li>CHRONIC </li></ul><ul><li>NECROTIZING/ABSCESS FORMATION </li></ul><ul><li>PNEUMONIAS in IMMUNOCOMPROMISED HOSTS </li></ul>www.freelivedoctor.com
  61. 61. Classifications of PNEUMONIAS <ul><li>COMMUNITY ACQUIRED </li></ul><ul><li>COMMUNITY ACQUIRED, ATYPICAL </li></ul><ul><li>NOSOCOMIAL </li></ul><ul><li>ASPIRATION </li></ul><ul><li>CHRONIC </li></ul><ul><li>NECROTIZING/ABSCESS FORMATION </li></ul><ul><li>PNEUMONIAS in IMMUNOCOMPROMISED HOSTS </li></ul>www.freelivedoctor.com
  62. 62. COMMUNITY ACQUIRED <ul><li>STREPTOCOCCUS PNEUMONIAE (i.e., “diplococcus”) </li></ul><ul><li>HAEMOPHILUS INFLUENZAE (“H-Flu”) </li></ul><ul><li>MORAXELLA </li></ul><ul><li>STAPHYLOCOCCUS (STAPH) </li></ul><ul><li>KLEBSIELLA PNEUMONIAE </li></ul><ul><li>PSEUDOMONAS AERUGINOSA </li></ul><ul><li>LEGIONELLA PNEUMOPHILIA </li></ul>www.freelivedoctor.com
  63. 63. STREPTOCOCCUS <ul><li>The classic LOBAR pneumonia </li></ul><ul><li>Normal flora in 20% of adults </li></ul><ul><li>Only 20% of victims have + blood cultures </li></ul><ul><li>“ Penicillins” are often 100% curative </li></ul><ul><li>Vaccines are often 100% preventive </li></ul>www.freelivedoctor.com
  64. 64. HAEMOPHILUS PNEUMONIA <ul><li>Commonest in CHILDREN <2, with otitis, URI, meningitis, cellulitis, osteomyelitis </li></ul><ul><li>PNEUMONIAS in CHILDREN <2 are often thought of as being H Flu until proven otherwise, otitis, meningitis too </li></ul><ul><li>Most common pneumonia from COPD in adults </li></ul><ul><li>BACTRIM (Trimethoprim-Sulfa) most common treatment </li></ul>www.freelivedoctor.com
  65. 65. MORAXELLA CATARRHALIS <ul><li>2nd most common COPD pneumonia, after haemophilus </li></ul><ul><li>Gram NEGATIVE coccobacillus </li></ul>www.freelivedoctor.com
  66. 66. STAPH aureus <ul><li>Most common pneumonia following viral pneumonias </li></ul><ul><li>M.R.S.A., of course, is usually NOT “community” acquired </li></ul>www.freelivedoctor.com
  67. 67. KLEBSIELLA PNEUMONIAE <ul><li>DEBILITATED MALNOURISHED PEOPLE </li></ul><ul><li>ALCOHOLICS with pneumonia are often thought of as having Klebsiella until proven otherwise </li></ul>www.freelivedoctor.com
  68. 68. PSEUDOMONAS Aeruginosa <ul><li>Usually NOT community acquired but nosocomial </li></ul><ul><li>CYSTIC FIBROSIS patients with pneumonia are presumed to have PSEUDOMONAS until proven otherwise </li></ul>www.freelivedoctor.com
  69. 69. LEGIONELLA (pneumophila) <ul><li>Often in OUTBREAKS </li></ul><ul><li>Often LOBAR </li></ul><ul><li>Spread by water “droplets” </li></ul><ul><li>Often immunosuppressed patients, but remember……….. </li></ul>www.freelivedoctor.com
  70. 70. Although pneumonia is one of the most common causes of death, it usually does NOT occur in healthy people spontaneously www.freelivedoctor.com
  71. 71. MORPHOLOGY <ul><li>ACUTE </li></ul><ul><li>ORGANIZING </li></ul><ul><li>CHRONIC </li></ul><ul><li>FIBROSIS vs. FULL RESOLUTION </li></ul><ul><li>“ HEPATIZATION”, RED vs. GREY </li></ul><ul><li>CONSOLIDATION </li></ul><ul><li>“ INFILTRATE ”, XRAY vs. HISTOPATH </li></ul><ul><li>Loss of “CREPITANCE” </li></ul>www.freelivedoctor.com
  72. 72. Classifications of PNEUMONIAS <ul><li>COMMUNITY ACQUIRED </li></ul><ul><li>COMMUNITY ACQUIRED, ATYPICAL </li></ul><ul><li>NOSOCOMIAL </li></ul><ul><li>ASPIRATION </li></ul><ul><li>CHRONIC </li></ul><ul><li>NECROTIZING/ABSCESS FORMATION </li></ul><ul><li>PNEUMONIAS in IMMUNOCOMPROMISED HOSTS </li></ul>www.freelivedoctor.com
  73. 73. COMMUNITY ACQUIRED , (atypical) <ul><li>VIRAL (INFLUENZA) </li></ul><ul><li>MYCOPLASMAL (MYCOPLASMA PNEUMONIAE (obligate intracellular)) </li></ul><ul><li>NOT BACTERIAL </li></ul><ul><li>CULTURES NOT HELPFUL </li></ul>www.freelivedoctor.com
  74. 74. VIRAL PNEUMONIAS <ul><li>Frequently “interstitial”, NOT alveolar </li></ul>www.freelivedoctor.com
  75. 75. INFLUENZA VIRUS <ul><li>A,B,C </li></ul><ul><li>1915, 1918, PAN-demics, type A </li></ul><ul><li>Has MUTATED throughout history, many STRAINS, avian swine, etc. </li></ul><ul><li>B and C in children </li></ul><ul><li>Exact strains can be ID’s by PCR </li></ul>www.freelivedoctor.com
  76. 76. www.freelivedoctor.com
  77. 77. SARS (Severe Acute Respiratry Syndrome) <ul><li>CORONA-VIRUS </li></ul><ul><li>2002 China outbreak </li></ul><ul><li>Spread CHIEFLY in Asia </li></ul><ul><li>Like most other NON-bacterial pneumonias confirmed by PCR </li></ul><ul><li>Like most viral pneumonias, interstitium infiltrated, some giant cells often present </li></ul>www.freelivedoctor.com
  78. 78. S A R S www.freelivedoctor.com
  79. 79. Classifications of PNEUMONIAS <ul><li>COMMUNITY ACQUIRED </li></ul><ul><li>COMMUNITY ACQUIRED, ATYPICAL </li></ul><ul><li>NOSOCOMIAL </li></ul><ul><li>ASPIRATION </li></ul><ul><li>CHRONIC </li></ul><ul><li>NECROTIZING/ABSCESS FORMATION </li></ul><ul><li>PNEUMONIAS in IMMUNOCOMPROMISED HOSTS </li></ul>www.freelivedoctor.com
  80. 80. NOSOCOMIAL <ul><li>Acquired in HOSPITALS, also called “hospital acquired”, versus “community acquired” pneumonias. </li></ul><ul><ul><li>DEBILITATION </li></ul></ul><ul><ul><li>CATHETERS, VENTILATORS </li></ul></ul><ul><ul><li>ENTEROBACTER, PSEUDOMONAS </li></ul></ul><ul><ul><li>STAPH (MRSA) </li></ul></ul><ul><ul><li>MRSA (MR=Methicillin R esistant) </li></ul></ul><ul><li>OTHER Common causes of Noso. Pneum. P. aeruginosa Klebsiella E. coli S. pneumoniae H. influenzae </li></ul>www.freelivedoctor.com
  81. 81. Classifications of PNEUMONIAS <ul><li>COMMUNITY ACQUIRED </li></ul><ul><li>COMMUNITY ACQUIRED, ATYPICAL </li></ul><ul><li>NOSOCOMIAL </li></ul><ul><li>ASPIRATION </li></ul><ul><li>CHRONIC (often granulomatous) </li></ul><ul><li>NECROTIZING/ABSCESS FORMATION </li></ul><ul><li>PNEUMONIAS in IMMUNOCOMPROMISED HOSTS </li></ul>www.freelivedoctor.com
  82. 82. ASPIRATION PNEUMONIAS <ul><li>UNCONSCIOUS PATIENTS </li></ul><ul><li>PATIENTS IN PROLONGED BEDREST </li></ul><ul><li>LACK OF ABILITY TO SWALLOW OR GAG </li></ul><ul><li>USUALLY CAUSED BY ASPIRATION OF GASTRIC CONTENTS </li></ul><ul><li>POSTERIOR LOBES (gravity dependent) MOST COMMONLY INVOLVED, ESPECIALLY THE SUPERIOR SEGMENTS of the LOWER LOBES </li></ul><ul><li>Often lead to ABSCESSES </li></ul>www.freelivedoctor.com
  83. 83. www.freelivedoctor.com
  84. 84. LUNG ABSCESSES <ul><li>ASPIRATION </li></ul><ul><li>SEPTIC EMBOLIZATION </li></ul><ul><li>NEOPLASIA </li></ul><ul><li>From NEIGHBORING structures: </li></ul><ul><ul><li>ESOPHAGUS </li></ul></ul><ul><ul><li>SPINE </li></ul></ul><ul><ul><li>PLEURA </li></ul></ul><ul><ul><li>DIAPHRAGM </li></ul></ul><ul><li>ANY pneumonia which is severe and destructive, and UN-treated enough </li></ul>www.freelivedoctor.com
  85. 85. www.freelivedoctor.com
  86. 86. Classifications of PNEUMONIAS <ul><li>COMMUNITY ACQUIRED </li></ul><ul><li>COMMUNITY ACQUIRED, ATYPICAL </li></ul><ul><li>NOSOCOMIAL </li></ul><ul><li>ASPIRATION </li></ul><ul><li>CHRONIC </li></ul><ul><li>NECROTIZING/ABSCESS FORMATION </li></ul><ul><li>PNEUMONIAS in IMMUNOCOMPROMISED HOSTS </li></ul>www.freelivedoctor.com
  87. 87. CHRONIC Pneumonias <ul><li>USUALLY NOT persistences of the community or nosocomial bacterial infections, but CAN BE, at least histologically </li></ul><ul><li>Often SYNONYMOUS with the 4 classic fungal or granulomatous pulmonary infections infections, i.e., TB, Histo-, Blasto-, Coccidio- </li></ul><ul><li>If you see pulmonary granulomas, think of a CHRONIC process, often years </li></ul>www.freelivedoctor.com
  88. 88. CHRONIC Pneumonias <ul><li>TB </li></ul><ul><li>HISTO-PLASMOSIS </li></ul><ul><li>BLASTO-MYCOSIS </li></ul><ul><li>COCCIDIO-MYCOSIS </li></ul>www.freelivedoctor.com
  89. 89. HISTOPLASMOSIS <ul><li>Spores in bird or bat droppings </li></ul><ul><li>Mimics TB </li></ul><ul><li>Histoplasma CAPSULATUM </li></ul><ul><li>Pulmonary granulomas, often large and calcified </li></ul><ul><li>Tiny organisms live in macrophages </li></ul><ul><li>Ohio, Mississippi valley </li></ul><ul><li>MANY other organs can be affected </li></ul>www.freelivedoctor.com
  90. 90. www.freelivedoctor.com
  91. 91. BLASTOMYCOSIS <ul><li>Spores in soil </li></ul><ul><li>Mimics TB, like ALL the granulomatous lung dideases do. </li></ul><ul><li>Blastomyces DERMATIDIS </li></ul><ul><li>Pulmonary granulomas, often large and calcified </li></ul><ul><li>Large distinct SPHERULES </li></ul><ul><li>Ohio, Mississippi valley, Great Lakes, WORLDWIDE </li></ul><ul><li>MANY other organs can be affected, especially SKIN </li></ul>www.freelivedoctor.com
  92. 92. COCCIDIOMYCOSIS <ul><li>Spores in soil </li></ul><ul><li>Mimics TB </li></ul><ul><li>Coccidioides IMMITIS </li></ul><ul><li>Pulmonary granulomas, often large and calcified </li></ul><ul><li>Tiny organisms live in macrophages </li></ul><ul><li>American SOUTHWEST </li></ul><ul><li>MANY other organs can be affected </li></ul>www.freelivedoctor.com
  93. 93. GRANULOMA www.freelivedoctor.com
  94. 94. COMPROMISED HOSTS <ul><li>PNEUMOCYSTIS CARINII </li></ul><ul><li>CYTOMEGALOVIRUS (CMV) </li></ul><ul><li>FUNGI </li></ul>www.freelivedoctor.com
  95. 95. PCP www.freelivedoctor.com
  96. 96. Methenamine SILVER stain for Pneumocystis Carinii www.freelivedoctor.com
  97. 97. LUNG TRANSPLANTATION <ul><li>EMPHYSEMA </li></ul><ul><li>Pulmonary Fibrosis </li></ul><ul><li>Cystic Fibrosis </li></ul><ul><li>Pulmonary Hypertension </li></ul>Any end-stage lung disease in which the patient can tolerate long term immunosuppression, and often just ONE lung is enough, donors very SCARCE! www.freelivedoctor.com
  98. 98. Lung Transplant Pathology <ul><li>Infections (immunocompromised patients) </li></ul><ul><ul><li>Bacterial </li></ul></ul><ul><ul><li>Viral (CMV) </li></ul></ul><ul><ul><li>Fungal </li></ul></ul><ul><ul><li>PCP </li></ul></ul><ul><li>ACUTE rejection, pneumonias, usually weeks to months </li></ul><ul><li>CHRONIC rejection, HALF of all patients by 3-5 years, “bronchiolitis obliterans” </li></ul>www.freelivedoctor.com
  99. 99. www.freelivedoctor.com
  100. 100. LUNG TUMORS <ul><li>Benign, malignant, epithelial, mesenchymal, but 90% are CARCINOMAS </li></ul><ul><li>BIGGEST USA killer. Why? Ans: Prevalence not as high as prostate or breast but mortality higher. Only 15% 5 year survival. </li></ul><ul><li>TOBACCO has polycyclic aromatic hydrocarbons, such as benzopyrene, anthracenes, radioactive isotopes </li></ul><ul><li>Radiation, asbestos, radon </li></ul><ul><li>C-MYC, K-RAS, EGFR, HER-2/neu </li></ul>www.freelivedoctor.com
  101. 101. PATHOGENESIS <ul><li>NORMAL BRONCHIAL MUCOSA </li></ul><ul><li>METAPLASTIC/DYSPLASTIC MUCOSA </li></ul><ul><li>CARCINOMA-IN-SITU (squamous, adeno) </li></ul><ul><li>INFILTRATING (i.e., “INVASIVE”) cancer </li></ul>www.freelivedoctor.com
  102. 102. TWO TYPES <ul><li>NON-SMALL CELL </li></ul><ul><ul><li>SQUAMOUS CELL CARCINOMA </li></ul></ul><ul><ul><li>ADENOCARCINOMA </li></ul></ul><ul><ul><li>LARGE CELL CARCINOMA </li></ul></ul><ul><li>SMALL CELL CARCINOMA </li></ul>www.freelivedoctor.com
  103. 103. The BIG list <ul><li>Squamous cell carcinoma </li></ul><ul><li>Small cell carcinoma </li></ul><ul><li>Combined small cell carcinoma   </li></ul><ul><li>Adenocarcinoma: Acinar, papillary, bronchioloalveolar, solid, mixed subtypes </li></ul><ul><li>Large cell carcinoma </li></ul><ul><li>Large cell neuroendocrine carcinoma </li></ul><ul><li>Adenosquamous carcinoma </li></ul><ul><li>Carcinomas with pleomorphic, sarcomatoid, or sarcomatous elements </li></ul><ul><li>Carcinoid tumor: Typical, atypical   </li></ul><ul><li>Carcinomas of salivary gland type </li></ul><ul><li>Unclassified carcinoma </li></ul>www.freelivedoctor.com
  104. 104. OTHER TUMORS www.freelivedoctor.com
  105. 105. www.freelivedoctor.com
  106. 106. TNM, Lung www.freelivedoctor.com T1 Tumor <3 cm without pleural or main stem bronchus involvement T2 Tumor >3 cm or involvement of main stem bronchus 2 cm from carina, visceral pleural involvement, or lobar atelectasis T3 Tumor with involvement of chest wall (including superior sulcus tumors), diaphragm, mediastinal pleura, pericardium, main stem bronchus 2 cm from carina, or entire lung atelectasis T4 Tumor with invasion of mediastinum, heart, great vessels, trachea, esophagus, vertebral body, or carina or with a malignant pleural effusion N0 No demonstrable metastasis to regional lymph nodes N1 Ipsilateral hilar or peribronchial nodal involvement N2 Metastasis to ipsilateral mediastinal or subcarinal lymph nodes N3 Metastasis to contralateral mediastinal or hilar lymph nodes, ipsilateral or contralateral scalene, or supraclavicular lymph nodes M0 No (known) distant metastasis M1 Distant metastasis present
  107. 107. LOCAL effects of LUNG CANCER www.freelivedoctor.com Clinical Feature Pathologic Basis Pneumonia, abscess, lobar collapse Tumor obstruction of airway Lipid pneumonia Tumor obstruction; accumulation of cellular lipid in foamy macrophages Pleural effusion Tumor spread into pleura Hoarseness Recurrent laryngeal nerve invasion Dysphagia Esophageal invasion Diaphragm paralysis Phrenic nerve invasion Rib destruction Chest wall invasion SVC syndrome SVC compression by tumor Horner syndrome Sympathetic ganglia invasion Pericarditis, tamponade Pericardial involvement SVC, superior vena cava.
  108. 108. SYSTEMIC effects of LUNG CANCER (PARA-NEOPLASTIC SYNDROMES)~ 5% ADH (hyponatremia) ACTH (Cushing) PTH (Hyper-CA) CALCITONIN (Hypo-CA) GONADOTROPINS SEROTONIN/BRADYKININ www.freelivedoctor.com
  109. 109. OTHER TUMORS www.freelivedoctor.com
  110. 110. METASTATIC TUMORS <ul><li>LUNG is the MOST COMMON site for all metastatic tumors, regardless of site of origin </li></ul><ul><li>It is the site of FIRST CHOICE for metastatic sarcomas for purely anatomic reasons! </li></ul>www.freelivedoctor.com
  111. 111. PLEURA <ul><li>PLEURITIS </li></ul><ul><li>PNEUMOTHORAX </li></ul><ul><li>EFFUSIONS </li></ul><ul><ul><li>HYDRO-THORAX (Peric-, Perito-) </li></ul></ul><ul><ul><li>HEMO-THORAX (Peric-, Perito-) </li></ul></ul><ul><ul><li>CHYLO-THORAX (Peric-, Perito-) </li></ul></ul><ul><li>MESOTHELIOMAS </li></ul>www.freelivedoctor.com
  112. 112. PLEURITIS <ul><li>Usual bacteria, viruses, etc. </li></ul><ul><li>Infarcts </li></ul><ul><li>Lung abscesses, empyema </li></ul><ul><li>TB </li></ul><ul><li>“ Collagen” diseases, e.g., RA, SLE </li></ul><ul><li>Uremia </li></ul><ul><li>Metastatic </li></ul>www.freelivedoctor.com
  113. 113. PNEUMOTHORAX <ul><li>SPONTANEOUS, TRAUMATIC, THERAPEUTIC </li></ul><ul><li>OPEN or CLOSED </li></ul><ul><li>“ TENSION” pneumothorax, “valvular” effect </li></ul><ul><li>“ Bleb” rupture </li></ul><ul><li>Perforating injuries </li></ul><ul><li>Post needle biopsy </li></ul>www.freelivedoctor.com
  114. 114. EFFUSIONS <ul><li>TRANSUDATE (HYDROTHORAX) </li></ul><ul><li>EXUDATE (HYDROTHORAX) </li></ul><ul><li>BLOOD (HEMOTHORAX) </li></ul><ul><li>LYMPH (CHYLOTHORAX) </li></ul>www.freelivedoctor.com
  115. 115. MESOTHELIOMAS <ul><li>“ Benign” vs. “Malignant” differentiation does not matter, but a self limited localized nodule can be regarded as benign, and a spreading tumor can be regarded as malignant </li></ul><ul><li>Visceral or parietal pleura, pericardium, or peritoneum </li></ul><ul><li>Most are regarded as asbestos caused or asbestos “related” </li></ul>www.freelivedoctor.com
  116. 116. www.freelivedoctor.com
  117. 117.  EM H&E, IMMUNOCHEMISTRY www.freelivedoctor.com

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