Normal Lab Values

Weeks 11-12: Respiratory System Pathology

Suggested readings from
Robbins 8th ed.

Vascular, Obstructive, & Restrictive Pulmonary Diseases: pp. 677-721

Pulmonary Neoplasms: pp. 721-738

Pathology Cases for Week 11

Microbiology Cases

Review Items for Weeks 11-12

 

Pathology Case Descriptions

CASE NUMBER 40
[ImageScope] [WebScope]

Clinical History:  A 45-year-old male entered the hospital two days prior to death for evaluation of shortness of breath. He was found dead by the nurse.

Image Gallery:

(Summary of Gross Findings - click here)
Both lungs were heavy, wet, slightly firm, and dark-red. Frothy clear fluid may be seen on the cut surface.
(Summary of Microscopic Findings - click here)
The alveoli are filled with a homogeneous pink material. The septal capillaries are engorged with blood. An incidental finding consists of anthracotic pigment near the pleural space.
(Review Normal Histology - click here)
Norm No. 24 Lung
[ImageScope] [WebScope]

The primary function of the lung is gas exchange. Therefore, alveoli have thin walls lined by thin flat pneumocytes and endothelial cells. There is no thickening or fibrosis of the interstitium. The bronchioli are lined with basally oriented ciliated columnar epithelium. The bronchi are lined by similar epithelium. There are mucous glands within the submucosa. The bronchial smooth muscle is not hypertrophied. The pulmonary vessels are patent with no evidence of intimal thickening or muscular hyperplasia.

 

What is the most likely diagnosis?

ANSWER

 

40-1. Causes of pulmonary edema include:

  1. Left heart failure
  2. Tricuspid stenosis
  3. Right heart failure
  4. Pulmonary thromboembolism
  5. NONE of the above

ANSWER

 

40-2. With regard to edema formation,

  1. ankle swelling is a sign of left heart failure
  2. sacral edema is a sign of right heart failure
  3. pulmonary edema is a sign of right heart failure
  4. periorbital edema is a sign of left heart failure

ANSWER

 

 

 

 

CASE NUMBER 92
[ImageScope] [WebScope]

Clinical History: A 65-year-old male had smoked for many years. He complained about increasing dyspnea over the last 10 years. The dyspnea had suddenly increased and the patient was admitted with signs of heart failure. He died one week after admission from an acute brain infarct.

Image Gallery:

(Summary of Gross Findings - click here)
The lungs were very large and upon palpation there was marked crepitation.
(Summary of Microscopic Findings - click here)
The alveolar spaces are distended and the alveolar septa are thickened by fibrous tissue. Numerous "free floating" alveolar septa are present, recognizable as pieces at alveolar wall not connected at either end to adjacent septa.
(Review Normal Histology - click here)
Norm No. 24 Lung
[ImageScope] [WebScope]

The primary function of the lung is gas exchange. Therefore, alveoli have thin walls lined by thin flat pneumocytes and endothelial cells. There is no thickening or fibrosis of the interstitium. The bronchioli are lined with basally oriented ciliated columnar epithelium. The bronchi are lined by similar epithelium. There are mucous glands within the submucosa. The bronchial smooth muscle is not hypertrophied. The pulmonary vessels are patent with no evidence of intimal thickening or muscular hyperplasia.

 

92-1. What is the most likely diagnosis?

  1. Lung abscesses
  2. Panacinar emphysema
  3. Asbestosis
  4. Centrilobular emphysema

ANSWER

 

92-2. What factor contributed most to this patient’s disease?

  1. Living in South Carolina
  2. Genetics
  3. Cigarette smoking
  4. Alcohol consumption

ANSWER

 

 

CASE NUMBER 51 (Micro Case 3)
[ImageScope] [WebScope]

Clinical History: A 45-year-old male became ill approximately 2 to 3 weeks ago following an alcoholic spree. He had nausea, vomiting, dehydration, confusion and high fever. He died suddenly shortly after admission.

Image Gallery:

(Summary of Gross and Lab Findings - click here)
Gram stain of sputum obtained before death shows Gram positive cocci in pairs. (This pathogen was previously called Diplococcus pneumoniae.) Streptococcus pneumoniae was cultured from the lung. The right lung was heavy weighing 700 grams. Its lower lobe showed diffuse gray consolidation. The trachea and bronchi contained a great deal of mucus, and the mucosa was dark red.
(Summary of Microscopic Findings - click here)
The alveoli are distended and contain a large amount of inflammatory exudate, which consists of many polymorphonuclear leukocytes, a few RBC's, macrophages and strands of fibrin. Many RBC's have been phagocytosed by the macrophages and are undergoing disintegration. The alveolar septa are delicate and well preserved, but markedly congested.
(Review Normal Histology - click here)
Norm No. 24 Lung
[ImageScope] [WebScope]

The primary function of the lung is gas exchange. Therefore, alveoli have thin walls lined by thin flat pneumocytes and endothelial cells. There is no thickening or fibrosis of the interstitium. The bronchioli are lined with basally oriented ciliated columnar epithelium. The bronchi are lined by similar epithelium. There are mucous glands within the submucosa. The bronchial smooth muscle is not hypertrophied. The pulmonary vessels are patent with no evidence of intimal thickening or muscular hyperplasia.

 

What is the MOST LIKELY diagnosis?

ANSWER

 

51-1. These images depict pneumonia in the stage of:

  1. Congestion
  2. Red hepatization
  3. Gray hepatization
  4. Resolution
  5. Abscess formation

ANSWER

 

51-2. Community acquired atypical pneumonia can be caused by which of the following organisms?

  1. Legionella pneumophilia
  2. Staphylococcus aureus
  3. Klebsiella pneumoniae
  4. Mycoplasma pneumoniae
  5. Pseudomonas aeruginosa

ANSWER

 

 

 

CASE NUMBER 39 (Micro Case 8)
[ImageScope] [WebScope]

Clinical History: 58 year old African American female had been hemiplegic on the right side for 3 months prior to death. She developed malaise, fever and chills after visiting with her grandchildren. Her infection progressed. She developed dyspnea and expired.

Image Gallery

(Summary of Gross and Lab Findings - click here)
A sputum gram stain showed small gram negative rods. This fastidious organism required chocolate agar for growth. A gram stain of the cultured organism is also shown. There was a thrombosis of the left internal carotid artery with infarction of the left cerebral hemisphere. There was a massive embolus of the right pulmonary artery. Both lungs were firm with mucopurulent exudate in the bronchi. The left lower lobe was firm and gray-yellow with a shaggy fibrinous exudate over the pleura.
(Summary of Microscopic Findings - click here)
Bronchi and alveoli are filled with neutrophils. There are scattered masses of fibrin.
(Review Normal Histology - click here)
Norm No. 24 Lung
[ImageScope] [WebScope]

The primary function of the lung is gas exchange. Therefore, alveoli have thin walls lined by thin flat pneumocytes and endothelial cells. There is no thickening or fibrosis of the interstitium. The bronchioli are lined with basally oriented ciliated columnar epithelium. The bronchi are lined by similar epithelium. There are mucous glands within the submucosa. The bronchial smooth muscle is not hypertrophied. The pulmonary vessels are patent with no evidence of intimal thickening or muscular hyperplasia.

 

Based on these clinical findings, what is the MOST LIKELY diagnosis?

ANSWER

 

39-1. What is usually the causative agent of this disease in most adults?

  1. Pseudomonas aeruginosa
  2. Mycoplasma pneumoniae
  3. Streptococcus pneumoniae
  4. Legionella pneumophilia
  5. Haemophilus influenzae

ANSWER

 

39-2. What organism would be MOST LIKELY to cause a persistent infection in cystic fibrosis?

  1. Pseudomonas aeruginosa
  2. Mycoplasma pneumoniae
  3. Streptococcus pneumoniae
  4. Legionella pneumophilia

ANSWER

 

CASE NUMBER 46
[ImageScope] [WebScope]

Clinical History: A 17 year old white female was in the first trimester of pregnancy and had complained of a flu-like symptoms and sore throat for 7 days. Cough and dyspnea did not respond to treatment with antibiotics and she died.

Image Gallery:

(Summary of Gross and Lab Findings - click here)
Both lungs were heavy, firm and rubbery.
(Summary of Microscopic Findings - click here)
The alveoli were filled with eosinophilic material representing fibrin. There is early proliferation of fibroblasts in some of these areas. At the periphery there are neutrophils and mononuclear cells. Note the alveolar hemorrhage. Brown, granular pigment is present in scattered macrophages. This is hemosiderin. Alveolar hemorrhage may be related to the acute glomerulonephritis that was also present in this patient. Note the diffuse neutrophilic infiltrate in alveolar walls.
(Review Normal Histology - click here)
Norm No. 24 Lung
[ImageScope] [WebScope]

The primary function of the lung is gas exchange. Therefore, alveoli have thin walls lined by thin flat pneumocytes and endothelial cells. There is no thickening or fibrosis of the interstitium. The bronchioli are lined with basally oriented ciliated columnar epithelium. The bronchi are lined by similar epithelium. There are mucous glands within the submucosa. The bronchial smooth muscle is not hypertrophied. The pulmonary vessels are patent with no evidence of intimal thickening or muscular hyperplasia.

 

What is the MOST LIKELY diagnosis?

ANSWER

 

46-1. Which of the following is true of bronchopneumonia?

  1. Tends to involve a single lobe
  2. Mainly shows chronic inflammation
  3. Tends to involve the right middle lobe
  4. An opaque, well-circumscribed lobe is seen on radiographs
  5. Tends to be bilateral and basal

ANSWER

 

 

 

CASE NUMBER 452
[ImageScope] [WebScope]

Clinical History: A 50-year-old African American female had chronic cough, chest pain, night sweats and a swollen abdomen for the past four years.

Image Gallery:

(Summary of Gross and Lab Findings - click here)
The lungs were heavy and had fibrous pleural adhesions. A large cavity containing caseous material was found in the apex of the left lung. The cavity communicated with a bronchus. In the left lower lobe there was large area of consolidation, which exuded creamy, yellow-gray, caseous material from the cut surface.
(Summary of Microscopic Findings - click here)
This section shows many foci of caseous necrosis, which is associated with marked proliferation of histiocytes around the caseous foci.
(Review Normal Histology - click here)
Norm No. 24 Lung
[ImageScope] [WebScope]

The primary function of the lung is gas exchange. Therefore, alveoli have thin walls lined by thin flat pneumocytes and endothelial cells. There is no thickening or fibrosis of the interstitium. The bronchioli are lined with basally oriented ciliated columnar epithelium. The bronchi are lined by similar epithelium. There are mucous glands within the submucosa. The bronchial smooth muscle is not hypertrophied. The pulmonary vessels are patent with no evidence of intimal thickening or muscular hyperplasia.

 

What is the MOST LIKELY diagnosis?

ANSWER

 

452-1. What type of necrosis is seen in these slides?

  1. Coagulative
  2. Liquefactive
  3. Caseous
  4. Fat

ANSWER

452-2. What type of inflammation is seen in these slides?

  1. Acute
  2. Acute and chronic
  3. Chronic
  4. Granulomatous

ANSWER

 

452-3. The pathology depicted in these images:

  1. Results from the spread of infection into the lymphatics
  2. Results from spread of the infection into the venous system
  3. Develops in the previously unexposed person
  4. Results from airway erosion and discharge of infected, necrotic debris

ANSWER

 

 

CASE NUMBER 281
[ImageScope] [WebScope]

Clinical History: A 47-year-old female had an eight year history of refractory anemia and pancytopenia. She was treated with steroids. She was admitted shortly before death with fever and sepsis.

Image Gallery:

(Summary of Gross and Lab Findings - click here)
White soft nodules in the lung parenchyma were observed.
(Summary of Microscopic Findings - click here)
Hematoxlin and eosin stain shows fungal elements and necrotic debris. The tissue was stained with methanmine silver to demonstrate the fungus. However, the tissue reaction to the fungus infection cannot be seen well with this stain. It does demonstrate the septate hyphae and radial pattern of growth of the organisms. Sputum culture results were reported after death. A typical fungus colony is shown. Fruiting bodies as illustrated here may occasionally be seen in necrotic tissue cavities.
(Review Normal Histology - click here)
Norm No. 24 Lung
[ImageScope] [WebScope]

The primary function of the lung is gas exchange. Therefore, alveoli have thin walls lined by thin flat pneumocytes and endothelial cells. There is no thickening or fibrosis of the interstitium. The bronchioli are lined with basally oriented ciliated columnar epithelium. The bronchi are lined by similar epithelium. There are mucous glands within the submucosa. The bronchial smooth muscle is not hypertrophied. The pulmonary vessels are patent with no evidence of intimal thickening or muscular hyperplasia.

 

What is the MOST LIKELY diagnosis?

ANSWER

 

281-1. The organism responsible for this pathology in the lung is MOST LIKELY to be:

  1. Mycobacterium tuberculosis
  2. Cryptococcus neoformans
  3. Aspergillus sp.
  4. Pseudomonas pseudomallei
  5. Staphyloccus aureus

ANSWER

 

 

CASE NUMBER 170
[ImageScope] [WebScope]

Clinical History: This was an incidental autopsy finding in the lung of a 67-year-old white male.

Image Gallery:

(Summary of Gross and Lab Findings - click here)
A chest CT from another patient illustrating a similar "coin" lesion in the inferior lobe of the right lung is shown. There was a hard, well circumscribed, round nodule with a yellow gray cut surface in the lung.
(Summary of Microscopic Findings - click here)
There is normal cartilage, hyperplastic bronchial epithelium, and fragments of lung tissue with the alveoli filled with mononuclear cells derived from the alveolar epithelial cells. These lesions are common and seldom cause clinical symptoms.
(Review Normal Histology - click here)
Norm No. 24 Lung
[ImageScope] [WebScope]

The primary function of the lung is gas exchange. Therefore, alveoli have thin walls lined by thin flat pneumocytes and endothelial cells. There is no thickening or fibrosis of the interstitium. The bronchioli are lined with basally oriented ciliated columnar epithelium. The bronchi are lined by similar epithelium. There are mucous glands within the submucosa. The bronchial smooth muscle is not hypertrophied. The pulmonary vessels are patent with no evidence of intimal thickening or muscular hyperplasia.

 

170-1. The main tissue seen in this tumor is:

  1. bone.
  2. collagen.
  3. epithelium.
  4. cartilage.
  5. fat

ANSWER

 

170-2. This tumor is best considered a form of:

  1. sarcoma.
  2. adenoma.
  3. hamartoma.
  4. teratoma.
  5. carcinoma.

ANSWER

 

170-3. The tumor had been considered a hamartoma but there is recent evidence to suggest that it should be considered a/an:

  1. chondrosarcoma because it metastases to distant sites.
  2. chondroma because it is monoclonal.
  3. chondromyxoid fibroma because it occurs in soft tissue as well.
  4. osteosarcoma with chondroid metaplasia because it produces osteoid.
  5. osteochondroma because it contains benign cartilage and bone.

ANSWER

 

170-4. With regard to the presentation of lung tumors:

  1. Carcinoid tumor is a type of neuroendocrine tumor with low grade malignant behavior.
  2. Inflammatory myofibroblastic tumor is more common in adults.
  3. Hypercalcemia is a paraneoplastic syndrome most commonly seen in small cell carcinoma.
  4. Bronchioloalveolar carcinoma is a form of squamous cell carcinoma commonly seen in male smokers.
  5. Horner syndrome is a common complication of a peripheral lung tumor.

ANSWER

 

CASE NUMBER 126
[ImageScope] [WebScope]

Clinical History: This 50-year-old male had respiratory difficulties for some time which increased in severity. Upon admission a large mass was seen in the X-ray films of the lung. The patient suddenly collapsed into a coma and died the following day from massive hemorrhage into a large brain metastasis.

Image Gallery:

(Summary of Gross and Lab Findings - click here)
The lungs were remarkable for a 5 cm mass in the right upper lobe. The cut surfaces were friable and yellowish-gray. Regional lymph nodes were filled with similar necrotic tumor.
(Summary of Microscopic Findings - click here)
The tumor tissue consists of glandular structures with very large nuclei which are often arranged in several layers. The nuclear to cytoplasmic ratio is low. There are several mitoses and the stroma contains increased amounts of collagen. Well differentiated adenocarcinomas, with a glandular pattern like this one, are uncommon in the lung.
(Review Normal Histology - click here)
Norm No. 24 Lung
[ImageScope] [WebScope]

The primary function of the lung is gas exchange. Therefore, alveoli have thin walls lined by thin flat pneumocytes and endothelial cells. There is no thickening or fibrosis of the interstitium. The bronchioli are lined with basally oriented ciliated columnar epithelium. The bronchi are lined by similar epithelium. There are mucous glands within the submucosa. The bronchial smooth muscle is not hypertrophied. The pulmonary vessels are patent with no evidence of intimal thickening or muscular hyperplasia.

 

What is the MOST LIKELY diagnosis?

ANSWER

 

126-1. This type of lung tumor:

  1. Is the most common histological type among cigarette smokers
  2. Always arises centrally from a main bronchus
  3. May stain positive for mucin
  4. N-RAS mutation is primarily seen
  5. Arises from neuroendocrine cells

ANSWER

 

 

 

CASE NUMBER 98
[ImageScope] [WebScope]

Clinical History: This 70-year-old man worked in a rock quarry as a crusher for 18 years. Six months prior to death he began to have dyspnea, orthopnea, paroxysmal nocturnal dyspnea and ankle edema. He was admitted for congestive heart failure and died suddenly with massive pulmonary embolism.

Image Gallery:

(Summary of Gross and Lab Findings - click here)
Both lungs were heavy, 900 grams for the left lung and 1120 grams for the right one. The lung was slate gray and firm.
(Summary of Microscopic Findings - click here)
In the left upper part of the section the characteristic lesions of silicosis are seen. There are masses of fibrous tissue which form concentric lamination around the blood vessels, and stellate scars when the fibrosis extends to the adjacent alveolar septa. A large amount of coal-black pigment and small crystals are found in the macrophages and the scar tissue. These crystals are best seen under polarized light. In advanced lesion the fibrous nodules become confluent as seen in the lower right part of this section. Notice the presence of arteriosclerosis and organizing thrombi in the pulmonary arteries and chronic inflammation of bronchi.
(Review Normal Histology - click here)
Norm No. 24 Lung
[ImageScope] [WebScope]

The primary function of the lung is gas exchange. Therefore, alveoli have thin walls lined by thin flat pneumocytes and endothelial cells. There is no thickening or fibrosis of the interstitium. The bronchioli are lined with basally oriented ciliated columnar epithelium. The bronchi are lined by similar epithelium. There are mucous glands within the submucosa. The bronchial smooth muscle is not hypertrophied. The pulmonary vessels are patent with no evidence of intimal thickening or muscular hyperplasia.

 

98-1. Which of the following is most frequently affected in this disease?

  1.  Pleura
  2. Lower lobes of lungs
  3. Upper lobes of lungs
  4. Pulmonary arteries

ANSWER

 

98-2. Patients with this disease are at increased risk for development of:

  1. Pneumococcal pneumonia
  2. Histoplasmosis
  3. Tuberculosis
  4. Bronchogenic carcinoma

ANSWER

 

98-3. The most likely diagnosis as depicted by these images is:

  1. Asbestosis
  2. Silicosis
  3. Anthracosis
  4. Berylliosis
  5. Siderosis

ANSWER

 

98-4. Which of the following statements is TRUE?

  1. Fibrotic nodules with concentric layers of hyalinized collagen is typical of anthracosis
  2. Asbestosis is marked by localized pleural plaques
  3. Silicotic nodules may undergo central cavitation
  4. Progressive massive fibrosis is a common complication of exposure to asbestos
  5. Coal workers’ pneumoconiosis is associated with increased susceptibility to tuberculosis

ANSWER

 

CASE NUMBER 60 [ImageScope] [WebScope]

Clinical history: This histologic section was prepared from the lung of a 72-year-old man, who was a retired shipyard worker with a history of smoking and mild dyspnea and died of a myocardial infarct.

Image Gallery (slide specimen and images courtesy of the University of Michigan):

  1. The fibrotic alveolar walls represent a nonspecific reaction to injury that is a common pathologic feature in many lung diseases. In this case, the golden brown bodies represent the etiologic agent. What are these bodies?

    ANSWER

  2. How did the fibrosis come about?

    ANSWER

  3. For what other pulmonary disorders or complications was this individual at increased risk?

    ANSWER

  4. Lung diseases are typically classified as either restrictive or obstructive. Which type is represented here and what are some examples of other lung diseases that would be similarly classified?

    ANSWER

  5. Predict the results of these pulmonary function tests (normal, increased, or decreased):

    • total lung capacity (TLC)
    • residual volume (RV)
    • forced vital capacity (FVC)
    • forced expiratory volume at 1 second (FEV1)
    • maximal expiratory flow rate (MEFR).

ANSWER

 

 

Microbiology Case Descriptions

Micro Case 9

Clinical history:A 52-year-old homeless, alcoholic man had a fever and a cough productive of thick sputum that worsened over several days. His temperature is 38.2°C.   Diffuse crackles are heard at the right lung base. Laboratory studies are as follows:

  • hemoglobin: 13.3 g/dL
  • hematocrit: 40%
  • platelet count: 291,8000/mm3
  • WBC count: 13,240/mm3 with 71 segmented neutrophils, 7% bands, 16% lymphocytes, and 6% monocytes.

Image Gallery

(Summary of Gross & Lab Findings - click here)
The sputum was thick and gelatinous. A gram stained smear shows gram negative rods.

 

m9-1. Based on these clinical findings, what is the likely causative agent?

ANSWER

 

m9-2. An 18-year-old Duke freshman presented to student health with severe headache, fever, and disorientation. A lumbar tap was performed with the following results:

  • cell count: 300 with 100% PMN
  • glucose: 10 mg/dl
  • protein: 100 mg/dl.

The gram stain of the spinal fluid revealed numerous PMNs with intracellular gram-negative diplococci. What is the most likely organism?

  1. Streptococcus pneumoniae
  2. Moraxella catarrhalis
  3. Haemophilus influenza
  4. Neisseria meningitidis

ANSWER

 

 

Micro Case 11

Clinical history: A suspicious envelope arrived for sorting at rural post office. The envelope was opened and found to contain white powder. Approximately two days later, the postal worker who handled the letter developed cutaneous boils, which were and 1 to 5 cm in diameter with central necrosis and eschars. He and his wife also developed a mild nonproductive cough with fatigue, myalgia for 72 hours, followed by severe dyspnea, diaphoresis and cyanosis.  Temperature of 39.5°C, pulse 105/min, respiration 25/min, and blood pressure 85/45mm Hg.  Crackles were heard at the lung bases. A chest xray shows a widened mediastinum and small pleural effusions. WBC count of 13,130/mm3, hemoglobin 13.7g/dL, hematocrit 41.2%, MCV 91 um3, and platelet count 244,000/mm3. Both died despite antibiotic therapy. Several cattle, horses, and sheep on the postal worker's farm also died.

Image Gallery

(Summary of Gross & Lab Findings - click here)
An example of the skin lesions is shown. These are painless puritic papules that have developed into pustules. Edema surronds the pustule and an eschar has developed. A gram stained smear of material from the pustule is shown. The organisms are spore-forming, Gram-positive rods.

m11-2. In a somewhat related case, when Pharaoh did not heed Moses to the let the captive Hebrews go, a series of plagues fell upon the land of Egypt. In the fifth plague, large domesticated mammals including cattle, horses, and sheep died. This was followed by a plague in which the Egyptians developed cutaneous boils. Some developed a mild nonproductive cough associated with fatigue, myalgia, and low grade fever over 72 hours, followed by a rapid onset of severe dyspnea with diaphoresis and cyanosis. Despite antibiotic therapy with both ciprofloxacin and doxycycline (had they been available), many of those affected would die. Which of the following organisms is most likely to have produced these findings?

  1. Bacillus anthracis
  2. Herpes simplex virus
  3. Mycobacterium leprae
  4. Staphylococcus aureus
  5. Yersinia pestis

ANSWER

 

 

 

 

Micro Case 17

Clinical history: A 50-year-old resident of Phoenix, Arizona, has a cough that has persisted for 1 month.  On physical examination, his temperature is 38.1°C. A chest radiograph shows 3.5-cm opacity with central cavitation in the right apical region.  An open lung biopsy is performed to exclude cancer.

Image Gallery:

(Summary of Microscopic Findings - click here)
Microscopic examination of the biopsy specimen shows caseating granulomatous inflammation containing 60-um spherules filled with smaller, rounded structures.

 

m17-1. Which of the following organisms is MOST LIKELY to be responsible for these findings?

  1. Aspergillus fumigates
  2. Coccidioides immitis
  3. Histoplasma capsulatum
  4. Mycobacterium tuberculosis
  5. Pseudomonas aeruginosa

ANSWER

 

 

 

Micro Case 18

Clinical history: For the past 3 weeks, a 52-year-old man has had a chronic cough with a low-grade fever. On physical examination, his temperature is 37.4°C.  A chest radiograph shows bilateral, scattered, 0.3- to 2-cm nodules in the upper lobes and hilar adenopathy.  A fine needle aspirate of one of the nodules shows inflammation with mononuclear cells, including macrophages that, with PAS or silver stains, show intracellular, 2- to 5-um, rounded, yeast-like organisms.

Image Gallery:

(Summary of Gross Findings - click here)
This gross section of lung shows a laminated granuloma.
(Summary of Microscopic Findings - click here)
This silver stained tissue section shows histiocytes in lung tissue.

 

m18-1. Which of the following infectious diseases is MOST LIKELY to produce these findings?

  1. Coccidioidomycosis
  2. Candidiasis
  3. Cryptococcosis
  4. Histoplasmosis
  5. Blastomycosis

ANSWER

 

 

 

Micro Case 19

Clinical history: For the past month, a 68-year-old man has had painful oral abcesses, fever, and a cough productive of yellow sputum.  On physical examination, there is dullness to percussion at the left lung base. A chest radiograph shows areas of consolidation in the left lower lobe.  Despite antibiotic therapy, the course of the disease is complicated by abscess formation, and he dies.

Image Gallery:

(Summary of Gross Findings - click here)
Abcess observed on chest surface with purulent, granular discharge.
(Summary of Microscopic Findings - click here)
Tissue surrounding the abcess is contains nodules with basophilic cores surrounded by polymorphonuclear leukocytes.

 

m19-1. Based on these clinical findings, what is the BEST diagnosis AND the likely causative agent?

ANSWER

 

m19-2. In a separate case, a middle aged man presented to his physician with a persistent cough of two months following an extended overseas trip to visit relatives. He had also noted a 10 pound weight loss and night sweats. A sputum was sent to the microbiology laboratory for routine bacterial culture and AFB culture. Kinyoun stain of his sputum was positive. What is the likely causative agent?

  1. Mycobacterium tuberculosis
  2. Actinomyces spp
  3. Fusobacterium nucleatum
  4. Nocardia spp.

ANSWER

 

 

Micro Case 20

Clinical history: A 42 year old HIV positive man has had a fever and cough for the past month. On physical examination, his temperature is 37.5. On auscultation of the chest, decreased breath sounds are heard over the right posterior lung. A chest radiograph shows a large area of consolidation with a central air-fluid level involving the right middle lobe. A transbronchial biopsy specimen contains gram-positive filamentous organisms that are weakly acid fast.

Image Gallery:

(Summary of Lab & Microscopic Findings - click here)
Gram stain of a bronchoalveolar lavage of the right middle lobe shows gram positive rods. Modified acid fast stain shows partially acid fast bacilli.

 

m20-1. What is the most likely organism?

  1. Mycobacterium tuberculosis
  2. Actinomyces spp
  3. Fusobacterium nucleatum
  4. Nocardia spp.

ANSWER

 

m20-2. Nocardia species are:

  1. branching, gram negative bacilli
  2. partially acid fast, beaded gram positive bacilli
  3. acid fast, branching gram negative filaments
  4. partially acid fast, gram variable filaments

ANSWER

 

 

LUNG PATHOLOGY Review Items

Key Vocabulary Terms (click here to search any additional terms on Stedman's Online Medical Dictionary)

acute interstitial pneumonia consolidation organizing pneumonia
adult respiratory distress syndrome cor pulmonale Pancoast tumor
allergic bronchopulmonary aspergillosis  Curschmann spiral paraneoplastic syndrome
alveolar-capillary membrane diffuse alveolar damage pigeon-breeder's lung
anthracosis dyspnea pink puffer
asbestos emphysema plexiform lesion
asbestosis empyema pneumoconiosis 
asteroid body farmer's lung pneumothorax
asthma ferruginous body pulmonary edema
atelectasis Ghon complex  pulmonary embolism
bagassosis Goodpasture syndrome pulmonary veno-occlusive disease
barrel chest Hamman-Rich syndrome rales
bird-fancier's disease heart failure cell Reid index
bleb hemoptysis restrictive lung disease
blue bloater hemothorax rhonchi
branchial cleft cyst histiocytosis X saddle embolus
bronchial cyst honeycomb lung scar carcinoma
bronchiectasis Horner syndrome Schaumann body
bronchiolitis obliterans hyaline membrane severe acute respiratory syndrome
bronchogenic carcinoma hypersensitivity pneumonitis silicatosis
bronchogenic cyst hypertrophic pulmonary osteoarthropathy silicosis
bronchopulmonary sequestration idiopathic interstitial pneumonia silo-filler's disease
bulla idiopathic pulmonary fibrosis singers’ nodes
byssinosis juvenile laryngeal papillomatosis small airways disease
Caplan syndrome lymphangiitic carcinomatosis status asthmaticus
Charcot-Leyden crystal Meigs syndrome tension pneumothorax
chronic bronchitis nasopharyngeal carcinoma tumorlet
chronic obstructive pulmonary disease non-small cell lung cancer vocal cord nodules
coin lesion obstructive lung disease  

LEARNING OBJECTIVES

  • Absolutely critical information you must know to practice medicine is in bold font.
  • Important information that will be needed for routine patient care is in regular font.
  • Information about less common diseases that you may encounter in clinical practice and that will probably appear on examinations is in italics
  1. Describe the mechanisms by which the following pulmonary defense mechanisms accomplish their functions:
    • nasal clearance
    • laryngeal (including epiglottic) action
    • tracheobronchial clearance
    • alveolar clearance

  2. Explain the pathogenesis of each of the manifestations of pulmonary disease:
    • pain
    • hypertrophic pulmonary osteoarthropathy
    • cough
    • secondary polycythemia
    • dyspnea
    • hemoptysis
    • sputum production
    • cor pulmonale
    • cyanosis
    • clubbing of fingers

  3. Discuss the following pulmonary congenital anomalies, in terms of morphology and clinical consequences:
    • agenesis
    • hypoplasia
    • congenital lobar overinflation ("emphysema")
    • congenital cyst
    • bronchopulmonary sequestration

  4. Contrast obstructive and restrictive pulmonary disease, in terms of:
    • morphologic features
    • radiologic manifestations
    • pulmonary function test results
    • clinical manifestations

  5. Compare and contrast the etiologies and effects of airflow obstruction that occur in lesions involving the airways with those that involve the alveolar parenchyma.

  6. Compare and contrast the clinical and pathologic features of:
    • emphysema
    • chronic bronchitis
    • bronchial asthma
    • bronchiectasis

  7. Compare and contrast the clinical and pathologic features of bronchial asthma:
    • atopic
    • non-atopic
    • drug-induced
    • occupational

  8. Compare and contrast the clinical and pathologic features of :
    • centriacinar (centrolobular) emphysema
    • focal emphysema
    • congenital lobar "emphysema"
    • interstitial emphysema
    • panacinar (panlobular) emphysema
    • senile "emphysema"
    • paraseptal (distal acinar) emphysema
     

  9. Discuss the Reid index.

  10. Discuss respiratory bronchiolitis of smokers (small airways disease) in terms of:
    • pathogenesis
    • morphology
    • clinical presentation

  11. Discuss bronchiectasis, in terms of:
    • predisposing conditions
    • the types of organisms typically cultured from bronchi
    • sequelae

  12. Compare and contrast neonatal and adult respiratory distress syndrome in terms of:
    • predisposing factors/associated conditions
    • pathogenesis
    • morphology
    • complications
    • clinical course

  13. Compare and contrast the clinical and pathologic features of the following lung diseases:
    • diffuse alveolar damage (DAD)
    • bronchilitis obliterans-organizing pneumonia (BOOP)
    • usual interstitial pneumonia (UIP)
    • desquamative interstitial pneumonia (DIP)
    • lymphoid interstitial pneumonia (LIP)
    • nonspecific interstitial pneumonia (NSIP)

  14. Discuss the clinical and pathologic features of the following disorders:
    • sarcoidosis
    • Goodpasture syndrome
    • idiopathic pulmonary hemosiderosis (IPH)
    • hypersensitivity pneumonitis (HP)
    • pulmonary alveolar proteinosis
    • pulmonary eosinophilic granuloma
    • pulmonary infiltrates with eosinophilia (PIE)
    • lipid pneumonia
    • Wegener granulomatosis
    • lymphomatoid granulomatosis

  15. Discuss pulmonary invovement in autoimmune ("collagen-vascular") diseases, noting the major morphologic manifestations in the lung of:
    • systemic lupus erythematosus (SLE)
    • rheumatoid arthritis (RA)
    • progessive systemic sclerosis (PSS)

  16. Discuss the basic pathogenesis of pneumoconioses.

  17. Compare and contrast the clinical and pathologic features of the following pneumoconioses:
    • coal workers' pneumoconioses
    • silicosis
    • asbestosis
    • berylliosis

  18. Discuss the clinical and pathologic features of these asbestos-related lung diseases:
    • fibrous pleural plaques
    • pleural effusion
    • asbestosis
    • bronchogenic carcinoma
    • malignant mesothelioma

  19. Discuss the acute and chronic stages of radiation lung injury, in terms of:
    • temporal features
    • pathogenesis
    • morphology
    • consequences

  20. Discuss drug-induced lung disease, enumerating drugs most commonly associated with the following pulmonary reactions
    • bronchospasm
    • pulmonary edema
    • hypersensitivity pneumonitis (HP)
    • eosinophilic pneumonia
    • diffuse alveolar damage (DAD)
    • pulmonary fibrosis

  21. Enumerate the general indications for lung transplantation, and complications:
    • pulmonary infection
    • acute rejection
    • chronic rejection

  22. Discuss the pulmonary features of cystic fibrosis (CF), in terms of:
    • frequency of involvement of lung in CF
    • pathogenesis
    • morphology
    • functional alterations
    • clinical manifestations
    • pulmonary complications
      • obstructive
      • infectious (including most common organisms involved)
    • treatment
    • prognosis

  23. Compare and contrast the clinical and pathologic features of:
    • bronchopneumonia
    • lobar pneumonia
    • primary atypical pneumonia
    • aspiration pneumonia
    • lung abscess
    • pulmonary infiltrates in the immunocompromised host

  24. Describe the four classic stages of the inflammatory response in lobar pneumonia in terms of:
    • temporal features
    • morphology

  25. Compare and contrast the clinical and pathologic features of :
    • anthrax
    • crytococossis
    • Legionnaire's disease
    • aspergillosis
    • actinomycosis
    • mucormycosis
    • nocardiosis
    • respiratory syncytial virus (RSV)
    • tuberculosis
    • influenza pneumonia
    • atypical mycobacteriosis
    • adenovirus pneumonia
    • mycoplasma pneumonia
    •  cytomegalic virus (CMV)
    • psittacosis
    • acute respiratory syndrome
    • histoplasmosis
    • Pneumocystis carinii pneumonia (PCP)
    • coccidioidomycosis
    • toxoplasmosis
    • blastomycosis
    • strongyloides

  26. Differentiate among tuberculosis, sarcoidosis, and granulomatous fungal disease
    • etiopathogenesis
    • morphologic features, including use of special stains
    • organs involved
    • radiologic features
    • clinical presentation
    • diagnostic tests
    • laboratory findings
    • prognosis

  27. Discuss pulmonary edema, embolism, and infarction in terms of:
    • predisposing factors and etiology
    • pathogenesis
    • morphologic features
    • radiologic features
    • clinical manifestations

  28. Compare and contrast the clinical and pathologic features of pulmonary embolism:
    • thrombus
    • fat
    • air
    • bone marrow
    • amniotic fluid
    • talc

  29. Compare and contrast primary and secondary pulmonary hypertension, in terms of:
    • predisposing factors/associated conditions
    • pathogenesis
    • age and sex distribution
    • clinical manifestations
    • size and type of vessels involved
    • morphologic features (including reversible vs. irreversible lesions)
    • hemodynamic consequences 
    • prognosis

  30. Discuss the clinical and pathologic features of:
    • pulmonary circulatory disease associated with congenital heart disease
    • persistent fetal circulation

  31. Compare and contrast the clinical and pathologic features of the following thoracic tumors:
    • squamous cell carcinoma of lung
    • bronchogeneic adenocarcinoma
    • bronchioloalveolar carcinoma
    • small cell carcinoma of lung
    • large cell carcinoma of lung
    • bronchial carcinoid
    • pulmonary hamartoma
    • malignant lymphoma
    • Hodgkin disease
    • metastatic neoplasm to thorax
    • pleural fibroma (solitary fibrous tumor)
    • malignant mesothelioma

  32. List likely etiologies and expected effects on pulmonary function of:
    • hydrothorax
    • empyema
    • hemothorax
    • chylothorax
    • pneumothorax
    • tension pneumothorax
    • pleural adhesion

  33. Discuss pleural fluid collections on the basis of fluid type and common association.

  34. List appropriate diagnostic procedures for patients with pleural effusions.

  35. Compare and contrast the clinical and pathologic features of:
    • nasal polyp
    • sinonasal papilloma
    • laryngeal nodule (singers' node)
    • laryngeal papilloma
    • juvenile laryngeal papillomatosis
    • laryngeal squamous cell carcinoma
    • nasopharyngeal carcinoma

 

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