Lower Pulmonary Pathology

What are the 3 test to listen to lung sounds?

egophony, tactile, and whispered pectoriloquy

What is an egophony lung test?

When the stethoscope touches your back say the letter "E"

If you hit a dense structures such as pneumonia the "E" will sounds like "AHH"

What is a tactile lung test?

Use your hand and every time you are touched on the back say "99"

Use metacarpals on all except sides of lungs (hand should look like knife)

Checking that both sides sound the same

What is a whispered pectoriloquy lung test?

Patient will whisper something like "99", "E" or "toy boat" as stethoscope touches their back

Where is pneumonia found?

infection in the functional tissue of the lung like the alveolis

When does pneumonia occur?

when pulmonary defenses are weakened

What do patients with pneumonia present with?

fever, chills, cough producing thick yellow/green pus sputum, rusty colored sputum indicating (hemoptysis), fast breathing rate (tachypnea), chest pain, SOB, elevated WBC, dullness to percus and decreased breath sounds

How is the diagnosis made for pneumonia?

chest x-ray, sputum culture with gram stain, and blood culture

What are the 3 forms of pneumonia?

lobar, bronchopneumonia (bacterial), and interstitial (viral)

Where is lobar pneumonia found?

consolidated to an entire lobe of a lung in the intra-aveolar space

What are the 2 bacteria that cause lobar pneumonia?

Streptococcus pneumoniae, klebsiella pneumoniae

Which bacteria that causes lobar pneumonia is more common?

Streptococcus pneumoniae

What are the 4 phases of lobar pneumonia?

congestion, red hepatization, gray hepatization, and resolution

What is congestion the first stage of lobar pneumonia?

edema (fluid retention) and inflammation in first 24 hours

What is red hepatization the second stage of lobar pneumonia?

Aveolar air space fills with neurtrophils and bloody exudate (mass of cells) and fibrin

Red cells flow out of intra-aveolar space

What is gray hepatization the second stage of lobar pneumonia?

Red cells hemolyze (breakdown) within exudate (mass of cells)

What type of pneumonia is Streptococcus pneumoniae?

Community-acquired (group setting)

Seen in middle age and elderly populations

In what population is Klebsiella pneumoniae found?

Individuals who are malnourished and debilitated (elder care homes), alcoholics, diabetes

Presents with "currant jelly" sputum (jelly-like, really red)

What is bronchopneumonia characterized by?

Scattered and patchy consolidations around the bronchioles

Multifocal and bilateral

Across multiple lobes

What bacteria are included in bronchopneumonia?

Staphylococcus aureus, Haemophilus influenza, Pseudomonas aeruginosa

Where does Staphylococcus aureus bronchopneumonia appear?

typically superimposed on a viral upper respiratory tract infection

What disease is Haemophilus influenza attached to?

COPD

What disease is Pseudomonas aeruginosa attached to?

Cystic Fibrosis (CF)

What is another name for interstitial pneumonia?

atypical

What are the etiological agents of interstitial pneumonia?

Influenza virus, myocoplasma pneumoniae, respiratory syncytial virus (RSV)

What population does Influenza virus interstitial pneumonia appear in?

elderly

What population does myocoplasma pneumoniae interstitial pneumonia appear in?

college students from dorms

What population does respiratory syncytial virus (RSV) interstitial pneumonia appear in?

infants

How many people are affected by Tuberculosis (TB) every year?

1 billion

How many people die from Tuberculosis (TB) every year?

1 million

How many new cases of Tuberculosis (TB) are there every year?

8.7 millions

What are the 2 forms of TB?

primary and secondary

What causes TB?

the inhalation of aerosolized mycobacterium tuberculosis

What percent of cases are primary TB?

90%

What is the immune response in primary TB when M. tuberculosis is inhaled deep into the lungs?

Alveolar macrophages begin to engulf the bacteria

The bacteria produces a protein that prevents lysosomes in the macrophage from fusing with the phagosomes containing the bacteria

The bacteria begins to multiply and produce a mild infections

What symptoms are present during a mild infection of primary TB?

asymptomatic or mild flu-like symptoms

What happens 3 weeks post infection in primary TB?

Cell-mediated immunity will wall off the infection producing a granuloma and hides the bacteria from the immune system

What is a Ghon's focus in primary TB

when the center of the granuloma dies and appears as a caseous necrosis

What happens to the bacteria in primary TB after Ghon's focus?

Transported to hilar lymph nodes

These lymph nodes then undergo fibrosis and calcification

What is a Ghon's complex in primary TB?

When the lung granulomas and fibrotic lymph nodes are combined

They are sub-pleural and in lower lobes of the lung

What is the Ranke complex in primary TB?

When the Ghon's complex and fibrotic mediastinal lymph nodes produce calcified scar tissue

Evolution of Ghon's complex

What are the 2 outcomes of primary TB?

the immune system destroys the TB or the TB is viable and will remain dormant/latent

What percent of cases are secondary TB?

5-10%

What do you die from due to secondary TB?

being immuno-compromised (AIDS, HIV, organ transplant, IVDU or aging) and getting a common cold

What happens during secondary TB?

TB reactvates or re-awakens and travels to upper lobes of the lungs where there is greater oxygenations

Memory T-cells then release cytokines causing more infectious caseous necrosis.

Tissues cavities and bacteria spreads though lymphatic drainage and airways causing bronchopneumonia

What happens if secondary TB enters the vascular system?

becomes systems, called systemic miliary TB

What is Pott's Disease?

associated with TB when it destroys the lumbar spine

What structures are affected by secondary TB?

kidneys, cervical lymph nodes, adrenal glands, lumbar vertebrae, meninges and liver

What does secondary TB do to the kidneys?

sterile pyuria (pus in the urine) with high WBC count

What does secondary TB do to the cervical lymph nodes?

lymphadenitis (inflammation of the lymph nodes) and scrofula (lesions in the neck)

What does secondary TB do to the Adrenal Glands?

causes Addison's disease (adrenal hypofunction)

What does secondary TB do to the lumbar vertebrae?

causes Pott's disease

What does secondary TB do to the meninges?

causes meningitis

What does secondary TB do to the liver?

causes hepatitis

What are the signs and symptoms of secondary TB?

hemoptysis, coughing that last 3 or more weeks, chest pain, pain when breathing or coughing, fatigue, night sweats, unintentional weight loss, fever, chills, scrofula

What are the TB tests?

PPD (purified protein derivative), Tine test, and Interferon gamma release assay (IGRA)

What is the PPD test for TB?

aka Mantoux test

inject TB antigen under the skin with needle (like shot), then if you have TB your skin will have a reaction (like seeing the redness spread)

What is the Tine test for TB?

4 pronged device that is inserted into the skin and deploys antigens into the skin then wait to see the reaction

What will happen if a patient has previously been exposed?

will have positive immune response, as in redness and induration (hardening) at the site of injection

What do the PPD and Tine test not test for?

distinguishment between active and latent

What is the gold standard test for TB?

Interferon gamma release assay (IGRA)

What does the IGRA test detect?

TB proteins

Why is the IGRA test so important?

more specific to TB than other mycobacterium and will not give false positives if patients have BCG vaccine

What do you do if the TB patient is symptomatic?

take a sputum sample or a bronchoalveolar lavage

What is the treatment for latent TB?

isoniazid (INH) for 9 months

What is the treatment for active TB?

INH and rifampicin

What are the condition in which an active TB patient is kept?

negative pressure (want air staying in and not out because want to keep the infection in the room), isolation and directly observed therapy (DOT)

Where does Mesothelioma occur?

malignant neoplasm of mesothelial cells, that are epithelial cells/tissue that lines the serous membranes (pleura, peritoneum, and pericardium)

What is Mesothelioma caused by?

asbestos

What do asbestos fibers look like?

jagged and 500x thinner than a human hair

What is asbestos used in?

Construction materials such as paint, insulation and roofing materials

Known for its resistance to fire and is a good insulator

What type of safety hazard is Mesothelioma?

occupational

What happens when the asbestos fibers are inhaled?

They make there way down to the mesothelium of the viseral and parietal pleura

Spikes start to stab air sacs and lungs then the bodies response is to wall off the hurt area

How long do the asbestos fibers last in the body?

for your lifetime

What does exposure to asbestos cause?

inflammatory response and DNA damage and tumor

What happens when the tumors develop into a mesothelial plaque?

they cover the lung

Where would asbestos be found if it swallowed or coughed?

in the stomach lining

What do Mesothelioma tumor cells express?

calretinin: calcium binding protein that regulates Ca2+ in and out of cells

What are the signs and symptoms of Mesothelioma?

dyspnea (difficulty breathing), SOB, possible pneumothorax (air in the pleural space), pleural effusion (water on the lung), bloody sputum

How do you diagnosis Mesothelioma?

with a chest x-ray, CT scan or biopsy the tumor

For a Mesothelioma biopsy, what are cells immunostained with antibody react with?

calretinin

What appearance does the immunostained reaction give the nucleus of the Mesothelioma tumor cells

fried egg

What is the prognosis for Mesothelioma?

very poor once detected

What is the treatment for Mesothelioma?

surgery, chemotherapy and radiation

What are the types of Pneumoconioses?

Coal workers', silicosis, berylliosis, and asbestosis

What is the Coal Workers' Pneumoconiosis?

Carbon dust leads to black lung

Associated with Rheumatoid arthritis

Mild exposure is not clinically significant called anthracosis

What is Silicosis Pneumoconiosis?

Seen in the silica mines and sand blasters

Fibrotic nodules in upper lung and more prone to develop TB

What is Berylliosis Pneumoconiosis?

Beryllium miners working in aerospace industry

Present with noncaseating granulomas in lung with increased risk of lung cancer

What is Asbestosis Pneumoconiosis?

Mesothelioma

What is Emphysema?

destruction of the alveolar air sacs

What is lost in Emphysema during expiration

elastic recoiling of elastic fibers, so air is trapped in lung

What is the number one cause of Emphysema?

smoking

What is Emphysema a form of?

COPD (chronic obstructive pulmonary disease)

What is the effect of cigarettes in the lungs?

The smoke irritates the lining of the alveoli and causes an immune response.

Macrophages and immune cells release leukotriene B4, IL-8 and TNF-alpha

Proteases, such as elastase and collegenases are released destroying connective tissue

What happens when the septa between the alveoli breaks down?

forms large air sacs which reduces the surface ares for gas exchange

What is the type of Emphysema more commonly caused by smoking?

Centriacinar (centrilobular)

Where is Centriacinar Emphysema seen?

in the upper lobe of the lung and effects the proximal acinus

What type of Emphysema is associated with the genetic disorder Alpha 1 Antitrypsin Deficiency (A1AD)?

Panacinar

What is the role of A1AD in the lungs?

Macrophages release proteases to clear debris from the alveoli. The lungs naturally produce the A1AD which is a protease inhibitor to keep unintended damage caused by the macrophages release to a minimum. But since A1AD is deficient protease destroys the entire acinus

What part of the lung does Panacinar Emphysema affect?

lower lobe of lung