scbm342-respiratory pathology i - mahidol university · 2018. 1. 23. · 1 scbm342-respiratory...

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SCBM342-Respiratory Pathology I

Associate Professor Dr. Wannee Jiraungkoorskul

Department of Pathobiology, Faculty of Science, Mahidol University

Tel: 02-201-5563, E-mail: wannee.jir@mahidol.ac.th

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• A 57 years old male, high 157 cm and weight 76 kg. He

has worked as the dump truck driver in the coal mine since

1980, and also smoked cigarette 1 pack/day more than 30

years. What are the risk factors of his disease or illness?

Problem

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• Air is breathed in through the nasal passageways, travels

through the trachea and bronchi to the lungs.

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• The PLEURA are the two membranes, actually one continuous

one folded on itself, that surround each lobe of the lungs and

separate the lungs from the chest wall.

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• The smallest subdivisions of the bronchial tubes are called

BRONCHIOLES, at the end of which are the air sacs or alveoli.

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• The ALVEOLI are the very small air sacs that are the

destination of air breathed in.

• The CAPILLARIES are blood vessels that are imbedded in

the walls of the alveoli. Blood passes through the

capillaries, brought to them by the PULMONARY ARTERY

and taken away by the PULMONARY VEIN.

• While in the capillaries the blood gives off carbon dioxide

through the capillary wall into the alveoli and takes up

oxygen from the air in the alveoli.

Respiratory system

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• 1. Nasopharyngeal clearance

– Sneezing and mucociliary escalator

• 2. Larynx

– Epiglotiic closure

• 3. Tracheobronchial clearance

– Coughing, mucociliary escalator

• 4. Alveolar clearance

– Phagocytosis by macrophages

Pulmonary defense mechanisms

• A - ciliated pseudostratified columnar epithelium

• B - lamina propria

• C - muscularis mucosae

• D - submucosa https://courses.stu.qmul.ac.uk/smd/kb/microanatomy/respiratory/images/l3a.jpg

8 http://ars.els-cdn.com/content/image/1-s2.0-S0300483X10001770-gr1.jpg

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Airway diseases

• Small airway obstruction

• Asthma

• Chronic bronchitis

• Emphysema

• Large airway disease

• Bronchiectasis

Parenchymal diseases

• Infective :

• Pneumonia

• TB

• Aspergillosis

• Non-infective :

• Pneumoconiosis

Pulmonary interstitial fibrosis

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Asthma • Asthma (Greek "panting") is the chronic inflammatory

disease of the airways characterized

– bronchospasm (the tightening of the muscles

surrounding the airways)

– inflammation (the swelling and irritation of the airways).

• Symptoms such as wheezing, coughing, chest tightness,

and shortness of breath.

11 http://www.nhlbi.nih.gov/health/health-topics/images/asthma.jpg

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13 http://www.drscottgraves.com/wp-content/uploads/2012/08/asthma-causes.jpg

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15 http://littledoctors.files.wordpress.com/2011/01/3.jpg

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• Asthma is associated with the______ immunoglobulin.

A. IgA

B. IgD

C. IgE

D. IgG

E. IgM

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• Which one is not the classic complication of asthma?

A. Ascites

B. Bronchoconstriction

C. Hypersensitivity

D. Excessive mucus

E. Wheezing

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• Which of the following dose not cause airway narrowing

in an asthma attack:

A. Bronchospasm

B. Destruction of airway

C. Inflammation

D.Mucus hypersecretion

E. Thickened airway wall

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Chronic bronchitis

• Chronic bronchitis is a chronic inflammation of the bronchi

(medium-size airways) in the lungs.

• It is defined clinically as a persistent cough that produces

sputum and mucus, for at least three months per year in

two consecutive years.

• Cause most often by exposure to airborne pollutants

such as cigarette smoke, excessive dust in the air, or

chemicals.

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Chronic bronchitis

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• Increase in size

and number of

mucus gland,

goblet cells

Persistent

irreversible

diffuse changes

Chronic bronchitis

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1. Hypertrophy and hyperplasia of submucosal

glands (Reid Index)

2. Goblet cell hyperplasia

3. Mucous hypersecretion with plugging

4. Variable degree of chronic inflammation

Chronic bronchitis

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Chronic bronchitis

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Increased thickness of

mucus gland layer in

bronchial mucosa

Cigarette smoke paralyses

cilia, predispose to

bronchial infection

Normal mucosa

CB

Chronic bronchitis

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Chronic bronchitis

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Emphysema

Emphysema (Greek "inflate“)

It is a lung disease involving damage to the alveoli.

There is progressive destruction of alveoli and the

surrounding tissue that supports the alveoli.

With more advanced disease, large air cysts develop where

normal lung tissue used to be.

Cause most often by cigarette smoke

27 http://img.webmd.com/dtmcms/live/webmd/consumer_assets/site_images/media/medical/hw/h9991437_001.jpg

28 http://www.meddean.luc.edu/lumen/MedEd/Radio/curriculum/Mechanisms/Emphysema.jpg

• The clusters of dilated air spaces which are conspicuous in the middle and lower

lobes of the right lung and the lower lobe of the left lung. Both lungs are markedly

enlarged.

29 http://upload.wikimedia.org/wikipedia/commons/a/ac/Centrilobular_emphysema_865_lores.jpg

• Lung showing centrilobular emphysema characteristic of smoking. Cut surface

shows multiple cavities lined by heavy black carbon deposits.

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Loss of alveolar septa,

Enlarged air spaces

Emphysema

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Destruction of alveolar wall

Emphysema

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• This lung shows emphysema (dilated

air spaces) throughout the whole lung,

being gross in a zone about 4 cm wide

along the lateral margin, and

approximately 2 cm wide along the

lower margin.

• The inner aspect of the lower lobe

exhibits considerable destruction of

the pulmonary tissue, being replaced

by a large cystic cavity (bulla).

• There is a large amount of black

pigment deposited in the lung. This is

carbon, derived from tar in cigarette

smoke.

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• Lose of alveoli elasticity is characteristic of

A. Asthma

B. Emphysema

C. Pneumonia

D. Pneumoconiosis

E. Tuberculosis

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Bronchiectasis

• Bronchiectasis is a disease defined by localized, irreversible

dilation of part of the bronchial tree caused by destruction

of the muscle and elastic tissue, associated with, abnormal

dilation of these airways.

• Patients have copious foul - smelling sputum, induced by

postural change

• Cause bacterial infections, Staphylococcus or Klebsiella,

Bordetella pertussis.

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Morphology of Bronchiectasis

• Gross exam:

– Marked dilatation of bronchial and bronchiolar airways

(up to 4x normal size); airways can be visibly followed

out to the pleural surfaces

• Microscopic exam:

– Acute and chronic inflammation, ulceration, necrosis,

abscess formation, squamous metaplasia and fibrosis

36 http://upload.wikimedia.org/wikipedia/commons/8/8f/Bronchiectasis.jpg

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Morphology of Bronchiectasis

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A-1 Fibrosis

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B-1 Bronchiectasis

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Morphology of Bronchiectasis

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• Bronchiectasis is an abnormal, permanent dilation of the

bronchial tubes in the lungs.

http://www.sopandiagnostic.org/digitalpathology.htm

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• Which disorder has the dilated bronchi?

A. Asthma

B. Bronchiectasis

C. Chronic bronchitis

D. Emphysema

E. Tuberculosis

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• Bronchiectasis is associated with disorder

A. Asthma

B. COPD

C. Cystic fibrosis

D. Edema

E. Tuberculosis

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Pneumonia • Pneumonia is an inflammatory affecting the alveoli,

associated with fever, chest symptoms, and a lack of air

space (consolidation) on a chest X-ray

• Infectious agents or injury caused by aspiration of dust or

chemical agents (gastric contents) causes fluid to enter the

alveolar spaces.

45 http://en.wikipedia.org/wiki/Pneumonia

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• Lobar pneumonia affects a section (lobe) of a lung.

• Bronchial pneumonia (or bronchopneumonia) affects

patches throughout both lungs.

Pneumonia

http://www.meddean.luc.edu/lumen/MedEd/MEDICINE/PULMONAR/images/hussain3/Scan26.jpg

47 http://4.bp.blogspot.com/-O98PSSNuLwY/UHh80kje_oI/AAAAAAAAH5U/QcLYeS14gcU/ s1600/lobar_pneumonia_leukocytic_alveolitis.jpg

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• Lobar pneumonia

demonstrates the

distinct difference

between the upper

lobe and the

consolidated lower

lobe

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• Bronchopneumonia, or bronchial pneumonia, is a type of pneumonia that originates in the bronchioles of the lungs, which are the smaller ducts of the bronchial tubes.

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50 http://upload.wikimedia.org/wikipedia/commons/d/da/Bronchopneumonia_lung.jpg

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• White nail syndrome

may also be called

leukonychia.

• Leukonychia can

occur with arsenic

poisoning, heart

disease, renal failure,

pneumonia, or

hypoalbuminemia.

http://images.nailsmag.com/post/M-NA0306disease-pic2-LR-1.jpg

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• What is pneumonia?

A. Acute inflammation of the lung parenchyma

B. Acute inflammation of the bronchial mucosa

C. Acute inflammation of the pleural membrane

D.Acute inflammation of the pharyngeal mucosa

E. Chronic inflammation of the trachea

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Tuberculosis

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• Miliary tuberculosis is characterized by a chronic, contagious bacterial

infection caused by Mycobacterium tuberculosis that has spread to other

organs of the body by the blood or lymph system.

55 http://en.wikipedia.org/wiki/File:Extrapulmonary_tuberculosis_symptoms.svg

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Mantoux tuberculin skin test

http://en.wikipedia.org/wiki/File:Mantoux_tuberculin_skin_test.jpg

http://health.state.tn.us/images/TB_Smear.jpg

Charles Mantoux (1877-1947) French physician

http://scielo.isciii.es/img/revistas/sanipe/v11n1/imagen_04.gif

57 http://1.bp.blogspot.com/_LkjzM3-fbyE/TTHjm2XyZ4I/AAAAAAAAAFU/ojhkfnAAS7w/s1600/pulmonary_ tuberculosis_chronic_inflammation_01.jpg

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Granuloma (tubercle) of tuberculosis with caseous necrosis

Multinucleated Giant Cell (Langhan)

Johann Ferdinand Friedrich Theodor Langhans

(1839-1915)

German pathologist

59 http://upload.wikimedia.org/wikipedia/commons/1/18/Cavitary_tuberculosis.jpg

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• The upper lobe of the lung exhibits

advanced cavitation from longstanding

tuberculosis.

• Note the thrombosed blood vessel

traversing the cavity.

• The rest of the upper lobe exhibits

advanced tuberculosis.

• There are scattered foci of "caseation"

(cheesy white areas of necrosis)

throughout the lobe.

• The pleura is considerably thickened by

fibrosis, particularly over the upper lobe.

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• The small millet seed

sized granulomas in

this lung are typical for

miliary tuberculosis.

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• What is the procedure that used for screening tuberculosis?

A. Alveoli biopsy

B. Gram stain

C. Lung function test

D. Mantoux test

E. Thoracocentesis

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Pulmonary Aspergillosis • Aspergillus spp. are widespread in the environment and are

commonly isolated from both the outdoor environment (i.e. soil,

plant debris) and indoor environment, including hospitals.

http://www.ijmm.org/articles/2010/28/4/images/IndianJMedMicrobiol_2010_28_4_402_71848_u3.jpg

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Pulmonary Aspergillosis

European Respiratory Review 2011 20: 156-174

• Pulmonary disease is caused mainly by Aspergillus fumigatus and

has a spectrum of clinical syndromes

65 European Respiratory Review 2011 20: 156-174

• Invasive pulmonary aspergillosis. a) Pulmonary parenchyma with necrosis

and pulmonary haemorrhage and Aspergillus hyphae (haematoxylin and

eosin 100×).

66 European Respiratory Review 2011 20: 156-174

• Invasive pulmonary aspergillosis. b) Branching Aspergillus hyphae involving

lung parenchyma (Grocott Methenamine silver fungus stain 200×).

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Pulmonary Aspergillosis

https://www.inspq.qc.ca/sites/default/files/images/moisissures/fumigatus_diag_2.jpg

Grocott's methenamine silver (GMS) stained tissue section of lung showing dichotomously branched, septate hyphae of Aspergillus fumigatus.

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Aspergilloma

https://m.ufhealth.org/sites/default/files/graphics/images/en/17263.jpg

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Aspergilloma

http://pathhsw5m54.ucsf.edu/case16/aspergilloma.html

• This slice of lung shows an

aspergilloma in the superior

segment of the lower lobe.

• Note the fibrous wall and the

parenchymal fibrosis that

extends to the pleura, which

is thickened.

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Aspergilloma

https://en.wikipedia.org/wiki/Aspergilloma#/media/File:Aspergillomas_complicating_tuberculosis.jpg

• Multiple aspergillomas within large cavity lesions of tuberculous origin

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• Aspergillosis is recognized in tissue by the presence of

A. Metachromatic granules

B. Psuedohyphae

C. Septate hyphae

D.Non-septate hyphae

E. Budding cells

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Pneumoconiosis • Deposition of mineral dusts in lung causing fibrosis i.e.,

progressive massive fibrosis, silicosis, asbestosis.

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• What is the condition that cause by prolonged inhalation of

abrasive particulate?

A. Cancer

B. Emphysema

C. Pneumoconiosis

D. Pneumonia

E. Tuberculosis

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Pulmonary interstitial fibrosis

• Interstitial lung diseases are a group of diseases,

caused by inflammation and scarring of the alveoli

(air sacs) and their supporting structures (the

interstitium).

• This leads to the loss of the functional alveolar units

and a reduction of the transfer of oxygen from air to

blood.

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• Diffuse insult

• Persistent, chronic

damage

• Interstitial

inflammation

Pulmonary interstitial fibrosis

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• Chronic

inflammation

• Fibroblasts

proliferate,

Fibrosis

Pulmonary interstitial fibrosis

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• Acini

“simplified”,

become cystic

spaces

• When patient

presents, lung

may show

fibrosis

Pulmonary interstitial fibrosis

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“Honeycomb Lung”

(end-stage changes)

Pulmonary interstitial fibrosis

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• Chronic inflammatory

cells

• Interstitial fibrosis

• Obliteration of some

air spaces

• Cystic dilatation of

others

Pulmonary interstitial fibrosis

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• Clinical Features

• Dry cough

• Impaired gas exchange – SOB, no wheeze

• Cyanosis (purple colour of tissues due to low oxygen levels

in blood) – late symptom.

• Clubbing of fingers: usually late

Pulmonary interstitial fibrosis

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Clubbing results from chronic low blood-oxygen levels. This can be seen

with cystic fibrosis, congenital cyanotic heart disease, and several other

diseases. The tips of the fingers enlarge and the nails become extremely

curved from front to back.

Pulmonary interstitial fibrosis

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• Bulbous swelling of the tip of the finger is called_______.

A. Cyanosis

B. Edema

C. Clubbing

D. Leukonychia

E. Hemorrhage

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References

Color Atlas and Text

of Pulmonary

Pathology

by

Philip Cagle

Roberto Barrios

Timothy Allen

2008

Pulmonary

Pathology

2nd ed.

by

Dani Zander

Carol Farver

2017

Respiratory Diseases.

By

Mostafa Ghanei

2012

Lung Pathology: A

Consultative Atlas.

by

Stuart Houser

Eugene Mark

Ulysses Balis

2005

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SCBM342

Respiratory Pathology I