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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: [email protected]
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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
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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.
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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
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27 http://img.webmd.com/dtmcms/live/webmd/consumer_assets/site_images/media/medical/hw/h9991437_001.jpg
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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.
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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
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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.
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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
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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.
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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
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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
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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
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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×).
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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