Resp Pathology

Question 1

Answer 1

Question 2

Type of respiraotyr epithelium?

Answer 2

Question 3

• 45M presents with renal colic, his second presentation in the last month
• Previously healthy, never smoker • Owns an autobody shop
• Mostly office stuff now, used to do lots of body work • No meds/allergies

• Tachycardic, Hypertensive,
other Vitals normal • No H&N adenopathy • Normal Resp exam • Normal CV exam • No abdominal
organomegaly, tenderness at
right CV angle

• CBC
• Hgb 140 (N Indices), Platelets 200, WBC 12.5 (N Diff)
• Electrolytes/Renal Function
• Na 135, K 4.0, Cl 95, HCO3 25, Creatinine 95 (eGFR 55) • Calcium 3.35mmol/L, Intact PTH 5ng/L, 1,25-Vit D 300pmol/L
• Liver Function Tests
• ALT 25, Bili 12, Albumin 40

Answer 3

I see bilateral hilar enlargement. could be lymphoma, sarcoidosis, environmental factors could point to nodules from silicosis or something.

Question 4

• 45M presents with renal colic, his second presentation in the
last month

Profile
• Previously healthy, never smoker

• Owns an autobody shop

Xray shows bilateral hilar enlargement, and biopsy shows this:

Answer 4

Sarcoidosis presents with non-necrotizing granulomas

Question 5

causes of non-nectrotizing Granulomatous Inflammation

Answer 5

Question 6

75M with progressive dyspnea/cough for 6 months
• Hypertension, 20pack-yr ex-smoker
• No history of CTD/malignancies/cardiac disease
• Retired librarian
• Meds: HCTZ. No allergies

Vitals normal • No H&N adenopathy • Resp exam: bibasilar crackles • Normal CV exam, clubbing on fingers.
• No signs hypervolemia

• Hgb 190 (N Indices), Platelets 185, WBC 8.0 (N Diff)
• Electrolytes/Renal Function
• Na 135, K 4.0, Cl 95, HCO3 25, Creatinine 70 (eGFR 75) • Calcium 2.35
• Liver Function Tests
• ALT 25, Bili 12, Albumin 40

Answer 6

• lower lobe bilateral haziness.
• silhouette sign
• peripheral fibrosis is seen.
• possible bronchiectasis– lots of dilation
• honey combing on the periphery suggests interstitial lung disease– UIP!!

Question 7

75M with progressive dyspnea/cough for 6 months
• Hypertension, 20pack-yr ex-smoker
• No history of CTD/malignancies/cardiac disease
• Retired librarian
• Meds: HCTZ. No allergies

Vitals normal • No H&N adenopathy • Resp exam: bibasilar crackles • Normal CV exam, clubbing on fingers.
• No signs hypervolemia

• Hgb 190 (N Indices), Platelets 185, WBC 8.0 (N Diff)
• Electrolytes/Renal Function
• Na 135, K 4.0, Cl 95, HCO3 25, Creatinine 70 (eGFR 75) • Calcium 2.35
• Liver Function Tests
• ALT 25, Bili 12, Albumin 40

Answer 7

thick fibrosis on the periphery of the lung.

• this is different from sarcoid and hypersensitivity pneumonitis because those two affect all parts of the lung.
• peripheral nodules on the subpleural zones, with temporal heterogeneity is classic UIP.

• ILD encompass a complex group of diseases
• Idiopathic Pulmonary Fibrosis
characteristic clinical/radiological presentation • New drugs available! (a disease with a poor prognosis)
Correct Diagnosis of ILD very Important (usually requires Path)
• Most common ILD • Characteristic pathology can confirm the diagnosis
• Some cases can be diagnosed with a very

Question 8

distribution of honeycomb lung for UIP

Answer 8

Question 9

UIP encompasses which diseases

Answer 9

1. idiopathic pulmonary fibrosis
2. manifestiation of CVD
3. chronic hypersensitivity pneumonities (less chronic presentations look more like sarcoidosis– granulomatous inflammation)
4. asbestosis.

Question 10

• 60F with small-volume hemoptysis for 2 weeks, has had a
worsened headache for the last week • Profile
• Current 40pack-yr smoker • Current waitress • Meds/Allergies: none

• Vitals normal • ?Left supraclavicular
lymphadenopathy • Resp exam: hyperinflation • Normal CV exam • No abdo organomegaly

• CBC
• Hgb 150 (N Indices), Platelets 285, WBC 9.0 (N Diff)
• Electrolytes/Renal Function
• Na 133, K 4.0, Cl 95, HCO3 28, Creatinine 80 (eGFR 75) • Calcium 2.35
• Liver Function Tests
• ALT 55, Bili 18, Albumin 30
Mild Liver Enzyme Abnormalities

ddx?

Answer 10

tuberculosis with tuberoma

• lung cancer– lung cancers associated with smoking is small cell lung caracinoma and squamous cell carcinoma.
• there is haziness, hilar enlargement.

Question 11

• 60F with small-volume hemoptysis for 2 weeks, has had a
worsened headache for the last week • Profile
• Current 40pack-yr smoker • Current waitress • Meds/Allergies: none

• Vitals normal • ?Left supraclavicular
lymphadenopathy • Resp exam: hyperinflation• Normal CV exam • No abdo organomegaly

• CBC
• Hgb 150 (N Indices), Platelets 285, WBC 9.0 (N Diff)
• Electrolytes/Renal Function
• Na 133, K 4.0, Cl 95, HCO3 28, Creatinine 80 (eGFR 75) • Calcium 2.35
• Liver Function Tests
• ALT 55, Bili 18, Albumin 30
Mild Liver Enzyme Abnormalities

Answer 11

Question 12

what type of cancer?

Answer 12

Squamous cell carcinoma

• more likely to affect airways than adenocarcinoma (more liekly to affect lung parenchyma)
• M>F
• metastasizes outside thorax only late
• likely to have paraneoplastic syndrome– hypercalcemia

Question 13

Answer 13

Squamous cell carcinoma

Question 14

Answer 14

Adenocarcinoma

F>M

• more likely to infiltrate the lung parenchyma rather than the main airways

Question 15

Answer 15

Question 16

what is being depicted in this slide

Answer 16

hyalination and white blood cell s

Question 17

conditions associated with ards

Answer 17

Question 18

3 stages of ARDS

Answer 18

1. exudatiev
2. proliferative
3. fibrotic– hyalization

Question 19

Answer 19

Question 20

phase of ARDS?

Answer 20

• proliferation type II cells
• fibroblast proliferation
• hyaline membrane deposit

Question 21

Answer 21

honey comb lung, usually indicates ILD– fibrosis

Question 22

65yo f

• productive cough for last decade
• worse in the morning– clear to white sputum
• increasing SOB with exertion over the past 2 years, where now she is breathless upon minimal exertion
• pulmonary function stuies show TLC 6.5 (expected 6L), FVC 4.5, and FEV1 2.5L. $

Answer 22

• see increased pulmonary markings for sure
• ct shows dilation
• EMPHYSEMA: abnormal permanent enlargemnet of the airspaces distal to the terminal bronchioles accompanied by destruction of the alveolar wall and without obvious fibrosis.
• part of COPD

Question 23

main risk factors associated with emphysema

Answer 23

1. smoking
2. alpha 1 antitrypsin deficiency
3. intravenous injection of methlphenidate

Question 24

there are three morphologic subtypes of emphysema based on their relationship to the secondary pulmonary lobule. what are they?

Answer 24

1. centriacinar emphysema: most common, affects proximal respiratory bronchioles and upper lobes predominate. strongly associated with smoking

2. panlobular (emphysema); affects entire secondary pulmonary lobule. most pronounces in the lower zones. associated with alpha 1 antitrypsin deficiney.

3. paraseptal emphysema; usually located adjacent to the pleural surfaces (including pleural fissues)– aka a more peripheral emphysema. associated with smoking and can lead to the formation of a sub pleural bullae and spontaneous pneumothorax

Question 25

type of peripheral emphysema. associated with smoking and can lead to the formation of a sub pleural bullae and spontaneous pneumothorax

Answer 25

paraseptal emphysema. look at the peripheral dilation

Question 26

this person has jaundice, reduced coagulaiton protein synthesis and cirrhosis. she also has this on her lung biopsy

Answer 26

**Panlobular (opanacinar) emphysema** affects entire **secondary pulmonary lobule** most pronounced in lower zones, matching areas of maximal blood flow a**ssoc with alpha-1-antitrypsin deficiency,** IV injection of methylphenidate (Ritalin lung)

Question 27

this person smokes like s chimney. this was a biopsy of the upper lobe left lung

Answer 27

**CENTRILOBULAR EMPHYSEMA** **MOST COMMON** **AFFECTS PROXIMAL RESPIRATORY** **BRONCHIOLES** UPPER LOBES PREDOMINANT STRONGLY ASSOCIATED WITH **SMOKING IN A DOSE-DEPENDENT WAY**

Question 28

location difference in panlobular, centriacinar and paraseptal emphysema

Answer 28

panlobular; affects lower zones of the lhng centriacinar; affects upper lobes of the lung paraseptal; affects peripheral parts of the secondary pulmonary lobule

Question 29

Answer 29

centriacinar is cloistered in the middle of the lub, but panacinar has uniform dilations everywhere too.

Question 30

in emphysema, there is a realease of proteolytic enzymes which digest the elastin framework of the alveoli causing airspaces to break down and enlarge. - this results in an ___ in lung volume, loss of surface area for gas exchange, and incresaed compliance. - emphysema causes airway obsrtuction due to loss of alveolar attachments to the bronchial walls - this results in collapse of the airways durign expiration with consequent airway obstruction

Question 31

30 yo runner had surgery on achilles tendon. 2 days later he noticed his leg was more swoollen than the other. pt suddenly coded in cardiorespiratory arrest. code was ran for an hour until he was pronounced dead.

Question 32

30 yo runner had surgery on achilles tendon. 2 days later he noticed his leg was more swoollen than the other. pt suddenly coded in cardiorespiratory arrest. code was ran for an hour until he was pronounced dead.

Answer 32

evident thrombus with characteristic lines of blood and fibrin

Question 33

factors that can lead to PE

Answer 33

virchows triad 1. hypercoaguability 2. vascular damage 3. stasis

Question 34

- 78 year old man with severe respiratory dysfunction and overall impairment - worked as a carpenter and had substantial exposure to asbestos - died and an autopsy was performed to reveal:

Answer 34

- peripheral fibrosis; characteristic UIP UIP has a peripheral predominant process with white around the periphery. also may have honeycombing cysts and more likely to affect lower zones (which this one did) UIP is most likely to be: 1. idiopathic pulmonary fibrosis 2. manifestion of CVD 3. chronic hypersensitivity pneumonitis 4. ASBESTOSIS

Question 35

usual interstitial pneumonia covers which diseases

Answer 35

UIP is most likely to be: 1. idiopathic pulmonary fibrosis 2. manifestion of CVD 3. chronic hypersensitivity pneumonitis 4. ASBESTOSIS

Question 36

- 78 year old man with severe respiratory dysfunction and overall impairment - worked as a carpenter and had substantial exposure to asbestos - died and an autopsy was performed to reveal:

Answer 36

Question 37

asbestos fibers is a group of ___ \_\_\_ fibers that can induce ___ ancer

Answer 37

group of magnesium silicate fibers that can form mesotheliomas

Question 38

- 78 year old man with severe respiratory dysfunction and overall impairment - worked as a carpenter and had substantial exposure to asbestos - died and an autopsy was performed to reveal:

Answer 38

mesothelioma

Question 39

- 30 yo female with peutz-jeghers syndrome with 2x prior bowel resection - never smoker - mother also has PJS and died of lung cancer - baseline CT imaging done as part of genetic counselling.

Answer 39

an evident nodule on the left lung. little dilations in both lungs. the lung cancer most likely to affect lung parencyhma and nonsmokers is adenocarcionma. - need a bronchoscopy biopsy

Question 41

- 30 yo female with peutz-jeghers syndrome with 2x prior bowel resection - never smoker - mother also has PJS and died of lung cancer - baseline CT imaging done as part of genetic counselling. - noduels were seen in lung and this is what the biopsy shows:

Answer 41

this lesion shows obvious glandular tissue with large atypical cells with abundant apical mucin and basally oriented nuceli lining the alveolar walls. this is consistent with primary pulmonary adenocarcinoma

Question 42

Answer 42

Question 43

Answer 43

Question 44

Answer 44

classic emphysema-- breakdown of alveolar walls

Question 45

Answer 45

COPD chronic bronchitis

Question 46

Answer 46

aka PARASEPTAL

Question 47

Answer 47

ILD

Question 48

Answer 48

honeycombing. the fact that this is a lower cut section indicates that it might be UIP going on. Really indicates severity of disease

Question 49

68 yo F lifetime non-smoker, previously well HPI: 2 days increasing SOB, cough PMHx: GERD Meds: Lansoprazole, Nitrofurantoin x past 9 days Exposures: None  Labs: WBC/PMNs/ALP/ALT/LDH elevated ** Room air ABG: 7.47/34/48/25**  A-a gradient: 40  EKG: sinus tachy

Answer 49

DRUG INDUCED PNEUMONITIS!! (type of ILD) - if you discontinue the macrobid they might feel better

Question 50

38 yo M – **smokes 1 ppd**  Cough and Dyspnea on exertion x 6 months  Weight loss x 10 pounds  Previously well  No meds, no allergies  No HP exposures, No CTD ** Works in a Foundry making metal castin**gs

Answer 50

Question 51

 68 yo M  Never smoker  **2-3 years progressive dyspnea on exertion**  PMHx: HIV - normal CD4, undetectable VL  Medications: ART, ASA 81  NKDA ** Velcro-crackles to lower lobes bilaterally**  Inspiratory squawks**/squeaks upper lobes**  Loud **P2**, RV heave, pedal edema, **JVP 4 cm** ASA  FEV 1 /FVC 0.79 DLCO33% predicted  FVC 49% predicted DL  Has a **backyard aviary x 30 years**  \>100 pigeons  3 parrots, 4 parakeets, 2 parrotlets – in his home

Answer 51

Hypersensitivity Pneumonitis (HP)

Question 52

Which of these is NOT a cause of HP?  1. Farming  2. Birds  3. Hot tubs  4. Cats  5. Wind Instruments

Answer 52

cats do not cause hypersensitivity pneumonitis

Question 53

 62 yo F with 2 years SOBOE and dry cough  PMHx: HTN, ex-smoker (30 pk-yrs), GERD  Meds: ACEI/HCTZ, PPI  NKDA  SHx: Manages a construction company, wood- working and painting as hobbies  FHx: No ILD, CTD  ROS: No symptoms of CTD, angina, CHF  Normal Vitals: Sp02 = 94% r/a ** Finger Clubbing** ** Velcro-like crackles to bases bilaterally**  CBC: Hgb = 165  ANA, RF, ENA, anti-CCP Ab all negative/normal

Answer 53

this is classic UIP; fibrosis in the periphery of the lung, preferring the bottom portion of the lung. UIP is mainly caused by idiopathic pulmonary fibrosis, chronic hypersensitivity pneumonitis or asbestosis (or as CVD)

Question 54

Answer 54

Question 55

Answer 55

Question 56

Answer 56

huge bronchiole dilations-- bronchiectasis

Question 57

2 classic findings that indicate bronchiectasis

Answer 57

1`. signet ring 2. tram tracks