diseases of the respiratory system pathology department of sichuan university su xueying

Diseases of the Respiratory System

Pathology Department of SiChuan University

Su Xueying

Normal structure of the respiratory tract

The lower respiratory

tract

Respiratory mucosa

• The respiratory system disease is very common

• Emvironmental factors is important

Major aetiological factors in respiratory disease

• Emvironmental Smoking Lung cancer Chronic bronchitis and emphysema Susceptibility to infection Air pollution Chronic bronchitis Susceptibility to infection Infection Influenza Pneumonia Tuberculosis Occupation Lung cancer Mesothelioma

• Genetic Cystic fibrosis Some asthma

OUTLINE

1.Pulmonary Infections Bacteria Pneumonias Atypical Pneumonias Tuberculosis 2.Chronic Obstractive Lung Diseases (COPD) Emphysema Chronic Bronchitis 3.Bronchiectasis 4.Cor Pulmonale 5.Lung tumors

• Definition

Bacteria pneumonia is due to bacteria infection affecting distal airways, especially alveoli, with formation of an inflammatory exudate.

often follows a viral upper respiratory tract infection

• Streptococcus pneumoniae

(pneumococcus)• Staphylococcus• Haemophilus influenzae• Klebsiella pneumoniae• Moraxella catarrhalis

Lobar pneumonia

congestion stage

red hepatization

gray hepatization

resolution

Bronchopneumonia

Lobar pneumonia

• Affects a large part, or the entirety of a lobe, frequently unilateral

• Affects otherwise healthy adults between 20 and 50 years of age, males more than females

• 90% due to Streptococcus pneumoniae

Stage of congestion

Red, edematous

Red hepatization

• Red• Solid• Consistency

resembling fresh liver

Gray hepatization

Fibrinous pleuralitis

Gray hepatization

• Dry• Pale• Firm

Gray hepatization

Resolution stage

Symptoms• High fever• Chills• Chest pain• Mucopurulent cough• with/without hemoptysis

(rusty sputum)• Dyspnea

Bronchopneumonia(Lobular pneumonia)

• Patchy consolidation• Centred on bronchioles or br

onchi• Usually in infancy or old age• Usually secondary to pre-exis

ting disease• Fever, cough

Bronchopneumonia

Outcomesof Pneumonia

• Complete recovery

• Complications developed

Abscess formation

Empyema

Bacteremic dissemination

• Organization

Empyema

Abscess formation

abscess formation

Organization

• Diagnosis & Therapy

Physical examination

X-ray

Blood culture

Penicillin or other sensitive antibiotic

treatment

OUTLINE


Total Recovery Death

Mainland 1807 1165 79

Guangdong 1304 1110 46

Beijing 339 33 18

Shanxi 108 8 4

Neimeng 25 8 3

Guangxi 12 0 3

Hunan 6 5 1

SiChuan 5 3 1

Fujiang 3 0 0

Shanghai 2 0 0

Henan 2 0 0

Ningxia 1 0 0

Atypical pneumonia

• The concept was set forth in 1938

• The clinical course is unlike the “typical” bacteria pneumonia

• Causes

mycoplasma

virus

chlamydia

• Gross morphology

Red, congested

Patchy or whole lobes

• Microscopic characteristic

the inflammatory reaction is largely

confined within the walls of the alveoli,

the septa are widened and edematous

with mononuclear cells infiltration---

interstitial pneumonia

interstitial pneumonia

Hyaline membrane

Virus inclusion body

• Clinical course

Cough, fever, headache, malaise

Sputum is modest

No bacteria be isolated

Leukocytosis is modest

Physical findings of consolidation is

varied

Prognosis

• Good in most uncomplicated cases

• Bad in complicated bacterial superinfection cases

OUTLINE

1.Pulmonary Infections Bacteria Pneumonias Atypical Pneumonias Tuberculosis 2.Chronic Obstractive Lung Diseases (COPD) Chronic Bronchitis Emphysema 3.Bronchiectasis 4.Cor Pulmonale 5.Lung tumors

Tuberculosis

• Tuberculosis (TB) is a communicable chronic granulomatous disease caused by Mycobacterium tuberculosis (tubercle bacillus).

• It usually involves the lungs but may affect any organ or tissue in the body.

• Typically, the centers of tubercular granulomas undergo caseous necrosis.

Epidemiology

• Tuberculosis remains a leading cause of death among medically and economically deprived persons throughout the world.

poverty

crowding

elderly person

chronic debilitating illness, including

AIDS

Epidemiology(western world)

• Deaths from tuberculosis peaked in 1800s, Steadily declined untill 1984, then increased beause of human immunodeficiency virus (HIV) infected

• 25,000 new cases in USA annually currently

Epidemiology(Asia)

• The incidence of TB in India is the highest in the world, china is the second

• It is estimated that there is near 400,000,000 persons have once been infected tubercle bacilli in china

Mycobacterium tuberculosis

• Slender rod shape• Gram +• Acid fast +• High content of complex li

pids• Obligate aerobe • M.hominis and M.bovis( or

opharyngeal and intestinal TB)

Pathogenesis

• Development of a targeted T cell-mediated immunity (>3weeks) that confers resistance to the organism and results in development of tissue hypersensitivity leading to caseous necrosis and granuloma formation

Tubercle （ Tuberculous granuloma)

•

Langhans giant cell and foreign body giant cell

•

Primary tuberculosis

• Previously unexposed, unsensitized person, most frequently in children

• Almost in the lungs• Typically in the distal airspaces of the lower par

t of the upper lobe or the upper part of the lower lobe, usually closed to the pleura

Primary tuberculosis

• Ghon complex (primary complex)

parenchymal lesion

lymphatitis

lymph node involvement

Ghon complex

•

Gohn complex

• Histology:

granulomatous inflammation with/without caseous necrosis

Clinical course

• Asymptom

• Fever, malaise, anorexia

Clinical course

• 95% cases development of cell-mediated immunity controls the infection and increases resistance

• The Gohn complex undergoes fibrosis and calcification

• The scaring foci may harbor viable bacilli for years

• A few immunocompromised patients develop progressive primary TB

Secondary Tuberculosis

• It arises in a previously sensitized host• reactivation of dormant primary lesions or exogenous reinfection • Less than 5% patients

Secondary Tuberculosis

• Pulmonary tuberculosis• Miliary Tuberculosis• Extrapulmonary tuberculosis

Secondary Pulmonary tuberculosis

• It is classically localized to the apex of upper lobes

• Cavitation occurs readly• The patient raises sputum c

ontaining bacilli

• Firm• Well circumscribed• Central caseation• Peripheral fibrosis

Tuberculoma•

Tuberculoma

Progressive pulmonary tuberculosis

Progressive pulmonary tuberculosis

•

Miliary Tuberculosis

• Systemic miliary tuberculosis

liver, spleen, bone marrow, kidney,

fallopian tubes

• Pulmonary miliary tuberculosis

miliary tuberculosis of liver

miliary tuberculosis of spleen

pulmonary miliary tuberculosis•

pulmonary miliary tuberculosis

Extrapulmonary tuberculosis

• Intestinal tuberculosis Secondary to the swallowing of coughed-up

infective material

Drinking of contaminated milk is the reason of primary lesion

Intestinal tuberculosis

lymphadenitis

• Most frequent form• Cervical region• Unifocal in HIV(-) pati

ents• Multifocal in HIV(+) p

atients

lymphadenitis

Renal tuberculosis

Vertebrae TB

Joint TB

Clinical course

• Asymptomatic

• Systemic symptoms

malaise

anorexia

weight loss

fever (low, remittent)

night sweats

Clinical course

• localizing pulmonary symptoms

Cough

Mucoid, purulent sputum

Hemoptysis

Pleural pain

Dyspnea• localizing extrapulmonary symptoms

• Diagnosis & Therapy

• History

• Physical and x-ray findings of consolidation

• Tubercle bacilli must be identified

• Multiple drugs treatment

OUTLINE


Chronic Obstractive Lung Diseases(COPD)

• 10% US adults involved• The 4th leading cause of death in USA• Persisting and irreversible airway

obstruction

OUTLINE


• Definition

Emphysema is characterized by permnent

Enlargement of the air spaces distal to the terminal bronchioles accompanied by destruction of their walls

Emphysema vs overinflationWith destruction without destruction

Complicated reasons compensatory

obstructive

Emphysema vs chronic bronchitis

Morphologic feature clinical feature

Restricted to acinus large and small

airway

The two deaseas usually coexist

Types of Emphysema

• Centriacinar

• Panacinar

• Distal acinar

(according to the distribution of lesions in the lobule and acinus)

Normal structure of acinus

Centriacinar Emphysema

• Cigarette smoking• The upper lobe, apical segments

Panacinar Emphysema

• а1- antitrypsin deficiency

• The lower lobe

Centriacinar vs

Panacinar Emphysema

Distal acinar Emphysema

• It is more striking adjacent to the pleura, septa, scaring , at the margins of the lobules

• Be more severe in the upper half of the lungs

Bullous emphysema(Distal acinar Emphysema)

• With the destruction of alveolar walls and loss of elastic tissue , Small airways tend to collapse during expiration-----an important cause of chronic airflow obstruction

pathogenesis

• Protease-antiprotease imbalance

• Oxidant-antioxidant imbalance

These two imbalances are almost always coexist

• Proteolytic activity

• а1- antitrypsin

Pathogenesis of emphysema

Clinical course

• Dyspnea• cough, purulent sputum (with bronchiti

s) • barrel-chest• Secondary pulmonary hypertension d

evelops gradually

OUTLINE


Chronic Bronchitis

• Definition (made on clinical ground)

persistent productive cough for at least

3 consecutive months in at least 2

consecutive years

It is often developed in middle age to

old men with cigarette smoking

• Causes

cigarette smoking

other air pollution

( sulfur dioxide, nitrogen dioxide)

• epidermal growth factor receptor

• Microbial infection

• Grossly, the mucosal of the trachea, bronchus, bronchiole is hyperemic, covered by a layer of mucinous or mucopurulent secretion

Increased numbers of chronic inflammatory cells in t

he submucosa.

Chronic bronchiolitis

Clinical course• Cough with mucus or mucopurulent sputum• With/without ventilatiory dysfunction, hypoxemia, hypercapnia (COPD developed) • Secondary pulmonary hypertension develop

s gradually

OUTLINE


• Definition Bronchiectasis is the permanent dilation of br

onchi and bronchioles caused by destruction of the muscle and elastic supporting tissue.

It is not a primary disease but rather is secondary to persisting infection or obstruction caused by variety of conditions

Conditions that predispose to bronchiecctasis

• Bronchial obstruction• Bacteria pneumonia• Congenital conditions

pathogenesis

• Obstruction Chronic infection

Tissue damage secretion accumulation

irreversible dilation

• Lower lobes bilaterally

• Distal bronchi and bronchioles are more severe

Cross-section of lung demonstrating dilated bronchi extending almost to the pleura

Bronchiectasis.

Dilated bronchus in which the mucosa and wall is not clearly seen because of the necrotizing inflammation

Clinical Course• severe, persistent cough with copious amou

nt of mucopurulent ,fetid sputum• Hemoptysis• symptoms are episodic and are precipitated

by upper respiratory tract infection• Secondary pulmonary hypertension develop

s gradually

OUTLINE


Cor pulmonale

• Definition

It also called pulmonary heart disease, is used to describe disease of the right-side cardiac chambers caused by pulmonary hypertension resulting from pulmonary parenchymal or pulmonary vascular disease

Disorders that predispose to cor pulmonale

Diseases of the lungs Chronic obstructive lung disease Diffuse pulmonary interstitial fibrosis Extensive, persistent atelectasis Cystic fibrosis Diseases of pulmonary vessels Pulmonary embolism Primary pulmonary vascular sclerosis Extensive pulmonary arteritis Drug-, toxin-, or radiation-induced vascular sclerosis Disorders affecting chest movement Disorders inducing pulmonary arteriolar constriction

Heart changes

• right ventricular, and often right artrial hypertrophy.

• It may be dilated when ventricular failure develops.

• Conic of pulmonary artery bulges

• The point of the heart become blunt and round

• Thickness of the right ventricle exceeds the left ventricle

• 2cm below the valves of the pulmonary artery>4.5cm

Pulmonary changes

• Primary lung diseases (such as chronic bronchitis, emphysema)

• with blood vessel changes-----pulmonary hypertension.

Clinical course

• Right cardiac failure

• Respiratory failure

OUTLINE


Lung tumors

• Bronchogenic carcinoma:95%• Miscellaneous group:5%

bronchial carcinoid tumor

fibrosarcoma

lymphoma

hamartoma

Bronchogenic carcinoma

• No.1 cause of cancer-related deaths in industrialized countries.

• Cigarette smoking is a important cause• The peak incidence occurs between ages 55

and 65 years.• The male to female ratio is 2:1• The prognosis of lung cancer is dismal

Histologic classification of Bronchogenic carcinoma

• Non-small cell lung carcinoma 1.squamous cell carcinoma(25%-30%) 2.adenocarcinoma,including bronchioloalveolar ca(30%-35%) 3.large cell carcinoma(10%-15%)

• Small cell carcinoma(20%-25%)• Combined pattens(5%-10%)

• Carcinoma with cavitation

Squamous cell carcinoma

adenocarcinoma

Small cell carcinoma

Metastatic cacinoma

Clinical course

• Silent, insidious lesion• Chronic cough and expectoration• Hoarseness, chest pain, pleural or pericardial

effusion• Symptoms emanating from metastatic spread

to the brain, liver,or bone• NSCLCs have a better prognosis than SCLCs

Methods to diagnose lung cancer

• X-ray, CT scanning• Cytological smear of

sputum or bronchial brush

• Biopsy from bronchus• Fine needle aspiration

of the tumor

diseases of the respiratory system pathology department of sichuan university su xueying

Documents

xray slide

cough slide

empyema slide

asthma slide

important slide

edematous slide

gray hepatization slide

respiratory mucosa slide