Transcript The Lung and the Upper Respiratory Tract

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
Air pollution
Infection
Occupation
•
Genetic
Lung cancer
Chronic bronchitis and emphysema
Susceptibility to infection
Chronic bronchitis
Susceptibility to infection
Influenza
Pneumonia
Tuberculosis
Lung cancer
Mesothelioma
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
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
bronchi
• Usually in infancy or old age
• Usually secondary to preexisting disease
• Fever, cough
Bronchopneumonia
Bronchopneumonia
Bronchopneumonia
Bronchopneumonia
Outcomes
of 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
X-Ray
• Diagnosis & Therapy
Physical examination
X-ray
Blood culture
Penicillin or other sensitive antibiotic
treatment
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
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
lipids
• Obligate aerobe
• M.hominis and
M.bovis( oropharyngeal
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
part 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
containing bacilli
•
•
•
•
Firm
Well circumscribed
Central caseation
Peripheral fibrosis
Tuberculoma
•
Tuberculoma
Progressive pulmonary tuberculosis
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(-)
patients
• Multifocal in HIV(+)
patients
lymphadenitis
Renal
tuberculosis
Vertebrae TB
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
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
Chronic Obstractive Lung Diseases
(COPD)
• 10% US adults involved
• The 4th leading cause of death in USA
• Persisting and irreversible airway
obstruction
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
Emphysema is characterized by permnent
Enlargement of the air spaces distal to the
terminal bronchioles accompanied by
destruction of their walls
Emphysema
vs
With destruction
Complicated reasons
overinflation
without destruction
compensatory
obstructive
Emphysema
vs
Morphologic feature
Restricted to acinus
chronic bronchitis
clinical feature
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)
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
bronchitis)
• barrel-chest
• Secondary pulmonary hypertension
develops gradually
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
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
the submucosa.
Chronic bronchiolitis
Chronic bronchiolitis
Clinical course
• Cough with mucus or mucopurulent sputum
• With/without ventilatiory dysfunction,
hypoxemia, hypercapnia
(COPD developed)
• Secondary pulmonary hypertension
develops gradually
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
Bronchiectasis is the permanent dilation of
bronchi 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
amount of mucopurulent ,fetid sputum
• Hemoptysis
• symptoms are episodic and are precipitated
by upper respiratory tract infection
• Secondary pulmonary hypertension
develops gradually
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
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
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
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%)
Bronchogenic
carcinoma
• Carcinoma with
cavitation
Bronchogenic
carcinoma
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