2015/4/14. Pneumonia. Diseases of Respiratory System Infection in the lung (distal airways, esp. alveoli) Lobar pneumonia.

Transcription

1 Pneumonia Diseases of Respiratory System Infection in the lung (distal airways, esp. alveoli) 邓红浙江大学医学院病理学系 LUNG(reformed)5y-DH 1 hongdeng@zju.edu.cn Pathology (DH) 2 Pneumonia Bacteria pneumonia Viral pneumonia Mycoplasma pneumonia Pneumocystis pneumonia An acute bacterial infection of a large portion of a lobe or of an entire lobe Fibrinous inflammation Symptoms: abrupt onset, high fever, shaking chills, pleuritic chest pain, a productive mucopurulent cough ( rusty sputum ) Pathology (DH) 3 Pathology (DH) 4 Etiology & Pathogenesis Pathogens: streptococcuspneumoniae, pneumobacillus Inducing factors: cold, excessive tired, anethesia Bacteria---alveoli---proliferate/capillary dilate/serious exudates---kohn s pores- --spreading entire lobe Acute congestion Red hepatization Gray hepatization Resolution Pathology (DH) 5 Pathology (DH) 6 1

2 Acute congestion:1st-2nd day NE Heavy, red, boggy LM Alveolar wall: cap. dilate, congestion Alveolar space: proteinaceous edema fluid, few neutrophils, RBC, and numerous bacteria Pathology (DH) 7 Pathology (DH) 8 Red hepatization: 3rd-4th day Alveolar space: a flock of RBC, packed with fibrin nets which stream from one alveolus through the Kohn s pores into adjacent alveoli, neutrophils Pathology (DH) 9 Pathology (DH) 10 Gray hepatization: 5th 6th day NE Gray-brown and solid, liver-like consistency LM Alveolar capillaries appear compressed Alveolar spaces: progressive disintegration of neutrophils along with the continued accumulation of fibrin Pathology (DH) 11 Pathology (DH) 12 2

3 Resolution: 1 week Resorption of exudate and enzymatic digestion of inflammatory debris, with preservation of the underlying alveolar wall architecture NE softening, volume LM WBC fibrin absorbed Pathology (DH) 13 Pathology (DH) 14 Complications Pulmonary carnification Empyema Abscess formation Septicemia or pyemia Infectious shock (resolution stage ) exudates within the alveoli are enzymatically digested and either resorbed or expectorated, leaving the Pathology basic (DH) architecture intact. 15 Pathology (DH) 16 ( Bronchopneumonia ) Clinic: infants, the aged, illness (much more prevalent at the extremes of age) Patchy distribution, a purulent inflammation that centered bronchioles Pathology (DH) 17 Pathology (DH) 18 3

4 Etiology and Pathogenesis NE Pathogens: Streptococcus pneumoniae Staphylococci, Influenza haemophilus Inducing factors: Cold, Heart failure Infection ways: respiratory tract, blood Patchy consolidation through one lobe, more often multilobar and frequently bilateral and basal 0.5-1cm, gray-red to yellow, slightly elevated, poorly delimited at the margins Severe: confluent bronchopneumonia Pathology (DH) 19 Pathology (DH) 20 LM Suppurative, neutrophil-rich exudates centered the bronchi, bronchioles, adjacent alveolar spaces Walls of bronchioles and alveoli: congestion Surrounding: hyperemic edematous, compensative emphysema Abscesses are marked by necrosis of the underlying architecture Pathology (DH) 21 Pathology (DH) 22 Pathology (DH) 23 Pathology (DH) 24 4

5 Pneumonia Complications Respiratory failure Heart failure Pyemia Abscess Bronchiectasis Bacteria Pneumonia Lobar Pneumonia Lobular Pneumonia Viral Pneumonia Mycoplasma pneumonia Pneumocystis pneumonia Pathology (DH) 25 Pathology (DH) 26 Viral Pneumonia Pathogens: Influenza virus A/B, Parainfluenza, Respiratory syncytial virus ( especially in infants and children), Adenovirus, Others (Measles, Chickenbox) Much depends on the resistance of the host, range from mild to severe Clinically, more serious lower respiratory tract infection is favored by infancy, old age, malnutrishment, alcoholism, immunosuppression Pathology (DH) 27 Viral Pneumonia NE Affected areas are congested, volume slightly enlarge, subcrepitant Pathology (DH) 28 Viral Pneumonia LM Interstitial pneumonia: Inflammation confined within the walls of the alveoli, the septa are widened and edematous, a mononuclear inflammatory infiltrate of lymphocytes, histocytes, plasma cells; alveolar spaces are remarkably free of cellular exudates Virus inclusion body Hyaline membrane: full-blown diffuse alveolar damage Pathology (DH) 29 Viral Pneumonia Interstitial pneumonia. The alveolar septa are widened and edematous and infiltrated with mononuclear cells. Pathology (DH) 30 5

6 Viral Pneumonia Viral Pneumonia Clinical course Virus inclusion body is round or oval shape, erythrocytelike in size, eosinophilic cytoplasmic or nuclear Extremely varied Onset: acute, nonspecific febrile illness Fever, headache, malaise, cough with minimal sputum Chest radiography: transient, ill defined patches, mainly in the lower lobes Physical findings: minimal and indistinguishable from bronchopneumonia Pathology (DH) 31 Pathology (DH) 32 Viral Pneumonia Clinical course Identifying the causative agent is difficult Rising titers of specific antibodies Mycoplasmal and chalymydia pneumonia-- -erythromycin Prognosis is good Pneumocystis carinii Pathology (DH) 33 Pathology (DH) 34 Interstitial lung disease Interstitial lung disease Pneumoconiosis Sarcoidosis Idiopathic pulmonary fibrosis Pneumoconiosis Inhalation and accumulation of harmful dust for a long time result in extensive fibrosis and injury in lung. Pathology (DH) 35 Pathology (DH) 36 6

7 Silicosis Silicosis -- Inhale of crystalline silica dioxide (silica) Pathogenesis <5μ m silica particles Formation of silicotic nodule Diffuse fibrosis in interstitial of lung Pathology (DH) 37 Pathology (DH) 38 Silicosis Silicosis NE LM Tiny, barely palpable, discrete, pale-toblackened nodules in the upper zones of the lungs Silicotic nodules Cellular silicotic nodules Fibrous silicotic nodules Hyaline silicotic nodules Interstitial extensive fibrosis Pathology (DH) 39 Pathology (DH) 40 Silicosis Silicosis Stages Stage Ⅰ located in hilar LN, without change in volume/ hardness StageⅡ silica nodules below 1 cm (< 1/3 of the whole lung) StageⅢ weight hardness volume confluent, pleura thickened Pathology (DH) 41 Pathology (DH) 42 7

8 Silicosis Complications Sarcoidosis Tuberculosis Cor pulmonary Pulmonary infection Autopneumothorax Pathology (DH) 43 Pathology (DH) 44 Idiopathic pulmonary fibrosis Tuberculosis A chronic granulomatous disease caused by Mycobacterium tuberculosis. Pathology (DH) 45 Pathology (DH) 46 Tuberculosis Etiology and Pathogenesis Mycobacterium tuberculosis Dissemination by respiratory passage (most) Components of the M. tuberculosis cell wall (such as cold factor, wax D, complement, heatshock protein, etc ) and host response Immunological reaction & type 4 Inhalation of virulent Mycobacterium tuberculosis organisms and culminating with the development of cell-mediated immunity to the organism. Pathology (DH) 47 Pathology (DH) 48 hypersensitivity 8

9 Tuberculosis Basic pathological changes Exudative lesion Proliferative lesion Necrotic lesion Tubercle Pathology (DH) 49 Pathology (DH) 50 Tubercle Tubercle Pathology (DH) 51 Pathology (DH) 52 Tuberculosis Fate of tuberculosis Healing Absorption and dissipation Fibrosis and calcification Aggravation Progression with infiltration Solvation and dissemination Tubercle Pathology (DH) 53 Pathology (DH) 54 9

10 Tuberculosis Pulmonary tuberculosis The lungs are the most commonly affected by tuberculosis than any other organs. Primary Secondary The natural history and spectrum of tuberculosis Pathology (DH) 55 Pathology (DH) 56 Primary pulmonary TB Primary pulmonary tuberculosis Childhood type TB Primary complex (the Ghon complex) Primary lesion (Ghon focus) Tuberculous lymphangitis Tuberculous lymphadenitis (in the hilar lymph nodes) Pathology (DH) 57 Pathology (DH) 58 Primary pulmonary TB Clinical features Asymptomatic usually Mild flu-like illness Primary pulmonary tuberculosis, Ghon complex. Pathology (DH) 59 Pathology (DH) 60 10

11 Primary pulmonary TB Fate of primary pulmonary TB Healing, 95% Progression, 5% Dissemination via the bronchus the lymphatic vessel the bloodstream Miliary pulmonary tuberculosis Pathology (DH) 61 Pathology (DH) 62 Secondary pulmonary tuberculosis Adult type TB Miliary tuberculosis of the spleen Pathology (DH) 63 Pathology (DH) 64 Focal pulmonary TB Infiltrative pulmonary TB Chronic fibrotic cavitary pulmonary TB Caseous pneumonia Tuberculoma Tuberculous pleuritis Earliest lesions Focal pulmonary TB Lung apex, one or more small focus of consolidation Small epithelioid granulemas characterized by caseous necrosis and fibrosis Usually asymptomatic Healing spontaneously or with therapy, resulting in a fibrocalcific nodule Progression along the many pathways Pathology (DH) 65 Pathology (DH) 66 11

12 Infiltrative pulmonary TB A most common form A activity pulmonary TB Heavy exudation and caseous necrosis, the lesion enlargement Complication: irregular acute cavities, spontaneous pneumothorax, tuberculosis pyopneumothorax. Clinic features: tuberculous toxic symptoms and chronic cough, frequently with hemoptysis. One, many or all lobes of both lungs Chronic cavities: the upper lobes, multiple variant sizes, thick-walled. Wall of cavity: a yellow-green caseous material, tuberculous granulation tissue and fibrous tissue Chronic fibrotic cavitary pulmonary TB Pathology (DH) 67 Pathology (DH) 68 Chronic fibrotic cavitary pulmonary TB Caseous pneumonia Bronchial disseminated many tuberculous lesions and diffuse fibrosis Later period, the lung becomes small, indurated, with pleural extensive adhesion, the function of the lung may be severely damaged. Pathology (DH) 69 Pathology (DH) 70 Tuberculoma Caseous necrosis lesion: a large solid and spherical mass (usually 2-5cm in diameter), welldemarcated margin, surrounded by fibrous tissue. Tuberculous pleuritis Moist tuberculous pleuritis (exudative tuberculous pleuritis) Dry tuberculous pleuritis (proliferative tuberculous pleuritis) Pathology (DH) 71 Pathology (DH) 72 12

13 Extrapulmonary tuberculosis Meningitis Tuberculomas of brain Vertebral tuberculosis Renal tuberculosis Intestinal tuberculosis Intestinal tuberculosis Pathology (DH) 73 Pathology (DH) 74 Respiratory tumors Nasopharyngeal carcinoma (NPC) Carcinoma of the larynx Lung cancer Vertebral tuberculosis Pathology (DH) 75 Pathology (DH) 76 Lung cancer Gross morphology Centralized type Peripheral type Diffuse type Pathology (DH) 77 Pathology (DH) 78 13

14 Lung cancer Histologic classification Squamous cell carcinoma Small cell carcinoma Adenocarcinoma Large cell carcinoma Adeno-squamous carcinoma Sarcomatoid carcinoma Carcinoid Salivary gland type carcinoma Pathology (DH) 79 Pathology (DH) 80 Squamous cell carcinoma Small cell carcinoma of the lung. Nests and cords of round to polygonal cell with scant cytoplasm, granular chromatin, and inconspicuous nucleoli. Pathology (DH) 81 Pathology (DH) 82 Adenocarcinoma Adenocarcinoma Pathology (DH) 83 Pathology (DH) 84 14

15 Lung cancer Early lung cancer: d<2cm, within the bronchial wall, LN(-) Occult lung cancer: Clinical & X-ray (-), cytology & biopsy (+), LN(-) Large cell carcinoma Pathology (DH) 85 Pathology (DH) 86 Lung cancer Spread of lung cancer Direct spread Metastasis by lymphatics and bloodstream Pathology (DH) 87 15