pp. 677 - 738

• Case 452
• Case 602
• Case 603
• Case 560
• Case 126
• Case 511
• Case 40

CASE NUMBER 452
[ImageScope] [WebScope]

Clinical History: A 45-year-old man presented to his primary care physician with a 6-week history of non-productive cough. Over the last month or so, he had lost 15 pounds and occasionally experienced hemoptysis. He was originally from India, but moved to the United States nine years ago. Physical exam revealed harsh breath sounds with crackling rales over the right posterior lung base.  Samples were taken for culture analysis; however, as he was leaving the doctor’s office, he experienced severe coughing with massive hemoptysis and died.

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452-1. Which of the following is the most likely diagnosis?

1. Berylliosis
2. Leprosy
3. Sarcoidosis
4. Tuberculosis
5. Viral pneumonia

ANSWER

 

452-2. Which of the following cells does Mycobacterium tuberculosis typically infect?

1. B cells
2. Cytotoxic T cells
3. Macrophages
4. Natural killer cells
5. T helper cells

ANSWER

 

452-3. Immunity to M. tuberculosis is primarily mediated by which of the following?

1. Plasma cells
2. Natural killer cells
3. T_H1 cells
4. T_H2 cells
5. T_H17 cells

ANSWER

CASE NUMBER 602
(no virtual slides for this case)

Clinical History: History is obtained from paramedics and from the patient's boyfriend. 41 year old woman with a history of severe asthma and reactive airways disease. This began in childhood, and attacks have necessitated intubation on a number of previous occasions. She was at a pharmacy and began to have an attack. Per her boyfriend, she began prompt self-treatment with a portable nebulizer, and EMS was called. By the time paramedics arrived, she was in severe respiratory distress. Intramuscular epinephrine was administered but she suffered a cardiac arrest. Upon arrival at the Emergency Department, she was pulseless and apneic. She was intubated and 40 minutes of CPR were administered, but a pulse was never re-established. She was pronounced dead.

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602-1. Which of the following is the most likely diagnosis?

1. Bronchiectasis
2. Aspiration
3. Bronchial asthma
4. Centrilobular emphysema
5. Chronic bronchitis
6. Obstructive sleep apnea

ANSWER

 

602-2. At autopsy, which of the following is the most likely histologic finding in the lungs?

1. Bronchial smooth muscle hypertrophy with proliferation of eosinophils
2. Diffuse alveolar damage with leakage of protein-rich fluid into alveolar spaces
3. Dilation of air spaces with destruction of alveolar walls
4. Hyperplasia of bronchial mucus-secreting submucosal glands
5. Permanent bronchial dilation caused by chronic infection, with bronchi filled with mucus and neutrophils

ANSWER

 

CASE NUMBER 603
(no virtual slides for this case)

Clinical History: A 62-year-old man is a smoker with a 10-year history of cough productive of copious mucopurulent sputum. Over the past 6 months, he has developed progressive dyspnea. Physi­cal examination shows bilateral pedal edema and a soft but enlarged liver. A chest radiograph shows bilateral pleural effu­sions and a prominent heart border on the right side. Arter­ial blood gas determinations show PO2 of 60 mm Hg, PCO2 55 mm Hg, pH 7.31, and HCO3- 28 mEq/L. The patient is intubated and placed on a ventilator, and he requires increas­ing amounts of oxygen.

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603-1. Which of the following is the most likely diagnosis?

1. Bronchiectasis
2. Aspiration
3. Bronchial asthma
4. Centrilobular emphysema
5. Chronic bronchitis
6. Obstructive sleep apnea

ANSWER

 

603-2. At autopsy, which of the following microscopic findings is most likely to be characteristic of his underlying pulmonary disease?

1. Infiltrates of eosinophils
2. Extensive interstitial fibrosis
3. Granulomas in bronchovascular distribution
4. Carcinoma filling lymphatic spaces
5. Hypertrophy of bronchial submucosal glands

ANSWER

CASE NUMBER 560
[WebScope] [ImageScope]

Clinical History: A 72-year-old man was found dead in his home by his wife. She told the medical examiner that he was a retired shipyard worker who had smoked 1 pack of cigarettes/day since he was 19.  Autopsy revealed that the cause of death was myocardial infarction.

Image Gallery (slide specimen and images courtesy of the University of Michigan):

560-1. Which of the following is the most likely diagnosis?

1. Adenocarcinoma
2. Histoplasmosis
3. Asbestosis
4. Mesothelioma
5. Silicosis

ANSWER

 

560-2. What are the golden-brown objects seen in the microscopic images?

1. Beryllium fragments
2. Charcot-Leyden crystals
3. Ferruginous bodies
4. Fungal spores
5. Hyaline membranes

ANSWER

 

560-3. Patients with this disease are at greatest risk for developing which of the following complications?

1. Acute interstitial pneumonia
2. Bronchogenic carcinoma
3. Diffuse alveolar damage
4. Hypersensitivity pneumonitis
5. Sarcoidosis

ANSWER

 

560-4. Which of the following pulmonary function test results is consistent with this patient’s diagnosis?

1. Decreased forced vital capacity
2. Decreased maximal expiratory flow rate
3. Increased forced expiratory volume at 1 second
4. Increased residual volume
5. Increased total lung capacity

ANSWER

 

CASE NUMBER 126
[ImageScope] [WebScope]

Clinical History: A 50-year-old man presented to his primary care physician with a 2-month history of increasing dyspnea and unexplained weight loss. Chest X-ray revealed a 5 cm right upper lobe mass. While he was waiting in radiology for a staging CT, he suddenly collapsed. He could not be resuscitated.

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126-1. Which of the following is the most likely diagnosis?

1. Adenocarcinoma
2. Carcinoid tumor
3. Large cell neuroendocrine carcinoma
4. Small cell carcinoma
5. Squamous cell carcinoma

ANSWER

126-2. Which of the following is true regarding this tumor?

1. It arises from neuroendocrine cells
2. It is the most common malignancy in non-smokers
3. It is typically hilar
4. Its incidence has decreased markedly in the last 20 years
5. Mutations in N-RAS are common

ANSWER

 

CASE NUMBER 511
(no virtual slides for this case)

Clinical History: A 67-year-old man presented to his primary care physician with a two-month history of fatigue and weight loss of ten pounds. Clinical history was relevant for a 60-pack-year smoking history and a 5-year history of hypertension and obstructive pulmonary disease. A chest x-ray revealed a right hilar mass and a subsequent CT scan showed this to be a 10 cm mass with associated lymphadenopathy. A biopsy was performed.

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511-1. Which of the following is the most likely diagnosis?

1. Adenocarcinoma
2. Carcinoid tumor
3. Pulmonary hamartoma
4. Small cell carcinoma
5. Squamous cell carcinoma

ANSWER

 

511-2. Which of the following is true regarding this disease?

1. Biologic behavior is typically indolent
2. Cells show a neuroendocrine phenotype
3. Hypercalcemia is commonly diagnosed in these patients
4. Incidence among non-smokers is rising
5. Surgical resection is standard therapy

ANSWER

 

511-3. Which of the following is most commonly associated with this disease?

1. Carcinoid syndrome
2. Horner syndrome
3. Hypoglycemia
4. Nephrotic syndrome
5. Syndrome of inappropriate antidiuretic hormone secretion

ANSWER

 

511-4. Which of the following has the strongest association with cigarette smoking?

1. Adenocarcinoma
2. Adenosquamous carcinoma
3. Pulmonary hamartoma
4. Small cell carcinoma
5. Squamous cell carcinoma

ANSWER

LUNG PATHOLOGY Review Items

Key Vocabulary Terms (click here to search any additional terms on Stedman's Online Medical Dictionary)

LEARNING OBJECTIVES

• Absolutely critical information you must know to practice medicine is in bold font.
• Important information that will be needed for routine patient care is in regular font.
• Information about less common diseases that you may encounter in clinical practice and that will probably appear on examinations is in italics

1. Describe the mechanisms by which the following pulmonary defense mechanisms accomplish their functions:
   • nasal clearance
   • laryngeal (including epiglottic) action
   • tracheobronchial clearance
   • alveolar clearance
     
     
2. Explain the pathogenesis of each of the manifestations of pulmonary disease:

   pain	hypertrophic pulmonary osteoarthropathy
   cough	secondary polycythemia
   dyspnea	hemoptysis
   sputum production	cor pulmonale
   cyanosis	clubbing of fingers

   
   
3. Discuss the following pulmonary congenital anomalies, in terms of morphology and clinical consequences:
   • agenesis
   • hypoplasia
   • congenital lobar overinflation ("emphysema")
   • congenital cyst
   • bronchopulmonary sequestration
   
   
4. Contrast obstructive and restrictive pulmonary disease, in terms of:
   • morphologic features
   • radiologic manifestations
   • pulmonary function test results
   • clinical manifestations
   
   
5. Compare and contrast the etiologies and effects of airflow obstruction that occur in lesions involving the airways with those that involve the alveolar parenchyma.


6. Compare and contrast the clinical and pathologic features of:
   • emphysema
   • chronic bronchitis
   • bronchial asthma
   • bronchiectasis
   
   
7. Compare and contrast the clinical and pathologic features of bronchial asthma:
   • atopic
   • non-atopic
   • drug-induced
   • occupational
   
   
8. Compare and contrast the clinical and pathologic features of :

   centriacinar (centrolobular) emphysema	focal emphysema
   congenital lobar "emphysema"	interstitial emphysema
   panacinar (panlobular) emphysema	senile "emphysema"
   paraseptal (distal acinar) emphysema

   
   
9. Discuss the Reid index.


10. Discuss respiratory bronchiolitis of smokers (small airways disease) in terms of:
    • pathogenesis
    • morphology
    • clinical presentation
    
    
11. Discuss bronchiectasis, in terms of:
    • predisposing conditions
    • the types of organisms typically cultured from bronchi
    • sequelae
    
    
12. Compare and contrast neonatal and adult respiratory distress syndrome in terms of:
    • predisposing factors/associated conditions
    • pathogenesis
    • morphology
    • complications
    • clinical course
    
    
13. Compare and contrast the clinical and pathologic features of the following lung diseases:
    • diffuse alveolar damage (DAD)
    • bronchilitis obliterans-organizing pneumonia (BOOP)
    • usual interstitial pneumonia (UIP)
    • desquamative interstitial pneumonia (DIP)
    • lymphoid interstitial pneumonia (LIP)
    • nonspecific interstitial pneumonia (NSIP)
    
    
14. Discuss the clinical and pathologic features of the following disorders:
    • sarcoidosis
    • Goodpasture syndrome
    • idiopathic pulmonary hemosiderosis (IPH)
    • hypersensitivity pneumonitis (HP)
    • pulmonary alveolar proteinosis
    • pulmonary eosinophilic granuloma
    • pulmonary infiltrates with eosinophilia (PIE)
    • lipid pneumonia
    • Wegener granulomatosis
    • lymphomatoid granulomatosis
    
    
15. Discuss pulmonary invovement in autoimmune ("collagen-vascular") diseases, noting the major morphologic manifestations in the lung of:
    • systemic lupus erythematosus (SLE)
    • rheumatoid arthritis (RA)
    • progessive systemic sclerosis (PSS)
    
    
16. Discuss the basic pathogenesis of pneumoconioses.


17. Compare and contrast the clinical and pathologic features of the following pneumoconioses:
    • coal workers' pneumoconioses
    • silicosis
    • asbestosis
    • berylliosis
    
    
18. Discuss the clinical and pathologic features of these asbestos-related lung diseases:
    • fibrous pleural plaques
    • pleural effusion
    • asbestosis
    • bronchogenic carcinoma
    • malignant mesothelioma
    
    
19. Discuss the acute and chronic stages of radiation lung injury, in terms of:
    • temporal features
    • pathogenesis
    • morphology
    • consequences
    
    
20. Discuss drug-induced lung disease, enumerating drugs most commonly associated with the following pulmonary reactions
    • bronchospasm
    • pulmonary edema
    • hypersensitivity pneumonitis (HP)
    • eosinophilic pneumonia
    • diffuse alveolar damage (DAD)
    • pulmonary fibrosis
    
    
21. Enumerate the general indications for lung transplantation, and complications:
    • pulmonary infection
    • acute rejection
    • chronic rejection
    
    
22. Discuss the pulmonary features of cystic fibrosis (CF), in terms of:
    • frequency of involvement of lung in CF
    • pathogenesis
    • morphology
    • functional alterations
    • clinical manifestations
    • pulmonary complications
      • obstructive
      • infectious (including most common organisms involved)
    • treatment
    • prognosis
    
    
23. Compare and contrast the clinical and pathologic features of:
    • bronchopneumonia
    • lobar pneumonia
    • primary atypical pneumonia
    • aspiration pneumonia
    • lung abscess
    • pulmonary infiltrates in the immunocompromised host
    
    
24. Describe the four classic stages of the inflammatory response in lobar pneumonia in terms of:
    • temporal features
    • morphology
    
    
25. Compare and contrast the clinical and pathologic features of :

    anthrax	crytococossis
    Legionnaire's disease	aspergillosis
    actinomycosis	mucormycosis
    nocardiosis	respiratory syncytial virus (RSV)
    tuberculosis	influenza pneumonia
    atypical mycobacteriosis	adenovirus pneumonia
    mycoplasma pneumonia	cytomegalic virus (CMV)
    psittacosis	acute respiratory syndrome
    histoplasmosis	Pneumocystis carinii pneumonia (PCP)
    coccidioidomycosis	toxoplasmosis
    blastomycosis	strongyloides

    
    
26. Differentiate among tuberculosis, sarcoidosis, and granulomatous fungal disease
    • etiopathogenesis
    • morphologic features, including use of special stains
    • organs involved
    • radiologic features
    • clinical presentation
    • diagnostic tests
    • laboratory findings
    • prognosis
    
    
27. Discuss pulmonary edema, embolism, and infarction in terms of:
    • predisposing factors and etiology
    • pathogenesis
    • morphologic features
    • radiologic features
    • clinical manifestations
    
    
28. Compare and contrast the clinical and pathologic features of pulmonary embolism:
    • thrombus
    • fat
    • air
    • bone marrow
    • amniotic fluid
    • talc
    
    
29. Compare and contrast primary and secondary pulmonary hypertension, in terms of:
    • predisposing factors/associated conditions
    • pathogenesis
    • age and sex distribution
    • clinical manifestations
    • size and type of vessels involved
    • morphologic features (including reversible vs. irreversible lesions)
    • hemodynamic consequences 
    • prognosis
    
    
30. Discuss the clinical and pathologic features of:
    • pulmonary circulatory disease associated with congenital heart disease
    • persistent fetal circulation
    
    
31. Compare and contrast the clinical and pathologic features of the following thoracic tumors:
    • squamous cell carcinoma of lung
    • bronchogeneic adenocarcinoma
    • bronchioloalveolar carcinoma
    • small cell carcinoma of lung
    • large cell carcinoma of lung
    • bronchial carcinoid
    • pulmonary hamartoma
    • malignant lymphoma
    • Hodgkin disease
    • metastatic neoplasm to thorax
    • pleural fibroma (solitary fibrous tumor)
    • malignant mesothelioma
    
    
32. List likely etiologies and expected effects on pulmonary function of:
    • hydrothorax
    • empyema
    • hemothorax
    • chylothorax
    • pneumothorax
    • tension pneumothorax
    • pleural adhesion
      
    
    
33. Discuss pleural fluid collections on the basis of fluid type and common association.
    


34. List appropriate diagnostic procedures for patients with pleural effusions.


35. Compare and contrast the clinical and pathologic features of:
    • nasal polyp
    • sinonasal papilloma
    • laryngeal nodule (singers' node)
    • laryngeal papilloma
    • juvenile laryngeal papillomatosis
    • laryngeal squamous cell carcinoma
    • nasopharyngeal carcinoma