Level 1

Semester II
Module 4 A
 Diseases of
lower respiratory
tract
• Name of instructor Contact: Dr. Hazem
Abdullah

• e-mail: drhazem_abdullah@yahoo.com

• Contact hours: any time

Content of lecture
• terminology of respiratory diseases.

• Starting some of lower respiratory tract

diseases; those involving lungs and pleura.
Learning outcomes
• Mention the definitions of some respiratory
diseases.

• Identify pathological features of lower

respiratory tract diseases.
Case senario
A 60 years old male patient with a long history of smoking of two
packs per day presents with chronic cough and expectoration for
3 consecutive months over the past 2 consecutive years.

1- what disease do you think the patient have?

2- do you think this is obstructive or restrictive in nature?

pneumonitis:
inflammation of lung tissue.

Obstructive lung diseases:

lung diseases characterized by Limitation of pulmonary

airflow.
Restrictive lung diseases:
lung diseases characterized by reduced lung expansion
with decrease of total lung capacity.
Chronic obstructive pulmonary diseases (COPD):

A group of pulmonary diseases characterized by increased

resistance to air flow due to partial or complete obstruction
at any level. This include

Chronic bronchitis

Emphysema

Bronchiectasis.
Chronic bronchitis:

It is persistent productive cough (with sputum)

for at least 3 consecutive months in at least 2

consecutive years.
Emphysema:

Permanent dilatation of air spaces distal to the

terminal bronchioles accompanied by damage

of their elastic walls without obvious fibrosis.

i.e. respiratory bronchioles, alveolar ducts &

alveoli (respiratory acinus).

Bronchiectasis:

Permanent (irreversible) dilatation of medium

sized bronchi & bronchioles caused by chronic

suppurative inflammation in their walls and

surrounding lung tissue.

Bronchial asthma:

A common disease characterized by recurrent

attacks of widespread broncho-constriction in

response to various stimuli.

Pneumoconiosis:

Occupational lung diseases, caused by inhalation of

large amounts of dust particles e.g. silicosis,

asbestosis,….
Atelectasis:

incomplete or non-expansion of lung alveoli in

newborn.
Collapse:

Deflation of fully aerated alveoli (i.e. after complete

inflation). It is usually occur in adult.

Hydrothorax:
accumulation of serous fluid transudate in the
pleural cavity.
Haemothorax:
accumulation of the blood in pleural cavity.

Chylothorax:
Accumulation of lymph in the pleural cavity.
 Content of lecture
• Definition of tuberculosis
• Predisposing factor/ organsism
• Mode of infection
• Type of reaction
• Pathogenesis
• Primary TB …sites/histopathological features/ component /fate
• Miliary TB
• Secondary TB …histopathological features/ fate and
complications
• Conept of Tuberculoma

:
 Learning outcomes
• To define tuberculosis
• To study the pathogenesis of primary and secondary TB

• To differentiate between primary and secondary TB regarding

sited histopathological features

• To explain the complications and fate of primary and

secondary TB

• To learn the concept of miliary TB and Tuberculoma

 Case scenario
LN biopsy from the neck of child shows foci of epitheliod cells,
giant cells and lymphocytes with central caseation. The
diagnosis is

A. Syphilitic lymphadenitis

B. Tuberculous lymphadenitis

C. Chronic non specific inflammation

D. Acute lymphadenitis

E. Suppurative lymphadenitis
 Definition:
chronic infective granuloma affecting
nearly all body systems but mainly the
lungs.

Reference:
Personal Predisposing factors:
A) Environmental
Low socioeconomic standard.
Bad general hygiene.
Contact with tuberculous persons.
Overcrowding.
Environmental pollution.
b) factors
Negroes (more than white persons)
Malnutrition
Debilitating diseases (as D.M)
Immune deficiency states
Causative organism
T.B bacilli are:
Aerobic acid fast non motile,
Do not produce toxins,
Carried by macrophages
• Mode of infection

• Human type…by droplet infection from an

open, active pulmonary disease.

• Bovine type ..Oropharyngeal and intestinal

lesions are acquired by drinking raw
contaminated milk by of bacilli.
Types of tuberculous
reaction
 Pathogenesis of tuberculosis
Level - 1 Semester - 2
 Pathogenesis of tuberculosis
Level - 1 Semester - 2
 Pathogenesis of tuberculosis

The reaction ends by the formation of epithelioid

granulomas with giant cells , central caseation
and peripheral fibrosis.
 Primary Tuberculosis

1 Lungs
2 Intestine
3 Tonsils
4 Skin
5 Nose
 Primary pulmonary complex
 It is the form of disease
that develops in a
previously unexposed,
and therefore
unsensitized persons.
 It is more common in
children.
 Source of infection is
exogenous.
 About 5% of infected
persons develop
significant disease.
 Primary pulmonary complex

Consists of-:
1 Gohn’s focus Parenchymatous lesion
in lung

2 Lymphangitis (Inflammation of
lymphatic vessels)

- 3Hilar lymphadenitis (Inflammation of

lymphatic vessels)
Primary pulmonary complex
Ghon’s focus:-
-1-1.5 cm in diameter, grey-white.
-Found in the lower part of upper
lobe or upper part of lower lobe
usually close to the pleura.
-Central part undergoes caseation.
Primary pulmonary complex
Fate of primary complex:
1 Good fate: Healing

2 Bad fate: spread:

a. Local……..pleura & adjacent lung tissue.
b. Blood……more in primary TB it leads to miliary
tuberculosis
c. Lymphatic ++leading to tuberculous
lymphadenitis.
d. Natural passages....less common than
secondary…it leads to the development of
tuberculous bronchopneumonia and pneumonia.
 Miliary TB lung
Grossly ..
Affected organ shows a
large number of
-Small
-Uniform
-Grayish – yellow dots
-Near small blood vessels.
-Not surrounded by a zone
of hyperemia.
The millet seeds (right), for
which the pattern is named,
have a similar size
 s
Miliary TB lung
M/E…..
The affected organ shows large
number of
-Small uniform epithelioid
granulomas with giant cell
but with little caseation and little or
no surrounding fibrosis.
 Secondary tuberculosis
 In secondary TB the organism may be acquired exogenously or
from reactivation of a healed primary complex.

 It usually occurs in adults.

 Hypersensitivity reaction leads to excessive tissue destruction

and extensive caseation.
 No nodal affection as the organism is destroyed in the necrotic
tissue.

 Organs most commonly affected are - Kidney -Suprarenal gland -

Fallopian tube - Epididymis. - Brain and meninges - Bone and
joints.
Secondary pulmonary tuberculosis

 An apical lesion
(Assmann focus) begins
as a small caseating
tuberculous granuloma.
 In most cases,
destruction of the lung
leads to cavitations.
 Secondary pulmonary tuberculosis

M/E:-
There’s a central area of
caseation that is
surrounded by
granulomatous
inflammatory reaction.

Reference:
Fate and Complications of pulmonary
tuberculosis
A. Regression (good fate)
B. progressive lesion (Bad Fate)
1- Local tissue destruction….
- Blood vessels…hemorrhage & hemoptysis
- Bronchi..open to the pleura leading to
pneumothorax and pyopneumothorax.
- Reactive systemic amyloidosis.
2- Pulmonary fibrosis…pulmonary hypertension
..right sided heart failure (cor pulmonale).
3- Spread…..*Local to the pleura (pleurisy)
*Bronchial…TB pneumonia and
bronchopneumonia
*Blood…..isolated organ TB or miliary TB
Tuberculous bronchopneumonia

TB bronchopneumonia in which spread of

infection occurs to the lower lobes of the
lungs.
Tuberculous bronchopneumonia

Yellowish patches
represent
inflammation of
bronchioles and
surrounding lung
tissue
(bronchopneumonia)
 Apical lesion + TB pneumonia

Spread of infection
from the apical lesion
to the surrounding
lung parenchyma
leads to tuberculous
pneumonia.
Hemorrhage into a T.B cavity

Erosion of blood vessels by

tuberculous reaction can
lead to hemorrhage into the
cavity with coughing of
blood (hemoptysis)
Tuberculoma
 It is a localized mass
of caseating
tuberculous reaction
surrounded by fibrous
tissue.
 It may reach a large
size (to be mistaken
for a tumor)
 It can occur at any
organ (lung, kidney,
brain…(
Case Scenario or clinical correlate

LN biopsy from the neck of child shows foci of

epitheliod cells, giant cells and lymphocytes with
central caseation. The diagnosis is

A. Syphilitic lymphadenitis

B. Tuberculous lymphadenitis

C. Chronic non specific inflammation

D. Acute lymphadenitis

E. Suppurative lymphadenitis
Summary

Tuberculosis is a chronic specific granuloma

with development of type IV hypersensitivity
reaction

It could be primary or secondary according to

the exposure and development of immunity

Both types have wide range of complications

 Question 1
The following are component of the primary
complex except

A. Bacteraemia

B. Gohn’s focus

C. Lymphadenitis

D. Lymphangitis
 Question 2
• What is the reaction of the body against
bacilli in secondary tuberculosis?