Respiratory Pathologies Continued – Tuesday, October 17, 2006

Immuno background
~ GAMED – Igs in highest to lowest concentration in blood
~ IgM – non-specific, 1st response
~ IgA – secretory IgA in all secretions (tears, saliva, LU, gut, semen, vaginal fluid,
breastmilk)
~ IgG – usually memory cells
~ IgE – allergies, parasites
~ IgD – surface receptors for basophils
~ omnipotent – turn into any cells
~ plueripotent – can divide into many different cell types
~ hypoclorhydria = decreased production of gastric acid by stomach
~ autoimmune disorder – antibodies against own parietal cells
~ can’t activate pepsinogen
~ means can’t break proteins which get sent to SI and may go into your cells
~ if similar to own tissues, B cells will make Ab to kill own proteins
~ Heparin is a vasodilator and helps clot
~ histamine is in charge of inflammation

Pleural Effusion
~ excess fluid in the pleural space
~ normally, 10 to 20mL of fluid spread thinly over visceral and parietal pleurae
~ visceral covers LU
~ parietal under ribs
~ pleural effusions are classified as transudates or exudates
~ transudates – elevations in microvascular pressure or to decrease in oncotic pressure
~ caused by disturbances of hydrostatic or colloid osmotic pressure, not by
inflammation
~ fluid that passes through a membrane which filters out much of the protein and
cellular elements to yield a watery solution
~ accumulates in tissues outside blood vessels and can cause edema
~ exudates – pleural inflammation (pleurisy) with increased permeability of the pleural
surface to fluid with protein
~ any fluid that filters from the circulatory system into lesions or areas of
inflammation
~ composition varies but generally includes water and the dissolved solutes of the blood
~ fluid rich in protein and cellular elements
~ oozes out of blood vessels due to inflammation and is deposited nearby
~ altered permeability of blood vessels allow passage of large molecules and solid
matter through walls

Conditions Causing Transudates

~ heart failure – increases systemic venous and pulmonary capillary pressures
~ hypoalbuminemia – bilateral pleural effusions
~ ex: Kwashiorkor – protein deficiency
~ ascite fluid – can move from peritoneal space into pleural space through diaphragmatic
defects or lymphatic channels
~ myxedema – usually transudates
~ seen in hypotheyroidism
~ post-parturition – small effusions, clear rapidly, usually only during the 1st 24 hrs
~ iatrogenic – doctor induced

Conditions Causing Exudates

~ mycotic pleurisy – blastomycosis, coccidioidomycosis (West Coast), rare in primary
histoplasmosis and cryptococcosis
~ parapneumoic effusion – visceral pleura overlying a pneumonia becomes inflamed
~ pulmonary embolism – pleural effusions in 30-50% of patients
~ metastatic neoplasms – m/c cause in persons > 60 yr
~ Hodgkin’s disease and non-Hodgkin’s lymphoma
~ malignant mesothelioma

Pneumothorax
~ air/gas in pleural space
~ spontaneous – affects tall, thin men between 20-40yoa
~ cigarette and family history are contributing factors
~ secondary – complication of underlying pulmonary lung disease like asthma, CF, TB,
COPD and whooping cough
~ traumatic – injury to chest
~ trauma may be penetrating or blunt

Hemothorax & Chylothorax

~ hemothorax – d/t trauma and rarely after rupture of vessel in parietopleural adhesion
~ pleural blood often does not clot and may be easily drawn with needle
~ chylothorax – traumatic or neoplastic injury to thoracic duct
~ lipid content (neutrla fat and fatty acids) of pleural fluid is high
~ treatment is directed at underlying cause of ductal change

Lung Abcess
~ A localized cavity with pus, resulting from necrosis of lung tissue, with surrounding
pneumonitis
~ can be putrid (anaerobic bacteria) or non putrid (anaerobes or aerobes)
~ gangrene of the lung – more diffuse and extensive in which necrosis predominates
~ usually b/c of infected material from upper airway aspirated when patient is
unconscious
~ causative organism usually anaerobes
~ single lung abscesses are most common
~ multiple abscesses usually unilateral
~ rupture of large abscess into bronchus or vigorous attempts at drainage may cause
widespread bronchial dissemination of pus with diffuse pneumonia and condition
resembling adult respiratory distress
Pleurisy
~ aka pleuritis
~ inflammation of pleura, usually producing an exudative pleural effusion and stabbing
chest pain worsened by respiration and cough

Pleurisy Etiology
~ underlying infection – pneumonia, infarction, TB
~ direct entry – infectious agent or irritating substance into pleural space (ex: ruptured
esophagus, amebic empyema)
~ transport – infectious or noxious agent or neoplastic cells to pleura via blood or
lymphatics
~ parietal pleural injury – like trauma, rib fracture, pleurodynia
~ asbestos-related pleural disease – in which asbestos particles reach the pleura by
transversing the conducting airways and respiratory tissues

Pleurisy Pathology
~ pleura becomes edematous and congested
~ cellular infiltration follows and fibrinous exudate develops on pleural surface
~ exudate my be reabsorbed or organized into fibrous tissue resulting in pleural
adhesions
~ may see marked fibrous or even calcific thickening of pleura without previous acute
pleurisy

Lung Cancers
~ may be benign or malignant primary tumours or metastases from primary cancers or
other organs and tissues
~ primary lung tumours include: bronchogenic carcinoma (m/c type of lung cancer),
bronchial carcinoid, and number of rarer types
~ can have SI cells go to LU and get cancer there

Bronchial Carcinoid
~ used to be called bronchial adenoma (adeno = gland)
~ benign or malignant
~ equal in both men and women
~ course is prolonged
~ can obstruct major bronchi
~ brisk bleeding from overlying mucous membrane often occurs
~ recurrent pneumonia (same LU zone) and localized pleural pain are common
~ metastases are uncommon

Metastases and other Cancers

~ metastases to lungs are common from primary CA of breast, colon, prostate (top 3)
~ can also be from kidney, thuyroid, stomach, cervix, rectum, testis, bone, and melanoma
~ less common primary lung tumours include chondromatous harmatroma (benign),
solitary lymphoma and sarcoma (malignant)
~ lungs are sometimes affected by multifocal lymphomas
Bronchogenic Carcinoma
~ a highly malignant primary lung tumour that accounts for most cases of lung cancer
~ poor prognosis
~ > 90% of all lung tumours
~ leading cause of cancer death among men (32%) and women (25%)
~ incidence rising in women
~ mc/ between 45-70 yoa

Bronchogenic Carcinoma Etiology

~ primary cause – cigarette smoking
~ 87% of all LU cancers attributed to tobacco
~ dose-response relationship occurs in 3 most common types of bronchogenic
carcinoma:
~ 1) squamous cell
~ 2) small cell
~ 3) adenocarcinoma
~ 15% men and 5% women
~ related to occupational agents: asbestos, radiation, arsenic, chromates, nickel,
cloromethyl ethers and mustard gas
~ role of air pollution is uncertain
~ sometimes bronchogenic carcinomas associated with pulmonary scars
~ damage to DNA, oncogene activation, and stimulation by growth factors now thought
to be of primary importance

Bronchogenic CA – Pathology
~ four histologic types of are distinguished:
~ 1) squamous cell – larger bronchi, spread via direct extension & lymphatic metastasis
~ 2) undifferentiated small cell – assocatied with early hematogenous metastases
~ 3) undifferentiated large cell – usually spreading through bloodstream
~ 4) adenocarcinoma – commonly peripheral, often spreading through the bloodstream
~ usually spread via lymphatics
~ bronchioalveolar carcinoma – subtype of adenocarcinoma consolidates airspaces and
often does not extend beyond the lungs
~ usually multifocal (ddx with other cancers)

Bronchogenic CA – metastasis
~ hematogenous metastatic spread to liver, brain, adrenals, and bone
~ can occur early – symptoms may appear there before pulmonary symptoms

Bronchogenic CA – Sequelae
~ small cell carcinomas – secrete ectopic ACTH (ex: Cushing’s syndrome) or ADH
(water retention and hypoatremia)
~ ectopic – made somewhere where it’s not supposed to be
~ also associated with carcinoid syndrome (flushing, wheezing, diarrhea, and cardiac
valvular lesions)
~ squamous cell carcinoma – secrete PTH-like substance  hypercalcemia
~ other endocrine syndrome with primary lung cancers include:
~ gynecomastia, hyperglycemia, thyrotoxicosis, skin pigmentation
~ may have hematologic disorders including thrombocytopenic purpura and
leukemoid reaction

Bening neoplasms
~ benign laryngeal neoplasms include: juvenile papillomas, hemangiomas, fibromas,
chrondromas, myxomas, neurofibromas
~ may affect any part of larynx
~ removal restores voice, functional integrity of laryngeal sphincter, and airwa