PNEUMONIA & SUPPURATIVE LUNG DISEASES

Dr. Thin Thin Win @ Safiya Yunus Department of Pathology, PPSP

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PNEUMONIA
Definition
 Inflammation of the lung parenchyma

(alveoli) resulting consolidation or hardening of lung parenchyma

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Etiology
 Caused by varieties of infectious agent

such as bacteria, viruses, fungi, mycoplasma etc:  Mostly bacterial pneumonia (Pneumococci, Klebsiella pneumoniae,
Staphylococci, Streptococci, H.influenzae, Pseudomonas aeruginosa) Community acquired acute pneumonia
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Etiology
 Result whenever pulmonary defense

mechanism are impaired or resistance of host is lowered  Pulmonary defense mechanism 1. cough reflex 2. mucociliary apparatus 3. phagocytic alveolar macrophages
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Clearing mechanism can be interfered with many factors:

1. Loss or suppression of cough reflex aspiration of gastric contents in coma, anesthesia, neuromuscular disorders, drugs, chest pain aspiration pneumonia

2. Injury to mucociliary apparatus

cigarette smoking, inhalation of hot or corrosive gases, viral infection, genetic disorders
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Clearing mechanism can be interfered with many factors:

3. Interfered phagocytic/ bactericidal action of alveolar macrophages alcohol, smoking, anoxia, O2 intoxication 4. Pulmonary congestion & edema 5. Accumulation of secretions
cystic fibrosis & bronchial obstruction

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Aetiology & antomical pattern of pneumonia

Community acquired acute pneumonia Aetiology Bacteria Community acquired atypical pneumonia Virus Mycoplasma Clamydia

Anatomical Lobar pneumonia Interstitial pneumonia involvement Bronchopneumonia

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Lobar pneumonia

 Consolidation of a large portion of a

lobe or an entire lobe  (whereas patchy consolidation in bronchopneumonia)

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Lobar pneumonia

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Bronchopneumonia

A closer view of the lobar pneumonia demonstrates the distinct difference between the upper lobe and the consolidated lower lobe.
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Uniformly consolidated lower lobe in lobar pneumonia ( gray hepatization) lower lobe become airless, liver like texture, gray white

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4 stages of inflammatory response in lobar pneumonia

 Congestion  Red hepatization  Gray hepatization  Resolution

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Stage of congestion
 Lung heavy, boggy, red  Vascular engorgement  Intra-alveolar fluid with few neutrophils & often

numerous bacteria

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Stage of red hepatization

 Massive confluent exudation with red

cells, neutrophils and fibrin filling the alveolar spaces  Gross lobe appear distinctly red, firm & airless with liver-like consistency

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Stage of red hepatization

Stages of gray hepatization

 Progressive disintegration of red cells  Macrophages replace PMN with fibrin

deposition  Persistence of fibrinosuppurative exudates  Gross grayish brown, dry surface

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Stages of gray hepatization

Stage of resolution
 Consolidated exudates within alveolar

spaces undergoes progressive enzymatic digestion to produce a granular, semi fluid debris  Resorbed & ingested by macrophages, coughed up or organized by fibroblasts growing into it

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Stage of resolution (by organization)

Bronchopneumonia
 Patchy consolidation of lung  May be one lobe or multilobar  Frequently bilateral & basal

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Bronchopneumonia
Gross  Lesions - 3 to 4 cm in diameter  Slightly elevated, dry, granular, gray-red to yellow  Poorly delimited at margin Histology  Suppurative, neutrophil-rich exudates that fills bronchi, bronchioles and adjacent alveolar spaces
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At higher magnification, the pattern of patchy distribution of a bronchopneumonia is seen.

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Bronchopneumonia

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Community acquired atypical pneumonia (Viral and Mycoplasma Pneumonia) Interstitial pneumonia Morphology
 Patchy or whole lobe  Bilateral or unilateral  Red-blue, congested & subcrepitant  Pleuritis or pleural effusion is infrequent
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Community acquired atypical pneumonia (Viral and Mycoplasma Pneumonia) Histology  Inflammatory reaction in interstitial tissue, virtually within the walls of alveoli  Alveolar septa widened, edematous with mononuclear infiltrates of L, H, P & N in acute cases  Alveoli free of exudates  Pink hyaline membrane in alveolar walls
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Chronic Pneumonia
 Localized lesion in Immunocompetent

patient  Granulomatous inflammation Mycobacterium tuberculosis, Fungal infection (Histoplasmosis, Blastomycosis, Coccidioidomycosis, Aspergillosis)

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Complication of pneumonia
1. Abscess formation - due to tissue destruction & necrosis 2. Pleuritis, Pleural effusion, Empyema - spread of infection to pleura cavity causing intra-pleural fibrinosuppurative reaction
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Complication of pneumonia
3. Organization of exudates - convert portion of lung into solid tissue with fibrous scar 4. Bacterial dissemination - to heart valves, pericardium, brain, kidneys,
spleen, joints resulting metastatic abscesses, endocarditis, meningitis, suppurative arthritis

5. Septicemia
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Clinical features
 Abrupt onset of high fever with chills  Productive cough  Mucopurulent sputum  Pleuritic pain & friction rub  Radiologic appearance

- well circumscribed radio-opacity in LP - focal opacities in BP

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SUPPURATIVE LUNG DISEASES

 Bronchiectasis  Lung abscess  Empyema

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BRONCHIECTASIS
Definition
 Disease characterized by permanent

dilatation of bronchi & bronchioles caused by destruction of the muscle & elastic tissue, resulting from or associated with chronic necrotizing infection

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Etiology
 Obstruction & infection major cause

- obstruction (mucus, tumor, FB) impaired normal clearing mechanism pooling of secretion distal to obstruction inflammation of airways  Severe infection necrotizing fibrosis and eventually dilatation of airways

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Etiology
 Congenital or hereditary

- cystic fibrosis - intralobular sequestration of the lung - immunodeficiency state - primary ciliary dyskinesia - Kartagener syndrome

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Morphology
 Lower lobes, bilaterally  Vertical air passages  Most severe in more distal bronchi &

bronchioles

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ross
 Airways dilated, up to 4 times  Long, tube-like enlargement of airways

cylindrical bronchiectasis  Fusiform or saccular distension saccular bronchiectasis  Dilated airways can be followed directly out to pleural surfaces  On C.S cysts filled with mucopurulent secretions
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Bronchiectasis
Bronchial tubes are extremely dilated with thicken, fibrotic wall. Adjacent lung is almost completely destroyed

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37 Focal area of dilated bronchi with bronchiectasis.

Histology
 Full-blown, active case

intense acute & chronic inflammatory exudation within the walls of bronchi & bronchioles  Desquamation of lining epithelium  Extensive areas of necrotizing ulceration

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Clinical course
 Cor pulmonale  Lung abscess  Metastatic brain abscesses  Amyloidosis

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LUNG ABSCESS
Definition
 A local suppurative process within the

lung, characterized by necrosis of lung tissue

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Etiology & Pathogenesis

 Oropharyngeal surgical procedures,

sinobronchial infection, dental sepsis, bronchitis

 Aerobic & anaerobic streptococci ,

Staphylococcus aureus, GN organisms

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Mechanisms
 Aspiration of infective material in acute

alcoholism, coma, anesthesia, sinusitis, gingivodental sepsis, debilitation - cough reflexes depressed  Antecedent primary bacterial infection post-pneumonic abscess, fungal infection, bronchiectasis  Septic embolism  Neoplasia  Miscellaneous
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Morphology
 Size -few mm to large cavities of 5-6 cm  Single or multiple  Abscess due to aspiration

more common on right ( more vertical right main bronchus ) and more single  Abscess from pneumonia or bronchiectasis usually multiple, basal, diffusely scattered
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Morphology
 Cavity filled with suppurative debris  If communication with air passage

partially drain air-containing cavity  Continued infection large, fetid, green-black, multilocular cavities (gangrene of the lung)  Suppurative destruction of lung parenchyma within central area of cavitation
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Seen here are two lung abscesses, one in the upper lobe and one in the lower lobe of this left lung.
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abscessing bronchopneumonia in which several abscesses with irregular, Dr TTW (2009) rough-surfaced walls are seen within areas of tan consolidation.

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pulmonary abscess cavity. Multiloculated with delicate strands of fibrous tissue crossing the space. No evidence of acute inflammation in the wall Dr TTW (2009) Fairly normal surrounding lung.

Old

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Course
 Most resolve with antimicrobial therapy  Extension of infection into pleural cavity

empyema  Hemorrhage  Septic emboli brain abscess, meningitis  Secondary amyloidosis

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EMPYEMA
 Collection of pus in pleural cavity  Suppurative pleuritis  Presence of purulent pleural exudates  Characterized by loculated, yellow-

green, creamy pus composed of neutrophils admixed with other leukocytes

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Etiology
 Contiguous spread of organisms from

intrapulmonary infection  Lymphatic dissemination  Haematogenous dissemination  Direct extension of infection below diaphragm (subdiaphragmatic or liver abscess) especially on right side
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Clinical course
 May resolve by antibiotics  Obliterate pleural space or envelope

the lungs expansion

embarrass pulmonary

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