Middle Examination

• Multiple choice 50%

• Short answers 25%

• Long answers 10%

• Case analysis 15%

• The weekend of 10th week, 150 min

• 总论 + 心血管系统疾病

Chapter 9Chapter 9Diseases of the Respiratory SystemDiseases of the Respiratory System

Department Of PathologyDepartment Of PathologyGuangxi Medical UniversityGuangxi Medical University

Zili Lv Zili Lv 吕自力吕自力 lvzili@yahoo.com.cnlvzili@yahoo.com.cn

Anatomic Structures and FunctionsAnatomic Structures and Functions

Bronchi

Bronchioles

Alveolar ducts

Alveoli

Clinical features of respiratory diseases

1. Cough 2. Sputum Production 咳痰 3. Hemoptysis 咯血 4. Dyspnoea 呼吸困难 5. Cyanosis 紫绀 6. Chest pain

Contents (6 hrs)Contents (6 hrs)

1. Pulmonary infections 2. Chronic obstructive pulmonary

diseases & chronic cor pulmonale 3. Chronic diffuse interstitial lung

disease, carcinoma of nasopharynx and lung.

Pulmonary infections

Acute Pneumonia

Chronic Pneumonia

Classification of pneumonia Clinical circumstance

Primary and Secondary Etiological agent

Bacterial, Virus, Fungal Host reaction

Fibrinous & Suppurative Anatomical pattern

Lobar & Lobular

Case 1 analysisCase 1 analysis

History: Male, 20, after suffering from cold and drunk, got high fever, chill, rapid breathing and chest pain. After 2 days, he coughed with “rusty” sputum.

T: 40 , R: 32 times/min.℃

Chest x-ray: show large-area uniform dense well-delimited shadow in his left upper lobe.

Blood examination: WBC: 13.5x 109/ L

BACTERIUM PNEUMONIABACTERIUM PNEUMONIALobar pneumoniaLobar pneumonia

Lobular pneumoniaLobular pneumoniaLegionella pneumoniaLegionella pneumonia

Lobar pneumoniaLobar pneumonia

Affects a large part, or the entirety of a lobe Relatively uncommon in infancy and old age Affects males more than females 90% due to pneumococcus ( 肺炎球菌） Cough and fever with purulent or

Rusty Sputum 铁锈色痰

A. EtiologyA. Etiology

Pathogen: Streptococcus pneumonia

肺炎球菌 III 型Infective Route: Inhalation, Aspiration 吸入 Risk Factors ： Cold, drunk, tired, diabetes

B. Pathology*B. Pathology*

Acute exudative fibrinous inflammation

（急性纤维素性炎） Involves one whole lobe or several lobes

The bronchi are not involved

Pathologic FeaturesPathologic Features

Acute congestion 充血水肿期 Red hepatization 红色肝样变期 Gray hepatization 灰色肝样变期 Resolution 溶解消散期

1. Stage of acute congestion1. Stage of acute congestion 1st-2nd day 1st-2nd day

(1)Gross changes: Heavy, dark red and firm (2)Microscopic change

Fluid, RBC, WBC in the air space (3)Clinical features:

Stage of acute congestionStage of acute congestion

Alveolar capillaries: Dilated

Air space: Fluid, RBC, WBC

Fever, cough, cyanopathy ( 发绀 ) Chest pain Bacteremia Bacteria can be found in sputum

Stage of acute congestionStage of acute congestionClinical FeaturesClinical Features

• Red and consolidation, just like liver

2. Stage of Red Hepatization: 2. Stage of Red Hepatization: 2nd-4th day 2nd-4th day

（1

）G

rossly

(2)Microscopic changes of red hepatization(2)Microscopic changes of red hepatization

A. Capillaries congestion

B. Exudation:

Fibrin, large number of RBC

C. Fibrinous pleurisy

Microscopical changesMicroscopical changes

红色肝样变期红色肝样变期 XX 线特点线特点(3)

Chest x-ray

• The middle segment of right upper lobe become consolidated and show large-area uniform dense shadow.

(4) Clinical features of red hepatization(4) Clinical features of red hepatization

Fever, cough, chest pain Rapid breathing, cyanopathy Dullness 浊音 Vocal fremitus enhancement 语颤增强 Rusty sputum 铁锈色痰

3. Stage of 3. Stage of graygray hepatization: hepatization: 5th-6th day 5th-6th day(1)Gross changes of grey hepatization

Dry Gray Firm Consolidation

(2)Histological changes(2)Histological changes Capillary is

not dilated anymore.

Alveolar space is filled with neutrophil and fibrin

Histological changes of grey hepatizationHistological changes of grey hepatization

X-ray features of gray hepatizationX-ray features of gray hepatization• (3)Chest x-ray: high dense shadow can

be found at the right upper lobe

(4)Clinical features of gray hepatization(4)Clinical features of gray hepatization

Consolidation: dullness, vocal fremitus enhancement

Sputum: mucus purulent sputum

Dyspnoea( 缺氧） : is not obvious

4. Stage of Resolution, 7 days later4. Stage of Resolution, 7 days later Gross changes: Friable and mottled Microscope: Microscope: The fibrin and cell debris are

digested by enzymatic, The exudation is remove.

Chest X-rayChest X-ray

Pathologic Features (4 stages)Pathologic Features (4 stages)

LOBULAR PNEMONIALOBULAR PNEMONIA

小叶性肺炎小叶性肺炎 (Bronchopneumonia)(Bronchopneumonia)

(( 支气管肺炎支气管肺炎 ))

Lobular pneumoniaLobular pneumoniaBronchopneumoniaBronchopneumonia

Bronchi are infected Patchy consolidation Centred on inflamed bronchioles or bronchi Secondary pneumonia Less virulent agents, in infancy or old age Suppurative inflammation 化脓性炎

Pathogen: many bacteria, Infection via: Inhalation, Aspiration Risk Factors: Secondary

A. Etiology

B. Pathology

Gross:

Lower lobes, dorsal side

Multiple firm areas, around inflamed bronchioles.

Microscope:Microscope:

1. Multiple lesions

Purulent bronchitis and bronchiolitis ( 化脓性细支气管炎 )

2. Alveolar spaces surrounding the lesions are filled with neutrophil

3. Compensatory emphysema ( 代偿性肺气肿 )

C. Clinical FeaturesC. Clinical Features

The onset is insidious, nonspecific Low-grade fever Dyspnea is not prominent The typical feature is

Purulent Sputum 脓痰 *

• Chest x-ray

• Several scattered patchy shadows evidently in bilateral lower lobes

Legionella pneumonia, 军团菌肺炎

 

•嗜肺军团杆菌•急性纤维素性化脓性炎—典型病例 , 严重者坏死—脓肿•临床表现复杂 : 肺内 \外表现

                                               

       

acute fibrino-purulent exudative pneumonia

急性纤维素性化脓性炎

Legionella pneumonia, 军团菌肺炎

军团菌病 (legionaires disease) 是由革兰染色阴性的嗜肺军团杆菌(legionella pneumophila) 引起的一种以肺炎为主的全身性疾病， 1976年被确认。

Lobar pneumonia

Lobular pneumonia

Air space pneumonia

Complications

Resolution

Complications of acute air space Complications of acute air space pneumoniapneumonia

Pleura involvement Bacteremia Suppuration (Abscess Formation) Necrotizing bacterial pneumonia Pulmonay carnification 肺肉质变

• Lung abscess

• Pulmonary carnification

Distribution

Number

Host

reaction

Clinical

Features

What are the differences?What are the differences?

Acute interstitial pneumoniaAcute interstitial pneumonia 间质性肺炎间质性肺炎

1. Agents: Virus (SARS, Avian influenza, Swine Flu) and Mycoplasma or Pneumocystis

2. Interstitium 3. Atypical pneumonia 4. Infiltration with lymphocyte, monocyte

Pathologic Features of Viral pneumonia Pathologic Features of Viral pneumonia

The alveolar septa are expanded Cell infiltrate: lymphocyte, plasma cells Air spaces are air filled Epithelial necrosis Inclusion bodies 病毒包涵体 Multinucleated giant cells 多核巨细胞 Hyaline membranes 透明膜

Viral Pneumonia

Severe Acute Respiratory Syndrom (SARS)

重症急性呼吸综合征 Atypical pneumonia （非典型肺炎） Cornonavirus 变异的冠状病毒 Extensive consolidation, hyaline membrane,

necrosis, pulmonary fibrosis Die in respiratory distress

SARSSARS

Clinical featuresClinical features

Electro microscopeElectro microscope

Avian Influenza 禽流感

人畜共患传染病

H5N1

Interstitial

Atypical

Bird fluBird flu

An infection disease of birds 1997, Hong Kong, outbreak Vascular disturbances Fever, cough All the other organs can be affected, for

example, liver, heart and kidney.

H1N1, Swine influenza A

H1N1, Swine influenza A

临床表现轻症：同普通流感；重症：肺炎，坏死性脑病 合并症：急性呼吸窘迫综合征 病理：肺部表现为支气管壁坏死、中性粒细胞

浸润、弥漫性肺泡损害伴肺透明膜病变。 发病机制：病毒损伤肺泡微血管导致肺出血与

血栓形成，体内免疫因子可对抗病毒感染并修复损伤，但炎症反应过度、渗出液充满肺组织又使肺瘢痕形成，进而限制肺功能。

H1N1 and H5N1

Interstitial pneumonia Atypical pneumonia Congested, edematous,

mononuclear cells infiltration

Mycoplasma pneumonia 支原体肺炎

Air space

pneumonia

Lobar pneumonia

Lobular pneumonia

Interstitial

pneumonia

Viral pneumonia

Mycoplasma pneumonia

ARDSARDSAcute Respiratory Distress SyndromeAcute Respiratory Distress Syndrome

An acute diffuse alveolar injury Terminal events in many of the patients Serious ill, the mortality rate > 50% Results from ischemic, endotoxins, enzymes.

Case 1 analysisCase 1 analysis

History: Male, 20, after suffering from cold and drunk, got high fever, chill, rapid breathing and chest pain. After 2 days, he coughed with “rusty” sputum.

T: 40 , R: 32 times/min.℃

Chest x-ray: show large-area uniform dense well-delimited shadow in his left upper lobe.

Blood examination:

WBC: 13.5x 109/ L

Questions Questions What is the diagnosis? Which type of inflammation? Why does the patient cough with the

“rusty” sputum?

Half a year later, this student was enrolled to the army.

The chest x-ray indicated there was a nodule in his left lung.

The nodule was checked under microscope, there was much granulation tissue in the alveolar spaces.

WHY?

Case abstract 2Case abstract 2 Male, 70-year-old, he had suffered

hypertensive heart disease and left heart failure for half a year, and cough and expectoration for 1 year. These symptoms aggravated 4 days ago with fever and purulent sputum.

T: 38 , HR: 112 times/min, R: 35 ℃times/min, BP: 22.6/13.5 kPa.

Blood WBC: 10.2 X 109/L

X-ray: Several scattered patchy shadows evidently in bilateral lower lobes.

Questions Questions

What is the diagnosis? Which type of inflammation? Why do patients cough with the purulent

sputum?

Summary Summary How to differentiate the lobar pneumonia

and the bronchopneumonia?

What is the “rusty sputum”?

See you next time!

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