-
Disease states that promote pulmonary embolism in situ?
hypertension, pulmonary atherosclerosis, heart failure
-
Number one cause for patients dying in the hospital?
Pulmonary embolism
-
Secondary hypercoagulable causes for pulmonary embolism?
oral contraceptives, recent surgery, obesity, cancer, pregnancy
-
Two main pathological consequences of PE
- respiratory compromise, non perfused but ventilated portion of the lung.
- cardiac compromise, increased pulmonary resistance
-
What is cor pulmanale?
Failure of the right heart due to pulmonary hypertension
-
Will a small pulmonary embolism cause an infarct?
not usually in an individual with normal heart function
-
How to distinguish from a pulmonary infarct or hemorrhage
An infarct will cause damage to the lung parenchyma
-
PE lesion has a wedge shape with apex pointing to hilum.
-
Septic infarct?
- PE that is infected, leads to more intense neutrophile exudation and more intense inflammatory response
- Some convert to abscesses.
-
Electromechanical dissociation
ECG shows a rhythm but there is no pulse.
-
Clinical symptoms after surviving a PE
chest pain, fever, dyspnea, shock, increased serum lactic dehydrogenase
-
-
Prophylactic treatment to prevent PE
early ambulation, elastic stockings, anti coagulation
-
Non thombotic forms of PE
air, fat, amniotic fluid, sickle cells, foreign bodies during IV drug use
-
What pressure is pulmonary hypertension?
1/4 systemic
-
In obstructive pulmonary disease pulmonary hypertension is caused by?
alveolar hypoxia causes vasoconstriction of its bronchioles
-
4 causes of pulmonary hypertension?
- 1. COPD, vasoconstriction due to hypoxia
- 2. left heard failure of mitral stenosus
- 3. PE
- 4. Autoimmune, sclerosis, attach of collagen leading to inflammation
-
P hypertension with no known cause
idiopathic primary p hypertenstion
-
Cause of primary pulmonary hypertension?
mutation in the BMOR2 signaling pathway
-
What is BMPR2
- cell surface protein of the TGF-beta family
- binds TGF, BMP, activin, inhibin
- in vascular smooth muscle BMPR2 causes inhibition of proliferation and favors apoptosis
- Two hit model where a person with BMP2 mutation needs additional genetic or environmental insult to develop the disease
-
Loss of _ promotes vascular constriction and plt adhesion
prostacyclin, NO
-
Environmental and drugs that have proven to cause pul htn
- crotalaria spectabilis, bush tea
- aminorex, appetite suppressant
- olive oil
- fenfluramine and phentermine, anti obesity drugs
-
plexogenic pulmonary arteriopathy?
tuft of capillaries that form producing a network that spans the lumens of dilated thin walled vessels.
-
coughing up blood?
hemoptysis
-
Hardening of tissues?
sclerosis
-
Causes of vascular lessons in pul htn
- atheromas
- intimal fibrosis
- medial muscular hypertrophy
- plexogenic arteriopathy
- organized thrombi, recanulization
-
Good pastures syndrom?
- autoimmune disease of circulating antibodies targeted to collagen IV
- Initiate an inflammatory destruction of the basement membrane in the lungs and kidney glomeruli
- Causes rapid progressive glomerulonephritis and necrotizing hemorrhagic interstitial pneumonitis
- may be unmasked by some environmental insult
- Deposits of immunoglobins on the BM
- Treat with plasma replacement and immunosuppresive therapy
-
Illness accompanying kidney failure?
Uremia
-
Idiopathic pulmonary hemosiderosis
- Intermittent diffuse alveolar hemorrhage
- Presents with cough, hemoptysis, anemia, weight loss
- longs have areas of consolidation
-
What is the key feature to idiopathic pulmonary hemosiderosis?
- There is hemorrhage into the alveolar space and hemosiderosis in the alveolar space and free macrophages in the alveoli
- No inflammation
-
abnormal accumulation of hemociderin
hemociderosis, iron overload disorder.
-
Wegener Granulomatosis
- autoimmune, upper respritory tract and lungs
- Diagnostic features are capillarities and scattered poorly formed granulomas
-
Infection of the lung parenchyma?
pneumonia
-
Most common infection?
respiratory, viral
-
Factors that affect resistance to infection?
- immunosupressive theropy
- chronic disease
- leukopenia
-
Ways the respritory clearing mechanism can be interfered with, 5?
- Loss of cough reflex; anesthesia, coma, drugs, chest pain
- Injury to ciliary apparatus; smoking, genetic, corrosive gases
- Loss of alveolar macrophages; smoking, drinking, anoxia, oxygen intoxication
- pulmonary congestion or edema
- accumulation of secretions; CF
-
One type of pneumonia can predispose you to another
-
Infection originating in the hospital
Nosocomial infaction
-
7 pneumonia syndromes
- 1. community acquired
- 2. community acquired atypical
- 3. nosocomial
- 4. aspiration
- 5. chronic
- 6. necrotizing and lung abcess
- 7. pneumonia in the immune compromised host
-
Bacterial invasion of the lung causes the alveoli to be?
filled with an inflammatory exudate, thus causing consolidation of the tissue.
-
Film produced my bacteria in the lungs to protect itself
alginate
-
Streptococcus pneumoniae, pneumococcus
- Most common community acquired
- Diagnosis with gram positive filled macrophages
- responds to PCN
- 20% of the population have this as normal flora, can then check for blood culture
-
Haemophilus influenzae
- pleomorphis, gram negative
- major cause of life threatening lower repritroy infections and meningitis in children
- community acquired acute pneumiae
- colonizes the pharynx
- two forms incapsulated and un-incapsulated, the encapsulated secretes haemocin that kills the un-cap
- can produce otitis media, sinusitis, and bronchopneumonia
- secretes a factor that disorganizes ciliary beating and a protease that that degrades IgA
- can cause acute pink eye in children
- Most common bacterial cause of acute COPD
-
Moraxella catarrhalis
community acquired, one of the top causes of otitis media in children
-
Staphylococcus aureus
- community and nosocomial
- secondary bacterial pneumonia following a viral infection
- lung abscess and empyema
-
Klebsiella pneumoniae
- community acquired
- most frequent cause of gram negative pneumonia
- Thick and gelatinous sputum
- commonly affects malnourished and debilitated people, alcoholics
-
Pseudomonas aeruginosa
most common cause of nosocomial pneumonia but also community acquired with cystic fibrosis patients
-
Legionella pneumophila
- Legionnaires disease
- pontiac fever
- lives in artificial aquatic environments, water cooling tower, portable water supplies
- predisposed by chronic organ disease
- diagnose by culture, antigens in the urine
-
Community acquired pneumonia morphology
- bronchial, patchy consolidation
- lobular consolidation
- four stages; congestion, red hepatization, grey hepatization, resolution
- red stages is blood filled exudate and when when blood is digested just fibrin exudate is left behind
-
complication of pneumonia
- tissue distraction with necrosis and abcsess formation
- spread of infection to the pleural cavity known as empyema
- organization of the exudate
- bacterial dissemination to the heart valves, brain kindness spleen and joints
-
Clinical course of community acquired pneumonia
- abrupt onset of fever, shaking chills, cough with mucopurulent sputum, hemptysis
- radio-opaque appearance of lobe or broncials
-
collection of pus and infection in the pleural cavity
empyema
-
fibrinosuppurative exudate
-
Community acquired atypical pneumonia
- modorate amount of sputum , no physical findings of consolidation, small elevation of white cells, lack of exudate and afebrile
- most common cause is mycoplasma pneumonia
- viral causes are; influenza, synctial, adenovirus, rhinovirus, herpis simplex, cytomeglovirus)
- most of the time identified as the common cold
- attaches to upper respritory tract and causes inflammation
-
Atypical pneumonia morphology
- trasidate edema in the alveoli
- Patchy or lobar ares of congestion without consolidation
-
Influenza infections
- viral envolope contains hemagglutinin and neuraminidase
- cleared by cytotoxic t cells
- pandemics occur when there are mutation in the hemaggluinin and neuraminidase; can be with the animal forms
-
Severe acute respiratory syndrome (SARS)
- Incubation period of 2-4 days
- dry cough, malaise, myalgias, fever and chills
- caused by a coronavirus, infects the lower respiratory tract and spreads throughout the body
-
-
general feeling of illness
malaise
-
Nosocomial pneumonia
- hospital acquired
- common in patients with severe underlying disease, immunosuppressed, prolonged antibiotic therapy, pt with IV catheters
- Gram negative rods of enterobacteria and staphylococcus aureus
-
Aspiraton pneumonia
- can aspire while unconscious or during repeated vomiting
- typically recover more then one organism from culture, aerobes are more common
-
Lung abscess
- a local suppurative process within the lungs
- common organisms are streptococci, staphylococcus auras and a host of gram negative
-
Introduction methods organisms of lung abscess
- 1. aspiration of infected material; in acute alcoholism, coma, anestesia, dental sepsis depressed cough reflex,
- 2. primary bacterial infection
- 3. septic emobolism
- 4. neoplasia, from a malignancy
- 5. miscellaneous; direct trauma, spread of infection,
- 6. no known cause, primary cryogenic lung abscesses
-
Morphology of abscesses
- very in size
- if due to inspiration, more common on right
- scattered if due to infection
- can lead to gangrene of the lung
- CARDINAL CHANGE; suppurative destruction of the lung parenchyma within the central area of cavitation
- must rule out carcinoma
-
Chronic pneumonia
- usually a localized lesion in the immunocompetent patient
- granulomatous inflammation
- Bacterial (tb)
- fungal ( histooplasmosis, blastomycosis, coodioidomycosis); granulomatous that resemble TB, thermally dimorphic,
- geographic distrabution
-
thermally dimorphic fungi?
grow as hyphae and produce spores at environmental temps but grow as yeasts at body temp
-
Histoplasmosis
- Histoplasma capsulatum is acquired by inhalation of dust particles for soil contaminated by bird or bat droppings
- ohio, mississippi river, and caribbean
- intercellular parasite of macrophages
- self limited primary pulmonary
- expresses a heat shock protein that binds to macrophage B2-integrin
- multiple in the phagasome and multiple in the macrophage before lysing it
- T cells recognize the fungal cell wall antigens and secrete interferon which activates the macrophage to kill the yeast
- Histoplasma induces macrophages to secrete TNF to recrouit more macrophages
- Disseminates in the immunecompromised patient
- seen in apices of the lungs
-
Blastomycosis
- Blastomyces dermatidis
- central and southeast US, canada, middle east, and africa
- can come through the skin
- abrupt illness with productive cough, headache, chest pain, fever, and pain
- pulmonary infiltrates
- suppurative granulomas in which macrophages can not digest, the prolonged precense of yeast cells keeps recruiting neutrophils
- skin can be involved and may be mis diagnosed as squamous cell cancer
-
Coccidiodomycosis
- coccidioides immitis
- almost 100% infection rate if inhaled
- southwest and far west US
- positive skin test reaction
- when ingested by the macrophage the fusion of the phagosome and lysosome is blocked to resist killing
- mostly asymptomatic
-
Pneumonia in the immunocompomised host
- infected by opportunistic bacteria
- in AIDs patients it is usually P. carinii
- Bacteria; pseudomonas aeruginosa, mycobacterium, legionella pneumophilia, listeria monocytogenes
- Viral; CMV and herpes
- Fungi; pneumocysetes caranii canidida, aspergillus, phycomycetes, cryptococcus neoformes
-
Pulmonary disease in HIV patients
- leading cause of disease in HIV patients
- oppurtunistic organisms
- Kaosi sarcoma and non hogkins lymphoma, both non infectious agents
- CD4 count; bacterial and tubrical infections with a count over 200, pneumocystis usually below 200, mycobacterium below 50.
|
|