INSTRUCTORS ONLY

Respiratory Laboratory 1:
The patient with cough/shortness of breath

Slide 60 [WebScope] [ImageScope]

An 83-year old man presents with an acute myocardial infarction and dies before intervention is performed. At autopsy, the pleural surfaces of both lungs were fibrotic. The cut surfaces of the lungs manifested diffuse fibrosis with extensive “honeycombing.” The hilar lymph nodes were not enlarged. When examining this slide, notice that many of the alveolar walls contain more nuclei than usual and that there are detached fragments of alveolar septa. Small deposits of anthracotic pigment are also evident. Many of the alveolar septa are thickened by fibrosis. Within these areas of fibrosis are golden brown beaded or “knobby” structures.

1. The fibrotic alveolar walls represent a nonspecific reaction to injury that is a common pathology feature in many of the restrictive lung diseases. In this case, the golden brown bodies represent the etiologic agent. What are these bodies?

2. How did the fibrosis come about?

3. What pulmonary disorders may result from asbestos exposure?

4. Do you think you have asbestos fibers in your lungs?

5. List examples of other restrictive lung disorders.

6. Predict the results of these pulmonary function tests (normal, increased, or decreased): total lung capacity, residual volume, forced vital capacity, forced expiratory volume in 1 second, and maximal expiratory flow rate.

Slide 26 [WebScope] [ImageScope]

A 60-year-old man sought medical attention because of weight loss. During his evaluation, the patient also complained of a decreased appetite, weakness, and night sweats. A non-productive cough had recently developed. Physical examination revealed hepatomegaly and splenomegaly. A chest radiograph manifested a diffuse reticulonodular infiltrate. Laboratory evaluation disclosed an anemia with leukopenia and an elevated alkaline phosphatase level. A liver biopsy sample was obtained and a diagnosis was established. The patient responded promptly to treatment. Slide 26 was obtained from a similar patient at autopsy.

1. Based on the clinical presentation and the findings contained in the autopsy slide, what diagnoses are most likely?

2. How could you confirm your diagnosis?

3. How does your diagnosis explain the clinical, radiographic, and laboratory findings?

4. What types of social settings increase the risk of infection by the agent responsible for the pathologic features manifested by this patient?

Slide 67 [WebScope] [ImageScope]

A 27 year old man presents for long-term follow up of a chronic medical disease to the pulmonology clinic. He has experienced cough productive of sputum since the age of two. He felt well until two years prior to this presentation, when he developed increasing shortness of breath and decreased energy. He has also experienced pancreatic insufficiency over the past several years. Eventually, he undergoes bilateral lung transplantation. These sections are taken from those explants

1. 1. What pathologic features are present in this slide?

2. 2. Bronchioles are more susceptible to ectasia than bronchi. Can you think of a reason for this?

3. What is your pathologic diagnosis?

4. 3. What are some predisposing factors for the development of bronchiectasis and how do they contribute to the formation of bronchiectasis?

5. 4. Name the two disorders in which bronchiectasis is a prominent or central pathologic feature and describe some clinical manifestations of each.

Slide 200 [WebScope] [ImageScope]

A 47 year old woman with a history of emphysema was admitted to the hospital with 2 weeks of shortness of breath. An initial chest x-ray was concerning for left upper lobe pneumonia. She was treated with antibiotics, but her oxygenation became progressively worse. She was eventually intubated, and evaluated for ECMO. Despite intensive management, the patient became increasingly hypoxemic and died. This section is prepared from autopsy material.

1. Of what are the hyaline membranes composed and how did they form?

2. What physiologic abnormalities result from this type of injury?

3. In what other clinical conditions may this form of lung injury occur?

4. Compare and contrast this form of lung injury to that involving an infant with respiratory distress syndrome.

Slide 59 [WebScope] [ImageScope]

A 62-year old man sought medical attention because of increasing shortness of breath. He had a long history of mild exertional dyspnea and a minimal cough productive of small amounts of mucoid sputum. He had lost some weight and appeared distressed. His lower intercostal spaces retracted with each inspiration. The patient had a long history of cigarette smoking. He underwent lung volume reduction surgery to treat his symptoms.

1. Based on the pathologic features and clinical history, what is your diagnosis?

2. What other clinical signs and symptoms were likely present in this case?

3. What chest radiographic features would have been present?

4. Predict the results of these pulmonary function tests (normal, increased, or decreased): total lung capacity, residual volume, forced vital capacity, forced expiratory volume in 1 second, and maximal expiratory flow rate

5. The slide contains fragments of alveolar walls. What is the most likely explanation for this?

6. What roles do neutrophil elastase and matrix metalloproteinases purported play in the development of this disorder?

7. If this patient were to come to autopsy, what would the patient’s lungs look like grossly?

8. Other than cigarette smoking, what other disorders can cause similar histology?

Slide 68 [WebScope] [ImageScope]

A 24-year old man presented to the emergency room with dyspnea, cough, and wheezing. He previously had numerous similar episodes, usually triggered or exacerbated by exposure to cold air, physical activity, and exposure to cats and birds. Physical examination revealed wheezing prominent in both phases of respiration. Despite intensive therapy, the patient died from respiratory failure.

1. What disorder is strongly suggested by the gross and microscopic findings?

2. Predict the gross autopsy appearance of the lung.

3. What histologic abnormalities are manifested by the bronchi and bronchioles?

4. Why do such patients find it difficult to breathe?

5. Mention a few risk factors for death from this disorder.

Clinicopathologic Exercise:

A 43-year old man was admitted to the hospital because of fever, night sweats, weight loss, and headache. He had felt well until the fever developed, 15 days earlier. Further questioning elicited a 4 month history of night sweats, a 3 month history of arthralgias, a 2 week history of headache, and a recent weight loss of 4-5 kilograms. His past medical history was unremarkable. There were no risk factors for HIV infection. The patient was a native of Morocco and had immigrated to this country just 4 months prior to admission.

The patient was thin but not acutely ill. His lungs were clear and the heart sounds were normal. The neck was questionably stuff. A complete metabolic panel was normal, as was a complete blood count. A urinalysis revealed proteinuria and microscopic hematuria; pyuria was absent. A chest x-ray revealed calcified nodules throughout the lungs, and punctate areas of increased density that raised the possibility of infection, neoplasm, or chronic interstitial lung disease. A CT study of the lungs confirmed the presence of the radiographic abnormalities.

A lumbar puncture yielded slightly yellowish cerebrospinal fluid that contained neutrophils and lymphocytes. The glucose level was abnormally low and the total protein content was increased. A lung biopsy was performed.

1. How do we know the patient has meningitis?

2. The patient’s clinical condition could have been caused by viral, parasitic, fungal, or bacterial infections. Why is a virus unlikely? Why is a parasite unlikely?

At this point, your instructor will illustrate the pathologic features present in the biopsy sample.

3. Fungal infections can account for the pathologic features. Why is a fungal infection unlikely based on clinical signs or symptoms

4. Your instructor will illustrate a special study performed on the tissue. What is the diagnosis?

The answers to the path lab questions will be posted approximately 48-72 hours after the lab sessions. These are abbreviated answers, not a full discussion of the topics. You can find them in the M2 CTools site resources. In the folder for each sequence the will be a folder called 'Path Lab Resources'