INSTRUCTORS ONLY

Respiratory Laboratory 2:
The patient with hemoptysis

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A 30-year old man had a severe shaking chill that lasted for an hour. Shortly afterwards, he developed a fever of 40.0 degrees centigrade, marked tachycardia, tachypnea, a dry cough, and right-sided pleuritic chest pain. His cough became productive of thick, tenacious, rust-colored sputum. He had been previously well. He presented for medical attention to his primary care physician.

He appeared ill and was in moderate respiratory distress. His respirations were shallow and there was increased tactile fremitus and dullness to percussion over the right hemithorax. Fever and tachypnea were present, as were bronchial breath sounds and crackles. Laboratory values included a leukocytosis with a left shift and an elevated sedimentation rate. Arterial blood gases revealed hypoxemia. A chest radiograph demonstrated opacification and air bronchograms of the right middle and lower lobes. Despite aggressive medical treatment, the patient died.

1. How might the right lung have appeared at the autopsy table?

2. Please describe the pathologic features manifested in your histologic section.

3. What is your pathologic diagnosis?

4. Had the patient lived, what other changes would have been manifested by the lung as the patient recovered?

5. A wide variety of local and distant complications may arise in such patients. Please mention several of them.

6. The presence of high fever, leukocytosis, and pulmonary infiltrate suggests the presence of community-acquired pneumonia. What organisms are most often implicated as causes of severe community-acquired pneumonia?

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A 23-year old patient with severe prolonged neutropenia developed left-sided chest pain and fever and began coughing up blood. She became seriously ill over the next 24 hours and subsequently required ventilator support. A chest x-ray showed patchy densities; a CT scan revealed a mass-like infiltrate surrounded by an area of low attenuation. The patient died several days after becoming comatose.

1. Based on your examination, what is your diagnosis?

2. What are some causes of neutropenia?

3. What is the natural habitat of the organisms noted in this section?

4. What other agents could infect this or a similar patient?

5. What is the most likely reason for the patient having become comatose?

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A 59-year old man sought medical attention because his chronic cough had become more severe and was interfering with his sleep. He had also noted that his sputum was occasionally blood-streaked. His subsequent evaluation demonstrated a 3 centimeter mass near the hilum of the left lower lobe, which was surgically resected.

1. Please classify this neoplasm.

2. What is the etiology of most lung carcinomas?

3. What other signs and symptoms may be associated with lung carcinomas?

4. What extrapulmonic sites are at risk for harboring metastatic foci from this neoplasm?

5. Perhaps the most common spirometric abnormality related to non-small cell lung cancer itself is a restrictive impairment. What clinical features may account for this?

Clinicopathologic Exercise

A 43-year old woman was admitted to the hospital because of hemoptysis and dyspnea. The patient had been well until 28 months ago, a mammogram showed a speculated right breast mass. Fine needle aspiration of the mass was positive for malignancy. She underwent a right modified radical mastectomy which demonstrated a 1.2 cm invasive ductal carcinoma with metastases to one of thirteen axillary lymph nodes. The patient underwent post-op chemotherapy and radiation. Over the ensuing months, metastatic disease was detected in bones and in the liver. An infiltrate of the left lower lobe was also detected.

Physical examination manifested local dullness at the left lung base, with diminished breath sounds and inspiratory crackles; no egophonoy or wheezing was heard. Abdominal examination disclosed tenderness of both lower quadrants without guarding; the liver and spleen were not felt. There was no peripheral edema or digital clubbing. The urine was normal. A CBC revealed a while blood count of 6500 with 73% neutrophils. The platelet count was 478,000/mm3. A chest x-ray showed infiltrates in the left lower and right upper lobes, and a left-sided pleural effusion. A bronchoscopic biopsy was unsuccessful because of bleeding from the left upper lobe. A bronchoalveolar lavage specimen from this site disclosed a few acid fast bacilli. Multiple examinations of sputum specimens revealed no acid fast bacilli and cultures were negative for mycobacteria. The radiographic chest infiltrates rapidly progressed. An open lung biopsy sample was obtained.

The patient developed acute hypoxemia, persistent dyspnea, and respiratory failure. Empiric antibiotic therapy and 100% oxygen therapy did not bring about clinical improvement.

1. Metastatic carcinoma may have been present, but the radiographic presentation is atypical. How do metastatses typically present radiographically?

2. Could pulmonary emboli explain the patient’s chest pain? Can any of the other signs and symptoms be explained on this basis? What factors predispose the patient to pulmonary emboli?

3. Drug toxicity may be manifested as diffuse pulmonary infiltrates and hypoxemic respiratory failure. Our patient did undergo chemotherapy. But, if this were the underlying cause of the pulmonary failure, why wouldn’t the radiographic presentation fit with this diagnosis?

4. Opportunistic infections are a definite possibility. Our patient was immunocompromised but not neutropenic. What organisms should be considered?

Your instructor will illustrate the open lung biopsy for you.

5. What is your diagnosis?

6. What are some possible physiologic effects of this pulmonary finding?

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'