PBL exam 3 .txt

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PBL exam 3 .txt
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LECOM bradenton PBL test 3
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  1. What are the four aspects of the disease process?
    • 1. Etiology or cause- genetic or aquired
    • 2. Pathogenesis- sequence of events in the response of cells or tissues to the etiologic event
    • 3. Morphologic change - structural alteration in cells or tissues that are either characteristic of the disease or diagnostic of the etiologic event.
    • 4. Clinical manifestation - The nature of the morphologic changes and their distribution in different organs or tissues influence normal function and determine the clinical features, course, and prognosis of the disease.
  2. The increase in the number of cells?
    Hyperplasia
  3. An increase in the size of individual cells?
    Hypertrophy
  4. A decrease in cell size and function?
    Atrophy
  5. The normal stages of cellular response to stress and injury
    During times of stress and increased demand the cell adapts, if there is an inability to adapt the cell will die. If the stimulus is injurious the cell will die. Cell injury is reversible up to a certain point but if the stimulus persists the cell reaches the point of no return and suffers irreversible cell injury and death.
  6. What are the two principle patterns of cell death?
    • 1. Necrosis - Response to abnormal stresses such as ischemia and chemical injury. Always pathologic.
    • 2. Apoptosis - Cell dies through activation of an internally controlled suicide program. Eliminates unwanted cells in embryogenisis and also occurs in some pathologic events.
  7. What is deposited at the site of cell death?
    Calcium
  8. Metabolic derangements cause what?
    The intercellular accumulation of a number of substances.
  9. Increased physiologic demand or increased tropic stimulus?
    Hyperplasia, hypertrophy
  10. Decreased nutrients or stimulation?
    Atrophy
  11. Chronic irritation (chemical or physical)
    Metaplasia
  12. Reduced oxygen supply, chemical injury, or microbial infection? Acute
    Acute reversible injury
  13. Reduced oxygen supply, chemical injury, or microbial infection? Progressive and severe
    Irreversible injury leading to cell death- necrosis or apoptosis
  14. Reduced oxygen supply, chemical injury, or microbial infection? Mild chronic injury
    Subcellular alterations in various organelles
  15. Induction of adaptation?
    • factors produced by the cell or surrounding cells
    • activation of cell surface receptors and downstream signaling molecules
  16. Requirement for cells to undergo hyperplasia?
    Capable of DNA synthesis and cell division
  17. Two divisions of physiologic hyperplasia?
    • hormonal - increase of the female breast at puberty and uterus during pregnancy
    • compensatory - increase tissue mass after damage or resection. The liver can regenerate. After nephrectomy the other kidney enlarges and makes up for the lose.
  18. Mechanism of hyperplasia?
    • Increase in local production of growth factors, increase in the number of growth factor receptors, or activation of intercellular signaling pathways.
    • -All lead to in increase production of transcription factors leading to cellular proliferation.
  19. Liver stem cells only proliferate if hepatocytes proliferation is compromised.
  20. Pathologic hyperplasia constitutes a fertile soil in which cancerous proliferation may occur.
  21. Causes of Pathologic hyperplasia?
    excessive hormonal stimulation or growth factors acting on a target.
  22. Increased size of cells is due to what?
    Synthesis of more structural components.
  23. Increase or decrease in cellular DNA during hypertrophy?
    Increase do to the arrest of the cell cycle without undergoing mitosis
  24. Cause of hypertrophy?
    Increased functional demand or by specific hormonal stimulation.
  25. Genes induced during CARDIAC hypertrophy?
    • Induction of embryonic genes - Beta myosin in place of alpha myosin.
    • Transcription factors -
    • Growth factors - TGF-B, IGF-1, FGF
    • Vasoactive agents- alpha adrenergic agonists, endothelin-1, angiotensin II.
  26. Atrial natriuretic factor ANF?
    • Secreted by the fetal atrium and ventricle and then by the adult atrium, response to pressure and volume change by regulating salt excretion to regulate volume and pressure.
    • ex. increased atrial pressure due to excess venous return leads to higher levels of ANF excretion and an increase in urine production by the kidneys.
  27. Two types of hypertrophic triggers for the heart.
    • 1. mechanical - stretch
    • 2. trophic- growth factors and vasoactive agents secreted by non myocytes.
  28. When does cardiac failure happen?
    when the muscle reaches it limit for enlargement and is no longer able to compensate.
  29. Common causes of atrophy? physiological and pathological
    • 1. Decreased workload
    • 2. Loss of innervation
    • 3. Diminished blood supply
    • 4. Inadequate nutrition- use of muscle for energy after fat stores are used up.
    • 5. Loss of endocrine stimulation- loss of estrogen after menopause results in atrophy of the endometrium, breast, and vaginal epithelium.
    • 6. aging
    • 7. pressure - enlarged benign tumor can compress and cause atrophy of surrounding tissue.
  30. Atrophied cells may have a diminished function but are not dead.
    can die if blood supply is inadequate for even the atrophied cell.
  31. Function of the ubiquin-proteasome pathway?
    • degradation of cytosolic and nuclear proteins.
    • Proteins are first conjugated to ubiquin then degraded within protease's.
    • Stimulated by glucocorticoids and thyroid hormones
    • Inhibited by insulin.
    • Cytokines such ad TNF are capable of increasing muscle proteolysis in this way.
  32. Metaplasia?
    • reversible change from one cell type to another. May represent an adaptive substitution where one cell type is better suited to withstand an adverse environment.
    • -most common is columnar to squamous, in the respiratory tract in response to chronic irritation. The new cells can survive but the special feature of mucus secretion is lost.
  33. Barret esophogus?
    Esophageal squamous cells are changed to columnar under the influence of refluxed gastric acid.
  34. Myositis ossification?
    Bone formation in muscle after bone fracture
  35. Mechanism of metaplasia?
    • Not a change in the phenotype but reprogramming of the stem cells in the tissue or of undifferentiated mesenchymal cells in connective tissue.
    • BMP's induce chondrogenic or osteogenic expression of stem cells while repressing differentiation to muscle of fat.
  36. Causes of cell injury?
    1. oxygen deprivation-
  37. Family pulmonary hypertension?
    BMP-2 receptor mutation,
  38. Largest resistance of air flow ( anatomy), healthy vs disease?
    • Healthy- large bronchi
    • Disease - bronchioles
  39. APC
    • -cleave surface gp of Va and VIIIa
    • -stimulates the release of t-PA
    • -inactivates inhibitors of t-PA
  40. alpha2-antiplasmin
    • -can not bind clot bound plasmin
    • -allows the destruction of a fibrin clot without the destruction of fibrinogen in circulation
  41. strptokinase
    not an enzyme but an allosteric modifier of human plasminogen that allows plasminogen to autocatylitically activate itself
  42. Plasminotigen activator release
    after stress
  43. Hemophilia A
    • -x linked
    • - bleeding into soft tissues (hematomas)
  44. Vitamin K
    • cofactor in the gamma carboxilation of factors 2,7,9,10
    • the carboxilation is of the glutamate side chain
    • carboxilated side chains bin to calcium and then to activates platelets
  45. AT3
    mostly thrombin but has some activity on 8,9,10,11
  46. High molecular wieght heparin
    Will bind to other plasma protein then AT3, this can cause the active amount in the blood to be reduced and spontaneous thrombi can be generated
  47. HITs
    • heparin binds to platelet factor four
    • induces a conformational change in PF4 causing the immune system to not recognize it
    • antibodies are made against heparin PF4 complex
    • when antibodies bind the platelets become activated
  48. Warfarin mechanism
    • bines vit K reductase enzyme needes to regenerate vit K
    • reduced gamma carboxilation, factors can not bind calcium or form complexes after coagulation is initiated
    • also blocks protein S and C
  49. Fondaparinux
    • pentasaccharide that enhances AT3 interaction with Xa
    • HIT is not a complication since fondaparinux does not bind for PF4
  50. Direct thrombin inhibitors?
    • Hirudin- discovered in leeches
    • irreversible reaction
    • bivalrudin, high binding aftinity for thrombin with a transient affect
  51. Glucocorticoids inhibit collogen synthesis
  52. Factor released by platelets to cause vasoconstriction?
    Thromoxin A2
  53. Four mechanisms to hemostasis?
    • 1. vascular constriction
    • 2. platelet plug
    • 3. blood coagulation
    • 4. growth of fibrous tissue
  54. Contactile fibers contained in platelets
    actin, myosin, thombosthenin
  55. Ion stored by platelets?
    Calcium, dence granual
  56. Functions of platelet derived growth factor
    causes vascular smooth muscle, vascular endothelial cells, and fibroblasts to grow and multiply
  57. Molecule on platelet surface that activates clotting (generic)
    phospholipids
  58. Half life of platelets and method of distraction
    8-12 days, tissue macrophages, mainly spleen
  59. when platelets bind to the endothelium what causes the release of granolas?
    contraction
  60. three location of vWF
    platelets, endothelium, circulation
  61. Two secretions of platelets that activate more platelets?
    ADP, thromboxan A2
  62. Loose plug
    platelets only
  63. Responsible for plugging thousands of vascular holes daily?
    platelts
  64. major functional unit of clot retraction?
    platelets
  65. Two outcomes of a blood clot?
    • 1. can be invaded by fibroblasts and form connective tissue, promoted by PDGF, 1-2 weeks
    • 2. dissolve
  66. Three essential steps of blood coagulation?
    • 1. formation of a complex of activated substances called prothrombin activator, rate limiting step in blood coagulation
    • 2. The activator catalyzes prothrombin to thrombin in the presence of calcium
    • 3. Thrombin convers fibrinogen to fibrin
  67. Prothrombin activator is formed in result of?
    • vascular damage
    • damage to special substances in the blood
  68. Name and function of GPIIb/IIIa?
    prothrombin receptor, on the cell membrane of platelets already bound to damaged tissues
  69. 2 alpha-2-globulins
    prothrombin and bradykinin
  70. Does fibrinogen leak of of vessels?
    • no, it is too large.
    • During pathological conditions vascular permeability can increase enough to let it out
  71. Reticulum of a blood clot?
    Long fibrin chain attached to clot
  72. Fibrin stabilizing factor, site of storage and function.
    released by activated platelets and cross links fibrin monomers by covalent bonds
  73. Origin of serum?
    • after a clot is formed the platelets contract and squeeze out all the fluid, this fluid is serum.
    • does not contain clotting factors
  74. Failure of a clot to retract indicates?
    low platelet level
  75. Platelets release what that cause clot contraction?
    ATP and calcium to activate actin/myosin and thrombosthenin
  76. Thrombin is proteolitic
  77. factors activated thrombin act on
    2, 8, 9, 10,11, and 12
  78. three initiating events of prothrombin activator formation
    • 1. trauma to vascular wall
    • 2. trauma to blood
    • 3. contact of blood with collagen
  79. Two pathways of prothrombin activator?
    • Intrinsic- damage to blood
    • Extrinsic-damage to vascular wall
  80. Factor that activates prothrombin activator?
    Xa
  81. What is released form damaged blood vessels to initiate the extrinsic pathway?
    tissue factor, tissue throboplastin
  82. Two main proteins of prothrombin activator
    • X and V and calcium
    • factor X is the protease in this complex, V accelerates the action
    • thrombin itself has posotive feedback on factor V
  83. Initiation of the intrinsic pathway?
    • blood trauma, release of factor XII (activated when it contacts collagen surface or glass)
    • exposure of of blood to collagen
  84. Cleavage of XI by XII needs?
    HMW kininogen, accelerated by prekallikrein
  85. Activation of X in the intrinsic pathway by?
    VIII and IX
  86. Steps on blood coagulation that do not need calcium
    XII activating XI and XI activating IX
  87. Function of citrate ion?
    De-ionize calcium to stop coagulation in collected blood
  88. Function of oxalate ion?
    precipitate calcium out of solution to prevent clotting
  89. Speed of two clotting pathways?
    extrinsic is much faster then intrinsic
  90. Three factors that prevent clotting in the normal endothelium?
    • 1. smoothness of endothelium
    • 2. layer of glycocalyx, mucopolysacharide
    • 3. thrombomodulin and heparin on surface
  91. Two function of thrombomodulin in anticoagulation?
    • binds thrombin and removes it from circulation
    • complex activates protein C which cleaves V and VIII and causes the release of t-PA
  92. Two most powerful thrombin removers?
    ATIII and fibrin mesh (prevents the spread of clot)
  93. Largest site of heparin production?
    mast cells, large amounts in lung and liver to stop the coagulation of slow moving venous blood
  94. Plasmin substrates?
    I, V, VIII, XII
  95. Plasmin is caught in the fibrin mesh and combined into the clot
  96. Disease or damage to what organ can cause bleeding problems
    liver
  97. 5 vit K d├ępendent coagulation factors?
    II, VII, IX, X, protein c
  98. Cause of vit K deficiency?
    liver fails to secrete bile into the GI tract, obstruction of the bile duct or liver disease, prevents adqauate fat absorption
  99. Inheritance of hemophilia A
    x linked
  100. two compound of factor VIII
    factor VIII and von willebrands factor (protects factor 8 in circulation)
  101. difference in bleeding with hemophilia a and thrombocytopenia?
    thrombocytopenia is small vessels and hemophilia in large
  102. thrombocytopenia purpura
    spleenectomy and whole blood transfusion are helpful
  103. DIC?
    • widespread clotting in the circulation
    • usually occurs with large amounts of traumatized or dying tissue that releases tissue factor into the blood
    • can remove many clotting factors and eventually cause bleeding
  104. Clotting disorder with septicemia
    DIC, caused by bacteria or endotoxins, part of the reason septic shock is lethal.
  105. Time for warfarin effect
    • 12 hours 50%
    • 24 hours 20% clotting power
  106. oxalate is toxic to the body
  107. can citrated blood be re-infused
    yes the liver will convert the citrate to glucose within a couple minutes
  108. what is hyperemia?
    increased blood flow to activated tissues
  109. PT time is a measure of what?
    concentration of prothrombin in the blood
  110. bacteria membrane receptor
    Toll like receptor
  111. How does renal failure cause metastatic calcification?
    secondary hyperparathyroidism due to phosphate retention.
  112. Cause of movement of gas from one point to another?
    partial pressure difference
  113. diffusion rate?
    PSA/d(mx^1/2)
  114. pO2 of alveolar and pulmonary arterial blood and blood leaving the aorta
    104 and 40 and 95
  115. Two reasons for increase in oxygen diffusion capacity during exercise?
    • increase in open pulmonary capillaries, more ideal retaliation perfusion ratio
    • blood is fully oxygenated about 1/3 of the way through the capillary
  116. ejection volume of rt ventricle to lt
    • left ejects 2-3% more volume due to addition of bronchial circulation
    • shunt flow
  117. an increase in blood flow through a tissue will increase the tissues pO2
  118. beriberi?
    vita B deficiency that affects cell oxygen utilization
  119. cyanide poisoning?
    disables cytochrome oxidase activity, cell can not utilize oxygen
  120. what two factors determine tissue pO2?
    delivery and use of oxygen
  121. pCO2 intracellular, interstitial, arterial blood, venous blood
    46, 45, 40, 45
  122. End effect of an increase in tissue metabolism on interstitial pCO2
    increase
  123. as pO2 rises so does the saturation of Hb
  124. amount of oxygen 1g of Hb can combine with?
    1.34 ml
  125. volume percent?
    amount of O2 (ml) in 100ml of blood
  126. under normal conditions how much oxygen is delivered to the tissues per 100 ml of blood?
    5ml, can increase to 15ml during heavy exercise
  127. What factors cause muscle pO2 to stay constantly at 40mmHg during exercise
    • increase in cardiac output
    • decrease in affinity for Hb, raise in temp CO2, 2.3DPG and decrease in pH
  128. utilization coefficient?
    percentage of blood that gives up its oxygen as it passes through the capillaries
  129. as oxygen is delivered to the tissue Hb releases more oxygen into the blood
  130. chronic hypoxic condition increase what?
    2,3, DPG (poor tissue blood flow)
  131. What is the main limiting factor what blood pO2 is greater then one for tissue metabolism?
    ADP
  132. effects of oxygen poisoning?
    brain convolutions and death
  133. What binds to the same site on Hb and oxygen but with a high affinity?
    CO, partial pressure of 0.4 will allow CO to equally compete with O2 for binding to Hb. 0.6 is lethal
  134. In CO poisoning what is the affect on blood pO2?
    • normal, no obvious signs of hypoxia
    • since pO2 is not depressed there is no low O2 feedback mechanism to increase respiration
    • can treat with pure oxygen and CO2 in the blood to increase breathing
  135. amount of CO2 transported from the tissues to the lungs in the blood per 100ml blood
    4ml
  136. Chloride shift
    • CO2 is higher in the venous blood causing an increase in production of H2CO3, this then dissociates and the H is buffered by Hb and the bicarb is exchanged for Cl. The chloride content of venous blood is less then arterial blood
    • Water moves into the cell to maintain the osmotic equilibrium and causes the cell to swell.
  137. acetazolamide
    carbonic anhydrase inhibitor, can cause tissue pCO2 to reach 80
  138. what is carbaminohemaglobin?
    • CO2 bound to the terminal amine group of Hb
    • pKa is around 7 so 50% is available at blood pH
  139. volume percent change for CO2
    52in venous blood to 48 in arterial, 4ml/100ml blood
  140. What is the Haldane effect?
    • the binding of oxygen to Hb displaces CO2 from the blood in the lungs
    • The combination of oxygen with Hb causes Hb to become a stronger acid
    • The more acidic Hb has less affinity for CO2 at the terminal amine group
    • The increased acidity of Hb causes it to release more H that in turn bind with bicarb and form water and CO2, the CO2 is released from the lungs
    • This effect doubles the amount of CO2 released from the blood in the lungs and double the amount picked up in the tissues. from 2ml to 4ml.
  141. Normal pH of arterial and venous blood?
    7.41 and 7.37
  142. Respiratory exchange ratio?
    • volume percent of CO2 over the volume percent of O2
    • Usually in the range of 82 %
    • using mainly carbohydrates for metabolism increases
    • using fates for metabolism decreases
    • Decreases in the fasting and starved states
  143. Disease states that promote pulmonary embolism in situ?
    hypertension, pulmonary atherosclerosis, heart failure
  144. Number one cause for patients dying in the hospital?
    Pulmonary embolism
  145. Secondary hypercoagulable causes for pulmonary embolism?
    oral contraceptives, recent surgery, obesity, cancer, pregnancy
  146. Two main pathological consequences of PE
    • respiratory compromise, non perfused but ventilated portion of the lung.
    • cardiac compromise, increased pulmonary resistance
  147. What is cor pulmanale?
    Failure of the right heart due to pulmonary hypertension
  148. Will a small pulmonary embolism cause an infarct?
    not usually in an individual with normal heart function
  149. How to distinguish from a pulmonary infarct or hemorrhage
    An infarct will cause damage to the lung parenchyma
  150. PE lesion has a wedge shape with apex pointing to hilum.
  151. Septic infarct?
    • PE that is infected, leads to more intense neutrophile exudation and more intense inflammatory response
    • Some convert to abscesses.
  152. Electromechanical dissociation
    ECG shows a rhythm but there is no pulse.
  153. Clinical symptoms after surviving a PE
    chest pain, fever, dyspnea, shock, increased serum lactic dehydrogenase
  154. Testing for PE
    D-dimer
  155. Prophylactic treatment to prevent PE
    early ambulation, elastic stockings, anti coagulation
  156. Non thombotic forms of PE
    air, fat, amniotic fluid, sickle cells, foreign bodies during IV drug use
  157. What pressure is pulmonary hypertension?
    1/4 systemic
  158. In obstructive pulmonary disease pulmonary hypertension is caused by?
    alveolar hypoxia causes vasoconstriction of its bronchioles
  159. 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
  160. P hypertension with no known cause
    idiopathic primary p hypertenstion
  161. Cause of primary pulmonary hypertension?
    mutation in the BMOR2 signaling pathway
  162. 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
  163. Loss of _ promotes vascular constriction and plt adhesion
    prostacyclin, NO
  164. 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
  165. plexogenic pulmonary arteriopathy?
    tuft of capillaries that form producing a network that spans the lumens of dilated thin walled vessels.
  166. coughing up blood?
    hemoptysis
  167. Hardening of tissues?
    sclerosis
  168. Causes of vascular lessons in pul htn
    • atheromas
    • intimal fibrosis
    • medial muscular hypertrophy
    • plexogenic arteriopathy
    • organized thrombi, recanulization
  169. 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
  170. Illness accompanying kidney failure?
    Uremia
  171. Idiopathic pulmonary hemosiderosis
    • Intermittent diffuse alveolar hemorrhage
    • Presents with cough, hemoptysis, anemia, weight loss
    • longs have areas of consolidation
  172. 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
  173. abnormal accumulation of hemociderin
    hemociderosis, iron overload disorder.
  174. Wegener Granulomatosis
    • autoimmune, upper respritory tract and lungs
    • Diagnostic features are capillarities and scattered poorly formed granulomas
  175. Infection of the lung parenchyma?
    pneumonia
  176. Most common infection?
    respiratory, viral
  177. Factors that affect resistance to infection?
    • immunosupressive theropy
    • chronic disease
    • leukopenia
  178. 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
  179. One type of pneumonia can predispose you to another
  180. Infection originating in the hospital
    Nosocomial infaction
  181. 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
  182. Bacterial invasion of the lung causes the alveoli to be?
    filled with an inflammatory exudate, thus causing consolidation of the tissue.
  183. Film produced my bacteria in the lungs to protect itself
    alginate
  184. 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
  185. 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
  186. Moraxella catarrhalis
    community acquired, one of the top causes of otitis media in children
  187. Staphylococcus aureus
    • community and nosocomial
    • secondary bacterial pneumonia following a viral infection
    • lung abscess and empyema
  188. Klebsiella pneumoniae
    • community acquired
    • most frequent cause of gram negative pneumonia
    • Thick and gelatinous sputum
    • commonly affects malnourished and debilitated people, alcoholics
  189. Pseudomonas aeruginosa
    most common cause of nosocomial pneumonia but also community acquired with cystic fibrosis patients
  190. 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
  191. 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
  192. 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
  193. Clinical course of community acquired pneumonia
    • abrupt onset of fever, shaking chills, cough with mucopurulent sputum, hemptysis
    • radio-opaque appearance of lobe or broncials
  194. collection of pus and infection in the pleural cavity
    empyema
  195. fibrinosuppurative exudate
  196. 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
  197. Atypical pneumonia morphology
    • trasidate edema in the alveoli
    • Patchy or lobar ares of congestion without consolidation
  198. 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
  199. 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
  200. pain in muscles
    myalgias
  201. general feeling of illness
    malaise
  202. 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
  203. Aspiraton pneumonia
    • can aspire while unconscious or during repeated vomiting
    • typically recover more then one organism from culture, aerobes are more common
  204. Lung abscess
    • a local suppurative process within the lungs
    • common organisms are streptococci, staphylococcus auras and a host of gram negative
  205. 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
  206. 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
  207. 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
  208. thermally dimorphic fungi?
    grow as hyphae and produce spores at environmental temps but grow as yeasts at body temp
  209. 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
  210. 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
  211. 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
  212. 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
  213. 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.

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