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Disease states that promote pulmonary embolism in situ?
hypertension, pulmonary atherosclerosis, heart failure
Number one cause for patients dying in the hospital?
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.
- PE that is infected, leads to more intense neutrophile exudation and more intense inflammatory response
- Some convert to abscesses.
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?
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
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?
Hardening of tissues?
Causes of vascular lessons in pul htn
- 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?
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.
- autoimmune, upper respritory tract and lungs
- Diagnostic features are capillarities and scattered poorly formed granulomas
Infection of the lung parenchyma?
Most common infection?
Factors that affect resistance to infection?
- immunosupressive theropy
- chronic disease
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
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
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
- 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
community acquired, one of the top causes of otitis media in children
- community and nosocomial
- secondary bacterial pneumonia following a viral infection
- lung abscess and empyema
- community acquired
- most frequent cause of gram negative pneumonia
- Thick and gelatinous sputum
- commonly affects malnourished and debilitated people, alcoholics
most common cause of nosocomial pneumonia but also community acquired with cystic fibrosis patients
- 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
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
- 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
- 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
- can aspire while unconscious or during repeated vomiting
- typically recover more then one organism from culture, aerobes are more common
- 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
- 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
- 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
- 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
- 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.