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1 Disease of respiratory system Wang Lin Department of Pathology Norman Bethune College of Medicine

2 Section one Pneumonia 肺炎

3 Review-1 呼吸系统的解剖学呼吸道分上下两部分

4 Anatomy of respiratory system 支气管 ---nose ---pharynx ---larynx ---trachea ---bronchi ---lung 肺泡细支气管

5 Histology of the lung General structure: ---capsule: ---parenchyma: all branches of bronchi and alveoli ---interstitia Small bronchus respiratory bronchiole alveolar duct alveolar sac terminal bronchiole alveoli

Normal Lung small bronchi bronchiole terminal

cartilage Respiratory bronchiole For gas

Part of the lung distal to terminal bronchiole

6 Normal Lung small bronchi bronchiole terminal bronchiole Bronchi cartilage Bronchiole no cartilage Respiratory bronchiole For gas exchange Terminal respiratory unit or Acinus Part of the lung distal to terminal bronchiole Contains 1. Respiratory bronchiole 2. Alveolar duct 3.Alveolar sacs/ Alveoli pulmonary lobule: one bronchiole and its all branches and all alveoli 1 2 3

7 Normal Lung alveoli

8 Classification of Pneumonia 1. On the basis of etiology ---Bacterial pneumonia ---Viral pneumonia ---Mycoplasmal pneumonia 2. On the basis of anatomic distribution ---Lobar pneumonia ---Lobular pneumonia ---Interstitial pneumonia 3. On the basis of inflammatory features ---Serous pneumonia ---Fibrinous pneumonia ---Suppurative pneumonia

9 Bacterial pneumonia 大叶性肺炎主要由肺炎球菌引起的以肺泡内弥漫性纤维素渗出为主的炎症通常累及肺大叶的全部或大部小叶性肺炎由化脓菌引起, 以肺小叶为单位的急性化脓性炎病变常以细支气管为中心, 故又称支气管肺炎

10 Lobar Pneumonia 大叶性肺炎 Lobar pneumonia is fibrinous inflammation that affects a large area of a lobe and even an entire lobe of a lung by acute bacterial infection.

11 Objective Describe the morphologic features of lobar pneumonia. Explain the clinical manifestations of patients with lobar pneumonia.

12 Lobar pneumonia Etiology Most lobar pneumonias are caused by Streptococcus pneumoniae, which enter the lungs via the airways. Pneumonia can result whenever the defense mechanisms are impaired or whenever the resistance of the host in general is lowered. Mainly between years old adult males previously healthy.

13 Lobar Pneumonia 大叶性肺炎 Etiology 病因学 Most lobar pneumonias are caused by Streptococcus pneumoniae, which enter the lungs via the airways. Common location: lower lobe or the right middle lobe Upper lobe Middle lobe Lower lobe Lower lobe

14 Lobar Pneumonia 大叶性肺炎 Pathological changes 病理变化 The following sequence of stages is "classic" but infrequently seen because of antibiotic therapy. Congestion Red hepatization Grey hepatization Resolution Pay attention

15 Lobar Pneumonia 大叶性肺炎 Congestion 充血水肿期 Grossly Early phase of infection Affected lobe(s) is (are) heavy, boggy and red. Congestive lung

16 Lobar Pneumonia 大叶性肺炎 Congestion 充血水肿期 Microscopically In the alveoli --vascular congestion --proteinaceous fluid --few neutrophils --numerous bacteria normal *

18 Lobar Pneumonia 大叶性肺炎 Red Hepatization (consolidation) 红色肝样变期 Grossly The lobe is red, firm with liver-like consistency.

19 Lobar Pneumonia 大叶性肺炎 Red Hepatization (consolidation) 红色肝样变期 Microscopically Alveolar space filled with cellular exudate, containing RBCs, neutrophils and fibrin. The basic alveolar architecture is maintained and congestive. normal

20 Lobar Pneumonia 大叶性肺炎 Red Hepatization (consolidation) 红色肝样变期 Microscopically Alveolar space filled with cellular exudate, containing RBCs, neutrophils and fibrin. The basic alveolar architecture is maintained and congestive. normal

21 Lobar Pneumonia 大叶性肺炎 Grey hepatization (consolidation) 灰色肝样变期 Grossly The lobe is dry, grey, and firm with liver-like consistency.

22 Lobar Pneumonia 大叶性肺炎 Grey hepatization (consolidation) 灰色肝样变期 Microscopically RBCs get lysed, while the fibrinous exudate persists within the alveoli. The basic alveolar architecture is maintained and ischemic. normal

23 Lobar Pneumonia 大叶性肺炎 Resolution 溶解消散期 The favorable final stage in which consolidated exudate undergoes enzymatic digestion and cellular degradation and clearance. Normal structure is restored.

24 Lobar Pneumonia 大叶性肺炎 Congestion 充血水肿期 Red hepatization 红色肝样变期 Resolution 溶解消散期 Grey hepatization 灰色肝样变期 The bronchi are not involved. The basic alveolar architecture is maintained.

25 complications of lobar pneumonia pulmonary carnification: organization of exudate into fibrotic scar tissue (incomplete resolution). pulmonary carnification pulmonary carnification

26 Do you remember? What is inflammation? Inflammation is the reaction of vascularized living tissues to local injury, leading to the accumulation of fluid and leukocytes in extravascular tissues. what Inflammation is a protective response intended to eliminate the initial cause of cell injury as well as the necrotic cells and tissues resulting from the original insult. why Inflammation accomplishes its protective mission by diluting, destroying, or otherwise neutralizing harmful agents. how 问题 1: 大叶性肺炎的发生发展与渗出液的关系?

27 病例男性,20 岁 2 天前回家路上恰遇暴雨, 躲避不及全身淋透, 回家后即高热 39.8, 伴寒战胸痛咳嗽咳铁锈色痰查体 : 右肺中部叩诊浊音, 听诊可闻及支气管呼吸音 ;X 线检查 : 见右肺中叶大片致密阴影临床诊断 : 大叶性肺炎问题 2: 如何解释大叶性肺炎的症状和体征?

28 病例分析发病人群 :vulnerable individual 诱因 :inducer 高热寒战 : high fever, shaking chills 胸痛 :chest pain 咳嗽咳铁锈色痰 : cough, productive of rusty sputum 触诊语颤增强, 叩诊浊音及支气管呼吸音 :vocal fremitus, percussion dullness and bronchial breath sound X 线 : x-ray: dense opacity

29 Lobar Pneumonia 大叶性肺炎 Diagnostic tools Chief complaint 主诉 Physical examination X-ray Laboratory analysis: Sputum, Blood

30 Lobar Pneumonia 大叶性肺炎 Clinical manifestation The major symptoms: fever, cough, productive of rusty sputum. Physical examination: may detect tachypnea and signs of consolidation, such as vocal fremitus, bronchial breath sounds, percussion dullness. The characteristic radiologic appearance: radio-opaque well-circumscribed lobe.

31 Lobar Pneumonia What? Where? Why? Lobar pneumonia is fibrinous inflammation of large area of a lobe and even an entire lobe of a lung by acute bacterial infection. The bronchi are not involved. The basic alveolar architecture is maintained.

alveoli, causing a lobular distribution.

32 Lobular pneumonia/bronchopneumonia Infection is centered on the bronchi but with the extension of the inflammatory exudate into the alveoli, causing a lobular distribution. It is characterized by foci of acute suppurative inflammation centered on bronchioles. -- 以肺小叶为单位的灶状急性化脓性炎症

33 Lobular pneumonia 小叶性肺炎 Bronchopneumonia 支气管肺炎 Marked by patchy exudative consolidation of acute suppurative inflammation in bronchi, caused most commonly by Staphylococcus aureus, Haemophilus influenzae and Streptococcus pneumoniae. It tends to occur in the more vulnerable two extremes of life --infancy and old age, particularly in those already suffering from some serious disorder.

34 Lobular pneumonia/bronchopneumonia Pathological changes Lobular pneumonia is characterized by foci of acute suppurative inflammation centered on bronchioles. Foci of inflammatory consolidation: distribute in patches throughout one or several lobes, frequently bilateral and basal Well-developed lesions: slightly elevated, dry, granular, grey-red to yellow, and poorly delimited at their margins. Foci vary in size. Confluence of these foci producing the appearance of total lobular consolidation (confluent bronchopneumonia). The lung substance immediately surrounding areas of consolidation: usually slightly hyperemic and edematous, but the large intervening areas are generally normal.

35 Lobular pneumonia/bronchopneumonia

36 Lobular pneumonia/bronchopneumonia 双肺散在分布多个实变病灶形状不规则大小不一, 直径相当于小叶范围灰黄色中央可见发炎的细支气管断面

37 Lobular pneumonia 小叶性肺炎 confluent lobular pneumonia

38 Lobular pneumonia LM Suppurative exudate that fills the bronchi bronchioles and adjacent alveolar spaces.

39 Lobular pneumonia Bronchopneumonia (Lobular pneumonia) is an acute exudative inflammation of the lungs characterised by foci of consolidation surrounded by normal parenchyma. Usually, bronchopneumonia affects one or more lobes and is bilateral.

(suppurative exudate in the lumen and parietal inflammation).

40 Lobular pneumonia Bronchopneumonia : focus of inflammatory condensation centred by a bronchiole with acute bronchiolitis (suppurative exudate in the lumen and parietal inflammation). Alveolar lumens surrounding the bronchia are filled with neutrophils ("leukocytic alveolitis").

41 Lobular pneumonia/bronchopneumonia

42 Clinical course Lobular pneumonia Resolution of the exudate usually restores normal lung structure, but organization may occur and result in fibrous scarring in some cases, or aggressive disease may produce abscesses. The major symptoms: fever, and cough productive of purulent sputum. Abscess formation. The characteristic radiologic appearance: focal opacities.

Complications of pneumonia (1) tissue destruction and necrosis, causing abscess formation; (2) spread of infection to the pleural cavity, causing the intrapleural

43 Complications of pneumonia (1) tissue destruction and necrosis, causing abscess formation; (2) spread of infection to the pleural cavity, causing the intrapleural fibrinosuppurative reaction known as empyema; (3) Fibrinous pleuritis (4) organization of the exudate, which may convert a portion of the lung into solid tissue pulmonary carnification 肺肉质变

44 大叶性肺炎与小叶性肺炎的区别大叶性肺炎小叶性肺炎病因肺炎球菌葡萄球菌肺炎球菌年龄青壮年小儿老人体弱者开始部位肺泡细支气管病变范围肺大叶肺小叶性质纤维素性炎化脓性炎肺泡破坏 ( ) (+) 胸膜炎 (+) ( ) 融合性可能有并发症少稍多临床实变体征明显无实变体征

45 Viral pneumonia Pathological changes Grossly The alveolar septa are expanded by hyperemia, edema Necrosis

46 LM: Viral pneumonia A predominance of interstitial with widened, edematous alveolar walls containing lymphocytes and plasma cells infiltrate. The alveolar spaces are airfilled. The formation of hyaline membranes, reflecting diffuse alveolar damage. Certain viruses cause necrosis of bronchial or alveolar epithelium in severe infections. Characteristic cytopathic changes are inclusion bodies, and multinucleated giant cells, which may be useful in identifying the specific agent if tissue biopsies are taken.

47 Viral pneumonia hyaline membranes Here is the microscopic appearance of a viral pneumonia with interstitial lymphocytic infiltrates. Note that there is no alveolar exudate.

48 Viral pneumonia necrosis inclusion bodies

49 Viral pneumonia multinucleated giant cells This is respiratory syntytial virus (RSV) in a child. The inset demonstrates a typical giant cell with a round, pink intracytoplasmic inclusion.

50 SARS Severe Acute Respiratory Syndrome 严重急性呼吸综合征

51 严重急性呼吸综合征 SARS 病原体 : 新型冠状病毒, 宿主 : 果子狸传播途径 : 近距离飞沫传播或直接接触发热为首发症状, 体温一般高于 38, 可伴头痛肌肉和关节酸痛 ; 干咳少痰, 严重者出现呼吸窘迫外周血白细胞一般不升高或降低, 常有淋巴细胞计数减少 X 线检查, 肺部常有不同程度的块状斑块状浸润性阴影

52 病理变化严重急性呼吸综合征 SARS 肺和免疫系统病变最为突出心肝肾肾上腺等实质性器官也不同程度受累, 除小血管症性病变外, 有不同程度的变性坏死和出血等改变肺部病变肉眼 : 双肺呈斑块状实变, 严重者双肺完全实变 ; 表面暗红, 切面可见出血灶和出血梗死灶

53 严重急性呼吸综合征 SARS 镜下 : 以弥漫性肺泡损伤为主 -- 肺组织重度充血出血和肺水肿 -- 肺泡腔内脱落和增生的肺泡上皮细胞及渗出的单核细胞淋巴细胞和浆细胞 -- 部分可见病毒包涵体和透明膜形成

54 透明膜严重急性呼吸综合征 SARS

55 Mycoplasmal pneumonia 支原体肺炎 Causes Mycoplasma pneumoniae Infection with this organisms evokes an acute inflammation that is usually restricted to the interstitium without involvement of the alveolar spaces.

56 Mycoplasmal pneumonia 支原体肺炎病变区域肺泡间隔明显增宽血管扩张充血, 间质水肿, 有多量淋巴细胞浆细胞和单核细胞渗出肺泡腔内无渗出物或混有少量单核细胞的浆液性渗出小支气管和细支气管壁及其周围组织也常有炎细胞浸润

57 Key points The characteristics of pneumonias and differences among the pneumonias

MMP-26对子宫颈癌细胞生物学行为的影响

MMP-26对子宫颈癌细胞生物学行为的影响呼吸系统疾病 ( 一 ) Diseases of respiratory system 白求恩医学院病理学系李伟 2010.5.4 Review-1 呼吸系统的解剖学呼吸道分上下两部分 Review-3 肺的组织学肺的实质和间质 : 实质 : 即支气管树, 包括肺内各级支气管及其末端的肺泡间质 : 即分布于支气管树之间的结缔组织, 内含血管神经淋巴管及较多的巨噬细胞等肺的血液循环 : 支气管循环