Disease of respiratory system Wang Lin Department of Pathology Norman Bethune College of Medicine
Section one Pneumonia 肺炎
Review-1 呼吸系统的解剖学 呼吸道分上下两部分
Anatomy of respiratory system 支气管 ---nose ---pharynx ---larynx ---trachea ---bronchi ---lung 肺泡 细支气管
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 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
Normal Lung alveoli
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
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
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.
Objective Describe the morphologic features of lobar pneumonia. Explain the clinical manifestations of patients with lobar pneumonia.
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 20-50 years old adult males previously healthy.
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
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
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
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 *
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.
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
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
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.
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
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.
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.
complications of lobar pneumonia pulmonary carnification: organization of exudate into fibrotic scar tissue (incomplete resolution). pulmonary carnification pulmonary carnification
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?
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?
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
Lobar Pneumonia 大叶性肺炎 Diagnostic tools Chief complaint 主诉 Physical examination X-ray Laboratory analysis: Sputum, Blood
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.
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.
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
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.
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.
Lobular pneumonia/bronchopneumonia
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
Lobular pneumonia 小叶性肺炎 confluent lobular pneumonia
Lobular pneumonia LM Suppurative exudate that fills the bronchi bronchioles and adjacent alveolar spaces.
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.
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").
Lobular pneumonia/bronchopneumonia
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 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
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
Viral pneumonia Pathological changes Grossly The alveolar septa are expanded by hyperemia, edema Necrosis
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.
Viral pneumonia hyaline membranes Here is the microscopic appearance of a viral pneumonia with interstitial lymphocytic infiltrates. Note that there is no alveolar exudate.
Viral pneumonia necrosis inclusion bodies
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.
SARS Severe Acute Respiratory Syndrome 严重急性呼吸综合征
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
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
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
透明膜 严重急性呼吸综合征 SARS
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.
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
Key points The characteristics of pneumonias and differences among the pneumonias