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Photo: Colorized scanning electron micrograph of the lung, showing alveoli. Seeley’s Anatomy & Physiology. 10th ed. New York, NY: McGraw-Hill 2010
Respiratory Pathology
Lecture 9
Learning Objectives
By the end of this presentation learnings will be able to:
1. Difference between bronchopneumonia and lobar pneumonia.
2. List and discuss the defense mechanisms that protect the lung against
bacterial infection.
3. Describe the agents most commonly cause bacterial pneumonia.
4. List and describe the four classical stages of lobar pneumonia.
5. Discuss the most important complications of bacterial pneumonia.
6. Describe the clinical features of bacterial pneumonia.
7. Identify primary atypical pneumonias, and describe the most common
causes.
8. Discuss the most frequent conditions that predispose to the formation of
pulmonary abscess.
9. Read gross and microscopic pathology plates and radiographic findings of
the most common bacterial and atypical pneumonias.
Marc Imhotep Cray, M.D. 2
Respiratory Pathology
Lecture 9
Pneumonia: Overview
Pneumonia is a respiratory disease characterized by inflammation of lung
parenchyma (excluding bronchi) caused by viruses, bacteria, fungi, or
irritants
General clinical signs and symptoms of pneumonia include:
Fever, chills, muscle stiffness, pleuritic chest pain, cough, blood-tinged or rusty sputum,
shortness of breath, rapid heart rate, and difficulty breathing
Diagnosis is made by several laboratory methods and (or) diagnostic
procedures, including:
Chest x-ray; Gram stain and culture (bacterial); bronchoalveolar lavage (Pneumocystis
carinii pneumonia [PCP]); serodiagnosis (Mycoplasma)
Classic laboratory findings associated with bacterial pneumonia are a
neutrophilic leukocytosis with an increase in band neutrophils (left shift)
Modified from Davis JL and King EE. Respiratory Pathology (Ch. 7) In: Deja Review Pathology , 2010 11
Respiratory Pathology
Lecture 9
Abscess: It results from lytic action of neutrophils and is most often found
in pneumonia caused by Staphylococcus aureus
Pulmonary Abscess
Pulmonary abscess is a local suppurative process within lung characterized by
necrosis of lung tissue
Pneumonia Case
A 65-year-old woman is taken to the emergency room by her daughter. She has
had “cold”-like symptoms for the past couple of days. This morning, her
temperature spiked to 102°F and she experiences shaking chills, pain in her
chest, and a productive cough with bloody sputum. Gram stain evaluation of the
sputum revealed the presence of gram-positive lancet-shaped diplococci. A
sputum specimen was sent to the laboratory for culture and sensitivity testing
and a course of penicillin begun. Preliminary laboratory results reported alpha-
hemolytic colonies on blood agar.
Klebsiella pneumoniae
Phy. Char: Gram-negative rod, large mucoid capsule
Etio. and Epi: found in soil, water, and large intestine colonization of
oropharynx is uncommon but can occur in individuals with compromised host
defenses (alcoholics, the elderly, chronic respiratory illness=COPD)
Aspiration of organisms from oropharynx leads to pneumonia (alcoholics w
LOC)
Clin. Findings: Opportunistic necrotizing pneumonia (and urinary tract
infections)
Bronchopneumonias are characterized by acute inflammatory infiltrates
from bronchioles into adjacent alveoli
Dark red “currant jelly” sputum (blood/mucus)
Pathogenesis: virulence factors include cell wall endotoxin, a thick mucoid
capsule, and a variety of proteases
Tx: resistant to many antibiotics, so sensitivity testing is required
Marc Imhotep Cray, M.D.
Respiratory Pathology
Lecture 9
Atypical pneumonia
Primary atypical pneumonia is an acute febrile respiratory disease
characterized by patchy inflammatory changes in lungs largely confined to
alveolar septa and pulmonary interstitium
Term atypical emphasizes lack of alveolar exudates a more accurate designation is
interstitial pneumonitis
Chest x-ray often appears worse than patient appears (walking pneumonia)
High-Yield Note: Q-fever is most common rickettsial pneumonia,
caused by Coxiella burnetii
Who typically gets Q-fever? People working with infected cattle or
sheep, people who consume unpasteurized milk from infected animals
Marc Imhotep Cray, M.D. 22
Respiratory Pathology
Lecture 9
Mycoplasma
Mycoplasma pneumoniae
Mycoplasma genitalium
Key Concepts:
Mycoplasma do not contain a cell wall therefore not
susceptible to action of cell wall antibiotics such as penicillins,
cephalosporins, vancomycin, bacitracin, and cycloserine
Cell membrane is unique contain sterols
Mycoplasma are smallest free-living bacteria
http://www.intechopen.com/books/respiratory-disease-
http://www.medicalgrapevineasia.com/mg/2012/11/20/the-mycoplasma-story/ and-infection-a-new-insight/pneumonia-in-children
Marc Imhotep Cray, M.D.
Respiratory Pathology
Lecture 9
Chlamydophila pneumoniae
Phy. Char: Previously a member of Chlamydia genus, Obligate
intracellular parasite, Gram-negative-like cell wall lacking typical
peptidoglycan
Etio. and Epi: Transmission by respiratory droplets
Clin. Findings: causes several respiratory illnesses including
pharyngitis, bronchitis, and pneumonia
Infection is characterized by a persistent cough that can last weeks
Pneumonia is atypical and similar to that caused by Mycoplasma
pneumoniae and Legionella pneumophila
Lab Dx: Serologic assays assist in diagnosis, Cell culture
Tx: sensitive to tetracyclines and macrolides (erythromycin and
azithromycin)
Marc Imhotep Cray, M.D.
Respiratory Pathology
Lecture 9
Pneumocystis carinii pneumonia
(Pneumocystis jiroveci pneumonia)
The most common opportunistic infection in patients with human
immunodeficiency virus (HIV), acquired immunodeficiency syndrome (AIDS)
and others with impaired immunity
Lung damage is seen in patients with pneumocystis infection is a diffuse,
interstitial pneumonitis
Best way to diagnose pneumocystis carinii pneumonia is bronchoalveolar
lavage, bronchial washing, or sputum
If unsuccessful, endobronchial biopsy open lung Bx
Human immunodeficiency virus (HIV), is a retrovirus that has a propensity
for helper T-cell lymphocytes
Depletion of these helper T cells (also known as CD4 cells) leads to infections such as
Pneumocystis jiroveci pneumonia, tuberculosis, esophageal candidiasis, cryptococcus
and histoplasmosis etc.
Marc Imhotep Cray, M.D. 32
Respiratory Pathology
Lecture 9
Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed., 2015
Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed., 2015
Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed., 2015
Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed., 2015
Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed., 2015
Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed., 2015
Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed., 2015
Aspiration, CT image
Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed., 2015 41
Marc Imhotep Cray, M.D.
Respiratory Pathology
Lecture 9
CASE
A 32-year-old man is brought into the emergency department
because of extensive bruising of the chest in a minor motor vehicle
accident. He is known to be HIV-positive. He complains of
progressive fatigue over the last 3 months and has not visited a
doctor for over a year. A complete blood count (CBC) shows
pancytopenia, and a bone marrow biopsy shows narrow-based
budding yeast.
What is the most likely diagnosis?
What are the usual mechanisms of HIV-induced disease?
CLINICAL CORRELATION
This 32-year-old man has an HIV infection.
Involvement of hemopoietic system is common, causing lymphadenopathy, anemia,
leukopenia, and thrombocytopenia
These effects can be due to virus itself, consequences of antiviral therapy, or opportunistic
infections
Histologic studies and culture of the lymph nodes or bone marrow are often diagnostic
Bone marrow aspirates may reveal malignancy or a fungal infection such as histoplasmosis
Histoplasmosis is an opportunistic infection that is seen most frequently in the Mississippi
and Ohio valleys, where Histoplasma capsulatum is endemic
Most common manifestation in HIV patients is reactivation after initial primary pulmonary
disease has been contained
Disseminated disease after reactivation can lead to fever, weight loss, hepatosplenomegaly,
and lymphadenopathy
Central nervous system involvement with a cerebral mass may be seen
Bone marrow involvement is common, with pancytopenia noted in approximately one-third
of patients
Treatment is with either Itraconazole or amphotericin B
Marc Imhotep Cray, M.D. 44
Respiratory Pathology
Lecture 9
Question 1
A patient in the hospital develops pleuritic chest pain, shortness of breath,
fever, chills, productive cough, and colored sputum after 3 days of being in the
hospital for major surgery.
Physical examination shows tenderness to palpation without any areas of
increased tactile fremitus. Blood and sputum cultures confirm gram-negative
rods that ferment lactose, have a large mucoid capsule, and form viscous
colonies.
The patient subsequently dies from her infection. Which of the following is
most likely to be found at autopsy?
(A) Acute inflammatory infiltrates from bronchioles into adjacent alveoli
(B) Congestion, red hepatization, gray hepatization, and resolution
(C) Diffuse, patchy inflammation localized to the alveolar wall interstitium
(D) Intra-alveolar hyaline membranes without alveolar space exudates
(E) Predominantly intra-alveolar exudate resulting in consolidation
Marc Imhotep Cray, M.D.
Respiratory Pathology
Lecture 9
Answer
The correct answer is A. The characteristics of the microorganism indicate
infection with Klebsiella species, while the physical exam points to a
bronochopneumonia rather than a lobar pneumonia. K. pneumoniae is a gram
negative rod that ferments lactose and has a mucoid capsule.
Bronchopneumonias are characterized by acute inflammatory infiltrates from
bronchioles into adjacent alveoli. Pneumonia resulting from infection by this
bacterium is often caused by aspiration, so that it is often seen in people with a
loss of consciousness (i.e. alcoholics). It is also more common in patients with
diabetes.
Question 2
A 28-year-old man comes to the physician because of worsening muscle
weakness that began in his legs and feet 3 days ago, and has now spread to his
arms and hands. Other than having a flu-like illness 2 weeks ago, the patient
has been in good health. Cerebrospinal fluid analysis shows an increased
protein concentration, a normal cell count, and a normal glucose level. An
infection with which of the following organisms is the most likely cause of the
nervous system syndrome described in this patient?
(A) Candida albicans
(B) Legionella pneumophila
(C) Mycoplasma pneumoniae
(D) Pseudomonas aeruginosa
(E) Streptococcus pneumoniae
Answer
The correct answer is C. The syndrome described is Guillain-Barré syndrome, a
common cause of acute peripheral neuropathy that results in progressive
weakness over a period of days. Although one-third of patients report no history
of an antecedent infection, the other two-thirds have recently experienced an
acute gastrointestinal or influenza-like illness prior to developing the neuropathy.
The most common epidemiologic associations involve infections with
Campylobacter jejuni, Haemophilus influenzae, CMV, EBV, Mycoplasma
pneumoniae, and VZV. Laboratory abnormalities associated with Guillain-Barré
syndrome include elevated gamma-globulin, decreased nerve conduction velocity
indicative of demyelination, and albuminocytologic dissociation (CSF shows
increased protein concentration with normal cell count in the setting of normal
glucose). Although the organisms listed frequently precede the syndrome, there
has never been any consistent demonstration of any single infectious agent in the
peripheral nerves of these patients, and the cause of the disease is thought to be
mediated by hypersensitive T lymphocytes.
Marc Imhotep Cray, M.D.
THE END
49
Respiratory Pathology
Lecture 9
Textbooks:
Kumar V and Abbas AK. Robbins and Cotran Pathologic Basis of Disease 8th ed. Philadelphia:
Saunders, 2014
Rubin R and Strayer DS Eds. Rubin’s Pathology: Clinicopathologic Foundations of Medicine,
6th Ed. Baltimore: Lippincott Williams & Wilkins, 2012
Marc Imhotep Cray, M.D. 50