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1、The Lung1.Pneumonia2.COPD3.Pneumoconiosis4.Chronic cor pulmonale5. Lung cancer2 days old. Dyspnea for 1 days.Fig. 13.02What is the diagnosis?1. PneumoniaLobar pneumoniaLobular pneumoniaLegionella pneumoniaViral pneumoniaMycoplasmal pneumoniaSARS1.1 Lobar pneumoniaLobar pneumonia is an acute bacteria
2、l infection resulting in fibrinosuppurative consolidation of a large portion of a lobe or of an entire lobe. Moreover, the same organisms may produce bronchopneumonia in one patient, whereas in the more vulnerable individual, a full-blown lobar involvement develops. Most important from the clinical
3、standpoint are identification of the causative agent and determination of the extent of disease.In lobar pneumonia, four stages of the inflammatory response have classically been described: congestion, red hepatization, gray hepatization, and resolution. Present-day effective antibiotic therapy freq
4、uently slows or halts the progression. In the first stage of congestion, the lung is heavy, boggy, and red. It is characterized by vascular engorgement, intra-alveolar fluid with few neutrophils, and often the presence of numerous bacteria. 充血水肿期The stage of red hepatization that follows is characte
5、rized by massive confluent exudation with red cells (congestion), neutrophils, and fibrin filling the alveolar spaces. On gross examination, the lobe now appears distinctly red, firm, and airless, with a liver-like consistency, hence the term hepatization. 红色肝样变期The stage of gray hepatization follow
6、s with progressive disintegration of red cells and the persistence of a fibrinosuppurative exudate, giving the gross appearance of a grayish brown, dry surface. 灰色肝样变期In the final stage of resolution, the consolidated exudate within the alveolar spaces undergoes progressive enzymatic digestion to pr
7、oduce a granular, semifluid, debris that is resorbed, ingested by macrophages, coughed up, or organized by fibroblasts growing into it.溶解消散期Pneumococcal pneumonia A, Acute pneumonia. The congested septal capillaries and extensive neutrophil exudation into alveoli corresponds to early red hepatizatio
8、n. Fibrin nets have not yet formed. B, Early organization of intra-alveolar exudate, seen in areas to be streaming through the pores of Kohn (arrow). C, Advanced organizing pneumonia (corresponding to gray hepatization), featuring transformation of exudates to fibromyxoid masses richly infiltrated b
9、y macrophages and fibroblasts.Lobar pneumonia-gray hepatization Complications of pneumonia include(1) tissue destruction and necrosis, causing abscess formation (particularly common with type 3 pneumococci or Klebsiella infections); (2) spread of infection to the pleural cavity, causing the intraple
10、ural fibrinosuppurative reaction known as empyema积浓积浓; (3) organization of the exudate, which may convert a portion of the lung into solid tissue; pulmonary carnification(4) bacteremic dissemination to the heart valves, pericardium, brain, kidneys, spleen, or joints, causing metastatic abscesses, en
11、docarditis, meningitis, or suppurative arthritis.大叶性肺炎大叶性肺炎(lobar pneumonia)病因和发病机制 （1）病原菌：肺炎链球菌占以上，少数为金葡菌，链球菌等。（2）诱因：受寒，疲劳，醉酒，感冒等。（3）途径：呼吸道感染。病理变化部位：一般单侧肺的大叶受累，多见于左肺下叶。基本特点：（）肺泡腔内渗出物，肺泡壁保留。（）支气管病变较轻。（）病变呈阶段性发展（分四期）。（）愈复后，肺组织可完全恢复其正常结构和功能。病理变化分期：（）病变早期（充血水肿期）（）实变期（天后进入该期）：又分红肝期（前天）和灰肝期（）溶解消散期（天后进入该期
12、）合并症（）肺肉质变肺肉质变(carnification)（）肺脓肿，脓胸或脓气胸（）纤维素性胸膜炎（）败血症，脓毒败血症或感染性休克 临床病理联系病变早期（充血水肿期）：泡沫样痰，湿性罗音。实变期：紫绀，呼吸困难，铁锈色痰，胸痛，呼吸音减弱，语颤增强，叩浊音，光呈大片致密阴影。溶解消散期：脓痰，体征逐渐消失，光阴影约在周后完全消失。病史摘要病史摘要男，28岁。因腹痛在医院胃镜取出一620.8cm塑料物。2天后咳嗽、突发胸闷、胸痛、气促情况，抢救无效死亡。食管：距喉头约4 cm处右侧食管壁可见一纵行裂口，长约1 cm，创缘整齐，创角较钝。外膜无出血。镜检：食管穿孔处可见黏膜消失，局部形成溃疡，
13、基底可见肉芽组织织及少数炎症细胞浸润。肉芽组织表面可见坏死及纤维蛋白渗出。其下方可见疤痕组织形成。其外膜未见异常。肺：右肺上叶数个空腔，大者62.52cm，小者直径1.5 cm，包膜菲薄，腔内见少量咖啡色液体。中叶及下叶片状出血实变。左肺切面暗红，含血量增加。镜检：二肺各叶切片见肺泡腔内有大量纤维蛋白，分叶核白细胞、单核细胞及淋巴细胞渗出。肺间质血管充血明显。部分肺泡腔内出血明显。有处肺组织坏死。有处可见脓肿。肺膜纤维组织增生而增厚，有处见纤维蛋白渗出。病理诊断病理诊断1两侧全肺两侧全肺融合性肺炎融合性肺炎，伴，伴肺脓肿肺脓肿形成；形成；2食管壁穿孔伴食管壁穿孔伴肉芽组织肉芽组织增生。增生。讨
14、讨 论论1 死者生前主要患有两肺全肺融合性肺炎伴肺脓肿形成，导致呼吸衰竭而死亡。2 根据其食管穿孔形态特征及病理组织变化，推测其形成约在10天以上。3 食管穿孔可以导致肺部感染。1.2 Bronchopneumonia 肺小叶、化脓性炎症Foci of bronchopneumonia are consolidated areas of acute suppurative inflammation.化脓性炎症 The consolidation may be patchy through one lobe but is more often multilobar and frequently
15、bilateral and basal because of the tendency of secretions to gravitate into the lower lobes.Well-developed lesions are usually 3 to 4 cm in diameter, slightly elevated, dry, granular, gray-red to yellow, and poorly delimited at their margins. Histologically, the reaction usually elicits a suppurativ
16、e, neutrophil-rich exudate that fills the bronchi, bronchioles, and adjacent alveolar spaces. Comparison of bronchopneumonia and lobar pneumonia Clinical CourseThe major symptoms of community-acquired acute pneumonia are abrupt onset of high fever, shaking chills, and cough productive of mucopurulen
17、t sputum; occasional patients may have hemoptysis. When fibrinosuppurative pleuritis is present, it is accompanied by pleuritic pain and pleural friction rub. The characteristic radiologic appearance of lobar pneumonia is that of a radio-opaque, usually well-circumscribed lobe, whereas bronchopneumo
18、nia shows focal opacities. 小叶性肺炎小叶性肺炎(lobular pneumonia)指主要由化脓菌感染引起，病变起始于细支气管，并向周围或末梢肺组织扩展，形成以肺小叶为单位、呈灶状散布的急性化脓性炎。又称支气管肺炎(bronchopneumonia)特点（与大叶性肺炎比较）：病因：种类较多如葡萄球菌，链球菌等。诱因：营养不良、传染病、恶病质、昏迷、麻醉、手术后等。病人：多见于小儿和年老体弱者或病毒性肺炎患者等。病变：两肺（以下叶背侧较严重）以细支气管为中心的肺小叶化脓性炎，可融合成片并破坏肺组织。并发症：并发心力衰竭，呼吸衰竭，脓毒败血症，支扩等。病史摘要病史摘要男
19、，88岁。因民事纠纷被推倒后掉入50 cm的坎下, 清醒后送当地医院诊治。入院诊断“右锁骨骨折；头皮挫裂伤；肺部感染；右侧胸腔积液”。行右锁骨内固定术后，逐渐出现呼吸困难、低氧血症、全身浮肿、昏迷死亡。病病 理理 诊诊 断断1. 支气管性肺炎支气管性肺炎(右下肺右下肺)；慢性支气管炎慢性支气管炎；气管及左支气管黏液阻塞；气管及左支气管黏液阻塞；2. 老年性肺气肿伴血管壁增厚老年性肺气肿伴血管壁增厚(符合符合肺动脉高压肺动脉高压);3. 左肺上叶左肺上叶微小癌微小癌。讨论讨论1死者生前主要患有支气管性肺炎，老年性肺气肿等，由于上述疾病导致其呼吸衰竭而死亡；2本例死亡前头皮挫裂伤及右锁骨骨折等外伤
20、，对其死亡有促进作用；3支气管内大量黏液阻塞可导致窒息。思考题：思考题：支气管性肺炎和大叶性肺炎的区别。 慢性支气管炎的病理特点？肺气肿的病理类型？1.3 Legionella pneumoniaLegionella pneumophilia is the agentOrgan transplant recipents are particularly susceptible诊断 Rapid diagnosis is facilitated by demostration of Legionella antigens in the urine or sputum samples;culture
21、 remains the gold standard of diagnosis1.4 ATYPICAL (VIRAL病毒病毒 AND MYCOPLASMAL支原体支原体) PNEUMONIASThe term “primary atypical pneumonia” was initially applied to an acute febrile respiratory disease characterized by patchy inflammatory changes in the lungs, largely confined to the alveolar septa and pu
22、lmonary interstitium. 肺间质The term “atypical” denotes the moderate amount of sputum, no physical findings of consolidation, only moderate elevation of white cell count, and lack of alveolar exudate. 临床表现不典型The pneumonitis is caused by a variety of organisms, the most common being Mycoplasma pneumonia
23、e. Other etiologic agents are viruses, including influenza virus types A and B, the respiratory syncytial viruses, adenovirus, rhinoviruses, rubeola, and varicella viruses; Chlamydia pneumoniae; and Coxiella burnetti (Q fever).The histologic pattern depends on the severity of the disease. Predominan
24、t is the interstitial nature of the inflammatory reaction, virtually localized within the walls of the alveoli. The alveolar septa are widened and edematous and usually have a mononuclear inflammatory infiltrate of lymphocytes, histiocytes, and occasionally plasma cells. In acute cases, neutrophils
25、may also be present.The alveoli may be free from exudate, but in many patients, there is intra-alveolar proteinaceous material, a cellular exudate, and characteristically pink hyaline membranes lining the alveolar walls.Interstitial pneumonia. The fibrosis, which varies in intensity, is more pronoun
26、ced in the subpleural region.Usual interstitial pneumonia.Fibroblastic focus with fibers running parallel to surface and bluish myxoid extracellular matrix. Clinical CourseEven patients with well-developed atypical pneumonia have few localizing symptoms. Cough may well be absent(?), and the major ma
27、nifestations may consist only of fever, headache, muscle aches, and pains in the legs. The edema and exudation are both strategically located to cause mismatching of ventilation and blood flow and thus evoke symptoms out of proportion to the scanty physical findings.1.5 Severe Acute Respiratory Synd
28、rome (SARS)The severe acute respiratory syndrome first appeared in November of 2002 in the Guangdong Province of China and subsequently spread to Hong Kong, Taiwan, Singapore, Vietnam, and Toronto, where large outbreaks also occurred.The ease of travel between continents clearly contributed to this
29、pandemic. Between fall of 2002 and spring of 2003, there were more than 8,000 cases of SARS, including 774 deaths. 临床表现After an incubation period of 2 to 10 days, SARS begins with a dry cough, malaise, myalgias, fever and chills. As compared to other atypical pneumonias caused, for example, by Mycop
30、lasmas, SARS less commonly gives rise to symptoms related to the upper respiratory tract such as sore throat. A third of patients improve and resolve the infection, but the rest progress to severe respiratory disease with shortness of breath, tachypnea呼吸急促, and pleurisy and nearly 10% of patients di
31、e from the illness, for which there is no specific treatment.病因The cause of SARS is a previously undiscovered coronavirus. Nearly a third of upper respiratory infections are caused by coronaviruses, however the SARS virus differs from previously known coronaviruses in that it infects the lower respi
32、ratory tract and spreads throughout the body. The SARS virus appears to have been first transmitted to humans through contact with wild masked palm civets狸猫 that are eaten in China. Subsequent cases were spread person-to-person, mainly through infected respiratory secretions, although some cases may
33、 have been contracted from stool.DiagnosisSARS can be diagnosed either by detection of the virus by PCR, or by detection of antibodies to the virus. Levels of the virus are low initially and peak 10 days after onset of illness, so testing of different specimens (respiratory secretions, blood, and st
34、ool) collected on several days may be needed to detect the virus. Detection of antibodies specific for the SARS virus is a very sensitive and specific test, however patients may not have a measurable antibody response for up to 28 days after infection.The pathophysiology of SARS is not understood, n
35、or is it known why the virus moved from animals to humans. The SARS coronavirus isolated from most human cases has a 29 nucleotide deletion in the RNA when compared to the virus found in wild animals, and this variation may enhance transmission or pathogenicity of the virus in humans. The lungs of p
36、atients who have died of SARS show diffuse alveolar damage and multinucleated giant cells. Coronaviruses can be seen within pneumocytes by electron microscopy.病毒性肺炎病毒性肺炎(viral pneumonia)指主要由上呼吸道病毒感染向下蔓延，主要引起肺间质（即支气管、血管周围及肺泡壁）病变，而肺泡腔病变轻，表现为间质性肺炎。病因：流感病毒，呼吸道合胞病毒，腺病毒，麻疹病毒等。病理变化（）早期或轻型呈间质性肺炎。（）病变较重者：肺泡内
37、炎性非化脓性渗出物浓缩凝结成透明膜透明膜，甚至组织坏死。支气管和肺泡上皮增生，形成多核巨细胞，胞浆和胞核内可见病毒包含体（病理诊断病毒性肺炎的重要依据）。临床病理联系呼吸道症状：咳嗽，呼吸困难。全身中毒症状支原体肺炎支原体肺炎(mycoplasmal pneumonia)指由肺炎支原体引起的间质性肺炎，儿童和青年发病率较高。病理变化：病变主要发生在肺间质，病灶呈节段性或灶性分布，常仅累及一个肺叶，镜下呈肺泡间隔充血、水肿、淋巴细胞和单核细胞浸润等。临床预后：良好，自然病程约为周。Male,43 days old.Vomit for 1 days.Sudden death.1.6 LUNG AB
38、SCESSThe term pulmonary abscess describes a local suppurative process within the lung, characterized by necrosis of lung tissue. Oropharyngeal surgical procedures, sinobronchial infections, dental sepsis, and bronchiectasis play important roles in their development.Etiology and PathogenesisAlthough
39、under appropriate circumstances any pathogen can produce an abscess, the commonly isolated organisms include aerobic and anaerobic streptococci, Staphylococcus aureus, and a host of Gram-negative organisms. Mixed infections occur often because of the important causal role that inhalation of foreign
40、material plays.Pyemic lung abscess in the center of section with complete destruction of underlying parenchyma within the focus of involvement 破坏破坏 The cardinal histologic change in all abscesses is suppurative destruction of the lung parenchyma within the central area of cavitation Clinical CourseT
41、he manifestations of pulmonary abscesses are much like those of bronchiectasis and are characterized principally by cough, fever, and copious amounts of foul-smelling purulent sputum. Fever, chest pain, and weight loss are common. Clubbing of the fingers and toes may appear within a few weeks after
42、the onset of an abscess. Diagnosis of this condition can be only suspected from the clinical findings and must be confirmed by roentgenography. Whenever an abscess is discovered, it is important to rule out an underlying carcinoma because this is present in 10% to 15% of cases.Complications include
43、extension of the infection into the pleural cavity, hemorrhage, the development of brain abscesses or meningitis from septic emboli, and (rarely) secondary amyloidosis (type AA).复习题1. Emphysema, Reid index, Bronchiectasis, Chronic cor pulmonale2. In lobar pneumonia, four stages of the inflammatory r
44、esponse have classically been described:3. Complications of pneumonia ？4. Chronic bronchitis is defined clinically?5. The characteristic histologic features of chronic bronchitis?6. There are four major type emphysemas?7. Various forms of atelectasis in adults?8. Comparison of bronchopneumonia and lobar pneumonia?9. What is the difference among Chronic bronchitis , Bronchiectasis , Asthma, Emphysema ?
