协和医学院病理呼吸系统课件

1、1Pulmonary diseaseInfections Obstructive Pulmonary DiseaseRestrictive pulmonary DiseaseTumors2Chronic Obstructive Pulmonary DiseaseChronic bronchitis EmphysemaBronchiectasisasthma3Chronic bronchitispersistent cough with sputum production for at least 3 months in at least 2 consecutive years.4Forms o

2、f Chronic bronchitissimple chronic bronchitis productive cough mucoid sputum no airflow obstruction.Chronic asthmatic bronchitisChronic obstructive bronchitis 5pathogenesisChronic irritation Cigarette smoking(最重要的病因) air pollutants (SO2, NO2 ) Microbial infectionHypersensitivityOthers 69REID INDEX=

3、b-c/a-d(Normally 0.4)1011In Chronic obstructive bronchitis, the morphologic basis of airflow obstruction :chronic bronchioles (small airway disease): goblet cell metaplasia mucous plugging, inflammation, fibrosis.12Clinical :Coughmucoid sputumWheezing13Complications:Bronchiectasis emphysema 最主要的chro

4、nic cor pulmonalebronchopneumonia14Emphysema a condition of the lung characterized by abnormal permanent enlargement of the airspaces distal to the terminal bronchiole, accompanied by destruction of their wall.过度充气+管壁破坏 compensatory Emphysema Senile 老年性Emphysema Overinflation过度膨胀15Type of EmphysemaA

5、cinar (alveolar) Emphysema obstructive EmphysemaInterstitial EmphysemaParacicatrial Emphysema Bullae lung(2cm)16Type of Acinar EmphysemaCentroacinar Emphysema (Centrilobular )Panacinar Emphysema (Panlobular)Periacinar Emphysema (Distal acinar)Irregular Emphysema17Irregular Distal panacinarnormalcent

6、ral18阻塞性肺气肿的关键环节:小气道炎症肺泡间隔断裂1920Oxidant-antioxidant imblance21Centrilobular emphysemaLobular septum22Long time smoker2324a1-AT deficencyIntravenous drug abuse252627Panacinar emphysema28Paraseptal (Distal Acinar) EmphysemaSubpleural upper lobesFibrosisbullae29Clinical :dyspneabarrel-chested, breath s

7、ound, percussion note is hyperreaonantX-ray: hyperinflation30Complications:chronic cor pulmonaleSpontaneous pneumothoraxAcute inflammatory31chronic cor pulmonale -pulmonary morphologySmaller arteries and arterioles thickening internal/medial hypertrophy Lumina narrow muscularization of arterioles 32

8、chronic cor pulmonale33Bronchiectasis Bronchiectasis is the permanent dilatin of bronchi and bronchioles caused by destruction of the muscle and elastic supporting tissue, resulting from or associated with chronic necrotizing infections.34Two processes are crucial and intertwined in the pathogenesis

9、 of bronchiectasis:obstruction and chronic persistent infection.35Bronchiectasis originsBronchial obstructionTumorsForeign bodiesOccasionally mucous impactionCongenital or hereditary conditionsCystic fibrosisImmotile cilia and Kartagener syndromesNecrotizing or suppurative pneumonia36Bronchiectasis与

10、慢支不同点Lower lobesEpithelium damageBronchial/bronchiolar wall destruction, fibrosis Duct irregular dilatationPeribronchiolar fibrosisChronic and active inflammation3738Bronchiectasis39Bronchiectasis40Bronchiectasis41Clinical :2.Severe,persistent coughCopious amounts of purulent sputum(fetid)Hemoptysis

11、3.Clubbing of the fingers42Pulmonary infections43Lobar pneumoniaAcute bacterial infection Initially from alveoli, involves segamental or an entire lobe.Diffuse fibrinous exudate infection MaleFemale, 30-50 yearsAbrupt malaise, fever, chest pain, cough productive of Brown sputum44Lobar Pneumonia Etio

12、logyLobar pneumonia , 90-95% are caused by pneumococciMost common are types 1,3,7 and 2.Type 3 causes a particularly virulent form of lobar pneumonia.Occasionally , Klebsiella pneumoniae(肺炎克雷伯杆菌), staphylococci葡萄球菌, streptococci琏球菌, H. influenzae and some of the gram-negative organisms.45Lobar pneum

13、onia (morphology)a diffuse fibrinous exudate infection that leads to spread through the pores Kohn consolidation of large areas & even lobes of the lung.46four stages of the histopathology 1. congestion (1-2days) 2. red hepatization (3-4days) 3. gray hepatization (5-10) 4. resolution (10- days)47此期细

14、菌大量繁殖1-2daysLobe is heavy, red and boggy Vascular congestionProteineous fluid浆液性渗出, scattered neutrophils and red cells in the alveoliMany bacteria 482.red hepatization纤维素通过肺泡间孔相连，限制细菌扩散3-4daysLobesis heavy，dark red，liver-like consolidation Vascular congestionAlveolar spaces are packed with many neu

15、trophils , red cells and fibrin Many bacteria 493.Gray hepatization无菌，病人自觉病症减轻，咳铁锈色痰，胸痛5-10 daysLobe(s) is large、dry、gray and firmVascular compressed 毛细血管受压充血消退，菌不入血Red cells are lysed, fibrin persists withs in the alveoli. Bacteria disappear50After 10 daysLobe(s) is soft as normal Alveolar exudates

16、 are enzymatically digested, resorbed and ingested.51lobular uniformly consolidation gray hepatization525354Clinical:Abrupt malaise, fever, X-ray：consolidation Cyanosiscough Brown sputumchest pain55Complications (lobar pneumonia)Organizing pneumonia Pulmonary carnificationAbscessesExudative pleuriti

17、sEmpyema56Bronchopneumonia (lobular pneumonia)Its an inflammation that originates in bronchioles and extends into the surrounding alveoli. Children or elder person 57Bronchopneumonia Often mixed Bacterial infection: staphylococci, streptococci, pneumococci , H. Influenzae Inhalation of noxious gases

18、 and dustsAspiration of fluid and solid contents of the alimentary tract58Morphology of Bronchopneumonia Patchy consolidation 实变灶大小不等，散在多发，不规那么One lobe/multilobar , frequently bilateral and basal part of the lung分布The lesions are 3-4cm in diameter, slightly elevated？ , dry , gray-red to yellow, poor

19、ly delimited at the margins病灶直径，颜色，边界59Bronchopneumonia histologyA suppurative, neutrophil-rich exudate that fills the bronchi, bronchioles , and adjacent alveolar spaces60616263Complications of bronchopneumonia Lung abscesses Empyema Suppurative pericarditis Bacteremia with metastatic abscess forma

20、tion in other organs and tissue in the body64Legionella pneumonia An outbreak of severe pneumonia affected 180 of about 4400 persons attending the Annual Convention of American Legionnaires in Philadolphia,USA during July 1976, causing 29 deathes. Gram (-) fibrinopurulent bronchopneumonia abundant f

21、ibrin, variable macrophage and neutrophils65Atypical pneumoniaUsualy absence of physical findings of consolidation and only moderate elevation of white cell count A pulmonary inflammatory large confined to alveolar septa and pulmonary interstitium, Lack of alveolar exudate(interstitial pneumonia)Com

22、monly caused by mycoplasma,viruses mycoplasma pneumonia viral pneumonias66Histologically:the inflammatory reactionis largely confined within the wall of the alveoli.67Clinically, respiratory distress seemingly out of proportion to the physical and radiographic findings68Severe acute respiratroy synd

23、rome(SARS)Coronavirus (SARS-CoV)Infect the lower respiratory tract and induce viremiaThe histopathology of lung of SARS usually demonstrated Diffuse alveolar damagePneumocystis卡氏肺孢菌 pneumoniaAn opportunistic infections occurred in immunocompromised person AIDS Organ transplantation chemotherapy maln

24、ourished children 70Pulmonary tuberculosis a chronic granulomatous disease caused by M. tuberculosis, usually affecting the lungs, but virtually any extra-pulmonary organ can be involved by isolated tuberculosis.71Characteristic tubercle - tuberculous granuloma即结核结节tubercle Central caseous necrosis以

25、及四种细胞成分 epithelioid cells Multinucleated giant cells Lymphocytes Fibroblastic cell 73Primary pulmonary tuberculosisChildren The form of disease that develops in a previously unexposed ,unsensitized personIt begins as a single granulomatous lesion ( Ghon focus即原发灶), subjacent to the pleura in the inf

26、erior upper lobe/superior lower lobe regions.The spread to draining bronchial and hilar门 nodes即引流到支气管和肺门淋巴结Combination of lung and lymph node lesions called the Ghon complex74Primary pulmonary tuberculosis,Ghon complex原发灶，淋巴管炎，肺门淋巴结结核Hilar LN7576Ziehl-Neelsen stain77Final results of the primary tube

27、rculosis a benign,self-limited disease, Induce hypersensitivity/resistance-自限results in local scarring and calcification ,may reactivation-局限progressive primary tuberculosis-进展Through the lymphohematogenous routes ,distant organs may be miliary disseminated tuberculosis or isolated organ tuberculous

28、 infection-播散78Progressive primary tuberculosisbronchopneumonia79Secondary tuberculosisAdult In a previously sensitized host Reinfection Most cases adult or secondary pulmonary tuberculosis represent reactivation of an old, possibly subclinical infection.80Secondary tuberculosisClassically localized

29、 to the apex of one or both upper lobesCavitation occurs readilyDissemination alone the airways81Secondary tuberculosisMorphologyLesion is almost invariably located in the apex of one or both lungs.位置A small focus of consolidation, usually less than 3 cm. In diameter within 1 or 2 cm. Of the apical

30、pleura.大小The foci are fairly sharply circumscribed, firm.gray-white to yellow areas that a greater or lesser component of central caseation and peripheral fibrous induration 边界清，质实，灰白到黄，伴不同程度的干酪样坏死和硬化.8283Secondary tuberculosisHistologically granulomas , with necrosis ( caseation)The progressive les

31、ions, more tubercles coalesce to create a confluent area of consolidatonThe favorable case,is converted to a fibrocalcific scar.May progress along several different pathways8485Cavitary fibrocaseous tuberculosisThe cavity remains localized to the apex is lined by a yellow-gray caseous material is mo

32、re or less walled off by fibrous tissueThrombosed arteries may traverse these cavities to produce apparent fibrous bridging bands.The infective material may disseminate through the airways.86Secondary tuberculosis: bilateral cavitary lesions8788Military tuberculosisLymphhematogenous dissemination ma

33、y give to militnary tuberculosis lymphatics major lymphatic ducts/venous right of the heart lungPulmonary venous systemic circulation distant seeding89Military tuberculosis of spleen90Secondary military tuberculosis91 Tuberculous bronchopneumoniaHighly sensitizedTuberculous infection may spread rapi

34、dly a diffuse bronchopneumonia or lobar pneumonia (galloping consumption 奔马痨)Histological features: exudates, caseation, numerous TB bacilli9293Pneumoconiosis-silicosisPneumoconioses encompass a group of chronic fibrosing diseases of the lung resulting from exposure to organic and inorganic particul

35、ates.Silicosis is caused by inhalation of crystalline silicon dioxide (silica), is the most common Pneumoconiosis in the world.94SilicosisDusts 5 nose cavity 3-5 bronchial cavity 2 alveoli Phagocytosis (macrophages) Respiratory bronchiole mucociliary flow Phagocytosis (macrophages) type I epithelium

36、 interstitial lymph vesselLN 95矽肺结节形成的学说1.机械刺激；2.化学毒性；3.免疫因素SiO2微粒肺间质巨噬细胞吞噬被巨噬细胞吞噬膜包绕在细胞内形成吞噬体与溶酶体融合次级溶酶体SiO2微粒外表H2O 次级溶酶体膜上磷脂或蛋白氢键改变溶酶体膜的通透性和稳定性释放多种水解酶细胞自溶崩解 产物 SiO2 刺激纤维母细胞增生、产生胶原， 重复以上过程 玻璃样变 反复过程形成矽结节96silicosisIn the early stages, (Asymptomatic)tiny discrete pale to blackened silicotic nodules

37、97silicosis98Cellular Silicotic nodules99Fiberal Silicotic nodules100Chronic Silicotic nodules101Silicotic nodules the nodular lesions consist of concentric layers of hyalinized collagen surrounded by a dense capsule of more condensed collagen.Examination of the nodules by polarized microscopy revea

38、ls the birefringent silica particles.102第一期循淋巴管肺门LN肺间质形成结节结节小，针头或绿豆大小，集中在中下肺近肺门出。胸膜下可有少量矽结节，但胸膜无增厚。肺气肿不明显。肺重量、体积。硬度无明显改变。X线：肺门阴影增大，密度增加，两肺中下叶可见矽结节影量少。此期一般临床容易忽略无病症。103第二期矽结节增多，涉及淋巴系统外的肺组织。结节融合黄豆大小仍以中下叶肺近肺门处较密集，肺门LN及胸膜下矽结节数量和病变程度增加，但总的病变范围不超过全肺的1/3。结节间可见肺气肿，胸膜增厚。X线：肺门阴影增大，密度大，肺野内可见密集矽结节影。104第三期矽结节密集融

39、合肿瘤样团块。团块直径超过2CM。肺重量、硬度明显增加。团块中央缺血、坏死甚至形成空洞。肺在水中下沉，无钙化，有代偿性肺气肿，甚至肺大泡。105ComplicationsSilicotuberculosischronic cor pulmonalePulmonary Infection Spontaneous pneumothorax106Acute respiratory distress syndrome (ARDS)A clinical syndrome caused by diffuse alveolar capillary and epithelial damageThe histo

40、logic manifestation is Diffuse alveolar damage (DAD)Rapid onset life-threatening respiratory insufficiency cyanosis severe arterial hypoxemia107Acute respiratory distress syndrome (ARDS)Diffuse alveolar damage(DAD)the adult respiratory distress syndrome (ARDS) A variety of related clinical syndromes

41、 including shock lung, posttraumatic pulmonary insufficiency, traumatic wet lung, congestive atelectasis, postperfusion pulmonary insufficiency, progressive pulmonary consolidation, adult hyaline membrane disease, and respirator lung108Causes of diffuse alveolar damage109pathogenesisLung injury is c

42、aused by an imbalance of pro-inflammatory and anti-inflammatory mediatorsNeutrophils are thought to have an important role in the pathogenesis of ARDS110111112 Acute stage organizing stage113Pathologic findings in DADEarly,acute, or exudative stage is most prominent in the first week of injury and is characterized by edema and hyaling membranes.Late, proliferative, or organizing stage in which fibrosis predominates occurs after 1 to 2 wee