Fungal, And Pathology Of, Pneumonias; Tb

1. A 9-year-old girl with known history of cystic fibrosis since birth now complains of increased difficulty breathing for over the past week. Her vital signs include T 38.5 C, P 80/minute, RR 30/minute, and BP 110/60 mm Hg. A chest radiograph shows prominent bronchial markings and some bronchi appear markedly distended. No other infiltrates or masses are present. Which of the following does she most likely have?

Hypersensitivity pneumonitis

Mycobacterium tuberculosis infection

Bronchiectasis

Lobar pneumonia

Aspiration peumonitis

The 9-year-old girl with cystic fibrosis is presenting with increased difficulty breathing and a chest radiograph showing prominent bronchial markings and distended bronchi. These findings are consistent with bronchiectasis, which is a common complication of cystic fibrosis. Hypersensitivity pneumonitis, Mycobacterium tuberculosis infection, lobar pneumonia, and aspiration pneumonia are less likely given the clinical presentation and radiographic findings.

Explanation

The 9-year-old girl with cystic fibrosis is presenting with increased difficulty breathing and a chest radiograph showing prominent bronchial markings and distended bronchi. These findings are consistent with bronchiectasis, which is a common complication of cystic fibrosis. Hypersensitivity pneumonitis, Mycobacterium tuberculosis infection, lobar pneumonia, and aspiration pneumonia are less likely given the clinical presentation and radiographic findings.

2. A 9-year-old girl with known history of cystic fibrosis since birth now complains of increased difficulty breathing for over the past week. Her vital signs include T 38.5 C, P 80/minute, RR 30/minute, and BP 110/60 mm Hg. A chest radiograph shows prominent bronchial markings and some bronchi appear markedly distended. No other infiltrates or masses are present. Which of the following does she most likely have?

Hypersensitivity pneumonitis

Mycobacterium tuberculosis infection

Lobar pneumonia

Bronchiectasis

Aspiration peumonitis

The 9-year-old girl with a known history of cystic fibrosis and presenting symptoms of increased difficulty breathing, along with the findings on the chest radiograph of prominent bronchial markings and distended bronchi, is most likely to have bronchiectasis. Bronchiectasis is a condition characterized by the permanent dilation and destruction of the bronchi, leading to impaired mucus clearance and recurrent infections. It commonly occurs in individuals with cystic fibrosis, and the symptoms and radiographic findings described are consistent with this diagnosis.

Explanation

The 9-year-old girl with a known history of cystic fibrosis and presenting symptoms of increased difficulty breathing, along with the findings on the chest radiograph of prominent bronchial markings and distended bronchi, is most likely to have bronchiectasis. Bronchiectasis is a condition characterized by the permanent dilation and destruction of the bronchi, leading to impaired mucus clearance and recurrent infections. It commonly occurs in individuals with cystic fibrosis, and the symptoms and radiographic findings described are consistent with this diagnosis.

3. A 55-year-old man presents with malaise and right chest pain for the past two weeks. He has a long history of alcoholism, advanced dental caries, fever, and a cough producing foul, purulent sputum. A chest x-ray reveals a fluid-filled cavity in the upper right lobe. What is the most likely diagnosis?

Adenocarcinoma

Abscess

Bronchiectasis

Infarct

Mycoplasma pneumonia

The most likely diagnosis for this patient is an abscess. The patient's history of alcoholism, advanced dental caries, and symptoms such as malaise, chest pain, fever, and cough producing foul, purulent sputum are indicative of a lung abscess. The presence of a fluid-filled cavity in the upper right lobe on the chest x-ray further supports this diagnosis.

Explanation

The most likely diagnosis for this patient is an abscess. The patient's history of alcoholism, advanced dental caries, and symptoms such as malaise, chest pain, fever, and cough producing foul, purulent sputum are indicative of a lung abscess. The presence of a fluid-filled cavity in the upper right lobe on the chest x-ray further supports this diagnosis.

4. During a cardiac arrest, a 58-year-old man, a non-smoker, receives cardiopulmonary resuscitative measures and is brought to the hospital, where he is intubated. During the intubation procedure he suffers aspiration of gastric contents and over the next 10 days develops a non-productive cough along with a fever to 37.9 C. A chest radiograph reveals a 4 cm diameter mass with an air-fluid level in the right lung. A sputum gram stain reveals mixed flora. Which of the following conditions is he most likely to have?

Squamous cell carcinoma

Lung abscess

Chronic bronchitis

Bronchiectasis

Bronchopulmonary sequestration

The patient's history of aspiration of gastric contents during intubation suggests that he developed a lung abscess. A lung abscess is a localized collection of pus within the lung parenchyma, usually caused by aspiration of oropharyngeal secretions. The non-productive cough and fever are consistent with an infection. The chest radiograph findings of a mass with an air-fluid level further support the diagnosis of a lung abscess. The sputum gram stain revealing mixed flora also suggests an infectious etiology. Squamous cell carcinoma, chronic bronchitis, bronchiectasis, and bronchopulmonary sequestration are less likely given the clinical presentation and radiographic findings.

Explanation

The patient's history of aspiration of gastric contents during intubation suggests that he developed a lung abscess. A lung abscess is a localized collection of pus within the lung parenchyma, usually caused by aspiration of oropharyngeal secretions. The non-productive cough and fever are consistent with an infection. The chest radiograph findings of a mass with an air-fluid level further support the diagnosis of a lung abscess. The sputum gram stain revealing mixed flora also suggests an infectious etiology. Squamous cell carcinoma, chronic bronchitis, bronchiectasis, and bronchopulmonary sequestration are less likely given the clinical presentation and radiographic findings.

5. A 24-year-old male immigrant from Guatemala is evaluated for fever and chronic cough with hemoptysis. The doctor suspects tuberculosis. What region of the lung is an infiltrate of reactivation tuberculosis most likely to be found?

Lower lobes

Mid-lung

Near hilar lymph nodes

Near inflamed pleura

Upper lobes

Reactivation tuberculosis is most likely to be found in the upper lobes of the lungs. This is because the upper lobes have a higher oxygen tension, which provides a favorable environment for the growth of Mycobacterium tuberculosis. Additionally, the upper lobes have greater ventilation and blood flow, allowing for better dissemination of the bacteria.

Explanation

Reactivation tuberculosis is most likely to be found in the upper lobes of the lungs. This is because the upper lobes have a higher oxygen tension, which provides a favorable environment for the growth of Mycobacterium tuberculosis. Additionally, the upper lobes have greater ventilation and blood flow, allowing for better dissemination of the bacteria.

6. An open-lung biopsy obtained from a 38-year-old African American woman with coalescing lung densities and enlargement of mediastinal lymph nodules reveals the shown histologic picture. Which of the following is the most likely diagnosis?

Histoplasmosis

Sarcoidosis

Tuberculosis

Coccidio(ido)mycosis

The most likely diagnosis in this case is sarcoidosis. This is suggested by the findings of coalescing lung densities and enlargement of mediastinal lymph nodules on the open-lung biopsy. Sarcoidosis is a systemic granulomatous disease that commonly affects the lungs and lymph nodes. It is more prevalent in African Americans and can present with non-caseating granulomas on histologic examination. Histoplasmosis, tuberculosis, and coccidioidomycosis may also cause similar histologic findings, but the clinical presentation and patient demographics make sarcoidosis the most likely diagnosis.

Explanation

The most likely diagnosis in this case is sarcoidosis. This is suggested by the findings of coalescing lung densities and enlargement of mediastinal lymph nodules on the open-lung biopsy. Sarcoidosis is a systemic granulomatous disease that commonly affects the lungs and lymph nodes. It is more prevalent in African Americans and can present with non-caseating granulomas on histologic examination. Histoplasmosis, tuberculosis, and coccidioidomycosis may also cause similar histologic findings, but the clinical presentation and patient demographics make sarcoidosis the most likely diagnosis.

7. A 27-year-old Hispanic woman in southern California was in the 7^th month of her second pregnancy when she noted fever, dry cough, and sore red bumps on her shins. After 2 weeks of symptoms, she went to her obstetrician, who obtained an Xray that showed in the left upper lobe an area of pneumonia that contained a cavity. What is your diagnosis?

Blastomycosis

Histoplasmosis

Sporotrichosis

Coccidiodomycosis

Aspergillosis

Cocci in pregnant women (especially in their 2nd and 3rd trimesters) is more likely to disseminate. Treat.
For Histo and Cocci, certain HLA serotypes (found in a higher percentage of certain ethnic groups-Blacks, Filipinos and Native Americans) are more likely to disseminate.

Chronic- slow progression like TB with expanding lesions, weight loss, night sweats.
Chest x-rays sometimes show cavitation or may have “coin” lesions.
Disseminated: Anywhere in the body; external clues can be found for:
Histoplasma capsulatum and Coccidioides immitis on mucous membranes.
Blastomyces dermatitidis :cutaneous surfaces.

Explanation

Cocci in pregnant women (especially in their 2nd and 3rd trimesters) is more likely to disseminate. Treat.
For Histo and Cocci, certain HLA serotypes (found in a higher percentage of certain ethnic groups-Blacks, Filipinos and Native Americans) are more likely to disseminate.

Chronic- slow progression like TB with expanding lesions, weight loss, night sweats.
Chest x-rays sometimes show cavitation or may have “coin” lesions.
Disseminated: Anywhere in the body; external clues can be found for:
Histoplasma capsulatum and Coccidioides immitis on mucous membranes.
Blastomyces dermatitidis :cutaneous surfaces.

8. This gross and microscopic section of lung was taken from a patient with a chronic productive cough who reports rust colored sputum. Physical examination reveals tachypnea and abnormal breath sounds heard over the upper lobe of the left lung. Egophony was also heard in the same area. Which of the following is the most likely diagnosis?

Primary TB

Histoplasmosis

Coccidiomycosis

Secondary TB

Primary Pulmonary Tuberculosis
= occurs in individuals lacking previous contact with tubercle bacilli (primary immune response). Begins as Ghon focus, then spreads to draining bronchial & hilar lymph nodes (Ghon complex). In most cases, healing takes place by scarring & calcification (infective organisms survive in such lesions for decades). In few cases (# debilitated and immunocompromized children), progressive tuberculous pneumonia & hematogenous dissemination takes place (tuberculous meningitis & miliary tuberculosis).
__________________________________________________
Secondary Pulmonary Tuberculosis
= infection in a previously sensitized individual (secondary immune response); MC reactivation of an old “healed” lesion; rarely a superinfection. Lesions are apical, and progress to cavitary fibro-caseous tuberculosis, tuberculous broncho-pneumonia or miliary tuberculosis.
• Clinically: progressive tuberculosis presents with fever, sweats, weight loss, cough & hemoptysis; and sputum positive for acid-fast bacilli. Drug-resistant strains of organisms are emerging (esp. in immunocompomized patients; e.g. AIDS).

Explanation

Primary Pulmonary Tuberculosis
= occurs in individuals lacking previous contact with tubercle bacilli (primary immune response). Begins as Ghon focus, then spreads to draining bronchial & hilar lymph nodes (Ghon complex). In most cases, healing takes place by scarring & calcification (infective organisms survive in such lesions for decades). In few cases (# debilitated and immunocompromized children), progressive tuberculous pneumonia & hematogenous dissemination takes place (tuberculous meningitis & miliary tuberculosis).
__________________________________________________
Secondary Pulmonary Tuberculosis
= infection in a previously sensitized individual (secondary immune response); MC reactivation of an old “healed” lesion; rarely a superinfection. Lesions are apical, and progress to cavitary fibro-caseous tuberculosis, tuberculous broncho-pneumonia or miliary tuberculosis.
• Clinically: progressive tuberculosis presents with fever, sweats, weight loss, cough & hemoptysis; and sputum positive for acid-fast bacilli. Drug-resistant strains of organisms are emerging (esp. in immunocompomized patients; e.g. AIDS).

9. Postmortem examination of a 58-year-old man with a diagnosed squamous cell carcinoma of the lung reveals an atelectasis with the shown histologic changes. Which of the following pathomorphologic diagnoses corresponds to the shown pathology?

Bacterial bronchopneumonia

Pulmonary edema

Pulmonary infarction

Lipoid pneumonia

The correct answer is Lipoid pneumonia. The histologic changes shown in the postmortem examination are consistent with lipoid pneumonia. Lipoid pneumonia occurs when lipid material, such as oil-based substances, enters the lungs and causes inflammation. This can happen due to aspiration of oil-based substances or inhalation of lipid-containing aerosols. The histologic changes typically include foamy macrophages filled with lipid droplets, chronic inflammation, and fibrosis. In this case, the presence of lipid-filled macrophages in the atelectasis suggests lipoid pneumonia as the most likely diagnosis.

Explanation

The correct answer is Lipoid pneumonia. The histologic changes shown in the postmortem examination are consistent with lipoid pneumonia. Lipoid pneumonia occurs when lipid material, such as oil-based substances, enters the lungs and causes inflammation. This can happen due to aspiration of oil-based substances or inhalation of lipid-containing aerosols. The histologic changes typically include foamy macrophages filled with lipid droplets, chronic inflammation, and fibrosis. In this case, the presence of lipid-filled macrophages in the atelectasis suggests lipoid pneumonia as the most likely diagnosis.

10. A 78 years old chronic smoker has developed pneumonia of the right lower lobe. What will be the clinical finding to the affected side?

Trachea will be in the midline, hyperresonant on percussion on the right increased tactile fremitus, diminished vesicular breath sound.

It cannot diagnosed clinically but only diagnosed radiologically.

The clinical finding to the affected side in a 78-year-old chronic smoker with pneumonia of the right lower lobe will be a dull percussion on the lower right side with increased tactile fremitus, bronchial type of breath sounds with crackles, bronchophony, egophony, and whispered pectoriloquy. This indicates consolidation and inflammation in the affected lung, causing a decrease in air movement and increased transmission of sound. The trachea will remain in the midline as there is no shift.

Explanation

The clinical finding to the affected side in a 78-year-old chronic smoker with pneumonia of the right lower lobe will be a dull percussion on the lower right side with increased tactile fremitus, bronchial type of breath sounds with crackles, bronchophony, egophony, and whispered pectoriloquy. This indicates consolidation and inflammation in the affected lung, causing a decrease in air movement and increased transmission of sound. The trachea will remain in the midline as there is no shift.

11. Mycobacterium tuberculosis is innately resistant to many drugs and has acquired resistance to others used to treat it. Which of the following best explains how this organism resists the action of so many antibiotics?

M. tuberculosis has cholesterol in its membrane and has acquired transposons that encode numerous antibiotic resistance genes.

M. tuberculosis has mycolic acids in its cell envelope and has acquired transposons that encode numerous antibiotic resistance genes

Mycobacterium tuberculosis has mycolic acids in its cell envelope, which provides a protective barrier against antibiotics. Additionally, some strains of M. tuberculosis have accumulated point mutations in genes encoding antibiotic targets, making them resistant to the action of antibiotics. This combination of factors allows the organism to resist the action of many antibiotics.

Explanation

Mycobacterium tuberculosis has mycolic acids in its cell envelope, which provides a protective barrier against antibiotics. Additionally, some strains of M. tuberculosis have accumulated point mutations in genes encoding antibiotic targets, making them resistant to the action of antibiotics. This combination of factors allows the organism to resist the action of many antibiotics.

12. A 59-year-old Caucasian male presents with low-grade fever, night sweats, malaise, wet cough and chest pain. He states that in childhood he had pulmonary TB. Sputum bacteriology reveals acid-fast bacilli. Tuberculin test reveals indurated hyperemic plaque 10 mm in diameter. PCR for HIV is negative. Which of the following is the most likely location of the lung lesion?

Subpleural area of the lower part of the upper lobe

Subpleural area of the upper part of the lower lobe

Posterior subapical areas of the upper lobe

Basal segments of the lower lobe

The patient's history of childhood pulmonary TB, along with the symptoms of low-grade fever, night sweats, malaise, wet cough, and chest pain, suggests a reactivation of tuberculosis. The presence of acid-fast bacilli in the sputum confirms the diagnosis. The tuberculin test reveals an indurated hyperemic plaque, indicating a positive reaction to the TB antigen. The most likely location of the lung lesion in this case is the posterior subapical areas of the upper lobe.

Explanation

The patient's history of childhood pulmonary TB, along with the symptoms of low-grade fever, night sweats, malaise, wet cough, and chest pain, suggests a reactivation of tuberculosis. The presence of acid-fast bacilli in the sputum confirms the diagnosis. The tuberculin test reveals an indurated hyperemic plaque, indicating a positive reaction to the TB antigen. The most likely location of the lung lesion in this case is the posterior subapical areas of the upper lobe.

13. A 78 year-old- woman is admitted to the hospital complaining of sudden shortness of breath and fever. She was was known to be suffering from ovarian cancer for about one year. Chest x-ray reveals complete consolidation of her right lower lobe, the left lobe appearing to be relatively normal. She dies in respiratory distress a week after admission. At autopsy, her right lung would likely display:

Gray hepatization

Hyaline membranes

Viral inclusions

Alveolar wall destruction

Invasive fungal organisms

Bacterial Pneumonia- Lobar Pneumonia

acute bacterial infection, with consolidation of whole segments or an entire lobe of the lung, mostly caused by pneumococci. Untreated cases show classical sequence of stages:
1- Congestion
2- Red hepatization
3- Gray hepatization*************
4- Resolution

Stages of lobar pneumonia
Congestion: This stage is characterized histologically by vascular engorgement, intra-alveolar fluid, small numbers of neutrophils, often numerous bacteria. Grossly, the lung is heavy and hyperemic.
Red hepatization: Vascular congestion persists, with extravasation of red cells into alveolar spaces, along with increased numbers of neutrophils and fibrin. The filling of airspaces by the exudate leads to a gross appearance of solidification, or consolidation, of the alveolar parenchyma. This appearance has been likened to that of the liver, hence the term "hepatization".
Gray hepatization: Red cells disintegrate, with persistence of the neutrophils and fibrin. The alveoli still appear consolidated, but grossly the color is paler and the cut surface is drier.
Resolution: The exudate is digested by enzymatic activity, and cleared by macrophages or by cough mechanism.

Explanation

Bacterial Pneumonia- Lobar Pneumonia

acute bacterial infection, with consolidation of whole segments or an entire lobe of the lung, mostly caused by pneumococci. Untreated cases show classical sequence of stages:
1- Congestion
2- Red hepatization
3- Gray hepatization*************
4- Resolution

Stages of lobar pneumonia
Congestion: This stage is characterized histologically by vascular engorgement, intra-alveolar fluid, small numbers of neutrophils, often numerous bacteria. Grossly, the lung is heavy and hyperemic.
Red hepatization: Vascular congestion persists, with extravasation of red cells into alveolar spaces, along with increased numbers of neutrophils and fibrin. The filling of airspaces by the exudate leads to a gross appearance of solidification, or consolidation, of the alveolar parenchyma. This appearance has been likened to that of the liver, hence the term "hepatization".
Gray hepatization: Red cells disintegrate, with persistence of the neutrophils and fibrin. The alveoli still appear consolidated, but grossly the color is paler and the cut surface is drier.
Resolution: The exudate is digested by enzymatic activity, and cleared by macrophages or by cough mechanism.

14. This gross appearance of the lung in a 65 year old woman with a history of poorly controlled diabetes mellitus most likely corresponds to which of the following microscopic findings

Non-necrotizing granulomata with giant cells

Granulomata with central caseous necrosis and giant cells

Numerous bacteria and polymorphonuclear leukocytes

Frothy exudate with “cup-shaped” microorganisms seen with silver impregnation

The gross appearance of the lung in a 65-year-old woman with poorly controlled diabetes mellitus most likely corresponds to numerous bacteria and polymorphonuclear leukocytes. This suggests the presence of a bacterial infection in the lung, which is common in individuals with poorly controlled diabetes mellitus. The presence of bacteria and polymorphonuclear leukocytes indicates an inflammatory response to the infection.

Explanation

The gross appearance of the lung in a 65-year-old woman with poorly controlled diabetes mellitus most likely corresponds to numerous bacteria and polymorphonuclear leukocytes. This suggests the presence of a bacterial infection in the lung, which is common in individuals with poorly controlled diabetes mellitus. The presence of bacteria and polymorphonuclear leukocytes indicates an inflammatory response to the infection.

15. Which other characteristic does the bacterial component described in the above question impart to M. tuberculosis?

Resistance to acid alcohol

Inhibition of phagosome-lysosome fusion

Evasion of phagocytosis

Ability to vary its surface antigens

Ability to form a biofilm

The bacterial component described in the question imparts resistance to acid alcohol to M. tuberculosis. This means that M. tuberculosis is able to withstand the effects of acid alcohol, which is commonly used in laboratory techniques to stain and identify bacteria. This resistance allows M. tuberculosis to survive and persist in various environments, including the human body, making it difficult to eliminate and contributing to its pathogenicity.

Explanation

The bacterial component described in the question imparts resistance to acid alcohol to M. tuberculosis. This means that M. tuberculosis is able to withstand the effects of acid alcohol, which is commonly used in laboratory techniques to stain and identify bacteria. This resistance allows M. tuberculosis to survive and persist in various environments, including the human body, making it difficult to eliminate and contributing to its pathogenicity.

16. A 47-year-old woman with ovarian cancer metastatic to the omentum receives chemotherapy. A week later she develops fever, cough, and chest pain. After seeing radiodensities on a chest x-ray, the astute oncologist suspects aspergillosis for what reason?

Neutropenia with absolute neutrophil count of 200 per mm3

X-ray showing a fungus ball in a cavity

History of patient living in an apartment with mold on ceiling tiles

Copious sputum that contained eosinophils

Invasive aspergillosis:
Major probl in transplant patients: heart and bone marrow (esp. if neutropenic)
Most commonly Aspergillus fumigatus
Spores land on nasal mucosa; colonize surface, sporulate  seed lungs. (huge #)
Pneumonia but with propensity to grow into blood vessels causing infarcts so there is also pulmonary hemorrhage.
___________________________________________________
Aspergillus spp. (commonly Aspergillus fumigatus)
Cause 4 distinctive pulmonary diseases:
Invasive pulmonary aspergillosis infection in immunocompromised patients
Fungus balls growing “free” in old TB cavities
Allergic Bronchopulmonary Aspergillosis where agent is growing mucous plugs in lungs of generally asthmatic folks with allergies including Aspergillus.
Farmers lung (allergy)

Explanation

Invasive aspergillosis:
Major probl in transplant patients: heart and bone marrow (esp. if neutropenic)
Most commonly Aspergillus fumigatus
Spores land on nasal mucosa; colonize surface, sporulate  seed lungs. (huge #)
Pneumonia but with propensity to grow into blood vessels causing infarcts so there is also pulmonary hemorrhage.
___________________________________________________
Aspergillus spp. (commonly Aspergillus fumigatus)
Cause 4 distinctive pulmonary diseases:
Invasive pulmonary aspergillosis infection in immunocompromised patients
Fungus balls growing “free” in old TB cavities
Allergic Bronchopulmonary Aspergillosis where agent is growing mucous plugs in lungs of generally asthmatic folks with allergies including Aspergillus.
Farmers lung (allergy)