Pulmonary Pathology II Case Studies

Return to the Laboratory Menu.

OBJECTIVES

  1. Recognize the gross and microscopic findings of acute and chronic hyaline membrane disease of the newborn.
  2. Describe the mechanisms and physiologic outcomes of acute and chronic pulmonary emboli.
  3. Recognize the gross and microscopic findings of neoplastic disease in the lungs. Describe the histologic differences between the major types of carcinoma, and state the clinical significance of distinguishing between the types.

CASE 1:

(Click here to go to the answers)

Clinical History:

Images 1, 2, and 3 are from a neonate who was born prematurely at 28 weeks gestation, weighing 700 grams (normal for 28 weeks is 950 grams). The mother was a two pack per day smoker who refused to cut down or stop smoking during her pregnancy. The baby survived for 6 days on a respirator requiring very high oxygen levels. Diffuse infiltrates were seen on chest x-ray, with a "ground glass" appearance, and the PO2 was low on blood gas analysis.

Clinical History:

Image 1.4 is from an infant with hyperbilirubinemia.

Image 1.1:

Image 1.2:

Image 1.3:

Image 1.4:

Questions:

  1. Describe the microscopic appearance of the lung sections.
  2. What is the material in the alveoli? What other findings are present that are significant in understanding this infant's demise?
  3. What is the diagnosis? What are the clinical manifestations of this disease?
  4. How might the mother's smoking history have contributed to the outcome? What factors are felt to contribute to the development of this disease?
  5. What is the chronic form of this disease called?
  6. What decisions must be faced when there is little possibility of a good outcome?


CASE 2:

(Click here to go to the answers)

Clinical History:

A 50-year-old man with a history of myotonic muscular dystrophy was admitted for pneumonia. He was doing well and improving after several days of IV antibiotics when he suffered a sudden cardiac arrest which did not respond to resuscitative efforts.

Image 2.1:

Image 2.2:

Image 2.3:

Image 2.4:

Image 2.5:

Questions:

  1. The radiographic, gross, and microscopic appearances shown are characteristic for what process. What acute changes might you see in the heart?
  2. What do you see in image 2.5 that helps you to date this process and the origin?
  3. Name as many predisposing conditions as you can think of that could lead to this process.
  4. What might we see in other sections of the lung that would be related to this process? What are these called? What are the signs and symptoms that should lead you to suspect this process?


CASE 3:

(Click here to go to the answers)

Clinical History:

This is a 50-year-old woman with a previous diagnosis of infiltrating ductal carcinoma of the breast. She underwent mastectomy. She now presents with increasing dyspnea.

Image 3.1:

Image 3.2:

Image 3.3:

Image 3.4:

Image 3.5:

Questions:

  1. What is demonstrated by radiologic imaging?
  2. What are the clusters of cells seen in this section? Where are they located?
  3. Look carefully at the smaller arterioles? What changes do you see in the vessels? What is the mechanism?
  4. What is/has gone on in the alveolar spaces? What is the brown pigment?
  5. What do you think this woman's respiratory symptomatology was during her terminal phase?
  6. What is the most common tumor in the lung?
  7. When should hospice care be considered?


CASE 4:

(Click here to go to the answers)

Clinical History:

A 63-year-old man presented with hemoptysis of three weeks' duration. He had a 50 pack year history of smoking. His chest x-ray showed a large central peri-hilar mass. A fine needle aspiration (FNA) of the mass was performed.

Image 4.1:

Image 4.2:

Image 4.3:

Image 4.4:

Image 4.5:

Image 4.6:

Questions:

  1. Describe the histopathology of the mass lesion (images 4.2 - 4.5). What is the diagnosis? What features do you use to make this diagnosis?
  2. Where does this lesion usually arise? What is the hypothesized mechanism of carcinogenesis?
  3. What might you see in the parenchyma of the lung behind the lesion (image 4.6)?


CASE 5:

(Click here to go to the answers)

Clinical History:

A 32-year-old man presented to his family doctor with cough of six weeks duration and recent onset of fever and malaise. A chest x-ray showed a right middle lobe infiltrate with suggestion of a proximal mass on lateral film. A chest CT scan was performed, and then he underwent bronchoscopy, biopsy, and subsequent right middle lobectomy.

Image 5.1:

Image 5.2:

Image 5.3:

Questions:

  1. Describe the main lesion. Where is it located? What is the diagnosis?
  2. The patient bled profusely when the lesion was biopsied. Why? Why had he recently developed fever and malaise and how does this relate to his chest x-ray and CT findings?
  3. What is the characteristic feature of these tumors by electron microscopy?
  4. In what other organs do these lesions commonly arise? What is the prognosis of these tumors?
  5. What is the related neoplasm with a more ominous prognosis? How does it differ histologically?


CASE 6:

(Click here to go to the answers)

Clinical History:

A 47-year-old school teacher, a non-smoker, was admitted for inguinal herniorrhaphy. A pre-operative routine chest x-ray revealed a 3 cm nodule in the right upper lobe which was not present on an x-ray taken two years prior. No evidence of mediastinal adenopathy was found on CT scan. A right upper lobectomy was performed.

Image 6.1:

Image 6.2:

Image 6.3:

Image 6.4:

Image 6.5:

Questions:

  1. Describe the location, gross appearance, and histopathology of this lesion.
  2. What is the diagnosis? Where are these lesions usually located?
  3. This lesion was enclosed within the lung and all of the hilar and mediastinal nodes sampled were free of tumor. What stage is this tumor? What is the prognosis for this patient?


CASE 7:

(Click here to go to the answers)

Clinical History:

A 54-year-old man suffered chest injuries in a car accident. X-rays showed no evidence of broken ribs, but an incidental finding of a solitary lung nodule was seen peripherally in the right lower lobe. No prior x-rays were available for comparison. CT scan showed the lesion to be sharply circumscribed, with no associated detectable adenopathy. Percutaneous CT guided fine needle aspiration (FNA) was attempted, but no cellular elements were obtained. He went to surgery, and after a frozen section diagnosis, a segmental wedge resection was performed and the patient spared a lobectomy.

Image 7.1:

Image 7.2:

Image 7.3:

Questions:

  1. Describe the gross appearance of the lesion and then identify histopathologic features, including as many elements as you can identify. Why do you think they were unable to obtain cellular material by FNA. Had they been able to make the diagnosis by FNA, what do you think they would have done differently?
  2. What is the diagnosis? What is the significance?
  3. Where does this lesion arise from?
  4. Why was the surgeon able to shell it out, rather than remove a lobe?


CASE 8:

(Click here to go to the answers)

Clinical History:

A fire inside a house results in minimal superficial burn injuries involving 22% total body surface area, mainly the head and neck area, to a 28-year-old woman. However, inhalation of hot gases from the fire in an enclosed space leads to inhalation injury. In hospital, she requires increasing FIO2 to 100% to maintain arterial oxygen saturations.

Image 8.1:

Image 8.2:

Image 8.3:

Image 8.4:

Questions:

  1. Describe the radiographic, gross and microscopic appearances of the lungs
  2. What is the diagnosis? How does this process occur?
  3. What is the natural history of this process?
  4. In addition to this disease, what other conditions reduce movement of air into the lungs? Of those conditions, which increase airway resistance?
  5. The patient has been intubated for a month, but has a steadily worsening respiratory status. Family members are arguing about what to do. What can you do?

Return to the Laboratory Menu.