Thrombo - phebitis : Thrombotic disease of veins accompanied by varying degrees of inflammation
Thrombophlebitis : Association between deep vein thrombosis and presence of cancer in an internal organ (Trousseau syndrome = Migratory Thrombo-phlebitis). The majority of the tumours are mucin-producing Adeno-Carcinomas of the pancreas
Clinical features of Thrombophlebitis :
• Minimal or marked oedema of the extremity
• Purulent Thrombo-Phlebitis: Marked chills and high temperature
Stasisulcer is a long term complication of thrombophlebitis
Thrombangitis Obliterans (Buerger's disease) : Rare thrombotic and inflammatory disease of the arteries and veins of unknown aetiology
Epidemiology of Buerger's Disease :
• Common in young men (20-35 years)
• Exacerbation by heavy cigarette smoking
To the pathologist, vasculitis generally denotes the presence of primary vascular inflammation, in the absence of infection, infarction, or other secondary cause
Classification of vasculitis depends on at least three major features:
Size and type of vessel involved
Presence of immune complexes
Association with known autoimmune disease, and systemic or localised distribution
Two vasculitic syndromes affect elastic arteries: Takayasu disease and Giant-cell arteritis
Two vasculitic syndromes affect muscular arteries in the absence of small vessel involvement: Polyarteritis nodosa and Kawasaki disease
A host of vasculitis syndromes affect small vessels (arterioles,capillaries, and venules)
• These vasculitides are generally divided into:
Those that are caused by immune complex deposition
Those that are pauci - immune (often antineutrophil cytoplasmic antibody [ANCA] related)
Increased activity of serum Angiotensin-Converting Enzyme
Sarcoidosis has findings of Schaumann & asteroid bodies
Pulmonary form of Tbc: Inhalation of droplets with the organism
Non-pulmonary form of Tbc: Ingestion of infected milk
Primary Tbc:
Initial infection, characterised by the primary or Ghon complex (Peripheral sub-pleural parenchymal lesion + Hilar lymph nodes)
Clinical picture: Asymptomatic; No clinically evident disease
Histopathology:
Tubercle (Granuloma of Tbc):
➢ Central caseous necrosis
➢ Langhans giant cells
Secondary Tbc:
Activation of a prior Ghon complex, with spread to a new pulmonary or extra-pulmonary site
Clinical features:
➢ Progressive disability
➢ Fever
➢ Haemoptysis
➢ Bloody pleural effusion
➢ Generalised wasting
Secondary Tbc:
Macroscopic picture:
➢ Localised lesions: Apical or posterior segments of the upper lobes
➢ Involvement of hilar lymph nodes
Microscopic picture:
➢ Liquefaction and expulsion of the caseous contents → Formation of cavitary lesions
Cavitation: Only in secondary Tbc
Caseation: Both primary and secondary Tbc
➢ Scarring and calcification
Miliary Tbc:
➢ Secondary Tbc, complicated by lymphatic and haematogenous spread
➢ Involvement of distal organs with innumerable small seed – like lesions
➢ Extra-pulmonary Tbc:
Tuberculous meningitis
Pott disease of the spine
Para-vertebral or psoas abscess
Emphysema : Irreversible enlargement of the airspaces distal to the terminal bronchiole, accompanied by destruction of their walls without obvious fibrosis
Emphysema is associated with cigarette smoking
Types of emphysema (according to anatomic distribution within the lobule):
Centri - acinar (95% of cases)
Pan - acinar
Para - septal
Irregular
Clinical features:
“ Pinkpuffer ” vs. “Blue bloater” (Chronic Bronchitis)
Action of proteolytic enzymes (e.g. elastase) on the alveolar wall
Elastase:
Induces destruction of elastin
Neutralised by the opposing action of alpha1-antitrypsin
Cigarette smoking:
Attracts neutrophils and macrophages (sources of elastase)
Inactivates alpha1-antitrypsin
Centri - acinar (Centri - lobular) Emphysema
Affects central or proximal parts of the acini, formed by respiratory bronchioles
Sparing of distal alveoli
More common and more severe in the upper lobes, particularly in the apical segments
Presence of large amounts of black pigment in the walls of the emphysematous spaces
Inflammation around bronchi and bronchioles
Association with heavy cigarette smoking and chronicbronchitis
Pan - acinar (Pan-lobular) Emphysema
Characterised by evenly enlarged acini from the level of respiratory bronchiole to the terminal blind alveoli (entire acinus: alveoli, alveolar ducts and respiratory bronchioles)
Uniform distribution throughout the entire lung
Occurrence mainly in the lower zones and in the anterior margins of the lung; Most severe at the bases
Association with a1 - antitrypsin deficiency
DistalAcinar (Para - septal) Emphysema
Dilatation of the distal part of the acinus (alveoli and lesser alveolar ducts)
Normal proximal portion of the acinus
Localised adjacent to the pleura (along the lobular connective tissue septa), and at the margins of the lobules
Occurrence adjacent to areas of fibrosis, scarring, or atelectasis
More severe in the upper half of the lungs
Multiple, continuous enlarged airspaces (0.5-2.0cm) → Large sub-pleural bullae or blebs → Pneumothorax
Irregular Emphysema
Irregular involvement of the acinus
Airspace enlargement with fibrosis
Pathogenesis: Inflammatory process → Scarring within the walls of enlarged air spaces → Irregular Emphysema
Complications of Emphysema:
Chronic Bronchitis
InterstitialEmphysema : Tear in the airways → “Leakage” of air into the interstitial tissue of the chest
Rupture of a surface bleb (apical bulla) → Pneumothorax
Bullous Emphysema
Localised accentuation of emphysema, resulting in the formation of large sub-pleural blebs or bullae (>1cm; distended state)
Occurrence, possible in any type of emphysema
Sometimes, in relation to old tuberculous scarring
Interstitial Emphysema
Entrance of air into the connective tissue stroma of the lung, mediastinum, or subcutaneous tissue
Cause/Pathology: Coughing + bronchiolar obstruction → Sharply increased pressures within the alveolar sacs → Alveolar tears → Entrance of air into the lung’s stroma
Other Causes:
Wound of the chest → Entrance of air within the lung substance
Fracturedrib → Puncture of the lung parenchyma → Entrance of air within the lung substance
Papilloma is a benign tumour
Papilloma is localised in the largebronchi
Multiple papilloma is associated with HPV infection in children
Solitary papilloma is associated with middle to old age with no association to HPV
Papilloma has a fibro - vascularstalk as a microscopic finding
Solitary pulmonary nodules have a coinlesion upon US
The risk of a coin lesion becoming malignant increases over 50 years old