CASE 1:

Clinical History:

A 49-year-old man with a 25 pack year smoking history presented to you at the homeless clinic with complaints of increasing cough that had gradually been getting worse over the previous six months. He noted that the sputum was blood-tinged on one occasion. He also felt extremely tired. His chest x-ray showed upper lobe cavitations with nodular infiltrates.

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Image 1.5:

Questions:

1. What does the chest radiograph show? (image 1.1).
2. Describe the gross appearance of this lung representative of the disease process in your patient's lungs (image 1.2).
3. Describe the microscopic appearance of the lungs (images 1.3 - 1.5). What is the probable diagnosis?
4. What tests can be performed to diagnose this condition? What additional clinical findings might be present?
5. Describe the additional gross pathologic patterns for this disease process (images 1.6 and 1.7). What is the differential diagnosis?
6. What standard pharmacologic therapies are available?

Image 1.6:

Image 1.7:

CASE 2:

Clinical History:

A 50-year-old man worked in a foundry (casting metal materials using earthen molds) for thirty years. He was asymptomatic until a few months ago, but now has increasing dyspnea. A routine chest x-ray shows a "snow-storm" appearance.

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Questions:

1. What does the chest radiograph show in image 2.1?
2. Describe what you see in images 2.2 and 2.3. What is the probable diagnosis?
3. How does this lesion form? What are the offending particles seen in image 2.2?
4. How do you explain the lengthy hiatus between exposure and symptomatology?
5. These patients are at high risk for developing what disease?
6. In a patient with a more severe form of this disease, what are factors that would contribute to hypoxemia with exercise? What factors may contribute to a high ventilation rate during exercise in a patient with diffuses interstitial pulmonary fibrosis?
7. What recourse does a patient have when the disease is a consequence of employment?

CASE 3:

Clinical History:

The patient is a 67-year-old veteran with a 50 pack year history of smoking who is currently hospitalized for pancreatitis. He developed a productive cough with thick yellow sputum, fever, and hypotension after a week in hospital. He had an elevated WBC count with left shift. A chest radiograph shows increased AP diameter and areas of patchy consolidation.

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Image 3.7:

Image 3.8:

Questions:

1. The patient has both a chronic and an acute process. Images 3.1 to 3.4 demonstrate the radiographic, gross, and microscopic appearances of the chronic process. Images 3.5 to 3.8 show gross and microscopic findings with the acute process. Describe both processes.
2. What is the chronic process? How does it develop, and to what in the clinical history is it related?
3. This represents one form of this type of lung damage. Name the other types, and what their respective etiologies are.
4. What is the acute process? How might this have developed and/or be related to his hospital course?
5. Draw the typical flow volume curve seen in obstructive and restrictive lung disease relative to normal.
6. What may reduce the FEV1 in a patient with chronic obstructive pulmonary disease (COPD)? What are the results of CO2 retention? What is the chief cause of hypoxemia?
7. What advance directives should be considered by this patient?

CASE 4:

Clinical History:

A 40-year-old woman has had a cough that is productive of purulent sputum. On occasion, she notes spots of blood in the sputum. She has been hospitalized for pneumonia twice in the past year. She does not have dyspnea, but she has recently developed wheezing episodes. Laboratory findings include an elevated WBC count with neutrophilia and left shift. Sputum culture grew 3+ Serratia marcescens and 2+ Pseudomonas aeruginosa. A chest radiograph reveals abnormalities involving the right lower lobe.

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Image 4.4:

Questions:

1. What is the most striking architectural change in the lung? Describe it and the related changes?
2. What are the possible etiologies of this condition?

Further Clinical History:

A 24-year-old man had the findings at autopsy shown below. At autopsy his heart weighed 450 grams and had a dilated right heart with right ventricular wall measuring 0.7 cm thick (normal < 0.5 cm).

Image 4.5:

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Image 4.7:

Image 4.8:

Questions:

1. What do you think is the etiology for his pulmonary findings? What changes do you see in the pulmonary vessels, image 4.7? How does this relate to autopsy findings?
2. Do you think he was currently suffering from acute respiratory symptoms when he died? Why or why not?

CASE 5:

Clinical History:

The patient is an 84-year-old woman who was hospitalized for a broken hip. She spiked a fever on the second hospital day, with cough producing a watery sputum, along with shaking chills and marked malaise, but antibiotics were not started and she died within 36 hours of becoming systemically ill. A chest x-ray shows a diffuse consolidation in the right upper lobe. A CBC showed an elevated WBC count with increased bands. Blood cultures were reported positive after she died.

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Questions:

1. What is the process demonstrated in these sections? How does this differ in pattern from what you saw in Case 3?
2. What organism(s) might have been cultured from her blood, had blood cultures been ordered?
3. Does the disease process in these sections look severe enough to result in a respiratory death?

CASE 6:

Clinical History:

A 47-year-old migrant farm worker recently moved from Florida to Southern California. Three weeks after beginning work in the orchards near Fresno he presented to a local clinic with fever, cough, night sweats and pleuritic chest pain. A chest radiograph revealed segmental infiltrates, some hilar adenopathy and a small pleural effusion.

Image 6.1:

Image 6.2:

Image 6.3: (GMS stain)

Questions:

1. What type of inflammatory process is present? Describe the features of this process.
2. What is the differential diagnosis? Which of these is most likely? What organism do you see?
for coccidioidomycosis.
3. How would the histopathology differ if the patient had underlying HIV infection with AIDS?
4. What proportion of normal hosts exposed to this agent develop clinical symptomatology? What are the possible outcomes/sequelae?
5. What therapy is available?

CASE 7:

Clinical History:

A 37-year-old patient who was known to be infected with the human immunodeficiency virus (HIV) for the past 8 years and whose last CD4 lymphocyte count was 75/microliter died in respiratory failure.

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Image 7.4:

Questions:

1. There are two etiologic agents. Identify and describe the manifestations of each, and name the probable organisms.
2. Why might this patient have had significant bleeding into his lung?
3. What other organs might be involved by these organisms?

CASE 8:

Clinical History:

A 56-year-old man with no prior major medical illnesses presented to the emergency room with acute onset of fever, cough, and dyspnea. His chest x-ray showed diffuse bilateral fluffy perihilar infiltrates.

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Image 8.4:

Questions:

1. What is the material in the alveoli?
2. What do you see on GMS (silver) stain in image 8.4?
3. What is his likely underlying condition?
4. If this patient had some other reason for being immunosuppressed, such as being on corticosteroids, receiving chemotherapy for malignancy, or having an undiagnosed lymphoma, how would the biopsy differ most likely?
5. How is this disease treated?
6. What advance directives should be considered by this patient?

CASE 9:

Clinical History:

A 9-year-old girl has the sudden onset of severe dyspnea with wheezing. She has had similar episodes in the past.

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Questions:

1. How do you explain the sputum cytologic findings?
2. Why do you seen the inflammatory cell type that predominates in image 9.3?
3. How is this disease likely to differ in adults?
4. What are the consequences of this disease? What is the functional effect on the lung? How does it differ from emphysema
5. What lung disorder(s) may result in an increase in the functional residual capacity (FRC)?
6. What pharmacologic therapies are available this disease?
7. What consent process is required to treat this child?