Middle Examination
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Multiple choice 50%
Short answers 25%
Long answers
10%
Case analysis
15%
The weekend of 10th week, 150 min
总论+心血管系统疾病
Chapter 9
Diseases of the Respiratory System
Department Of Pathology
Guangxi Medical University
Zili Lv 吕自力
lvzili@yahoo.com.cn
Anatomic Structures and Functions
Bronchi
Bronchioles
Alveolar ducts
Alveoli
Clinical features of respiratory
diseases
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1. Cough
2. Sputum Production咳痰
3. Hemoptysis 咯血
4. Dyspnoea呼吸困难
5. Cyanosis紫绀
6. Chest pain
Contents (6 hrs)
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1. Pulmonary infections
2. Chronic obstructive pulmonary
diseases & chronic cor pulmonale
3. Chronic diffuse interstitial lung disease,
carcinoma of nasopharynx and lung.
Pulmonary infections
Acute Pneumonia
Chronic Pneumonia
Classification of pneumonia
Clinical circumstance
Primary and Secondary
 Etiological agent
Bacterial, Virus, Fungal
 Host reaction
Fibrinous & Suppurative
 Anatomical pattern
Lobar & Lobular
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Case 1 analysis

History: Male, 20, after suffering from cold
and drunk, got high fever, chill, rapid
breathing and chest pain. After 2 days, he
coughed with “rusty” sputum.

T: 40℃, R: 32 times/min.

Chest x-ray: show large-area uniform
dense well-delimited shadow in his left
upper lobe.

Blood examination: WBC: 13.5x 109/ L
BACTERIUM PNEUMONIA
Lobar pneumonia
Lobular pneumonia
Legionella pneumonia
Lobar pneumonia
Affects a large part, or the entirety of a lobe
 Relatively uncommon in infancy and old age
 Affects males more than females
 90% due to pneumococcus (肺炎球菌）
 Cough and fever with purulent or
Rusty Sputum铁锈色痰

A. Etiology
Pathogen:
Streptococcus pneumonia
肺炎球菌 III型
Infective Route:
Inhalation, Aspiration 吸入
Risk Factors：
Cold, drunk, tired, diabetes
B. Pathology*
Acute exudative fibrinous inflammation
（急性纤维素性炎）
 Involves one whole lobe or several lobes
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The bronchi are not involved
Pathologic Features
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Acute congestion 充血水肿期
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Red hepatization 红色肝样变期
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Gray hepatization 灰色肝样变期
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Resolution 溶解消散期
1. Stage of acute congestion
1st-2nd day
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(1)Gross changes:
Heavy, dark red and firm
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(2)Microscopic change
Fluid, RBC, WBC in the air space
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(3)Clinical features:
Stage of acute congestion
Alveolar capillaries: Dilated
Air space: Fluid, RBC, WBC
Stage of acute congestion
Clinical Features
Fever, cough, cyanopathy (发绀)
 Chest pain
 Bacteremia
 Bacteria can be found in sputum

2. Stage of Red Hepatization:
2nd-4th day
（
）
1 Grossly
• Red and
consolidation,
just like liver
(2)Microscopic changes of red hepatization
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A. Capillaries congestion

B. Exudation:
Fibrin, large number of RBC
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C. Fibrinous pleurisy
Microscopical changes
(3)
Chest
x-ray
红色肝样变期X线特点
• The middle
segment of
right upper
lobe become
consolidated
and show
large-area
uniform
dense
shadow.
(4) Clinical features of red
hepatization
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Fever, cough, chest pain
Rapid breathing, cyanopathy
Dullness浊音
Vocal fremitus enhancement 语颤增强
Rusty sputum 铁锈色痰
3. Stage of gray hepatization:
5th-6th day
(1)Gross changes of grey hepatization
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Dry
Gray
Firm
Consolidation
(2)Histological changes
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Capillary is
not dilated
anymore.
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Alveolar
space is
filled with
neutrophil
and fibrin
Histological changes of grey hepatization
• (3)Chest x-ray: high dense shadow can
X-ray
features
gray hepatization
be
found
at theofright
upper lobe
(4)Clinical features of gray
hepatization

Consolidation: dullness, vocal fremitus
enhancement
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Sputum: mucus purulent sputum
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Dyspnoea(缺氧）: is not obvious
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4. Stage of Resolution, 7 days later
Gross changes: Friable and mottled
Microscope: The fibrin and cell debris are
digested by enzymatic, The exudation is
remove.
Chest X-ray
Pathologic Features (4 stages)
LOBULAR PNEMONIA
小叶性肺炎
(Bronchopneumonia)
(支气管肺炎)
Lobular pneumonia
Bronchopneumonia
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Bronchi are infected
Patchy consolidation
Centred on inflamed bronchioles or bronchi
Secondary pneumonia
Less virulent agents, in infancy or old age
Suppurative inflammation化脓性炎
A. Etiology
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Pathogen: many bacteria,
Infection via: Inhalation, Aspiration
Risk Factors: Secondary
B. Pathology
Gross:
Lower lobes, dorsal side
Multiple firm areas,
around inflamed
bronchioles.
Microscope:
1. Multiple lesions
Purulent bronchitis and bronchiolitis
(化脓性细支气管炎)
2. Alveolar spaces surrounding the lesions are filled
with neutrophil
3. Compensatory emphysema
(代偿性肺气肿)
C. Clinical Features
The onset is insidious, nonspecific
 Low-grade fever
 Dyspnea is not prominent
 The typical feature is
Purulent Sputum脓痰*
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• Chest xray
• Several
scattered
patchy
shadows
evidently
in bilateral
lower
lobes
Legionella pneumonia,
军团菌肺炎
•嗜肺军团杆菌
•急性纤维素性化脓性
炎—典型病例,严重者
坏死—脓肿
•临床表现复杂:肺内\
外表现
Legionella pneumonia,
军团菌肺炎
急性纤维素性化脓性炎
acute fibrino-purulent
exudative pneumonia

军团菌病(legionaires disease)是由革
兰染色阴性的嗜肺军团杆菌
(legionella pneumophila)引起的一
种以肺炎为主的全身性疾病，1976
年被确认。
Resolution
Lobar
pneumonia
Air space
pneumonia
Lobular
pneumonia
Complications
Complications of acute air space
pneumonia
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Pleura involvement
Bacteremia
Suppuration (Abscess Formation)
Necrotizing bacterial pneumonia
Pulmonay carnification肺肉质变
• Lung
abscess
• Pulmonary carnification
What are the differences?
Distribution
Number
Host
reaction
Clinical
Features
Acute interstitial pneumonia间质性肺炎
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1. Agents: Virus (SARS, Avian influenza,
Swine Flu) and Mycoplasma or Pneumocystis
2. Interstitium
3. Atypical pneumonia
4. Infiltration with lymphocyte, monocyte
Pathologic Features of Viral
pneumonia
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The alveolar septa are expanded
Cell infiltrate: lymphocyte, plasma cells
Air spaces are air filled
Epithelial necrosis
Inclusion bodies 病毒包涵体
Multinucleated giant cells 多核巨细胞
Hyaline membranes 透明膜
Viral Pneumonia
SARS
Severe Acute Respiratory Syndrom (SARS)
重症急性呼吸综合征
 Atypical pneumonia（非典型肺炎）
 Cornonavirus 变异的冠状病毒
 Extensive consolidation, hyaline membrane,
necrosis, pulmonary fibrosis
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Die in respiratory distress
Clinical features
Electro microscope
Avian Influenza
禽流感
H5N1
Interstitial
Atypical
人畜共患传染病
Bird flu
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An infection disease of birds
1997, Hong Kong, outbreak
Vascular disturbances
Fever, cough
All the other organs can be affected, for
example, liver, heart and kidney.
H1N1, Swine influenza A
H1N1, Swine influenza A
临床表现
轻症：同普通流感；重症：肺炎，坏死性脑病
 合并症：急性呼吸窘迫综合征
 病理：肺部表现为支气管壁坏死、中性粒细胞
浸润、弥漫性肺泡损害伴肺透明膜病变。
 发病机制：病毒损伤肺泡微血管导致肺出血与
血栓形成，体内免疫因子可对抗病毒感染并修
复损伤，但炎症反应过度、渗出液充满肺组织
又使肺瘢痕形成，进而限制肺功能。

H1N1 and H5N1
Mycoplasma pneumonia
支原体肺炎
Interstitial pneumonia
 Atypical pneumonia
 Congested, edematous,
mononuclear cells infiltration
Lobar pneumonia
Air space
pneumonia
Lobular pneumonia
Interstitial
Viral pneumonia
pneumonia
Mycoplasma pneumonia
ARDS
Acute Respiratory Distress Syndrome
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An acute diffuse alveolar injury
Terminal events in many of the patients
Serious ill, the mortality rate > 50%
Results from ischemic, endotoxins, enzymes.
Case 1 analysis

History: Male, 20, after suffering from cold
and drunk, got high fever, chill, rapid
breathing and chest pain. After 2 days, he
coughed with “rusty” sputum.

T: 40℃, R: 32 times/min.

Chest x-ray: show large-area uniform
dense well-delimited shadow in his left
upper lobe.

Blood examination:
WBC: 13.5x 109/ L
Questions
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What is the diagnosis?
Which type of inflammation?
Why does the patient cough with the
“rusty” sputum?
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Half a year later, this student was enrolled to
the army.
The chest x-ray indicated there was a nodule in
his left lung.
The nodule was checked under microscope,
there was much granulation tissue in the
alveolar spaces.
 WHY?
Case abstract 2

Male, 70-year-old, he had suffered
hypertensive heart disease and left heart
failure for half a year, and cough and
expectoration for 1 year. These symptoms
aggravated 4 days ago with fever and
purulent sputum.

T: 38℃, HR: 112 times/min, R: 35
times/min, BP: 22.6/13.5 kPa.

Blood WBC: 10.2 X 109/L

X-ray: Several scattered patchy shadows
evidently in bilateral lower lobes.
Questions
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What is the diagnosis?
Which type of inflammation?
Why do patients cough with the purulent
sputum?
Summary
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How to differentiate the lobar pneumonia
and the bronchopneumonia?

What is the “rusty sputum”?
See you next time!
2015/4/13
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