Chapter 8 Diseases of Respiratory System OBSERVATION METHODS OF SPECIMEN The visceral pleura overly the lungs, through which many polygonal lobules are visible. Normal lungs are light red, soft, and sponginess. Weight of adult lungs is equivalent to 1/50 of body weight. The left lung is divided into two lobes (upper and lower); the right lung has three lobes (upper, middle, lower). The main bronchi branch dichotomously give rise to gradually smaller and smaller bronchi. While observing the sample we should discern which side of lung it is, if the pleura has exudation, adhesion and is thickened .While observing the lung sections, we should notice the distribution, thickness and color of the bronchi, the mucous membrane is smooth or not, bronchus lumens are dilated or narrow. See if there are exudation, secretions, blood clotting, foreign material, neoplasm , etc ,in the bronchus lumens; whether the thickness of the bronchial wall is normal; whether the alveoli are dilated(focal or diffused) or not; whether there are consolidation and neoplasm in the lung parenchyma. Observe the position, size, shape, distribution, structure, texture and color of the lesions, their relations with bronchi, changes around the lesions and lymph node at the hilum of lung, etc. Observing the tissue sections of lung should note the lung structure Grossly: with low power microscopy, observe if there are changes on the pleura, the structure of the alveolus, the status of the bronchi and blood vessels, the structure and distribution of the lesions and their relations with the bronchi and surrounding tissues. On the basis of observation in low power microscopic appearance, we can choose one or several lesions to observe especially with the high power microscope, focusing on the tissue structure and morphologic characteristics of the lesion ,etc. AIMS 1 1. To grasp the pathological characteristics and relationship between clinic and pathology of lobar pneumonia, lobular pneumonia and viral pneumonia. 2. To grasp the pathological characteristics and clinical pathological correlation of chronic bronchitis, pulmonary emphysema, bronchiectasis, silicosis and chronic cor pulmonale. 3. To grasp the pathological characteristics and clinic pathological correlation of lung cancer. 4. To comprehend the pathological characteristics and relationship between clinic and pathology of asthma, sarcoidosis, idiopathic pulmonary fibrosis, ARDS, and nasopharyngeal carcinoma. CONTENTS Chronic obstructive pulmonary diseases Gross specimen Tissue section Emphysema Chronic bronchitis Bronchiectasis Emphysema Asthma Bronchiectasis Chronic cor pulmonale Changes of the heart Changes of the lung Pneumonia Lobar pneumonia Lobar pneumonia Lobular pneumonia Lobular pneumonia Viral pneumonia Diffuse interstitial diseases Silicosis Silicosis Asbestosis Asbestosis Sarcoidosis Idiopathic pulmonary fibrosis Respiratory distress syndrome ARDS 2 Lung cancer Centralized type Small cell carcinoma Peripheral type Bronchioloalveolar carcinoma Diffuse type Large cell carcinoma Carcinoid of lung KEY POINTS OF SPECIMEN OBSERVATION 1. Chronic obstructive pulmonary diseases (ⅰ) Chronic bronchitis Basic pathologic changes Histopathology ◆ Pathological changes occur originally in the larger airways, then involve gradually the smaller bronchi and bronchioles. ◆ Injury and repair of mucosa epithelium. There is degeneration, necrosis and desquamation accompanied by an increased number of goblet cells and squamous metaplastic changes in the lining epithelial cells. ◆ Hyperplasia and hypertrophy of the glands and serous metaplasia of mucous glands in the submucosa is the diagnostic feature of chronic bronchitis in the major airways. Mucus plug may appear in the bronchial lumens. ◆ Hyperemia, mononuclear cells and neutrophils infiltration, rupture of smooth muscles and atrophy and calcification of cartilage can be seen in the bronchial walls. Specimen observation Case abstract: Male, 74 years old, a cigarette smoke. He has coughed and expectorated white spumous sputum for 20 years, which occurred in every winter and spring and last up to 3 months every year. Physical examination: the chest signs are weak breath sound to auscultation and few moist rales in the lower left lung. Laboratory examination: WBC: 10.2×109/L. Chest X-ray: lung texture increases. Tissue section (Fig.8-01 a,b,c,d): To observe the changes of epithelium of the mucosa, glands, cartilage and 3 smooth muscle of bronchi, whether there is obstruction in the lumens of the bronchi, and the changes of lung tissue around the bronchi. (a) The lining epithelial cells are necrosis and desquamation accompanied by lymphocytes and plasma cells infiltration, and the smooth muscles are rupture. (b) Squamous metaplastic changes in the lining epithelial cells. (c) Atrophy and calcification of cartilage in the bronchial walls. (d) The mucous glands are hyperplastic and hypertrophic; the serous glands show metaplasia of mucous glands in the submucosa. Question: What are the pathologic changes that lead to cough and the production of sputum in patients with chronic bronchitis? (ⅱ) Emphysema Alveolar emphysema Basic pathologic changes (1) Gross morphology ◆ The lungs appear voluminous with round margin. ◆ The color of lungs looks pale, and the cut surface of the lungs is alveolate. ◆ The lung tissue is pillowy with decreased elasticity. (2) Histopathology ◆ Abnormal enlargement of the airspaces; thinning and destruction of alveolar septa; the adjacent airspaces can combine into large bullae. ◆ Obvious loss of the pulmonary capillaries surface area; fibrous thickness of intima of the pulmonary small arteries. ◆ Bronchiolitis involving the terminal and respiratory bronchioles. Specimen observation Case abstract: Male, 65 years old. He has suffered chronic bronchitis for 13 years. Dyspnea accompanied by wheezing after physical labor occurred 5 years ago. Physical examination: Inspection: Barrel-chest; Percussion: hyper-resonance; Auscultation: weak breath sound and scattered dry rales. Chest X-ray: The 4 transparency of bilateral lungs increases. Gross specimen (Fig.8-02): ① To observe the volume and texture of lung and the changes of lung sections. ② What type of emphysema is this sample classified as? What diseases may cause it? Tissue section (Fig.8-03a,b): To observe the alveolus changes, especially its size, the width and destruction of alveolar walls. See if the capillaries of the alveolar walls, bronchi and bronchioles have changes. Question: Why patients with pulmonary emphysema often develop hypoxia? Interstitial emphysema Gross specimen (Fig.8-04): Toruliform small gas vacuoles distributed reticular in lobular septa and subpleura, and the gas spread to the hilum and mediastinum, causing the hilum and mediastinum emphysema. (ⅲ) Asthma Histopathology ◆ An increase in number of goblet cells and in size of the submucosal glands. There are hypertrophy of the bronchial wall muscle, and thickening of the basement membrane of the bronchial epithelium. ◆ An inflammatory infiltrate in the bronchial walls, with a prominence of eosinophils, monocytes, lymphocytes and plasma cells. ◆ There are occlusion of bronchi and bronchioles by thick, tenacious mucous plugs. Histologically the mucous plugs contain Curschmann spirals and Charcot-leyden crystals. Specimen Observation Case abstract: Male,26 years old. Ten years ago, she suffered from dyspnea, wheezing and chest distress triggered by pollens. Anti-allergic medicine and antiasthmatic medicine could relieve the symptoms. Tissue section (Fig08-05a,b): (a) An inflammatory infiltrate in the bronchial walls. 5 The airways are filled with mucous plugs, and pink, needle-like Charcot-leyden crystals are present. (b) The bronchial wall muscle are hyperplasic with infiltration of eosinophils, and the lumen contains Curshman spiral. (ⅳ) Bronchiectasis Basic pathologic changes (1) Gross morphology ◆ The most severe involvements are found in the smaller bronchi and bronchioles which are dilated. The dilated segments may be long and tube-like (cylindroid), or they may be fusiform or saccular in shape. ◆ The lumens of the affected bronchi are characteristically filled with suppurative yellow-green, sometimes hemorrhagic exudates. ◆ In the more chronic cases, fibrosis of peribronchial lung tissue often develops. (2) Histopathology ◆ There is chronic inflammatory exudate within the walls of the affected airways that is associated with desquamation of the lining epithelium and extensive areas of necrotizing ulceration. ◆ Fibrosis of the bronchial and bronchiolar walls and peribronchiolar fibrosis develop. Specimen observation Case abstract: Female, 27 years old. She has coughed and expectorated yellow purulent sputum for 18 years. Hemoptysis occurred 3 years ago. Physical examination: the chest signs are moist rales to auscultation in the lower left lung. Chest X-ray: The texture of the lower left lung increase, and there are several irregular annular bright shadows. CT: The thickness of the bronchial walls increases, and the dilated bronchi of the lower left lung appear cylindroid or saccular in shape. Gross specimen (Fig.8-06): To focus on the pathological changes of the bronchi and their surrounding tissue. ① To notice the sizes and shapes of the lumens of the bronchi. ② Whether there is obstruction in the lumens of the bronchi, and if so, result from what reason? 6 ③ What changes occurred in the bronchial walls and the peribronchial lung tissue? ④ How to diagnose bronchiectasis by gross observation? Tissue section (Fig.8-07a,b): Compared with the tissue section of chronic bronchitis, observe the size, shape and content of bronchial lumens, the changes of bronchial mucous membrane, the wall of bronchi and their surrounding tissues, etc. Question: Why patients with bronchiectasis often cough with large amounts of purulent sputum when their body postures change? Can bronchiectasis result in the cor pulmonale and lung cancer? Why? 2. Chromic cor pulmonale Basic pathologic changes (1) Gross morphology ◆ Changes of the lung: we can see the original lesions, such as chronic bronchitis, and emphysema, etc. in the lung tissue. ◆ Changes of the heart: the right ventricular wall develops hypertrophy, and its thickness exceeding 0.5cm right under the pulmonary artery valve 2cm is the diagnosis criterion of chronic cor pulmonale in pathology. The right ventricle may be dilated and the pulmonary arterial cone is significantly inflated. (2) Histopathology ◆ In the lung tissue pathological changes of original pulmonary diseases can see the loss of the capillaries. ◆ The small arteries are affected with increase in muscular thickness of the media, and there are muscularization of arterioles, arteriolitis accompanying with organizing or recanalized thrombi and with the loss of the capillaries. ◆ Myocytes of the right ventricle develop hypertrophy with enlarged and deep-staining nucleus. Specimen observation: Case abstract: Male, 64 years old. He has coughed and expectorated for 20 years, panting after physical labor for 10 year. These symptoms aggravated one week ago, 7 coughing with purulent sputum. Physical examination: The body temperature is normal. Heart rate 130 times / min. Systole phase noises can be heard in the district of bicuspid valve. The chest shows the signs of pulmonary emphysema. Liver shows enlargement. The lower limbs are edematous. The chest X-ray: The transparency of the lung increase. The texture of the lower lobes appears the shape of residual root. The diameter of the heart increases with the round and blunt cardiac apex. The pulmonary artery segment is protruded and the diameter of the right lower pulmonary artery increases. Gross specimen (Fig.8-08): ① To observe the thickness of right ventricular wall, the changes of the trabeculae carneae, papillary m, cardiac chamber and pulmonary artery cone. ② To notice the changes of cardiac valve, epicardium and left heart. Tissue section (Fig.8-09a,b,c): (a) The media of the small muscular artery thicken. (b) Muscularization of arterioles. (c) Arteriolitis accompanying with thrombosis and organization of thrombus. Question: What’s the mechanism of the hypertrophy and dilatation of the right heart in the chronic cor pulmonale? Why patients at the late stage of chronic cor pulmonale can show congestion of systemic circulation? 3. Pneumonia (ⅰ) Lobar pneumonia Basic pathologic changes Four anatomic stages of lobar pneumonia have classically been described of congestion, red hepatization, gray hepatization, and resolution. (1) Gross morphology ◆ The lesion usually involves a segment or even whole lobe of the lung. ◆ The affected lobe is swollen. ◆ The color is dark red or gray. ◆ With the development of the lesion, the consistency changes from soft to firm (liver-like) and then to soft. (2) Histopathology 8 ◆ Vascular engorges, while in gray hepatization the capillaries in the alveolar wall are compressed. ◆ Intra-alveolar contents are different in different stages, the basic component is large amounts of fibrinous exudates, and massive exudation with red cells (red hepatization) or large amounts of neutroplils (gray hepatization). ◆ The underlying alveolar wall architecture is preserved. ◆ If the fibrinous exudates are not completely dissolved, they will be organized by granulation, called pulmonary carnification. Specimen observation Case abstract: Male, 29 years old. After suffering from cold, he got high fever, chill, rapid breathing and chest pain. After two days, he coughed with “rusty” sputum. In hospital he was considered to be pneumonia and given drugs like sulphanilamide. Physical examination: body temperature 40 ℃, breath rate 32 times /min. The chest signs are dullness to percussion and vocal fremitus enhancement to palpation in the middle right lung and upper left lung. Chest X-ray: the anterior segment of right upper lobe and the apex-posterior segment of left upper lobe become consolidated and show large-area uniform dense well-delimited shadow (Fig.8-10). Laboratory examination: WBC: 20.0×109/L Gross specimen (Fig.8-11a,b): ① To notice whether the volume of lung increases, and what changes does the pleura have? ② What changes and color do the lung sections have? ③ Which stage is this type of pathological change defined? What symptoms and signs can the patients at this stage have? Tissue section (Fig.8-12a,b,c,d,e): ① To notice how the pathological changes distribute in lung tissue. ②To observe the pathological characteristics of the lung parenchyma, whether the alveolar septa are destroyed, whether the capillaries are dilated and what contents are in the alveoli. ③ Which stage is the histopathological change defined? Why? Question: Which type of inflammation dose the lobar pneumonia belong to? Why do patients cough with the “rusty” sputum? Can the involved lung tissue be recovered completely? 9 (ⅱ) Lobular pneumonia Basic pathologic changes (1) Gross morphology ◆ Gray-yellowed foci of inflammatory consolidation distribute patchily throughout one or several lobes on the surface and the cut surface. ◆ The lesions vary in size up to 1cm in diameter, and irregular, and poorly delimited at their margins. ◆ The cross section of bronchiole is usually seen in the center of the foci. ◆ Confluence of foci occurs in the more florid instances, producing the appearance of total lobular consolidation. (2) Histopathology ◆ The bronchiole wall is hyperemic and edematous, and neutrophils infiltrate. The mucosal epithelial are necrosis, and a suppurative exudates fills the bronchi and bronchioles. ◆ Adjacent alveolar spaces are filled with suppurative exudates, RBC and necrotic alveolar epithelium. ◆ In severe instances, the foci may confluent to present patchy distribution. ◆ The adjacent alveolar spaces show compensating emphysema. Specimen observation Case abstract: Male, 70 years 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. Physical examination: body temperature 38 ℃, pulses 112 times / min, breath rate 35 times/min, blood pressure 22.6/13.5 kPa. Lips appear cyanosis. The chest signs are resonance to percussion and the scattered moise rales to auscultation in the bilateral lungs. Laboratory examination: WBC: 10.2×109/L The chest X-ray: there are several scattered patchy shadows evidently in bilateral lower lobes. Gross specimen (Fig8-13a,b): ① To notice the volume change of lung and the exudate on the pleura. ② To observe the characteristics of the lesions on the lung 10 surface and section, such as shape, color and distribution. Tissue section (Fig8-14a,b,c): ① Are the pathological changes focal or diffused? ② To pay attention to the characteristics, involvement of pathological changes and the relation between bronchioles and foci. ③ What changes occur to the lung tissue surrounding the foci? Can you call it pulmonary emphysema, why? Question:what differences are between lobar pneumonia and lobular pneumonia? (ⅲ) Viral pneumonia Basic pathologic changes (1) Gross morphology ◆ The lesions are usually unobvious. The affected lung tissue are congested and edematous, and the volume of the lungs is only mildly increased. (2) Histopathology ◆ The alveolar septa are widened and edematous and have a mononuclear inflammatory infiltrate of lymphocytes, histocytes. Predominant is the interstitial nature of the inflammatory reaction. ◆ The alveolar spaces are free of exudates but may contain a proteinaceous fluid. ◆ In severe cases, there are intra-alveolar exudates, and the alveolar epithelial cells are degeneration and necrosis. ◆ Sometimes there are pink hyaline membranes lining the alveolar walls, and multinuclear giant cells. ◆ Viral inclusion body (the round or oval shape, erythrocyte-like in size, acidophil and having peripheral vacant space) can be seen in cytoplasm and nucleus of the hyperplastic epithelium and multinuclear giant cell. Specimen observation Case abstract: Male, 5 years old. After catching cold the boy showed pharyngagia, weakening, high fever and coughed with no sputum. Physical examination: body temperature 39.5 ℃, pulses 140 times / min, breath 45 times / min. The chest signs are dullness to percussion in the lower left lobe and weaken breath sound and a small 11 amount of moist rales in the bilateral lobes. Laboratory examination: WBC: 9.5×109/L; the proportion of lymphocyte is 0.60. Chest X-ray: The texture of bilateral lung increases. The lower left lung show large patchy shadow. Tissue section (Fig.8-15a,b,c):To observe the changes of alveolar septa, the types of the inflammatory cells infiltrated in the lesion, and the exudate in the alveoli. Question: ① What are the differences of pathological changes among lobar pneumonia, lobular pneumonia and viral pneumonia? ② Which part of the lung does the viral pneumonia involve? And what pathogen can result in this kind of pneumonia besides to virus? ③ What’s the main evidence to diagnose the viral pneumonia in histology? 4. Diffuse interstitial diseases (ⅰ)Silicosis Basic pathologic changes (1) Gross morphology ◆ Gray-white, 2-5mm in diameter, hard silicotic nodules can be palpated in the lung substance. ◆ In the late stages, the silicotic nodules coalesce with fibrotic lung tissue to form conglomerate masses, some of which may undergo central cavitation due to necrosis and liquefaction. ◆ The pleura are dense fibrosing thickened. (2) Histopathology ◆ Silicotic nodules: in early stage, the nodules are the local aggregation of macrophages phagocytosed the silica, and progressively undergo fibrosis and hyaline degeneration. ◆ Diffuse pulmonary interstitial fibrosis. ◆ According to the number , size and scope and extent of fibrosis of the silictic nodules, silicosis is divided into 3 stages: stageⅠ: silicotic nodules are small and few, only located in the hilum; stageⅡ: silicotic nodules are large and more, 12 but the scope <1/3 of the whole lung; stageⅢ: silicotic nodules coalesce into tumor like masses, the scope >1/3 of the whole lung. Specimen observation Case abstract: Male, 45 years old, working on porcelain casting for 20 years. He has coughed and expectorated repeatedly for 9years and panted for 5 years. Physical examination: body temperature 37.6℃. The breath sound of bilateral lungs is weak and no rale can be heard. Chest X-ray: Bilateral lungs show shadows of several big nodules with the size of 3cm×2.5cm. The shadow of the hilum of lung, the lung texture and the transparency of lung increase. Gross specimen (Fig.8-16): ①There is a large number of carbon powder deposited in the lung which makes the lung tissue black. ② To look for small ashen nodules on the black background of the lung. ③What changes do the involved lung tissue and its surrounding tissue occur? ④What changes does the lymph node at the hilum of lung occur? Tissue section (Fig.8-17a,b): ① To observe and describe characteristics of the pathological changes, which kind of pathological change is what you see? ② What changes does the surrounding tissue have? Question: ① If the patients with early stage of silicosis leave the environment of silicon, whether their pathological changes can be fully recovered or stop developing? ② Why the patients at late stage of silicosis often present the clinic symptoms of severe dyspnea and hear failure? ③ Why are the patients easy to develop the complication of pulmonary tuberculosis? (ⅱ) Asbestosis (1)Gross morphology ◆ Diffuse interstitial fibrosis results in the shrinkage and the hardness of the lungs. ◆ If accompanied with apparent emphysema and bronchiectasis, the affected regions become honeycombed. ◆ The pleura undergoes thickening, and well-circumscribed pleural plaques form. The plaques exhibit the appearance of ivory and the consistency of leather and 13 with irregular bosselations on the surface. (2)Histopathology ◆ There are large amounts of alveolar epithelial cells and macrophages in the alveolar spaces. ◆ Diffuse interstitial fibrosis accompanying with lymphocytes and monocytes infiltration. ◆ Asbestos bodies are found in the walls of the bronchioles or within alveolar spaces. Specimen observation Gross specimen (Fig.8-18): The lungs are shrinkage and the pleura is diffuse thickening to form yellow-white, well-circumscribed, bosselated pleural plaques. Tissue section (Fig.8-19a,b): Fibrosis of pulmonary interstitium. Asbestos bodies appear as golden brown, beaded rods in the fibrosis tissues or within alveolar spaces. (ⅲ) Sarcoidosis Basic pathologic changes ◆ Non-specific alveolitis, noncaseating granulomas and pulmonary interstitial fibrosis are presented. ◆ The granulomas are composed of an aggregate of tightly clustered epithelioid cells, with Langhans giant cells. Central necrosis is unusual Stellate inclusions known as asteroid bodies and Shaumann bodies are enclosed with giant cells. Specimen observation Tissue section (Fig.8-20): Noncaseating granulomas are present, consisting of tight clusters of epithelioid macrophages and multinucleated giant cells. (ⅳ) Idiopathic pulmonary fibrosis Basic pathologic changes (1) Gross morphology ◆ The lungs become shrinkage and solid, gray-white, and small cysts are seen to give the appearance of the honeycomb lung on the cut surface. 14 (2) Histopathology ◆ In the early stages, there is patchy interstitial chronic inflammation, later there is diffuse interstitial fibrosis. Specimen observation Tissue section (Fig.8-21): There is diffuse pulmonary interstitial fibrosis as well as thickening of the interstitial septa, and the pneumocytes are hyperplasia. 5. ARDS Basic pathologic changes ◆ The lungs are congestion, edema and the alveolar walls are lined with waxy hyaline membranes. There are also local lung collapse. Specimen observation Tissue section (Fig.8-22): The alveoli are lined by eosinophilic hyaline membranes, consisting of precipitated plasma proteins and fibrin and nuclear debris from sloughed epithelial cells. 6. Carcinoma of the lung Basic pathologic changes (1) Gross morphology ◆ Lung carcinoma can be divided into three types, which are the centralized lung carcinoma, diffuse lung carcinoma and peripheral lung carcinoma. (2) Histopathology ◆ The four major histologic types of bronchogenic carcinoma are squamous cell carcinoma, adenocarcinoma, small cell carcinoma and large cell carcinoma. Specimen observation Case abstract: Male, 68 years old, a cigarette smoker. He has coughed and expectorated for 15 year. The sputum contained blood for 20 days. The chest X-ray: A round shadow with coarse edge can be seen at the hilum of the left lung. Chest CT: the bronchus of upper left lobe is narrow, and a soft tissue lump is found around the left bronchus. 15 Gross specimen (Fig.8-23a,b,c): ① To observe the location of the lesion and its relation with the hilum of lung and larger bronchus. ② To observe the size, shape , distribution , color , texture and boundary of the lesion. ③ What changes do the bronchial lymph node and the pulmonary hilar lymph node occur? ④ Which type does the carcinoma belong to according to gross morphology? Tissue section (Fig.8-24a,b,c,d) :① What’s the histologic type of the carcinoma? ② What’s the significance of histologic classification of the lung carcinoma? CASE DISCUSSION Case 1 Case abstract. 25 years old, male. He suffered chill, fever, cough with brown sputum and chest pain for 1 week. Present medical history. About one week ago, he feel malaise, then suffered chill, fever with body temperature 40℃. The symptoms alleviated slightly after treated by antibiotics. He still suffered chill and high fever on the second day. He developed chest pain, dry cough accompanying with brown reddish sputum then developed dyspnea in the afternoon. Past history. Healthy. Physical examination. Good nutrition, consciousness, high fever features, mandible lymph nodes swell, tenderness (+). There are herps around mouth, congestion at pharynx. Tubular breath sound can be heard at right scapular region, no dry rales and wet rales; Heart rate: 100/min. Body temperature: 39.7℃,X-ray: there are large piece of clouding shadow at upper lobe of right lung. Blood routine. WBC: 15000, st: 19, S: 76, L: 5. Process of treatment. After treated by antibiotics and anti-symptom therapy, fever relieved rapidly; symptoms disappeared. He discharged after 3-week treatment. Discussion 1. What is the diagnosis of the case? 2. What lesions does this case show? 16 3. What are the reasons of these symptoms, signs and abnormal results of lab examination? Case 2 Case abstract. 65 years old. She showed cough with purulent sputum after catching cold 15 years ago. Since then, she developed cough and expectoration of white spumous sputum every winter and spring. Since 3 years ago, she felt breath shortness and palpitation after physical labor. Pitting edema occurred repeatedly on her lower limbs for 2 years. Two months ago after catching cold, she developed fever, cough with purulent sputum, palpitation, breath shortness, and abdominal distension, and couldn’t lie down. The patient failed to rescue and died after being in hospital. Physical examination. Body temperature 37.6 ℃, pulses 102times / min, breath rate 30 times / min, blood pressure 13.5/10.5kPa. Chronic sickness appearance, up-straight sit breathing , sleepiness, dark purple lip and skin, cervical venous engorgement, barrel-shape chest, hyper-resonance to percussion, scattered dry and moist rales. Heart rate 102 times / min, cardiac rhythm is normal. Abdominal bulge, a large amount of ascites, the liver is hard with the rim under the rib 7.8cm, Lower limbs show pitting edema. Laboratory examination: Hemoglobin 98g/L, leukocyte 6.7X109/L. Autopsy findings. There are 250ml accumulating fluid respectively in the Left and right thoracic cavity, and 500ml light-yellow transparent accumulating liquid with the specific gravity of 1.012 in the abdominal cavity. The lungs appear voluminous and inflated weighing 760 grams each. In the section of the lung scattered ashen consolidation areas can be seen, more severely affecting lower lobes. Histological features. airspaces are dilated, alveolar septa become thin and partly destructed. Edema fluid, Neutrophils, deciduous necrotic epithelia fills the bronchioles and adjacent alveolar spaces. An increased number of goblet cells and squamous metaplastic changes can be seen in the lining bronchial epithelial cells. Hyperplasia and hypertrophy occur to mucous glands. Focal calcification and fibrosis 17 of cartilage develop. Fibrous tissue proliferates. Mononuclear cells and neutrophils infiltrate are present. The weight of the heart is 350g. The thickness of the right ventricular wall is 0.55cm. The right ventricle is obviously dilated with thickening of trabeculae carneae and papillary muscle. The pulmonary arterial cone is inflated. The live shows cardiogenic liver cirrhosis. Extensive congestion and degeneration of parenchyma cells occur to other organs. Discussion 1. To make a diagnosis according to the clinical manifestation and autopsy examination and state the diagnostic basis. 2. To explain the process of the development of the disease of this patient. 3. To explain the patient’s symptoms and signs with the pathological changes. PRACTICE REPORT 1. To paint the histological morphology of lobar pneumonia. 2. To describe the pathologic characteristic of lobular pneumonia. 3. To write out the discussion outline of case2. QUESTIONS FOR REVIEW 1. If it could be called lobar pneumonia when confluent lobular pneumonia involves the entire lobe? 2. Which diseases learned could cause chronic cor pulmonale. 3. If the silicotic nodules are granuloma? What is the difference to foreign body granuloma? 4. Which type of lung cancer has the worst prognosis? ( Haerbin Medical University Zhao Ruibo ) 18