2Chief ComplaintChest pressure for one month progressively worsened for 2 daysWeakness for 4 daysNon-productive cough for 1 week
3History of Presenting Illness A 64y old Caucasian female with past medical history of hypertension and CAD went to outside hospital with chest pressure which has been going on for one month with worsening for 2 days. Pain was in middle of the chest, retrosternal, 4/10, no radiation or shift, no aggravating or relieving factors, associated with non-productive cough for last 1 week.Negative for hemoptysis and weight loss.
4Social History Past Medical and Surgical History Medications Hyperlipidemia, CAD, HypertensionAppendectomy, Tonsillectomy, Nasal surgeryMedicationsASA, Atenolol, AllegraSocial History12 pack years, quit at 28yrs of ageWorked as spray painter in a boat manufacturing industryNo alcohol or drug useFAMILY HX:No hx of diabetes mellitus, pre-mature heart disease or cancers .
5Physical ExamTemp: 97.9 F, Pulse : 81/min, Resp: 18/min , BP: 118/69, SpO2 : 99% on 2LGEN: AO x 3, no distressHEENT : Non-contributoryNECK: No JVD, No lymph-adenopathyChest: Non tender on palpation, clear on auscultation B/LHeart : Normal heart sounds, No murmurs heardAbdomen: Soft, non-tender, no organomegaly,BS+Extremities: No edema, DP +Neuro: Non-focal examSkin: No rashes , echymosis or purpura
6Labs Na 134 K 4 Cl 100 HCO3 24 BUN 9 Creatinine 0.7 Glucose 171 Ca 8.9 Total Bili0.4AST20ALT17Alk Phos86Total protein8ALB4.6
8Summary64 y/o caucasian female with PMH of HTN, CAD, presented with 1 month H/O retrosternal, non radiating 4/10, chest pressure, progressively worsening for last 2 days, weakness for 4 days, nonproductive cough for 1 week with no hemoptysis or weight loss. Remote H/O smoking , quit 36 years back and worked as a boat painter.Lab- significant only for Mild normocytic anemia.
9Additional History Required Comprehensive review of systems- Fever or chill, night sweat, anorexia.Any Associated SOB, dysphagia, odynophagia , hoarsenessPain with deep breathing or coughingDescription of weakness- Focal or generalized, vs any UE s/s- numbness/paresthesiaAxillary, inguinal supraclavicular lymph node examinationAny Breast examination for lump/massLateral CXR to evaluate the mediastinal location.
11Lung vs Mediastinal Mass The following characteristics indicate that a lesion originates within the mediastinum:Mediastinal mass will not contain air bronchograms.Mediastinal lines (azygoesophageal recess, anterior and posterior junction lines) will be disrupted.There can be associated spinal, costal or sternal abnormalities.A lung mass abutts the mediastinal surface and creates acute angles with the lung, while a mediastinal mass will sit under the surface creating obtuse angles with the lung
19Bronchogenic Carcinoma Lung cancer is the leading cause of cancer death in the United States, accounting for approximately 29% of all cancer deaths.lung cancer is the second most common cancer in man and womenDuring 2008, approximately 213,380 new cases of lung cancer were diagnosed (114,760 among men and 98,620 among women).
20EpidemiologyAge Distribution-predominately in persons aged years.Nearly 70% of patients are older than 65 years and fewer than 3% are younger than 45 years.Sex- In the United States, the probability of developing lung cancer remains equal in both sexes until age 39 years It then starts to increase among men compared with women, reaching a maximum in those older than 70 years.Prevalence-incidence rates are similar among African American and white women.Approximately 45% higher among African American men than among white menCurrent 5-year survival rates are estimated to be 16% among whites and 13% among non-whites
21Etiology Causes: Smoking (90% of all Lung cancers)- The risk of developing lung cancer for a current smoker of 1 ppd for 40 years is approximately 20 times that of someone who has never smoked.Risk declines slowly after smoking cessation. The relative risk remains high in the first 10 years after cessation and gradually declines to 2-fold approximately 30 years after cessation.Asbestos exposure- risk of Lung cancer is 5 times. Synergistic with smoking times greater risk than control population
22Environmental toxins- Radon , halogen , ether, arsenic atmospheric pollutionChromium, nickel , Vinyl chlorideRadiation therapy —increase the risk of a second primary lung cancer in patients who have been treated for other malignancies.Pulmonary fibrosis —The risk for lung cancer is increased about sevenfold patients with pulmonary fibrosis, Independent of SmokingHIV infection — The incidence among individuals infected with HIV appears to be increased compared to that seen in uninfected controlsGenetic Exposure-. The ras gene mutations occur almost exclusively in adenocarcinoma and are found in 30% of such cases.mutations in c-myc and c-raf among oncogenes and retinoblastoma (Rb) and p53 among tumor suppressor gene are found in NSCLC include
23Classification Lung Cancer Non-small Cell Cancer- 85%-90% of Lung cancersSmall Cell Lung cancer- 10%-15%of Lung cancersAdenocarcinoma((including bronchioloalveolar carcinoma) — 38 percentSquamous cell carcinoma — 20 percentLarge Cell Carcinoma %Other non-small cell carcinomascannot be further classified (18 percent)Others- Sarcomatoid, NE tumors %
24AdenocarcinomaAdenocarcinoma, arising from the bronchial mucosal glandsThe most frequent NSCLC in the United States, % of all lung cancers.It usually occurs in a peripheral location within the lung.Adenocarcinoma is the most common histologic subtype, and may manifest as a “scar carcinoma.” most commonly in persons who do not smoke. This type may manifest as multifocal tumors in a bronchoalveolar form.Significant variation in architecture of neoplastic gland formation.Variant Subtypes:- Acinar- Papillary- Bronchiloalveolar Carcinoma- Solid Adenocarcinoma with mucin production
25Bronchiloalveolar Carcinoma Bronchoalveolar carcinoma is a distinct subtype of adenocarcinoma with a classic manifestation as an interstitial lung disease on chest radiograph.Bronchoalveolar carcinoma arises from type II pneumocytes and grows along alveolar septa. This subtype may manifest as a solitary peripheral nodule, multifocal disease, or a rapidly progressing pneumonic form. A characteristic finding in persons with advanced disease is voluminous watery sputum.In the new classification scheme, these tumors have been renamed as adenocarcinoma in situhas a propensity for intrapulmonary metastases and a more indolent course
26Squamous Cell Carcinoma 25-30% of all lung cancers.Tends to occur centrally, with endobronchial lesionsHistologically : presence of keratin pearls detected with cytologic studies and has a tendency to exfoliate. It is the type most often associated with hypercalcemia.Historically, most squamous cell carcinoma (60 to 80 percent) arose in the proximal portions of the tracheobronchial treeA minority of cases occur peripherally and may be associated with bronchiectatic cavities or scars. Central and peripheral squamous cell carcinomas may show extensive central necrosis with resulting cavitationThe classic manifestation is a cavitary lesion in a proximal bronchus.
27Large Cell Undifferentiated Carcinoma only 10% of lung cancers.Typically manifest as a large peripheral mass on chest radiographHistologically, this type has sheets of highly atypical cells with focal necrosis, with no evidence of keratinization (typical of SCC) or gland formation (typical of adenocarcinomas).LCC is a diagnosis of exclusion intended to include all poorly differentiated NSCLCs that are not further classifiable by routine light microscopy.
28Sarcomatoid Carcinoma Represents a heterogeneous group of NSCLCs that contain a component of sarcoma or sarcoma-like elements:Pleomorphic carcinomaSpindle cell carcinomaGiant cell carcinomaCarcinosarcoma —defined by the presence of a typical carcinoma combined with sarcomatous elements (bone, cartilage or skeletal muscle). Typical sarcomatous components include rhabdomyosarcoma, osteosarcoma, and chondrosarcoma.Pulmonary blastoma —biphasic malignancies that have an adenocarcinoma component that has the appearance of fetal adenocarcinoma and a stroma that resembles that seen in Wilms tumor. They are usually large at the time of presentation and are highly malignant
29Pulmonary Neuroendocrine Tumors Small cell carcinomalarge cell neuroendocrine carcinomaTypical carcinoid, and atypical carcinoidDIPNH- diffuse idiopathic pulmonary neuroendocrine cell hyperplasia, a possibly preinvasive epithelial lesionTypical and atypical carcinoids - similar to carcinoid lesions arising at other sites.Small cell carcinomas and large cell neuroendocrine carcinomas more aggressive course and pathologically by a much higher mitotic activities.
30Small Cell Lung CancerSmall cell lung carcinoma (SCLC) accounts for approximately 15 percent of all bronchogenic carcinomas.SCLC shows a strong correlation(>95%) with cigarette smoking and is extremely rare in persons who have never smoked.SCLC is usually more aggressive than NSCLC .Presents as a central lesion with hilar and mediastinal invasion along with regional adenopathy.65-70% of patients with SCLC have disseminated or extensive disease at presentationThe most common sites of metastasis of lung cancer are the bones, liver, adrenal glands, pericardium, brain, and spinal cord.production of various peptide hormones leads to a wide range of paraneoplastic syndromes
32Paraneoplastic Syndromes from lung cancers: Hypercalcemia- Squamous cell carcinomaTrousseau syndrome- AdenocarcinomaHypertrophic pulmonary osteoarthropathy- NSCLCClubbing – all types.
33Paraneoplastic Syndromes Of SCLC Organ SystemSyndromeMechanismFrequencySIADHAntidiuretic homone5%- 10%EndocrineEctopic sec of ACTHACTH5%Atrial Natriuretic factorsEaton-Lambert reverse myasthenic syndrome5%-6%NeurologicSubacute cerebellar degenerationSubacute sensory neuropathyLimbic encephalopathyAnti-Hu, Anti-Yo antibodies
34Diagnostic Imaging CXR- may show the following: Pulmonary nodule, mass, or infiltrateMediastinal wideningAtelectasisHilar enlargementPleural effusionCT Scan -mediastinal lymphadenopathy. CT had a pooled sensitivity of 57%, a specificity of 82%, and a negative predictive value of 83%.PET FDG- pooled sensitivity of 84% and a specificity of 89%, with a PPV of 79% and a NPV of 93%.Combined positive predictive value and negative predictive value of CT scanning and PET-FDG were 83% to 93% and 88% to 95%, respectively.PET-FDG is superior to CT scanning in the staging of disease in patients with mediastinal lymph node involvement.
35Staging of SCLC TNM system is generally not used in these patients. The Veterans Administration Lung Study Group staging system is typically used, : as limited or extensive.Limited-stage disease -limited to one hemithorax, with hilar and mediastinal lymphadenopathy that can be encompassed within one tolerable radiotherapy portal.Extensive-stage disease consists of any disease that exceeds those boundaries. Most patients (60% to 70%) with SCLC present with clinically extensive-stage disease. significant differences in median and 5-year survival among these patients depending on the stages.Combination chemotherapy is the cornerstone of treatment for both limited-stage and extensive-stage SCLC.
36Metastatic Neoplasm to Lungs Approximately 10-30% of all malignant nodules resected from the lung are metastaticFrequent sources of malignancy:Head and neckColonKidneyBreastThyroid glandMelanomaIn addition to solitary or multiple nodules, metastases of carcinoma to the lung include lymphangiitic, endobronchial, pleural, and embolic patterns.Most common Clinical situation: multiple or innumerable nodules.
37Lymphomatous proliferation involving Lungs 3 different ways:Haematogenous dissemination of Non-Hodgkins lymphoma (NHL) or Hodgkins diseaseContiguous invasion from a hilar or mediastinal site of nodal lymphomaPrimary pulmonary involvement.
38Non-Hodgkins Lymphoma Epidemiology- Approximately 56,000 new cases (NHL) are diagnosed in the United States annually, with approximately 24,000 people dying from this disease each year.The incidence of NHL increases exponentially with age and is greater in men than women and in whites than blacks.Risk Factors:Autoimmune disease and immunodeficiency states have a known association with NHL.NHL may also be caused by viruses – EBV- Burkitts lymphoma, HTLV-1- Adult T cell leukemia- lymphoma, HHV-8- Body cavity lymphomaSeveral chemicals, such as organochlorine agents (for example, DDT), have been weakly associated with an increased risk for NHL.Farming - consistently shows an association with an increased risk for NHL, which is often thought to be related to the use of pesticides
39Classification Criteria: WHO Classification Of Lymphoid MalignancyLymphoid NeoplasmsB cell neoplasmsT- cell and NK -cell neoplasmsHodgkins LymphomaClassification Criteria:MorphologyClinical featuresGenetic featuresImmunophenotype
4080%-85% of NHL in adults are B-cell in origin Remainder – mostly T cell in originB cell Lymphomas- based on biology and natural history:Indolent vs Aggressive vs Highly aggressive GroupsIndolentAggressiveHighly AggressiveSmall LymphocyticDiffuse large cellBurkettFollicularMantle CellLymphoblasticMarginalAIDS relatedMALTSplenicNodal
41Clinical presentations Aggressive NHLs -acutely or subacutely with a rapidly growing mass, systemic B symptoms (ie, fever, night sweats, weight loss), and/or elevated levels of serum LDH and uric acid50% present with secondary extranodal disease, 10%-35% Primary extranodal lymphoma- Most common EN site- GI tract then skin. Others – Testis, Bone, Kidneypotentially are curable with combination chemotherapy.Indolent lymphomasAre often insidious, presenting only with slow growing lymphadenopathy, hepatomegaly, splenomegaly, or cytopenias..Mostly present at advanced stage, incurableMedian survival 7-10years.
42Chest and Lung NHLApproximately 20 percent of patients with NHL present with mediastinal adenopathy on clinical examination or chest radiographPrimary mediastinal large B cell lymphoma or part of diffuse Systemic diseaseCough, chest discomfort, or asymptomatic with abnormal CXR3%-8%- SVC syndromeOther - include pleural and, less commonly, pericardial effusions. Chylothorax, alone or in combination with chylopericardium or chylous ascitesPleural disease is seen in up to 10 percent of all patients with NHL at diagnosis.
43PA (upper panel) and lateral (lower panel) radiographs of a patient with a large right-sided mediastinal mass (arrows). The biopsy was consistent with diffuse large B-cell non-Hodgkin's lymphoma.
44CT scan of Chest in NHLTypical radiographic findings include alveolar opacities (consolidation, masses, or nodules) and peribronchial disease.parenchymal lung lesions can be seen with no evidence of mediastinal or hilar lymphadenopathy.Diagnosis:NCCN recommends- An excisional biopsy of an intact node- histologic, immunologic, and molecular biologic assessmentIncluding flow cytometry and fluorescent in-situ hybridization or cytogenetics.Staging- CT chest abdomen, pelvis, PET scan, CBC, CMP, LDH, β−2 microglobulin, Uric acid, BM Bx, Lumber puncture, Echocardiogram, NM scan
45Diffuse Large B Cell Lymphoma Most common Lymphoid malignancy. 25% of NHLCaucasian Americans having higher rates than Blacks, Asians, and American Indian or Alaska Nativesmale predominance ; approximately 55 percent of cases in menMedian age at presentation is 64 years. Younger for Blacks.Typically presents as rapidly enlarging symptomatic mass, nodal enlargement- usually neck and abdomenB-symptoms- 30%BM – 30%, Extramedullary- 40%tumors derived from germinal center B cells or post-germinal center B cells (also called activated B cells)majority of DLBCL tumors demonstrate translocations or mutations that result in the increased expression of the B cell lymphoma 6 (BCL-6) gene.
46Systemic DLBL with mediastinal involvement PMLBLSystemic DLBL with mediastinal involvementYounger women-3rd-4thdecadeOlder age at Dx- median age at Dx-7th decadelocally invasive anterior mediastinal mass with invasion of local structures ,(SVC, effusion)Systemic B symptoms and elevated LDH levels are not uncommon.Can spread to Supraclavicular and cervical LN later to Kidneys or CNSIf BM involvement or more distant LN spread then Dx is more likely DLBLImmunophenotyping-express pan-B cell antigens, have weak expression of CD30, and only rarely express CD15express pan B cell antigens (CD19, CD20, CD22, CD79a), as well as CD4550%-75% of tumors express surface or cytoplasmic monoclonal (Ig), most often of the IgM isotype.
47Hodgkins LymphomaArises from germinal or post-germinal center B cells.Incidence- approximately 10 percent of all lymphomas in economically advanced countries.Age and sex- Bimodal distribution- 1 peak in young adults (age 20 years) and one in older age (age 65 years); the majority of patients are young adults; male predominanceBased on the appearance and immunophenotype of the tumor cells:Nodular lymphocyte predominant HL (NLPHL)Classical HLClassic HL is usually diagnosed by lymph node biopsy.On light microscopy, the tumor contains a minority of neoplastic cells (Reed-Sternberg cells and their variants) in an inflammatory background.The neoplastic cells typically express CD15 and CD30, variably express CD20, and do not express CD3 or CD45
48Classical HL is further divided into the following four subtypes: Nodular sclerosis classical HLMixed cellularity classical HLLymphocyte rich classical HLLymphocyte depleted classical HLClinical presentations includeNontender lymphadenopathy in the neck or mediastinumIncidental finding of a mediastinal mass on routine chest x-raySystemic symptoms - in less than 20 percent of stage I/II Hodgkin lymphomaup to 50 percent of patients with more advanced disease.Nonspecific symptoms- retroperitoneal LAD, cholestatic liver disease, alcohol-induced pain, skin lesions, neurologic symptoms, nephrotic syndrome, hypercalcemia, and abnormalities in blood counts.Spread- via lymphatic channels before disseminating to distant nonadjacent sites and organs.It is uncommon to have pulmonary disease at presentation without Hodgkin lymphoma being present within the hilar lymph nodes, usually on the ipsilateral side
49Primary Pulmonary Lymphoma (PPL) clonal lymphoid proliferation affecting one or both lungs (parenchyma and/or bronchi) in a patient with no detectable extrapulmonary involvement at diagnosis or during the subsequent 3 monthsPPL is very rare; 0.5–1% of primary pulmonary malignancies, <1% of NHLThe current definition of PPL covers:1) lowgrade B-cell PPL (PPL-B), the most frequent form2) high-grade PPL-B3) lymphomatoid granulomatosis (LG), a rare disorder.
50Bronchial MALT lymphoma High grade PPL-B Low grade B-cell PPLBronchial MALT lymphomaHigh grade PPL-B58–87% of cases of PPL.90% of these cases correspond to MALT-type NHLAge of onset is- 50–60 yrs (12–79 yrs)The two sexes are equally affected11-19% cases of PPLMALT type NHL coexists in ~50% of casesOften occurs in pts with underlying disorders HIV, Immunosuppresive medications. Sjogren’s.Median age- ~60yrs50% are asymptomatic at Dx, With Incidental CXRUsual CXR-50%- 90%Localized alveolar opacity with<5 cm diam and associated with air bronchogram (50%)CT- Bilateral and multiple appx 60%-70%, can- hilar or med LAD<10%- B/L reticulonodular opacities, atelectasisor pleural effusionUsually symptomatic, Resp s/s, fever or wt lossRadiology: Single pulmonary mass or atelectasis. Pleural effusionHIV- Multiple excavated opacitiesBronchial , Transbronchial or transthoracic biopsyBX Blast like lymphoid cell with high mitotic activity5 year survival rate >80%,Median survival time >10yrsPrognosis is poor. Median survival 8-10yrs
51Lymphomatoid Granulomatosis Lymphoproliferative disorder in the family of Epstein-Barr virus (EBV)-associated B cell lymphomas. Extremely rareAge of onset- 30 and 50, Men are more commonly affected than women, with an estimated male to female ratio of 2:1.The lung is the most commonly involved organ; the skin and neurologic system may be affected separately or concurrently.most common presenting symptoms and signs include cough, fever, rash/nodules, malaise, weight loss, neurologic abnormalities, dyspnea, and chest pain.CXR typically shows- multiple ill-defined nodular opacities.Histolgy- triad of polymorphic lymphoid infiltrates, transmural infiltration of arteries and veins by lymphoid cells ("angiitis"), and focal areas of necrosis within the lymphoid infiltratesclinical course is variable, ranging from remission without treatment to death within 2 years from malignant lymphoma.
52Pulmonary Tuberculosis Mycobacterium tuberculosis, an acid-fast–staining bacillus- inhaled into the respiratory system by airborne droplets.Prevalence in foreign-born U.S. residents is 9.7 times higher than that in U.S.-born personsIn the AW- alveolar macrophages ingest the bacteria .Can not arrest the multiplications- get destroyedInfected macrophages are carried to LN- Form Ghon complex- (localized parenchymal infection and lymph node involvement)- quiescent state- infection is recognized only by reactivity to tuberculin skin testing.Malnutrition, immunosuppressed states, and stress are risk factors for primary progression or reactivation of quiescent tuberculosis.In some patients, a pulmonary Ghon complex may reach significant size and calcification status to be visible on radiographs.
53Clinical menifestations: pulmonary tuberculosis are often asymptomatic.Constitutional symptoms, including anorexia, fatigue, weight loss, chills, fever, night sweats, and local symptoms such as cough, may develop.Hemoptysis and chest pain from pleural involvement indicate advanced disease.HIV-infected or other immunocompromised patients - greater likelihood of dissemination or extrapulmonary infection.Radiological findings:Reactivation tuberculosis classically - lesions in the apical-posterior segments of the upper lung and superior segments of the lower lobe. Cavitation may be present.Primary progressive tuberculosis may manifest as hilar lymphadenopathy or infiltrates in any part of the lung, similar to bacterial pneumonia.Atypical or absent radiologic findings commonly occur in in immunocompromised patients.Miliary tuberculosis may have the characteristic “millet seed” appearance. CT scans may identify abnormalities not yet visible on chest radiographs.
54Pulmonary histoplasmosis Most prevalent endemic mycosis in the United States. Most prevalent in the midwestern and central states along the Ohio and Mississippi River valleys.H. capsulatum proliferates best in soil contaminated with bird or bat droppings, favoring sporulation of the organism.Exposure include excavation, construction, demolition, remodeling, wood cutting and gathering, and exploring caves.Majority of cases- Lungs provide portal of entry. Cause a localized or patchy bronchopneumonia.Most common syndrome following infection- Asymptomatic pulmonary histoplasmosisSymptomatic pulmonary histoplasmosis- typically presents as a subacute pulmonary infection weeks to months following exposure-productive cough, dyspnea, chest pain, fatigue, fevers, and sweats andRadiographs typically show focal fibrotic apical infiltrates with cavitation and mediastinal or hilar lymphadenopathy.
55Following extensive exposure, - majority of patients develop acute diffuse pulmonary histoplasmosis within a week or two.Diffuse reticulonodular or miliary pulmonary infiltrates are noted and the disease can progress to respiratory failure or progressive extrapulmonary disseminationPatients with underlying lung disease are at risk for the development of chronic pulmonary infection following exposure .Shared similar findings as Sarcoidosis;Histoplasmosis must be excluded before treating patients with presumed sarcoidosis with immunosuppressive medicationsPositive fungal stains or cultures and detection of antigen in urine or serum support a diagnosis of active histoplasmosis rather than sarcoidosis.Elevated titers of antibodies to H. capsulatum do not exclude a diagnosis of sarcoidosis .
56BlastomycosisAspergillosisBlastomyces dermatitidis is a dimorphic fungus found primarily in the southeastern United States; around the Great Lakes.lungs are the most common site of infection, followed by the skin, bones, and genitourinary tract.C/F: Asymptyomatic in 50% cases, Acute or chronic pneumonia( Chronic more common)Extrapulmonary symptomsAcute PNA- resembles- viral or bacterial CAPChronic- cases- often mimic malignancy or TBAspergillus is a ubiquitous mold found in soil and other moist environments throughout the worldClassically, the diseases caused by Aspergillus species are:Allergic bronchopulmonary aspergillosis.Invasive aspergillosis,Aspergilloma (fungus ball).Risk factors- for invasive aspergillosisneutropenia, corticosteroid therapy, HSC /solid organ transplantation, advanced AIDS, and chronic granulomatous disease.Low grade fever, cough with productive sputum, chest pain, SOB, hemoptysis, with or w/o wt lossEP features- Skin- 2nd most common- verrucous or ulcerative lesions,SQ nodules, OM next commonABPA- is manifested by as persistent severe asthma, expectoration of brown sputum that contains Aspergillus organisms, pulmonary infiltrates, and fibrosis.Aspergilloma has been divided into chronic cavitary aspergillosis and single aspergilloma.
57Blastomycosis Aspergillosis Radiographic--Alveolar infiltrates with or without cavitation, mass lesions, and fibronodular infiltrates are most common . Tree in bud opacitiesMore common in upper lobes.Small pleural effusion or thickening common. No hilar LADCT scan- The “halo sign” (nodules bordered by a ground-glass attenuation) is the classic findingDx- Culture of specimenDirect visualization yeast form in clinical specimensDx- culture from BAL, transbronchial biopsy, needle aspiration, and VAT biopsy.A definitive diagnosis requires histologic demonstration of the organisms in tissue.If not possible- Fungal Ag assay in blood, CSF, or urineGalactomannan assays of blood or spinal fluid; and assays for (1-3)-β-D glucans.
58Cryptococcal infections Coccidioidimycosis Common opportunistic pathogen, associated mainly with HIV and, less frequently, transplantation.The lungs are the presumed portal of entry, and pulmonary disease is one of the most common manifestations.(CNS) disease may also occur.dimorphic fungus that lives in soil in parts of Arizona, California, New Mexico, west Texas, and parts of northern MexicoThe disease is transmitted through inhalation of the arthroconidia, which are formed from the mycelia in soilSubclinical primary infections are common and most are asymptomatic.Infection can persist in a latent state; if the host immune system becomes compromised organisms may be liberated from the granulomatous complexes and cause active infection.Symptomatic pulmonary cryptococcosiscan also occur in apparently immunocompetent patients.C/F - range from asymptomatic pneumonia to acute respiratory failure. The presentation of pulmonary cryptococcosis in patients with HIV is more acute and severe than in other hosts.More than 50% of all infections are subclinicalC/F- acute or subacute pneumonia, w/wo pleural effusions or empyema-Xray- of acute disease may show infiltrates; pleural effusions or empyema; and cavitary lesions.Xray- in chronic infections may show findings consistent with COPD, fibrosis, infiltrates and thin-walled cavities.
60Bronchial Carcinoid Tumors Low grade malignant neoplasm characterized by neuroendocrine differentiation and indolent clinical behavior1%-2% of all lung malignancies, 20% of all carcinoidsLung- 2nd most common site after GI tractTypical vs Atypical CarcinoidAverage age of onset of typical B Carcinoid-45 yearsAtypical carcinoid- appears approx 10 years later80% to 90% of tumors develop within a bronchus of subsegmental size or greater.10% to 20% of tumors are located in the pulmonary periphery.Atypical carcinoid tumors comprise about 10% of all pulmonary carcinoid tumors.endodermal origin, arising from stem cells of the bronchial epithelium known as Kulchitsky cells.
61Secrets biologically active peptides and hormones; serotonin, ACTH, ADH, melanocyte-stimulating hormone (MSH), and others.Excess serotonin production -Carcinoid syndrome. (constellation of symptoms, including tachycardia, flushing,bronchoconstriction, hemodynamic instability, diarrhea, and acidosis)Carcinoid syndrome much less frequent in pulmonary type than GI carcinoid. <2%.Cushing’s Syndrome: 1 to 2 percent of patients with bronchial carcinoid tumors and can be the initial reason for seeking medical attention. The onset is usually acute, and hypokalemia is often present.
62Clinical presentation: Most of them centrally-located tumor & are symptomatic from the tumor mass with coughing, hemoptysis, wheezing, or a recurrent postobstructive pneumonia.Peripheral lesions present most often as an asymptomatic solitary pulmonary nodule.Atypical carcinoids present more often with hilar or mediastinal nodal metastases and have a higher recurrence rate compared with typical carcinoids.Diagnosis: CT scan is the most useful imaging procedure,Generally confirmed either by bronchoscopic biopsy (for central lesions) or by transthoracic needle biopsy for peripheral lesions
63SarcoidosisMultisystem, granulomatous, inflammatory condition of unknown cause that occurs in young adults of both sexes.3-4 times more common in African American than White. 70%-90% of the cases occur years of ageRanges from asymptomatic to acute systemic presentations with fever, erythema nodosum, polyarthralgia, and hilar lymphadenopathy (Löfgren syndrome).90% of patients have pulmonary involvement at the time of presentation.Typical Xray findings- B/L hilar LAD, Reticular opacitiesCommonly involves the eyes and skin; the CNS, heart.GI tract are less commonly involved.HRCT is not required in most patients, but findings can be characteristic -a pattern of reticulonodular abnormalities in a central distribution along the bronchovascular lymphatic vessels associated with bilateral hilar and mediastinal lymphadenopathy.
64Diagnosis:Elevated angiotensin converting enzyme (ACE) level and hypercalciuria.Pulmonary function tests - demonstrate a restrictive defect with impaired gas exchange.Elevated CD4 to CD8 ratio may be detected by BAL.Noncaseating granulomas are the characteristic histopathologic abnormality.Classical Lofgren's syndrome and bilateral hilar LAD do not require biopsy .The diagnosis- requires compatible clinical and radiographic manifestations, exclusion of other diseases that may present similarly, and histopathologic detection of noncaseating granulomas
65Neurogenic tumors 19 to 39 percent of all mediastinal tumors Develop from mediastinal peripheral nerves, sympathetic and parasympathetic ganglia, and embryonic remnants of the neural tube.most frequent in the posterior compartment of the mediastinumBenign and malignant tumors of peripheral nerve origin can occurSchwannoma is the most common-affects patients of both sexes predominantly in the third and fourth decade of lifeBenign schwannomas are most often asymptomaticsigns of nerve compression and paralysis, Pancoast's syndrome, and Horner's syndrome can occur.CT reveals a round, well circumscribed mass located in the paravertebral region or intercostal spaces. Focal calcifications and cystic changes are frequent.A characteristic clinico-radiological aspect -extension through an intervertebral foramen, resulting in dumbbell-shaped tumors, and neurologic symptoms of spinal cord compression.
66Asbestos assciated Lung disease Risk factors- Cumulative exposure to the asbestos fiber.construction industry, the automotive servicing industry, and the shipbuilding and repair industryUnderlying factors- genetics, sex, ethnic origin, immune function, and fiber clearance.Pleural plaques- most common sequelae .are focal, often partially calcified, fibrous tissue collections on the parietal pleuraTypically develop bilaterally, with a latency of 10 to 20 years.Usually asymptomatic. Can be seen in CXR 50%-80% of timesDiffuse pleural thickening- more extensive fibrosis of the pleura .Obliterates the costophrenic angles. More likely to be associated with restrictive pulmonary physiology and may develop hypercapnic respiratory failure
67Rounded atelectasis-(Shrinking pleuritis, Blesovsky syndrome, and folded-lung syndrome) is the result of infolding of thickened visceral pleura with collapse of the adjacent peripheral lung.As single or multiple masses, which must be distinguished from a malignancy.The classic Xray finding is a “comet tail” on chest CT scan extending from the hilum toward the base of the lung and then sweeping into the inferior pole of the lesionBenign Pleural effusion:Asbestos-related pleural effusion is a diagnosis of exclusionMost patients are asymptomatic.Typically exudative and may be hemorrhagic.Asbestosis Strictly the term refers only to bilateral interstitial fibrosis of the lung parenchyma caused by inhalation of asbestos fibers.Asbestosis associated Lung Cancerwell establishedCigarette smoke and asbestos have a synergistic (multiplicative) effect