curs 1-2 - patologie respiratorie
TRANSCRIPT
8/16/2019 Curs 1-2 - Patologie Respiratorie
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Patologia aparatului respirator
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Structura normala• Plamanul drept – 3 lobi (450g); plamanul stang – 2 lobi
(400g);
• Traheea se ramifca in bronhiile principale dreapta sistanga; bronhia dreapta orientata mai ertical
• !e la bi"urcatia traheei si pana la cele mai mici bronhiiau loc # $ ramifcari
• %ronhiolele se diid de 3&4 pana la bronhiolele terminalecare au '2 mm in
• cinul pulmonar portiunea situata distal de bronhiolaterminala* cuprinde+
– 3&5 bronhiole respiratorii – ducte aleolare (fecare bronhiola respiratorie se diide in
catea ducte aleolare)
– saci aleolari (fecare duct aleolar se deschide in mai multisaci aleolari)
• ,obulul pulmonar & #5 acini -bronhiola terminala
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Structura normala
• Pl.m/nii au dublaasculariatie+ s/nge o1igenatdin arterele bronsice si sangeenos de la arterelepulmonare;
• Pl.m/nii au pe supra"atanumeroase lim"atice caredreneaa n ple1ul subpleural
• ,gg de la nielul hilului i cei
traheobronici primesc lim"asi o dreneaa n canalultoracic
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%ronhii & histologie• %ronhiile i subdiiiunile lor*
p/n. la bronhiole suntc.ptuite cu epiteliu cilindricciliat pseudostratifcat(epiteliului respirator) cestecelule sunt amestecate cucelule calici"orme secretoarede mucus care se reduc pemasura ce se apropie debronhiole
• ucoasa bronhiilor con6inenumeroase glande cu secretiede mucus i celuleneuroendocrine* omologecelulelor argentafne aletractului digesti
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%ronhiole & histologie
•%ronhiolele sunt c.ptuitede un epiteliu cilindricciliat pseudostratifcat darnu si de celule secretoarede mucus (spre deosebire
de bronhii* nu con6insecre6ie de mucus lasupra"a6.)
• 7le con6in celule 8lara
non&ciliate care secretaproteine bogate n lioimi 9g* dar* spre deosebirede aleole nu con6insur"actant
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Septurile aleolare• Peretii aleolari cuprind+
– capilare*
– tesut interstitial (cantitate : decolagen* fbroblaste* fbre elasticefne* celule musculare netede*catea mastocite si celulemononucleare)*
– epiteliul aleolar (2 tipuri de celule*
pneumocitele de tip 9*membranoase ce acopera # 5<din supra"ata aleolara sipneumocitele de tip 99* granulare*proemina in lumen si sunt acoperitede microili)*
– macro"agele aleolare se a=a atatlibere in spatiul aleolar cat siatasate de celulele aleolare*
– porii lui >ohn (locul cone1iunii dintrealeolele adiacente; permit trecereabacteriilor si a e1udatului);
• ?bs@ Pneumocitele de tip 99repreinta celulele de reera*
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9n"ectii pulmonare
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Pneumoniile
• %oli pulmonare in=amatorii acute* deetiologie in"ectioasa si nein"ectioasa(to1ica* prin iradiereA)* caracteriate prin
aleolita e1udatia B infltrat in=amatorinterstitial
• Pneumonia C in=amatie acuta aparenchimului pulmonar distal debronhiola terminala (bronhiolerespiratorii* ducte aleolare* sacialeolari)
• Termenul DconsolidareE este utiliat la
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Pneumoniile
• Comunitare (community acquired) – Tipice: Streptococcus pneumoniae
(pneumococ)*
– Atipice:• Gcoplasma pneumoniae
• irusuri+ in=uena* sincitial respirator
• 8hlamGdophila pneumoniae
• 8hlamGdophila psittaci• Chlamydia trachomatis
• Nosocomiale (hospital acquired)• Pseudomonas aeruginosa* >lebsiella
pneumoniae* Proteus* 7scherichia coli
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Patogenie
H spiratia secretiilor contaminate (de lanielul nao-oro"aringelui)
2 9nhalarea picaturilor in"ectate
3 Transmitere pe cale hematogena de laun "ocar in"ectios a=at la distanta
4 71tensia directa de la un procesin=amator acut al unui organ adiacent
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ecanisme de aparare
H Fe=e1ul de inchidere al corilorocale
2 Fe=e1ul de tuse
3 8learance&ul mucociliar
4 ctiitatea macro"agelor si sistemulimun
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Pneumonia Iranc ,obara
• !efnitie+ in=amatie acuta e1udatia cea"ecteaa+ – un lob pulmonar
– mai multi lobi pulmonari (rar)
– o portiune mare a unui lob (segment)
!istributia lobara depinde de irulenta
agentului etiologic si de ulnerabilitateagadei
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7tiologie+• Streptococcus pneumoniae (pneumococ)
– 0&5< ; Serotipul 3 are o capsuladeosebit de groasa si o agresiitate Jproducand pneumonii seere
• >lebsiella pneumoniae (≈ 5<) – mai"recent la pacienti cu !* %P?8*alcoolici
• ocaional+ StaphGlococus aureus – la pacienticonsumatori de droguri cu administrare 9K
Streptoccocus pGogenes
Laemophilus in=uenae
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8linic• Irison – este de obicei unic* dureaa 30&40 minute
• Iebra* 3&40M8• Nunghi toracic* intens* se accentuaa cu respiratia
sau tusea
• Tuse – initial uscata* iritatia* deine productia*cu sputa caracteristic ruginie si aderenta de as;uneori sputa poate deeni "ranc hemoptoica saupurulenta
•!ispnee• Lerpes
• Foseata partii superioare a obraului a=at departea pneumoniei
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71amen obiecti local&auscultatia
• !iminuarea miscarilor respiratorii;
• ccentuarea ibratiilor ocale;
• Faluri crepitante fne de inducere* apoi su=u tubar si ulterior in"aa de resorbtie →raluri crepitante de intoarcere mari si inegale
• ?%S@ Falurile sunt produse prin punerea in miscare a secretiilor
patologice din caile respiratorii de catre coloana de aer* de aceease modifca mult cu tusea
• Falurile crepitante (aleolare)+ – par secundar desprinderii e1udatului de pe peretii aleolari* in momentul
patrunderii aerului;
–Fepreinta o succesiune de gomote fne* cu caracter uscat* – Se aud numai in inspir
• Su=ul tubar patologic (in condensarile pulmonare) este intens&condensarile pulmonare transmit mai bine undele sonore & are otonalitate inalta si se aude atat in inspir cat si in e1pir; se asemanacu gomotul care se aude atunci cand se su=a aer printr&un tubrigid
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Pneumonie a1ilara ,S!
8ondensare pulmonara lobara –
opacitate omogena* delimitata desciuri-pleura* cu bronhograma aerica
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Stadiile Pneumoniei ,obare
H 8ongestie(prehepatiatie)
2 Lepatiatierosie
3 Lepatiatiecenusie
4 Feolutie
9n fecare stadiude eolutie inaleole e1istaproportii ariatede+
Iluid de edemLematii,eucocite
(neutrofle)Iibrina
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H Stadiul de congestie(prehepatiatie)• Macroscopic: ,ob pulmonar a"ectat+
Fosu Kolum marit
• Microscopic: Liperemie asculara O septuri aleolare ingrosate leolita seroasa (e1udat seros)
Iluid intraaleolar (lichid de edem) 8atea P Bacterii numeroase – coloratie Gram 8elule descuamate
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Pneumonie a1ilara ,S!
8ondensare pulmonara lobara –
opacitate omogena* delimitata desciuri-pleura* cu bronhograma aerica
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H Prehepatiatie(congestie)
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rosie
• Macroscopic:
,ob rosu* distinct* "erm* neaerat* deconsistenta J asemanatoare cu a fcatului(hepatiatie)
8repitatii absente
Se poate asocia cu pleureie fbrinoasa saufbrinopurulenta• Microscopic: Liperemie asculara O septuri aleolare
ingrosate leolita fbrinohematica (e1udat
fbrinohematic)ematii (e1traaarea hematiilor in spatiile
aleolare)
Iluid intraaleolar
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Lepatiatie rosie• Supra"ata de
sectiune aparenchimuluipulmonarcondensat
(indurat) este rosie
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Lepatiatie rosie
ta u e epat at e
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ta u e epat at ecenusie
• Macroscopic: ,ob brun&palid sau cenusiu&galbui* supra"ata de
sectiune uscata 8onsistenta "erma 8repitatii absente Iriabil
• Microscopic: Septuri aleolare pastrate Feducerea hiperemiei (capilare colabate datorita
e1udatului abundent) Al#eolita $"rinoleucocitara (e1udat
fbrinoleucocitar)!eintegrare masia a hematiilorIluid intraaleolarPMN in cantitate % (in di&' &ae de degradare)!i"rina
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Lepatiatie cenusie
• Supra"ata de
sectiune aparenchimuluipulmonarcondensat este
cenusie&galbuie
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Lepatiatie cenusie
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4 Feolutia
• Macroscopic:
,ob pulmonar aspectnormal
• Microscopic:
Predomina macro"agele(e1udatul aleolar estesupus digestieienimatice si este
indepartat de catremacro"agele aleolaresau prin mecanismul detuse)
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Pneumonie a1ilara ,S! in reolutie (stg)
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8omplicatii+
• ?rganiare (3<) – fbroare postpneumonica(carnifcare)
• Pleureie (5<) B aderente intre pleuraiscerala si cea parietala
• Septicemie
• 7mpiem pulmonar (H<) – puroi in caitateapleurala
• bces pulmonar (" rar)
Q 8omplicatii la distanta – artrita purulenta*
meningita* pericardita purulenta* endocardita
bacteriana
7 i l
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7mpiemul• cumulare de puroi
intr&o caitate naturala+ – 7mpiem pleural
(piotora1)
b l l
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bcesul pulmonar• A"cesul – in=amatie "ocala* circumscrisa;
lia tesuturilor si "ormarea unei caitati
umplute cu puroi• Se caracterieaa prin+
• predominanta in e1udat a P;
• preenta necroei (to1ine bacterieneRtulburari circulatorii – tromboaasculara* actiunea compresia aedemului in=amator)
• proteolia determinata de deenimele proteolitice eliminate deP&urile ii sau in curs dedeintegrare
• Puroiul& lichid ascos galben&erui-cenusiu*constituit din+
• P&uri care su"era modifcaridistrofce (distrofe grasa) si sedeintegreaa treptat Opiocite
• detritusuri tisulare
• microorganisme
% h i
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%ronhopneumonia• 9n=amatie acuta e1udatia
localiata in bronsiole si
aleolele adiacente ce seeidentiaa macroscopic prin"ocare nodulare de condensarepulmonara* cu distributieneregulata* a"ectand unul sau
mai multi lobi (multilobara*bilaterala* baala)
• ultiple "ocare diseminate*a=ate in stadii di"erite de
eolutie Dpolimorfsm leionalE
• 8on=uarea "ocarelorbronhopneumonice O aspectpseudolobar
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acroscopic+
• Iocare centrate de o bronsiola+ limite imprecisetalie ariabila ( pot sa atinga si 2&4 cm)consistenta crescuta
"riabilecrepitatii absenteculoare de la rosie&cenusie pana la galbenacontinut purulent la nielul bronsiolelor* ce se
elimina la comprimare (dopuri purulente)
• Iocarele %P se a=a in stadii di"erite deeolutie intre ele sau in aceeasi leiune
%ronhopneumonia spect
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%ronhopneumonia & spectacroscopic
Bronhopneumonia Pneumonia
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Bronhopneumonia Pneumonia
Localizare - frecvent bilaterala
- bazala (lobii inferiori)
arie larga, uneori este afectat intregul
lob
Cale de
transmitere
de la bronchiole spre
alveolele din vecinatate
atat prin alveolele (porii Kohn –
coneiuni interalveolare) cat si prin
bronsiolele
!tindereainfectiei
condensare (induratie)neuniforma
intregul lob devine condensat(indurat)
"usceptibilitate copii, varstnici adulti# caracteristic la alcoolici,
malnutriti,
$indecare organizare focala aplamanului prin fibroza
- tratament prompt%vindecare(restitutio ad integrum)
- organizarea eudatului %fibroza %cicatrice si disfunctie pulmonara
permanenta
&bservatii pacientii imobilizati%retentia
- frecvent se asociaza bacteriemia
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icroscopic
• 71udat purulent la niel bronsic (PJa=ate in di" stadii de degradare)
• odul peribronsic cu leiuni di"erite de lacentru spre peri"erie+
• leolita purulenta (leucocitara)• leolita fbrinoasa• leolita seroasa
• ,a peri"erie+• 7mfem
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3 Pneumonia interstitiala(pneumonia atipica primara)
• 9n=amatie acuta pulmonaracaracteriata prin infltrat in=amatorinterstitial (septurile aleolare) Ba"ectare aleolara
7tiologie
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7tiologie
• Kirusul sincitial respirator (FSK)
• Kirusul in=uena si %
• denoirusuri
•Kirusul rubeolei (pneumonia cu celulegigante; complicatiiOtraheobronsita)*aricelei
• 8Gtomegaloirus
• Lerpes irus
• Gcoplasma pneumoniae (copii* adultitineri)
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8linic
•insidios – "ebra* ce"alee* mialgii
•dupa catea ile tuse seaca* neproductiacu senatie de arsura retrosternala
Q %iologic – leucocitoa 'H5000-mmc
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Pneumonie interstitiala
9nfltrat interstitial C opacitati reticulo&nodulare localiate intr&un lob-di"ue
icroscopic+
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icroscopic+• Septuri aleolare ingrosate datorita
hiperemiei si infltratului in=amatorrepreentat de+ – ,im"ocite
– Listiocite
– Plasmocite (uneori)
• leole libere - cu un material eoinofl(ro) proteinaceu in ecinatatea septurilor
aleolare cu aspect de membrane hialine• odifcari reactie la nielul epiteliului
bronhiolelor si aleolelor care
proli"ereaa in preenta irusurilor (pot
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P i i t titi l
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Pneumonia interstitiala(micro)
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5 Tuberculoa pulmonara
$ iti
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e$nitie
• 9n=amatie cronica* proli"eratia*
granulomatoasa* specifca determinatade Gcobacterium tuberculosis (bacilul>och) si ocaional de bois*
a"ricanum* microti* pinnipedii si canettii
ermenii pot patrunde in organism pe
cale respiratorie (5< din cauri)*digestia (ingestie de lapte in"ectat* sputacontaminata& 4<) sau cutanata (prinsolutii de continuitate* aand caracterro"esional& H<
* id ti t l i ti l i
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*#identierea agentului etiologic
• Gcobacterium tuberculosis* agentul etiologic altuberculoei* este un bacil aerob* acid&alcoolo&reistent* cu multiplicare relati lenta* care estedistrus de raele ultraiolete
• 8oloratia iehl&eelsen O eidentiaaGcobacterium tuberculosis (bacilul >och)Obastonase subtiri* rosii* usor curbate* iolate sau
grupate in perechi sau grupuri• 9nsamantare pe mediu ,Uenstein& Nensen (V sapt)
• P8F (PolGmerase 8hain Feaction)
• iagnostic indirect
• diagnostic biologic prin e"ectuarea uneiintradermoreactii (9!F) cu utilitate diagnostica siepidemiologica
• Pentru realiarea 9!F se "oloseste tuberculina (dinpunct de edere imunologic este o sensitina) sauderiatul proteic purifcat (PP!) al acesteia
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Tu"erculoa: + &ae
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Tu"erculoa: + &ae
• T%8 primara – repreinta prima e1punere la bacilul>och (b>)
• T%8 secundara – cand organismul este deWasensibiliat prin e1punerea anterioara la b>
• Transmiterea tuberculoei se "ace predominant pecale aeriana
• Sursa de in"ectie este repreentata aproape e1cluside bolnaii cu tuberculoa pulmonara* in special de
cei cu microscopie poitia a sputei• !ensitatea surselor de in"ectie* precum si durata sigradul de intimitate al contactului cu acestea sunt"actorii determinanti ai riscului de in"ectie pentru
persoanele sanatoase
Tu"erculoa primara
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Tu"erculoa primara• ada nein"ectata R particule in"ectante cu T% O
distrugerea T% sau multiplicarea T% O "ocar
in=amator (prin atragerea de macro"age si monocite)denumit &ocar Gohn (H&H*5 cm)* situat cel mai "recentsubpleural in partea in"erioara a lobului superior saupartea superioara a lobului in"erior
• %acilii si antigenele eliberate de acestia sunt drenati de
catre macro"age prin asele lim"atice in lim"oganglioniisateliti* determinand aparitia lim&angitei siadenopatiei satelite'
• A&ectul primar* lim&angita si adenopatia satelita constituie comple,ul primar – comple, Ghon
• 7olutia "ocarului hon+ – 9nchistare prin fbroa* calcifcare* uneori osifcare – T%8 primara progresia in care "ocarele pulmonare
primare cresc rapid* erodeaa arborele bronsic si
determina leiuni satelite
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Tu"erculoa primara
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Tu"erculoa primara
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Tuberculoa
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Tuberculoa
!upa 2&4 sapt de la in"ectia
cu %>* apare o reactie dehipersensibilitate intariatade tip 9K* mediata celular* ceduce la "ormarea degranuloame cu necroacaeoasa centrala
ermenii pot patrunde inorganism pe cale+respiratorie (5< din cauri)*
digestia (ingestie de lapte
in"ectat& 4<* sputacontaminata)
cutanata (prin solutii decontinuitate* aand caracterpro"esional& H<)
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Tuberculoa secundara
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Tuberculoa secundara• 8and are loc
– reactiarea tuberculoei primare – rein"ectia unui indiid anterior e1pus
acroscopic+
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,eiunile nodulare (circumscrise)+
granulatiile miliare (H&2 mm)* boabe de mei nodulii simpli (0*5&3 cm) tuberculomul (5&H0 cm)* "ormatiune unica
(plaman* rinichi* fcat* creier)
,eiunile di"ue+ infltrat pulmonar (pneumonie T%8* %P T%8)
seroitele tbc (pleureie* pericardita* peritonita)
,eiunile alterati&ulceratie+ caerna
acroscopic+
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acroscopic
• 8aeumulul (material necrotic – necroade caeifcare) are un aspectcaracteristic
• 8aeumul recent este alb&galbui cuconsistenta branoasa – paracaeinatulde calciu; ulterior deine cenusiu aandconsistenta de creta
• 8on=uarea onelor de necroa caeoasasi eliminarea materialului necrotic (prinbronsii la niel pulmonar) conduce laa aritia ca#ernelor leiuni
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8aerna
• ,ocaliata pulmonar saue1trapulmonar
• Semnifca o aparare mai slaba a
organismului• 7olutie spre+
• inchistare (aparitia tesutului fbros la
peri"erie)• calcifcare* osifcare* remaniere
proli"eratia (tesut de granulatie
specifc) si ramolire (in=amatie
8aernele
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8aernelerecente
• eliminareacaeumului lichefatprintr&o bronhie de
drenaWOcaitatecaptusita intern dematerial galben&cenusiu si delimitata
la e1terior de peretefbros subtire
8aernele echi
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8aernele echi
• sunt localiate oriunde
• sunt mari* cu pereti curati* caurmare a eliminarii completea caeumului* traersate debride sau punti fbroase cecontin artere tromboate sau
ectaiate (microanerismeFassmussen* ce se pot rupecu producerea de hemoptiii"atale) si delimitate de pereti
grosi fbrosi• in Wurul caernelor se
produce o fbroapericaitara* asociata cufbroa peribronsica si
periasculara
Tuberculoa miliara& macroscopic
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p
• granulatii de 2&3 mm*comparate cu boabele de mei*
incolore* gri&opalin daca suntpriite la lupa* neregulatunghiulare; partea centrala areun aspect opac* galbui* datoritacaeumului
• granulatiile con=ueaa realiand"ormatiuni mai oluminoase
• a"ectare simetrica* bilaterala a
plamanilor B
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icroscopic+
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p• !oliculul TBC (-oster)• necroa de caei$care – necroa acidofla* anhista*
fn granulara in carepersista $"rele de reticulina
(impregnare argentica . negru) si $"releelastice (orceina .rosu/"run0 reorcina/&u,ina1eigert . #iolet); element patognomonicneobligatoriu
• celule gigante multinucleate 2anghans: celulemari (40&H50 Xm) cu citoplasma am"o"ila-eoino"ila*granulara in centrul celulei si nuclei dispusi laperi"erie aand pe sectiune aspect de potcoaa* cer*semicerc; sunt patognomonice* dar neobligatorii
• celulele epitelioide* dispuse in Wurul caeumului Bal celulelor ,anghans; sunt elemente patognomonicesi obligatorii; au citoplasma abundenta* palida* limiteneclar preciate si nuclei oalari sau alungiti (nucleu
inE piscot de sampanieE) cu marginatie cromatiniana
TBC ili
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TBC miliara
! li li TBC ( i )
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!oliculi TBC (micro)
id
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Sarcoidoa• boala sistemica de etiologie necunoscuta (%esnier – %oecY – Schaumann)
caracteriata prin preenta de granuloame noncaeoase in tesuturi siorgane
• Irecent diagnosticata inainte de 40 ani
• ranulomul noncaeos este alcatuit din+ celule gigante multinucleate*celule epitelioide* macro"age* lim"ocite Zi plasmocite
• !iagnosticul di"erential se "ace cu T%8 prin+ lipsa necroei de caeifcare*"oliculi bine indiidualiati "ara tendinta la con=uare* preen[a fbroei
• Felati caracteristica este preenta corpilor asteroii * incluiuni stelateinglobate in celulele gigante si corpilor Schaumann* "ormatiuni laminarealcatuite din proteine Zi calciu
• 0< din pacienti au a"ectare pulmonara; granuloamele se gasesc ininterstitiu
• 25< au leiuni cutanate
• 7ritemul nodos* leiune patognomonica in "orma acuta consta in aparitiaunor noduli de culoare rosie* proeminenti* durerosi * localiati pe "ataanterioara a membrelor in"erioare
Sarcoidoa –F\; pt dg 8T este mai
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Sarcoidoa F\; pt dg 8T este maiutila
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8 i t i i
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8orpi asteroii
8orpi Schaumann
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8orpi Schaumann
ti i
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ctinomicoa• in"ectie cu ctinomGces 9sraelii (bacterie flamentoasa* gram R*
anaeroba)a care se localieaa cu predilectie in regiuneacerico&"aciala* dar si in alte regiuni ale organismului (toracice*abdomen* pelis in particular asociat cu dispoitie decontraceptie intrauterine sau cicatrici apendiculare)
• 9n"ec[ia este endogena* bacilul find preent in =ora normala aoro"aringelui* aginei si tractului gastro&intestinal
• icroorganismul poate inada osul subiacent si ocaional poatedisemina hematogen in creier sau prin aspira[ie in plaman
• 8linic+
– tumeferea DlemnoasaE a regiunii cerico&"aciale – "ebra*
– :greutate*
– leucocitoa in sangele peri"eric*
– tuse si hemoptiie cand este implicat si pl.m/nul
i i
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icroscopic+
• granuloame ce contin incentru granule Dde sul"urE(colonia de actinomicete*care are aspectul de Dsoare
care ardeE)* inconWurata deneutrofle si fbrina
• coloniile de ctinomGces(ghemuri cu aspect
micelian dispuse radiar*care se termina la peri"erieprin dilatatii cu aspect demaciuca* intens eoinofle)la peri"erie numeroase P
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spergiloa
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spergiloa
• Produsa de spergillus"umigatus- alte tipuri inrudite
• 9n"ectie "ungica
• Sporii sunt preenti in aerulpe care il respiram* dar au opatogenitate :
• 8and reistenta organismuluieste : * cand e1ista a"ectiunipulmonare anterioare* alergii
• spergillus poate determinain"ectii care se pot preentasub "orma+
– spergiloa inaia – spergilom
– spergiloabronhopulmonara alergica
• Aspergiloa in#ai#a este intalnita la pacientiimunocompromisi si are o rata J a mortalitatii (25&
0<)• 7ste mai "recent intalnita in plamani* dar poate
disemina in S8* sinusuri* os* inima* rinichi* sange*ochi
• Iactori de risc+ pacienti tratati cu steroii* dupachimioterapie * stadiile tardie ale 9!SA
• Aspergilomul C masa "ungica intalnita in plamanulfbros sau intr&o caitate pulmonara pree1istenta(T%8* sarcoidoa* fbroa chistica)
• acroscopic+ "ormatiune rotunda* libera* maronie
• 8linic+ hemoptiie* redusa cantitati* dar cand estein cantitate J repreinta o urgenta medicala
• Paraclinic+
– F1 – 8T
– 8ultura din sputa
– %ronhoscopie - laaW bronsic
– !eterminarea c in ser
• icroscopic+ flamente groase* de 5&H0 Xm* septate*ramifcate dicotomic in unghi de 40^ $
L 7 PS
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L7 PS
$$
F?8?TT
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F?8?TT
$
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8riptococoa
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8riptococoa• gent etiologic+ 8rGptococcus neo"ormans
("ung)
• icroscopic+ "orma rotunda* 4&H0 Xm* se diideprin inmugurire* este inconWurat de o capsula
care apare ca un halou in col L7* dar secoloreaa cu mucicarmin in rosu stralucitor si cualbastru alcian in albastru deschis
• Pasarile* in special porumbeii* prin e1cremente
in"ectate pot f sursa de in"ectie* plamanul findprima localiare 9n"ectia pulmonara poate fasimptomatica 8and in"ectia disemineaa*poate produce meningita criptococcica
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8riptococoa pulmonara
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8riptococoa pulmonara
3
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Listoplasmoa
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Listoplasmoa• gent etiologic+ Listoplasma capsulatum ("ung)
• este mai "recenta in S`* de/a lungul raurilor ?hio* ississippisi St ,arence
• 7ndemicitatea este determinata de e1istenta conditiilor naturalepropice deoltarii "ungilor* care pre"era* in general* solul umed*mai ales cand acesta este "ertiliat cu guano (e,crementele
anumitor pasari – grauri si lilieci) !upa ce au crescut in sol* "ungiisporuleaa si produc conidii* care in cursul anumitor actiitati caregenereaa aerosoli pot f inhalate in plamani
• 7olutia in"ectiei cu Listoplasma depinde "oarte mult decantitatea de inocul patogen si de imunitatea organismului0
putand f asimptomatica* simptomatica cu indecare completa* sause poate cronicia* determinand complicatii pulmonare sau chiarsistemice aWoritatea adultilor din onele endemice suntseropoitii
• icroconidiile sunt sufcient de mici pentru a patrunde in aleoleprin inhalare si sunt trans"ormate aici in "orme inmugurite*determinand a aritia unei reactii ranulomatoase* care oate
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Listoplasmoa
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• 2a persoanele imunocompetente* e1puse la o cantitate marede conidii* simptomele sunt adesea reduse* simuland o stare
gripala cu &e"ra0 &risoane0 o"oseala0 tuse si dureretoracica* care se indeca "ara a necesita tratament specifcanti"ungic
• istoplasmoa diseminata poate include mani"estarigastrointestinale (hepatosplenomegalie si lim"adenopatie)*
complicate uneori cu abdomen acut chirurgical* suprarenaliene(proces granulomatos e1tensi ce poate determina insufcientahormonala)* ale sistemului neros central (meningita cronica*granuloame intracerebrale) sau endocardita cu egetatii mariPoate f a"ectata orice ona a tractului gastrointestinal* iar
leiunile ulceratie pot sugera macroscopic un proces tumoral ?caracteristica a bolii este ulcerul oroåian care poateproduce dis"agie* raguseala sau o leiune dureroasa la niellingual sau gingial ,eiunile cutanate (eritematoasemaculopapulare* purpurice) sunt rare si apar prin inoculare
directa intradermica
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L7 F?8?TT
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H0H
Listoplasmoa
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p
ranuloame ce preinta necroa de coagulare*macro"age cu X&organisme* tesut "ibros
H02
!g di"erentialistoplasma capsulatum Cryptococcus neo&ormans
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istoplasma capsulatum
• Listoplasma capsulatumeste un "ung dimor"* cepoate f identifcat prin
preenta hi"elor* care poartaatat spori mari cat si mici(microconidii)
• 9n pofda numelui sau*"ungul nu preinta capsula
Cryptococcus neo&ormans
8itomegaloirusul
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g(8K)
• 8K este un irus ! din grupul herpes&irusurilor (herpes 5)
• 8K se gaseste in+ sange* sali#a* lapte matern*secretie aginala* sperma* urina* tesuturi
• 8ai de transmitere+ – intrauterina* – postnatala*
• din salia* cel mai "recent• laptele mamei*• se1uala*• trans"uii de sange*• transplant medular
icroscopic+
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p
• in interstitiu infltrat in=amator "ormat dinmonocite
• ase hiperemice• caracterul de specifcitate al leiunii il repreinta
celula paraitata de 8K C celula mare* cu
nucleu mare* pleomor" datorita incluiei nucleareirale care masoara pana la 20m in diametru• incluia poate ocupa de din nucleu si este
inconWurata de un halou clar* bine demarcat demembrana nucleara care este net trasata
• preenta acestor modifcari a "ost comparata cuaspectul in ochi de bu"nitaE• in citoplasma apar si mici incluii
baofle-eoinofle de H&3 m
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%oli pulmonare obstructie cronice (%P?8)
%oli pulmonare obstructie cronice
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•8uprind 4 entitati caracteriate prindis"unctie entilatorie obstructia+
• Astmul "ronsic
• Bronsita cronica• *m$emul pulmonar
• Bronsiectaiile
?%S@ "ost inclusa in cadrul %P?8 si"ronsiolita – in=amatia bronhiilor micisi a bronhiolelor
A&ectiune Caracteristici patologice
b i i $ l l l l d
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stm bronsic ipertro$a celulelor musculare netedede la niel bronsic
iperplaia glandelor submucoase si acelulelor calici"orme8ai aeriene cu continut de mucus ascos3pirale Curschmann* eoinofle sicristale Charcot/2eyden
%ronsitacronica
iperplaia gl submucoase O%indicelui 4eid* raportul dintre grosimeastratului glandular si peretele bronsic
7mfempulmonarilatarea anormala
a spatiilor aerienedistal de bronsiola terminala* cudistrugerea peretilor aleolari: elasticitatii pulmonare
%ronsiectaia %ronhii anormal dilatate* pline cu
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stmul bronsic
stmul bronsic• !efnitie & boala cronica caract prin episoade recurente de
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p po"structie "ronsica paro,istica proocata de in5amatia si hiperreacti#itatea cailor aeriene la stimuli ariati
• boala in=amatorie cronica a cailor respiratorii distale("ronhii mici si "ronhiole cu diametrul6+ mm) carepreinta urmatoarele caracteristici clinico&"unctionale+
• clinic crie paro1istice de dispnee e1piratorie* tuse siheeing
• "unctional+ episoade de o"structie "ronsica di&ua*ariabila si reersibila determinata de triada+
– spasmul musculaturii "ronsice* edemul mucoasei sisecretia de mucus ascos si aderent* pe "ond dehiperreactiitate bronsica
– o"structia "ronsica O reducerea anormala a =u1ului deaer in caile respiratorii
– hiperreacti#itatea "ronsica (4B) C raspunsulbronhoconstrictor e1agerat la actiunea unor stimuli care
nu genereaa un raspuns patologic al cailor aeriene la
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Patogenea astmului bronsic• e1istenta unor interactiuni comple1e intre celulele
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e1istenta unor interactiuni comple1e intre celulelein=amatorii (mastocite* eoinofle* lim"ocite Th* neutrofle*macro"age) si celulele epiteliale de la nielul cailoraeriene
• eenimentul comun este actiarea-degranulareamastocitelor de la nielul interstitiului pulmonar*declansata prin mecanism 9g7&dependent (in astmul
e1trinsec) sau 9g7&independent (in astmul intrinsec) cu 2consecinte +
• a) reactia acuta (raspunsul imediat) & declansareacriei de astm "ronsic (o"structie re#ersi"ila)
!egranularea mastocitelor Oeliberare de histamine*leuYotriene* prostaglandine* platelet actiating "actor si"actori chemotactici pentru eoinofle si neutrofle 7"ectulacestor mediatori este "ronhoconstrictia* edemul*hipersecretia de mucus si acumularea de eoino$le
si neutro$le
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Astm "ronsic & tipuri*,trinsec(i )
7ntrinsec (non/
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(imun)
• copii si adulti tineri*• istoric "amilial
• antecedente clinice
alergice• alergeni
• teste cutanatepoitie
• niel seric crescut de9g7
• Iara emfemB
bronsita cronica
imun)
• adulti
• nu
• nu• nu
• nu
• nu• "recent %8 si
emfem
specte mor"ologice in astmul bronsic• M: plamani destinsi; pe
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supra"ata de sectiune dopuride mucus #ascos ce
determina ocluia bronhiilor sibronhiolelor
• μ: in mucus se identifcaspiralele Curschmann "ormate din epiteliul respirator
normal sau degenerat care"ormeaa beni rasucite; sputacontine numeroase eoinofle sicristale (diamond&shaped)deriate din eoinofle(cristalele Charcot-Leyden );
peretele bronsic are membranabaala ingrosata* edem insubmucoasa si infltratin=amator (lim"ocite*plasmocite si eoinofle)0
hiperplaia glandelor
ipertro$a celulelor muscularenetede "ronsice
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Mucus in lumenul"rosic
Cartila 8
7n$ltrat in5amator0 &rec#ente
stm bronsic e1trinseci fl
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& numeroase eoinofle
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*#olutia o"structiei in
astmul "ronsic
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%ronsita cronica
%ronsita cronica• e$nitie: in=amatie cronica a cailor respiratorii
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• e$nitie: in=amatie cronica a cailor respiratoriidistale si pro1imale* caracteriata prin tuse
cronica producti#a timp de 9 lunian* minimum + ani consecuti# si preenta dis&unctiei#entilatorii o"structi#e
• *tiologie:
– "umatul (a"ecteaa miscarile cililor* "unctiamacro"agelor* determina hipertrofa si hiperplaiaglandelor secretoare de mucus* determina obstructiacailor aeriene mici* stimuleaa agul determinand
bronhoconstrictie) – poluarea atmos"erica
– in"ectiile respiratorii repetate cu rinoirusuri
• ipersecretie de mucus datorata hiperplaiei
glandelor secretoare de mucus
inde1 Feid C raportul grosimii glandelor submucoase-grosimeatotala aperetelui bronsic ,a persoane normale 9Feid C 0*44R-&
0 0 iar la pacientii cu bronsita cronica 9F C 0 52R- 0 0$
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0*0* iar la pacientii cu bronsita cronica 9F C 0*52R-&0*0$
%ronsita cronica• M:
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M: – perete ingrosat* hiperemic* edematiat;
– in lumenul "ronhiilor si "ronhiolelorcontinut muco/purulent
• μ:
– hipertro$a si hiperplaia gl' secroare demucus din su"mucoasa "ronhiilor mari(care au cartilaW);
– epiteliul bronsic poate preenta metaplaie si
displaie; in$ltratul in5amator este redus sieste repreentat de lim&ocite;
– in caile aeriene mici lipsite de cartilaWOhiperplaia celulelor calici&orme ; $"roa
intraluminala si peri"ronsica
Clinic: <"lue "loater=• presiunea gaelor sanguine nu
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presiunea gaelor sanguine nupoate f mentinuta in limitenormale prin hiperentilatie
re=e1a si determina aparitiaprecoce a hipo1emiei si acianoei* respecti coloratiaalbastra a tegumentelor (DblueE)
• scaderea traaliului entilator
presupune scurtarea respiratiei• asoconstrictie pulmonara
re=e1a si hipertensiunepulmonara
• insufcienta cardiaca dreapta
(cord pulmonar cronicE) siedeme peri"erice (DbloaterE)
• policitemie
• degetele hipocratice
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7mfemul pulmonar
IiaoCbaZic.
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7tiologie• Iumatul (durata* nr
ti i- i) i hib
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tigari-i); inhibaactiunea al"aH&
antitripsinei• Poluarea
• Karsta (40 ani la"umatori)
• !efcitul de al"aH&antitripsina
• ?%S@ al"aH&antitripsina – proteinaprodusa de fcat*
proteWeaa structurileelastice aleplamanului de e"ecteleelastaei eliberata deneutrofle in timpul
in=amatiei
Patogenie
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• deechilibru ntre sistemul elastaa Ziantielastaa* prin+
• J actiita[ii elastaei (proteaee1tracelulare sau enime proteolitice)
eliberate de neutrofle n "ocarul in=amator• defcienta anti&elastaei (al"a H&
antitripsina* enima ce inhiba elastaa)
!efcienta poate f congenitala (7Pprecoce) sau dobandita ("umatori)
•
8linic+ <pin puDer=
i il i l i
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• Liperentilatie Ocoloratianormala a "aciesului (EpinYE)
• J traaliului entilator Odispneea marcata (DpuerE)
• hiperin=atia pulmonaraOEtoracele n butoiE
(oriontaliarea coastelor*marirea spatiilor intercostale)
• e1piratia prelungita cubuele protruionate producela nielul cailor respiratoriipro1imale o presiune cepreine colabarea cailorrespiratorii distale
Tipuri de emfem
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Tipuri de emfem
CP>?@?+/+E
• Centroacinar (pro,imalacinar)
• Panacinar•istal acinar
• *m$em neregulat
• Centroacinar (pro,imalacinar)
• Panacinar•istal acinar
• *m$em neregulat
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7mfem 8entroacinar• Cel mai &rec#ent tip
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• Cel mai &rec#ent tipde em$em
• Mai &rec#ent la F
• A&ecteaapredominant lo"ii
superiori• !actori &a#orianti:
&umatul si pra&ul demina
• A&ecteaa numai "ronsiolelerespiratorii
(portiunile centrale
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*m$emPanacinar•i&u
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•7ncepe in
lo"ii in&eriori0la persoanele#arstnice
•A&ectareacompleta alo"ululuirespirator (dela "ronsiolele
respiratorii laal#eole )
•Asociere cu
de$citul de
*m$em istalAcinar
• Pneumotora
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• Pneumotora, spontan la
adultii tineri
• HonelesuperioareI
marginiantpost
• Cea mairara &orma
de em$em
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!orme particulare de em$em (spatii aeriene dilatate numite impropriu emfem)
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• *m$emul compensator (hiperin=a[ie
compensatorie)+ supradistensia cailor aeriene* "aradistructia peretelui aleolar* cauata de arii decondensare pulmonara de ecinatate sau post&lobectomie
• *m$emul senil este supradistensia plamanului laarstnici* cu ↑Ф antero&posterior al cutiei toracice Zie1pansiunea secundara a plamanului Otorace inbutoi Pierderea tesutului elastic* subtierea si atrofa
ductelor aleolare si a aleolelor• *m$emul o"structi# este termenul utiliat cande1ista obstructia partiala a arborelui bronsic de catreun corp strain sau o tumora care se asociaa cu
supradistensia aleolelor din ecinatate
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%ronsiectaia
7ctasis Cdilatare
!efnitie* etiologie* clinic
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• e$nitie: dilatatia permanenta a bronhiilor si
bronhiolelor (2 mm in Ф) prin distructia cartila8ului sia tesutului elastic datorata in"ectiilor cronicenecrotiante
• *tiologie:
– bronsiectaie congenitala – de"ect de deoltare a sistemuluibronsic
– fbroa chistica
– in"ectii (tbc* adenoirusuri* staflococul auriu* Laemophilusin=uenae)
– obstructie bronsica (e1 corpi straini* tumori bronhopulmonare) – dischineia ciliara primara
• Clinic: bolnaii preinta tuse recurenta* hemoptiie* Zie1pectoratie cu sputa in"ectata
%ronsiectaia & macroscopic• !upa aspectul anatomo&patologic+
" hii dil i
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"ronhii dilatate0 cu secretiemucopurulenta ("recent localiare inambii lobii in"eriori )
– % cilindrice
– % aricoase ( cilindrice cu peretineregulati)
– % ampulare
– % sacci"orme
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icroscopic+
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•epiteliul "ronsic poate f normal*ulcerat sau metaplaiat scuamos
• peretele bronsic preinta in$ltratin5amator acut si cronic R distructiatesutului elastic si muscular → inlocuirea acestora prin fbroa
• pleura din ona a&ectata esteaderenta* pot e1ista beni de tesutfbros intre bronhie si pleura
%ronsiolita
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• !efnitie+ in=amatie a bronhiolelor*"recent intalnita la copii mici* bronhioleleacestora find inguste se obstrueaa usor(mucus si in=amatie)
• 7tiologie+ in"ectii irale (# 50< din ele sedatoreaa irusului sincitial respirator)
• Kindecare in _&H0 ile
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telectaia pulmonara
telectaia neonatala &totala
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totala
• ,a nou&nascutul mort• acroscopic+ plamani de olum
redus* de culoare iolacee*
consistenta crescuta* lipsiti decrepitatii
• icroscopic+ spatii aleolare mici
delimitate de un epiteliu cubic
!efnitie• Atelectaia primara C
e1pansiunea incompleta a
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p pplamanului sau a unei parti a
acestuia• Atelectaiasecundaracolapsulpulmonar C reducerea uneiarii pulmonare anterior aerata
si e1pansionata – !ebut in perioada
neonatala prin+
& defcit de sur"actant(sindromul de detresa
respiratorie)& obstructia cailor respiratorii
(aspiratie de sg-lichidamniotic)
– !ebut la adult prin+
telectaia de absorbtie (obstructieintrinseca)
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• ecanism+ obstructia bronsica intrinseca determina
absorbtia aerului din unitatile pulmonarecorespunatoare
• 8onsecinte+
– colaps aleolar
– retractia teritoriului pulmonar respecti si a onelor ecine – deplasarea inspiratorie a traheei si mediastinului de partea
a"ectata
• 8aue+
– cancer bronsic cu obstructie completa
– dopuri de mucus R secretii ascoase* corpi straini aspirati
– postinterentii chirurgicale* det de+
• – inhalarea de ?2 pur B resp super"* clinostatism
• –anesteice secr ascoase
telectaia de compresie(compresiune e1trinseca)
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• ecanism+compresiunea e1trinseca a uneiportiuni din plaman
• 8onsecinte+ – colaps aleolar
– deierea mediastinului de partea opusaplamanului a"ectat
• 8aue+
– colectii pleurale masie – pneumotora1
– masa tumorala pulmonara
distensia abdominala importanta
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Pneumoconioe
Pneumoconioele• Boli pro&esionale cauate de inhalarea
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pprelungita a pulberilor B substante olatile
din mediul ambiant (pneumoconioa –pneumo plaman* Yonis pra")
• !eoltarea acestor boli depinde de+
– 8antitatea de pulberi acumulata – !imensiunea si "orma particulelor (V&25X; H&5 X; '
HX)
– Solubilitatea si compoitia chimica
– !urata e1punerii – socierea cu "umatul sau alti iritanti
– 9munitatea gadei
– ecanismul de clearance muco ciliar
ntracoa•cumulare de pra" decarbune* accentuatade poluare si "umat
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•Se accentueaa cuarsta
•u este o boalapulmonara inadearatul sens alcuantului
•Pigment negru*"agocitat demacro"agele aleolare*
care se acumuleaa in
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Pneumoconioa minerilor din
minele de carbuneDmult pra" Zi puJina fbro.E
Pneumoconioa minerilor din minele de carbune
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•9nhalarea pra"ului de carbune carecontine carbon
• 2 categorii+
•Pneumoconioa minerilor din minele decarbune simpla (asimptomatica-cuminima dis&unctie pulmonara)
• Pneumoconioa minerilor din minele decarbune complicata C $"roa masi#aprogresi#a
Pneumoconioa minerilor din minele decarbune simpla (asimptomatica-cu
minima dis"unctie pulmonara)
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minima dis"unctie pulmonara)
• Macroscopic:
– macule decarbune '5mm
(H&2 mm) deculoare neagra*"recent in lobiisuperiori
• Microscopic:
– agregate de macro"age(ce contin pigment
negru) preente inaleole* in interstitiu si in Wurul bronhiolelorrespiratorii
– emfem "ocal→distensie R usoaradistructie a septuriloraleolare
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Pneumoconioa minerilor din minele decarbune
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Silicoa
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• pare la cei ce lucreaa in mina* lataietorii in piatra si la cei ceprelucreaa sticla
• Silicoa+ boala pulmonarafbronodulara produsa prin inhalareade pulberi de siliciu (Si?2)
• !eria din termenul latin sile1 (rocadura* cremene)
• 9n _5< din cauri se asociaa cu T%8
7tiopatogenie• Pulberile cu 5 sunt retinute de bariera
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Pulberile cu 5 sunt retinute de bariera
muco&ciliara* cele de H&5 aWung in aleole si ininterstitiul pulmonar
• Particulele de siliciu sunt "agocitate demacro"age si incorporate in "agoomi* ele
distrug membrana acuolei "agoomice sienimele lioomale se raspandesc incitoplasma macro"agului pe care odigeraOmoartea macro"agului OinterleuYina&H
care "aorieaa proli"erarea fbroblastica sisintea de colagen
• "ectarea macro"agelor initiaa un raspuns
in=amator mediat de enimele lioomale si de
acroscopic
d li ii
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• noduli cenusii&
negriciosi de H&5 mmlocaliati in lobiisuperiori* adeseacalcifcati
• noduli conglomerati de2& 4 cm in diametru*consistenta dura* deculoare cenusie
• ,im"ogangionii din hilulpulmonar au leiuniasemanatoare ("ermi*duri* gri* aspect uscat)
icroscopic• nodulul silicotic localiat in interstitiu* in
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apropierea "ronsiolei respiratorii* alcatuitdin+
• ona centrala areactia+ – particule re"ractile de siliciu
– colagen dispus in straturi concentrice; ulterior*hialiniare centrala si necroa centrala ischemica
• ona peri"erica reactia+ – macro"age* lim"ocite si fbroblaste
• in ariile subpleurale in Wurul nodulului silicotic Oone de emfem
• preenta nodulilor con=uenti (in stadii aansate)
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sbestoa
Dpu[in pra" Zi mult. fbro.E
sbestoa• sbestoa este o pneumoconioa colagena proocata de
inhalarea prelungita de fbrele de asbest (iolatii
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termice-igni"uge)
• As"estoa corpi as"estoici&eruginosi – fbre de asbestcu inelis proteinaceu bogat in fer (glicoproteina sihemosiderina) cu aspect de haltera; fbroa pulmonarainterstitiala di"ua se instaleaa predominant in lobii
in"eriori 7a este lineara* si nu nodulara ca in silicoa* sidetermina o ingrosare a septurilor interaleolare siinterlobulare
• !i"roa pleurala #iscerala– ingrosarea pleurei iscerale
• Placile pleurale $"rocalci$cate (leiuni "recenteasociate e1punerii la asbest) & ' Hcm* plane* "erme-dure*bine delimitate situate bilateral* mai "recent in partileposterolaterale ale pleurei parietale si pe supra"ata pleuraladia"ragmatica; X+ tesut colagenos hialiniat B calci"icat; in
general "ara corpi asbestoici in placile pleurale
Complicatii:•%ronsiectaii*
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*
•Pleureii seroase•8arcinoamebronhopulmonare;riscul J de 5\ lane"umatori si de #H0\ la "umatori•eotelioame;
asocierea cue1punerea laasbest preenta in
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sbestoa
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Al"astru dePrusia
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%erilioa• Pneumoconioa rara determinata de
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• Pneumoconioa rara determinata de
e1punerea la beriliu• 9ndustria nucleara si aerospatiala*
echipamente electronice* in industria
corpurilor de iluminat (becuri=uorescente)
• 71punere intensa* acutaOpneumonie
• 71punere cronicaOleiunigranulomatoase non&caeoaseasemanatoare celor din sarcoidoa
%erilioa acuta
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• 71punere intensa de durata scurta(2&4 saptamani)
• Pneumonie e1udatia chimica in care
aleolele sunt pline cu un =uid bogatin proteine cu "ormare de membranehialine
• 8linic+ dispnee durere substernala;eolutie "aorabila
%erilioa cronica
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• !upa e1punere indelungata (20 ani)• ranuloame noncaeoase dispuse di"u inparenchimul pulmonar* asemanatoare celor dinsarcoidoa
• ranuloamele contin celule gigante cu 3 tipuri deincluii+
• H cristale bire"ringente
• 2 corpi Schaumann
• 3 corpi asteroii stelati• ceste incluii sunt descrise si in granuloamele
din sarcoidoa
%erilioa
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%erilioa
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Sindromul de detresa respiratorie acuta(boala membranelor hialine)
%oala membranelor hialine• la nou&nascutii prematuri
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•Plamani colabati* deconsistenta "erma
• odifcari ischemice lanielul septurilor
aleolare* patrundereaproteinelor plasmatice(fbrinogen) in aleole→"ormarea membranelor
hialine alcatuite din fbrinasi resturi celularenecroate
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embrane hialine;Lplaia si Ltrofa pneumocitelor de tip 99
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8arcinomul pulmonar
!efnitie si clasifcare• Tumora maligna pulmonara cu origine la nielul epiteliului bronsic sau
aleolar
• 9n "unctie de localiare+
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• Central+ origine in bronhiole Hmm in diametru; se asociaa cu "umatul
• Peri&eric+ originea in parenchimul pulmonar* cai aeriene ' H mm indiametru; nu se asociaa cu "umatul
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L&plaia
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Iocarin=amator
L&plaia
pneumocitelor 99
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denocarcinom non&mucinos minim inai
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denocarcinoamele pulmonare inaie
• Tumori maligne epiteliale cu di"erentiere glandulara * cuproductie de mucina sau cu e1primarea marYerilor 9L8 pt
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pneumocite• u pattern de crestere ariabil+ acinar* papilar*
micropapilar* lepidic sau solid
• Pot f mucinoase sau nonmucinoase
• B3O "ormare de glande sau productie de mucina Oadenocarcinom
• Trebuie sa stabilim daca tumora este primara sausecundara (metastatica) O9L8* istoric
• 9L8+ TTIHR (ThGroid transcription "actor&H)* apsin R*• !eterminarea mutatiei genei 7IF (7pidermal rothIactor Feceptor) este importanta in tratament (raspuns"aorabil la terapia anti&7IF cu inhibitori tiroin&Yinaici(geftinib* erlotinib* a"atinib)
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acroscopic
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• oduli deculoare alb&cenusie* cufbroa centralaasociata cupigmentareantracotica si
aspect barcit*stafdit alpleurei din
denocarcinom lepidic-8arcinom bronhiolo&aleolar
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denocarcinomul lepidic• Proli"erare a pneumocitelor de tip 99 sau a celulelor
8lara de&a lungul supra"etei peretilor aleolari
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g p p
• !> cu pattern predominant lepidic atunci candcel putin un "ocar masoara 5mm in cea maimare dimensiune
• !g di"erential cu+ hiperplaia adenomatoida
atipica si cu adenocarcinomul minim inai• !> cu pattern predominant lepidic cand preinta+
– 9naia aselor lim"atice* sanguine* a pleurei
– ecroa tumorala
– 8omponenta inaia masoara 5 mm – Se e1tinde in spatiile aleolare din Wurul tumorii
denocarcinom acinar
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denocarcinom acinar• Proli"erarea de structuri glandulare delimitate
de celule tumorale;
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• 8elulele tumorale si lumenele glandulare potsa contina mucina
• spectul cribri"orm este considerat tot tipacinar* desi are un prognostic mai ne"aorabil
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denocarcinom micropapilarPapile mici* lipsite se a1 conWunctio&ascular*detasate-atasate de peretele aleolar
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!> papilar !>micropapilar
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denocarcinom solidPlaWe de celule poligonale; dg di" cu carcinomul scuamos si cucel cu celula mare;arYeri 9L8@
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denocarcinom solid*pseudoscuamos
TTI
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H R;pV3&
8oloratie
denocarcinomul mucinos inai
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spect galben&gelatinos;plamanul inlocuit de tumora
denocarcinomul coloid
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denocarcinomul "etal de grad scaut % de grad inalt
spect asemanator plamanului "etal (aspectpseudoglandular)
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denocarcinom entericStructurile glandulare tumolare sunt asemanatoare cu celecolo&rectale
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Iactori de prognostic
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• Prognostic ne"aorabil+• Tumorile 2*5 cm*
• Subtipurile histologice micropapilar si
solid
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8arcinomul scuamospulmonar
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8arcinomul scuamos
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!actori de risc:•Iumatul & J de H0 \ riscul de a de un cancer pulmonar; 40 tigari-i timp de20 ani OJ riscul de V0&_0\; dupa H0 ani de abstinenta riscul :•Poluare•Iactori ocupationali+ a"est* radiatii* beriliu* nichel•
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acroscopic• pare in bronhiile principale sau
in unul din segmentele sale(centralC la nielul hilului)
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• Tumora incepe ca o onarugoasa micape mucoasa bronsica labi"urca6ie Pe masura ce tumorase mareste* mucoasa bronic.
se ingroasa O aspect nodular Bsupra"ata ulcerata IuionareanodulilorO o masa s"erica"riabila* de H&5 cm ce ingusteaai determina ocluia lumenului
• Pe supra"ata de sectiune tumoraeste alb&galbuie* cu "ocare denecroa si hemoragie care potproduce leiuni caitare
8arcinomul scuamos (macroscopic)
• Central (asociat cu o
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bronhie)• Poate atinge dimensiuni
mari
• Poate inada
mediastinulOcompresiasi-sau inaia K8SOsindrom de K8S (apare prin
extinderea mediastinala a
procesli tmoral! pacientiipre"inta ce#alee, verti$, ciano"a
#aciala, edem al #etei, distensia
venelor capli, %atli si
membrelor sperioare) Sindrom de
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icroscopic – carcinomul scuamos Yeratiniant•Perlele de Yeratina (orto& si para&)
•Punti intercelulare
•>eratiniarea indiiduala a celulelor
•8elule scuamoase cu pleomorfsmnuclear
aWoritatea carcinoamelorscuamoase inaie suntmoderat spre slabdi"erentiate;
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•Preenta de mitoe tipice si atipice
•rii centrale de necoa
•one de hemoragie
•9L8+ pV3R* p40R* 8>5-VR* TTIH&
H & 20< Yeratiniare2& '20< Yeratiniare3 – Yeratiniare indiiduala
8arcinom scuamos neYeratiniant
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P?;
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8arcinom scuamos baaloid
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p?
;
8arcinomul cu celula mica (in bob de oa)• Central
• sociat cu "umatul
• Tumora epiteliala maligna cu
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punct de plecare celulele>ulchitYG apartinandsistemului neuroendocrindi"u P`!
• Irecent asociat cu productiaectopica de hormoni(pacientii pot preenta sdr'Cushing datorita secretiei
unei substante ACT/liYesau hipersecreJiei de A prin secretia hormonuluiantidiuretic sau natriureticatrial)
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8arcinom pulmonar cu celula mica(small cell carcinoma)
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CE@
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71tindere• 9naia structurilor adiacente ; metastae pe cale lim"atica si
hematogena
• >' in#aia prin peretele "ronhiei cu distrugerea si
inlocuirea tesutului pulmonar peribronsic Se e1tinde spre
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inlocuirea tesutului pulmonar peribronsic Se e1tinde sprebronhia opusa aWunge in caitatea pleurala* in pericard si de&a lungul aselor determinand constrictia acestora 71tensiatumorii localiata la ape1ul pulmonar in caitatea toracicapoate a"ecta ple,ul "rahial si lantul simpatic
determinand durere si tulburari senoriale O sindromulPancoast
• +' e,tensia pe cale lim&atica: initial sunt a"ectatilim"oganglionii lim"atici de la nielul hilului; ulteriormetastaele apar in lgg mediastinali* cericali*supraclaiculari si para&aortici 9naia ductului toracicproduce ascita chiloasa
• 9' e,tensia pe cale hematogena: fcat* suprarenale* oase*pancreas* creier* plamanul opus* rinichi* tiroida
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8arcinoidtipic
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,eiuni pleurale
Fearsate pleurale non&in=amatorii
• Lidrotora1 – transudat in caitatea pleurala(insufcienta cardiaca renala ciro a) lichid
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(insufcienta cardiaca* renala* ciroa) ; lichidclar* cu densitate 'H0H2* proteine H gm-dl*rare celule; '300 mlO"ara semne si
simptome• Lemotora1 – sange in caitatea pleurala
traumatisme* anerism de o rupt; eacuarerapida pt a se eita coagularea sangelui
• 8hilotora1 – lim"a in caitatea pleurala;ruptura- obstructia ductului toracic* lichid cuaspect laptos
9n=amatii
•71udat
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71udat – seros O pleureie seroasa
– fbrinos O pleureie fbrinoasa
– serofbrinos O pleureie serofbrinoasa
– purulent O pleureie supuratia(empiem-piotora1)
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7mpiem
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Pneumotora1ul
•!efnitie+ preenta aerului sau a altori l l l
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!efnitie+ preenta aerului sau a altorgae in sacul pleural
• Spontan
• Traumatic• 9atrogen
• ,a pacientii entilati mecanic
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