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STUDENT DIGITAL NEWSLETTER ALAGAPPA INSTITUTIONS |
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William L. Ledger MA DPhil Oxon MB ChB FRCOG
Toward a Greener Anthrosphere through Industrial Ecology 299 and at the anode where electrons are removed spasms in stomach buy cheap baclofen 10 mg on-line, O2 is released as the water is oxidized: 2H2O O2 + 4H+ + 4e(11 spasms from sciatica cheap 25mg baclofen mastercard. At the cathode spasms lower stomach cheap baclofen 10 mg on-line, a dissolved chemical species could be reduced directly or the hydrogen generated could add to a species muscle relaxant pinched nerve buy generic baclofen 10 mg on line, reducing it. And at the anode another species could be oxidized directly by loss of electrons or the oxygen generated could add to a species, oxidizing it. Apparatus for electrolysis in which a direct current of electricity is passed through a reaction medium, in this case water with a dissolved salt to make it electrically conducting. Reduction occurs when electrons are added to the medium at the cathode and oxidation when they are removed at the anode. The dimethyl sulfate reagent used to accomplish the methylation poses toxicity problems in that it is a known primary carcinogen (a compound that does not require bioactivation to cause cancer). The methanol can be recirculated through the system to generate addional dimethyl carbonate reagent. Media Chemical reactions are often carried out in media, usually organic solvents or water. The major role of a solvent in chemical reactions is to provide a medium in which feedstocks and reagents can dissolve and come into close, rapid contact at the molecular level. Substances dissolved in a solvent are solvated by binding of the solvent to the molecules or ions of the dissolved substance, the solute. Because of its polar nature and the ability to form hydrogen bonds (see Chapter 7, Section 7. However, many organic feedstocks and reagents are not soluble in water or are decomposed by it, so organic solvents have to be used as reaction media. Many of the environmental and health problems associated with making chemicals are the result of the use of organic solvents as media. Although many hydrocarbon solvents are not particularly toxic, some can cause the condition of peripheral neuropathy mentioned in Section 11. Released to the atmosphere, hydrocarbons can also participate in photochemical processes leading to the formation of photochemical smog (see Chapter 8, Section 8. One approach to making chemical synthesis processes greener is to replace specific solvents with less hazardous ones. The methyl group in toluene can be acted upon by human metabolic systems to produce a harmless metabolite (hippuric Chap. As another example of solvent replacement, n-hexane, which can cause peripheral neuropathy in exposed individuals, can be replaced with 2,5-dimethylhexane, which does not cause this condition, for reactions where the higher boiling temperature of the latter compound is not a problem. H H H H H H H H C C C C C C C H H H H H H H H H Cl C C Cl Cl Heptane Trichloroethylene the greenest solvent is water, and significant effort has been made in replacing organic solvents used for reaction media with water. Although water does not appreciably dissolve many nonpolar organic compounds, in some cases these may be suspended as very small colloidal particles in water, enabling close enough contact of organic materials to undergo reactions. Water is a good solvent for some of the biological materials, such as glucose, now favored as chemical feedstocks where they can be used. Supercritical carbon dioxide is a good solvent for organic compounds and can be used as a reaction medium for organic chemical reactions. An advantage of supercritical carbon dioxide in this application is that its viscosity is only about 1/30 that of common liquid organic solvents, which enables reactant species to migrate much faster through the fluid, thus speeding the reactions that they undergo. At temperatures and pressures below, but near those at which carbon dioxide becomes critical, it exists as separate gas and liquid phases while retaining many of the solvent properties of supercritical carbon dioxide. Under these conditions carbon dioxide is called a dense phase fluid, a term that also encompasses supercritical fluids. Adjustment of the composition and conditions under which dense phase fluid carbon dioxide is maintained can provide significant variations in its solvent properties and adjustment of its ability to act as a reaction medium. In addition to variations in temperature and pressure, dense phase fluid carbon dioxide may be mixed with small quantities of other solvents, such as methanol, to further vary its solvent properties. In addition to its solvent properties, dense phase fluid carbon dioxide offers the advantage of low toxicity and low potential for environmental harm (the small amounts of greenhouse gas carbon dioxide released from its application as a solvent are negligible compared to quantities released from combustion of fossil fuels). A big advantage of dense phase fluid carbon dioxide is its volatility, meaning that it separates readily from reaction products when pressure is released. Furthermore, carbon dioxide released from 302Green Chemistry, 2nd ed a reaction mixture can be captured and recycled for the same application. Carbon dioxide can be obtained at low cost from biological fermentation processes. Ionicliquids present another alternative to organic solvents for use as media for chemical synthesis. Inorganic salts consisting of ions, such as NaCl composed of Na+ and Cl ions, are normally hard, high-boiling solids. However, when one or both of the ions are composed of large charged organic molecules, as shown by the cation in the example below, 1-Butyl-3-methylimidazolium hexafluorophosphate the salts can be liquids at room temperature and are called ionic liquids. These materials have the potential to act as suitable media in which substances can be dissolved and undergo reactions, and active research is underway to explore this possibility. There is an enormous variety of such ionic liquids with widely varying solvent properties because of the large number of kinds of ions that can be combined leading to almost limitless possibilities for various ionic liquids. The ultimate approach to eliminating problems with solvents in chemical synthesis is to do reactions without solvents of any kind. Some reactions can be performed in which the reactants are simply mixed together or are held on solid supports, such as clays. Microwave heating of such reaction mixtures has proven effective in providing energy to enable reactions to occur rapidly. F N + N H H H H F F H3C C C C C H P F F H H H H F Catalysts Recall from Chapter 4, Section 4. Large numbers of different catalysts are used in chemical processes and their potential toxicities, production of byproducts and contaminants, recycling, and disposal are matters of considerable importance in the chemical industry. Catalysts are divided into the two major categories of heterogeneous catalysts that are held upon some sort of support where they interact with reactants and homogeneous catalysts that are actually mixed with the reactants, often in solution in the media in which the reactions are carried out. Heterogeneous catalysts offer the advantage of being readily separated from reaction products, whereas homogeneous catalysts require measures such as distillation to remove them from the product. In many cases, however, homogeneous catalysts are much more effective in carrying out reactions. One of the objectives of green chemistry, therefore, has been to develop heterogeneous catalysts that equal homogeneous catalysts in their performance. An important area of endeavor in the development of improved catalysts with respect to green chemistry is selectivityenhancement. Basically, this means developing a catalyst that is very selective in what it does, ideally making the right product and nothing else. Toward a Greener Anthrosphere through Industrial Ecology 303 material (increased percent yield) and decreases the amount of waste byproducts from undesired side reactions. Another important attribute of a good catalyst is related to the basic way in which a catalyst works, which is by lowering the activation energy that is required to make a reaction proceed at a significant rate. As a consequence, catalysts lower the total amount of energy that must be put into a chemical process to get it to occur. Lowered energy requirements are a basic part of the practice of green chemistry and in this respect good catalysts can be extremely beneficial in lowering costs and environmental impact. In consideration of this fact, a great deal of attention is being devoted to using organisms, especially bacteria, to carry out chemical processes. By splicing desired genes for making specific enzymes into bacteria so that they will carry out desired reactions, genetic engineering has the potential of making an enormous contribution to the development of enzyme-catalyzed green chemical processes. Chemists are trying to use enzymes as models for synthetic catalysts that have performance characteristics of enzymes, but which are much simpler and work under conditions that would destroy enzymatic catalysts. A promising area in which this might be accomplished is the use of iron-containing catalysts to oxidize alkene (C=C) groups in organic compounds using relatively mild hydrogen peroxide reagent, H2O2. Organisms accomplish this task using catalysts in which the Fe2+ ion is bonded by four N atoms in relatively large heme porphyrin molecules. A big advantage of this catalyst that is shared with enzyme catalysts that enable peroxide oxidations is that it does not cause the decomposition of hydrogen peroxide as do a number of synthetic catalysts. Action of an iron-containing compound modelled after iron-based enzymes as a catalyst to bring about the oxidation of an alkene hydrocarbon group with hydrogen peroxide. Give the name of the processes to which materials and components are subjected in industrial ecosystems. What is the general pathway of materials through industrial systems as they currently operate Name the three kinds of analyses and three categories considered in a life-cycle assessment. What are the three kinds of products, classified in part on their amenability to recycling, that are normally considered in life-cycle assessments
It occurs more frequently in persons with blood group A muscle relaxant essential oils cheap baclofen 25mg visa, suggest ing a genetic predisposition gut spasms order baclofen 10 mg without prescription. This ulcerating adenocarcinoma of the stomach has no relationship to its benign counterpart back spasms 36 weeks pregnant generic baclofen 10mg otc, peptic ulcer of the stomach; however muscle relaxant adverse effects generic baclofen 10 mg line, clinical distinction is obviously crucial. Rolled elevated edges in the cancer are suggestive signs, but differentiation by biopsy is essential. Incidence of the disease is greatly increased in populations who eat large amounts of smoked fish and meat and pickled vegetables. Characteristics (1) Histologically, stomach carcinoma is almost always adenocarcinoma. The tumor cells often contain abundant mucin, displacing the nucleus to one side and resulting in so-called signet ring cells. Morphologic variants of stomach carcinoma (1) Intestinal type (a) Often, this variant is manifest as polypoid (fungating) carcinoma, which forms a solid mass projecting into the lumen of the stomach. Peptic ulcer usually exhibits a smooth base with nonelevated, punched-out margins. In contrast, carcinoma tends to form an ulcer with an irregular necrotic base and firm, raised margins. The stomach with stiff rigid walls caused by infiltrating tumor cells and extensive fibro sis has been referred to as a "leather-bottle stomach. Occurrence is most frequent in the first portion of the duodenum, the stomach, or the 2. Except for peptic ulcer of the stomach, peptic ulcer is always associated with hypersecre tion of gastric acid and pepsin. Frequency of occurrence is increased in persons of blood group 0, suggesting that genetic factors may play a role. Complications often include hemorrhage with melena (black stools containing blood). The ulcerogenic effect of these drugs may be medi ated by inhibition of prostaglandin synthesis. Zollinger-Ellison syndrome, increased tendency toward peptic ulcer formation, which is caused by gastric acid hypersecretion due to gastrin-secreting islet cell tumor of the pancreas. Recurrent peptic ulcer or peptic ulcer in aberrant sites, such as the jejunum is suggestive of the Zollinger-Ellison syndrome. This chronic inflammatory condition of unknown etiology may affect any part of the gastrointestinal tract but most commonly involves the distal ileocecum, small intes tine, or colon. Crohn disease tends to affect young people in the second and third decades of life, c. However, neoplastic transformation is much less frequent in Crohn disease than in ulcerative colitis. Submucosal edema with elevation of the surviving mucosa, producing a cobblestone appearance (Figure 15-3). Fistulas between loops of intestine and between the intestine, bladder, vagina, and skin C. Meckel diverticulum is a remnant of the embryonic vitelline duct and is located in the distal small bowel. The condition is usually asymptomatic but complications, including peptic ulceration in ectopic gastric mucosa with bleeding or perforation, may occur. Intussusception (invagination of a proximal segment of bowel into a more distal seg ment), causing bowel obstruction. Intussusception occurs more often without preex isting bowel pathology and is seen most often in infants and young children. Celiac disease is caused by sensitivity to gluten in cereal products (Figure 15-4). Clinical manifestations include weight loss, weakness, and diarrhea with pale, bulky, frothy, foul-smelling stools. Diagnosis involves documentation of malabsorption, small intestinal biopsy demon strating blunting of small intestinal villi, and clinical improvement and restoration of normal intestinal morphology on a gluten-free diet. This finding and the presence of antibodies directed against gliadin (a glycoprotein component of gluten) and transglutaminase suggest that both genetic and immune-mediated mechanisms may be involved. These antibody tests may also be used for screening prior to definitive diagnosis by biopsy. Blunting of the small intestinal villi and lympho cytic infiltration of the lamina propria are seen. Approximately 10%-15% of cases lead to small intestinal malignancy, most often enteropathy-type T-cell lymphoma. Other malabsorption syndromes include tropical sprue, Whipple disease, disaccharidase defiCiency, abetalipoproteinemia, and intestinal lymphangiectasia. Tumors of the small intestine make up a small percentage of gastrointestinal neoplasms. Carcinoid occurs most frequently in the appendix; it is localized to the small intestine in about 30% of cases. Although characteristically slow growing, the tumor is of low-grade malignancy; in contrast to other carcinoids, appendiceal carcinoid almost never metastasizes. Carcinoid, when metastatic to the liver can be manifest as the carcinoid syndrome; this syndrome is: (1) Caused by the elaboration of vasoactive peptides and amines, especially serotonin (2) Manifest clinically by: (a) Cutaneous flushing (b) Watery diarrhea and abdominal cramps (c) Bronchospasm (d) Valvular lesions of the right side of the heart 3. In spite of being rare, it is one of the most common primary malignant tumors of the small intestine. Hirschsprung disease (congenital megacolon) is dilation of the colon due to the absence of ganglion cells of the submucosal and myenteric neural plexuses; dilation is proximal to the aganglionic segment. Diverticula are pulsion (or false) diverticula (pockets of mucosa and submucosa herniated through the muscular layer) that most frequently involve the sigmoid colon. Diverticulosis is defined by the presence of multiple diverticula without inflammation. Complications may include perforation, peritonitis, abscess formation, or bowel stenosis. Presenting features may include lower abdominal pain and tenderness, fever, leuko cytosis, and other signs of acute inflammation. The cause is atherosclerotic occlusion of at least two of the major mesenteric vessels. Most often affected are the splenic flexure and the rectosigmoid junction, which lie in the relatively poorly vascularized regions (so-called watershed areas) between areas supplied by the superior mesenteric artery and the inferior mesenteric and internal iliac arteries. The result is mucosal, mural, or transmural infarction involving the wall of the intestine. Angiodysplasia Gastr o intestinalTract 227 is tortuous dilation of small vessels spanning the intestinal mucosa or submucosa. This condition is an extremely common cause of otherwise unexplained lower bowel 3. Characteristics (1) Mucosal inflammation and ulceration limited to the large intestine; the rectum is always affected but the entire colon may be involved. Inflammatory changes almost entirely confined to the mucosa and submucosa; the most characteristic feature is the crypt abscess, in which there are infiltrates of neutrophils in the crypts of Lieberkuhn. In contrast to Crohn disease, which can involve any part of the gastrointestinal tract, ulcerative colitis is limited to the colon. This condition is morphologically distinguished by superficial grayish mucosal exu dates consisting of necrotic, loosely adherent mucosal debris (pseudomembrane). Clinical characteristics include fever, toxicity, and diarrhea, most often occurring in patients on broad-spectrum antibiotic therapy. The cause is infection with Vibrio cholerae, a noninvasive toxin-producing bacterium. Characteristics include toxin-mediated loss of fluid and electrolytes with mucosa of the small bowel and colon remaining normal in appearance. Non-neoplastic polyps (1) Hyperplastic polyps can occur anywhere in the colon or small intestine. They have (2) Inflammatory polyps include benign lymphoid polyps and inflammatory pseudopolyps consisting of granulation tissue and remnants of mucosa, caused by chronic inflammatory bowel disease. Peutz-Jeghers polyps have no malignant potential themselves, but the syndrome is associated with increased propensity for adenocarcinoma of the colon (contrary to an older teaching) and malignancy at other sites, such as the stomach, breast, or ovaries. Adenomatous polyps are true neoplasms rather than benign proliferations of tissue. Tubular adenomas jiJ (1) these are the most common type (75%) of adenomatous polyp.
Drug-induced hemolytic anemias with IgG antibodies and complement-mediated cytotoxicity (or an autoantibody) implicated may occur after treatment with penicillins spasms in your back quality 10 mg baclofen, quinidine infantile spasms 9 months order baclofen 10 mg with mastercard, -methyldopa spasms just before sleep generic 10 mg baclofen with mastercard, and some cephalosporins spasms urethra purchase baclofen 25 mg free shipping. Deposition of immune complexes in tissues results in a tissue reaction initiated by complement activation that may lead to mast cell degranulation, leukocyte chemotaxis, and inflammation induced by the cell influx. For a description of the immunological events central to the mechanism of serum sickness, see Sect. As well as the most common cause of classical serum sickness reactions, namely equine antisera given as an antitoxin, other foreign proteins such as vaccines, anti-lymphocyte globulins, streptokinase, and hymenoptera venoms have also been implicated in reactions. Drugs can cause a reaction that is clinically similar to the protein-induced condition although nonprotein antigens generally do not induce the response. Lymphadenopathy is common and fever, one of the earliest signs of serum sickness, tends to persist throughout the illness. Note, however, that lymphadenopathy has not been reported in penicillin-induced serum sickness. Cutaneous symptoms occur in up to 95 % of patients with urticarial and morbilliform eruptions being the most common and erythema and petechiae sometimes appearing. Angioedema may be seen and arthritis or arthralgia and gastrointestinal symptoms of cramping, nausea, vomiting, or diarrhea occur in up to 67 % of patients. Joints (knee, ankle, shoulder, elbow, wrist, spine, jaw) may be severely affected; respiratory symptoms and splenomegaly occurs; and hepatomegaly, peripheral neuropathies, encephalomyelitis, and pericarditis have been reported. With few if any laboratory-detected changes to help with the diagnosis, serum sickness-like reactions, as with classic serum sickness, tend to be diagnosed clinically. Although the drug-induced reaction can be severe, most are mild and usually resolve spontaneously within a few days or weeks after discontinuing the drug. Serum sickness-like reactions are said to make up 4 % of all adverse drug reactions to amoxicillin. Rather, it is a number of related responses seen in a variety of reactions that may have beneficial or undesirable consequences for the host and which, at first sight, do not seem to have a lot in common except for their cellular immune base. A well-known example of allergic contact dermatitis is the reaction provoked by the lipid-soluble chemicals, mixed pentadecacatechols in urushiol oil present in plants of the Rhus genus, namely, poison ivy, poison oak, and poison sumac. The main features of the different categories in one such classification include: 1. Naturally, this heterogeneity affects the clinical picture and adds to the difficulties of the clinician in coming to a confident diagnostic conclusion. Delayed cutaneous hypersensitivity reactions to drugs generally begin from about 7 to 21 days after contact with the drug. Identification and specificity of the drug is established from oral challenge studies, patch tests, and intradermal tests read after a delay of at least 48 h. Different cell subsets with their individual profiles of cytokines and chemokines are associated with different skin hypersensitivity reactions although there is often overlapping cytokine involvement. Summarized descriptions of the most important immune-mediated delayed cutaneous adverse drug reactions follow. Contact dermatitis is the most common occupational disease although it should be remembered that not all contact dermatitis has an immune basis; some irritants such as detergents, solvents, acids, and alkalis may provoke irritant contact dermatitis. The reaction is generally confined to the contact site but generalized reactions may occur. Other skin sites may become involved by the patient touching other areas of skin after touching the worldclimbs@gmail. The skin may be red, swollen, and show blistering or be dry and bumpy but in the active stage, the skin usually shows redness, with raised areas and blisters. Ethnicity appears to be involved, for example, American blacks show a prevalence of only 0. As well as drugs, psoriasis may be triggered by smoking, alcohol, and withdrawal of systemic or topical corticosteroids. One study showed 23 % of patients were taking more than three medications and 11 % of these were taking more than ten medications. With kind permission from Springer Science+Business Media presentation of the disease is, typically, sharply demarcated erythematous papules and rounded plaques covered by silvery micaceous scales most commonly on the scalp, elbows, umbilicus, lumbar region, and knees. Lesions of psoriasis vulgaris may show small pustules but various forms of pustular psoriasis including generalized and localized variants have been described. Both the more common vulgar form and the pustular form may progress to psoriatic erythroderma affecting the whole body. Drugs can affect psoriasis in a number of ways-they may induce the disease, cause skin eruptions, induce lesions in previously unaffected skin in patients with psoriasis, and induce a form of psoriasis that is resistant to treatment. Drugs that provoke psoriasis can be divided into two categories-drugs that induce psoriasis but withdrawal of the drug stops further progression of the disease and drugs that aggravate psoriasis but the disease still progresses even after drug withdrawal. Lithium, -blockers, and synthetic antimalarials are the drugs most commonly mentioned in triggering or worsening psoriasis, but there are many other drugs that have been implicated either as inducers of the disease or for provoking eruptions. In the former case, the list includes acetazolamide, aminoglutethimide, amiodarone, amoxicillin, ampicillin, aspirin, chloroquine, cimetidine, corticosteroids, cyclosporin, diclofenac, diltiazem, hydroxychloroquine, indomethacin, lithium, methicillin, propranolol, and terbinafine. According to Litt (2006), there are at least 125 different drugs known to be responsible for the eruption or induction of psoriasis. The mechanism is currently believed to be by inhibition of the intracellular release of calcium as a result of lithium-induced worldclimbs@gmail. Supporting this is the beneficial effect of inositol supplementation in lithium-provoked psoriasis. The administration of the antimalarials chloroquine and hydroxychloroquine to patients with psoriasis is considered to be contraindicated by some. Exacerbation of psoriatic lesions and the induction of the disease have been found after use of these drugs and chloroquine has been implicated in resistance to treatment when given as an antimalarial. Clinical improvement is seen after withdrawal of -blockers in cases where the drugs have induced or exacerbated psoriasis. Although the treatment and management of drug reactions are beyond the scope of this book, it is worth noting that a number of biological agents are currently being used either in the clinic or experimentally to treat psoriasis. Clinical presentation is diverse and can vary from an erythematous rash mimicking a viral or bacterial exanthem to generalized symmetric eruptions of both isolated and confluent erythematous plaques. These often start on the trunk and then spread to the extremities and neck without involvement of the mucosa. The pink to red macules or papules tend to blanch when pressed and purple, non-blanchable spots (purpura) may appear on the lower legs. Reactions usually tend to progress over a few days before regressing over a 2-week period often with accompanying desquamation. Histologically, lymphocytes are seen in papillary dermis and at the junction of the dermis and epidermis while degenerated, necrotic and some dyskeratotic keratinocytes and spongiosis are visible in early lesions. Those commonly implicated are chiefly antibiotics, especially aminopenicillins. The incidence of the disease is said to be about three to five cases per million per year with a mortality rate of about 5 %. The patient had positive patch tests to amoxicillin and ampicillin and negative tests to benzylpenicillin, dicloxacillin, and a number of cephalosporins. With kind permission from Springer Science+Business Media and groin a few days after administration of the offending drug before becoming widespread. The patient experienced systemic symptoms, skin reactions with nonspecific maculopapular rash, and exfoliative dermatitis with facial edema (photograph courtesy of Dr.
Bronchogenic carcinoma is the leading cause of death from cancer in both men and women muscle relaxants sleep cheap baclofen 25mg otc. It is increasing in incidence muscle relaxant anesthesia discount 25mg baclofen with amex, especially in women spasms brain generic baclofen 25mg with mastercard, in parallel with cigarette smoking muscle relaxant drugs over the counter cheap 10mg baclofen with amex. Various histologic changes, including squamous metaplasia of the respiratory epithelium, often with atypical changes ranging from dysplasia to carcinoma in situ, precede bronchogenic carcinoma in cigarette smokers. Asbestos; increased incidence with asbestos and greater increase with combination d. Clinical manifestations may include cough, hemoptysis, and bronchial obstruction, often with atelectasis and pneumonitis. Other clinical features include: (1) Superior vena cava syndrome; compression or invasion of the superior vena cava, resulting in facial swelling and cyanosis along with dilation of the veins of the head, neck, and upper extremities (2) Pancoast tumor (superior sulcus tumor); involvement of the apex of the lung, often with Horner syndrome (ptosis, miosis, and anhidrosis); due to involvement of the cervical sympathetic plexus (3) Hoarseness from recurrent laryngeal nerve paralysis (4) Pleural effusion, often bloody; bloody pleural effusion suggests malignancy, tuber culosis, or trauma. Bronchogenic carcinoma is subclassified into squamous cell carcinoma, adenocarci noma (including bronchioloalveolar carcinoma), small cell carcinoma, and large cell carcinoma; it appears that all share a common endodermal origin despite their mor phologic differences. For therapeutic purposes, the bronchogenic carcinomas are often subclassified into small cell carcinoma, which is not considered amenable to surgery, and non-small cell carcinoma, in which surgical intervention may be considered. Clinicopathologic Foundations r Review Test Directions: Each of the numbered items or incomplete statements in this section is followeq by answers or by completions of the statement. A 3-year-old girl presents to the emer gency department with fever, hoarseness, a "seal bark-like" cough, and inspiratory stri dor. Her father states that she has had a cold for the past few days, with runny nose, nasal congestion, sore throat, and cough. Fungus Gram-negative bacteria (e) Gram-positive bacteria (D) Parasite (E) Virus the patient is diagnosed with chronic bronchitis. Bronchial smooth muscle hypertrophy with proliferation of eosinophils (8) Diffuse alveolar damage with leakage of protein-rich fluid into alveolar spaces (e) Dilation of air spaces with destruction of alveolar walls (D) Hyperplasia of bronchial mucus-secreting submucosal glands (E) Permanent bronchial dilation caused by chronic infection, with bronchi f illed with mucus and neutrophils (A) (A) (8) 2. Bronchial smooth muscle hypertrophy with proliferation of eosinophils (8) Diffuse alveolar damage with leakage of protein-rich fluid into alveolar spaces (e) Dilation of air spaces with destruction of alveolar walls (D) Hyperplasia of bronchial mucus-secreting submucosal glands (E) Permanent bronchial dilation causd by chronic infection, with bronchi filled with mucus and neutrophils 4. A 65-year-old woman with a significant smoking history presents with cough and shortness of breath. Computed tomography of the chest reveals a central mass near the left mainstem bronchus. Histologic examination reveals small round blue cells, and a diagnosis of small cell carcinoma is made. Generally amenable to surgical cure at time of diagnosis (8) More common in women, and a less clear relation to smoking than other forms of lung cancer (e) Secretes a parathyroid-like hormone (D) Secretes either corticotrophin or antidi uretic hormone (E) Usually in a peripheral rather than in a central location (A) (A) 3. A 60-year-old woman with a heavy smok ing history presents with chronic productive cough that has been present for 3 consecu tive months over the past 2 consecutive years. A 23-year-old man presents with radi ographic evidence of bilateral hilar lym phadenopathy and interstitial lung disease. Initially episodic, his "attacks" had increased in frequency and at the time of death had become continuous and intractable. At autopsy, which of the fol lowing is the most likely histologic finding in the lungs Bronchial smooth muscle hypertrophy with proliferation of eosinophils (B) Diffuse alveolar damage with leakage of protein-rich fluid into alveolar spaces (e) Dilation of air spaces with destruction of alveolar walls (0) Hyperplasia of bronchial mucus-secreting submucosal glands (E) Permanent bronchial dilation caused by chronic infection, with bronchi filled with mucus and neutrophils 6. An aO-year-old woman, a retirement home resident, has multiple bouts of pneu monia caused by Streptococcus pneumoniae. In an attempt to prevent such infections, polyvalent vaccines directed at multiple serotypes of the organism have been admin istered but have not elicited long-acting immunity. A 50-year-old man dies of a respiratory ill ness that had been characterized by dysp nea, cough, and wheezing expiration of (A) (A) 8. A 60-year-old man presents with fever and chills, productive cough with rusty sputum, pleuritic pain, and shortness of breath for the past several days. Acute respiratory distress syndrome Goodpasture syndrome Idiopathic pulmonary fibrosis (0) Idiopathic pulmonary hemosiderosis (E) Malignant mesothelioma of the pleura (A) (8) (C) 10. A 46-year-old woman presents with fever, hemoptysis, weight loss, and night sweats. This patient is put on contact precautions, and a regimen for tuberculosis is started. Acquired immunodeficiency syndrome Congenital immunodeficiency Miliary tuberculosis, with seeding of distal organs with innumerable small millet seed-like lesions (0) Primary tuberculosis, characterized by the Ghon complex (E) Secondary tuberculosis, resulting from activation of a prior Ghon complex, with spread to a new pulmonary site A 25-year-old African-American woman presents with fatigue, dyspnea, nonproduc tive cough, and chest pain. A chest radiograph reveals promi nent bilateral hilar lymphadenopathy ("potato nodules") and diffuse reticular densities in the interstitium of the lung. Laboratory studies reveal polyclonal hyper gammaglobulinemia, hypercalcemia, and increased serum angiotensin-converting enzyme. She is placed on a ventilator for assisted breathing, and a diagnosis of neonatal respiratory distress syndrome (hyaline membrane disease) is made. Bronchopulmonary dysplasia Intraventricular brain hemorrhage Lack of fetal pulmonary maturity and deficiency of surfactant (0) Necrotizing enterocolitis (E) Patent ductus arteriosus (A) (8) (C) (A) (8) (C) 11. A 5 0-year-old woman has been immobilized in bed for several days after a motor vehicle accident. She had been improviIlg, but this morning she suffered the sudden onset of pleuritic chest pain, hemoptysis, tachypnea, tachycardia, and dyspnea. The chest radiograph of a 23-year-old medical student reveals a calcified cavitary pulmonary lesion. The tuberculin test is pos itive, but sputum smears and cultures are negative for Mycobacterium tuberculosis. If further studies, including a biopsy, were performed, which of the (A) (B) Calcification Caseating granulomas (e) Cavitation (D) Langhans giant cells (E) Positive tuberculin test result Answers and Explanations 1. This is a classic case of acute laryngotracheobronchitis (croup), an acute inflammation of the larynx, trachea, and epiglottis. Due to the destruction of alveolar walls, a lack of elastic recoil causes air to become trapped in alveoli, and, thus, airflow obstruction occurs on expiration. The pathologic hallmark of chronic bronchitis is marked hyperplasia of bronchial submucosal glands and bronchial smooth muscle hypertrophy, which can be quantified by the Reid index, a ratio of glandular layer thickness to bronchial wall thickness. Small cell carcinoma of the lung is the most aggressive type of bron chogenic carcinoma. This is an undifferenti ated tumor with small round blue cells and is least likely to be cured by surgery because it is usually already metastatic at diagnosis. Associated paraneoplastic syndromes include secretion of adrenocorticotropic hormone and antidiuretic hormone. The illustration shows noncaseating granulomas and giant cells, which, in the clinical setting described, are diagnostic of sarcoidosis. A frequent abnormal labo ratory finding is polyclonal hypergammaglobulinemia along with hypercalcemia. Patients most often present with lung findings and hilar lymphadenopa thy, but any organ system can be involved. Antibody responses to the more than 80 differing carbohydrate capsular antigens of the various strains of Streptococcus pneumoniae are generally T-cell-independent, and antibody formation is entirely B-cell-mediated. Because of this, memory cells are not formed, and long-lasting immunity is not achieved. Bronchial asthma, or hyperreactive airway disease, is a type of chronic obstructive pulmonary disease caused by narrowing of airways. Asthma is manifest mor phologically by bronchial smooth muscle hypertrophy, hyperplasia of bronchial submu cosal glands and goblet cells, and airways plugged by mucus-containing Curschmann spirals (whorl-like accumulations of epithelial cells), eosinophils, and Charcot-Leyden crystals (crystalloids of eosinophil-derived proteins). Interstitial pneumonia is characterized by diffuse, patchy inflammation localized to the interstitial areas of alveolar walls, with no exudate in alveolar spaces, and intra-alveolar hyaline membranes. Pneumocystis jiroveci (carinii) pneumonia is the most common opportunistic infection in patients with acquired immunodeficiency syndrome or other immunodeficiency disorders. Viral pneumonias are the most common type of pneumonia in childhood, caused most commonly by the influenza virus. The organism is also known as the pneumococcus, and the disease entity is often 9. Tuberculosis, at one time a frequent hazard in the United States, is now relatively uncommon except in immunocompromised individuals and persons returning from parts of the world where the disease remains a common problem. Primary tubercu losis is the initial infection by Mycobacterium tuberculosis, and is restricted to the pri mary, or Ghon, complex, a combination of a peripheral subpleural parenchymal lesion and involved hilar lymph nodes. Cavitation and selective localization to the pulmonary apices are characteristics of secondary tuberculosis. Secondary tuberculosis may spread through the lymphatics and blood to other organs, resulting in miliary tuberculosis.
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