A 62-year-old man worked most of his adult life in a metals foundry before becoming eligible for permanent disability three years ago due to extreme exertional dyspnea and PFT results that included an FEV1/FVC = 34% of predicted. He began smoking as a teenager and continued until his death last week from a heart attack. A 2-cm thick slice of his right middle lobe is shown on the right. What is the most likely diagnosis of his underlying pulmonary disease?
c. Centriacinar emphysema
The most correct answer is c, centriacinar emphysema.
The distribution of the dilated airspaces is a centrilobular distribution, which corresponds microscopically to a centriacinar distribution. Furthermore, this patient's history and PFT data are most consistent with a smoking-induced disability, which in his case may have had cardiovascular as well as pulmonary consequences. The absence of any remarkable cough or sputum production makes chronic bronchitis less a feature of his obstructive pattern (answer d), and thus bronchiectasis is also less likely to have developed (answer a). Foundry work is more often associated with metal toxicity than asthma (answer b). The gross appearance of his lung is not a convincing demonstration of the numerous bullae that are common in bullous emphysema (answer e).
This image of lung tissue was labeled, but its patient source has been misplaced. To which of the following cases does it most likely belong?
a. Postmortem tissue of a 10-year-old boy dying of status asthmaticus
b. Biopsy of a 45-year-old nonsmoking man with simple chronic bronchitis
c. Autopsy specimen of a 72-year-old woman dying with bronchiectasis
The most correct answer is a.
A 10-year-old child dying of status asthmaticus. The high-resolution CT and histopathology of this patient were evaluated by Dr. Silva and her colleagues in the Department of Radiology at Vancouver General Hospital (Am J Radiology. 2004;183:817-824. ©American Roentgen Ray Society). Using the thick segment of cartilage at right as a point of reference to identify a large bronchus (Chap. 2), the labeled image is noteworthy in showing impressive thickening of the basement membranes (opposing thin arrows), muscle layer hypertrophy (thick arrow), and a thick bronchial plug of mucus (asterisk). A patient with simple chronic bronchitis (answer b) would not likely have such an obstructive accumulation of airway mucus. Neither mucus plugging nor smooth muscle hyperplasia are consistent findings in patients dying with bronchiectasis (answer c).