IPLab:Lab 1:Tuberculosis

Clinical Summary

This 70-year-old man was admitted to the hospital with a history of upper abdominal pain, anorexia, nausea, and general malaise, all of approximately three weeks' duration. His hospital stay was characterized by fever and severe respiratory distress. There were multiple densities in the patient's chest x-ray consistent with pneumonia and examination of a stained sputum specimen showed acid fast bacilli. Despite intensive therapy, the patient progressively deteriorated and died 14 days after admission.

Autopsy Findings

It was determined at autopsy that the patient suffered from pulmonary tuberculosis with widespread dissemination throughout the body. The left lung weighed 620 grams and the right lung 1230 grams. These were characterized by marked congestion and edema. In addition, multiple gray-white nodules ranging from pinpoint size up to 1 cm were diffusely distributed throughout the lung parenchyma.

Images

Error creating thumbnail: Unable to save thumbnail to destination	This is a gross photograph of a cut section of lung from this patient with disseminated tuberculosis. The numerous small white nodules scattered throughout this lung tissue represent individual tuberculosis granulomas. In addition, note the dark areas throughout the lung which represent deposits of anthracotic pigment.
Error creating thumbnail: Unable to save thumbnail to destination	This is a closer view of the same section of lung containing multiple white granulomas which are now more easily identified (arrows). These lesions are referred to as miliary tuberculosis. Dark areas of anthracosis are also prominent in this lung.
Error creating thumbnail: Unable to save thumbnail to destination	This gross photograph shows hilar lymph nodes from another patient with disseminated tuberculosis. The white, cheesy-appearing nodules (arrows) in the lymph nodes give rise to the descriptive terminology of caseous necrosis. The black pigment in the lymph nodes is anthracotic pigment that has drained from the lungs.
Error creating thumbnail: Unable to save thumbnail to destination	This is a low-power photomicrograph of a histology section from the lung of this patient with a chronic history of respiratory disease. Note the multiple eosinophilic nodules (arrows) seen at low power in this section. Other areas of the lung are relatively normal and several bronchi and large vessels can be seen at this low power. The pleural surface of the lung is at the left and the remaining edges are cut edges of the tissue block.
Error creating thumbnail: Unable to save thumbnail to destination	This higher-power photomicrograph of the eosinophilic nodules (arrows) illustrates their discreet nature and the surrounding inflammatory response in the remaining normal lung tissue.
Error creating thumbnail: Unable to save thumbnail to destination	This photomicrograph shows a single nodule with an amorphous eosinophilic center and accumulations of cells around the outer edge. This is typical of a granuloma associated with tuberculosis in which there is a necrotic center (1) and a rim of lymphocytes, macrophages, and occasional multinucleated giant cells around the periphery.
Error creating thumbnail: Unable to save thumbnail to destination	This is a higher-power view of the granuloma with the amorphous eosinophilic material representing caseation necrosis (1), giant cells near the center (2), and inflammatory cells around the periphery.
Error creating thumbnail: Unable to save thumbnail to destination	This is a high-power photomicrograph of the Langhans-type multinucleated giant cell which is characteristic of tuberculous granulomas (arrow). Note the horseshoe shape of the nuclei in this giant cell. The majority of the cells in the upper left portion of this section are macrophages which provide the major cellular component in a granuloma. Note the smaller number of small blue-staining cells in the peripheral portions of this granuloma to the left of which are lymphocytes.

Study Questions

• From where does the term caseous necrosis originate?

"Caseous" means "cheesy." Grossly, the lesions look white and cheesy.

• What makes up the caseous core of the lesion in this case?

Amorphous granular debris composed of fragmented, coagulated cells enclosed within a granuloma.

Additional Resources

Reference

• eMedicine Medical Library: Tuberculosis
• Merck Manual: Tuberculosis
• Centers for Disease Control: Tuberculosis

Journal Articles

• Lee MP, Chan JW, Ng KK, Li PC. Clinical manifestations of tuberculosis in HIV-infected patients. Respirology 2000 Dec;5(4):423-6.

Images

• PEIR Digital Library: Tuberculosis Images
• WebPath: Granulomatous Disease Images