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PATH 417 Case 3: From India to Canada The Body System Summary By: Sunny Chen Signs and Symptoms • Signs-objective characteristics detected by the physician – Recognition of crackles in the right lung upon auscultation – Recognition of the decreased breath sounds in the right lower lung field upon auscultation – Measured body temperature of 38.5°C (fever) – Chronic productive cough (if observed by the physician) Signs and Symptoms • Symptoms-characteristics experienced by the patient – Chills – Night sweats – Fever – Chronic productive cough Signs and Symptoms Conclusion and Additional Info • Possible causative agents: – Streptococcus pneumoniae (pneumococcal disease) – Mycobacterium tuberculosis (tuberculosis) • Most likely causative agent provided immigration history: – Mycobacterium tuberculosis Streptococcus pneumoniae Mycobacterium tuberculosis Signs and Symptoms Conclusion and Additional Info • Other symptoms of pneumococcal disease: – Chest pain when breathing – Shortness of breath – Drowsiness and confusion (commonly within the elderly) • Other signs of pneumococcal disease: – – – – “Rusty” blood-stained sputum Diarrhea Nausea Vomiting • Additional symptoms of active tuberculosis: – Coughing up blood – Unintentional weight loss – Loss of appetite The Affected Body System Overview • The respiratory system is likely affected • Specific areas include: – – – – – – – – – – – – nose mouth nasal cavity oral cavity sinuses pharynx larynx trachea bronchi bronchioles alveoli lungs The Affected Body System- Normal Physiological Functions of Nose, Mouth, Nasal cavity & Oral cavity • • • • • Nose & mouth: primary external openings where oxygen (O2) is inhaled and carbon dioxide (CO2) is exhaled Nose: primary respiratory pathway Nasal cavity: a humidifier for incoming air Mouth & oral cavity: provide a passageway for gas exchange – mouth doesn’t moisturize the incoming air – oral cavity lacks fine hair and mucosal lining to provide much immune protection Cilia and mucous found in the nasal cavity all the way to the bronchioles: serve as a part of the first line of defense in the immune response to trap debris and foreign organisms The Affected Body System- Normal Physiological Functions of Pharynx, Larynx, Trachea • Pharynx (throat): acts a tunnel to transport air from the nasal and oral cavities to the lungs; – • The end of the pharynx is divided into the trachea and esophagus by the epiglottis (a cartilage) – • it can move to cover the esophagus or trachea based on whether it is inhaled air or swallowed food The larynx (aka voice box, i.e. to create sound): connects the laryngopharynx (hypopharynx) with the trachea – • divided into 3 regions: the nasopharynx, oropharynx, and laryngopharynx (hypopharynx) where air passes in order of listed made up of cartilage that may enlarge during puberty (for males) The trachea: an U-shaped cartilaginous tube – – connects the larynx to the lungs constantly kept open by a ring of cartilage to provide a clear pathway for air to enter and exit the lungs The Affected Body System- Normal Physiological Functions of Bronchi, Bronchioles, Alveoli (Part 1) • Bronchi- divided into three subdivisions: – – – – • primary bronchi secondary bronchi tertiary bronchi each has different structural characteristics Primary bronchi: bronchial tube connected to the trachea; divided into the left and right branches • The right bronchus: – – slightly larger than the left bronchus place most foreign bodies reside • Structural characteristic: have C-shaped cartilage that keep the airway open • Secondary bronchi: connected each of the primary bronchi to the left and right side of the lung, respectively • supply air to the two left lobes and three right lobes of the lungs The Affected Body System- Normal Physiological Functions of Bronchi, Bronchioles, Alveoli (Part 2) • Tertiary bronchi: branch off from secondary bronchi (and subsequently bronchioles) – • Bronchioles do not have any cartilage, only smooth muscles and elastin proteins – produce very little mucus in order to keep the pathway clear • smooth muscles help regulate the airflow by: – relaxing to dilate the bronchi and bronchioles during events requiring more airflow – contracting during rest to prevent hyperventilation • aid in the immune response by using their cilia and mucosal lining to trap airborne contaminants Secondary/Tertiary bronchi structural characteristic: cartilage spread throughout and more smooth muscles for more flexibility The Affected Body System- Normal Physiological Functions of Bronchi, Bronchioles, Alveoli (Part 3) • Alveoli: sac-like structures located at the terminal ends of bronchioles – only have squamous epithelial cells to allow the exchange of gases with the blood passing through the capillaries – two types of alveolar cells: • Type I pneumocyte(alveolar cell) – facilitates gas exchange between alveoli and blood • Type II pneumocyte (alveolar cell) – responsible for surfactant(contain Lamellar bodies) secretion to keep the alveoli open The Affected Body System- Normal Physiological Functions of Bronchi, Bronchioles, Alveoli (Part 4) • Exchange of gases: occur between the alveoli and blood in the capillaries – Due to pressure difference – the incoming oxygen has higher partial pressure than the outgoing carbon dioxide, causing the gases to passively diffuse from high to low in their pressure gradients The Affected Body System- Normal Physiological Functions of Lungs • • • spongy and surrounded by a pliable membrane that allows them to expand with air asymmetrical – left lung has two lobes due to its proximity to the heart and the right lung has three lobes muscles surrounding the lungs to aid in inhalation and exhalation – inhalation: the pressure in the lungs increases as it fills with air until it matches the external pressure – exhalation: the diaphragm and external intercostal muscles relax while the internal intercostal muscles contract to reduce lung volume and pressure within the lungs The Affected Body System- Normal Physiological Functions of Diaphragm • • • a membranous muscle that separates the abdominal cavity from the chest cavity responsible for respiration by expanding and contracting the lungs under stress and/or respiratory conditions: muscle can spasm, causing hiccups, hyperventilation and coughing Normal Physiological Functioning Disturbance • Similar disturbances in both cases (i.e. pneumococcal disease and tuberculosis): – ventilation inhibition (decrease in ventilation) – varying levels of pulmonary edema (decrease in respiration in lungs) – pleural effusion (build up of fluid in lungs) – inflammation and damage of the lung tissues Normal Physiological Functioning Disturbance-S. pneumoniae • invasion and overgrowth of the microorganism in the host’s lung parenchyma • the normal physiological functions of the respiratory system are disturbed by: – the bacteria’s cytotoxicity – damage from the host immune response Normal Physiological Functioning Disturbance-S. pneumoniae – inflammation causes damage to the lung tissue – an accumulation of fluid in the alveoli, lead to pulmonary edema • • thickens the blood-air barrier which impairs the process of gas exchange leading to decreased oxygenation of the blood impairing pulmonary ventilation by limiting the expansion of the lungs – inflammatory response thicken the walls of the lungs and bronchial tubes causing hypoxemic respiratory failure through bronchoconstriction and limiting – the combination of the acute inflammatory response, fluid accumulation, and fibrosis of the lung tissues make it difficult for the patient to breath and carry out efficient respiration Normal Physiological Functioning Disturbance-M. tuberculosis • respiring zone of the lung consisting of the alveoli is infected • normal function that’s disrupted: – inhalation and exhalation – normal gas exchange activity • secretion of too much mucus, fluid due to immune responses – destruction of a patent vessel located in the wall of the cavity – the rupture of a dilate vessels • difficulty in breath and other complications – inflamed parenchyma causes pleuritic chest pain and extensive disease Secondary Infections • Both S.pneumoniae and M.tuberculosis can establish secondary infections at other areas of the body • Our patient in this case doesn’t show any signs/symptoms of secondary infections Secondary Infections- S.pneumoniae • Once bacteria have successfully spread to the lower respiratory system, they’re capable to travel to other areas of the body via: – host’s circulatory system • Pathogen infects the mucosal epithelium of the lower respiratory tract vascularized with blood capillaries (bacteria translocate into the blood)pathogen can now easily travel to other areas of the body – Various bacterial components allow the pathogen to survive in the blood • capsular polysaccharides – inhibit complement protein binding, prevent phagocytosis • protease produced – capable of cleaving antibodies against the pathogen Secondary Infections- S.pneumoniae • The pathogen can affect these other parts of the body : – Using the same bacterial invasion and infection techniques – Cell wall proteins are important for the attachment and initiation of infection – Triggering of inflammation • Autolysins proteins autolysisrelease of bacterial componentinflammationdamage to the tissue of the secondary site of inflammation • Pneumolysins also trigger release of pro-inflammatory cytokines – Have an important role in developing meningitis Secondary Infection (Meningitis)S.pneumoniae • • • Most severe case of secondary infection due to S. pneumoniae Inflammation of the membrane surrounding the brain and spinal cord If no treatment, can lead to serious long-term consequences – • Bacteria reaches the CNS via: – • e.g. Deafness, Epilepsy, Hydrocephalus, Cognitive deficits travelling in the bloodcrossing the blood brain barrier (crossing via attachment to the endothelial cells) infect the brain membraneactivates the Platelet-activating factorthis factor binds to bacterial phosphorylcholine (on cell wall)induce inflammation response to the surrounding membrane of the brain and spinal cord (recall PAMP recognized by PRR) Damage associated with the host responses that antagonize the pathogen (e.g. antimicrobial peptides, reactive oxygen species and proteases) damage of brain endothelial tissues severe brain damage Other Secondary Infections associated with S.pneumoniae Infection Site Heart Infection leads to endocarditis where the inner layer of the heart becomes inflamed Blood Infection can result in septic shock and the spread of bacteria to other areas of the body Soft tissues Myositis (inflammation of the muscles) Joints and Bones Osteomyelitis (inflammation of the bone marrow and septic arthritis in the inflammation of the joints) Peritoneum Results in peritonitis (an infection of the thin tissue which lines the walls of the abdomen ) Sinuses Infection of the sinuses Ear Otitis media (infection of the ears) Inflammation of the conjunctiva (outermost layer of the eye) Eye Periorbital cellulitis; inflammation of the eyelid Secondary Infections-M. tuberculosis • Various ways to travel and infect secondary sites: – via the haematogenous or lymphatic circulatory systems – E.g. immune evasion: secondary infections are more common in individuals with compromised immune systems or children – Intracellular growth- preventing antibody and complement destruction – inhibition of phagosome-lysosome fusion by secretion of bacterial proteins that alter the phagosome membrane – enzyme productioninhibit reactive oxygen species e.g. AhpC, SodA and SodC – antigen 85 complex: a group of proteins that binds to fibronectin and walls off the bacteria from the immune response – slow generation time: makes it difficult for the host immune system to be triggered – high lipid concentration in its cell wall: impermeability and resistance to antimicrobial peptides, promotes resistance to osmotic lysis and attack by lysosomes Other Secondary Infections associated with M.tuberculosis (Part 1) Miliary Tuberculosis Tuberculosis lesion occurs at the blood vessels the bacteria travel into the bloodstreambacteremia and the dissemination of the bacteria throughout the body Meningitis (Most severe type of 2nd infection) The lesions of the meningeal areas inflammation of the brain membrane and spinemorbidity and mortality (similar as S.pneumoniae) Lymphadenitis chronic specific granulomatous inflammation of the lymph node with caseation necrosis Genitourinary tuberculosis Infection can affect many organs and components of the renal, ureteral, bladder, epididymal, testicular, prostatic, genital, and urethral regions Tuberculosis Peritonitis Bacteria spreads from the abdominal lymph nodes and eventually infects the peritoneum inflammation Tuberculosis Pericarditis Arises from affected mediastinal lymph nodes or pleural tuberculosisinflammation of the pericardiumheart failure (potentially) Other Secondary Infections associated with M.tuberculosis (Part 2) Bone and Joint Tuberculosis can arise after trauma & weight-bearing joints are the most commonly affected sites Infection of the liver; generally arises in people who have advanced pulmonary tuberculosis or miliary tuberculosis; Hepatic Tuberculosis usually resolved without complications if the primary infection is treated; the bacteria can also spread to the gallbladder nearby jaundice (under certain conditions) infection of the peritoneum, hollow or solid abdominal organs and abdominal lymphatics Gastrointestinal Tuberculosis The peritoneum and the ileocecal region—most likely infection sites/in the majority of cases by hematogenous spread or through swallowing of infected sputum from primary pulmonary tuberculosis Image Sources • • • • Slide 5 – https://www.google.ca/imgres?imgurl=https%3A%2F%2Fwww.nasa.gov%2Fmission_pages%2Fstation%2Fresearch%2Fexperiments%2FSPEGI S1.jpg&imgrefurl=https%3A%2F%2Fwww.nasa.gov%2Fmission_pages%2Fstation%2Fresearch%2Fexperiments%2F1036.html&docid=z1hq4N Ce1LygmM&tbnid=9jZKb_2ijN3MJM%3A&vet=10ahUKEwiM7vCh_ODSAhVR4mMKHdTWAD4QMwg4KAcwBw..i&w=499&h=376&bih=651&bi w=1366&q=streptococcus%20pneumoniae&ved=0ahUKEwiM7vCh_ODSAhVR4mMKHdTWAD4QMwg4KAcwBw&iact=mrc&uact=8 – https://www.google.ca/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&ved=0ahUKEwjWx6DY_eDSAhVL82MKHT50DFkQjRwIBw&url=http %3A%2F%2Fwww.barnstablecountyhealth.org%2Fdisease-agents%2Fmycobacteriumtuberculosis&bvm=bv.149760088,d.cGc&psig=AFQjCNFu23vVqHyorX4OKOvYiNFJUAbkUw&ust=1489958367759822 Slide 7 – https://www.google.ca/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&ved=0ahUKEwjO6oOFgeHSAhUBLmMKHcIC0oQjRwIBw&url=http%3A%2F%2Fwww.lindastorm.net%2Fthe-functions-of-the-respiratorysystem%2F&bvm=bv.149760088,d.cGc&psig=AFQjCNEZJEnDUpYzGPP8EWFcUgMRHPSXVw&ust=1489959224716210 Slide 8 – https://www.google.ca/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&ved=0ahUKEwjh45DniOHSAhUHyGMKHYl7AGEQjRwIBw&url=http %3A%2F%2Fwww.dummies.com%2Feducation%2Fscience%2Fanatomy%2Fan-overview-of-the-oralcavity%2F&bvm=bv.149760088,d.cGc&psig=AFQjCNH5NHGA1_PZ4wJXWVeYzE3tvSJJ3g&ust=1489961266881654 Slide 9 – https://www.google.ca/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&ved=0ahUKEwjc2qrXjuHSAhVNwGMKHfdsCugQjRwIBw&url=https% 3A%2F%2Fwww.cancer.gov%2Ftypes%2Fhead-and-neck%2Fpatient%2Fhypopharyngeal-treatmentpdq&bvm=bv.149760088,d.cGc&psig=AFQjCNH1Uli6yW5SEXuztL1r-aHG9AWo4Q&ust=1489961946467215 Image Sources • • • • • • Slide 10 – https://www.google.ca/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&ved=0ahUKEwjCrI_WkeHSAhUQ4mMKHaIoAyMQjRwIBw&url=http s%3A%2F%2Fwww.boundless.com%2Fbiology%2Ftextbooks%2Fboundless-biology-textbook%2Fthe-respiratory-system-39%2Fsystems-ofgas-exchange-219%2Fmammalian-systems-and-protective-mechanisms-83212076%2F&bvm=bv.149760088,d.cGc&psig=AFQjCNHXXsFcp4cw5idZ8-zM1nwGkf2GSQ&ust=1489963594175497 Slide 11 – https://www.google.ca/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&ved=0ahUKEwjF6N6mqOHSAhUH72MKHVnRB_4QjRwIBw&url=htt p%3A%2F%2Fwww.austincc.edu%2Fapreview%2FPhysText%2FRespiratory.html&bvm=bv.149760088,d.cGc&psig=AFQjCNHXXsFcp4cw5idZ8zM1nwGkf2GSQ&ust=1489963594175497 Slide 12 – https://www.google.ca/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&ved=0ahUKEwiIhpGprHSAhUQ2WMKHRLnBQsQjRwIBw&url=https%3A%2F%2Fwww.anatomylibrary.us%2Falveoli-function-in-respiratorysystem%2F&bvm=bv.149760088,d.cGc&psig=AFQjCNEItxCOX0qIwe-Li0CX5kxFbtUobA&ust=1489971618625433 – https://www.google.ca/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&ved=0ahUKEwio7oH0rHSAhWFMGMKHSysBf4QjRwIBw&url=http%3A%2F%2Fouopentextbooks.org%2Fbiol3103%2Frespiratorysystems%2F&bvm=bv.149760088,d.cGc&psig=AFQjCNFsfcWp6BLc4dlHEMA1-MuzCTaA1g&ust=1489971864139997 Slide 13 – https://image.slidesharecdn.com/chapter7-respirationpart2-141111210504-conversion-gate02/95/biology-form-4-chapter-7-respirationpart-2-21-638.jpg?cb=1415740079 – https://classconnection.s3.amazonaws.com/947/flashcards/3551947/jpg/alveolar_gas_exchange-1451B4F6FCF1F6AC33C.jpg Slide 14 – https://scienceeasylearning.files.wordpress.com/2015/01/picture121.jpg Slide 15 – http://yogadork.com/wp-content/uploads/2013/10/diaphragm-breathing-500x313.jpg Image Sources • • • Slide 17/18 – https://www.rchsd.org/wp-content/uploads/kidshealth/images/image/ial/images/5328/5328_image.png – https://s-media-cache-ak0.pinimg.com/736x/1c/8a/9e/1c8a9e1116001e2e4870692bfd9c44ad.jpg Slide 19 – http://healthfavo.com/wp-content/uploads/2017/01/tuberculosis-28061857.jpg Slide 23 – http://diseasespictures.com/wp-content/uploads/2012/10/Meningitis.jpg Thank you!
