Pathlet 001
Ed Friedlander MD

These pathlets are edutainment. This site collects no information about visitors, and cannot substitute for your own doctor's care. There are many questions without clear right-or-wrong answers. I did all the scripting and can make a pathlet with you if you have a good case.

Rembrandt painting
of a homeless man
Chicago, 1977. Mid-autumn.

A 55 year old homeless man presented with cough and difficulty swallowing.

He had smoked 1-2 packs of cigarets daily since age 11, and drunk heavily through most of his adult life. He had been brought to the emergency room by friends because of a cough and weight loss of approximately 25 lb during the past two months.

The patient stated that while he has no difficulty swallowing liquids, solid food seems to stick in his chest. "It makes it half way down, then stops for a while, hands up kind of." He did not believe he ever choked or aspirated, and that except for some beef that he had vomited, most of the food eventually made it to his stomach. He says his cough is non-productive, and that he thinks he may have had a fever. He denies regurgitation, heartburn, hemoptysis, chest pain, and night sweats.

Physical exam shows a slender man 5'10" and weighing 105 lb. He is lucid, oriented, and pleasant. There is no odor of ethanol, no tremulousness, and he says his last drink of alcohol abuse was about 18 hours ago. He says he may be interested in stopping drinking at some time in the future.

Temperature is 99.5 F, pulse 90, respirations 28. Physical exam is remarkable for increased chest diameter, coarse and increased breath sounds, and some examiners felt there were patchy "velcro" rales. It was specifically noted that there was no cyanosis.

Which would you do now? Choose all that apply.

Get a chest x-ray
Order electrolytes
Order a complete blood count
Order a routine chemical profile
Order a urinalysis
Send something for a toxicology screen
Send arterial blood for blood gases
Examine a gram-stain of the sputum
Examine an acid-fast stain of the sputum
Send sputum to the cytology lab
Culture sputum for normal bacteria
Culture sputum for mycobacteria
Culture sputum for fungi
Place a tuberculin skin test
Get an electrocardiogram
Get a barium swallow / upper GI films
Get an CT scan of the chest
Perform a lumbar puncture
Gastroenterology consult -- upper endoscopy
Pulmonology consult -- bronchoscopy
Put the patient in respiratory isolation
Give him a soft diet
Give him a cough suppressant
Give diazepam for alcohol withdrawal

Here is what we think is good practice. Most physicians will probably give you similar answers.

Get a chest x-ray -- YES
Order electrolytes -- PROBABLY
Order a complete blood count -- YES
Order a routine chemical profile -- YES
Order a urinalysis -- PROBABLY
Send something for a toxicology screen -- PROBABLY NOT
Send arterial blood for blood gases -- MAYBE
Examine a gram-stain of the sputum -- YES
Examine an acid-fast stain of the sputum -- YES
Send sputum to the cytology lab -- PROBABLY
Culture sputum for normal bacteria -- YES
Culture sputum for mycobacteria -- YES
Culture sputum for fungi -- YES
Get an electrocardiogram -- PROBABLY
Place a tuberculin skin test -- PROBABLY
Get a barium swallow / upper GI-- PROBABLY
Get an CT scan of the chest -- NOT AVAILABLE
Perform a lumbar puncture -- NO
Gastroenterology consult -- upper endoscopy -- PROBABLY
Pulmonology consult -- bronchoscopy -- MAYBE
Put the patient in respiratory isolation -- MAYBE
Give him a soft diet -- YES
Give him a cough suppressant -- PROBABLY NOT
Give diazepam for alcohol withdrawal -- NO

Anyone with a cough who's sick enough to come into the hosptial deserves a chest x-ray. A chemical profile will tell us something about this person's overall state of health, and if there's liver or kidney insufficiency, it will let you know before you go prescribing medications. Anyone with cough and fever had bacterial pneumonia until proved otherwise, and checking the gram-stained sputum is a must-do. Checking for acid-fast bacteria would reveal tuberculosis early. With the likelihood of obstruction of the esophagus, a barium swallow and a visit from a gastroenterologist are probably in order. This is 1977 and CT scanning is not yet widely available, especially for chests. Blood gases are a big deal in 1977 -- the pulse oximeter is not yet available, and you have to puncture the radial artery and send the glass tube on ice to a lab that at this hospital was known for being unreliable. A tuberculin skin test is worth considering in anyone who is chronically ill, especially an alcoholic with a cough. Sputum for cytology to screen asymptomatic people for lung cancer, but this person has enough of a chance of having lung cancer to make this worthwhile. The hospital may have some policy about respiratory isolation when there is possible tuberculosis. In the absence of signs or symptoms of alcohol withdrawal, it's hard to justify giving diazepam. Without a clear desire to change, calling an alcohol rehabilitation specialist does not seem justified.

We will tell you in a moment what was done. Based on the history and physical exam, what likelihood would you assign each of the following?

endocarditis: Very Unlikely               Very Likely
ASPIRATION PNEUMONIA: Very Unlikely               Very Likely
BACTERIAL PNEUMONIA: Very Unlikely               Very Likely
BLASTOMYCOSIS: Very Unlikely               Very Likely
ESOPHAGEAL CANCER: Very Unlikely               Very Likely
HISTOPLASMOSIS: Very Unlikely               Very Likely
LUNG CANCER: Very Unlikely               Very Likely
TUBERCULOSIS: Very Unlikely               Very Likely
VIRAL PNEUMONITIS: Very Unlikely               Very Likely
ZENKER DIVERTICULUM: Very Unlikely               Very Likely

Chicago Water Tower

Different physicians will give you somewhat different estimates. These are just ours. We strongly suspected both esophageal cancer and either a community-acquired pneumonia or tuberculosis. We know he has emphysema and chronic bronchitis just from his history of heavy smoking and increased AP diameter, but that these were longstanding problems. endocarditis is a consideration, especially with the weight loss. Blastomycosis is very common in Chicago, and histoplasmosis fairly common, and both of these can produce the subacute pneumonia. If the patient is a poor historian, then perhaps the lung changes are aspiration pneumonia and the esophageal obstruction more severe than we had thought. A viral chest cold seems very unlikely to hang on for this long. endocarditis is a possibility except that there's been no regurgitation; Zenker's is more likely to produce regurgitation rather than dysphagia.

The medical intern in charge of the case had little supervision. She obtained a CBC which showed a slight increase in total neutrophils without a left shift, and in total monocytes. Red cells and platelets were normal. A chemical profile was remarkable only for slightly low serum albumin and slightly increased globulin; liver transaminases (SGOT/AST and SGPT/ALT were high-normal). Sputum gram-stain showed no bacteria. The medical intern did not check the sputum for acid-fast bacilli, but did send it for culture.

A chest x-ray very similar to the patient's is shown on the right. A barium swallow showed no abnormality of the esophagus or stomach. The medical intern made the diagnosis of presumptive esophageal cancer with aspiration pneumonia. She prescribed ampicillin and gentamicin, and sent a consult to the gastroenterology clinic. The gastroenterologist was on vacation and endoscopy was scheduled for next week.

Is there anything you would have done differently?

I am almost certain you would have done at least something differently. Choose all that apply -- you would have...

... applied a tuberculin skin test with controls for anergy
... checked the sputum yourself for tubercle bacilli
... looked for acid-base bacilli in another sputum specimen
... obtained surgical consultation on the expectation of an esophageal resection
... put him in respiratory isolation out of concern over TB
... requested a pulmonologist to get lung / mediastinal tissue for diagnosis
... sent three more sputum specimens to cytology to check for cancer

The patient had no difficulty withdrawing from alcohol and mentioned he was glad to be away from it at long last. He remained febrile and the antibiotics did not help the cough, which grew worse and was productive of a small amount of blood. On the second day, the lab reported a light growth of pneumococcus and H. flu in the sputum, no surprise in a smoker. He continued to lose weight. On the tenth day after admission, upper endoscopy was performed. The gastroenterologist said there were no lesions.

The medical intern did not believe this, and asked that repeat endoscopy be performed by a different gastroenterologist. On the seventeenth hospital day, the second gastroenterologist reported no lesions.

The patient's cough and cyanosis grew more severe, he continued to lose weight, and complained of the same sensation of food sticking in mid-chest. No other treatments were administered. It was decided to present this patient as a difficult case. The internal medicine chief resident reviewed the medical intern's work for the first time on the 24th hospital day. He was concerned, and called for a pulmonology consultation which had not been requested before. He also initiated respiratory isolation for the patient. Too late! In the early morning of the 25th hospital day, the patient died.

The resident obtained permission from the family for an autopsy.

Which do you think killed this man?

Chronic bronchitis / emphysema
Esophageal cancer
Lung cancer
Something else

You'll get your answer in just a minute. It was the pathology intern's sixth autopsy. He was thrilled with his new specialty. He had just gotten the call from the medical intern who assured him that he would find cancer of the esophagus. After briefly reviewing the chart, he and the autopsy assistant went to work.

When the chest plate was removed, a look of triumph came over the pathology intern's face. "Why, both lungs look like big blocks of blue cheese! I know just what this is!" He took the lungs out and began sectioning them, revealing some little cavities and most of the lung transformed into stuff with the various consistencies of various types of cheese.

The pathology intern astutely noticed that the esophagus was extrinsically compressed in its midportion by greatly-enlarged hilar lymph nodes on both sides; these were also breaking down into the cheeselike material. He exclaimed, "So that explains the food getting caught in the mid-thorax, the clinical diagnosis of esophageal cancer, and why no cancer was visible on endoscopy!"

As the pathology intern held the sections of lung up for viewing, a fine powder flew from their surfaces, transforming the autopsy suite briefly into a snow globe.

The lungs looked like this public-domain photo from VirtualMedic, but MUCH worse.

What did the more experienced pathologists tell the pathology intern and the autopsy assistant do after the organ presentation?

Wash down the entire autopsy suite with denatured ethanol
Wash down the entire autopsy suite with hypochlorite bleach
Wash down the entire autopsy suite with Lysol
Wash down the entire autopsy suite with phenol
Wash down the entire autopsy suite with povidone iodine

After washing the autopsy suite down with phenol (strong stuff but what we used back in the way), and being happy to have learned an important lesson, the pathology intern went home. He submitted microscopic sections the next day, and a few days later examined the lung under the microscope. He saw what he expected on H&E, similar to what is shown in this GRIPE photo.

Which lung diseases are still under consideration?

Atypical mycobacterial infection
Cystic fibrosis, adult type
Klebsiella pneumonia
Lung cancer -- adenocarcinoma
Lung cancer -- large cell undifferentiated
Lung cancer -- small cell undifferentiated
Lung cancer -- squamous cell carcinoma
Pneumococcal pneumonia
Pulmonary infarcts

The three reasonable choices for caseating granulomatous infection in the lung of a man living in Chicago are tuberculosis, histoplasmosis, and blastomycosis.

The pathology intern ordered a stain that revealed these microbes, and made the diagnosis of tuberculosis. At about this time, the patient's sputum cultures in life, from admission, grew out tuberculosis bacteria.

What stain revealed the "red snappers"?

Congo red
Fite modified Acid Fast
Gram stain
Indigo carmine
Luxol fast blue
Periodic acid - Schiff (PAS)
Prussian Blue
Ziehl-Neelson Acid Fast

Chicago's Oak Street Beach
Lots of great memories
Pleased with the Ziehl-Neelsen stain results, the pathology intern presented the case at an interesting medicine conference. Over the next two years, the pathology house officer did a lot of running and swimming, and attributed his weight loss to this. He is 6'0" with a light frame, and he thought that 135 lb was good, given that he had pretty good muscle mass and definition for his late twenties. His old asthma was never more than a mild nuisance, and he never did develop a cough. But he eventually began to wonder whether something might be wrong. It wasn't until the night sweats began that he sought medical attention.

The tuberculin skin test was strongly positive, and a small shadow was noted in his left lower lobe. After only about a week on antituberculosis medication, he started feeling noticeably like his usual state of health. He completed his 18-month course of medication, and a chest x-ray a few years later showed the tuberculosis shadow was gone.

Pathology Teaching Assistants!

This is my offer of a prototype for a "Pathlet", similar to what's been described to me by a colleague as a helpful learning tool for anyone who wants to have fun doing my favorite subject.

Please give me your constructive feedback on the pathlet, and then get with Dr. Gustafson and set about to create one of your own for posting on "Pathguy" with your name.


When you are ready to make your own, see Dr. Gustafson. He has a huge number of cases to choose from. Your pathlet should have...

Don't forget to have fun with this next component of your adventure in Pathology 209.

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