Acute arterial necrosis in the lungs

Abstract

PLATES LXXVTTI-LXXX)SECROTIC lesions in the arterial walls in the lungs have been described most frequently in the condition known as " polyarteritis nodosa ".Involvement of lung vessels in this condition, however, was thought to be uncommon. Brenner (1935), in his extensive study of the pathology of the pulmonary circulation, was not convinced of their occurrence in a severe form and, more recently, Smith (1948) was reluctant to consider as an example of polyarteritis nodosa a case with symptoms of asthma in which acute arterial necrosis was found in the lungs as well as in other organs. However, many cases with lung lesions have now been reported, and t,he incidence of pulmonaryartery involvement) is probably in the region of 30 per cent. (Spiegel, 1936).On the other hand, acute arterial necrosis confined to the lung vessels is rare, extensive changes of this kind not having been described until 1950, when Old and Russell observed severe arterial necrosis in a case of congenital heart disease of the Eisenmenger-complex type. A similar case was reported in 1951 by Kipkie and Johnson. McKeown (1952) noted four cases in patients with right heart failure of uncertain origin and Symmers (1952) two cases, one of which was associated with mitral stenosis, as was the case described by Desclin and Gepts (1952, quoted by Symmers). The present paper records a case with numerous interesting features, including acute arterial lesions confined to the lungs, in a patient with mitral stenosis. The mechanism of production of this change is discussed, not only in relation to the lung lesions, but also to the more general problem of the development of similar arterial lesions elsewhere in the body. Case report Clinical historyThe patient, a male aged 31 years, had a long history of rheumatic fever beginning in childhood. In recent years he had experienced numerous attacks of cardiac failure. A well-developed mitral stenosis was present, but he was considered unsuitable for valvulotomy. His final admission to hospital with gross cardiac failure was associated with jaundice. For two weeks before admission he had had a cough with sputum and some joint pains. An antistreptolysin titre of 1 in 250 indicated recent infection with 6-haemolytic J. PATH. BACT.-VOL. LXV (1953) 333Arch. I r z t . Med., liv, 170.

The Natural History of Polyarteritis

“…occurring in patients with pulmonary hypertension (due in one case to mitral stenosis and in the other to emphysema). At least 10 cases of this sort have been described previously (Jones, 1942;Old and Russell, 1950;McKeown, 1952;Symmers, 1952: Hicks. 1953Wade and Ball, 1957), and Park-er and Weiss (1916) described five cases of mitral stenosis in which thern was necrosis of pulmonary arterioles without any inflamiiiiiaiory reaction.…”

The Small Pulmonary Blood Vessels in Atrial Septal Defect

“…Evans (1951) has described similar changes in another case of atrial septal defect complicated by severe pulmonary arterial hypertension. They have been described commonly in patients in whom severely raised pulmonary artery blood pressure has been associated with Eisenmenger's complex (Stewart and Crawford, 1933;Old and Russell, 1950;, ventricular septal defect (Heath et al, 1956), patent ductus arteriosus (Johnson et al, 1950;Cosh, 1953;Dammann et al, 1953;Hultgren et al, 1953;, idiopathic pulmonary hypertension (Gilmour and Evans, 1946;Branwood, 1954;Aitchison and Richmond, 1955;and Heath et al, 1957), and mitral stenosis (Larrabee et al, 1949;Henry, 1952;Hicks, 1953;Denst et al, 1954;and Heath and Whitaker, 1955b). Furthermore, these vascular changes, which may be associated with pulmonary atheroma, medial necrosis confined to the blood vessels of the lung, dilatation of the branches of the muscular pulmonary arteries, and the development of bronchopulmonary anastomoses (Heath and Whitaker, 1956) appear to be associated with a clinical picture that is dominated by the clinical signs and symptoms of pulmonary arterial hypertension.…”

The electron microscopy of "fibrinoid necrosis" in pulmonary arteries.

“…Fibrinoid necrosis occurs in the systemic circulation as a hallmark of "malignant hypertension." It is also found in the pulmonary circulation in a wide group of diseases including mitral stenosis (Elkeles and Glynn, 1946;Hicks, 1953), patent ductus arteriosus with severe pulmonary hypertension (Hultgren et al, 1953), Eisenmenger's complex (Old and Russell, 1950), and primary pulmonary hypertension (Symmers, 1952;Shepherd et al, 1957).…”