成年人巨细胞病毒性肺炎.ppt

Cliquez pour modifier le style du titre,Cliquez pour modifier les styles du texte du masque,Deuxime niveau,Troisime niveau,Quatrime niveau,Cinquime niveau,*,*,成年人巨细胞病毒性肺炎,影像学及病理学表现,1,Case,Name,：,Me Ping,Sex,：,Female,Age,：,46,P No.,：,P10044471,2,Case,Examine Date 2009-08-17,Thin-section(1-mm collimation)computed tomographic(CT)scan shows Bilateral diffuse ground-glass attenuation with thickened interlobular septa,and A lobular distribution,segmental consolidation with the“inflated bronchia”sign.There are several lymph nodes in the mediastina.No pleural effusion.The heart,liver,spleen and other scanned areas are normal.,3,Case,Diagnosis:Bilateral diffuse lesion of lung,considered as infection.,Differentiate Diagnosis,：,(1)Viral pneumonia(CMV,EBV),(2)PCP,(3),Chlamydia pneumonia,4,成年人病毒性肺炎,流感病毒、麻疹病毒、汉坦病毒、腺病毒、单纯疱疹病毒、水痘,-,带状疱疹病毒、巨细胞病毒以及,EB,病毒等多种病毒能够引起成年人下呼吸道感染。,成年人病毒性肺炎可分为两种类型：发生于健康宿主的非典型性肺炎,；发生于免疫缺陷宿主的病毒性肺炎。,5,免疫正常及免疫缺陷患者常见的病毒感染,免疫正常患者,流感病毒,汉坦病毒,EB,病毒,腺病毒,免疫缺陷患者,单纯疱疹病毒,水痘,-,带状疱疹病毒,巨细胞病毒,麻疹病毒,腺病毒,6,成年人病毒性肺炎,影像学表现多种多样且相互重叠,。,患者年龄、免疫状况、社区性爆发、起病状况、严重程度及持续时间、有无发疹等临床信息对于诊断具有重要帮助。,实验室检查,7,常见的病理学表现,病毒能够引起：气管支气管炎，细支气管炎，肺炎。,上皮细胞及相邻间质组织学改变最为显著。,8,常见的病理学表现,气管支气管炎：气道壁充血，管腔内单核细胞浸润,，上皮细胞变性、脱落。,细支气管炎：儿童常见，上皮细胞坏死，管腔内嗜中性粒细胞渗出，气道壁内单核细胞为主的炎性细胞浸润。,9,常见的病理学表现,实质受累（肺炎）：终末及呼吸性细支气管相邻肺组织首先受累，,可进展至整个肺叶。,老年及免疫缺陷患者可发生快速进展的肺炎。,组织学上，双肺弥漫性肺泡破坏（间质淋巴细胞浸润，气腔内出血，水肿及纤维蛋白渗出，,2,型肺泡上皮增生，透明膜形成）,10,Photomicrograph(original magnification,100;hematoxylin-eosin stain)of a lung biopsy specimen from a 36-year-old man with pneumonia due to herpes simplex virus type 1 shows a fibrous exudate(large arrows)along the alveolar walls.Note the interstitial thickening due to fibroblastic proliferation(small arrows).,11,常见的影像学表现,气管支气管炎：急性期很少出现异常影像学改变，但多年后粘膜破坏可表现为支气管扩张。,细支气管炎：气道阻塞常为不完全性，影像学上表现为过度通气及边界不清的结节灶。,12,常见的影像学表现,病毒性肺炎：,边界不清的结节（,4-10mm,的气腔内结节）。,细支气管周围斑片状磨玻璃密度及气腔实变。,常伴有过度通气。,快速进展型肺炎：实变区快速融合，引起弥漫性肺泡损害（均一性或斑片状单侧或双侧气腔内实变，以及磨玻璃密度灶或界限不清的小叶核心结节）。,13,Photomicrograph(original magnification,100;hematoxylin-eosin stain)of a lung biopsy specimen from a 36-year-old man with pneumonia due to herpes simplex virus type 1 shows a fibrous exudate(large arrows)along the alveolar walls.Note the interstitial thickening due to fibroblastic proliferation(small arrows).,Photomicrograph(original magnification,100;hematoxylin-eosin stain)of a lung biopsy specimen from a 36-year-old man with pneumonia due to herpes simplex virus type 1 shows a fibrous exudate(large arrows)along the alveolar walls.Note the interstitial thickening due to fibroblastic proliferation(small arrows).,Photomicrograph(original magnification,100;hematoxylin-eosin stain)of a lung biopsy specimen from a 36-year-old man with pneumonia due to herpes simplex virus type 1 shows a fibrous exudate(large arrows)along the alveolar walls.Note the interstitial thickening due to fibroblastic proliferation(small arrows).,Pneumonia due to influenza virus(type C)in a 46-year-old man with dyspnea.Initial chest radiograph shows diffuse reticulonodular areas of increased opacity in both lungs.,14,Pneumonia due to influenza virus(type C)in a 46-year-old man with dyspnea.Follow-up chest radiograph obtained 15 days later shows progression of the extent of disease with diffuse consolidation throughout both lungs.,Pneumonia due to influenza virus(type C)in a 46-year-old man with dyspnea.,(a),Initial chest radiograph shows diffuse reticulonodular areas of increased opacity in both lungs.,(b),Follow-up chest radiograph obtained 15 days after,a,shows progression of the extent of disease with diffuse consolidation throughout both lungs.,(c),Thin-section(1-mm collimation)computed tomographic(CT)scan obtained 16 days after,a,at the level of the aortic arch shows diffuse ground-glass attenuation with some irregular linear areas of increased attenuation in both lungs.(Case courtesy of Dr Jung Hwa Hwang,Soonchunhyang University Seoul Hospital,Korea.),Pneumonia due to influenza virus(type C)in a 46-year-old man with dyspnea.,(a),Initial chest radiograph shows diffuse reticulonodular areas of increased opacity in both lungs.,(b),Follow-up chest radiograph obtained 15 days after,a,shows progression of the extent of disease with diffuse consolidation throughout both lungs.,(c),Thin-section(1-mm collimation)computed tomographic(CT)scan obtained 16 days after,a,at the level of the aortic arch shows diffuse ground-glass attenuation with some irregular linear areas of increased attenuation in both lungs.(Case courtesy of Dr Jung Hwa Hwang,Soonchunhyang University Seoul Hospital,Korea.),Pneumonia due to influenza virus(type C)in a 46-year-old man with dyspnea.,(a),Initial chest radiograph shows diffuse reticulonodular areas of increased opacity in both lungs.,(b),Follow-up chest radiograph obtained 15 days after,a,shows progression of the extent of disease with diffuse consolidation throughout both lungs.,(c),Thin-section(1-mm collimation)computed tomographic(CT)scan obtained 16 days after,a,at the level of the aortic arch shows diffuse ground-glass attenuation with some irregular linear areas of increased attenuation in both lungs.(Case courtesy of Dr Jung Hwa Hwang,Soonchunhyang University Seoul Hospital,Korea.),15,Pneumonia due to influenza virus(type C)in a 46-year-old man with dyspnea.Thin-section(1-mm collimation)computed tomographic(CT)scan obtained 1 day after the second chest radiograph at the level of the aortic arch shows diffuse ground-glass attenuation with some irregular linear areas of increased attenuation in both lungs.,16,成年人巨细胞病毒性肺炎,巨细胞病毒：,DNA,病毒,疱疹病毒的一种,免疫缺陷患者严重症状的肺炎。,17,成年人巨细胞病毒性肺炎,致病机制,组织病理学特点,同种异体移植受体,T,细胞介导抗原,-,抗体反应。,即使抑制病毒复制时也可发生严重的坏死性肺炎。,坏死性炎症显著,感染巨细胞病毒的细胞相对较少,AIDS,患者,免疫缺陷更严重,巨细胞病毒的细胞致病作用引起肺损害。,弥漫肺泡损害常较不患有,AIDS,的患者常见大量巨细胞病毒包涵体。,18,成年人巨细胞病毒性肺炎,常见,CT,表现：,磨玻璃密度影,实变,结节灶,边界不清的小叶核心结节,支气管扩张,小叶间隔增厚,19,成年人巨细胞病毒性肺炎,Kang et al,报告了,10,例患巨细胞病毒性肺炎移植受体 的,CT,表现：结节,(,n,=6),实变,(,n,=4),(,n,=4),不规则线状影,(,n,=1),。,Kim and Lee,报告了,11,例免疫缺陷患者的高分辨,CT,表现,磨玻璃密度影,(,n,=11),不规则线状影,(,n,=10),实变,(,n,=7),多发小结节或肿块,(,n,=6),支气管扩张或小叶间隔增厚,(,n,=5),。20,Pneumonia due to cytomegalovirus in a 28-year-old man with acute myeloid leukemia.Thin-section(1-mm collimation)CT scan obtained at the level of the bronchus intermedius shows multifocal patchy ground-glass attenuation and poorly defined centrilobular nodules(arrows)in both lungs.,21,Pneumonia due to cytomegalovirus in a 28-year-old man with acute myeloid leukemia.Photomicrograph(original magnification,40;hematoxylin-eosin stain)shows diffuse interstitial and intraalveolar fibroblastic proliferation(arrows)with some mononuclear cell infiltration(diffuse alveolar damage,organizing stage).,22,Title,Pneumonia due to cytomegalovirus in a 28-year-old man with acute myeloid leukemia.(1)Photomicrograph(original magnification,400;hematoxylin-eosin stain)shows three large nuclei containing eosinophilic inclusion bodies(arrows)within hyperplastic pneumocytes.(2)Photomicrograph(original magnification,400;immunohistochemical marker for cytomegalovirus)shows positive intranuclear inclusion bodies(arrows).,23,Title,Pneumonia due to cytomegalovirus in a 45-year-old man who underwent liver transplantation.Chest radiograph obtained 4 weeks after liver transplantation shows patchy air-space consolidation in both lungs.An endotracheal intubation tube,a pigtail drainage catheter in the right pleural space,a chest tube in the left pleural space,and a central venous catheter are seen.,24,Title,Pneumonia due to cytomegalovirus in a 45-year-old man who underwent liver transplantation.Thin-section(1-mm collimation)CT scan obtained at the level of the right upper lobe bronchus 2 days before the Chest radiograph shows multifocal patchy ground-glass attenuation in both lungs.Note the consolidation(white arrow)and the small,poorly defined nodules(black arrows).There are associated bilateral pleural effusions.,25,成年人病毒性肺炎的影像学表现多种多样且相互重叠，巨细胞病毒性感染时可伴有其它病毒及不典型致病菌的感染，,不能仅依靠影像学特点做出病毒性肺炎特定微生物的诊断。,总结,26,感谢聆听！,27,