成年人巨细胞病毒性肺炎case讲义.ppt

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1、成年人巨成年人巨细胞病毒性肺炎胞病毒性肺炎case讲义CaseCaseName：Me PingSex：FemaleAge：46P No.：P10044471 CaseCaseExamine Date 2009-08-17Thin-section(1-mm collimation)computed tomographic(CT)scan shows Bilateral diffuse ground-glass attenuation with thickened interlobular septa,and A lobular distribution,segmental consolidati

2、on 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.CaseCaseDiagnosis:Bilateral diffuse lesion of lung,considered as infection.Differentiate Diagnosis：(1)Viral pneumonia(CMV,EBV)(2)PCP (3)Chl

3、amydia pneumonia 成年人病毒性肺炎成年人病毒性肺炎 流感病毒、麻疹病毒、汉坦病毒、腺病毒、流感病毒、麻疹病毒、汉坦病毒、腺病毒、单纯疱疹病毒、水痘单纯疱疹病毒、水痘-带状疱疹病毒、巨细带状疱疹病毒、巨细胞病毒以及胞病毒以及EBEB病毒等多种病毒能够引起成病毒等多种病毒能够引起成年人下呼吸道感染。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于健康宿主的非典型性肺炎 ；发生于免疫；发生于免疫缺陷宿主的病毒性肺炎。缺陷宿主的病毒性肺炎。免疫正常及免疫缺陷患者常见的病毒感染免疫正常及免疫缺陷患者常见的病毒感染免疫正常

4、患者免疫正常患者 流感病毒流感病毒 汉坦病毒汉坦病毒 EB病毒病毒 腺病毒腺病毒免疫缺陷患者免疫缺陷患者 单纯疱疹病毒单纯疱疹病毒 水痘水痘-带状疱疹病毒带状疱疹病毒 巨细胞病毒巨细胞病毒 麻疹病毒麻疹病毒 腺病毒腺病毒 成年人病毒性肺炎成年人病毒性肺炎影像学表现多种多样且相互重叠。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。临床信息对于诊断具有重要帮助。实验室检查实验室检查常见的病理学表现常见的病理学表现病毒能够引起：气管支气管炎，细

5、支气管炎，病毒能够引起：气管支气管炎，细支气管炎，肺炎。肺炎。上皮细胞及相邻间质组织学改变最为显著。上皮细胞及相邻间质组织学改变最为显著。常见的病理学表现常见的病理学表现气管支气管炎：气道壁充血，管腔内单核气管支气管炎：气道壁充血，管腔内单核细胞浸润细胞浸润 ，上皮细胞变性、脱落。，上皮细胞变性、脱落。细支气管炎：细支气管炎：儿童常见，上皮细胞坏死，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。细胞为主的炎性细胞浸润。常见的病理学表现常见的病理学表现实质受累（肺炎）：终末及呼吸性细支气实质受累（肺炎）：终末及呼吸性细支气

6、管相邻肺组织首先受累，管相邻肺组织首先受累，可进展至整个肺可进展至整个肺叶。叶。老年及免疫缺陷患者可发生快速进展的肺老年及免疫缺陷患者可发生快速进展的肺炎。炎。组织学上，双肺弥漫性肺泡破坏（间质淋组织学上，双肺弥漫性肺泡破坏（间质淋巴细胞浸润，气腔内出血，水肿及纤维蛋巴细胞浸润，气腔内出血，水肿及纤维蛋白渗出，白渗出，2 2型肺泡上皮增生，透明膜形成）型肺泡上皮增生，透明膜形成）Photomicrograph(original magnification,100;hematoxylin-eosin stain)of a lung biopsy specimen from a 36-year-o

7、ld 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).常见的影像学表现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改变，但多年后粘膜破坏可表现为支气管扩张。张。细支气管

8、炎：气道阻塞常为不完全性，影细支气管炎：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。像学上表现为过度通气及边界不清的结节灶。常见的影像学表现常见的影像学表现 病毒性肺炎：病毒性肺炎：边界不清的结节（边界不清的结节（4-10mm4-10mm的气腔内结节）。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。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。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

9、叶内实变，以及磨玻璃密度灶或界限不清的小叶核心结节）。核心结节）。Photomicrograph(originalmagnification,100;hematoxylin-eosinstain)ofalungbiopsyspecimenfroma36-year-oldmanwithpneumoniaduetoherpessimplexvirustype1showsafibrousexudate(largearrows)alongthealveolarwalls.Notetheinterstitialthickeningduetofibroblasticproliferation(smalla

10、rrows).Photomicrograph(originalmagnification,100;hematoxylin-eosinstain)ofalungbiopsyspecimenfroma36-year-oldmanwithpneumoniaduetoherpessimplexvirustype1showsafibrousexudate(largearrows)alongthealveolarwalls.Notetheinterstitialthickeningduetofibroblasticproliferation(smallarrows).Photomicrograph(ori

11、ginalmagnification,100;hematoxylin-eosinstain)ofalungbiopsyspecimenfroma36-year-oldmanwithpneumoniaduetoherpessimplexvirustype1showsafibrousexudate(largearrows)alongthealveolarwalls.Notetheinterstitialthickeningduetofibroblasticproliferation(smallarrows).Pneumonia due to influenza virus(type C)in a

12、46-year-old man with dyspnea.Initial chest radiograph shows diffuse reticulonodular areas of increased opacity in both lungs.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 dif

13、fuse consolidation throughout both lungs.Pneumoniaduetoinfluenzavirus(typeC)ina46-year-oldmanwithdyspnea.(a)Initialchestradiographshowsdiffusereticulonodularareasofincreasedopacityinbothlungs.(b)Follow-upchestradiographobtained15daysafterashowsprogressionoftheextentofdiseasewithdiffuseconsolidationt

14、hroughoutbothlungs.(c)Thin-section(1-mmcollimation)computedtomographic(CT)scanobtained16daysafteraattheleveloftheaorticarchshowsdiffuseground-glassattenuationwithsomeirregularlinearareasofincreasedattenuationinbothlungs.(CasecourtesyofDrJungHwaHwang,SoonchunhyangUniversitySeoulHospital,Korea.)Pneumo

15、niaduetoinfluenzavirus(typeC)ina46-year-oldmanwithdyspnea.(a)Initialchestradiographshowsdiffusereticulonodularareasofincreasedopacityinbothlungs.(b)Follow-upchestradiographobtained15daysafterashowsprogressionoftheextentofdiseasewithdiffuseconsolidationthroughoutbothlungs.(c)Thin-section(1-mmcollimat

16、ion)computedtomographic(CT)scanobtained16daysafteraattheleveloftheaorticarchshowsdiffuseground-glassattenuationwithsomeirregularlinearareasofincreasedattenuationinbothlungs.(CasecourtesyofDrJungHwaHwang,SoonchunhyangUniversitySeoulHospital,Korea.)Pneumoniaduetoinfluenzavirus(typeC)ina46-year-oldmanw

17、ithdyspnea.(a)Initialchestradiographshowsdiffusereticulonodularareasofincreasedopacityinbothlungs.(b)Follow-upchestradiographobtained15daysafterashowsprogressionoftheextentofdiseasewithdiffuseconsolidationthroughoutbothlungs.(c)Thin-section(1-mmcollimation)computedtomographic(CT)scanobtained16daysaf

18、teraattheleveloftheaorticarchshowsdiffuseground-glassattenuationwithsomeirregularlinearareasofincreasedattenuationinbothlungs.(CasecourtesyofDrJungHwaHwang,SoonchunhyangUniversitySeoulHospital,Korea.)Pneumonia due to influenza virus(type C)in a 46-year-old man with dyspnea.Thin-section(1-mm collimat

19、ion)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.成年人巨细胞病毒性肺炎成年人巨细胞病毒性肺炎 巨细胞病毒：巨细胞病毒：DNADNA病毒病毒疱疹病毒的一种疱疹病毒的一种免疫缺陷患者严重症状的肺炎。免疫

20、缺陷患者严重症状的肺炎。成年人巨细胞病毒性肺炎成年人巨细胞病毒性肺炎致病机制致病机制组织病理学特点组织病理学特点同种异体同种异体移植受体移植受体T细胞介导抗原细胞介导抗原-抗体反抗体反应。应。即使抑制病毒复制时也即使抑制病毒复制时也可发生严重的坏死性肺可发生严重的坏死性肺炎。炎。坏死性炎症显著坏死性炎症显著感染巨细胞病毒的细胞相感染巨细胞病毒的细胞相对较少对较少AIDS患者患者 免疫缺陷更严重免疫缺陷更严重巨细胞病毒的细胞致病巨细胞病毒的细胞致病作用引起肺损害。作用引起肺损害。弥漫肺泡损害常较不患有弥漫肺泡损害常较不患有AIDS的患者常见。的患者常见。大量巨细胞病毒包涵体。大量巨细胞病毒包涵体

21、。成年人巨细胞病毒性肺炎成年人巨细胞病毒性肺炎 常见常见CTCT表现：表现：磨玻璃密度影磨玻璃密度影实变实变结节灶结节灶边界不清的小叶核心结节边界不清的小叶核心结节支气管扩张支气管扩张小叶间隔增厚小叶间隔增厚成年人巨细胞病毒性肺炎成年人巨细胞病毒性肺炎Kang et al Kang et al 报告了报告了1010例患巨细胞病毒性肺例患巨细胞病毒性肺炎移植受体炎移植受体 的的CTCT表现：结节表现：结节 (n n=6),=6),实实变变 (n n=4),(=4),(n n=4),=4),不规则线状影不规则线状影 (n n =1)=1)。Kim and LeeKim and Lee报告了报告了1

22、111例免疫缺陷患者的高例免疫缺陷患者的高分辨分辨CTCT表现表现,磨玻璃密度影磨玻璃密度影(n n=11),=11),不规不规则线状影则线状影 (n n=10),=10),实变实变 (n n=7),=7),多发多发小结节或肿块小结节或肿块 (n n=6),=6),支气管扩张或小支气管扩张或小叶间隔增厚叶间隔增厚 (n n=5)=5)。Pneumonia due to cytomegalovirus in a 28-year-old man with Pneumonia due to cytomegalovirus in a 28-year-old man with acute myeloid

23、 leukemia.Thin-section(1-mm collimation)CT scan acute myeloid leukemia.Thin-section(1-mm collimation)CT scan obtained at the level of the bronchus intermedius shows obtained at the level of the bronchus intermedius shows multifocal patchy ground-glass attenuation and poorly defined multifocal patchy

24、 ground-glass attenuation and poorly defined centrilobular nodules(arrows)in both lungs.centrilobular nodules(arrows)in both lungs.Pneumonia due to cytomegalovirus in a 28-year-old man with Pneumonia due to cytomegalovirus in a 28-year-old man with acute myeloid leukemia.Photomicrograph(original acu

25、te myeloid leukemia.Photomicrograph(original magnification,40;hematoxylin-eosin stain)shows diffuse magnification,40;hematoxylin-eosin stain)shows diffuse interstitial and intraalveolar fibroblastic proliferation interstitial and intraalveolar fibroblastic proliferation(arrows)with some mononuclear

26、cell infiltration(diffuse(arrows)with some mononuclear cell infiltration(diffuse alveolar damage,organizing stage).alveolar damage,organizing stage).Title Pneumonia due to cytomegalovirus in a 28-year-old man with Pneumonia due to cytomegalovirus in a 28-year-old man with acute myeloid leukemia.(1)P

27、hotomicrograph(original acute myeloid leukemia.(1)Photomicrograph(original magnification,400;hematoxylin-eosin stain)shows three magnification,400;hematoxylin-eosin stain)shows three large nuclei containing eosinophilic inclusion bodies(arrows)large nuclei containing eosinophilic inclusion bodies(ar

28、rows)within hyperplastic pneumocytes.(2)Photomicrograph(original within hyperplastic pneumocytes.(2)Photomicrograph(original magnification,400;immunohistochemical marker for magnification,400;immunohistochemical marker for cytomegalovirus)shows positive intranuclear inclusion bodies cytomegalovirus)

29、shows positive intranuclear inclusion bodies(arrows).(arrows).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 tu

30、be,a pigtail drainage catheter in the right pleural space,a chest tube in the left pleural space,and a central venous catheter are seen.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 r

31、ight 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.成年人病毒性肺炎的影像学表现多种多样且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。像学特点做出病毒性肺炎特定微生物的诊断。总结总结人有了知识，就会具备各种分析能力，明辨是非的能力。所以我们要勤恳读书，广泛阅读，古人说“书中自有黄金屋。”通过阅读科技书籍，我们能丰富知识，培养逻辑思维能力；通过阅读文学作品，我们能提高文学鉴赏水平，培养文学情趣；通过阅读报刊，我们能增长见识，扩大自己的知识面。有许多书籍还能培养我们的道德情操，给我们巨大的精神力量，鼓舞我们前进。谢谢！谢谢！