成年人巨细胞病毒性肺炎ca.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影像学及病理学表影像学及病理学表现CaseName：Me PingSex：FemaleAge：46P No.：P10044471CaseExamine 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 consolida

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

3、ydia 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、流感病毒、麻疹病毒、汉坦病毒、腺病毒、坦病毒、腺病毒、单纯疱疹病毒、水痘疱疹病毒、水痘-带状疱疹病毒、巨状疱疹病毒、巨细胞病毒以及胞病毒以及EB病毒等多种病毒能病毒等多种病毒能够引起成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成年人病毒性肺炎可分为两种两种类型：型：发生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免疫正常及免疫缺陷患者常见的病毒感染的病毒感染免疫正常患者免疫正常患者 流感病毒流感病毒

4、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影像学表现多种多多种多样且相互重叠。且相互重叠。患者年患者年龄、免疫状况、社区性爆、免疫状况、社区性爆发、起病、起病状况、状况、严重程度及持重程度及持续时间、有无、有无发疹等疹等临床信息床信息对于于诊断具有重要帮助。断具有重要帮助。实验室室检查常常见的病理学表的病理学表现病毒能病毒能够引起：气管支气管炎，引起：气管支气管炎，细支气管炎，支气管炎，肺炎。肺炎。上皮上皮细胞及相

5、胞及相邻间质组织学改学改变最最为显著。著。常常见的病理学表的病理学表现气管支气管炎：气道壁充血，管腔内气管支气管炎：气道壁充血，管腔内单核核细胞浸胞浸润，上皮，上皮细胞胞变性、脱落。性、脱落。细支气管炎：支气管炎：儿童常儿童常见，上皮，上皮细胞坏死，胞坏死，管腔内嗜中性粒管腔内嗜中性粒细胞渗出，气道壁内胞渗出，气道壁内单核核细胞胞为主的炎性主的炎性细胞浸胞浸润。常常见的病理学表的病理学表现实质受累（肺炎）：受累（肺炎）：终末及呼吸性末及呼吸性细支气支气管相管相邻肺肺组织首先受累，首先受累，可可进展至整个肺展至整个肺叶。叶。老年及免疫缺陷患者可老年及免疫缺陷患者可发生快速生快速进展的肺展的肺炎。

6、炎。组织学上，双肺弥漫性肺泡破坏（学上，双肺弥漫性肺泡破坏（间质淋淋巴巴细胞浸胞浸润，气腔内出血，水，气腔内出血，水肿及及纤维蛋蛋白渗出，白渗出，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(originalmagnification,100;hematoxylin-eosinstain)ofalungbiopsyspecimenfroma36-year-oldmanwithpneumoniaduetoherpessimplexvirustype1showsafibrousexudate(largearrows)alongthealveolarwal

7、ls.Notetheinterstitialthickeningduetofibroblasticproliferation(smallarrows).常常见的影像学表的影像学表现气管支气管炎：急性期很少出气管支气管炎：急性期很少出现异常影像学异常影像学改改变，但多年后粘膜破坏可表，但多年后粘膜破坏可表现为支气管支气管扩张。细支气管炎：气道阻塞常支气管炎：气道阻塞常为不完全性，影像不完全性，影像学上表学上表现为过度通气及度通气及边界不清的界不清的结节灶。灶。常常见的影像学表的影像学表现 病毒性肺炎：病毒性肺炎：边界不清的界不清的结节（4-10mm的气腔内的气腔内结节）。）。细支气管周支气管周围

8、斑片状磨玻璃密度及气腔斑片状磨玻璃密度及气腔实变。常伴有常伴有过度通气。度通气。快速快速进展型肺炎：展型肺炎：实变区快速融合，引起弥漫区快速融合，引起弥漫性肺泡性肺泡损害（均一性或斑片状害（均一性或斑片状单侧或双或双侧气腔气腔内内实变，以及磨玻璃密度灶或界限不清的小叶，以及磨玻璃密度灶或界限不清的小叶核心核心结节）。）。Photomicrograph(originalmagnification,100;hematoxylin-eosinstain)ofalungbiopsyspecimenfroma36-year-oldmanwithpneumoniaduetoherpessimplexvir

9、ustype1showsafibrousexudate(largearrows)alongthealveolarwalls.Notetheinterstitialthickeningduetofibroblasticproliferation(smallarrows).Photomicrograph(originalmagnification,100;hematoxylin-eosinstain)ofalungbiopsyspecimenfroma36-year-oldmanwithpneumoniaduetoherpessimplexvirustype1showsafibrousexudat

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

11、olarwalls.Notetheinterstitialthickeningduetofibroblasticproliferation(smallarrows).Pneumoniaduetoinfluenzavirus(typeC)ina46-year-oldmanwithdyspnea.Initialchestradiographshowsdiffusereticulonodularareasofincreasedopacityinbothlungs.Pneumoniaduetoinfluenzavirus(typeC)ina46-year-oldmanwithdyspnea.Follo

12、w-upchestradiographobtained15dayslatershowsprogressionoftheextentofdiseasewithdiffuseconsolidationthroughoutbothlungs.Pneumoniaduetoinfluenzavirus(typeC)ina46-year-oldmanwithdyspnea.(a)Initialchestradiographshowsdiffusereticulonodularareasofincreasedopacityinbothlungs.(b)Follow-upchestradiographobta

13、ined15daysafterashowsprogressionoftheextentofdiseasewithdiffuseconsolidationthroughoutbothlungs.(c)Thin-section(1-mmcollimation)computedtomographic(CT)scanobtained16daysafteraattheleveloftheaorticarchshowsdiffuseground-glassattenuationwithsomeirregularlinearareasofincreasedattenuationinbothlungs.(Ca

14、secourtesyofDrJungHwaHwang,SoonchunhyangUniversitySeoulHospital,Korea.)Pneumoniaduetoinfluenzavirus(typeC)ina46-year-oldmanwithdyspnea.(a)Initialchestradiographshowsdiffusereticulonodularareasofincreasedopacityinbothlungs.(b)Follow-upchestradiographobtained15daysafterashowsprogressionoftheextentofdi

15、seasewithdiffuseconsolidationthroughoutbothlungs.(c)Thin-section(1-mmcollimation)computedtomographic(CT)scanobtained16daysafteraattheleveloftheaorticarchshowsdiffuseground-glassattenuationwithsomeirregularlinearareasofincreasedattenuationinbothlungs.(CasecourtesyofDrJungHwaHwang,SoonchunhyangUnivers

16、itySeoulHospital,Korea.)Pneumoniaduetoinfluenzavirus(typeC)ina46-year-oldmanwithdyspnea.(a)Initialchestradiographshowsdiffusereticulonodularareasofincreasedopacityinbothlungs.(b)Follow-upchestradiographobtained15daysafterashowsprogressionoftheextentofdiseasewithdiffuseconsolidationthroughoutbothlung

17、s.(c)Thin-section(1-mmcollimation)computedtomographic(CT)scanobtained16daysafteraattheleveloftheaorticarchshowsdiffuseground-glassattenuationwithsomeirregularlinearareasofincreasedattenuationinbothlungs.(CasecourtesyofDrJungHwaHwang,SoonchunhyangUniversitySeoulHospital,Korea.)Pneumoniaduetoinfluenza

18、virus(typeC)ina46-year-oldmanwithdyspnea.Thin-section(1-mmcollimation)computedtomographic(CT)scanobtained1dayafterthesecondchestradiographattheleveloftheaorticarchshowsdiffuseground-glassattenuationwithsomeirregularlinearareasofincreasedattenuationinbothlungs.成年人巨成年人巨细胞病毒性肺炎胞病毒性肺炎 巨巨细胞病毒：胞病毒：DNA病毒病毒

19、疱疹病毒的一种疱疹病毒的一种免疫缺陷患者免疫缺陷患者严重症状的肺炎。重症状的肺炎。成年人巨成年人巨细胞病毒性肺炎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

20、。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。成年人巨成年人巨细胞病毒性肺炎胞病毒性肺炎 常常见CT表表现：磨玻璃密度影磨玻璃密度影实变结节灶灶边界不清的小叶核心界不清的小叶核心结节支气管支气管扩张小叶小叶间隔增厚隔增厚成年人巨成年人巨细胞病毒性肺炎胞病毒性肺炎Kang et al 报告了告了10例患巨例患巨细胞病毒性肺炎胞病毒性肺炎移植受体移植受体 的的CT表表现：结节(n=6),实变(n=4),(n=4),不不规则线状影状影(n=1)。Kim and Lee报告了告了11例免疫缺陷患者的高例免疫缺陷患者的高分辨分辨CT表表现,磨玻璃密度影磨玻璃密度影(n=11),不不规则线状影

21、状影(n=10),实变(n=7),多多发小小结节或或肿块(n=6),支气管支气管扩张或小叶或小叶间隔增厚隔增厚(n=5)。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 c

22、entrilobular nodules(arrows)in both lungs.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 infi

23、ltration(diffuse alveolar damage,organizing stage).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 hyperplasti

24、c pneumocytes.(2)Photomicrograph(original magnification,400;immunohistochemical marker for cytomegalovirus)shows positive intranuclear inclusion bodies(arrows).TitlePneumoniaduetocytomegalovirusina45-year-oldmanwhounderwentlivertransplantation.Chestradiographobtained4weeksafterlivertransplantationsh

25、owspatchyair-spaceconsolidationinbothlungs.Anendotrachealintubationtube,apigtaildrainagecatheterintherightpleuralspace,achesttubeintheleftpleuralspace,andacentralvenouscatheterareseen.TitlePneumoniaduetocytomegalovirusina45-year-oldmanwhounderwentlivertransplantation.Thin-section(1-mmcollimation)CTs

26、canobtainedattheleveloftherightupperlobebronchus2daysbeforetheChestradiographshowsmultifocalpatchyground-glassattenuationinbothlungs.Notetheconsolidation(whitearrow)andthesmall,poorlydefinednodules(blackarrows).Thereareassociatedbilateralpleuraleffusions.成年人病毒性肺炎的影像学表成年人病毒性肺炎的影像学表现多种多多种多样且且相互重叠，巨相互重叠，巨细胞病毒性感染胞病毒性感染时可伴有其它可伴有其它病毒及不典型致病菌的感染，不能病毒及不典型致病菌的感染，不能仅依靠影依靠影像学特点做出病毒性肺炎特定微生物的像学特点做出病毒性肺炎特定微生物的诊断。断。总结总结