成年人巨细胞病毒性肺炎case精要课件

成年人巨细胞病毒性肺炎 影像学及病理学表现 胸组读片 2010-03-02 刘晶华 Case Name：Me Ping Sex：Female Age：46 P No.：P10044471 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. Case Diagnosis: Bilateral diffuse lesion of lung, considered as infection. Differentiate Diagnosis： (1)Viral pneumonia(CMV,EBV) (2)PCP (3) Chlamydia pneumonia 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。 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 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 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。 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。 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） 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). 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。 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）。 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. 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.) 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. 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。 成年人巨细胞病毒性肺炎 致病机制组织组织 病理学特点 同种异体 移植受体 T细细胞介导导抗原-抗体反 应应。 即使抑制病毒复制时时也 可发发生严严重的坏死性肺 炎。 坏死性炎症显显著 感染巨细细胞病毒的细细胞 相对较对较 少 AIDS患 者 免疫缺陷更严严重 巨细细胞病毒的细细胞致病 作用引起肺损损害。 弥漫肺泡损损害常较较不患 有AIDS的患者常见见。 大量巨细细胞病毒包涵体。 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 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) 。 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. 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). 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). Title Pneumonia due to cytomegalovirus in a 45-year-old man who underwent liver transplantation. Chest radiogra