肺部感染-影像学和病理.ppt

肺部感染 影像学和病理 Outline 流行病学影像学病理学 细菌性 大叶性肺炎 病原菌 Streptococcuspneumoniae CAP 35 KlebsiellapneumoniaeLegionellapneumophila病理生理 如下图 early A andadvanced B stagesoflobarpneumoniacausedbyStreptococcuspneumoniae In A theairspacesarefilledwithedemafluid onlyoccasionalneutrophilsareevident In B neutrophilspredominate 细菌性 小叶性肺炎 病原菌 StaphylococcusaureusEscherichiacoliPseudomonasaeruginosaAnaerobesHaemophilusinfluenzae 病理生理 A 病原菌到达细支气管形成小叶中心结节和分枝斑片B C 支气管周围实变 小叶或部分小叶分布 呈多中心 实变不跨国小叶间裂 Acutebronchopneumonia Lowmagnificationphotomicrographshowsseveralsmallfociofconsolidationlocatedaroundthelumensofsmallbronchioles arrows Chestradiographshowsareasofconsolidationintherightupperandleftlowerlobes Thepatientwasa23 year oldmanWithbronchopneumonia High resolutioncomputedtomography CT scanshowscentrilobularnodules arrows andlobularareasofconsolidation arrowhead andground glassopacity curvedarrow Thepatientwasa53 year oldmanwithbronchopneumonia 并发症 肺脓肿 病原菌 anaerobicbacteria S aureus P aeruginosa andK pneumoniaeInflammatorymasswithcentralpurulentnecrosisFrequentlycavitateSmoothorshaggyinnermarginsAir liquidlevelscommonMaximalwallthicknessusually 15Low attenuationcentralregionandrimenhancementonCTscan 并发症 坏死性肺炎 Bulgingfissuresign Posteroanteriorchestradiographshowsdenserightupperlobeairspaceconsolidationwithdownwardbulgingoftheminorfissure Thepatientwasa66 year oldmanwithpneumococcalpneumonia Necrotizingpneumonia Chestradiograph A showsinhomogeneousanddenseconsolidationintherightlung Computedtomography CT B imageshowsalargecavityandsloughedlungwithinthecavity arrow Thepatientwasa42 year oldalcoholicmanwithnecrotizingpneumoniasecondarytoKlebsiellapneumoniaeandanaerobicorganisms 并发症 气瘤 病原菌 金葡菌 儿童 PCP 免疫抑制的成人 特点 薄壁含气空洞 数天或周内扩大 可导致气胸 数周或数月吸收 肺脓栓 来源 心内膜炎 血栓性静脉炎 静脉置管 起搏器导线 影像学特点 空洞小结节 Feedingvesselsign image A showstwovesselsapparentlycoursingintoanodule feedingvesselsign image B demonstratesthattheonlyvesselinclosecontactwiththenoduleisadrainingvein arrow 肺炎链球菌肺炎 CAP的主要致病菌 40 危险因素 高龄 慢性心肺疾病主要影像学表现 均一实变 毗邻脏层胸膜次要表现 小叶性肺炎 20 35 球形实变 圆肺炎 叶间裂膨出高密度实变其他 胸腔积液 10 同侧淋巴节肿大 CT上50 CT价值 明确有无空洞或积脓 Lobarpneumoniaduetostreptococcuspneumonia RoundpneumoniaduetoStreptococcuspneumoniae BronchiolitisandbronchopneumoniaduetoStreptococcuspneumoniae ExtensivebilateralpneumoniaduetoStreptococcuspneumoniae 葡萄球菌肺炎 肺脓肿 Coccalcoloniesaredenselysurroundedbyneutrophils HE StrongbasophiliaofthebacteriainH EpreparationindicatesGrampositivity IncidentalterminalaspirationofMRSAcoloniesintothelung leadingtoaculture positiveresult HE MorphologicstudycaneasilydistinguishMRSA inducedinfectionfromthecarrierstateofMRSAwithoutprovokingclinicalmanifestation S aureusbronchopneumonia ischaracterizedhistologicallybypredominantlyperibronchiolarinflammation BronchopneumoniaduetoStaphylococcusaureus Chestradiographshowsbilateralpoorlydefinednodularopacitiesandpatchyareasofconsolidation Alsonotedisacentralvenousline Thepatientwasa70 year oldmanwithMRSApneumonia EmpyemaduetoStaphylococcusaureus Thepatientwasa44 year oldmanandanintravenousdruguser Hehadnoradiologicevidenceofsepticembolism SepticembolismduetoStaphylococcusaureus Thepatientwasa43 year oldmanwithpositivebloodculturesforStaphylococcusaureus 克雷白肺炎 CAP占1 5 HAP占15 危险因素 嗜酒 慢性支气管肺病 ICU病人常见影像学表现 CAP 均一大叶实变 右肺上叶多见 HAP 多中心单侧 60 双侧 40 实变 小叶性肺炎 其他常见发现叶间裂膨出 30 胸腔积液 60 70 肺脓肿 脓胸CT价值 明确空腔或脓肿 AutopsiedlungwithseverepneumoniainapatientwithdegenerativeneuronalDisorder Numerouslargeandlongpathogensaredispersedwithintheedematousalveolarspace Thepathogensarenotphagocytizedbyneutrophils HE lowpower LobarpneumoniaduetoKlebsiellapneumoniae Thepatientwasa73 year oldwomanwithK pneumoniaepneumonia Klebsiellapneumoniaepneumoniaandabscessformation Thepatientwasa53 year oldman C D 3dayslater 大肠埃希氏菌肺炎 CAP 4 HAP的5 20 危险因素 操劳过度病人常见影像学表现 多中心单侧或双侧实变 支气管肺炎 下叶为主其他表现 胸腔积液 BronchopneumoniaduetoEscherichiacoli Chestradiographshowspoorlydefinednodularopacities arrows intherightupperlobeandsmallbilateralfociofconsolidation 铜绿假单胞菌肺炎 HAP占20 危险因素 COPD 机械通气 抗生素运用 囊型纤维化定植菌常见影像学表现 小叶性肺炎 所有肺叶受累 CT提示小叶中心结节和tree in bud其他常见表现 肺脓肿 20 胸腔积液 60 左上 右上 Perivascularcuffing征 左下 美兰细菌染色 右下 痰图片染色 胶质铁染色 痰染色 左 胶质铁染色右 革兰染色 SeverepneumoniaduetoPseudomonas 流感嗜血杆菌肺炎 5 20 的CAP病原菌危险因素 COPD 嗜酒 高龄常见影像学表现 小叶性肺炎 50 60 大叶性肺炎 30 40 非常见表现 CT示小结节和树芽征 圆肺炎 空洞 不超过15 胸腔积液 50 图左 NeonatalpneumoniacausedbyHaemophilusinfluenzaeinfection图右 阳性痰涂片 BronchiolitisandbronchopneumoniaduetoHaemophilusinfluenza Thepatientwasa50 year oldmanwithH influenzapneumonia 军团菌肺炎 2 5 CAP危险因素 高龄 男性 肿瘤或器官移植主要影像学表现 大叶性肺炎 进展至多叶受累少见表现 球形实变 圆肺炎 单个或多个结节或者肿块样实变并发症 空洞 免疫抑制病人 肺门淋巴结肿大 免疫抑制病人 胸腔积液 35 60 Fatalhospital acquiredpneumoniaseeninaprematureinfant left Thelungismassivelyinfiltratedbymacrophages HE right Numerousshortrodsareseeninthecytoplasmofalveolarmacrophages 痰涂片 希门尼斯染色 巨噬细胞胞浆可见军团菌 LobarpneumoniaduetoLegionellapneumophila Thepatientwasa77 year oldmanwithlegionellapneumonia