病例讨论――肺炎支原体肺炎

支原体肺炎病例讨论,临床资料,患者：女，23岁主诉：间断发热、咳嗽、咳痰6天现病史：患者于6天前无明显诱因出现发热伴恶心、呕吐，为胃内容物，体温达39.6摄氏度，伴头疼、全身肌肉关节疼痛，伴轻微寒战、咳嗽、咳痰，黄色粘痰，量较多，自服解热止痛药未见退热，遂去医大二院给予清开灵、地红霉素、东松等消炎退热治疗仍不见好转，后去下瓦房医院予阿奇霉素静脉点滴2日后，体温波动于3739.8摄氏度之间。来我院查胸CT示右肺炎。自发病以来曾上肢红色皮疹后自行消退，食欲欠佳，大小便正常，体重无著变,临床资料,既往史：否认肝炎、结核等传染病史，无外伤手术史，无过敏史，预防接种史不详个人史：无外地久居史，无疫区接触史，无吸烟室，无饮酒史家族史：无遗传性家族病史,临床资料,入院查体：T:39.6P:110bpmR:28bpmBp:116/67mmHg患者年轻女性，既往体健，发育正常，营养中等，面容安静，意识清楚，皮肤粘膜无黄染、出血点，浅表淋巴结未及肿大，头颅五官端正，气管居中，咽红，胸廓对称，右肺第4肋间叩浊音，余叩诊清音，双肺呼吸音略粗，未闻及干、湿性啰音。心律齐，心音有力。腹平坦，肝脾不大。生理反射存在，病理反射未引出。,临床资料,辅助检查:入院血常规：血红蛋白137g/L，红细胞4.141012/L，白细胞6.6109/L，中性粒细胞90.6%，淋巴细胞6.5%，单核细胞2.9%血沉：53mm/1h血清结核抗体试验：TB-IgG（）血生化：TP61g/L，GLO23g/L，ALP39/LCRP：17.8mg/dLPCT:4.00ng/mL（12月30日）尿RBC：166/HPF，尿WBC：85/HPF,临床资料,细小病毒B19IgG抗体（）细小病毒B19IgM抗体（）嗜肺军团菌抗体（）巨细胞病毒IgM抗体（）血培养+药敏：无菌落发育痰细菌培养+药敏：肺炎克雷白氏菌（+）铜绿假单胞菌（+）恶臭假单胞菌（+）痰真菌培养：无真菌生长HIV抗体（），梅毒抗体（）,临床资料,(危重期):心肌酶LDH:587U/L，CK:462U/L，HBDH:389U/L心肌功能AST：70U/L,CK：590U/L,LDH:788U/LUREA：12.8mmol/L,CREA：189.0umol/L（12月27日）CA-test（冷凝集试验）：（）MP-IgM（肺炎支原体抗体IgM）：（）（1月4日）MP-IgM：阳性1：320,胸部CT平扫（2010-12-28）,胸部CT平扫（2010-12-28）,CT检查报告,1.右肺及左下叶多发实变及斑片状磨玻璃密度影，考虑感染性病变。右中下叶支气管管腔变窄，远端闭塞。右下肺门显示不清2.右侧胸腔积液3.双侧肾实质密度不均匀性减低,其他检查,ECG：窦性心动过速BUS：1.右侧胸腔积液（于仰卧位难以定位穿刺）2.左侧胸腔及腹腔未见明显液性暗区24小时脑电监测报告：记录期间除心电及电极伪差外，ECG可见全导无反应性、失节律性、超低幅（小于3uv）杂散可凝电活动，脑电趋于电静息水平，24小时未见改善迹象,请讨论！,治疗及抢救经过,患者主因肺感染予抗感染治疗后于12.29出现呼吸衰竭，12.30早上行气管插管和呼吸机辅助，呼衰持续不缓解，于12.30下午行ECMO植入术，术后转入SICU，予呼吸机辅助ECMO支持治疗，密切监测并抗炎及对症支持治疗，左胸腔闭式引流。后查体发现患者双侧瞳孔散大，5:5mm，呼吸循环不稳定，肝肾功能不全，病情危重，家属放弃治疗。于2011年1月6日19:01分宣布临床死亡死亡原因：多脏器功能衰竭死亡诊断：1.多脏器功能衰竭2.重症肺炎,肺炎支原体肺炎mycoplosmapneumoniaepneumonia，MPP,社区获得性肺炎最常见类型之一，常见于健康年轻人、儿童病理学特征：急性细胞性细支气管炎、支气管壁水肿和溃疡灶；支气管血管周围间质浸润；小叶性肺炎；严重病例可进展为DAD胸片：片状气腔阴影（实变、GGO）和/或网状间质浸润，不具特征性CT/HRCT：GGO(7886)，常呈小叶性分布；支气管壁或支气管血管束斑片状实变(6179)、增厚(4081)和小叶中心性结节(7889)(p均0.0001)为特征表现；单或双侧或多叶，下肺分布多；进展性病变呈双侧弥漫性其他：小叶间隔增厚(10)、网状线影(27)、淋巴腺病(1023)、胸膜渗出(720)影像学表现反映病理改变,A,B,40-year-oldwomanwithMycoplasmapneumoniaepneumonia.A,Chestradiographrevealspatchyareasofnonsegmentalair-spaceopacificationinbothlowerlobes.B,HRCT(1.5-mmcollimation)showsfocalareasofair-spaceconsolidationinnonsegmentaldistributionandmultiple,partlyconfluentair-spacenodulesincentrilobulardistribution.,30-year-oldmanwithMycoplasmapneumoniaepneumonia.A,Chestradiographrevealscoarsereticulationandthickeningofbronchovascularbundlesinrightlowerlobe.B,HRCT(1.5-mmcollimation)showsnonsegmentalsubpleuralair-spaceconsolidation(curvedarrow),centrilobularnodules(straightarrow),extensiveareasofground-glassattenuation,andinterlobularseptalthickening.,A,B,17-year-oldboywithM.pneumoniaepneumonia.HRCT(1.0-mmcollimation)revealsnodulessmallerthan10mmindiameter(arrows)inpredominantlycentrilobulardistributionandareasofGGO.Notesharpdemarcationbetweennormalandabnormalsecondarypulmonarylobules,consistentwithlobularpneumonia.,55-year-oldmanwithM.pneumoniaepneumonia.HRCT(1.0-mmcollimation)atlevelofrightupper(A)andlower(B)lobesshowpoorlydefinednodularandbranchingopacitywithpredominantlycentrilobulardistribution(straightarrow,B)andbronchialwallthickening(curvedarrow,AandB).,A,B,30-year-oldwomanwithM.pneumoniaepneumonia.CTshowsbronchialwallthickening(arrows).LobularareasofconsolidationandGGOarealsoseen.,BMCMedicalImaging2009,9:7doi:10.1186/1471-2342-9-7(1),24-year-oldmanwithM.pneumoniaepneumonia.CTshowscentrilobularnodules(tree-in-bud,arrows),bronchialwallthickeningisalsoseen.,BMCMedicalImaging2009,9:7doi:10.1186/1471-2342-9-7(2),Radiology:Volume238:Number1January2006(5),Thin-sectionCTscandemonstratesM.pneumoniaebronchopneumoniain23-year-oldman.Branchingcentrilobularnodules(tree-in-bud,arrowheads)areseenonabackgroundoffaintGGO.Bronchialwallthickening(arrow)isalsonoted.,影像学鉴别诊断,肺炎链球菌肺炎：炎症主要在肺泡腔，呈大片实变，段性支气管很少进展性病变，少见支气管壁增厚和树芽征金葡菌肺炎：密集的气腔实变，呈小叶性分布或融合成大片，多发，空洞干酪性肺炎、支气管内膜结核：虫蚀样空洞、多发播散灶巨细胞病毒性肺炎：双侧无数小结节，多见于免疫受损患者卡氏肺孢子菌病：双肺斑片状或大片GGO，呈地图样分布，边界常清楚，多见于免疫受损患者肺炎衣原体肺炎：小叶中心性结节，支气管扩张、壁增厚，带状实变；难鉴别结节病：广泛支气管血管周围结节样增厚,细菌性肺炎（bacterialpneumonia）,肺炎链球菌肺炎（streptococcuspneumoniaepneumonia）发生在任何年龄，是最常见的社区获得性肺炎，也是最常见的医源性肺炎（约40%）金黄色葡萄球菌肺炎（staphylococcalpneumonia）是相对不常见的社区获得性肺炎，很多医源性原因是由耐青霉素导致的，特别是监护室的病人细菌性肺炎是通过痰培养或血培养，以及BAL灌洗液确诊,肺炎链球菌肺炎炎症主要在肺泡腔，呈大片实变，段性支气管很少进展性病变，少见支气管壁增厚和树芽征ImagingfeaturesofS.pneumoniaepneumonia:（1）Lobar(partorall)consolidationmostfrequentmanifestation（2）Consolidationmaybemultilobarorspherical（3）Cavitationandpneumatoceleformationrelativelyuncommon（4）Lymphadenopathyfrequent(onCT)（5）Accompanyingpleuraleffusionfrequent(50%)andofteninfected(empyema),金葡菌肺炎多表现为密集的气腔实变，呈小叶性分布或融合成大片，多发，空洞等ImagingfeaturesofS.aureuspneumonia:（1）Patchyorbronchopneumonicconsolidation-unilateralorbilateral（2）Acinarnodules(upto1cmdiameter)frequent（3）Tree-in-budandcentrilobularnodulesidentifiableonCT（4）Abscessformationwithinconsolidationcommon（5）Pneumatocelesmorefrequentinchildrenthaninadults（6）Pneumothoraxandpleuraleffusions(empyema)arecommoncomplications,39-year-oldmanwithS.pneumoniaepneumonia.CTshowsair-spaceconsolidationinleftlowerlobe.,BMCMedicalImaging2009,9:7doi:10.1186/1471-2342-9-7(3),支气管血管束管壁增厚、支气管周围性结节或小叶中心性结节出现比例远小于肺炎支原体肺炎和肺炎衣原体肺炎,A49-year-oldmanwithS.pneumoniaepneumonia.HRCT(1-mmcollimation)revealsnon-segmentalair-spaceconsolidationinvolvingtherightlowerlobe.GGOisonlydetectedaroundareasofair-spaceconsolidation(arrows),EurRadiol(2003)13:515521DOI10.1007/s00330-002-1490-3(1),Thin-sectionCTscandemonstratesS.pneumoniaepneumoniain54-year-oldman.Segmentalconsolidationwithairbronchograms(arrows)isseeninrightmiddlelobe.FocalareaofGGO(arrowhead)isnotedinrightlowerlobe.,Radiology:Volume238:Number1January2006(4),AxialCTimageshowsbilateralconsolidationandground-glassdensitiesina61-year-oldbonemarrowrecipientwithmyelodysplasticsyndrome.Staphylococcusaureuswasculturedfrombronchoalveolarlavage.,DiagnIntervRadiol2008;14:75-82,A38-year-oldmanwithStaphylococcusaureuspneumonia.HRCTscan(1-mmcollimation)showspatchyareasofair-spaceconsolidation,consistentwithbronchopneumonia,EurRadiol(2003)13:515521DOI10.1007/s00330-002-1490-3(4),31-year-oldmanwithsevereM.pneumoniaepneumoniawithrespiratoryfailurerequiringmechanicalventilation.CTshowsbilateralair-spaceconsolidationandpleuraleffusion.,BMCMedicalImaging2009,9:7doi:10.1186/1471-2342-9-7(4),31-year-oldmanwithsevereM.pneumoniaepneumoniawithrespiratoryfailurerequiringmechanicalventilation.CTshowsbilateralair-spaceconsolidationandpleuraleffusion.,BMCMedicalImaging2009,9:7doi:10.1186/1471-2342-9-7(4),浸润性肺结核（infiltrativepulmonarytuberculosis）,共同点：都可出现小叶中心性分布的病灶，结节状或小斑片状气腔实变影及树芽征,都很少出现间质纤维化改变不同点：浸润性肺结核多见于年长儿，结核中毒症状较重。多位于肺上叶，呈多样性，肺内播散灶为边界清晰的多发点状、小结节状阴影，变化缓慢，吸收后仍留有痕迹，即影像学可见新旧病灶并存，出现钙化，少见GGOMPP短期内病变范围迅速扩大，且一般在治疗12周可以明显吸收或完全吸收。鉴别主要还是通过痰涂片和实验室检查。,AxialCTimageshowsconsolidationandill-definednodulesintheposteriorsegmentofrightupperlobeinaneutropenicpatientwithtuberculousinfection.,DiagnIntervRadiol2008;14:75-82,巨细胞病毒性肺炎（cytomegaloviruspneumonia,CMP）,病原体CMV属疱疹病毒亚科，为双链DNA病毒，可通过体液传播CMP是免疫抑制患者最常见的致命性并发症之一，常见于免疫缺陷患者，例如器官移植患者、AIDS患者及服用过免疫抑制药物的患者，也可发生于各种年龄的血液病患者CMP的主要病理表现为弥漫性肺泡损伤及局灶性间质性肺炎。CMP的影像学表现主要以病理学改变为基础,GGO是CMP最常见的影像学表现CMV的典型影像表现：双侧弥漫性分布的微小结节，直径1-5mm，边缘光滑或不规则，磨玻璃密度，为间质性肺炎的表现常见胸腔积液及淋巴结肿大,AxialCTimageshowsbilateralcentrilobularnodulesandpleuraleffusioninCytomegalovirusinfectionina38-year-oldbonemarrowrecipient.,DiagnIntervRadiol2008;14:75-82,A31-year-oldwomanwithcytomegaloviruspneumoniaafterbonemarrowtransplantation.HRCTscan(1.5-mmcollimation)demonstratesnumeroussmallnodules(arrows),EurRadiol(2003)13:515521DOI10.1007/s00330-002-1490-3(5),24-year-oldmanwithM.pneumoniaepneumonia.CTshowscentrilobularnodules(tree-in-budappearance,arrows).Bronchialwallthickeningisalsoseen.,BMCMedicalImaging2009,9:7doi:10.1186/1471-2342-9-7(4),Pneumoniaduetocytomegalovirusina45-year-oldmanwhounderwentlivertransplantation.(a)Chestradiographobtained4weeksafterlivertransplantationshowspatchyair-spaceconsolidationinbothlungs.Anendotrachealintubationtube,apigtaildrainagecatheterintherightpleuralspace,achesttubeintheleftpleuralspace,andacentralvenouscatheterareseen.(b)Thin-section(1-mmcollimation)CTscanobtainedattheleveloftherightupperlobebronchus2daysbeforeashowsmultifocalpatchyground-glassattenuationinbothlungs.Notetheconsolidation(whitearrow)andthesmall,poorlydefinednodules(blackarrows).Thereareassociatedbilateralpleuraleffusions.,卡氏肺孢子肺炎（pneumocystiscariniipneumonia,PCP）,肺孢子虫属真菌，形态上类似原虫，可寄生于正常人体肺部。正常机体可通过细胞免疫和单核吞噬细胞系统将其清除，因此对健康宿主不致病对免疫抑制患者(如HIV感染、器官移植术后及放、化疗或免疫抑制剂治疗者)，由于免疫功能极度低下，机体防御机制破坏严重，从而对其清除能力明显下降，此时，肺孢子虫大量繁殖即可引发PCP临床表现可有干咳、呼吸困难和低烧,PCP的影像学改变以两肺间质性和肺泡性病变这两种类型为基础典型影像表现为双肺，特别肺门周围的和弥漫性轮廓不清的、孤立的、不对称的GGO斑片，呈“碎石路”分布，边界常清楚，可伴有小叶间隔增厚等间质性炎症，进展34天后可发展为肺泡性实变,A28-year-oldmanwithAIDSandPneumocystiscariniipneumonia.HRCTscan(1.5-mmcollimation)revealsextensivebilateralareasofGGOinageographicdistributionwithsharpdemarcationbetweennormalandabnormallung,EurRadiol(2003)13:515521DOI10.1007/s00330-002-1490-3(2),Pcariniipneumoniaina32-year-oldmanwithacquiredimmunodeficiencysyndrome.High-resolutionCTscanshowsareasofground-glassattenuationwithintralobularlines.,1512November-December2003RGfVolume23Number6RadioGraphics,肺炎衣原体肺炎（chlamydiapneumoniaepneumonia,CPP）,CPP是由衣原体引起的肺炎，衣原体有沙眼衣原体（chlamydiatrachomatis,CT）、肺炎衣原体（chlamydiapsittaci,CP）、鹦鹉热衣原体和家蓄衣原体。与人类关系密切的为CT和CP，偶见鹦鹉热衣原体肺炎非典型肺炎。发病率占社区获得性肺炎的6%12%，是继肺炎链球菌肺炎和MPP之后第三大社区获得性肺炎CPP临床症状及影像表现均无特异性，与MPP鉴别较困难，确诊有赖于实验室诊断微量免疫荧光试验(MIF)是目前国际上标准的且是最常用的CP血清学诊断方法,文献总结出三条临床鉴别要点：（1）MPP会发生中枢神经系统并发症，例如脑膜炎或脊髓炎；CPP患者很少有此并发症；（2）仅CPP患者与冠状动脉疾病相关联；（3）CPP经常发生再感染，或携带CPP抗体且偶尔需要一段长期的药物治疗去根除疾病的患者的慢性感染,影像上，肺实变、磨玻璃密度、小叶中心性结节、支气管血管束增粗在肺炎衣原体肺炎及支原体肺炎中都较常见。但肺炎衣原体肺炎患者中肺间质改变、支气管扩张和肺气肿较支原体肺炎患者常见，慢性阻塞性肺病更偏向于出现在肺炎衣原体肺炎,Transversethin-sectionCTscandemonstratesC.pneumoniaepneumoniawithGGOpredominancein23-year-oldman.ExtensiveareasofGGOareseenintheleftlowerlobe,whichdemonstratesthickenedbronchovascularbundles(arrows)andfinereticularframework(ie,crazy-pavingappearance).,Radiology:Volume238:Number1January2006(1),Thin-sectionCTscandemonstratesC.pneumoniaebronchopneumoniain66-year-oldman.Centrilobularnodules(arrows)andlobularconsolidationwithbilateralairwaydilatation(arrowheads).Notetheassociatedareasoflinearopacity.,Radiology:Volume238:Number1January2006(1),胸内结节病,结节病(sarcoidosis)是一种多系统多器官受累的肉芽肿性疾病，病因未明，是未知抗原与机体细胞免疫和体液免疫功能相互抗衡的结果常侵犯肺、双侧肺门淋巴结，临床上90%以上有肺的改变胸内结节病临床表现约50%患者早期常无明显症状和体征，25%患者主诉咳嗽和呼吸困难，可有乏力、发热、盗汗、食欲减退、体重减轻等，25%的患者有胸腔外症状，经常累及皮肤和眼睛,异常的胸部影像表现常是结节病的首要发现，占90%以上胸内淋巴结增大是结节病最常见的影像表现，占85%以上双肺门区淋巴结增大伴或不伴有纵隔淋巴结增大发生于95%的累及淋巴结的病人两侧肺门淋巴结对称性增大时结节病的较为特征性改变，仅有1%3%的患者出现单侧肺门淋巴结增大,51-year-oldmanwithCTfindingofnodularperibronchovascularinterstitialthickening(arrow).Resultsoftransbronchialbiopsywerepositiveformultipleepithelioidgranulomainalveolarparenchymaandbronchialwall,suggestingsarcoidosis.Resultsofspecialstainsforacid-fastbacilliandfungiwerenegative.,AJR:191,October2008(3),Sarcoidosisina25-year-oldasymptomaticman.High-resolutionCTscanshowsscatteredbilateralareasofground-glassattenuationassociatedwithinterandintralobularlines.,1512November-December2003RGfVolume23Number6RadioGraphics,Hilaradenopathyina27-year-oldmanwithHeerfordtsyndrome.(a)Chestradiographdemonstratestypicalbilateralhilaradenopathy.Adenopathyintherightparatrachealandleftaortic-pulmonarywindownodes(arrowheads)isalsoidentified.(b)Contrastmaterialenhancedcomputedtomographic(CT)scanclearlydepictsthebilateralhilaradenopathy(arrowheads).,RGfVolume24Number1,儿童肺炎支原体肺炎,儿童（18岁）影像表现常与细菌性肺炎类似：叶、段性实变（100）胸膜渗出（肺炎旁积液）（80）肺门、纵隔淋巴结增大（80）肺容积轻度减少（73）,Fig.a,b1-year-oldgirlwithM.pneumoniaepneumonia.a.Axialcontrast-enhancedCTscan(5-mmcollimation)showsalobarconsolidationintheleftupperlobewithpleuraleffusion(arrowheads).Mildmediastinalshiftingsuggestsmildvolumedecreaseoftheleftlung.Noteanothersubsegmentalconsolidationintherightupperlobe(arrow).b.18monthsafterashowscompleteresolutionofthepreviouslynotedconsolidations.Afocalregionofmosaicoligemiaisseenintherightupperlobe(arrows),suggestiveofconstrictivebronchiolitis.Theentireleftupperlobealsoshowsdiffuseregionsoflucency