AIDS相关胸部疾病的影像诊断

艾滋病相关胸部疾病的影像诊断ImagingofthethoraxinAIDS,上海复旦大学附属公共卫生临床中心Shanghaiaffiliatedpublichealthcentre施裕新张志勇王桂龙shiyuxinzhangzhiyongwangguilong,背景Background,发病率：大多数，新AIDS50%Morbidity:50%ofnewAIDSpresentation意义:致病率和死亡率的重要原因Meaning:importantcauseofmorbidityandmortality新特点:1.治疗抗病毒和预防性抗生素Newfeature:Tharapycombinationanti-retroviraltherapyandtheuseofprophylacticantibiotics2.病原体传统(PJP),少见（巨毒及鸟分菌)Pathogentradition(PJP),lesscommon(CMVandMAC)3.人群妇女、儿童Populationcharacteristicswomenandchildren,背景Background,4.影像:多样,重叠Radiologicalappearances:varietyandoverlap5.影像结合临床:Imagingbeinterpretedinconjuctionwithclinicalinformation获得背景，并发症，CD4+细胞数，治疗缓急程度血氧分析和痰菌培养NatureofHIVacquisition,previousinfectionsornon-infectionscomplications,CD4+cellcount,currentdrugtherapy,andacutenessofonsetandseverityoftheillness,pulseoximetryandsputummicroscopy,CD4细胞计数与肺部并发症,CD4细胞计数（106个/L）肺部病原体(种类、表现)200细菌性肺炎结核（继发性）肺癌50200细菌性肺炎结核（原发性）肺癌肺孢子虫肺炎Kaposi肉瘤淋巴瘤真菌感染弓形体病杆菌性血管瘤病普通胸片CTissuperiortoplainchestradiographyCT确诊率不高,约50%AccuracyofCTinthediagnosisofthoraciccomplicationsofAIDSlow,about50%确定病变，胸片-/Confirmingsuspectedchestdisease定性诊断Clarificationofabnormalitiesidentifiedonplainchestradiographs病变范围和形态Theextentofdiseaseandthepatternofparenchymalchange纵隔异常Evaluationofmediastinalabnormalities肿瘤分期或随访Stagingofmalignantdiseaseorre-stagingposttherapy指导活检、胸腔积液和气胸引流Biopsyplanning,drainingofloculatedpleuralfluidcollections,卡氏肺孢子菌肺炎(Pneumocystisjirovecipneumonia),PJP是最常见呼吸道感染PJPwasthecommonestrespiratorytractinfectiontooccurintheAIDSpopulation预防用药提高预期寿命，细菌性肺炎Prophylacticpreventativetherapyincreaselifeexpectancy，bacterialpneumoniasuperseded进行性咳嗽和发热、低氧表现Historyofcoughandfever，hypoxicdevelopingoverseveraldays痰标本、活检Inducedsputumsample,BAL,transbronchialbiopsy,X线典型：Chestradiograph:两侧肺门分布毛玻璃或网格状浸润Bilateralground-glassorreticularinfiltratesmostmarkedinaperihilardistribution,卡氏肺孢子菌肺炎(Pneumocystiscariniipneumonia),CT（1）肺门周围毛玻璃样浸润，地图样分布Perihilarground-glassinfiltrat,geographicaldistribution（2）线状或网格状伴有小叶间隔增厚吸收较慢Alinearorreticularinterstitialpatternwiththickeningoftheinterlobularseptae-slowesttoresolve,卡氏肺孢子菌肺炎(Pneumocystiscariniipneumonia),不典型：局部实变、肿块、多发结节、胸腔积液、气胸、空洞、淋巴结增大和偶结节钙化Lesstypicalradiographicpatterns:focalareasofconsolidation,masslesions,multiplelungnodules,pleuralfluid,pneumothorax,cavitation,lymphnodeenlargementandoccasionalnodalcalcification与细菌性肺炎和分支杆菌鉴别Difference:bacterialpneumoniasandtypicaloratypicalmycobacterialinfection喷他咪叮预防-PJP局限于上叶或以上叶病变为主。Pentamidineprophylaxis-isolatedtoorpredominantintheupperlobes,肺门周的毛玻璃样浸润，呈地图样分布，累及肺组织被正常肺实质分开,吸收较慢线状或网格状小叶间隔增厚,其他表现,卡氏肺孢子菌肺炎(Pneumocystiscariniipneumonia),10%-38%肺囊肿或气胸1038%ofcasespulmonarycystsorpneumatocoeles典型：充气气囊，薄壁，内外壁光整Typicallythinwalled,withsmoothinnerandoutermargins不典型：厚壁空洞，外形规则或不规则，不含有液体或其他物质Regularorirregularinshape,donotcontainfluidorothermaterial毛玻璃样+囊腔或气胸-PCPGGO+Cysts-PJP气胸和纵隔气肿是肺囊肿并发症PneumothoraxandpneumomediastinumarerecognizedasfurthercomplicationsHRCT评价非典型有价值HRCTishelpfulinatypicalcases,肺囊肿或气胸10%-38%病例,细菌性肺炎（Bacterialpneumonia）,CD4+低高CD4+lowhigh细菌性肺炎五倍，败血症100倍TheincidenceofbacterialpneumoniaapproximatelyfivetimesgreaterthaninanotherwisesimilarbutHIVnegativepopulation,thedevelopmentofpneumococcalsepticaemiais100timesgreaterthaninthegeneralpopulation临床表现和过程相同，但进展、空洞、双肺渗出和脓肿形成快TheclinicalpresentationofpneumoniaisgenerallythesameasintheHIV-negativepopulation,thetendencytorapidprogression,cavitation,parapneumoniceffusionandempyemaformationgreater,细菌性肺炎（Bacterialpneumonia）,病原体多数类似Theorganismsencounteredsametogeneral少数免疫抑制后期：罗卡利马体菌，马红球菌，空洞性肺炎+纵隔淋巴结肿大Opportunisticbacterialinfectionsencounteredinthelaterstagesonimmunosuppression,includingRochalimaeasp.AndRhodococcusequi,whichusuallycausesacavitatorypneumoniaoftenwithassociatedmediastinallymphadenopathy,细菌性肺炎（Bacterialpneumonia）,叶、段实变多Lobarorsegmentalconsolidationtheusualradiographicfindings空洞和胸膜病变Cavitationandpleuralcomplications间质渗出、小结节、树芽征、马赛克样密度-支气管炎，细支气管炎和支气管扩张Interstitialinfiltrate,multiplesmallnodules,treeinbud,mosaicattenuation-bronchitis,bronchiolitisandbronchiectasis,叶或段实变,细菌性感染支气管炎细支气管炎和支气管扩张,治疗前后,结核分支杆菌（Mycobacteriumtuberculosis）,正常人群几百倍,更易发生在免疫抑制后期，类似细菌性肺炎。PPD无反应。病原学诊断尤为重要，早期诊断可提高生存期TheincidenceseveralhundredtimesgreaterintheAIDSpopulation.Increasinglycommontowardsthelaterstagesofimmunosuppression.PPDnoreaction.Etiologyisimportant,espcialyearlydiagnosis.临床和放射学特征依赖于免疫抑制的程度BoththeclinicalandradiologicalfeaturesofTBaredependentonthedegreeofimmunosuppression较高CD4+（0.1109/L)-继发TBHigherCD4+（0.05109/L)counts-resemblere-activationTB较低CD4+-原发TB特征更典型，淋巴结显著肿大，胸膜炎症，血行以及支气管肺播散，少见部位的叶实变LowerCD4+counts-primaryinfection,withlymphnodeenlargement,pleuraldiseaseandatendencytohaematologicalandbronchopulmonarydissemination.,痰菌阳性胸片正常高达45%，CT较胸片为敏感Sputum+with45%normalchestplain;CTmoresensitiveCT:实变、空洞(少见)consolidation,cavitation(less)单发或多发结节,尤其是粟粒性肺结核常见solitaryormultiplenodules，especiallyphthisismiliaris胸腔积液pleuraleffusions分枝状结节或“树芽征”centrilobularbranchingnodulesortreeinbud周边强化的淋巴结肿nodalenlargementwithnecrosis,血行性播散,治疗前后,淋巴结结核,淋巴结结核,淋巴结结核,AIDS合并肺TB,血中找到猪霍乱杆菌,AIDS合并肺TB,AIDS合并肺TB,AIDS合并肺TB,继发性肺结核,非典型分枝杆菌（Atypicalmycobacteria）,临床特点：CD4+低（50106/L)，胃肠道获感染,CD4+countsbelow10-6cells,acquiredviathegastrointestinaltract1/3AIDS发病,血培养或骨髓抽吸明确诊断MACaffectsupto35%ofpatientsduringthecourseoftheirillness影像:间质性或腺泡渗出，肺门淋巴结肿大和少见的空洞Imagingfinding:interstitialoralveolarinfiltrates,Hilarlymphadenopathy,rarelycavitation与结核类似，胸腔积液或正常的胸片更为常见SimilartoMycobacteriumtuberculosis,pleuraleffusionsoranormalchestradiographaremorecommon粟粒状、结节状病灶少见,可有“树芽征”Miliarynodlesdiseaselesscommon,Treeinbudappearance,鸟型分支杆菌（MAC）,杆菌性血管瘤病（Bacillaryangiomatosis）,亨氏巴尔通氏菌感染，只发生AIDSOccursalmostexclusivelyinAIDSpatients放射表现:1mm数cm单发或多发结节，Radiologicalappearances:solitaryormultiplepulmonarynodulesrangingfrom1mmtoseveralcentimetresindiameter纵隔淋巴结肿大Mediastinallymphadenopathy显著强化-气道或肺实质局部的血管增殖Intenseenhancement,Airwaysandlungparenchymaproliferation,真菌感染（Fungalinfections）,AIDS病人发生真菌感染并不常见UncommonincomparisonwithotherinfectivedisordersinAIDS隐球菌最常见的肺部真菌病原体CryptococcusisthecommonestpulmonaryfungalpathogenintheAIDSpopulation脑膜炎是最常见的临床表现Meningitisisthecommonestmanifestationofcryptococcalinfection肺是感染门户LungisthoughttobetheportalofentryCD4+细胞数量低于10010-6occuratlowCD4+countsoflessthan10010-6cells,典型：局部结节或空洞性结节，很少见。Classicalappearances:focalnoduleformation,withorwithoutcavitation,lesscommon最常见：网状或结节状网格间质性渗出、肺泡实变、毛玻璃样改变、粟粒状结节、肿大淋巴结和少量胸腔积液。Commonestradiologicalfeatures:reticularorreticulonodularinterstitialinfiltrates,alveolarconsolidation,ground-glasschange,miliarynodules,lymphadenopathyandsmallpleuraleffusions需与PJP、TB以及化脓性细菌感染相鉴别DifferentialdiagnosisofPCP,TBandpyogenicbacterialinfections,曲霉菌(Aspergillusfumigatus),好发于HIV感染后期深度免疫抑制的病人Patientswithprofoundimmunosuppression最常见表现：厚壁空洞，可有内壁肿块Commonestradiographicfindings:thick-walledcavitieswithorwithoutanintracavitarymass血管侵犯导致血管性梗塞Haemorrhagicinfarctionasaresultofangioinvasion少见表现：结节和肺实变。Lesscommonfindings:non-cavitatingnodulesandlungconsolidation.气管支气管壁结节样增厚thickeningofthetrachealandbronchialwalls双侧的下叶肺膨胀不全和肺实变bilaterallowerlobeatelectasisandconsolidationPJP或TB空洞内曲菌球。mycetomaformationinpreexistingcavityduetopreviousPCPorTB,PJP并曲菌感染,荚膜组织胞浆菌(Histoplasmacapsulatum),少见,多生活于流行区，通常于免疫抑制较重时Uncommon,originatefromorliveinanendemicarea,profoundlevelsofimmunosuppression影像：两侧结节或间质性阴影，小于3-5mmBilateralnodularorinterstitialshadowing,noduleslessthan35mmindiameter肺实变,少量胸腔积液,肺门或纵隔淋巴结肿大lungconsolidation,smallpleuraleffusions,hilarormediastinallymphadenopathy病原体检测有重要价值,痰检并不可靠,支气管冲洗可靠Sputumanalysisunreliableandexaminationofbronchialaspiratesisnecessaryfordiagnosis,星状奴卡菌(Nocardiaasteroides),CD4+很低CD4+countlow放射：多样Radiologicalappearances:variable最常见：小叶或多个小叶实变约占1/2Commonestappearance:Lobarormultilobarconsolidation其次孤立肿块，网状结节渗出Solitarypulmonarymasses,reticulonodularinfiltrates胸腔积液，空洞常见Pleuraleffusions,Cavitation,病毒感染（Viralinfections）,巨细胞病毒致病率和致死率最高CMVisthemostcommonviralpathogentocausemorbidityandmortalityinpatientswithAIDSCD4+非常低（平均29106个/L）CD4+verylow低氧，进行性呼吸加快和间质性渗出Hypoxia,increasedrespiratoryratesandinterstitialinfiltrates很少单独存在，通常与肺外巨细胞感染或KS一同存在CMVpneumonitiswasrarelyfoundinisolation,frequentlybeingincombinationwithextrathoracicCMVinfectionorKS,巨细胞病毒(Cytomegalovirus),放射学表现多样，没有特异性Radiologicalappearances:variedandnon-specific主要：磨玻璃样密度Include:ground-glassattenuation高密度实变denseconsolidation支气管壁增厚或支气管扩张bronchialwallthickeningorbronchiectasis间质网状改变interstitialreticulationwithoutairspacedisease散在的肺部结节或肿块discretepulmonarynodules通常围绕肺门并延伸至下野mosttypicallyperihilarandextendintothelowerzones.,单纯疱疹(Herpessimplex),很少发病，通常发生于严重免疫抑制病人RareasacauseofpneumoniaintheHIVinfectedpopulation,usuallyassociatedwithprofoundimmunosuppression影像表现：局部坏死性气管支气管弥漫性间质性肺炎Focalnecrotizingtracheobronchitisoradiffuseinterstitialpneumonitis,寄生虫性感染（Parasiticinfections）,很少发生肺部感染rarecauseoflungdiseaseintheHIVinfectedpopulation影像:结节状渗出、网状结节渗出和胸腔积液，无特异性nodularinfiltratesorreticulonodularinfiltratesandpleuraleffusions.有的类似PJPSimilartoPJP,淋巴细胞性间质性肺炎（Lymphocyticinterstitialpneumonitis）,反应性肺部淋巴组织增生，更多发生在免疫抑制病人reactivepulmonarylymphoproliferativedisorderoccurringmorecommonlyinimmunocompromisedpatients平片典型表现：下野网格状或结节网格状阴影，磨玻璃阴影，实变或单个小结节的浸润chestradiography:reticularorreticulonodularshadowinginthelowerzones,ground-glassshadowing,consolidationoranodularinfiltrate,淋巴细胞性间质性肺炎（Lymphocyticinterstitialpneumonitis）,淋巴细胞性间质性肺炎（Lymphocyticinterstitialpneumonitis）,典型CT：双侧磨玻璃样阴影bilateralground-glassshadowing边界不清小叶中心结节poorlydefinedcentrilobularnodules胸膜下或支气管血管周小结节smallsubpleuralorperibronchovascularnodules其他表现：小叶间隔增厚、支气管血管束增粗,支气管充气实变、大结节肺囊肿、蜂窝状改变、支气管扩张,胸膜增厚和淋巴结增大septalthickening,thickenedbronchovascularbundles,airspaceconsolidation,largenodules,lungcysts,肺囊肿位于肺实质深部Lungcystsaretypicallylocateddeepwithinthelungparenchyma,滤泡细支气管炎（Follicularbronchiolitis）,CT特征：小叶中心或小叶周结节,区域性毛玻璃样改变CTcharacteristicfindings:centrilobularorperilobularnodulesandareasofgroundglassopacity较少见：支气管壁增厚、支气管扩张、肺气肿、支架结构扭曲、小叶间隔增厚和支气管充气性实变LesscommonCTfinding:bronchialwallthickening,bronchialdilatation,emphysema,architecturaldistortion,interlobularseptalthickeningandperibronchovascularairspaceconsolidation,卡波济肉瘤（Kaposissarcoma）,西方和非洲最常见恶性疾病KSisthemostcommonAIDS-associatedmalignancyinWesterncountriesandAfrica疱疹病毒是KS的诱发因素,肺KS可发于皮肤KS病人Kaposissarcomaassociatedherpesvirus(KSHV),PulmonaryKSoccursin1847%ofpatientswithknowncutaneousKS大多数为双侧肺门肺部浸润,通过沿支气管血管束侵犯到肺部实质BilateralperihilarpulmonaryinfiltratesextendintothepulmonaryparenchymaalongthebronchovascularbundlesCT特征：边界不清的实质结节,周围有小范围的毛玻璃样阴影包绕CTfeatures:illdefinedparenchymalnodules,maybesurroundedbyasmallareaofground-glassshadowing其他：