葉寧肺真菌病影像與臨床

1、1,,各位專家、老師們好！,2,肺真菌病影像表現(xiàn),天津醫(yī)科大學(xué)總醫(yī)院放射科葉 寧,3,真菌感染 多見于免疫功能低下者或接受HSCT者粒細(xì)胞減少是最主要的危險因素曲霉菌是為最常見的病原菌，其它真菌： 念珠菌、隱球菌、毛霉菌等等以肺部感染多見,4,肺曲菌病,侵襲性：急性出血性壞死性肺炎 粒細(xì)胞減少、廣譜抗菌素應(yīng)用中、激素、免疫抑制者變應(yīng)性支氣管肺曲菌病 滲出性細(xì)支氣管炎、粘液嵌塞、支氣管中心性肉芽腫 支氣管

2、近端的囊性擴(kuò)張、肺實變 嗜酸性粒細(xì)胞肺炎、哮喘曲菌球：發(fā)生在已存在的肺內(nèi)腔內(nèi) 結(jié)核、支擴(kuò)、肺囊腫、結(jié)節(jié)病、組織胞漿菌病 AS 、肺癌、胸膜腔內(nèi)、咯血,5,觀察 伏立康唑 治療血液病患者并發(fā)侵襲性真菌感染(IFI)的臨床療效及安全性93例血液病患者并發(fā)IFI感染部位以 肺 部為主(87例,占93.5%)出現(xiàn)影像學(xué)改變者71例(76.3%) 磨玻璃影最多(44例), 多發(fā)斑片狀陰影(13例) 不規(guī)則多發(fā)

3、結(jié)節(jié)高密度影5例, 有暈征者4例, 有空洞形成者2例,天津醫(yī)科大學(xué)總醫(yī)院血液腫瘤科,6,觀察卡泊芬凈治療血液病患者侵襲性真菌感染(IFI)的療效和安全性80例血液病并發(fā)IFI患者,感染部位以肺部為主，62例 (77.5%)其他部位18例,包括胃腸道、口腔、鼻面部等胸部影像學(xué)改變 新月征1例,余為磨玻璃密度影或多發(fā)斑片狀影,天津醫(yī)科大學(xué)總醫(yī)院血液腫瘤科,7,肺部真菌感染影像表現(xiàn),實變陰影 沿支氣管分布的小片狀影磨玻

4、璃密度影單發(fā)或多發(fā)結(jié)節(jié)、腫塊可有淺分葉 多位于肺中外帶,8,,,consolidation in lobar pneumonia,9,10,The ground-glass opacity is defined as a hazy increase in attenuation without obscuration of the underlying vesselsThis sign is seen in avarie

5、ty of hemorrhagic,TB ，inflammatory, and neoplastic nodules,,11,,Centrilobular nodules Nodules are positioned 5 to 10 mm from costal and visceral pleural surfaces and interlobular septaRandom nodules They ar

6、e found in relation to the visceral pleura, interlobular septa, and center of the lobule roughly equally,12,小葉中心結(jié)節(jié)與胸膜面、葉間裂、小葉間隔 有數(shù)毫米的距離圍繞或遮蓋了小動脈，可見細(xì)支氣管影,13,15-year-old boy with Aspergillus infection 133 days after

7、 bone marrow trans-plantation. large nodule with irregular margins in lingula and several small nodules. Some small nodules are centrilobular (curved arrows), and some are in a random distribution (straight arrow)

8、.,14,圍繞結(jié)節(jié)或腫塊周圍的磨玻璃密度為侵襲性曲霉菌病灶 周圍出血征象不具特異性，可見于其他類型的結(jié)節(jié)的出血，或腫瘤的肺浸潤 （如腺癌）,15,邊界模糊的低密度影小葉中心性結(jié)節(jié)亞急性過敏性肺泡炎,16,multiple bilateral nodules of variable sizes, some of them with surrounding ground-glass attenuation,17,,asp

9、ergillosis,18,,Primary tuberculosis in a 45-year-old woman with neutropenia following bone marrow transplantationA: consolidation and adjacent ground-glass opacity in t

10、he left upper lobe B: Photomicrograph of wedge biopsy specimen from the left upper lobe demonstrates lung microabscesses (A) surrounded by a layer (arrows) of epithelioid histiocytes, the two components of the granuloma

11、tous inflammatory reaction of tuberculosis. Also note fibrinous exudates (arrowheads) in alveolar spaces surrounding necrotic granulomas,19,肺部真菌感染影像表現(xiàn),曲菌球 游離、與洞壁間有新月形間隙空洞 厚壁洞外緣模糊，“暈征” 薄壁洞外緣較清楚支擴(kuò) 多在兩肺

12、門附近其它 肺門、縱隔淋巴結(jié)腫大 胸腔積液，骨破壞,20,空洞內(nèi)曲菌球形成 洞內(nèi)腫塊可移動,隨體位改變而移動近地側(cè),22,Fungus ball (aspergilloma). a thick-walled cyst (arrow) with a round intracavitary mass. The cavity was pre-existing, representing a pneu

13、matocele following treatment of staphylococcal pneumonia.,,23,空氣新月征 air cresent sign感染后2、3周出現(xiàn)標(biāo)志中性粒細(xì)胞恢復(fù)、預(yù)后好,24,一種新月形氣體蓄積， 將空洞壁與洞內(nèi)腫塊分開原有空洞內(nèi)曲霉菌的寄生(aspergillus colonization)或 血管侵襲性曲霉菌病時 梗死肺回縮的特征表現(xiàn)其它：結(jié)核、韋格肉芽腫、空洞內(nèi)出

14、血、肺癌、足分支菌病,25,26,Angioinvasive pulmonary aspergillosis6 days after (A) with recovery from neutropenia demonstrates air crescent (arrows) within area of airspace consolidationa 30-year-old man with acute myelogenous l

15、eukemia,27,當(dāng)外周血白細(xì)胞<1000/mm3 時發(fā)生，侵襲性肺曲霉病是免疫功能受損者的常見感染類型平片：發(fā)現(xiàn)早期病變困難 單/多發(fā)局灶陰影、實變，外周分布CT：血管侵襲型、（侵襲性曲霉菌病通常指血管侵襲型）氣道侵襲型,曲霉菌?。╝spergillosis）,28,29,30,,Bilateral upper lobe aspergillomas,aspergillomas with surrou

16、nding air crescent a 65-year-old man who had previously had TB,31,,Lower lobe aspergillomaair-crescent signa 55-year-old man with idiopathic pulmonary fibrosis,32,,33,halo sign，暈征，早期征象病理為出血性梗死該征也見于： 念珠菌、巨細(xì)胞病毒感

17、染、Wegener肉芽腫、 轉(zhuǎn)移性血管肉瘤等,34,The halo sign consists of a nodule or focal area of consolidation surrounded by a halo of ground-glass attenuation This sign is seen in a variety of hemorrhagic, inflammatory, and neopla

18、stic nodules,,35,,28-year-old woman with invasive aspergillosis 104 days after bone marrow transplantationlarge nodule surrounded by ground-glass attenuation CT： halo sign,36,Invasive pulmonary aspergillosis in a 3

19、9-year-old manwith acute myelogenous leukaemia and neutropenia. multiple nodules surrounded by a halo of ground glass opacity in both upper lobes.,37,,,38,,Chronic necrotizing aspergillosis (semi-invasive aspergillos

20、is)53-year-old man with diabetes and emphysema,39,反暈征 reversed halo sign,局限性類圓形磨玻璃密度灶，周圍有完整或不完整實變環(huán), 少見，最初報道認(rèn)為是 COP 的特異征象，隨后也被描述在 副球孢子菌病(paracoccidioidomycosis)與暈征相似，隨著在其他疾病中被識別出，將失去其特異性,40,,肺孢子菌感染,41,免疫受損者常見并發(fā)癥，

21、 尤見于白血病治療后遷延粒細(xì)胞減少者臨床表現(xiàn)為發(fā)熱、咳嗽、進(jìn)行性呼吸困難， 病死率達(dá)60％，存活依賴于早期診斷和治療病理表現(xiàn)分兩型：血管侵襲型：菌絲栓塞中至大管徑動脈， 致感染性梗死氣道侵襲型：相對少見，約占30％， 侵犯氣道，深達(dá)基底膜,侵襲性曲霉菌病（Invasive aspergillosis）,42,HRCT： 結(jié)節(jié)或腫塊周圍磨玻密度（暈征） 亞段或段

22、性實變 空氣新月征 小血管影增粗鑒別診斷： 巨細(xì)胞病毒、單純皰疹肺炎、 Wegener肉芽腫、轉(zhuǎn)移性血管肉瘤、 Kaposi肉瘤,血管侵襲型,43,較少見平片：支氣管肺炎 CT： 小葉中心性結(jié)節(jié) 支氣管周圍實變均不具特征性,氣道侵襲型,44,HRCT支氣管周圍實變（曲霉菌性 支氣管肺炎）小葉中心性結(jié)節(jié)（曲霉菌性 細(xì)支氣管炎）,氣道侵襲型,45,,Invasive bronchiolar

23、aspergillosis in a patient who underwent bone marrow transplantation(a) peripheral branching structures (arrow) associated with focal areas of consolidation(b) Corresponding photograph of the autopsy specimenshows mul

24、tiple yellowish acinar nodules (arrows). (c) Photomicrograph of a lung biopsy specimen shows complete destruction of the bronchiolar wall (arrowheads) by Aspergillus organisms (arrow).,,,47,48,,Allergic bronchopulmonary

25、 aspergillosiscentral bronchiectasis (arrows) , small nodules (arrowheads)a 33-year-old asthmatic man with chronic cough,49,中央性支氣管擴(kuò)張， 典型的呈廣泛分布粘液栓線樣和分支狀結(jié)節(jié)（樹芽）周圍部實變或彌漫性磨玻璃影馬賽克灌注、呼氣時空氣潴留,變應(yīng)性支氣管肺曲菌病,50,,Aspergill

26、osis in a 52歲 with a chronic cough a 23-mm poorly defined nodular ground-glass opacity several peripheral solid portions (arrows) a subtle groundglass opacity (arrowhead)

27、,51,52,,小氣道疾病的直接征象 小葉中心結(jié)節(jié)曲霉菌沿著小氣道播散,,,53,Inflammation of the bronchiolar wall and intraluminal exudate results in linear opacities The combination of centrilobular branching linear and nodular o

28、pacities is known as the tree-in-bud pattern,54,,Progression of bronchopneumonia,55,,56,,樹芽征 小葉中心細(xì)支氣管擴(kuò)大，管腔被黏液液體或膿液嵌塞，常伴細(xì)支氣管周圍炎 見于 過敏性支氣管肺曲菌病 小氣道疾病、細(xì)支氣管擴(kuò)張、結(jié)核 偶見于肺泡癌,57,,58,bronchiolitis tree-in-bud pattern,,59

29、,,BronchiolitisExtension of the inflammatory process into the parenchyma results in 4 to 10 mm diameter centrilobular nodular opacities,60,,樹芽征 哮喘、細(xì)支氣管炎小結(jié)節(jié)伴分枝，提示細(xì)支氣管擴(kuò)張，有膿液或粘液,61,支氣管囊腫（ bronchocele ）,管狀或Y形、V形分支

30、狀結(jié)構(gòu)類似戴著手套的手指黏液一般呈軟組織密度， 但依其成分可有變化，如 過敏性支氣管肺曲霉菌病 時呈高密度先天性支氣管閉鎖，因通氣和灌注減少，周圍肺密度可減低,62,,Allergic bronchopulmonary aspergillosis,2-1,63,Allergic bronchopulmonary aspergillosis,multifocal bilateral consolidation and

31、 poorly defined nodular opacitiesparenchymal consolidation, bronchiectasis, mucus plugging (arrows), bilateral small centrilobular nodule,tree-in-bud patternspecimen: mucus plug containing mucin and numerous eos

32、inophilsa 41-year-old asthmatic man with chronic cough, fever, and dyspnea,2-2,64,支氣管擴(kuò)張中的曲菌感染,65,支氣管囊腫（ bronchocele ）,管狀或Y形、V形分支狀結(jié)構(gòu)類似戴著手套的手指黏液一般呈軟組織密度， 但依其成分可有變化，如 變應(yīng)性支氣管肺曲霉菌病 時呈高密度先天性支氣管閉鎖， 因通氣和灌注減少，周圍肺密度可

33、減低,66,,Osteomyelitis owing to aspergillus infection in a 15-year-old boy with acute myelogenous leukemia. a large low-attenuation extrapleural abscess (A) extending into the chest wall ( arrows ）,67,,例1,56歲，男性，急性髓系白血病

34、，右上葉后段節(jié)段性實變＋ GGO；光鏡（HE×100)顯示慢性出血性梗死（Radiology,1998; 208:777-782）,例2,58歲女性，急性髓系白血病 Halo sign; 約4周后，Air-crescent sign，標(biāo)志進(jìn)入感染恢復(fù)期，與白細(xì)胞計數(shù)恢復(fù)相一致 （Radiology 2001; 218:230–232）,例3,33歲，女性骨髓移植術(shù)后發(fā)生侵襲性肺曲霉菌病a. 左上葉結(jié)節(jié)并暈

35、征; b. 四周后復(fù)查出現(xiàn)空氣新月征,a,b,例4,男，49歲，白血病治療中出現(xiàn)發(fā)熱、咯血。痰培養(yǎng)：煙曲霉菌,,白血病 骨髓移植術(shù)后， 細(xì)支氣管侵襲性曲霉菌?。簩嵶儭⑿∪~中心性結(jié)節(jié)、樹丫征 (RadioGraphics 2001; 21:825–837),半侵襲性肺曲霉菌病（Semi-IPA）,慢性壞死性肺曲霉菌病， 易發(fā)生于輕度免疫抑制或存在慢性疾病者危險因素 糖尿病、酗酒、塵肺、膠原性血管病

36、、COPD、 放療史、營養(yǎng)不良、心肌梗死及小劑量激素； 結(jié)構(gòu)性肺病變（structural lung disease） 增加感染的危險性病程數(shù)月，與患者免疫抑制程度有關(guān)； 空洞形成一般在感染后5-7月 出現(xiàn)咳嗽、咳痰、發(fā)熱及白細(xì)胞增高； 可有反復(fù)咯血,,男性、68歲，慢性支氣管炎，反復(fù)少量咯血雙上肺多發(fā)實變，空洞尸檢標(biāo)本照片見邊緣不規(guī)則空洞性病變，呈褐色，由壞死物質(zhì)及曲霉菌感染所致（RadioGraphi

37、cs 2001; 21:825–837）,75,指免疫功能正?；颊?在沒有任何肺原發(fā)病癥和結(jié)構(gòu)異常的情況下 形成的肺內(nèi)慢性或亞急性真菌感染性 隨健康體檢的普及而增多多表現(xiàn)為孤立性結(jié)節(jié)，少數(shù) 多發(fā)結(jié)節(jié) 極易誤診為肺癌、 肺結(jié)核,原發(fā)肺真菌性肉芽腫,76,肺部真菌感染主要鑒別,支氣管炎-肺炎 血管炎性肉芽腫 肺結(jié)核 肺部轉(zhuǎn)移瘤、原發(fā)性腫瘤,77,pneumatocele,肺氣囊 肺內(nèi)薄壁的含氣囊腔