肺部感染影像學(xué)和病理

肺部感染-

影像學(xué)和病理Outline流行病學(xué)影像學(xué)病理學(xué)細(xì)菌性-大葉性肺炎病原菌：Streptococcuspneumoniae，CAP(35%),

Klebsiellapneumoniae

Legionellapneumophila

病理生理：如下圖early(A)andadvanced(B)stagesoflobarpneumoniacausedbyStreptococcuspneumoniae.In(A),theairspacesarefilledwithedemafluid;onlyoccasionalneutrophilsareevident.In(B),neutrophilspredominate.細(xì)菌性-小葉性肺炎病原菌：Staphylococcusaureus

Escherichiacoli

Pseudomonasaeruginosa

Anaerobes

Haemophilusinfluenzae

病理生理：

A:病原菌到達(dá)細(xì)支氣管形成小葉中心結(jié)節(jié)和分枝斑片B，C:支氣管周圍實(shí)變，小葉或部分小葉分布，呈多中心，實(shí)變不跨國小葉間裂Acutebronchopneumonia.Lowmagnificationphotomicrographshowsseveralsmallfociofconsolidationlocatedaroundthelumensofsmallbronchioles(arrows).Chestradiographshowsareasofconsolidationintherightupperandleftlowerlobes.Thepatientwasa23-year-oldmanWithbronchopneumonia

High-resolutioncomputedtomography(CT)scanshowscentrilobularnodules(arrows)andlobularareasofconsolidation(arrowhead)andground-glassopacity(curvedarrow).Thepatientwasa53-year-oldmanwithbronchopneumonia.并發(fā)癥-肺膿腫病原菌：anaerobicbacteria，S.aureus,P.aeruginosa,andK.pneumoniaeInflammatorymasswithcentralpurulentnecrosis

Frequentlycavitate

Smoothorshaggyinnermargins

Air-liquidlevelscommon

Maximalwallthicknessusually<15

Low-attenuationcentralregionandrimenhancementonCTscan并發(fā)癥-壞死性肺炎Bulgingfissuresign.Posteroanteriorchestradiographshowsdenserightupperlobeairspaceconsolidationwithdownwardbulgingoftheminorfissure.Thepatientwasa66-year-oldmanwithpneumococcalpneumonia.Necrotizingpneumonia.Chestradiograph(A)showsinhomogeneousanddenseconsolidationintherightlung.Computedtomography(CT)(B)imageshowsalargecavityandsloughedlungwithinthecavity(arrow).Thepatientwasa42-year-oldalcoholicmanwithnecrotizingpneumoniasecondarytoKlebsiellapneumoniaeandanaerobicorganisms.并發(fā)癥-氣瘤病原菌：金葡菌（兒童），PCP（免疫抑制的成人）特點(diǎn)：薄壁含氣空洞，數(shù)天或周內(nèi)擴(kuò)大，可導(dǎo)致氣胸，數(shù)周或數(shù)月吸收肺膿栓來源：心內(nèi)膜炎，血栓性靜脈炎，靜脈置管，起搏器導(dǎo)線。影像學(xué)特點(diǎn)：空洞小結(jié)節(jié)，F(xiàn)eedingvesselsignimage(A)showstwovesselsapparentlycoursingintoanodule(feedingvesselsign）image(B)demonstratesthattheonlyvesselinclosecontactwiththenoduleisadrainingvein(arrow).肺炎鏈球菌肺炎CAP的主要致病菌（40%）危險因素：高齡，慢性心肺疾病主要影像學(xué)表現(xiàn)：均一實(shí)變，毗鄰臟層胸膜次要表現(xiàn)：小葉性肺炎（20-35%），球形實(shí)變（圓肺炎），葉間裂膨出高密度實(shí)變其他：胸腔積液（10%），同側(cè)淋巴節(jié)腫大（CT上50%）。CT價值：明確有無空洞或積膿

LobarpneumoniaduetostreptococcuspneumoniaRoundpneumoniaduetoStreptococcuspneumoniaeBronchiolitisandbronchopneumoniaduetoStreptococcuspneumoniaeExtensivebilateralpneumoniaduetoStreptococcuspneumoniae葡萄球菌肺炎肺膿腫Coccalcoloniesaredenselysurroundedbyneutrophils(HE).StrongbasophiliaofthebacteriainH&EpreparationindicatesGrampositivityIncidentalterminalaspirationofMRSAcoloniesintothelung,leadingtoaculture-positiveresult(HE).MorphologicstudycaneasilydistinguishMRSA-inducedinfectionfromthecarrierstateofMRSAwithoutprovokingclinicalmanifestation.S.aureusbronchopneumonia,ischaracterizedhistologicallybypredominantlyperibronchiolarinflammationBronchopneumoniaduetoStaphylococcusaureus.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%危險因素：嗜酒，慢性支氣管肺病，ICU病人常見影像學(xué)表現(xiàn)：CAP:均一大葉實(shí)變(右肺上葉多見）HAP:多中心單側(cè)（60%），雙側(cè)（40%）實(shí)變（小葉性肺炎）其他常見發(fā)現(xiàn)葉間裂膨出（30%），胸腔積液（60-70%），肺膿腫，膿胸CT價值：明確空腔或膿腫AutopsiedlungwithseverepneumoniainapatientwithdegenerativeneuronalDisorder。Numerouslargeandlongpathogensaredispersedwithintheedematousalveolarspace.Thepathogensarenotphagocytizedbyneutrophils(HE,lowpower).LobarpneumoniaduetoKlebsiellapneumoniae.Thepatientwasa73-year-oldwomanwithK.pneumoniaepneumonia.Klebsiellapneumoniaepneumoniaandabscessformation。Thepatientwasa53-year-oldman.C,D(3dayslater)大腸埃希氏菌肺炎CAP(4%),HAP的5-20%危險因素：操勞過度病人常見影像學(xué)表現(xiàn)：多中心單側(cè)或雙側(cè)實(shí)變（支氣管肺炎），下葉為主其他表現(xiàn)：胸腔積液

BronchopneumoniaduetoEscherichiacoli.Chestradiographshowspoorlydefinednodularopacities(arrows)intherightupperlobeandsmallbilateralfociofconsolidation.銅綠假單胞菌肺炎HAP占20%危險因素：COPD,機(jī)械通氣，抗生素運(yùn)用，囊型纖維化定植菌常見影像學(xué)表現(xiàn)：小葉性肺炎，所有肺葉受累，CT提示小葉中心結(jié)節(jié)和tree-in-bud其他常見表現(xiàn)：肺膿腫（20%），胸腔積液（60%）左上，右上:Perivascularcuffing征，左下：美蘭細(xì)菌染色。右下：痰圖片染色（膠質(zhì)鐵染色）痰染色左：膠質(zhì)鐵染色右：革蘭染色SeverepneumoniaduetoPseudomonas.流感嗜血桿菌肺炎5-20%的CAP病原菌危險因素：COPD,嗜酒，高齡常見影像學(xué)表現(xiàn)：小葉性肺炎（50-60%）大葉性肺炎（30-40%）非常見表現(xiàn)：CT示小結(jié)節(jié)和樹芽征，圓肺炎，空洞（不超過15%），胸腔積液（50%）圖左：NeonatalpneumoniacausedbyHaemophilusinfluenzaeinfection圖右：陽性痰涂片BronchiolitisandbronchopneumoniaduetoHaemophilusinfluenza.Thepatientwasa50-year-oldmanwithH.influenzapneumonia.軍團(tuán)菌肺炎2-5%CAP危險因素：高齡，男性，腫瘤或器官移植主要影像學(xué)表現(xiàn)：大葉性肺炎，進(jìn)展至多葉受累少見表現(xiàn)：球形實(shí)變（圓肺炎），單個或多個結(jié)節(jié)或者腫塊樣實(shí)變并發(fā)癥：空洞（免疫抑制病人），肺門淋巴結(jié)腫大(免疫抑制病人），胸腔積液（35-60%）Fatalhospital-acquiredpneumoniaseeninaprematureinfant。left）Thelungismassivelyinfiltratedbymacrophages(HE)right）Numerousshortrodsareseeninthecytoplasmofalveolarmacrophages痰涂片希門尼斯染色，巨噬細(xì)胞胞漿可見軍團(tuán)菌LobarpneumoniaduetoLegionellapneumophila.Thepatientwasa77-year-oldmanwithlegionellapneumonia.

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