1、 艾滋病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 Imaging of the thorax in AIDS 上海复旦大学附属公共卫生临床中心 Shanghai affiliated public health centre 施裕新 张志勇 王桂龙 shiyuxin zhangzhiyong wangguilong 背景背景 BackgroundBackground 发病率：大多数，新AIDS50% Morbidity: 50% of new AIDS presentation with thoracic complications 意义 : 致病率和死亡率的重要原因 Meaning
2、: complications have become important cause of morbidity and mortality 新特点: 1.治疗 抗病毒和预防性抗生素 New clinic features: Tharapy combination anti-retroviral therapy and the use of prophylactic antibiotics 2.病原体 传统 (PJP ),少见（巨毒及鸟分菌 ) Pathogen tradition (PJP) , less common (CMV and MAC) 3.人群 妇女、儿童 Population
3、characteristics women and children 背景背景 BackgroundBackground 4.影像 :多样,重叠 Radiological appearances: variety and overlap 5.影像结合临床: Imaging be interpreted in conjuction with clinical information 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 Nature of HIV acquisition, previous infections or non- infections complica
4、tions, CD4+ cell count, current drug therapy, and acuteness of onset and severity of the illness, pulse oximetry and sputum microscopy CD4CD4细胞计数与肺部并发症细胞计数与肺部并发症 CD4CD4细胞计数（细胞计数（106 106 个个/L/L） 肺部病原体肺部病原体( (种类、表现种类、表现) ) 200200 细菌性肺炎细菌性肺炎 结核（结核（继发性继发性） 肺癌肺癌 5050200 200 细菌性肺炎 结核（结核（原发性原发性） 肺癌 肺孢子虫肺炎肺
5、孢子虫肺炎 KaposiKaposi肉瘤肉瘤 淋巴瘤淋巴瘤 真菌感染真菌感染 弓形体病弓形体病 杆菌性血管瘤病杆菌性血管瘤病 高 CD4+ lowhigh 细菌性肺炎五倍，败血症100倍 The incidence of bacterial pneumonia approximately five times greater than in an otherwise similar but HIV negative population, the developmentof pneumococcal septicaemia is 100 times greater than in the ge
6、neral population 临床表现和过程相同，但进展、空洞、双肺渗出和脓肿形成快 The clinical presentation of pneumonia is generally the same as in the HIV-negative population, the tendency to rapid progression,cavitation, parapneumonic effusion and empyema formation greater 细菌性肺炎（细菌性肺炎（Bacterial pneumoniaBacterial pneumonia） 病原体多数类似
7、The organisms encountered same to general 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 Opportunistic bacterial infections encountered in the later stages on immunosuppression, including Rochalimaea sp. And Rhodococcus equi, which usually causes a cavitatory pneumonia often with associated mediastinal lymphad
8、enopathy 细菌性肺炎（细菌性肺炎（Radiology of Radiology of Bacterial pneumoniaBacterial pneumonia） 叶、段实变多 1.Lobar or segmental consolidation is the usual radiographic findings 空洞和胸膜病变 2.Cavitation and pleural complications 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 3.Interstitial infiltrate, multiple small nodules,
9、tree in bud, mosaic attenuation- bronchitis,bronchiolitis and bronchiectasis 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（结核分支杆菌（Mycobacterium Mycobacterium tuberculosistuberculosis） 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 The incidence is several hundred times greater in the AIDS popu
10、lation than that of HIV-nagatitive populations. Increasingly common towards the later stages of immunosuppression. PPD no reaction. Etiology is important, espcialy early diagnosis. 临床和放射学特征依赖于免疫抑制的程度 Both the clinical and radiological features of TB are dependent on the degree of immunosuppression 较
11、高CD4+ （0.2109/L)-继发TB Higher CD4+ （0.2109/L )counts - resemble re-activation TB 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 Lower CD4+ counts -primary infection, with lymph node enlargement, pleural disease and a tendency to haematological and bronchopulmonary dissemination. 痰菌阳性胸片正常高达45%，CT较
12、胸片为敏感 Sputum + and normal chest plain was reported to 45% ;CT is more sensitive to detect lesions than plain radiography CT:实变、多叶段病变，空洞(少见) 1.consolidation, cavitation(less) 单发或多发结节,尤其是粟粒性肺结核常见，大小、分布不均，易融合 2.solitary or multiple nodules，especially phthisis miliaris 胸腔积液（多见） 3.pleural effusions 分枝状结节
13、或“树芽征”,似小叶性肺炎 4.centrilobular branching nodules or tree in bud 周边强化的淋巴结肿，部分病例淋巴结病变多于肺病变 5.nodal enlargement with necrosis,enhancement 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（混合感染） 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 非典型分枝杆菌非典型分枝杆菌 （Atypical mycobacteriaAtypical mycobacteria） 临床特点：CD4+低
14、（50106/L)，胃肠道获感染, CD4+ counts below 50106/L cells, acquired via the gastrointestinal tract 1/3AIDS发病,血培养或骨髓抽吸明确诊断 MAC affects up to 35% of patients during the course of their illness 影像:间质性或腺泡渗出，肺门淋巴结肿大和少见的空洞 Imaging finding : interstitial or alveolarinfiltrates,Hilar lymphadenopathy, rarely cavitat
15、ion 与结核类似，胸腔积液或正常的胸片更为常见 Similar to Mycobacterium tuberculosis, pleural effusions or a normal chest radiograph are more common 粟粒状、结节状病灶少见,可有“树芽征” Miliary nodles disease less common,Tree in bud appearance 鸟型分支杆菌（MAC） 真菌感染（真菌感染（Fungal infectionsFungal infections） AIDS病人发生真菌感染并不常见 Uncommon in comparis
16、on with other infective disorders in AIDS 隐球菌最常见的肺部真菌病原体 Cryptococcus is the commonest pulmonary fungal pathogen in the AIDS population 脑膜炎是最常见的临床表现 Meningitis is the commonest manifestation of cryptococcal infection 肺是感染门户 Lung is thought to be the portal of entry CD4+细胞数量低于10010-6 usually occur at
17、 patients with low CD4+ counts of less than 10010-6 cells 典型：局部结节或空洞性结节，很少见。 Classical appearances:focal nodule formation,with or without cavitation,but less common 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。 Commonest radiological features:reticular or reticulonodular interstitial infiltrate
18、s,alveolar consolidation, ground-glass change, miliary nodules, lymphadenopathy and small pleural effusions 需与PJP、TB以及化脓性细菌感染相鉴别 Differential diagnosis of PJP, TB and pyogenic bacterial infections 曲霉菌曲霉菌(Aspergillus fumigatus) 好发于HIV感染后期深度免疫抑制的病人 uaually occur at Patients with profound immunosuppres
19、sion 最常见表现：厚壁空洞，可有内壁肿块 Commonest radiographic findings: thick-walled cavities with or without an intracavitary mass 血管侵犯导致血管性梗塞 Haemorrhagic infarction as a result of angioinvasion 少见表现：结节和肺实变。 Less common findings: non-cavitating nodules and lung consolidation. 气管支气管壁结节样增厚 thickening of the trachea
20、l and bronchial walls 双侧的下叶肺膨胀不全和肺实变 bilateral lower lobe atelectasis and consolidation PJP或TB空洞内曲菌球。 mycetoma formation in preexisting cavity due to previous PCP or TB PJP并曲菌感染 病毒感染病毒感染（Viral infectionsViral infections） 巨细胞病毒 致病率和致死率最高 CMV is the most common viral pathogen to cause morbidity and mo
21、rtality in patients with AIDS CD4+非常低（平均29106个/L） CD4+ very low 低氧，进行性呼吸加快和间质性渗出 Hypoxia, increased respiratory rates and interstitial infiltrates 很少单独存在，通常与肺外巨细胞感染或KS一同存在 CMV pneumonitis was rarely found in isolation, frequentlybeing in combination with extrathoracic CMV infection or KS 巨细胞病毒巨细胞病毒(
22、 (CytomegalovirusCytomegalovirus) ) 放射学表现多样，没有特异性 Radiological appearances:varied and non-specific 主要：磨玻璃样密度 Include: ground-glass attenuation 高密度实变 dense consolidation 支气管壁增厚或支气管扩张 bronchial wall thickening or bronchiectasis 间质网状改变 interstitial reticulation without airspace disease 散在的肺部结节或肿块 discr
23、ete pulmonary nodules 通常围绕肺门并延伸至下野 most typically perihilar and extend into the lower zones. 卡波济肉瘤卡波济肉瘤（Kaposis sarcoma） 西方和非洲最常见恶性疾病 KS is the most common AIDS-associated malignancy in Western countries and Africa 疱疹病毒是KS的诱发因素,肺KS可发于皮肤KS病人 Kaposis sarcoma associated herpes virus (KSHV), Pulmonary K
24、S occurs in 1847% of patients with known cutaneous KS 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 Bilateral perihilar pulmonary infiltrates extend into the pulmonary parenchyma along the bronchovascular bundles CT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 CT features:ill defined parenchymal nodules, maybe surrounded by a small
25、 area of ground-glass shadowing 其他：小叶间隔增厚,叶间裂呈结节状，胸腔积液,心包积液和纵隔淋巴结增大 thickening of the interlobular septae and nodularity of the fissures,Pleural effusions,pericardial effusions and mediastinal lymphadenopathy 全身皮肤KS 淋巴瘤（淋巴瘤（LymphomaLymphoma） 发生较高 NHL is the second most common AIDS-associated maligna
26、ncy HL比NHL少见，具有侵犯性 Hodgkins lymphoma is less common than NHL 最常见表现：多发胸膜或肺内肿块,通常位于肺门周,偶为空洞 The most frequent imaging findings :multiple pleural or intrapulmonary masses, usually peripheral and occasionaly show cavitation. 较少见表现：孤立性肺结节，胸腔积液或纵隔淋巴结肿大 Less common: solitary pulmonary nodule, Pleural effusions, mediastinal lymphadenopathy, thoracic lymphadenopathy 放射学表现与其他疾病相互重叠，穿刺活检有价值 Overlap, CT guided biopsy be effective in differentiating
