1、整理课件1成年人巨细胞病毒性肺炎成年人巨细胞病毒性肺炎 影像影像学及病理学表现学及病理学表现整理课件2CaseCase Name：Me Ping Sex：Female Age：46 P No.：P10044471 整理课件3CaseCase Examine Date 2009-08-17 Thin-section(1-mm collimation)computed tomographic(CT)scan shows Bilateral diffuse ground-glass attenuation with thickened interlobular septa,and A lobular
2、 distribution,segmental consolidation with the“inflated bronchia”sign.There are several lymph nodes in the mediastina.No pleural effusion.The heart,liver,spleen and other scanned areas are normal.整理课件4CaseCase Diagnosis:Bilateral diffuse lesion of lung,considered as infection.Differentiate Diagnosis
3、：(1)Viral pneumonia(CMV,EBV)(2)PCP (3)Chlamydia pneumonia 整理课件5成年人病毒性肺炎成年人病毒性肺炎 流感病毒、麻疹病毒、汉坦病毒、腺病毒、流感病毒、麻疹病毒、汉坦病毒、腺病毒、单纯疱疹病毒、水痘单纯疱疹病毒、水痘-带状疱疹病毒、巨细带状疱疹病毒、巨细胞病毒以及胞病毒以及EBEB病毒等多种病毒能够引起成病毒等多种病毒能够引起成年人下呼吸道感染。年人下呼吸道感染。成年人病毒性肺炎可分为两种类型：发生成年人病毒性肺炎可分为两种类型：发生于健康宿主的非典型性肺炎于健康宿主的非典型性肺炎 ；发生于免疫；发生于免疫缺陷宿主的病毒性肺炎。缺陷宿主的
4、病毒性肺炎。整理课件6免疫正常及免疫缺陷患者常见的病毒感染免疫正常及免疫缺陷患者常见的病毒感染 免疫正常患者免疫正常患者 流感病毒流感病毒 汉坦病毒汉坦病毒 EB病毒病毒 腺病毒腺病毒 免疫缺陷患者免疫缺陷患者 单纯疱疹病毒单纯疱疹病毒 水痘水痘-带状疱疹病毒带状疱疹病毒 巨细胞病毒巨细胞病毒 麻疹病毒麻疹病毒 腺病毒腺病毒 整理课件7成年人病毒性肺炎成年人病毒性肺炎 影像学表现多种多样且相互重叠。影像学表现多种多样且相互重叠。患者年龄、免疫状况、社区性爆发、起病患者年龄、免疫状况、社区性爆发、起病状况、严重程度及持续时间、有无发疹等状况、严重程度及持续时间、有无发疹等临床信息对于诊断具有重要
5、帮助。临床信息对于诊断具有重要帮助。实验室检查实验室检查整理课件8常见的病理学表现常见的病理学表现 病毒能够引起：气管支气管炎，细支气管炎病毒能够引起：气管支气管炎，细支气管炎，肺炎。，肺炎。上皮细胞及相邻间质组织学改变最为显著。上皮细胞及相邻间质组织学改变最为显著。整理课件9常见的病理学表现常见的病理学表现 气管支气管炎：气道壁充血，管腔内单核气管支气管炎：气道壁充血，管腔内单核细胞浸润细胞浸润 ，上皮细胞变性、脱落。，上皮细胞变性、脱落。细支气管炎：细支气管炎：儿童常见，上皮细胞坏死，儿童常见，上皮细胞坏死，管腔内嗜中性粒细胞渗出，气道壁内单核管腔内嗜中性粒细胞渗出，气道壁内单核细胞为主的
6、炎性细胞浸润。细胞为主的炎性细胞浸润。整理课件10常见的病理学表现常见的病理学表现 实质受累（肺炎）：终末及呼吸性细支气实质受累（肺炎）：终末及呼吸性细支气管相邻肺组织首先受累，管相邻肺组织首先受累，可进展至整个肺可进展至整个肺叶。叶。老年及免疫缺陷患者可发生快速进展的肺老年及免疫缺陷患者可发生快速进展的肺炎。炎。组织学上，双肺弥漫性肺泡破坏（间质淋组织学上，双肺弥漫性肺泡破坏（间质淋巴细胞浸润，气腔内出血，水肿及纤维蛋巴细胞浸润，气腔内出血，水肿及纤维蛋白渗出，白渗出，2 2型肺泡上皮增生，透明膜形成）型肺泡上皮增生，透明膜形成）整理课件11 Photomicrograph(original
7、 magnification,100;hematoxylin-eosin stain)of a lung biopsy specimen from a 36-year-old man with pneumonia due to herpes simplex virus type 1 shows a fibrous exudate(large arrows)along the alveolar walls.Note the interstitial thickening due to fibroblastic proliferation(small arrows).整理课件12常见的影像学表现常
8、见的影像学表现 气管支气管炎：急性期很少出现异常影像学气管支气管炎：急性期很少出现异常影像学改变，但多年后粘膜破坏可表现为支气管扩改变，但多年后粘膜破坏可表现为支气管扩张。张。细支气管炎：气道阻塞常为不完全性，影细支气管炎：气道阻塞常为不完全性，影像学上表现为过度通气及边界不清的结节灶像学上表现为过度通气及边界不清的结节灶。整理课件13常见的影像学表现常见的影像学表现 病毒性肺炎：病毒性肺炎：边界不清的结节（边界不清的结节（4-10mm4-10mm的气腔内结节）。的气腔内结节）。细支气管周围斑片状磨玻璃密度及气腔实变。细支气管周围斑片状磨玻璃密度及气腔实变。常伴有过度通气。常伴有过度通气。快速
9、进展型肺炎：实变区快速融合，引起弥漫快速进展型肺炎：实变区快速融合，引起弥漫性肺泡损害（均一性或斑片状单侧或双侧气腔性肺泡损害（均一性或斑片状单侧或双侧气腔内实变，以及磨玻璃密度灶或界限不清的小叶内实变，以及磨玻璃密度灶或界限不清的小叶核心结节）。核心结节）。整理课件14 Pneumonia due to influenza virus(type C)in a 46-year-old man with dyspnea.Initial chest radiograph shows diffuse reticulonodular areas of increased opacity in both
10、 lungs.整理课件15 Pneumonia due to influenza virus(type C)in a 46-year-old man with dyspnea.Follow-up chest radiograph obtained 15 days later shows progression of the extent of disease with diffuse consolidation throughout both lungs.整理课件16 Pneumonia due to influenza virus(type C)in a 46-year-old man wi
11、th dyspnea.Thin-section(1-mm collimation)computed tomographic(CT)scan obtained 1 day after the second chest radiograph at the level of the aortic arch shows diffuse ground-glass attenuation with some irregular linear areas of increased attenuation in both lungs.整理课件17成年人巨细胞病毒性肺炎成年人巨细胞病毒性肺炎 巨细胞病毒：巨细胞
12、病毒：DNADNA病毒病毒 疱疹病毒的一种疱疹病毒的一种 免疫缺陷患者严重症状的肺炎。免疫缺陷患者严重症状的肺炎。整理课件18成年人巨细胞病毒性肺炎成年人巨细胞病毒性肺炎致病机制致病机制组织病理学特点组织病理学特点同种异体同种异体移植受体移植受体T细胞介导抗原细胞介导抗原-抗体反抗体反应。应。即使抑制病毒复制时也即使抑制病毒复制时也可发生严重的坏死性肺可发生严重的坏死性肺炎。炎。坏死性炎症显著坏死性炎症显著感染巨细胞病毒的细胞相感染巨细胞病毒的细胞相对较少对较少AIDS患者患者 免疫缺陷更严重免疫缺陷更严重巨细胞病毒的细胞致病巨细胞病毒的细胞致病作用引起肺损害。作用引起肺损害。弥漫肺泡损害常较
13、不患有弥漫肺泡损害常较不患有AIDS的患者常见。的患者常见。大量巨细胞病毒包涵体。大量巨细胞病毒包涵体。整理课件19成年人巨细胞病毒性肺炎成年人巨细胞病毒性肺炎 常见常见CTCT表现：表现：磨玻璃密度影磨玻璃密度影 实变实变 结节灶结节灶 边界不清的小叶核心结节边界不清的小叶核心结节 支气管扩张支气管扩张 小叶间隔增厚小叶间隔增厚整理课件20成年人巨细胞病毒性肺炎成年人巨细胞病毒性肺炎 Kang et al Kang et al 报告了报告了1010例患巨细胞病毒性肺例患巨细胞病毒性肺炎移植受体炎移植受体 的的CTCT表现：结节表现：结节 (n n=6),=6),实实变变 (n n=4),(=
14、4),(n n=4),=4),不规则线状影不规则线状影 (n n =1)=1)。Kim and LeeKim and Lee报告了报告了1111例免疫缺陷患者的高例免疫缺陷患者的高分辨分辨CTCT表现表现,磨玻璃密度影磨玻璃密度影(n n=11),=11),不规不规则线状影则线状影 (n n=10),=10),实变实变 (n n=7),=7),多发多发小结节或肿块小结节或肿块 (n n=6),=6),支气管扩张或小支气管扩张或小叶间隔增厚叶间隔增厚 (n n=5)=5)。整理课件21Pneumonia due to cytomegalovirus in a 28-year-old man wi
15、th Pneumonia due to cytomegalovirus in a 28-year-old man with acute myeloid leukemia.Thin-section(1-mm collimation)CT scan acute myeloid leukemia.Thin-section(1-mm collimation)CT scan obtained at the level of the bronchus intermedius shows obtained at the level of the bronchus intermedius shows mult
16、ifocal patchy ground-glass attenuation and poorly defined multifocal patchy ground-glass attenuation and poorly defined centrilobular nodules(arrows)in both lungs.centrilobular nodules(arrows)in both lungs.整理课件22Pneumonia due to cytomegalovirus in a 28-year-old man with Pneumonia due to cytomegalovi
17、rus in a 28-year-old man with acute myeloid leukemia.Photomicrograph(original acute myeloid leukemia.Photomicrograph(original magnification,magnification,40;hematoxylin-eosin stain)shows diffuse 40;hematoxylin-eosin stain)shows diffuse interstitial and intraalveolar fibroblastic proliferation inters
18、titial and intraalveolar fibroblastic proliferation(arrows)with some mononuclear cell infiltration(diffuse(arrows)with some mononuclear cell infiltration(diffuse alveolar damage,organizing stage).alveolar damage,organizing stage).整理课件23Title Pneumonia due to cytomegalovirus in a 28-year-old man with
19、 Pneumonia due to cytomegalovirus in a 28-year-old man with acute myeloid leukemia.(1)Photomicrograph(original acute myeloid leukemia.(1)Photomicrograph(original magnification,magnification,400;hematoxylin-eosin stain)shows three 400;hematoxylin-eosin stain)shows three large nuclei containing eosino
20、philic inclusion bodies(arrows)large nuclei containing eosinophilic inclusion bodies(arrows)within hyperplastic pneumocytes.(2)Photomicrograph within hyperplastic pneumocytes.(2)Photomicrograph(original magnification,(original magnification,400;immunohistochemical marker 400;immunohistochemical mark
21、er for cytomegalovirus)shows positive intranuclear inclusion for cytomegalovirus)shows positive intranuclear inclusion bodies(arrows).bodies(arrows).整理课件24Title Pneumonia due to cytomegalovirus in a 45-year-old man who underwent liver transplantation.Chest radiograph obtained 4 weeks after liver tra
22、nsplantation shows patchy air-space consolidation in both lungs.An endotracheal intubation tube,a pigtail drainage catheter in the right pleural space,a chest tube in the left pleural space,and a central venous catheter are seen.整理课件25Title Pneumonia due to cytomegalovirus in a 45-year-old man who u
23、nderwent liver transplantation.Thin-section(1-mm collimation)CT scan obtained at the level of the right upper lobe bronchus 2 days before the Chest radiograph shows multifocal patchy ground-glass attenuation in both lungs.Note the consolidation(white arrow)and the small,poorly defined nodules(black arrows).There are associated bilateral pleural effusions.整理课件26成年人病毒性肺炎的影像学表现多种多样且成年人病毒性肺炎的影像学表现多种多样且相互重叠，巨细胞病毒性感染时可伴有其它相互重叠，巨细胞病毒性感染时可伴有其它病毒及不典型致病菌的感染，不能仅依靠影病毒及不典型致病菌的感染，不能仅依靠影像学特点做出病毒性肺炎特定微生物的诊断。像学特点做出病毒性肺炎特定微生物的诊断。总结总结整理课件27
