肺部感染影像學(xué)和病理

1、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：Streptococcus pneumoniae ，CAP(35%), Klebsiella pneumoniae Legionella pneumophila 病理生理：如下圖early (A) and advanced (B) stages of lobar pneumonia caused by Streptococcus pneumoniae. In (A), the airspaces are filled with edema fluid; only occasional neutrophils are

2、 evident. In (B), neutrophils predominate. 細(xì)菌性-小葉性肺炎病原菌：Staphylococcus aureus Escherichia coli Pseudomonas aeruginosa Anaerobes Haemophilus influenzae 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(guó)小葉間裂Acute bronchopneumonia. Low magnification photomicrograph shows several small foci

3、 of consolidation located around the lumens of small bronchioles (arrows). Chest radiograph shows areas of consolidation in the right upper and left lower lobes. The patient was a 23-year-old man With bronchopneumonia High-resolution computed tomography (CT) scan shows centrilobular nodules (arrows)

4、 and lobular areas of consolidation (arrowhead) and ground-glass opacity (curved arrow). The patient was a 53-year-old man with bronchopneumonia. 并發(fā)癥-肺膿腫 病原菌：anaerobic bacteria ，S. aureus, P. aeruginosa, and K. pneumoniae Inflammatory mass with central purulent necrosisFrequently cavitateSmooth or s

5、haggy inner marginsAir-liquid levels commonMaximal wall thickness usually 15Low-attenuation central region and rim enhancement on CT scan 并發(fā)癥-壞死性肺炎 Bulging fissure sign. Posteroanterior chest radiograph shows dense right upper lobe airspace consolidation with downward bulging of the minor fissure. T

6、he patient was a 66-year-old man with pneumococcal pneumonia. Necrotizing pneumonia. Chest radiograph (A) shows inhomogeneous and dense consolidation in the right lung. Computed tomography (CT) (B) image shows a large cavity and sloughed lung within the cavity (arrow). The patient was a 42-year-old

7、alcoholic man with necrotizing pneumonia secondary to Klebsiella pneumoniae and anaerobic organisms. 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)eeding vessel sign image (A) shows two vessels apparently coursing into a nodule (feeding ves

8、sel sign ）image (B) demonstrates that the only vessel in close contact with the nodule is a draining vein (arrow). 肺炎鏈球菌肺炎 CAP的主要致病菌（40%）危險(xiǎn)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(jià)值：明確有無空洞或積膿Lobar pneumonia due to streptococcus pneumoniaRo

9、und pneumonia due to Streptococcus pneumoniae Bronchiolitis and bronchopneumonia due to Streptococcus pneumoniae Extensive bilateral pneumonia due to Streptococcus pneumoniae 葡萄球菌肺炎肺膿腫Coccal colonies are densely surrounded by neutrophils (HE). Strong basophilia of the bacteria in H&E preparation ind

10、icates Gram positivity Incidental terminal aspiration of MRSA colonies into the lung, leading to a culture-positive result (HE).Morphologic study can easily distinguish MRSA-induced infection from the carrier state of MRSA without provoking clinical manifestation.S. aureus bronchopneumonia, is chara

11、cterized histologically by predominantly peribronchiolar inflammation Bronchopneumonia due to Staphylococcus aureus. Chest radiograph shows bilateral poorly defined nodular opacities and patchy areas of consolidation. Also noted is a central venous line. The patient was a 70-year-old man with MRSA p

12、neumonia. Empyema due to Staphylococcus aureus. The patient was a 44-year-old man and an intravenous drug user. He had no radiologic evidence of septic embolism. Septic embolism due to Staphylococcus aureus . The patient was a 43-year-old man with positive blood cultures for Staphylococcus aureus. 克

13、雷白肺炎 CAP占1%-5%，HAP占15%危險(xiǎn)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(jià)值：明確空腔或膿腫Autopsied lung with severe pneumonia in a patient with degenerative neuronal Disorder。Numerous large and long pathogens are dispersed within the edem

14、atous alveolar space. The pathogens are not phagocytized by neutrophils (HE, low power).Lobar pneumonia due to Klebsiella pneumoniae. The patient was a 73-year-old woman with K. pneumoniae pneumonia. Klebsiella pneumoniae pneumonia and abscess formation 。The patient was a 53-year-old man .C ,D(3 day

15、s later)大腸埃希氏菌肺炎CAP(4%), HAP 的5-20%危險(xiǎn)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 Bronchopneumonia due to Escherichia coli .Chest radiograph shows poorly defined nodular opacities (arrows) in the right upper lobe and small bilateral foci of consolidation. 銅綠假單胞菌肺炎HAP占20%危險(xiǎn)因素：COPD,機(jī)械通氣，抗生素運(yùn)用，囊型纖維

16、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:Perivascular cuffing 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Severe pneumonia due to Pseudomonas. 流感嗜血桿菌肺炎5-20%的CAP病原菌危險(xiǎn)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：Neonat

17、al pneumonia caused by Haemophilus influenzae infection圖右：陽性痰涂片Bronchiolitis and bronchopneumonia due to Haemophilus influenza .The patient was a 50-year-old man with H. influenza pneumonia. 軍團(tuán)菌肺炎2-5%CAP危險(xiǎn)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(gè)或多個(gè)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

18、），胸腔積液（35-60%）Fatal hospital-acquired pneumonia seen in a premature infant。left）The lung is massively infiltrated by macrophages (HE) right）Numerous short rods are seen in the cytoplasm of alveolar macrophages 痰涂片 希門尼斯染色，巨噬細(xì)胞胞漿可見軍團(tuán)菌Lobar pneumonia due to Legionella pneumophila. The patient was a 77-year-old man with legionella pneumonia. Mass-like consolidation due to