呼吸次常見病診斷課件

Respiratorydisease

62221361肺隔離癥Pulmonarysequestration一部分肺與正常肺分離，且不接受肺動脈供血，而僅接受來自體循環(huán)異常血管的供血肺葉內(nèi)型肺隔離癥：隔離肺與鄰近正常肺位于同一臟層胸膜內(nèi)，供血動脈多來自降主動脈或其分支，靜脈回流多經(jīng)過肺靜脈肺葉外型肺隔離癥：有單獨的臟層胸膜包裹，90%位于左下葉后基底段，也可位于膈下或縱隔內(nèi)，供血動脈來自腹主動脈，靜脈回流通過下腔靜脈、奇靜脈或半奇靜脈回流到體循環(huán)。30%合并膈疝235Pulmonarysequestration6Pulmonarysequestration7肺真菌病肺霉菌病，因人體抵抗力低下而真菌侵入引起真菌種類多，但對人體能致病者只有十余種，按其致病的部位可分為淺部真菌和深部真菌深部真菌的多數(shù)可引起肺部病變。常見的有曲菌、念珠菌、奴卡菌、放線菌、新型隱球菌等。這些真菌有的廣泛存在于自然界中，為腐物寄生菌，有的寄生于正常人體內(nèi)正常人體對真菌有較強的抵抗力，肺真菌病少見9可能引發(fā)肺真菌病的因素機體抵抗力降低口腔衛(wèi)生不佳生活和職業(yè)中接觸較多被真菌孢子污染的物質(zhì)抗生素的大量應(yīng)用，人體對抗生素敏感和不敏感的致病菌之間的相互拮抗作用產(chǎn)生紊亂，敏感者被抑制，有利于不敏感者的繁殖長期應(yīng)用激素使機體的免疫功能低下惡性腫瘤、嚴重燒傷或大手術(shù)后，免疫功能低下10感染途徑與病理變化內(nèi)源性感染：口腔和上呼吸道內(nèi)寄生的真菌，如放線菌和念珠菌，由于口腔衛(wèi)生不佳或身體抵抗力降低時，侵入肺部引起感染外源性感染：帶有真菌孢子的塵土吸入肺內(nèi)，如奴卡菌病、曲菌病和隱球菌病繼發(fā)性感染：體內(nèi)其他部位的真菌病變經(jīng)血行或淋巴播散到肺部，或膈下病變直接侵犯蔓延到肺部病理變化：過敏、急性炎癥、化膿性病變、肉芽腫形成、空洞、纖維化和鈣化擴散方式：直接侵犯、淋巴播散和血行播散11肺真菌病的影像學表現(xiàn)腫塊及空洞：腫塊常為多發(fā)，密度較高，其內(nèi)可有多處透亮區(qū)。部分單發(fā)腫塊周圍可見暈輪樣改變，稱為暈輪征，為曲菌感染的早期表現(xiàn)真菌球：多見于曲菌病?？斩椿蚩涨粌?nèi)邊緣光整的球形致密影，其大小因所在空洞或空腔的大小和病變發(fā)展程度而不同。曲菌球與洞壁或腔壁之間可見新月狀空隙，為空氣半月征其他：縱隔或肺門淋巴結(jié)腫大、胸腔積液或膿胸，胸膜肥厚粘連。侵犯縱隔及心包，形成縱隔膿腫或心包炎。病程長者有纖維性病灶和鈣化灶13影像診斷與鑒別診斷肺曲菌病的曲菌球和暈輪征具特征性，其他肺真菌病影像學表現(xiàn)缺乏特征性以下幾點有助于提示肺真菌病的診斷①肺部病灶影存在時間長，又缺乏某些常見疾病的特征，且在鑒別中也無其他疾病應(yīng)有的臨床癥狀時，提示肺真菌病的可能②經(jīng)較長時間的動態(tài)觀察，病灶變化不大，或雖有所變化，但不符合一般炎癥、結(jié)核等病的發(fā)病規(guī)律時，提示本病的可能③病人有長期應(yīng)用大量抗生素、激素、免疫抑制劑等類藥物的病史，提示本病的可能14肺曲菌病Aspergillosis又稱肺笰狀菌病，肺部最常見的真菌病曲菌廣泛存在于自然界，孢子在空氣中到處皆有，吸入其孢子不一定致病，大量吸入可引起急性氣管、支氣管炎或肺炎常寄生在人體上呼吸道，痰培養(yǎng)中?？砂l(fā)現(xiàn)，很少使健康人致病慢性病病人免疫功能低下時，入侵肺部發(fā)生肺曲菌病15肺曲菌病臨床與吸入曲菌量有關(guān)，也與機體對曲菌發(fā)生的變態(tài)反應(yīng)有關(guān)無癥狀有的起病急，有發(fā)熱、咳嗽、咳痰、咯血等癥狀，酷似急性肺炎有的起病緩慢，有低熱、夜間盜汗、咳嗽、咳膿痰帶血，病情時好時壞，頗似肺結(jié)核17X線表現(xiàn)肺空洞或空腔內(nèi)的圓形或類圓形致密陰影3～4cm，密度較均勻，邊緣較光整可有鈣化，呈斑點鈣化或邊緣鈣化不侵及空洞壁，體積小于空洞內(nèi)腔，立位與臥位比較，位置可有改變，且總是處于近地位。曲菌球與空洞壁間可見新月形空隙，為空氣半月征曲菌球易發(fā)于肺結(jié)核空洞，兩上肺尖后段多見，洞壁多較薄侵襲型曲菌病表現(xiàn)為一側(cè)或兩側(cè)肺野的單發(fā)或多發(fā)斑片狀影，也可為肺葉或肺段的實變影，病灶壞死可形成膿腫，少數(shù)見空洞形成18CT表現(xiàn)薄壁空洞或空腔內(nèi)的孤立球形灶，邊緣光滑銳利，大小不等，常見空氣半月征曲菌球處于近地位，呈軟組織密度，有時見鈣化，無強化支氣管粘液嵌塞表現(xiàn)為柱狀致密影侵襲型曲菌病感染早期，肺部出現(xiàn)結(jié)節(jié)或腫塊狀實變影，周圍出現(xiàn)暈輪征，即在結(jié)節(jié)或腫塊狀病灶周圍可見環(huán)繞的較低密度區(qū)域，其密度介于結(jié)節(jié)與正常肺組織間，形似暈輪，為周圍出血所致小葉性實變或小葉融合性影，多發(fā)球形病灶伴空洞形成及肺門淋巴結(jié)腫大19BilateralaspergillomasM71,withresidualtuberculosislargecavitiesbilaterallyintheupperlobescontainingfungusballsofdifferentsizes21RadiographyMycetomas:asolid,roundorovalmasswithsoft-tissueopacitywithinalungcavitySeparatedfromthewallofthecavitybyanairspaceofvariablesizeandshape,resultinginthe"aircrescent"signMoveswiththepatientchangesposition22MobileaspergillomawithinapulmonarycysticcavityM43SupineandproneAchangeinthepositionAfumigatuswasdiscoveredatbronchoscopy23Parasites（寄生蟲?。㎡rganismsobtainnourishmentandshelterfromotherorganismsHostmayeitherbeunaffectedorsufferharmfulconsequencesVarywidelyinsizeandcomplexity,fromrelativelysimpleunicellularprotozoans(amebae)tomorecomplexmulticellularorganisms(worms,flukes)Distributedworldwide,ahigherprevalenceindevelopingcountries,inadequatesanitation25CommonhumaninfectionthroughouttheworldEpidemicsofparasiticdiseases(malaria)havedevastatedlargepopulationsandposeaseriousbarriertoprogressinmanydevelopingcountriesEconomicandsocialchangesoverthepastdecadesarestimulatingrural-to-urbanmigrationinmostendemicareas,parasiticdiseasesthataremorecommoninruralareasarenolongerentirelyabsentintheurbanpopulationInindustrializedcountries,riskgroupsforparasiticdiseasesincludestravelers,recentimmigrants,andpatientswithAIDSParasites26肺包蟲病肺棘球蚴病，為細粒棘球絳蟲或多房棘球絳蟲之幼蟲（即棘球蚴）感染人體所致，在人體寄生的棘球蚴病稱為包蟲囊腫傳染源多為狗，寄生于狗腸內(nèi)的細粒棘球絳蟲蟲卵隨糞便排出污染牲畜皮毛、水源及牧草等，病人多因食入污染的食物或水而感染，蟲卵也可經(jīng)呼吸道吸入而發(fā)生感染29發(fā)病過程棘球蚴蟲卵在十二指腸內(nèi)孵化為六鉤蚴，進入腸壁的毛細血管，并經(jīng)門脈至肝臟，再經(jīng)肝靜脈、下腔靜脈、右心、肺動脈到達肺六鉤蚴周圍有大單核細胞和嗜酸性粒細胞浸潤，并逐漸長成棘球蚴的囊狀體，有的可形成巨大的囊腫包蟲囊腫的壁分為兩層，外層為角質(zhì)層，較堅韌，起保護和營養(yǎng)胚層的作用；內(nèi)層為胚層（或稱為生發(fā)層），能分泌液體，具有繁殖作用，液體內(nèi)有毛鉤和頭節(jié)，頭節(jié)脫落則形成子囊囊腫破裂，囊液溢出，頭節(jié)可在鄰近形成新的囊腫肺包蟲囊腫可破入支氣管及繼發(fā)感染30癥狀咳嗽、咯血、胸痛及發(fā)熱破入胸腔引起氣胸和胸腔積液破入支氣管時咳出大量囊液較小的包蟲囊腫可無癥狀嗜酸性粒細胞增多皮試及血清學試驗有助診斷31X線單發(fā)或多發(fā)的圓形或類圓形影，1～10cm密度均勻，囊狀，邊緣光滑清楚，可環(huán)形鈣化外囊破裂，并與支氣管相通，少量氣體進入內(nèi)外囊之間，在囊腫上部形成新月形透亮影內(nèi)外囊同時破裂，并與支氣管相通，部分囊內(nèi)的內(nèi)容物咳出，空氣進入囊內(nèi)形成氣液平面內(nèi)外囊同時破裂后，若內(nèi)囊塌陷，漂浮于液平面上形成凹凸不平的形態(tài)，稱為“水上浮蓮”征肺表面的囊腫破裂可形成氣胸或液氣胸32CT囊腫1cm以下時，邊緣模糊的片狀影?！?cm，輪廓清楚的類圓形囊性影，分葉狀。邊緣光整，密度均勻，CT值為液體密度囊壁薄厚不一，囊腫與胸膜或縱隔相鄰處變平囊腫衰老呈不規(guī)則狀，似實質(zhì)性腫瘤，但密度仍較低合并感染時邊緣模糊，類似肺膿腫破裂可形成支氣管瘺，咳出部分囊液且空氣進入囊內(nèi)后出現(xiàn)氣液面破入支氣管后，若外囊有細小裂口而內(nèi)囊未破，可有少量氣體進入內(nèi)外囊之間，呈現(xiàn)新月形或鐮刀狀氣體影空氣進入外囊內(nèi)，內(nèi)囊塌陷并漂浮于液面，“水上浮蓮征”33LifeCycleofEgranulosusThedefinitivehostisusuallyadog(orothercarnivore)Theadultwormlivesintheproximalsmallbowelofthedefinitivehost,attachedbyhookletstothemucosaEggsarereleasedintothehost'sintestineandexcretedinthefecesSheeparethemostcommonintermediatehosts.TheyingesttheovumwhilegrazingoncontaminatedgroundTheovumlosesitsprotectivechitinouslayerasitisdigestedintheduodenumThereleasedhexacanthembryo,oroncosphere,passesthroughtheintestinalwallintotheportalcirculationanddevelopsintoacystwithintheliver34LifeCycleofEgranulosusWhenthedefinitivehosteatsthevisceraoftheintermediatehost,thecycleiscompletedHumansmaybecomeintermediatehoststhroughcontactwithadefinitivehost(usuallyadomesticateddog)oringestionofcontaminatedwaterorvegetablesOnceinthehumanliver,cystsgrowto1cmduringthefirst6monthsand2–3cmannuallythereafter,dependingonhosttissueresistance35Lifecycle(dog-sheepcycle)ofEgranulosusDiagramshowsthemostprevalentlifecycleofEgranulosus,inwhichadogandsheepserveasthedefinitiveandintermediatehosts,respectively36ThreelayersOuterpericyst,composedofmodifiedhostcellsthatformadenseandfibrousprotectivezoneMiddlelaminatedmembrane,isacellularandallowsthepassageofnutrientsInnergerminallayer,thescolices(thelarvalstageoftheparasite)andthelaminatedmembraneareproducedMiddlelaminatedmembraneandthegerminallayerformthetruewallofthecyst37HydatidCystStructureDaughtervesicles(broodcapsules)aresmallspheresthatcontaintheprotoscolicesandareformedfromrestsofthegerminallayerBeforebecomingdaughtercysts,thesedaughtervesiclesareattachedbyapedicletothegerminallayerofthemothercystAtgrossexamination,thevesiclesresembleabunchofgrapesDaughtercystsmaygrowthroughthewallofthemothercyst,particularlyinbonedisease38MultivesicularcystPhotographofahumankidneybesectionedalongthemidcoronalplaneAlargecystwiththetypical"bunchofgrapes"appearanceduetodaughtercysts(→)ureter39HydatidCystCystfluidisclearorpaleyellow,hasaneutralpH,andcontainssodiumchloride,proteins,glucose,ions,lipids,andpolysaccharidesThefluidisantigenicandmayalsocontainscolicesandhookletsWhenvesiclesrupturewithinthecyst,scolicespassintothecystfluidandformawhitesedimentknownashydatidsand40HydatidDiseaseinhumansOncetheparasitepassesthroughtheintestinalwalltoreachtheportalvenoussystemorlymphaticsystem,theliveractsasthefirstlineofdefenseandisthereforethemostfrequentlyinvolvedorganHydatiddiseaseinvolvestheliverin75%ofcases,thelungin15%,andotherorgansin10%Thelungsarethesecondmostfrequentsiteofhematogenousspreadinadultsandprobablythemostcommonsiteinchildren41HematogenousDisseminationCompressibleorganssuchasthelungorbrainfacilitatethegrowthofthecystMostcystsareacquiredinchildhood,remainasymptomaticforalongperiodoftime,andarelaterdiagnosedincidentallyatchestradiographyCystsaremultiplein30%ofcases,bilateralin20%,andlocatedinthelowerlobesin60%Calcificationinpulmonarycystsisveryrare,althoughitmaybeseeninpericardial,pleural,andmediastinalcysts42PulmonaryhydatidcystM3Awell-circumscribed,masslikelesionwithapolycyclicconfigurationintheleftlowerlobeThereisobliterationoftheleftcostophrenicangle43PulmonaryhydatidcystSuddencoughingattacks,hemoptysis,andchestpainarethemostcommonsymptomsAftercystrupture,expectorationofcystfluid,membranes,andscolicesmayoccurRuptureintothepleuralcavitymayoccurBacterialinfectionofthecystisthemostseriouscomplicationcommonlyseenafterrupture44PulmonaryhydatidcystWell-definedmasses,usuallyround,peripheralcystsmaybeovalorpolycyclicAircollectionappearsasathin,radiolucentcrescentintheupperpartofthecystandisknownasthecrescentsignormeniscussignAsaircontinuestoenterthisspace,thetwolayersseparatecompletelyandthecystshrinksandruptures,allowingthepassageofairintotheendocyst45PulmonaryhydatidcystAnair-fluidlevelinsidetheendocystandairbetweenthepericystandtheendocystwithan"onionpeel"appearanceconstitutetheCumbosignAfterpartialexpectorationofthecystfluidandscolices,thecystemptiesandthecollapsedmembranescanbeseeninsidethecyst(serpentsign).Whenithascompletelycollapsed,thecrumpledendocystfloatsfreelyinthecystfluid(waterlilysign)Ifthefluidisentirelyevacuatedbyexpectoration,theremainingsolidcomponentswillfalltothemostdependentpartofthecavity("masswithinacavity")46OpencystsAchildwithfever,cough,andexpectorationLeftlateraldecubituspositionAlargecavitarylesionwithanair-fluidlevelintheinferiorleftlungAirisseenbetweenthepericystandthelaminatedmembraneofthecystPulmonaryinfiltrateadjacenttothecystPleuraleffusionduetosuperimposedbacterialinfection47AchildwithpreviousepisodesofcoughandexpectorationLateralchestradiographAnintracysticserpentinestructurerepresentingcollapsedmembranes48OpenlungcystM20,experiencedasuddencoughingattackfollowedbyexpectorationofclearfluidleftlateraldecubituspositionAcavitarylesionintherightupperlobewithsolidcontentsthathavesettledinthemostdependentpartofthecavityThesolidcomponentrepresentsthedetached,crumpledendocyst49Pulmonaryhydatiddisease,EgranulosusM43,AlargecystintherightlowerlungF32,Ahypoattenuatingcrescentsign(meniscussign)50AlveolarEchinococcosisandPolycysticEchinococcosisCausedbyEmultilocularisandEvogeliHaveasimilarclinicopathologiccourseandareacquiredthroughthesamemechanism,similartothatdescribedforEgranulosusTheparasitegrowsfromthemetacestode(larva)intheliverand,resemblinganeoplasmLunginvolvementislessfrequentthaninunilocularcysticechinococcosis,resultsfrommetastaticdisseminationordirectextension51AlveolarandPolycysticEchinococcosisInfectionbecomessymptomaticafter5–15yearssecondarytolocalcompressionordysfunctionoftheaffectedorgan,usuallytheliverNonspecificsymptomssuchasfatigue,weightloss,cough,andhemoptysiscanbepresentAmassoffibroustissuecontainingseveralscatteredcavitiesofwidelyvaryingdiameterswithnecroticareasisfrequentlyseen,ascalcifications52AlveolarandPolycysticEchinococcosisDiagnosiscanbemadewithimmunohistochemicalandhistologicanalysis,serologictestsCTandMRIaretheimagingmodalitiesofchoiceforbetterdefiningthelocationandextentofpulmonarydiseaseCalcificationsmaydevelopasthediseaseprogresses(33%–100%ofcases)Secondarylungcompromisebydirectextensionmaymimicalungcancer53PolycysticechinococcosisM25ChestradiographMultipleperipheralroundareasofsoft-tissueopacity54PolycysticechinococcosisCTclearlydefinedcapsulewitharelativelyhypoattenuatingcenter,afindingthatreflectsthecysticnatureofthelesionsEvogeliwasidentifiedatpathologicanalysisastheetiologicagent55PolycysticechinococcosisofthechestwallfromEvogeliM13Cysticthickeningofthepleurawithchestwallinvolvement.56Schistosomiasis（血吸蟲?。㏒hematobium,Smansoni,andSjaponicumSmansoniisendemictoAfrica,SaudiArabia,Brazil,Madagascar,Venezuela,andPuertoRicoSjaponicumismorefrequentlyseenineastAsiaInfectionisacquiredthroughexposureoftheskintowatercontaminatedwithcercariaeexcretedbysnails,whichhavetheabilitytopenetratetheskinortheintestinalwall,thenmigratetothelungandafterwardtotheliver,wheretheparasitecontinuesitslifecycleThesecondmostcommoncauseofmortalityamongparasiticinfectionsaftermalaria,affecting150–200millionpeopleandcausing500,000deathseachyear57lifecycleofSchistosomaspecies58GeographicdistributionofSchistosomaspecies59PulmonaryschistosomiasisEarlypulmonaryschistosomiasis(3–8weeksafterparasiticpenetration)resultsfromimmunologicreaction,inwhicheosinophilsaresequesteredinthelungsSymptoms：shortnessofbreath,wheezing,anddrycough60EarlypulmonaryschistosomiasisThediagnosisissuggestedinpatientswholiveinorhavetraveledtoendemicareasandwhopresentwitheosinophiliaMayhavebothclinicalandradiologicmanifestationsaftertheonsetofsymptomsAssociatedurticaria,arthralgia,hepatosplenomegaly,hepatitis,eosinophilia61EarlypulmonaryschistosomiasisSmallnodularlesionswithill-definedbordersor,lesscommonly,areticulonodularpatternorbilateraldiffuseareasofground-glassincreasedopacityorhyperattenuationatradiographyandCTAsymptomaticcasesthatmanifestwithabnormalradiologicfindingsmayalsobeseenSensitivityislowfortheexaminationofstoolandurineforeggsinthisstageofinfection62EarlypulmonaryschistosomiasisM28hadtraveledtoMaliInitially,hadfeverandurticaria,afterwhichexperienceddrycough,predominantlyatnightCTshowsmultiplenodularlesionswithill-definedbordersinthelowerlobes.HistologicanalysisrevealedSmansoni

63Resultsfromgranulomatousreactiontoeggsdepositedinthepulmonaryvasculature,whichleadstointimalfibrosis,pulmonaryhypertension,andcorpulmonaleOftenprecededbyliverinvolvementbyportalhypertension,whichallowstheeggstoshuntfromtheportalsystemintothepulmonaryvasculatureDyspnea,chestpain,fatigue,palpitations,cough,and,lately,right-sidedheartfailureChronicpulmonarydisease64ChronicpulmonarydiseaseRadiographicandCTfindingsarealsoconsistentwiththeseclinicalfindingsandincludecardiomegalyandpulmonaryarterialenlargementDiagnosisismadebyidentifyingeggsinstoolorurinesamplesoratrectalbiopsySerologictestsarenotveryhelpfulbecausetheycannothelpdifferentiateaformerinfectionfromcurrentdisease65七律二首送瘟神1958.07.01綠水青山枉自多，華佗無奈小蟲何！千村薜荔人遺矢，萬戶蕭疏鬼唱歌。坐地日行八萬里，巡天遙看一千河。牛郎欲問瘟神事，一樣悲歡逐逝波。春風楊柳萬千條，六億神州盡舜堯。紅雨隨心翻作浪，青山著意化為橋。天連五嶺銀鋤落，地動三河鐵臂搖。借問瘟君欲何往，紙船明燭照天燒

66毛澤東詩詞《送瘟神》鑒賞1958年7月1日，讀6月30日人民日報，余江縣消滅了血吸蟲。浮想聯(lián)翩，夜不能寐。微風拂煦，旭日臨窗。遙望南天，欣然命筆當毛澤東得知江西余江縣消滅了為害極廣的的血吸蟲病時，作為共和國的締造者，一個時刻系念著人民的領(lǐng)袖，他激動不已，徹夜難眠，感慨和熱忱化作了這兩首七律領(lǐng)袖的愛國愛民之情，閃射出了燦爛的藝術(shù)光輝67第一首，詩人回顧過去，描述了瘟神給中國帶來的無窮災(zāi)難。首聯(lián)“綠水青山枉自多，華佗無奈小蟲何”，抒發(fā)了詩人的悲憤心情祖國的南方，向來以魚米之鄉(xiāng)著稱，這里青山綠水、風景秀麗?？墒?，一個小小的血吸蟲竟使大好河山蕭殺黯淡，就連華佗這樣的名醫(yī)奈之不何“綠水青山”與“枉自多”對舉，“華佗”與“無奈”相聯(lián)，強烈的反差、對比，寄寓了詩人多么深厚的感情，又飽含了人民大眾多少苦楚！“千村薜荔人遺矢，萬戶蕭疏鬼唱歌”，“千村”“萬戶”極言受災(zāi)地域之廣，受災(zāi)人數(shù)之多鑒賞268“坐地日行八萬里，巡天遙看一千河”道出人民尋求解脫災(zāi)禍的強烈呼聲隨著地球的自轉(zhuǎn)和公轉(zhuǎn)，人們尋遍長天，看過無數(shù)的星河然而，年年歲歲慘況依然，苦難依舊，人們到哪里去尋求幫助他們解脫疾病、消滅瘟君的救星呢？鑒賞369鑒賞4通過“坐地”“巡天”的超凡想象，詩的尾聯(lián)引出了神話傳說中天河邊的牛郎：“牛郎欲問瘟神事，一樣悲歡逐逝波”牛郎是勞動人民的化身神，他當然關(guān)心著人民的疾苦，要問“瘟神”肆虐之“事”。如何回答呢？詩人的答詞是：一切悲歡離合都隨著時光的流逝而成為過去了這樣，人間天上渾然一體，極大地開拓了詩詞包容的時空和思想蘊含，寫出了舊中國帶給人民的災(zāi)禍，那是天怒人怨，世所難容70第二首情緒熱烈、語調(diào)高亢，與第一首感情抑郁、語義哽咽形成了鮮明的對比首連“春風楊柳萬千條”二句即是一幅意氣飛揚的畫面。在經(jīng)歷了冰封雪裹的嚴冬之后，新忠告大地萬物復蘇，一片欣欣向榮。如今的南方春天，千萬條楊柳隨風飄拂，景象格外優(yōu)美。孟子說“人皆可以為堯舜?！钡诜饨ㄉ鐣?，這對于地位極其低下的民眾來說，只不過是一種幻想。即使是那些認識到“民可載舟，民可覆舟”的明君圣主，也仍是站在歷史的對立面，把民眾當成負載自己功業(yè)的工具鑒賞571集領(lǐng)袖與詩人與一身的毛澤東，從歷史唯物主義的高度，認識到人民的力量及其創(chuàng)造歷史的作用，因而寫出了“六億神州盡舜堯”的詩句。表達了毛澤東對人民群眾的期待與歌頌，也表達了毛澤東真正民主的人本思想。解放了的人民，確定了社會主人的地位，本質(zhì)力量得到了淋漓的發(fā)揮，讓高山地頭，令河水讓路，將扼住人們命運的瘟神徹底消滅，這樣的人民是真正的神、真正的舜堯。詩人用一顆熱愛人民、服務(wù)人民的心，唱出了熱情澎湃的心聲，表達了無產(chǎn)階級革命領(lǐng)袖對人民的關(guān)懷、推崇72鑒賞6“紅雨隨心翻作浪，青山著意化為橋”景物完全化為了情思，自然景物變得通人心、隨人意，人與美麗的景色交融一體。暮春的落花飄入水中，隨人的心意翻著錦浪，一座座青山相互連同，就象專為人們搭起的凌波之橋，整個中國呈現(xiàn)出一派興盛的氣象此時的水和山，仍然是從前的“綠水青山”，可在舊時代，山河被瘟神糟蹋，雖多亦枉然。到了新時代，人人成為舜堯，山水也煥發(fā)青春，大地在日新月異地改變著面貌73鑒賞7“天連五嶺銀鋤落，地動山河鐵臂搖”，歌頌了人民群眾改天換地的威力?！拔鍘X”綿延在南方，“三河”奔騰于北國，這兩個地名，代表了整個中國。祖國到處皆是銀鋤齊揮、鐵臂同搖，人民群眾的凌云之志，山河動容詩人以高妙的藝術(shù)手筆，概括了當時社會主義建設(shè)的雄偉場面，令人嘆服。同時，詩句中還滲透了詩人“力拔山兮”的偉岸精神和自力更生的進取意識。詩人“人定勝天”的思想，化成美妙的詩句，閃射出了動人心魄的魅力74鑒賞8全詩名為“送瘟神”，但第二首的前六句卻不見瘟神的影子，只在尾聯(lián)點出“借問瘟君欲何往，紙船明燭照天燒。”，這是為什么呢？實際上，在前六句中，詩人對此已作了暗示。正是由于消滅了瘟神，人民才可以著么揚眉吐氣，河山才這樣妖嬈動人可以想象，六億人民皆成舜堯，意氣風發(fā)，改天換地，完成了許多前人所不敢想象的事業(yè)，對付小小的血吸蟲當然不在話下，瘟神必然逃脫不了滅亡的下場75鑒賞9詩人稱瘟神為“瘟君”，實乃一種諷刺戲謔的口吻，充分顯示了人民的信心和力量，辛辣嘲笑瘟神（一切反動派）的無能和無奈“照天燒”三字，是全詩的結(jié)穴，象征中國人民不僅能消滅血吸蟲病，同時也能改變“東亞病夫”和貧窮落后的形象，也能掃除一切的瘟神和一切害人蟲，自立于世界民族之林76鑒賞毛澤東是具有革命浪漫主義氣質(zhì)的詩人，《送瘟神》二首便是其革命浪漫主義的杰作之一。在詩中，詩人的內(nèi)心世界隨著神奇的想象、多變的畫面得到了多方面的展示。既有理想，又有現(xiàn)實；既有科學，又有神話；既有對舊時代人民苦難生活的嘆息，又有為新時代人民壯舉的喝彩。情致高昂，想象豐富。詩人的才情得到了極致的展現(xiàn)，詩作的審美情趣也得到了極大的豐富

77Paragonimiasis（肺吸蟲?。〤ausedbythetrematodeParagonimuswestermaniorotherParagonimusspeciesthroughtheingestionofraworpartiallycookedfreshwatercrabsorcrayfishinfectedwiththemetacercariaThemainendemicareasareeastAsia,SoutheastAsia,LatinAmerica(primarilyPeru),andAfrica(primarilyNigeria)78GeographicdistributionofParagonimusspecies79肺吸蟲病囊蚴寄生在中間宿主石蟹及喇蛄等體內(nèi)，當生食或食入未煮熟的石蟹、喇蛄而感染后，幼蟲在腸道內(nèi)脫囊后穿過腸壁進入腹腔，1～2周后經(jīng)膈進入胸腔及肺而引起感染在肺內(nèi)由幼蟲發(fā)育為成蟲，在蟲體周圍肺組織充血并發(fā)生炎性反應(yīng)。蟲體在肺內(nèi)可隨意穿行，形成隧道樣腔隙或囊腫。增生的纖維組織包裹蟲體則形成囊腫樣病變，當囊腫樣病變內(nèi)的成蟲死亡或脫落后病變可吸收或縮小，也可纖維化或鈣化80LifecycleofParagonimusspecies81ParagonimiasisThelungisthetargetorganFever,chestpain,respiratorysymptomssuchaschroniccoughandhemoptysisConfirmedbydetectingparasiteeggsinthesputum,pleuralfluid,orfecesLarvaeoftenbefoundatbronchialbrushingIntradermalandserologictestsarealsoavailable82臨床表現(xiàn)咳嗽、咳痰、咯血、胸痛、氣短等呼吸道癥狀，咳果醬樣粘痰為特征性表現(xiàn)疲乏及體重減輕，如無混合感染也可不發(fā)熱痰中可找到肺吸蟲蟲卵、嗜酸性粒細胞和夏科雷登結(jié)晶83X線肺內(nèi)浸潤陰影，斑片狀、圓形或橢圓形，1～3cm，邊緣模糊，密度低，為肺吸蟲引起的肺內(nèi)出血及組織破壞所致，中、下肺多見浸潤陰影內(nèi)可見單發(fā)或多發(fā)囊狀透明區(qū)，多位于肺門附近及下肺野，為肺吸蟲在肺內(nèi)隨意穿行而形成的隧道及囊腫圓形或橢圓形結(jié)節(jié)陰影，單發(fā)或多發(fā)，其邊界清楚，中心可見透亮影，周圍有條索狀影，為肉芽組織及纖維組織增生硬結(jié)和鈣化陰影，呈結(jié)節(jié)、條索狀，密度高，邊緣清楚為病變吸收愈合的表現(xiàn)可有肺紋理增多、紊亂，胸膜增厚、粘連84ParagonimiasisRadiologicfindingscorrelatewellwiththestageofthediseaseThepenetrationofjuvenilewormsthroughthediaphragmintothepleuralcavitycancausepleuraleffusionorpneumothoraxOncetheparasitesgettothelung,patchyairspaceconsolidationcanoccur,aphenomenonthatreflectsthepresenceofanexudativeorhemorrhagicpneumoniawhichcancavitate85CT斑片狀病灶、結(jié)節(jié)病灶及空洞斑片狀病灶的邊緣模糊結(jié)節(jié)病灶邊緣清楚空洞壁厚薄不一，其內(nèi)可見條狀高密度蟲體上述表現(xiàn)可并存，也可單獨出現(xiàn)病灶常多發(fā)，可在肺任何部位，以兩下葉常見有時見胸腔積液和胸膜肥厚86ParagonimiasisE+CTshowhypoattenuatingfluid-filledcystssurroundedbyhyperattenuatingconsolidationintheadjacentlungLinearareasofincreasedopacityorhyperattenuationindicateperipheralatelectasisorwormmigrationWormcystsrangefrom0.5to1.5cm,arebettervisualizedaftertheconsolidationresolvesandmanifestaseithersolitaryormultiplenodulesorgas-filledcystsdependingontheircontentandtheircommunicationwiththeairway87RadiographicandCTfindingsAringshadowusuallylessthan3mmthickAcrescent-shapedareaofincreasedopacityHyperattenuationwithinthecystthatrepresentswormsattachedtothewallComplicationsofcystsincludepleuraleffusion,empyema,andpneumothorax88PulmonaryparagonimiasisM35Alveolarareasofincreasedopacity,predominantlyintheleftlung89Pulmonaryparagonimiasisbilateralill-definedareasofconsolidationandareasofground-glassattenuationassociatedwithleftpneumothoraxEggsofPwestermaniwerefoundatbronchoalveolarlavage90PulmonaryparagonimiasisM27cavitatedareasofincreasedopacityinthemiddlelobeandleftupperlobe91PulmonaryparagonimiasisAcavitatedareaofconsolidationinthemiddlelobeandhelpedconfirmthepresenceofacavitatednoduleintheleftupperlobe(notshown)EggsofPwestermaniwerefoundatbronchoalveolarlavage92Pulmonaryparagonimiasis

M43Asoft-tissuenoduleinmiddlelobeCTclearlyrevealsthenoduleHistopathologicanalysisperformedaftersurgicalresectiondemonstratedPwestermani93特發(fā)性肺間質(zhì)纖維化原因不明的彌漫性纖維性肺泡炎又稱Hamman-Rich綜合征為肺泡壁損傷所引起的非感染性炎性反應(yīng)近認為系免疫性疾病，可能與遺傳有關(guān)94病理急性期：肺泡內(nèi)皮細胞和基底膜受損，肺泡和間質(zhì)內(nèi)蛋白樣物質(zhì)滲出，伴透明膜形成，繼而淋巴細胞和單核細胞滲出。肺泡內(nèi)皮細胞再生覆蓋在滲出物表面并使其整合入肺間質(zhì)，肺泡壁增厚，膠原纖維扭曲、紊亂而機化。病變發(fā)展，間質(zhì)纖維化加重晚期：肺泡壁、小葉間隔及胸膜下廣泛纖維化，肺體積縮小變硬，毛細血管網(wǎng)和氣道的終末部分被破壞。在范圍較大的纖維化區(qū)域，可有終末氣道的代償性擴張，形成直徑數(shù)mm至2cm的囊樣含氣腔隙95Hamman-RichSyndrome多見于中年，男、女無差別多起病隱匿，初期無癥狀進行性呼吸困難和干咳進展速度因人而異：快者1～2年內(nèi)出現(xiàn)發(fā)紺和杵狀指，并發(fā)肺心病慢者可數(shù)年甚或十幾年不出現(xiàn)明顯缺氧癥狀，但最終出現(xiàn)缺氧及肺心病易合并肺部感染，反復感染可加快肺纖維化的發(fā)展肺功能檢查呈限制性通氣障礙及低氧血癥96胸部X線平片早期正常，或僅見兩肺中下野細小網(wǎng)織陰影病變發(fā)展，出現(xiàn)不對稱性、彌漫性網(wǎng)狀、條索狀及結(jié)節(jié)狀陰影，可擴展至上肺野晚期，結(jié)節(jié)狀陰影增大，并伴有廣泛厚壁囊狀陰影，形似蜂窩狀，故稱為蜂窩肺并發(fā)阻塞性肺氣腫時，肺野透亮度增強囊腫破裂可發(fā)生自發(fā)性氣胸肺纖維化嚴重時可發(fā)生肺動脈高壓和肺心病97Idiopathicpulmonaryfibrosis早期發(fā)現(xiàn)肺間質(zhì)纖維化并準確了解病變的分布CharacteristiconCT磨玻璃樣影及實變影，內(nèi)見含氣支氣管影，支氣管血管數(shù)增粗Ground-glassattenuation與胸膜面垂直的細線形影，長1-2cm，寬約1mm，多見于兩肺下葉，也見于其他部位兩肺中內(nèi)帶小葉間隔增厚表現(xiàn)為分支狀細線形影Reticularattenuationwithinterlobularseptalthickening胸膜下0.5cm內(nèi)與胸壁內(nèi)面弧度一致的弧線狀影，長5-10cm，邊緣較清或略模糊，見于兩下肺后外部98Idiopathicpulmonaryfibrosis蜂窩狀影，數(shù)mm至2cm大小不等的圓形或橢圓形含氣囊腔，壁薄而清楚，與正常肺交界面清楚。分布于兩肺基底部胸膜下區(qū).Ahoneycombpatternpredominantlybasalandperipheralindistribution小結(jié)節(jié)影，邊緣較清楚，為纖維條索病變在橫斷面的表現(xiàn)，或相互交織而成小葉中心性肺氣腫：散在、直徑2-4mm的圓形低密度區(qū)，無明確邊緣，多見于肺外圍部，病變發(fā)展可漸見于肺中央部。有時胸膜下見1-2cm大圓形或類圓形肺氣囊中小支氣管擴張，多柱狀，伴支氣管扭曲、并攏Architecturaldistortionwithassociatedtractionbronchiectasisandbronchiolectasis99IdiopathicpulmonaryfibrosisF47GGO:peripheraldistributionInterlobularseptalthickeningIrregularityofthefissuresBronchiectasisEarlyinterstitialpneumonia22mlater,progressionofinterstitialpneumoniaDiffuseGGO,interlobularseptalthickeningAhoneycombpattern100鑒別診斷肺類風濕性病的廣泛性肺間質(zhì)纖維化，最后發(fā)展為蜂窩肺，與HRS相似。但前者有漸進性壞死結(jié)節(jié)即肉芽腫及胸腔積液表現(xiàn)，有別于HRS紅斑狼瘡的胸部表現(xiàn)以心肌炎所致的心臟增大、間質(zhì)性肺炎、節(jié)段性盤狀肺不張和胸腔積液等所見為特征，與HRS不同硬皮病的肺間質(zhì)纖維化發(fā)展至晚期可出現(xiàn)蜂窩肺，如有皮膚的改變以及在食管造影見其張力減低或狹窄等表現(xiàn)，則有助于硬皮病的診斷101結(jié)節(jié)?。⊿arcoidosis）原因不明的多系統(tǒng)肉芽腫性疾病，良性經(jīng)過，可累及淋巴結(jié)、肺、胸膜、皮膚、骨、眼、脾、肝、腮腺及扁桃體等病理特征為非干酪性肉芽腫淋巴結(jié)大，但不融合。肺門LN易受累，次為氣管旁和AA旁肺內(nèi)病變沿支氣管血管周圍結(jié)締組織鞘及小葉間隔發(fā)展蔓延，肺內(nèi)肉芽腫主要分布在間質(zhì)，小，直徑在0.4mm以下，胸膜下肺間質(zhì)內(nèi)肉芽腫更密集。小肉芽腫可融合成大結(jié)節(jié)急性發(fā)病者肉芽腫大多經(jīng)治療消退或自行消退。慢性發(fā)病者常導致進行性肺纖維化102Sarcoidosis見于任何年齡，20～40歲多見，女性多病程緩慢，輕者無癥狀癥狀與影像學表現(xiàn)常不相稱，本病特點之一咳嗽，咳少量粘痰、乏力、低熱、盜汗、納差及胸悶等。肝脾腫大、皮膚結(jié)節(jié)、關(guān)節(jié)疼痛、腮腺腫大、外周淋巴結(jié)腫大及眼部病變癥狀實驗室檢查Kveim試驗陽性，ACE（血管緊張素轉(zhuǎn)化酶）升高，血、尿鈣值升高103胸部X線平片縱隔、肺門淋巴結(jié)腫大，半數(shù)為唯一異常多組淋巴結(jié)腫大，兩肺門對稱性淋巴結(jié)腫大，狀如土豆，為典型表現(xiàn)肺門淋巴結(jié)腫大的程度比其他部位更加顯著少有縱隔淋巴結(jié)而無肺門淋巴結(jié)者淋巴結(jié)腫大一般在6-12個月期間可自行消退，恢復正常；或在肺部出現(xiàn)病變過程中，開始縮小或消退；或不繼續(xù)增大，為結(jié)節(jié)病的發(fā)展規(guī)律104Sarcoidosis肺部病變多發(fā)生在淋巴結(jié)病變之后兩肺彌漫性網(wǎng)狀結(jié)節(jié)影，但肺尖或肺底少或無。結(jié)節(jié)大小不一，多為1-3mm大小，輪廓尚清楚肺內(nèi)圓形病變，直徑約1.0-1.5cm，密度均勻，邊緣較清楚，單發(fā)者類似肺內(nèi)良性病變或周圍型肺癌，多發(fā)者酷似肺轉(zhuǎn)移瘤節(jié)段性或小葉性浸潤，類似肺部炎性病變，一般伴或不伴胸腔內(nèi)淋巴結(jié)病變少數(shù)為單純粟粒狀，似急性粟粒型結(jié)核105Sarcoidosis以纖維性病變?yōu)橹髡?，不易與其他原因所致的肺纖維化區(qū)別，且可引起多種繼發(fā)性改變胸膜滲液可能為胸膜臟、壁層廣泛受累所致。肥厚的胸膜為非干酪性肉芽腫骨病變約占10%。損害一般限于手、足的短管狀骨，顯示小囊狀骨質(zhì)缺損并伴有末節(jié)指（趾）的骨質(zhì)吸收，變細、變短106CT縱隔、肺門淋巴結(jié)腫大，密度均勻，邊緣清楚，周圍脂肪界面存在。增強掃描呈均勻強化肺內(nèi)可見大小結(jié)節(jié)影或塊狀影晚期支氣管血管束扭曲、聚攏或變形，葉間裂、血管支氣管移位，支氣管擴張和不同程度肺氣腫支氣管血管束增厚，邊緣不規(guī)則或結(jié)節(jié)狀，周圍可有大小不等的結(jié)節(jié)狀影；小葉間隔增厚和細小蜂窩影，見于胸膜下區(qū)胸膜初期為胸腔積液，可自然吸收，少數(shù)可發(fā)展為胸膜肥厚107鑒別診斷肺門結(jié)核：年輕，有輕度中毒癥狀。氣管旁、支氣管旁淋巴結(jié)腫大，可有鈣化。結(jié)素反應(yīng)陽性，痰中找到結(jié)核桿菌霍奇金?。撼Ｏ扔蓄i部、鎖骨上淋巴結(jié)腫大，然后出現(xiàn)不對稱性雙側(cè)或單側(cè)縱隔淋巴結(jié)腫大，前縱隔較后縱隔多見。縱隔淋巴結(jié)腫大的程度常較肺門淋巴結(jié)腫大顯著非霍奇金淋巴瘤：多為單側(cè)縱隔淋巴結(jié)腫大，即使雙側(cè)縱隔淋巴結(jié)腫大亦不對稱。后縱隔多于前縱隔淋巴結(jié)腫大，晚期才有肺門淋巴結(jié)腫大。縱隔淋巴結(jié)多大于肺門淋巴結(jié)未分化型小細胞肺癌：多為單側(cè)縱隔或（和）肺門分葉狀淋巴結(jié)腫大，雙側(cè)縱隔淋巴結(jié)腫大較少見。部分伴有不同程度的阻塞性肺炎或肺不張。病程發(fā)展迅速間質(zhì)性病變：當病變發(fā)展至纖維化期則需與癌性淋巴管炎、間質(zhì)性肺炎、嗜酸性肉芽腫等鑒別108SarcoidosisAsystemicdisorderofunknowncauseCharacterizedbynoncaseatinggranulomaswithproliferationofepithelioidcellsAffectsyoungandmiddle-agedpatients,withaslightlyhigherprevalenceinwomenHasdistinctgeographicandracialpredilections,withAfrican-Americans,Swedes,andDanesappearingtobemostcommonlyaffected109SarcoidosisSymptomsandsignsarenonspecific,halfasymptomaticFatigue,weightloss,generalmalaise,feverBilateralhilarlymphadenopathyisthemostcommonradiologicfindingAdenopathyintherightparatrachealnodes,leftaortic-pulmonarywindow,andsubcarinalnodescanalsobeseen,oftenwithassociatedpulmonaryinfiltratesExtrathoracicinvolvementcanbeaninitialmanifestationinone-halfofsymptomaticpatientsSkinandocularlesionsarecommon,theliver,spleen,lymphnodes,parotidglands,CNS,genitourinarysystem,muscles,andbonesmayalsobeinvolved110LaboratoryAngiotensinconvertingenzyme(ACE)levelelevatedandmaycorrelatewithactivityTheCD4:CD8ratioiscommonlydecreasedHypercalcemiaduetoincreasedintestinalabsorptionofcalcium,resultingfromactivationofvitaminDbymacrophagesinsarcoidgranulomas111ClinicalCourseandPrognosisMaycorrelatewiththemodeofonsetandtheextentofdiseaseAcuteonsetwitherythemanodosumorasymptomaticbilateralhilarlymphadenopathyusuallyportendsaself-limitingcoursewithspontaneousresolutionInsidiousonset,especiallywithlunginvolvementormultipleextrapulmonarylesions,maybefollowedbyprogressivefibrosisofthelungandotherorgansDirectcauseofdeathin5%(4%fromcardiacinvolvement,1%frompulmonarycomplications)112TreatmentCorticosteroidsareeffectivelyusedfortreatmentSomerespondrapidly,othersmayrequirelong-termtherapyIncasesofaggressivediseaseorfrequentrecurrence,immunosuppressivedrugssuchasmethotrexateandcyclophosphamidemayberequired113HilaradenopathyM27TypicalbilateralhilaradenopathyAdenopathyintherightparatrachealandleftaortic-pulmonarywindownodes114HilaradenopathyE+CTclearlydepictsthebilateralhilaradenopathy115MediastinalLymphNodesBilateralhilaradenopathyRightparatrachealadenopathyLeftparatrachealandaortic-pulmonarywindownodesarealsocommonlyenlargedCalcificationoccursinaffectednodes，Itcanbeamorphous,punctate,oreggshell-like;itiscloselyrelatedtothedurationofthediseaseandsuggestsachroniccondition116MediastinaladenopathyM26SeverebackpainEnlargedrightparatrachealnodesLeftaortic-pulmonarywindownodeswithassociatedminimalhilarinvolvementarealsoseen117MediastinaladenopathyMediastinaladenopathy,60MCalcificationintheaffectedhilarnodes,hugesubcarinallymphnodesAnunusualfindinginothergranulomatousdiseasessuchastuberculosis118PulmonarysarcoidosisLunginvolvementin20%ofpatientsHasastrongpredilectionfortheupperlungDyspneaanddrycougharecommonmanifestations,whereashemoptysisisrareAthistologicanalysis,sarcoidgranulomasinthelungaretypicallydistributedalongthelymphaticvessels,whichrunwithintheinterstitialtissuesofbronchovascularbundlesandthesubpleuralandperilobularspaces119PulmonarysarcoidosisMultiplesmallnodulesinaperivasculardistribution,alongwithirregularthickeningofbronchovascularbundlesandinterlobularseptaUpperlungpredominance,andcoexistenceofmediastinallymphadenopathy,distinguis