高分辨率肺部ct诊断（下）

Case 61 in a 73-year-old woman with cough,支扩,大边界不清的结节,树芽征,What is the most likely diagnosis in this patient最可能的诊断? (a) Bacterial bronchopneumonia细菌性支气管肺炎 (b) Tuberculosis肺结核 (c) Infection with atypical mycobacteria非典型分支杆菌感染,Infection with atypical mycobacteria Correct. In an elderly woman, the combination of bronchiectasis, nodules, and tree-in-bud is highly suggestive of MAC infection 支扩、结节、树芽征高度暗示分支杆菌感染。,Case 62 in a 35-year-old man with leukemia 白血病,On the lung window scan, a lung nodule is surrounded by a halo of ground-glass opacity磨玻璃晕征. This is termed the “halo sign晕征”. On the soft tissue window scan, low-attenuation necrosis is visible in the central portion of the nodule结节中心可见坏死.,晕征,坏死,Diagnosis: Invasive 入侵的aspergillosis曲霉病 with the “halo sign晕征“,Case 63 in a 28-year-old man with leukemia 白血病and treated aspergillosis曲霉病治疗,不规则的空洞,结节影像,Diagnosis: Invasive aspergillosis 曲霉病with infarction坏死 and air-crescent sign 新月征,Case 64 in a 31-year-old woman with an abnormal chest radiograph异常胸部表现.,Diagnosis: Wegeners granulomatosis with multiple nodules韦格纳肉芽肿 DISCUSSION：Large lung nodules can be associated with a variety of lung diseases, and in most instances, their appearance is nonspecific无特殊性 . The differential diagnosis鉴别诊断 includes metatstatic tumor转移瘤, infectious 感染or inflammatory lesions炎性损害, infarctions肉芽肿病, nodules of Wegeners granulomatosis, sarcoidosis结节病, and fibrotic masses 纤维块as are common in sarcoidosis or silicosis在结节病、硅肺病.,INCREASED OPACITY,肺不透明性增加,Case 65 in a 35-year-old woman who has a history of asthma哮喘史, progressive shortness of breath进行性喘憋,Does the principal abnormality visible on CT represent consolidation or ground-glass opacity首要异常是实变还是磨玻璃改变? (a) Consolidation实变 (b) Ground-glass opacity磨玻璃密度,Consolidation Correct. HRCT shows patchy areas of consolidation in the lung periphery肺外围不均的实变. Note that vessels are not visible within the areas of increased opacity密度增高影内肺血管影像未见. Some areas of ground glass opacity are also visible一些磨玻璃区是可见的.,实变,Diagnosis: Chronic eosinophilic pneumonia慢性嗜伊红肺炎, presenting with consolidation呈现实变。,Case 66 in a 43-year-old woman with a low-grade fever低热, progressive shortness of breath气短,肺外围实变影,There was a marked eosinophilia in the peripheral blood外围血嗜伊红细胞增多. The most likely diagnosis is最可能的诊断: (a) BOOP机化性肺炎 (b) pneumonia肺炎 (c) hypersensitivity pneumonitis过敏性肺炎 (d) eosinophilic pneumonia嗜伊红肺炎,eosinophilic pneumonia Correct. Diagnosis: Chronic eosinophilic pneumonia慢性嗜伊红肺炎, presenting with consolidation呈现实变.,Case 67 in a 56-year-old woman with a low-grade fever低热, progressive shortness of breath over 2 months喘憋2月以上。,HRCT shows patchy areas of consolidation in the lung periphery and in the peribronchovascular region肺外围、支气管血管束周围片状实变影. Note that vessels are not visible within the areas of increased opacity在其内血管影不见. At a more cephalad level, patchy consolidation and ground-glass opacity磨玻璃影 are visible.,实变、磨玻璃影,What is the most likely diagnosis可能的诊断? (a) Pneumonia肺炎 (b) Eosinophilic pneumonia嗜伊红肺炎 (c) BOOP机化性肺炎,BOOP Correct. The differential diagnosis鉴别诊断 includes a number of infectious and noninfectious diseases包括许多感染、非感染疾病. In patients with subacute or chronic symptoms在亚急性、慢性, pneumonia is less likely肺炎少见, and the most likely diagnoses include bronchiolitis obliterans organizing pneumonia (BOOP)更多的诊断是机化性肺炎, eosinophilic pneumonia嗜伊红肺炎, bronchioloalveolar carcinoma细支气管肺泡癌 and lymphoma淋巴瘤, interstitial pneumonia间质性肺炎, and alveolar proteinosis肺泡蛋白沉积症. Biopsy revealed 病理是BOOP.,Diagnosis: Bronchiolitis obliterans organizing pneumonia (BOOP), presenting with consolidation and ground-glass opacity出现实变、磨玻璃密度.,The HRCT findings in patients with BOOP include机化性肺炎: 1) patchy consolidation片状实变 (seen in 80% of cases) or ground-glass opacity磨玻璃影 (in 60% of cases), often with a subpleural 胸膜下and/or peribronchial distribution支气管周围; and 2) small ill-defined nodules 小结节(30-50% of cases) which may be peribronchial or peribronchiolar. Findings may closely mimic those seen in patients with eosinophilic pneumonia与嗜伊红肺炎近似.,Case 68 47-year-old woman with 6 weeks history of a low-grade fever低热6周, nonproductive cough, and malaiseishen不舒服,HRCT shows ill-defined nodular areas of consolidation 边界不清实变结节in the peribronchovascular regions在支气管束周围. Air-filled bronchi can be identified within some of these opacities支气管可见. This appearance mimics the peribronchovascular nodules sometimes seen in patients with sarcoidosis类似（支气管血管束结节）在结节病可见, but note that, unlike sarcoidosis, no subpleural nodules are visible in this case但该病无胸膜下结节. Additional history revealed a recent upper respiratory infection另外最近有上呼吸道感染. Biopsy showed病理是 BOOP.,边界不清的实变影,Diagnosis: Bronchiolitis obliterans organizing pneumonia (BOOP) resulting from respiratory infection因呼吸道感染发生, presenting with consolidation呈现实变.,Case 69 53-year-old man with a history of unresolved respiratory infection未治愈的感染, low-grade fever低热, and nonproductive cough咳嗽,HRCT shows ill defined nodular areas of ground-glass opacity in the lung periphery肺外围磨玻璃密度.,Diagnosis: Bronchiolitis obliterans organizing pneumonia (BOOP) resulting from respiratory infection因呼吸感染所致, presenting with centrilobular nodules呈现小叶中心结节.,Case 70 n a 15-year-old boy with a recent history of hemoptysis近日咳血史.,Does HRCT show consolidation or ground-glass opacity实变还是磨玻璃密度? (a) Consolidation实变 (b) Ground-glass opacity磨玻璃密度,Ground-glass opacity Correct. HRCT shows an ill-defined increase in lung opacity, but pulmonary vessels remain visible within the abnormal lung regions在异常区肺纹理可见. This appearance is termed ground-glass opacity.术语：磨玻璃密度。,磨玻璃密度,What is the most likely diagnosis最可能的诊断? (a) Viral pneumonia病毒性肺炎 (b) Pulmonary hemorrhage肺出血 (c) Pulmonary edema肺水肿 (d) Hypersensitivity pneumonitis过敏性肺炎,Pulmonary hemorrhage Correct. A large number of diseases can be associated with ground-glass opacity. The most common causes of ground-glass opacity 磨玻璃密度包括include hypersensitivity pneumonitis过敏性肺炎, pneumonia 肺炎(particularly atypical pneumonias caused by pneumocystis carinii, virus, and mycoplasma), pulmonary edema肺水肿 or hemorrhage出血, alveolar proteinosis肺泡蛋白沉积症, acute interstitial pneumonia 急性间质性肺炎or other causes of diffuse alveolar damage (ARDS), or interstitial pneumonia (DIP or UIP). In this patient, the history of hemoptysis suggests pulmonary hemorrhage咳血史支持肺出血 .,Case 71 in a 46-year-old woman with a history of progressive shortness of breath喘憋, low-grade fever低热, and nonproductive cough咳嗽,HRCT shows ill defined patchy areas of ground-glass opacity片状磨玻璃密度区. Bronchi look “too black” compared to lung parenchyma, representing air bronchograms支气管相对肺实质“较黑”.,What it the most likely diagnosis最可能的诊断? (a) Viral pneumonia病毒性肺炎 (b) Pulmonary hemorrhage肺出血 (c) Pulmonary edema肺水肿 (d) Hypersensitivity pneumonitis过敏性肺炎,Hypersensitivity pneumonitis Correct. The exposure to molds makes 模型铸造hypersensitivity pneumonitis most likely 过敏性肺炎更像。,Diagnosis: Hypersensitivity pneumonitis过敏性肺炎, presenting with ground-glass opacity呈现磨玻璃密度.,DISCUSSION Hypersensitivity pneumonitis过敏性肺炎 (HP) is an allergic lung disease过敏性肺疾患 caused by the inhalation of antigens contained in a variety of organic dusts吸入多种抗原的灰尘. Farmers lung农民肺, which is the best-known HP syndrome, results from the inhalation of fungal organisms 吸入真菌有机体(thermophilic actinomycetes) that grow in moist hay潮湿的干草多见. HRCT is usually performed in the subacute stage of disease, weeks to months following first exposure to the antigen. Typical findings include patchy ground-glass opacity典型表现：磨玻璃密度(80%) and small ill-defined centrilobular nodules of ground-glass opacity小边界不清的小叶中心结节 (80%). Patchy lobular lucency小叶透亮区 and air trapping空气潴留 may also be seen, and is characteristic of hypersensitivity pneumonitis, reflecting the presence of bronchiolitis细支气管炎是过敏性肺炎典型表现 .,小叶透亮区,常规CT检查均为吸气相；呼气时肺内的含气量明显减少，正常肺野的透光度应均匀或阶梯性降低；合并小气道管腔狭窄或闭塞时，相应肺泡内的气体不能呼出而呈片状低密度，称之为空气潴留征。所以呼气相CT主要判断有无小气道的病变，一定程度上反应了肺的局部通气功能。,低密度病变：提示肺内含气量过多、肺结构破坏、肺内潜在腔隙扩大以及纤维化等。根据有无囊壁分为：（1）有壁低密度病变或含气囊腔：常见病变为肺囊肿、支气管扩张、蜂窝肺、肺淋巴管平滑肌瘤病等。（2）无壁低密度病变或含气囊腔：主要见于肺气肿、肺大泡、空气潴留征和马赛克灌注。,Case 72 in 57-year-old woman with exposure to birds as pets接触鸟史, progressive shortness of breath喘憋, low-grade fever低热, and nonproductive cough咳嗽,HRCT shows ill defined patchy areas of ground-glass opacity边界不清的磨玻璃密度影. Focal areas of lucency病灶区域的透亮区, representing air trapping are also visible表现空气潴留.,磨玻璃密度,空气潴留,闭塞性细支气管炎：局部空气潴留、通气不良、反射性低灌注，马赛克灌注-在这种情况下，血液再分配到通气正常区补丁状或地图状，病变区（低密度区）内血管管径减小，并有支气管异常；正常区（ 高密度区）内血管管径正常或变大，而磨玻璃密度肺动脉大小正常。,The most likely diagnosis is最可能的诊断: (a) viral pneumonia病毒性肺炎 (b) pulmonary hemorrhage肺出血 (c) pulmonary edema肺水肿 (d) hypersensitivity pneumonitis过敏性肺炎,hypersensitivity pneumonitis过敏性肺炎 Correct. The exposure to birds makes hypersensitivity pneumonitis most likely与鸟有关. The appearance of ground-glass opacity with focal lucent regions is typical磨玻璃密度伴透亮区（空气潴留）.,Diagnosis: Hypersensitivity pneumonitis过敏性肺炎, presenting with ground-glass opacity and air trapping呈现磨玻璃密度和空气潴留.,DISCUSSION The combination of patchy ground-glass opacity and patchy lucency due to air trapping is highly suggestive of hypersensitivity pneumonitis补钉状磨玻璃密度、透亮区支持过敏性肺炎. This combination reflects lung infiltration (ground-glass opacity磨玻璃密度反映肺感染), and bronchiolitis 细支气管炎(patchy lucency due to air trapping空气潴留地图状透亮区), common in this disease. This variegated appearance has been likened to that of a sausage多样变化比作腊肠, so-called “head cheese猪头肉冻征“, made from various parts of the head of a hog. The variegated appearance of lung seen with the head cheese sign indicates the presence of ground-glass opacity in association with normal lung attenuation and areas of low attenuation due to air trapping. It is strongly suggestive of hypersensitivity pneumonitis.,猪头肉冻征,Case 73 in a 56-year-old woman with chronic cough慢性咳嗽, whose symptoms began开始在 at a time she was burning moldy wood in the fireplace燃烧发霉的木头,HRCT shows some patchy areas of consolidation in the right upper lobe右肺上叶补钉状实变, but the predominant abnormality突出的异常 is patchy and geographic ground-glass opacity,补钉状、地图状磨玻璃密度 and some lobular regions of lucency小叶透亮区. In viewing the sequence of images, the abnormalities have an upper lobe predominance上叶优势, and the lung bases (Figure 4) are relatively spared.,实变,磨玻璃密度,小叶透亮区,The combination of ground-glass opacity实变的磨玻璃密度, normal lung, and areas of lucency透亮区 suggests what diagnosis支持什么诊断? (a) BOOP机化性肺炎 (b) Hypersensitivity pneumonitis过敏性肺炎 (c) Alveolar proteinosis肺泡蛋白沉积症,Hypersensitivity pneumonitis过敏性肺炎 Correct. This is another example of the head-cheese sign猪头肉冻征, a finding strongly suggesting the diagnosis of hypersensitivity pneumonitis强烈支持过敏性肺炎. Open lung biopsy was performed.,Case 74 in a 42-year-old HIV positive 艾自病毒man fever and shortness of breath发热、喘憋,The most likely diagnosis is最可能的诊断: (a) viral pneumonia病毒性肺炎 (b) pneumocystis pneumonia卡氏肺孢子虫肺炎 (c) pulmonary hemorrhage肺出血 (d) pulmonary edema肺水肿 (e) hypersensitivity pneumonitis过敏性肺炎,pneumocystis pneumonia pcp肺炎Correct. HRCT shows extensive regions of ground-glass opacity,广泛磨玻璃密度 involving包括the upper lobes diffusely上叶弥漫, and the lower lobes in a patchy 下叶补钉状and geographic fashion地图状. In viewing the sequence of images, the abnormalities have an upper lobe and parahilar predominance上叶肺门、优势. The differential diagnosis of this appearance is extensive, but with the history of AIDS and fever, Pneumocystis carinii pneumonia (PCP) must be strongly considered, and appropriate diagnostic tests performed鉴别诊断是广泛的，结核病史可考虑pcp.,Case 75 in a 54-year-old woman with lymphoma 淋巴瘤being treated with chemotherapy在化疗. Symptoms症状 include fever发热, cough咳嗽, and shortness of breath喘憋,HRCT shows patchy areas of ground-glass opacity in the upper lobes上叶磨玻璃密度补丁状区域. Many of the opacities appear lobular or centrilobular不透明表现小叶或小叶中心, and interlobular septal thickening is also clearly seen小叶间隔增厚可见. At lower levels, the areas of ground-glass opacity appear geographic 下叶磨玻璃密度表现地图状(Figure 5) and at least one area of consolidation 至少一个区域实变(Figure 4) is present. An irregular nodule is also seen, but unrelated不规则结节可见但无关. The nodule represented an aspergillus infection为曲霉菌感染.,小叶或小叶中心性（上叶补丁状不透明区）,小叶间隔增厚,地图状磨玻璃密度,不规则结节霉菌感染,The most likely diagnosis is最可能的诊断: (a) viral pneumonia病毒性肺炎 (b) pneumocystis pneumonia卡氏囊虫肺炎 (c) pulmonary hemorrhage肺出血 (d) pulmonary edema肺水肿 (e) hypersensitivity pneumonitis过敏性肺炎,A definite diagnosis cannot be made明确诊断是困难的. In a patient with lymphoma on chemotherapy淋巴瘤化疗, I would consider each of these is possible所诉每一诊断都是可能的. Bronchoscopy revealed Pneumocystis carinii pneumonia镜检为 (PCP).,Diagnosis: Pneumocystis carinii pneumonia (PCP), presenting with ground-glass opacity磨玻璃密度 and septal thickening小叶间隔增厚. Pneumocystis carinii pneumonia (PCP) may occur in any immunosuppressed patient间质性浆细胞肺炎可以发生在任何免疫抑制患者.,Case 76 in a 48-year-old man with a history of substance abuse身体滥用, cough, fever, and shortness of breath,HRCT shows patchy areas of ground-glass opacity in the upper lobes上叶磨玻璃密度 (Figure 1). Interlobular septal thickening 磨玻璃区可见小叶间隔增厚is also visible in relation to the areas of ground-glass opacity. At a lower level下部, a focal area of consolidation is present 可见实变病灶(Figure 4).,上叶磨玻璃密度,小叶间隔增厚,下叶实变灶,The most likely diagnosis is最可能的诊断: (a) viral pneumonia病毒性肺炎 (b) pneumocystis pneumonia卡氏囊虫肺炎 (c) pulmonary hemorrhage肺出血 (d) pulmonary edema肺水肿 (e) hypersensitivity pneumonitis过敏性肺炎,A definite diagnosis cannot be made based on the HRCT appearance不能明确诊断. In this clinical setting, each of these is possible每一病例是可能的. Bronchoscopy and culture revealed a viral pneumonia (CMV)镜检示病毒性肺炎.,Diagnosis: Viral pneumonia 巨细胞病毒性肺炎(cytomegalovirus), presenting with ground-glass opacity磨玻璃密度 and septal thickening间隔增厚.,Case 77 in a 60-year-old woman with a history of recent pneumonia最近肺炎史, cough咳嗽, low grade fever低热,HRCT shows patchy and geographic areas of ground-glass opacity in the upper lobes地图状、补丁状磨玻璃密度增高影, with lobular areas of lucency also visible小叶透亮区. Patchy ground-glass opacity and consolidation are visible at other levels补丁状磨玻璃密度和实变在其它区域可见. This appearance is nonspecific表现无特殊性.,磨玻璃密度,小叶透亮区,实变,Diagnosis: Mycoplasma pneumonia支原体肺炎, presenting with ground-glass opacity and patchy air trapping呈现磨玻璃密度、补丁状空气潴留. The combination of patchy ground-glass opacity磨玻璃密度的实变 and patchy lucency due to air trapping补丁状空气潴留 (i.e. the “head cheese sign”) is highly suggestive of hypersensitivity pneumonitis支持过敏性肺炎, but can be seen in other diseases associated 但在其他疾病亦可见with lung infiltration肺感染 and bronchiolitis细支气管炎, including包括 sarcoidosis结节病 and atypical infections非典型感染.,Case 78 in a 47-year-old woman with a history of lymphoma 淋巴瘤史and symptoms of cough, malaise不舒服, and fever,HRCT shows patchy and somewhat nodular areas of ground-glass opacity in the right middle lobe右中叶可见磨玻璃密度区 . Interlobular septal thickening小叶间隔增厚 is also visible in relation to the areas of ground-glass opacity. At a lower level, the lingula舌段有类似异常 shows similar abnormalities.,中叶补丁状磨玻璃密度影,小叶间隔增厚,舌段的类似异常,Diagnosis: Viral pneumonia病毒性肺炎, presenting with ground-glass opacity磨玻璃密度 and septal thickening间隔增厚.,Case 79 in a 57-year-old woman with a history of lymphoma淋巴瘤史, failed chemotherapy induction失败的化疗, and shortness of breath气短,HRCT shows patchy areas of ground-glass opacity补丁状磨玻璃密度影. Interlobular septal thickening 小叶间隔增厚is also visible, as is mild thickening of the fissures叶裂轻度增厚.,磨玻璃密度影,小叶间隔增厚,叶裂轻度增厚,The most likely diagnosis is最可能的诊断: (a) viral pneumonia病毒性肺炎 (b) pneumocystis pneumonia卡氏肺囊虫肺炎 (c) pulmonary hemorrhage肺出血 (d) pulmonary edema肺水肿 (e) BOOP机化性肺炎,In a patient with this history, each of these diagnoses is possible上诉诊断都可能. She improved following diuresis.利尿后减轻 Diagnosis: Pulmonary edema肺水肿 due to fluid overload, presenting with ground-glass opacity and septal thickening.磨玻璃密度、小叶间隔增厚。,Case 80 in a 46-year-old woman with a history of bilateral lung transplantation 双肺移植史and rapidly迅速进行性喘憋 progressing shortness of breath,HRCT shows patchy areas of ground-glass opacity with a striking peripheral and subpleural predominance磨玻璃影外围胸膜下为优势. Considering her history of immunosuppression考虑肺移植史, infection must be considered感染必须被考虑. However, no infections were found at bronchoscopy不能气管镜. The patient progressively worsened and eventually died患者严重死亡. Autopsy showed lung congestion 尸检肺充血and pulmonary edema肺水肿 secondary to pulmonary veno-occlusive disease.,以胸膜下为主的磨玻璃影,Diagnosis: Pulmonary edema肺水肿 secondary to pulmonary veno-occlusive disease肺静脉闭塞, occurring as a complication of lung transplantation因肺移植, presenting with ground-glass opacity呈现磨玻璃影.,Case 81 in a 42-year-old man with a history of leukemia白血病 and hemoptysis咳血,HRCT shows patchy areas of ground-glass opacity磨玻璃密度 (Figure 1). A fine reticular pattern 明显的网状(Figure 2) is superimposed在磨玻璃影上 on the ground-glass opacity. This appearance is consistent with pulmonary hemorrhage与肺出血是一致的, suspected from the history支持病史.,Diagnosis: Pulmonary hemorrhage 肺出血 esecondary to leukemia白血病, presenting with ground-glass opacity呈现磨玻璃密度影。DISCUSSION讨论 Pulmonary hemorrhage may result from anticoagulation, leukemia with low platelet counts (as in this case)白血病血小板减少, Goodpastures syndrome, or other causes of vasculitis其他脉管炎. Regardless of its cause, HRCT shows patchy or diffuse, ground-glass opacity or consolidation不管原因：表现补丁状、弥漫的磨玻璃影或实变影. Reticular opacities or interlobular septal thickening may be superimposed可以有网状改变.,Goodpastures syndrome,Case 82 in a 29-year-old woman with a history of systemic lupus erythematosus系统性红斑狼疮 and shortness of breath喘憋,Diagnosis: Active interstitial pneumonia急性间质性肺炎 secondary to systemic lupus erythematosus红斑狼疮, presenting with ground-glass opacity磨玻璃密度影.,Case 83 in a 19-year-old woman with newly diagnosed systemic erythematosus and hemoptysis 系统红斑狼疮,The most likely diagnosis is最可能的诊断: (a) viral pneumonia病毒性肺炎 (b) pneumocystis pneumonia卡氏费囊虫肺炎 (c) pulmonary edema肺水肿 (d) pulmonary hemorrhage肺出血 (e) lupus pneumonitis狼疮肺炎,Each of these could explain the HRCT findings每一个都能解释. The history of hemoptysis suggests pulmonary hemorrhage 据历史诊断肺出血。,Case 84 in a 59-year-old w