S1HIV感染肺炎

1、pneumonia in hiv, approached by specific diseases通过特定疾病考察通过特定疾病考察hiv感染肺炎感染肺炎 mandell, douglas, and bennetts principals and practice of infectious disease. sixth edition.传染性疾病的要点与实践：第六版传染性疾病的要点与实践：第六版最常见病因最常见病因细菌肺炎链球菌流感嗜学血杆菌未发现微生物，但对抗细菌药物有反应分枝杆菌结核分枝杆菌真菌肺囊虫肺炎不常见但在某些场合可具有重要临床意义不常见但在某些场合可具有重要临床意义细菌绿脓杆菌金

2、黄色葡萄球菌肠杆菌科军团菌奴卡菌马红球菌分枝杆菌坎沙西分枝杆菌鸟型分枝杆菌复合物真菌新型隐球菌荚膜组织胞浆菌厌酷球孢子曲霉菌皮炎芽生菌马尔尼菲青霉菌病毒流感病毒巨细胞病毒单纯疱疹病毒腺病毒呼吸道合胞病毒副流感病毒寄生虫刚地弓形虫粪类圆线虫微孢子虫微小隐孢子虫非感染性卡波济肉瘤非何杰金淋巴瘤肺癌原发肺动脉高压充血性心力衰竭淋巴细胞性（或淋巴样）间质肺炎肺气肿阿巴卡韦过敏3.3%14.7%4.6%25.6%18.7%bureau of epidemiology, cdc , moph mycobacterium infection - mycobacterium tuberculosis (m.

3、tb)- mycobacterium avium complex (mac)fungal infection- pneumocystis jirovecii- cryptococcus neoformansbacterial infection- nocardia spp.- rhodococcus equi- miscellaneous 分枝杆菌感染分枝杆菌感染 - 结核分枝杆菌 (m. tb)- 鸟分枝杆菌复合物 (mac) 真菌感染真菌感染- 肺囊虫肺炎 - 新型隐球菌 细菌感染细菌感染- 诺卡氏菌 - 马红球菌 - 其它细菌 leading aids-related oi enhanc

4、e hiv replication might accelerate the natural progression of hiv infection drug interaction between rmp vs. arv 结核是首要的结核是首要的艾滋病艾滋病相关相关机会机会性感染性感染 结核可增强结核可增强hiv复制复制 结核有可能加速结核有可能加速hiv感染的自感染的自然病程然病程 利福平与抗逆转录药物的相互利福平与抗逆转录药物的相互作用作用 high rate of primary tb and reactivationincrease incidence of extrapulmon

5、ary and disseminated tbincrease incidence of paradoxical reactionmight need longer treatment coursemore adverse drug reactionsincrease incidence of mdr-tb high mortality rate 原发结核的高发病率和再激原发结核的高发病率和再激活活 增加肺外结核和播散性结核增加肺外结核和播散性结核的发病率的发病率 增加异常反应的发生率增加异常反应的发生率 可能需要延长疗程可能需要延长疗程 增加药物不良反应增加药物不良反应 增加耐多药性结核病的

6、发生增加耐多药性结核病的发生率率 高死亡率高死亡率 for practical purposes , early and late may be defined as cd4+cell counts 300 cells/mm and 300 个细胞个细胞/mm a和和 300- patchy or nodular infiltration- location in apical or subapicoposterior segment of upper lobe or superior segment of lower lobe- dry, thick wall cavitation (50%

7、), air-fluid level is uncommon- lymphadenopathy is unusual- pleural effusion could be found “typical radiographic pattern of ptb” cd4 300- 斑片或结节浸润影- 定位于肺尖或上叶尖下后段或下叶上段- 干性厚壁空洞 (50%)，气液平不常见- 淋巴腺病不常见- 可见胸膜渗出 “肺结核的典型放射线表肺结核的典型放射线表现现”cd4 200- alveolar infiltration, diffuse interstitial infiltration, or m

8、ixed infiltration- location in any segments or lobes- common enlarged lymphadenopathy- common extrapulmonary involvement- normal cxr (14-20%) in advanced aids (cd450) “non-specific radiographic pattern” cd4 200- 肺泡浸润，弥漫间质浸润或混合浸润- 定位于任何肺段或肺叶- 一般化增大的淋巴结- 一般化的肺外受累- 晚期艾滋病患者(cd450)可有正常的x线表现 (14-20%)“非特异放

9、射线表现非特异放射线表现”afb stain;acid-fast bacilli抗酸杆菌染色；抗酸杆菌染色； 抗酸杆菌gram stain;ghost bacilli革兰氏染色；革兰氏染色；血影杆菌h&e stain苏木素和伊苏木素和伊红染色红染色afb stain抗酸杆菌染色抗酸杆菌染色mycobacterium avium complex鸟分枝杆菌综合症鸟分枝杆菌综合症(mac)prior history of underlying lung pathologymiddle-age to old mantypical radiographic pictures- upper lob

10、e fibronodular lesion, associated with pleural thickening- cavitations tend to be higher than tuberculosis (60-90% vs. 50%) and more likely to be thin-wall, quite large- pleural effusion is common“pulmonary disease” 有基础肺疾病史有基础肺疾病史 从中年到老年均可发生从中年到老年均可发生 典型放射线表现典型放射线表现- 上叶纤维结节病灶，与胸膜增厚有关- 空洞的发生比结核多（分别为6

11、0-90%和50%），更多见大的薄壁空洞- 胸膜渗出常见“肺部疾病肺部疾病”mac infection in a 52-year-old copd man, with history of prolong fever, weight loss, cough, intermittent hemoptysis, and dyspnea某52岁慢阻肺患者的mac感染，持续发热，体重下降，咳嗽，间断性咯血和呼吸困难mandell, douglas, and bennetts principals and practice of infectious disease. sixth edition.cd4

12、 50the most common organs involved;- spleen, liver, intestines, colon, lymph nodes, bone marrowthe less common organs involved;- lung (10%), adrenal glands, stomach, central nervous system (cns)radiographic pictures, simulating tb;- alveolar/interstitial infiltration - nodules/cavitations are uncomm

13、on- adenopathy is not dominant “disseminated disease”cd4 50最常受累的器官：最常受累的器官：- 脾，肝，小肠，结肠，淋巴结，骨髓 最少受累的器官：最少受累的器官：- 肺 ( - risk for pneumothorax- unilateral infiltration, nodules, cavitations lymphadenopathy, pleural effusion 典型表现典型表现:- 早期疾病可有正常胸部x线表现 (10-39%)- 弥漫性双侧浸润（毛玻璃样表现） 非典型表现非典型表现:- 薄壁囊，气泡 - - 发生气

14、胸风险- 单侧浸润，结节，空洞，淋巴腺病，胸膜渗出cd4 200disease burden is higher but severity is lesssymptoms; lasting from weeks to monthsextrapulmonary pneumocystosis; in advanced aids without pcp prophylasis or only aerosolized pentamidinecxr; cavitations, lymphadenopathy and pleural effusion are unusual“cavity, adenopa

15、thy and pleural effusion are unusual”cd4 200疾病负荷更高，但严重度较小疾病负荷更高，但严重度较小症状：症状：持续数周到数月肺外肺外肺囊虫肺炎：肺囊虫肺炎：可见于不做pcp预防治疗或仅做戊烷脒雾化治疗的进展期艾滋病患者胸部胸部x线表现线表现：空洞、淋巴腺病、胸膜渗出不常见“空洞、腺病和胸膜渗空洞、腺病和胸膜渗出不常见出不常见”gms stain;cluster of round or cup shaped cystsgms染色染色；成堆的圆形或杯状囊成堆的圆形或杯状囊h&e stain;frothy eosinophilic honeycomb

16、ed material filling alveolar space苏木素和伊红染色；苏木素和伊红染色；空泡化嗜酸粒蜂窝样物空泡化嗜酸粒蜂窝样物质充填于肺泡间隙质充填于肺泡间隙susceptible hostssymptoms range;- asymptomatic colonization of the airway to life-threatening pneumonia (depend on immune status)radiographic characteristics include;- well-defined noncalcified single/multiple no

17、dules, mass-like infiltration or dry thin-wall cavitationsthe two common sites are lung and cns 易感宿主易感宿主 症状范围：症状范围：- 从气道的无症状聚集到威胁生命的肺炎都可能发生（取决于免疫状态） 放射线放射线特点包括：特点包括：- 分界清楚的非钙化单发/多发结节，肿块样浸润或干性薄壁空洞 两个常见部位为肺和中枢神两个常见部位为肺和中枢神经系统经系统mandell, douglas, and bennetts principals and practice of infectious disea

18、se. sixth edition.hiv感染淋巴增生异常肉瘤皮质激素治疗高-igm综合征高-ige综合征单克隆抗体（如英利昔单抗）系统性红斑狼疮*hiv阴性cd4+t淋巴细胞减少症糖尿病#器官移植*腹膜透析肝硬化*免疫抑制治疗可能导致易感性。#糖尿病长期以来就被认为是新型隐球菌感染的危险因素。但由于糖尿病是一个很常见的疾病，因此不能确定糖尿病就是新型隐球菌感染的危险因素。摘自 casadevall a, perfect jr.新型隐球菌，华盛顿：asm press；1998:410表表261-1：已知或可能与新型隐已知或可能与新型隐球菌感染有关的情形球菌感染有关的情形mandell, dou

19、glas, and bennetts principals and practice of infectious disease. sixth edition.cd4 100more cns and extrapulmonary infectionsfor cns infection;- high rate of +india ink, +cryptococcal ag, +blood culture, and few csf inflammatory cells for lung infection (only 5-25% of cases);- coinfection have been

20、reported with tb, pcp, nocardiosis“limited pneumonia is uncommon and coinfection is considered”cd4 100更多的中枢神经系统和肺外感染更多的中枢神经系统和肺外感染中枢神经系统感染：中枢神经系统感染：- 高阳性率的印度墨汁染色，新型隐球菌抗原，血培养和脑脊液炎性细胞 肺感染（发生率只有肺感染（发生率只有5-25%）：）：- 曾见于结核、卡氏肺囊虫肺炎、诺卡菌病的联合感染“限制性肺炎不常见，此时要限制性肺炎不常见，此时要考虑联合感染考虑联合感染”radiographic pictures;- diff

21、use bilateral interstitial infiltration (mimic pcp)- focal/nodular infiltration, consolidation, dry thin-wall cavitations- lymphadenopathy- pleural involvement is unusual“radiographic patterns often mimic pcp” 放射线表现放射线表现：- 弥漫双侧间质浸润（酷似卡氏肺囊虫肺炎）- 局灶/结节浸润，实变，干性薄壁空洞- 淋巴腺病- 胸膜受累不常见“放射线表现放射线表现常酷似卡氏肺囊虫常酷似卡氏

22、肺囊虫肺炎肺炎”afb stain;encapsulated yeast cells and acid-fast bacilli抗酸杆菌染色抗酸杆菌染色;包囊化酵母细胞和抗酸包囊化酵母细胞和抗酸杆菌杆菌wright stain;encapsulated yeast cells莱特染莱特染色；色；包囊化酵母细胞包囊化酵母细胞preexisting immunocompromised host;- alcoholism- diabetes mellitus- organ transplantation/lymphoreticular neoplasm- long-term corticostero

23、id usage - chronic lung disease- aids 3 forms;1. progressive cutaneous/lymphocutaneous disease2. pulmonary disease3. disseminated infection: cns, eye, skin, bone&joint, heart, lung and kidney 存在免疫受损的宿主：存在免疫受损的宿主：- 酗酒- 糖尿病- 器官移植/淋巴网状系统肿瘤- 长期应用皮质激素 - 慢性肺疾病- 艾滋病 3种形式种形式：1. 进展性皮肤/淋巴皮肤疾病2. 呼吸疾病3. 播散感

24、染：中枢神经系统，眼，皮肤，骨/关节，心脏，肺和肾radiographic pictures;- irregular nodules, mass-like condolidation, abscesses, reticulonodular infiltration - pleural effusion/empyema- contiguous extension to deep structures and surfacenocardiosis in aids-patients; - cd4 200- overall incidence in aids-patient is low!“clinical clues to suspected nocardiosis” spread to contiguous structures, especially soft tissue swelling or external fistulas, and to cns 放射线表现放射线表现;- 不规则结节，肿块样实变，脓肿，网状结节浸润- 胸膜渗出/积脓- 向深部结构和体表连续进展 艾滋病患者的诺卡菌病：艾滋病患者的诺卡菌病： - cd4 200- 在艾滋病患者中整体发病率较低！“诺卡菌病的临床线索诺