AIDS相关胸部疾病的影像诊断课件

1、 艾滋病相关胸部疾病的影像诊断 Imaging of the thorax in AIDS背景Background发病率：大多数，新AIDS50% Morbidity: 50% of new AIDS presentation with thoracic complications意义 : 致病率和死亡率的重要原因Meaning: complications have become important cause of morbidity and mortality新特点: 1.治疗 抗病毒和预防性抗生素New clinic features: Tharapy combination anti

2、-retroviral therapy and the use of prophylactic antibiotics 2.病原体 传统 (PJP ),少见（巨毒及鸟分菌 ) Pathogen tradition (PJP) , less common (CMV and MAC) 3.人群 妇女、儿童 Population characteristics women and children 背景Background 4.影像 :多样,重叠 Radiological appearances: variety and overlap 5.影像结合临床: Imaging be interprete

3、d in conjuction with clinical information 获得背景，并发症，CD4+细胞数，治疗缓急程度 血氧分析和痰菌培养 Nature of HIV acquisition, previous infections or non-infections complications, CD4+ cell count, current drug therapy, and acuteness of onset and severity of the illness, pulse oximetry and sputum microscopyCD4细胞计数与肺部并发症CD4细

4、胞计数（106 个/L） 肺部病原体(种类、表现)200 细菌性肺炎 结核（继发性） 肺癌50200 细菌性肺炎 结核（原发性） 肺癌 肺孢子虫肺炎 Kaposi肉瘤 淋巴瘤 真菌感染 弓形体病 杆菌性血管瘤病普通胸片 CT is superior to plain chest radiographyCT确诊率不高,约50% Accuracy of CT in the diagnosis of thoracic complications of AIDS low ,about 50%确定病变，胸片-/ Confirming suspected chest disease on plain ch

5、est radiography定性诊断 Clarification of abnormalities identified on plain chest radiographs病变范围和形态 The extent of disease and the pattern of parenchymal change纵隔异常 Evaluation of mediastinal abnormalities肿瘤分期或随访 Staging of malignant disease or re-staging post therapy指导活检、胸腔积液和气胸引流 Biopsy planning ,draini

6、ng of loculated pleural fluid collections耶氏肺孢子菌肺炎(Pneumocystis jiroveci pneumonia)PJP是最常见呼吸道感染 PJP was the commonest respiratory tract infection to occur in the AIDS population预防用药提高预期寿命，细菌性肺炎 Prophylactic preventative therapy increase life expectancy，bacterial pneumonia superseded进行性咳嗽和发热、低氧表现 Hist

7、ory of cough and fever，hypoxic developing over several days 痰标本、活检 Induced sputum sample, BAL,transbronchial biopsyX线典型： Chest radiograph:两侧肺门分布毛玻 璃或网格状浸润Bilateral ground-glass or reticular infiltrates most marked in a perihilar distribution耶氏肺孢子菌肺炎(Pneumocystis carinii pneumonia)CT（1）肺门周围毛玻璃样浸润，地图样

8、分布 Perihilar ground-glass infiltrat, geographical distribution-急性（2）线状或网格状伴有小叶间隔增厚吸收较慢-亚急性 A linear or reticular interstitial pattern with thickening of the interlobular septae-slowest to resolve卡氏肺孢子菌肺炎(Pneumocystis carinii pneumonia)不典型：局部实变、肿块、多发结节、胸腔积液、气胸、空洞、淋巴结增大和偶结节钙化 Less typical radiographic

9、 patterns: focal areas of consolidation, mass lesions, multiple lung nodules, pleural fluid, pneumothorax, cavitation ,lymph node enlargement and occasional nodal calcification与细菌性肺炎和分支杆菌鉴别 Difference:bacterial pneumonias and typical or atypical mycobacterial infection喷他咪叮预防-PJP局限于上叶或以上叶病变为主。 Pentam

10、idine prophylaxis-isolated to or predominant in the upper lobes肺门周的毛玻璃样浸润，呈地图样分布，累及肺组织被正常肺实质分开吸收较慢线状或网格状小叶间隔增厚其他表现耶氏肺孢子菌肺炎(Pneumocystis carinii pneumonia)10%-38%肺囊肿或气胸 1038% of cases pulmonary cysts or pneumatocoeles典型：充气气囊，薄壁，内外壁光整 Typically thin walled, with smooth inner and outer margins不典型：厚壁空洞，

11、外形规则或不规则，不含有液体或其他物质 Regular or irregular in shape, do not contain fluid or other material毛玻璃样+囊腔或气胸-PJP GGO + Cysts -PJP气胸和纵隔气肿是肺囊肿并发症 Pneumothorax and pneumomediastinum are recognized as further complicationsHRCT评价非典型有价值 HRCT is helpful in atypical cases肺囊肿或气胸10%-38%病例细菌性肺炎（Bacterial pneumonia）CD4+

12、低高 CD4+ lowhigh细菌性肺炎五倍，败血症100倍 The incidence of bacterial pneumonia approximately five times greater than in an otherwise similar but HIV negative population, the developmentof pneumococcal septicaemia is 100 times greater than in the general population临床表现和过程相同，但进展、空洞、双肺渗出和脓肿形成快 The clinical presen

13、tation of pneumonia is generally the same as in the HIV-negative population, the tendency to rapid progression,cavitation, parapneumonic effusion and empyema formation greater细菌性肺炎（Bacterial pneumonia）病原体多数类似 The organisms encountered same to general 少数免疫抑制后期：罗卡利马体菌，马红球菌，空洞性肺炎+纵隔淋巴结肿大 Opportunistic

14、bacterial infections encountered in the later stages on immunosuppression, including Rochalimaea sp. And Rhodococcus equi, which usually causes a cavitatory pneumonia often with associated mediastinal lymphadenopathy细菌性肺炎（Radiology of Bacterial pneumonia）叶、段实变多 1.Lobar or segmental consolidation is

15、the usual radiographic findings 空洞和胸膜病变 2.Cavitation and pleural complications间质渗出、小结节、树芽征、马赛克样密度-支气管炎，细支气管炎和支气管扩张 3.Interstitial infiltrate, multiple small nodules, tree in bud, mosaic attenuation-bronchitis,bronchiolitis and bronchiectasis 叶或段实变细菌性感染支气管炎细支气管炎和支气管扩张 治疗前后结核分支杆菌（Mycobacterium tubercu

16、losis）正常人群几百倍,更易发生在免疫抑制后期，类似细菌性肺炎。PPD无反应。病原学诊断尤为重要，早期诊断可提高生存期 The incidence is several hundred times greater in the AIDS population than that of HIV-nagatitive populations. Increasingly common towards the later stages of immunosuppression. PPD no reaction. Etiology is important, espcialy early diagn

17、osis.临床和放射学特征依赖于免疫抑制的程度 Both the clinical and radiological features of TB are dependent on the degree of immunosuppression较高CD4+ （0.2109/L)-继发TB Higher CD4+ （0.2109/L )counts - resemble re-activation TB较低CD4+-原发TB特征更典型，淋巴结显著肿大，胸膜炎症，血行以及支气管肺播散，少见部位的叶实变 Lower CD4+ counts -primary infection, with lymph

18、 node enlargement, pleural disease and a tendency to haematological and bronchopulmonary dissemination.痰菌阳性胸片正常高达45%，CT较胸片为敏感 Sputum + and normal chest plain was reported to 45% ;CT is more sensitive to detect lesions than plain radiography CT:实变、多叶段病变，空洞(少见) 1.consolidation, cavitation(less) 单发或多发结

19、节,尤其是粟粒性肺结核常见，大小、分布不均，易融合 2.solitary or multiple nodules，especially phthisis miliaris 胸腔积液（多见） 3.pleural effusions 分枝状结节或“树芽征”,似小叶性肺炎 4.centrilobular branching nodules or tree in bud 周边强化的淋巴结肿，部分病例淋巴结病变多于肺病变 5.nodal enlargement with necrosis,enhancement 血行性播散治疗前后 淋巴结结核 淋巴结结核 淋巴结结核AIDS合并肺TB（混合感染）血中找到

20、猪霍乱杆菌AIDS合并肺TBAIDS合并肺TBAIDS合并肺TB 继发性肺结核非典型分枝杆菌（Atypical mycobacteria）临床特点：CD4+低（50106/L)，胃肠道获感染, CD4+ counts below 50106/L cells, acquired via the gastrointestinal tract1/3AIDS发病,血培养或骨髓抽吸明确诊断 MAC affects up to 35% of patients during the course of their illness影像:间质性或腺泡渗出，肺门淋巴结肿大和少见的空洞Imaging finding

21、 : interstitial or alveolarinfiltrates,Hilar lymphadenopathy, rarely cavitation 与结核类似，胸腔积液或正常的胸片更为常见 Similar to Mycobacterium tuberculosis, pleural effusions or a normal chest radiograph are more common 粟粒状、结节状病灶少见,可有“树芽征” Miliary nodles disease less common,Tree in bud appearance 鸟型分支杆菌（MAC）真菌感染（Fun

22、gal infections）AIDS病人发生真菌感染并不常见 Uncommon in comparison with other infective disorders in AIDS隐球菌最常见的肺部真菌病原体 Cryptococcus is the commonest pulmonary fungal pathogen in the AIDS population脑膜炎是最常见的临床表现 Meningitis is the commonest manifestation of cryptococcal infection肺是感染门户 Lung is thought to be the p

23、ortal of entryCD4+细胞数量低于10010-6 usually occur at patients with low CD4+ counts of less than 10010-6 cells 典型：局部结节或空洞性结节，很少见。 Classical appearances:focal nodule formation,with or without cavitation,but less common最常见：网状或结节状网格间质性渗出、肺泡实变、毛玻璃样改变、粟粒状结节、肿大淋巴结和少量胸腔积液。 Commonest radiological features:reticu

24、lar or reticulonodular interstitial infiltrates,alveolar consolidation, ground-glass change, miliary nodules, lymphadenopathy and small pleural effusions需与PJP、TB以及化脓性细菌感染相鉴别 Differential diagnosis of PJP, TB and pyogenic bacterial infections 曲霉菌(Aspergillus fumigatus)好发于HIV感染后期深度免疫抑制的病人 uaually occu

25、r at Patients with profound immunosuppression最常见表现：厚壁空洞，可有内壁肿块 Commonest radiographic findings: thick-walled cavities with or without an intracavitary mass 血管侵犯导致血管性梗塞 Haemorrhagic infarction as a result of angioinvasion少见表现：结节和肺实变。 Less common findings: non-cavitating nodules and lung consolidation

26、. 气管支气管壁结节样增厚 thickening of the tracheal and bronchial walls 双侧的下叶肺膨胀不全和肺实变 bilateral lower lobe atelectasis and consolidation PJP或TB空洞内曲菌球。 mycetoma formation in preexisting cavity due to previous PCP or TBPJP并曲菌感染病毒感染（Viral infections）巨细胞病毒 致病率和致死率最高 CMV is the most common viral pathogen to cause

27、morbidity and mortality in patients with AIDSCD4+非常低（平均29106个/L） CD4+ very low 低氧，进行性呼吸加快和间质性渗出 Hypoxia, increased respiratory rates and interstitial infiltrates很少单独存在，通常与肺外巨细胞感染或KS一同存在 CMV pneumonitis was rarely found in isolation, frequentlybeing in combination with extrathoracic CMV infection or

28、KS巨细胞病毒(Cytomegalovirus)放射学表现多样，没有特异性 Radiological appearances:varied and non-specific主要：磨玻璃样密度 Include: ground-glass attenuation 高密度实变 dense consolidation 支气管壁增厚或支气管扩张 bronchial wall thickening or bronchiectasis 间质网状改变 interstitial reticulation without airspace disease 散在的肺部结节或肿块 discrete pulmonary

29、 nodules 通常围绕肺门并延伸至下野 most typically perihilar and extend into the lower zones.卡波济肉瘤（Kaposis sarcoma）西方和非洲最常见恶性疾病KS is the most common AIDS-associated malignancy in Western countries and Africa疱疹病毒是KS的诱发因素,肺KS可发于皮肤KS病人 Kaposis sarcoma associated herpes virus (KSHV), Pulmonary KS occurs in 1847% of patients with known cutaneou