肺部感染-影像学和病理-课件

肺部感染-

影像学和病理第1页，共51页。Outline流行病学影像学病理学第2页，共51页。细菌性-大叶性肺炎病原菌：Streptococcuspneumoniae，CAP(35%),

Klebsiellapneumoniae

Legionellapneumophila病理生理：如以下图第3页，共51页。第4页，共51页。early(A)andadvanced(B)stagesoflobarpneumoniacausedbyStreptococcuspneumoniae.In(A),theairspacesarefilledwithedemafluid;onlyoccasionalneutrophilsareevident.In(B),neutrophilspredominate.第5页，共51页。细菌性-小叶性肺炎病原菌：Staphylococcusaureus

Escherichiacoli

Pseudomonasaeruginosa

Anaerobes

Haemophilusinfluenzae

第6页，共51页。第7页，共51页。第8页，共51页。Chestradiographshowsareasofconsolidationintherightupperandleftlowerlobes.Thepatientwasa23-year-oldmanWithbronchopneumonia

第9页，共51页。High-resolutioncomputedtomography(CT)scanshowscentrilobularnodules(arrows)andlobularareasofconsolidation(arrowhead)andground-glassopacity(curvedarrow).Thepatientwasa53-year-oldmanwithbronchopneumonia.第10页，共51页。并发症-肺脓肿病原菌：anaerobicbacteria，S.aureus,P.aeruginosa,andK.pneumoniaeInflammatorymasswithcentralpurulentnecrosis

Frequentlycavitate

Smoothorshaggyinnermargins

Air-liquidlevelscommon

Maximalwallthicknessusually<15

Low-attenuationcentralregionandrimenhancementonCTscan第11页，共51页。第12页，共51页。并发症-坏死性肺炎Bulgingfissuresign.Posteroanteriorchestradiographshowsdenserightupperlobeairspaceconsolidationwithdownwardbulgingoftheminorfissure.Thepatientwasa66-year-oldmanwithpneumococcalpneumonia.第13页，共51页。Necrotizingpneumonia.Chestradiograph(A)showsinhomogeneousanddenseconsolidationintherightlung.Computedtomography(CT)(B)imageshowsalargecavityandsloughedlungwithinthecavity(arrow).Thepatientwasa42-year-oldalcoholicmanwithnecrotizingpneumoniasecondarytoKlebsiellapneumoniaeandanaerobicorganisms.第14页，共51页。并发症-气瘤病原菌：金葡菌〔儿童〕，PCP〔免疫抑制的成人〕特点：薄壁含气空洞，数天或周内扩大，可导致气胸，数周或数月吸收第15页，共51页。肺脓栓来源：心内膜炎，血栓性静脉炎，静脉置管，起搏器导线。影像学特点：空洞小结节，Feedingvesselsign第16页，共51页。image(A)showstwovesselsapparentlycoursingintoanodule(feedingvesselsign〕image(B)demonstratesthattheonlyvesselinclosecontactwiththenoduleisadrainingvein(arrow).第17页，共51页。肺炎链球菌肺炎CAP的主要致病菌〔40%〕危险因素：高龄，慢性心肺疾病主要影像学表现：均一实变，毗邻脏层胸膜次要表现：小叶性肺炎〔20-35%〕，球形实变〔圆肺炎〕，叶间裂膨出高密度实变其他：胸腔积液〔10%〕，同侧淋巴节肿大〔CT上50%〕。CT价值：明确有无空洞或积脓第18页，共51页。

第19页，共51页。Lobarpneumoniaduetostreptococcuspneumonia第20页，共51页。RoundpneumoniaduetoStreptococcuspneumoniae第21页，共51页。BronchiolitisandbronchopneumoniaduetoStreptococcuspneumoniae第22页，共51页。ExtensivebilateralpneumoniaduetoStreptococcuspneumoniae第23页，共51页。葡萄球菌肺炎第24页，共51页。肺脓肿第25页，共51页。Coccalcoloniesaredenselysurroundedbyneutrophils(HE).StrongbasophiliaofthebacteriainH&EpreparationindicatesGrampositivity第26页，共51页。IncidentalterminalaspirationofMRSAcoloniesintothelung,leadingtoaculture-positiveresult(HE).MorphologicstudycaneasilydistinguishMRSA-inducedinfectionfromthecarrierstateofMRSAwithoutprovokingclinicalmanifestation.第27页，共51页。第28页，共51页。S.aureusbronchopneumonia,ischaracterizedhistologicallybypredominantlyperibronchiolarinflammation第29页，共51页。BronchopneumoniaduetoStaphylococcusaureus.Chestradiographshowsbilateralpoorlydefinednodularopacitiesandpatchyareasofconsolidation.Alsonotedisacentralvenousline.Thepatientwasa70-year-oldmanwithMRSApneumonia.第30页，共51页。EmpyemaduetoStaphylococcusaureus.Thepatientwasa44-year-oldmanandanintravenousdruguser.Hehadnoradiologicevidenceofsepticembolism.第31页，共51页。SepticembolismduetoStaphylococcusaureus.Thepatientwasa43-year-oldmanwithpositivebloodculturesforStaphylococcusaureus.第32页，共51页。克雷白肺炎CAP占1%-5%，HAP占15%危险因素：嗜酒，慢性支气管肺病，ICU病人常见影像学表现：CAP:均一大叶实变(右肺上叶多见〕HAP:多中心单侧〔60%〕，双侧〔40%〕实变〔小叶性肺炎〕其他常见发现叶间裂膨出〔30%〕，胸腔积液〔60-70%〕，肺脓肿，脓胸CT价值：明确空腔或脓肿第33页，共51页。AutopsiedlungwithseverepneumoniainapatientwithdegenerativeneuronalDisorder。Numerouslargeandlongpathogensaredispersedwithintheedematousalveolarspace.Thepathogensarenotphagocytizedbyneutrophils(HE,lowpower).第34页，共51页。LobarpneumoniaduetoKlebsiellapneumoniae.Thepatientwasa73-year-oldwomanwithK.pneumoniaepneumonia.第35页，共51页。Klebsiellapneumoniaepneumoniaandabscessformation。Thepatientwasa53-year-oldman.C,D(3dayslater)第36页，共51页。大肠埃希氏菌肺炎CAP(4%),HAP的5-20%危险因素：操劳过度病人常见影像学表现：多中心单侧或双侧实变〔支气管肺炎〕，下叶为主其他表现：胸腔积液第37页，共51页。

BronchopneumoniaduetoEscherichiacoli.Chestradiographshowspoorlydefinednodularopacities(arrows)intherightupperlobeandsmallbilateralfociofconsolidation.第38页，共51页。铜绿假单胞菌肺炎HAP占20%危险因素：COPD,机械通气，抗生素运用，囊型纤维化定植菌常见影像学表现：小叶性肺炎，所有肺叶受累，CT提示小叶中心结节和tree-in-bud其他常见表现：肺脓肿〔20%〕，胸腔积液〔60%〕第39页，共51页。左上，右上:Perivascularcuffing征，左下：美兰细菌染色。右下：痰图片染色〔胶质铁染色〕第40页，共51页。痰染色左：胶质铁染色右：革兰染色第41页，共51页。SeverepneumoniaduetoPseudomonas.第42页，共51页。流感嗜血杆菌肺炎5-20%的CAP病原菌危险因素：COPD,嗜酒，高龄常见影像学表现：小叶性肺炎〔50-60%〕大叶性肺炎〔30-40%〕非常见表现：CT示小结节和树芽征，圆肺炎，空洞〔不超过15%〕，胸腔积液〔50%〕第43页，共51页。图左：NeonatalpneumoniacausedbyHaemophilusinfluenzaeinfection图右：阳性痰涂片第44页，共51页。BronchiolitisandbronchopneumoniaduetoHaemophilusinfluenza.Thepatientwasa50-year-oldmanwithH.influenzapneumonia.第45页，共51页。常见影像学表现：小叶性肺炎〔50-60%〕大叶性肺炎〔30-40%〕Thepatientwasa42-year-oldalcoholicmanwithnecrotizingpneumoniasecondarytoKlebsiellapneumoniaeandanaerobicorganisms.Mass-likeconsolidationduetoLegionellamicdadeiContrast-enhancedWithbronchopneumonia来源：心内膜炎，血栓性静脉炎，静脉置管，起搏器导线。aureus,P.early(A)andadvanced(B)stagesoflobarpneumoniacausedbyStreptococcuspneumoniae.危险因素：操劳过度病人影像学特点：空洞小结节，Feedingvesselsign常见影像学表现：小叶性肺炎〔50-60%〕大叶性肺炎〔30-40%〕CAP:均一大叶实变(右肺上叶多见〕ThepatientCAP的主要致病菌〔40%〕军团菌肺炎2-5%CAP危险因素：高龄，男性，肿瘤或器官移植主要影像学表现：大叶性肺炎，进展至多叶受累少见表现：球形实变〔圆肺炎〕，单个或多个结节或者肿块样实变并发症：空洞〔免疫抑制病人〕，肺门淋巴结肿大(免疫抑制病人〕，胸腔积液〔35-60%〕第46页，共51