病理学课件 传染病和寄生虫-2016 May-liugy

InfectiousDiseases

刘国元gyliu@PathologyDepartment,SchoolofBasicMedicalSciences,FudanUniversityEtiology:pathogenicmicrobes

parasite

epidemiologysourceofinfectionrouteoftransmissionSusceptiblepopulation

Pathogenesisentrycelltoxin/enzyme,vesselinjuryimmuneresponseInfectiousDisease

CommonFeaturesLeprosy(麻风)

Syphilis(梅毒)

Typhoidfever(伤寒)

Bacillarydysentery（细菌性痢疾）传染病

Leprosy(麻风)Leprosy,HansendiseaseSlowlyprogressiveMycobacteriumleprae麻风杆菌AffectingtheskinandperipheralnervesResultinginparalysedskinlesion,rigidandswollennerves,disablingdeformities.

麻木性皮肤损害、周围神经粗大、手足残废和畸形IntroductionHistoryEpidemiology热带地区较多

Harm

EtiologyM.lepraeOneoftheoldestpathogenthatafflicthumansDiscoveredinNorwayin1873byDr.ArmauerHansenAcid-fastobligateintracellularbacterium

抗酸杆菌、胞内寄生SimilartomycobacteriumtuberculosisEtiologydoesnotgrowinculturebutcanbegrowninthearmadillo(犰狳).Preferlowtemperature(32to34℃)

andgrowslowlyvirulenceisbasedonpropertiesofitscellwall麻风菌素

HumanbeingseemstobetheonlyvictimTransmissionContainedinsecretionRespiratorypathway呼吸道Abrasionorwounds破损的皮肤Takenupbymacrophagesdisseminatesthroughtheblood大约95％的人具有自然免疫力

PathogenesisLatentperiod:2-4yearsCellularimmunityHumeralimmunityLepromintest麻风菌素注射于皮肤，局部出现

迟发型变态反应，菌体的热休克蛋

白可诱发细胞免疫所致

PathogenesisAbipolardisease

根据细胞免疫强弱，分成截然不同的两种类型

tuberculoidleprosy结核样型麻风(T-cellmediatedimmuneresponse，细胞免疫强)

lepromatousleprosy瘤型麻风

(Immunityanergic免疫无反应性，体液免疫，

抗体+++)

Typesaccordingtopathologicalchanges分型Tuberculoidleprosy70%Lepromatousleprosy20%Borderlineleprosy中间界线类少见Indeterminateleprosy未定类麻风很少见Tuberculoidleprosy(60-70%)Intactcellularimmuneresponse Slowcourse,spanningdecades Limitedlesions

FewbacilliwithinthelesionMainlyinvolveskinandnervesClinicalfeature:lepromintest(+) lowinfectivity goodprognosisTuberculoidleprosy

Granuloma

resembleshardtuberclesepithelioidmacrophagesgiantcellswithoutcaseousnecrosisPeripheral:CD4+Th1IL-2&IFN-γfewsurvivingmycobacteriaTuberculoidleprosy

Skinlesions:maculaorpapula斑疹或丘疹gross:flatandredirregularshapeswithindurated,elevated,hyperpigmentedmarginsanddepressedpalecenters好发于面部、臀部、躯干四肢伸面SkinlesionsLM: tuberculoidgranuloma结核样结节enclosebloodvessels,cutaneousappendagesandnervesextendtothebasalcellsofepidermisTuberculoidleprosyTuberculoidleprosyPeripheralneuropathy:rigidandswollennerves神经变硬、不规则增粗，如绳索 Fromsmalldermalnervestonervetrunk N.auricularismagnus(耳大)

N.auricularisposterior(耳后) LM：

GranulomatousinflammatoryreactionsenclosedneuronandmaydestroyitFibrosis,absenceofnervesNervedegeneration,destruction,fibrosis

ClinicalpathologicconferenceAnesthesia感觉障碍,atrophy(失神经营养),paralysis,liabletotrauma,autoamputationoffingersortoes(肢体自动脱落),disablingdeformities,indolentskinulcers,keratitis角膜炎,cornealulcerations.Tuberculoidleprosy鹰爪手Lepromatousleprosy(20%)anergicimmunity细胞免疫反应弱lepromintest(-)Largeamountsofbacilliinfectious传染性强Acutedeteriorate,poorprognosis,

伴麻风反应：高热、神经痛Generallyinvolvedtheskin,peripheralnerves,anterioreye,upperairways,testes,lymphnode,visceral,etcLepromatousleprosylargeaggregatesoflipidladenmacrophages(leprosycells),oftenfilledwithmassesofacid-fastbacilli

麻风细胞:巨噬细胞吞噬大量的麻风杆菌，胞质内有大量类脂空泡，呈泡沫状lymphocytesinfiltratedLackCD4+TH1cellsatthemarginsbutinsteadcontainmanyCD8+suppressorTcellsLepromatousleprosySkinlesions:

Macular斑疹,papular丘疹,ornodularlesionsform结节、麻风瘤

ontheface,ears,back,extremitiesWithprogression,thenodularlesionscoalescetoyieldadistinctiveleoninefaces(狮面).SkinlesionshypoestheticoranestheticLepromatousleprosySkinlesions:LM:largeamountsoflepracellsandafewlymphcytesinfiltrationenclosevesselsandappendages

真皮深层聚集大量麻风细胞Clearline无浸润带病灶和表皮之间的真皮浅层有无细胞浸润带，又称为自由带

LepromatousleprosyPeripheralnerves：resembletuberculoidleprosyLossofsensationandatrophicchanges.Nose

糜烂或溃疡，鼻中隔穿孔Spleenandliver成堆泡沫细胞Lymphnodes

泡沫细胞Testes

精液中带菌Thevitalorgansandcentralnervoussystemarerarelyaffected.

TuberculoidtypeLepromatoustypeIncidence70%20%ImmuneresponseIntenseSubduedSkinlesionMaculaorpapula,tuberculoid,fewbacilliProtuberant,largeamountofbacilliLepromintest(+)(-)Humoralantibody(+/-)(+++)InvolvedtissueLimitedtoskinandnervesExtendtootherorgansProcessDevelopslowlyRelativefastInfectivityWeakStrongComparisonSexuallyTransmittedDisease

性传播性疾病（STD）

VenerealDiseases,VDFiveclassicvenerealdiseasesSyphilis梅毒Gonorrhea淋病Chancroid软下疳granulomainguinale腹股沟肉芽肿lymphogranulomavenereum性病淋巴肉芽肿SexuallyTransmittedDisease,STDInthepastdecade,thespectrumofsexuallytransmitteddisease(STD)haswidenedconsiderablyClassificationofImportantSTDCausalAgentDiseaseManifestationsExclusivelyorRegularlyTransmittedbySexualcontactViralHIV-1,HIV-2HSV-1,HSV-2PapillomavirusesAIDSHerpeslesions生殖器疱疹Condyloma,cervicalneoplasiaChlamydial,MycoplasmalChlamydiatrachomatis(Ltype)ChlamydiatrachomatisUreaplasma

urealyticumLymphogranuloma

venereum性病淋巴肉芽肿Nongonorrhea

urethritis,cervicitisNongonorrheal

urethritis,cervicitisBacterialNeisseria

gonorrhoeaeTreponema

pallidumHaemophilus

ducreyiCalymmatobacterium

donovaniGonorrhea淋病Syphilis(lues

venerea)梅毒Chancroid软下疳Granuloma

inguinale腹股沟肉芽肿ProtozoalTrichomonasvaginalisTrichomoniasis

滴虫ByArthropodPhthiruspubisPediculosispubis(crab)阴虱病TransmissibleSexuallyorbyOtherMeansViralCytomegalovirus,hepatitisBvirus,Epstein-Barrvirus,molluscum

contagiosumvirusHepatitis,mononucleosis,wartsBacterialGroupBstreptococci;gram-negativebacilliNeonatalsepsis,cystitisFungalCandidaThrush,vaginitisPotozoalEntamoeba

histolyticaColitis,liverabscessSyphilis(Lues)梅毒AnimportantSTDMultipleclinicalpresentations(thusdesignatedthegreatimposter)chronicandslowlyprogressiveinvolvemanyvitalorgansinlateperiod

EtiologyPathogen:

SpirocheteTreponemapallidum

梅毒螺旋体cannotbecultureddetectablebysilverstainsdarkfieldexaminationTransmissionMode:

Sexualintercourse(>95%)Acquiredsyphilis后天性(获得性)梅毒

TransplacentaltransmissionCongenitalsyphilis先天性梅毒Pathogenesis

TraverseabradedskinandmucosaEnterlymphcirculation

TravelthroughbloodandreachvariousorgansandtissueLatentperiod:10-90days,averageat21daysPathogenesisScarceproteinonsurface(Weakantigenicity) Down-regulationofTH1cells

InadequatecellularandhumoralimmuneresponseRelapsesyphilisandtertiarysyphilisLatentsyphilis隐性梅毒血清反应阳性，而无病变无症状MorphologyMayaffectnearlyanyorganortissueinthebodyTwomorphologicpatternsoftissueinjuryObliterativeendarteritis

闭塞性小动脉内膜炎Gumma树胶样肿病原体引发的迟发性超敏反应Morphology1

Proliferativeendarteritis增生性动脉内膜炎

Obliterativeendarteritis Perivascularinflammation

小血管周围炎

concentricendothelialandfibroblasticproliferativethickeningofthesmallvessels asurroundingmononuclear(principallyplasmacell)inflammatoryinfiltrate,knownascuffing血管周围套病变周围组织发生缺血性细胞坏死和纤维化，见于各期梅毒Morphologylatelesionoccurredinanysite(liver,bone,testes)Varyinsize小的肉眼不能见到，大的直径达3-4cmgray,toughandrubbery,likegumAbsorbed,fibrosis,scared后期可被吸收、纤维化、疤痕形成Scarcelycalcification绝少钙化最后导致病变组织破坏和瘢痕挛缩2.

Gumma(syphiloma梅毒瘤)发生于晚期梅毒，大小不一，灰白色，质地韧有弹性似树胶，称树胶样肿。Morphologyacenterofcoagulativenecrosissurroundedbymanymononuclearleukocytesadmixedwithmacrophages(someresemblingepithelioidcells)中央为凝固性坏死，但不如结核干酪样坏死彻底，弹力纤维尚保存坏死灶周围有许多单核细胞（淋巴细胞、浆细胞)、上皮样细胞(巨噬细胞）Gumma:resemblethelesionoftuberculosis.镜下颇似结核结节Acquiredsyphilis

ThreedistinctstagesPrimarySecondaryTertiaryEarlystage(contagious)LatestagePrimarysyphilis一期梅毒Chancre硬下疳

直径为1cm大小有浅表溃疡的无痛性硬块Afterlatentperiod(about3weeks)Atthesiteofinoculation,penis,vulvaorcervixindurated,button-likepapuleatfirstErodesAsingle,painless,copper-colored,Clean-based,shallowulcer,withelevatedandinduratedmargin单个、无痛性、红铜色、边界隆起、溃疡基底干净PrimarysyphilisChancreAccompaniedbylymphadenopathy淋巴结肿大LM: obliterativeendarteritis

perivascularplasmacellcuffingDarkfieldexaminationoftheexudate

渗出液检查可找到螺旋体Spontaneoushealing自愈Secondarysyphilis二期梅毒Mucocutaneousrash梅毒疹1-3monthsaftertheprimarysyphilisWidespreadpatchyordiffuse广泛Bilateral,symmetric,maculopapular,

red-blown对称分布斑丘疹Condylomatalata梅毒扁平湿疣LM:typicalvasculitisNonspecificlymphadenopathy

肿大淋巴结为非特异性炎症SecondarysyphilisFever,malaise,weightlossSerologictest(+)Spontaneoushealingafter1-3monthsRelapse复发梅毒疹，疹量较少Latentsyphilis隐性梅毒 asymptomatic

serologictests(+)Tertiarysyphilis三期梅毒Afteralatencyperiodof10-20yearsMayaffectanypartofthebodyCardiovascularsystem(80-90%)Centralnervoussystem(5-10%)Liver,bone,testes,etc.Gummaandscartissueformation皮肤黏膜损害

结节型梅毒疹好发于头皮、肩胛、背部及四肢的伸侧。树胶样肿常发生在小腿部，为深溃疡形成，萎缩样瘢痕TertiarysyphilisSyphiliticaortitis梅毒性主动脉炎

80-90%Confinedtothoracicaorta胸主动脉升部和根部Obliterativeendarteritisofnutrientarteries

闭塞性滋养小动脉炎wrinklingor“treebarking”oftheintimalsurface内膜树皮状皱缩

Secondaryatheroscleroticplaques弹力纤维染色，显示大动脉中层弹力纤维破坏

Syphiliticaneurysm梅毒性主动脉瘤Aorticinsufficient主动脉瓣关闭不全梅毒性主动脉瘤TertiarysyphilisNeurosyphilis神经梅毒5%-10%Meningovascularsyphilis脑膜血管性梅毒TabesDorsalis脊髓痨Generalparesis麻痹性痴呆Braingumma脑树胶样肿TertiarysyphilisBone:septalperforation(saddlenose)

鼻中隔穿孔（马鞍鼻）骨膜炎、骨髓炎、骨炎导致骨硬化（象牙化）Liver肝梅毒TestesCongenitalsyphilis先天性梅毒OnsetafterthefourthmonthofpregnancyEarlycongenitalsyphilis(perinatalperiod)

早期胎传梅毒MucocutanouslesionRashes(vesicularorbullous水疱、大疱)Extensivedesquamationoftheskin广泛性皮肤脱屑Diffuseinterstitialinflammation,prominentfibrosisLung,liver,spleen,pancreas,etc.Osteochondritisandperichondritis骨软骨炎及骨膜炎Saddlenose,sabershins马刀胫骨Congenitalsyphilis口角放射状疤痕梅毒疹（大疱）马刀胫骨马鞍鼻CongenitalsyphilisLatecongenitalsyphilis>2y

Hutchinson三联症Hutchinson’steethNervedeafness神经性耳聋Interstitialkeratitis间质性角膜炎Mayremainlatentuntiladolescence锯齿形门牙ClinicalStagesandFeaturesTyphoidFever

(伤寒)

张仲景《伤寒论》

吴有性《瘟病论》Conception

Anacuteinfectiousdiseasecausedby

Salmonellatyphi.伤寒杆菌Characterizedbyulcerationofthesmallintestine小肠溃疡systemicreticuloendothelialcellshyperplasia单核巨噬细胞增生

Mainmanifestations:fever,leukopenia,delirium,abdominalpain,diarrhea,rosespots,andsplenomegalyintestinalbleedingandperforation.Epidemic贵州、云南、广西、浙江、江苏和新疆

Etiology

Typhoidbacillusgram-negativerodbacteriaEndotoxinflagellar(H)antigencellwall(O)lipopoysaccharideantigenpolysaccharidevirulence(Vi)antigenlocatedinthecellcapsule.Astory:TyphoidMarryHealthycarrierSourceoftransmissionillpersonsfeces,urine,vomitus,andoralsecretionsChroniccarriersfecesPathogenesisStomach,smallintestinemononuclearphagocytes

ilealPeyer’spatchesandmesentericlymphnodeschills,fever,rosespots,etcfeces,urineofpatientsorcarrierflyFoodandwatermouthbacteremiaToxemia,septicemiamononuclearphagocyteshyperplasiahepatomegaly,splenomegaly,lymphdenopathyPathogenesisMorphologyCharacteristicsofpathologicalchanges:Aninflammation-proliferationofreticulo-endothelialsystemtyphoidcell:large,richincytoplasm,oftencontainsingestedbacteria,celldebris,anderythrocytetyphoidgranuloma伤寒肉芽肿,伤寒细胞聚集成团Diagnosticvalue巨噬细胞增生，并有极强的吞噬能力。病灶内无中性粒细胞渗出。Morphology:typhoidnoduleMorphology1. 1stweek(髓样肿胀期)Gross:sharplydelineated,plateau-likeelevationsupto8cmindiameter,withenlargementofdrainingmesentericlymphnodesLM:typhoidgranuloma,edema,hyperemiaCF:Highfever,bradycardia,splenomegaly,rosespots

IntestinePayer’spatchesintheileum回肠

isthemostaffectedpart淋巴滤泡增生、肿胀，似“脑回”

Intestine髓样肿胀期2.2ndweek

Necrosis:坏死期

Gross:thelesionofPeyer’spatchisnecroticandstainedbybile.LM:StructurelesseosinophilicsubstanceCF:bacteremia,toxemia滤泡中心/表层坏死，边缘肿胀LM:嗜酸性无结构物质Intestine3.3rdweekUlceration:溃疡期

Necrotictissueisdissolvedbyenzymeovalulcerswiththeirlongaxisinthedirectionofbowelflowulcermaybeverydeep CF:bleeding,perforation穿孔,abdominalpain,diarrhea腹泻

，

全身中毒症状缓和Intestine

Intestine溃疡期溃疡长轴与肠长轴平行，较深，易引起肠穿孔、出血4.Healing:愈合期 4th–5thweek Granulationtissueformswithsmallscarformation CF:symptomssubsideanddisappear, widal’stest(+)溃疡底部肉芽组织长入，粘膜再生

不形成瘢痕，不造成肠腔狭窄IntestineorgansrelatedtoreticuloendothelialsystemMesentericlymphnode:IntheterminalileumTyphoidcell,TyphoidgranulomaSpleen:

enlarged,softandcherryredincolorprominentsinushistocytosisandreticuloendothelialproliferation质软，脾髓组织可用刀背刮下organsrelatedtoreticuloendothelialsystemLiver:enlargedandswellingwithtensecapsuleandroundedgestyphoidcell,typhoidgranulomasmall,randomlyscatteredfociofparenchymalnecrosisBonemarrow:typhoidgranulomawithscatteredfociofnecrosisFailureofnormalhematopoiesis造血功能Salmonellatyphi.(+)骨髓培养阳性率可高达90%OthersCholecystitis

胆囊炎，细菌在胆汁中繁殖，传染源CNS

小血管内膜炎，胶质细胞增生，嗜睡、伤寒面容OthersMyocardium

心肌细胞浑浊肿胀，重脉，相对缓脉Skinandmuscle毛细血管细菌栓塞，横纹肌腊样坏死。玫瑰疹、肌痛Typhoidsepticemia伤寒败血症Complicationandprognosis4-5weeksChloramphenicol氯霉素remainstobeeffectivesinceitsintroductionin1942Complications:intestinalhemorrhage肠出血perforationandperitonitis肠穿孔、腹膜炎lobularpneumonia

临床病理联系初期菌血症、毒血症、单核巨噬细胞系统增生坏死期败血症，稽留热、神志不清、嗜睡、谵妄溃疡期机体抵抗力占优势，菌血症消失症状缓和愈合期机体占绝对优势，体温阶梯下降，恢复BacillaryDysentery

(细菌性痢疾)IntroductionAnacuteinflammationofthecolon,causedbyshigella.Summer,autumnMorphologicalfeatures:pseudomembranousinflammationand

irregularsuperficialulcerationsMainclinicalmanifestations:fever,abdominalpain,diarrhea,pus-mucin-bloodmixedstool

粘液脓血便EtiologyandepidemiologyCausativeagent:Shigella,gram-negativefacultativeanaerobes

Shigelladysenteriae

ShigellaFlexneri ShigellaBoydii ShigellaSonneiInfectonlyhumansTransmissionSource:Carrier,patientRoute: Fecal-oral ContaminatedfoodorwaterPathogenesisInvadetheintestinalmucosalcells,butdonotusuallygobeyondthelaminapropria固有层Proliferationwithintheepithelialcells,destroyhostcellsEndotoxin:Shigatoxincauseshemorrhagiccolitis hemolytic-uremicsyndrome溶血-尿毒症综合征Shigelladysenteriae:extrotoxinneurotoxicantcytotoxicenterotoxinTypesAcutebacillarydysentery1-2weeksChronicbacillarydysentery>2monthsToxicbacillarydysenteryAcutebacillarydysenteryA.Colon:Mucoidcatarrhinfl.Pseudo-membranousinfl.糠皮样假膜

Ulcerformation浅表不规则溃疡

Hyperemic,edematous,PMN中性粒腹痛、腹泻、里急后重、粘液稀便mucosanecrosis,fibrinogenexudation,hemorrhage粘液脓血便necrotictissueshedoffrectum,sigmoidflexureGross:Pseudomembranousinflammation ulcerformation(irregularandsuperficial)糠皮样假膜、浅表溃疡MucosaofColon,esp.leftAcutebacillarydysenteryLM: Psuedomembrane纤维蛋白性炎Infiltrationofinflammatorycells中性粒细胞

NecrotictissueFibrinexudationRedbloodcellsAcutebacillarydysenteryB.Lymphdenopathyofmesenterymildsplenomegaly

C.Otherorgans:heart,liver,kidney

cellulardegenerationornecrosisAcutebacillarydysenteryClinicalmanifestation:Toxemia:fever,headache,fatigue,leukocytosisIntestinallesion:abdominalpain,diarrheawithtenesmus里急后重, pus-mucus-bloodmixedstool,dehydration,etc.AcutebacillarydysenteryPrognosisMostlycuredColonicperforation(rare)ScarcelycolonichemorrhageAfewdevelopintochronicperiodChronicbacillarydysentery慢性细菌性痢疾ChronicbacillarydysenteryOccurswhengeneralconditionispoorortreatedimproperlyatacutestageImportanttransmissionsources:chroniccarrier病程超过2个月ChronicbacillarydysenteryCharacteristics:Associatedwithspeciesofshigellae:FlexneriPersistseveralyearspathology:Chroniculcerformation;variedinsizeanddepth;Fibrosis,thewallofcolonisthickenedInfiltratedbylymphocytes,monocytesandplasmacellsSometimestheepithelialcellsmayalsoproliferateandformpolyps急性菌痢转变而来，福氏菌、耐药菌株病情起伏，可有急性发作病理—新旧溃疡混杂（较深，多达肌层，边缘粘膜可有过度增生息肉形成）大量肉芽组织、纤维瘢痕—肠壁增厚肠腔狭窄临床病理联系：—病程延长表现起伏腹痛、腹泻、便秘与腹泻交替慢性菌痢急性发作，表现和急性菌痢相似慢性带菌者(重要传染源)慢性细菌性痢疾Toxicbacillarydysentery中毒性菌痢ToxicbacillarydysenteryCharacteristics:toxemiaisveryseverebutthemorphologicalchangesarenotenlargementofthelymphoidfollicles“follicularenteritis”Thenatureoftheinflammationis“serous”,oftenassociatedwithtoxicshock2-5yearsoldShigellaFlexneri,ShigellaSonnei起病急骤：全身中毒症状严重（中毒性休克、呼吸循环衰竭）endotoxinInjuryofendothelialcellofbloodvesselDICSpasmofbloodvesselHypoxiaDilatationofcapiBloodvolshockIncreaseofpermeabilityedemaThemechanismoftoxicshockandDICPlatelet,neutrophilsvasoactive

substancesParasitosis寄生虫病

2010Jun.ClassificationProtozoaldiseaseTrematodiasisTeniasisNematodosis原虫病阿米巴病黑热病疟疾吸虫病肝吸虫病肺吸虫病血吸虫病绦虫病囊虫病包虫病线虫病钩虫病蛔虫病丝虫病Amoebiasis

阿米巴病病原：溶组织内阿米巴原虫寄生部位：结肠（尤其右半结肠）

肠外

(肝、肺、脑等）流行现状：

热带、亚热带地区，我国南方多见。世界10%人口携带，无任何国家幸免感染。

近年多为散发慢性、不典型病例及带虫者。EntamoebahistolyticaHumans(largebowel)Ingestionofcysts(persontoperson)Trophozoites,cystsinfecesCystssurviveinfood,waterEntamoebahistolytica溶组织内阿米巴原虫Sourceofinfectionchronicpatientandparasitecarrierkilledbydesiccation干燥,temperaturesabove55℃spreadbythefecal-oralrouteRoutesofinfection生活史：滋养体、包囊两期成熟包囊小滋养体(食物、水)

（小肠下段）

大滋养体(致病型)小滋养体

（结肠肠壁）包囊前期成熟包囊（感染型）食物、水

（结肠肠腔）抵抗力结肠功能正常>90%Exopathicfactor

contact-mediatedcytolysis接触性细胞溶解(膜结合磷脂酶A)excretemanyfactors分泌多种因子channel-formingproteincysteineproteinase

pseudopodialmovementandphagocytosis

伪足运动及吞噬作用免疫抑制和逃避Internalfactorsusceptibilityofhost宿主易感性intestinaldysfunction肠道功能紊乱intestinal

concurrentinfection肠道合并感染Pathogenesisamebicdysentery肠阿米巴病(阿米巴痢疾）Sites：Cecum盲肠Ascendingcolon升结肠SigmoidRectumAppendix分期：急性慢性肠内氧分压较低，肠内容物生理性滞留有关acuteamebicdysentery急性阿米巴痢疾Amoebiasisofintestine结肠阿米巴病

Gross

flask-shapedulcer(烧瓶状溃疡)口小底宽急性期粘膜有多个圆形隆起，中央有点状坏死溃疡MorphologicChange结肠阿米巴病溃疡间粘膜正常病变扩展期，溃疡在粘膜下相互沟通，形成隧道样病变，粘膜坏死脱落，呈破絮状严重者溃疡深达肌层并侵及血管，甚至浆膜层Microscopically

mainlyinvolvingthemucosaandsub-mucosaanecroticprocesswithminimalinflammatoryexudate Lymphocytesandplasmacells炎症反应轻微Trophozoites

滋养体scatteredattheperipheryMorphologicchange阿米巴滋养体bloodydiarrhea果酱样，腐败腥臭味intestinalpaintrophozoite(+)全身症状轻微，无发热Clinicalfeatures99%

achievedacompletecureasmallproportionofcasesperforationhemorrhageprogressiontochronicinflammationsecondarybacterialinfectionpurulentLesionprogressesruptureintoadjacentstructuresPrognosis2chronicamebicdysentery慢性阿米巴痢疾ComplexTissueregenerationLesionprogressMucosaatrophyInflammatorypolypsamoeboma（阿米巴瘤）肠壁肉芽组织增生过多，形成局限性包块MorphologicChangeIntermittentbellyache间歇性腹痛diarrhea腹泻intestinalobstruction

肠梗阻malnutritionClinicalfeaturesamebicdysentery急性

病理：组织溶解坏死烧瓶状溃疡，边缘滋养体

临床：痢疾样症状，果酱样便，滋养体（+）慢性

病理：病变复杂“阿米巴瘤”

临床：轻度肠道功能紊乱症状，肠梗阻，营养不良等。

大便包囊体（+）

肠外阿米巴病阿米巴性肝脓肿阿米巴性肺脓肿阿米巴性脑脓肿amebicliverabscess阿米巴肝脓肿amebicliverabscess肠阿米巴病最常见的合并症MorphologicChangeGrosssingletherightlobe(80%)theabscesscontentsischocolate-colored

“巧克力脓肿”脓肿壁破絮状脓腔内容物呈棕褐色，由坏死肝组织和陈旧性血液混合而成，果酱样。Microscopically

extensiveliquefactivenecrosisascantinflammatoryreactionattheirmargins

TrophozoitesscatteredattheperipheryashaggyfibrinliningUsuallyprognosisisgood Metronidazole甲硝唑SecondarybacterialinfectionpurulentLesionprogressesruptureintoadjacentstructuresPrognosisamebicpulmonaryabscesssingleInferiorlobeofrightlungAnextensionofahepaticabscessAmebicbrainabscessthroughbloodstream

multiplecerebralcortex

Schistosomiasis

血吸虫病Schistosomajaponicum日本血吸虫

ChinaandAsiaSchistosomamansoni曼氏血吸虫

LatinAmerica,centralAfrica,theMiddleEast

schistosomahaematobium埃及血吸虫

northernAfricaPathogens流行状况

75个国家流行：2+亿人感染，5-6亿人受威胁我国：长江中下游13个省市流行

解放初期：1+亿人受威胁，病人1千万

五十年代：血防运动，70%流行区消灭

八十年代：1+亿人受威胁，有螺面积33.8亿m2Endemicparasitoses(地方性寄生虫病)Zoonoticinfections(人畜共患)

human,ox,horse,goat,etcMajorpathologicmanifestation

granulomasandfibrosis

成虫:门静脉系统主要危害:虫卵严重后果:肝汇管区纤维化、慢性肠道病变SchistosomajaponicumDioecism(雌雄异体)MaleoralsuckerventralsuckerFemaleheme-derivedpigmentsEggsinfeces(passedintowater)Hatchedlarvae毛蚴

penetratefreshwatersnail(intermediatehost)Developmentofotherlarvalstagesinsnail（母包蚴、子包蚴）CercariaepenetrateskinofhumansCercariae尾蚴emergefromsnail(water)HUMANS

adultwormsinblood(veins)Lifecycleofschistosomes钉螺病原与传染途径

血吸虫卵

毛蚴

胞蚴尾蚴

童虫

成虫

虫卵

肠腔

粪便排出

肝脏

肠壁

虫卵结节

部分粪便排出入水钉螺中间宿主入水（疫水）钻入皮肤粘膜肠系膜V（病人畜粪便）经粘膜溃疡（16%）（大肠50%，小肠<10%）顺血流（23%）逆血流PathogenesisMechanicaldamage各阶段均可见ImmunologicaldamageAllkindsofantigens(solubleeggantigens,SEA,可溶性虫卵抗原)Cellularimmunity产生肉芽肿病变1L-2,IFN-γ,IL-4,1L-5,etcMorphologicchanges血吸虫发育的不同阶段，尾蚴、童虫、成虫和虫卵均可对宿主引起不同的损害和复杂的免疫病理反应由于各期致病因子的不同，宿主受累的组织、器官和机体反应性也有所不同，引起的病变和临床表现亦具有相应的特点和阶段性causedbywormscausedbyeggsCercaria:dermatitis(itching,localedema)尾蚴性皮炎Schistosomulum童虫:angitis,spothemorrhage(lung)allergicreaction血管炎、血管周围炎、超敏反应Adultworms成虫:Local:endophlebitis,periphlebitis

静脉内膜炎、静脉周围炎Totalbody:anemia,allergicreaction

贫血、发热、荨麻疹、血象中嗜酸性粒细胞增多等PathologycausedbywormsPathologycausedbyeggsImmatureeggs:atypicalchronicgranulomas

毛蚴不成熟，无毒性分泌物Matureeggs:acuteeosinophilicabscesschronic

granulomas可溶性虫卵抗原Acuteeggnodule:Eosinophilicabscess嗜酸性脓肿Egg(yellowrefractingeggshellandapear-likemyracidium)Hoeppliphenomenon(redradiatingflame-likesubstance)急性虫卵结节（嗜酸性脓肿）中央：1-2个成熟虫卵，Hoeppli现象

周围：大量变性坏死的嗜酸性粒细胞浸润

肉眼：灰黄色粟粒至绿豆大小结节急性肺血吸虫病虫卵结节嗜酸性脓肿Pseudotubercle假结核结节Fibrousnodule纤维化虫卵结节Someeggnodulesarechronicattheverybeginning,withoutexperiencingtheacutestage.Chroniceggnodule虫卵内毛蚴死亡

pseudotubercleeggssurroundedbyradiatingeosinophilicmaterialEosinophils,epithelioidcells,multinucleatedgiantcellslymphocytes,granulationtissue(scarce)假结核结节虫卵巨噬细胞类上皮细胞、异物多核巨细胞周围：淋巴细胞、少量肉芽组织假结核结节纤维钙化虫卵结节

eggsdestroyedandcalcified

granulomatousinflammationreplac