呼吸次常见病诊断课件

Respiratorydisease

62221361肺隔离症Pulmonarysequestration一部分肺与正常肺分离，且不接受肺动脉供血，而仅接受来自体循环异常血管的供血肺叶内型肺隔离症：隔离肺与邻近正常肺位于同一脏层胸膜内，供血动脉多来自降主动脉或其分支，静脉回流多经过肺静脉肺叶外型肺隔离症：有单独的脏层胸膜包裹，90%位于左下叶后基底段，也可位于膈下或纵隔内，供血动脉来自腹主动脉，静脉回流通过下腔静脉、奇静脉或半奇静脉回流到体循环。30%合并膈疝235Pulmonarysequestration6Pulmonarysequestration7肺真菌病肺霉菌病，因人体抵抗力低下而真菌侵入引起真菌种类多，但对人体能致病者只有十余种，按其致病的部位可分为浅部真菌和深部真菌深部真菌的多数可引起肺部病变。常见的有曲菌、念珠菌、奴卡菌、放线菌、新型隐球菌等。这些真菌有的广泛存在于自然界中，为腐物寄生菌，有的寄生于正常人体内正常人体对真菌有较强的抵抗力，肺真菌病少见9可能引发肺真菌病的因素机体抵抗力降低口腔卫生不佳生活和职业中接触较多被真菌孢子污染的物质抗生素的大量应用，人体对抗生素敏感和不敏感的致病菌之间的相互拮抗作用产生紊乱，敏感者被抑制，有利于不敏感者的繁殖长期应用激素使机体的免疫功能低下恶性肿瘤、严重烧伤或大手术后，免疫功能低下10感染途径与病理变化内源性感染：口腔和上呼吸道内寄生的真菌，如放线菌和念珠菌，由于口腔卫生不佳或身体抵抗力降低时，侵入肺部引起感染外源性感染：带有真菌孢子的尘土吸入肺内，如奴卡菌病、曲菌病和隐球菌病继发性感染：体内其他部位的真菌病变经血行或淋巴播散到肺部，或膈下病变直接侵犯蔓延到肺部病理变化：过敏、急性炎症、化脓性病变、肉芽肿形成、空洞、纤维化和钙化扩散方式：直接侵犯、淋巴播散和血行播散11肺真菌病的影像学表现肿块及空洞：肿块常为多发，密度较高，其内可有多处透亮区。部分单发肿块周围可见晕轮样改变，称为晕轮征，为曲菌感染的早期表现真菌球：多见于曲菌病。空洞或空腔内边缘光整的球形致密影，其大小因所在空洞或空腔的大小和病变发展程度而不同。曲菌球与洞壁或腔壁之间可见新月状空隙，为空气半月征其他：纵隔或肺门淋巴结肿大、胸腔积液或脓胸，胸膜肥厚粘连。侵犯纵隔及心包，形成纵隔脓肿或心包炎。病程长者有纤维性病灶和钙化灶13影像诊断与鉴别诊断肺曲菌病的曲菌球和晕轮征具特征性，其他肺真菌病影像学表现缺乏特征性以下几点有助于提示肺真菌病的诊断①肺部病灶影存在时间长，又缺乏某些常见疾病的特征，且在鉴别中也无其他疾病应有的临床症状时，提示肺真菌病的可能②经较长时间的动态观察，病灶变化不大，或虽有所变化，但不符合一般炎症、结核等病的发病规律时，提示本病的可能③病人有长期应用大量抗生素、激素、免疫抑制剂等类药物的病史，提示本病的可能14肺曲菌病Aspergillosis又称肺笰状菌病，肺部最常见的真菌病曲菌广泛存在于自然界，孢子在空气中到处皆有，吸入其孢子不一定致病，大量吸入可引起急性气管、支气管炎或肺炎常寄生在人体上呼吸道，痰培养中常可发现，很少使健康人致病慢性病病人免疫功能低下时，入侵肺部发生肺曲菌病15肺曲菌病临床与吸入曲菌量有关，也与机体对曲菌发生的变态反应有关无症状有的起病急，有发热、咳嗽、咳痰、咯血等症状，酷似急性肺炎有的起病缓慢，有低热、夜间盗汗、咳嗽、咳脓痰带血，病情时好时坏，颇似肺结核17X线表现肺空洞或空腔内的圆形或类圆形致密阴影3～4cm，密度较均匀，边缘较光整可有钙化，呈斑点钙化或边缘钙化不侵及空洞壁，体积小于空洞内腔，立位与卧位比较，位置可有改变，且总是处于近地位。曲菌球与空洞壁间可见新月形空隙，为空气半月征曲菌球易发于肺结核空洞，两上肺尖后段多见，洞壁多较薄侵袭型曲菌病表现为一侧或两侧肺野的单发或多发斑片状影，也可为肺叶或肺段的实变影，病灶坏死可形成脓肿，少数见空洞形成18CT表现薄壁空洞或空腔内的孤立球形灶，边缘光滑锐利，大小不等，常见空气半月征曲菌球处于近地位，呈软组织密度，有时见钙化，无强化支气管粘液嵌塞表现为柱状致密影侵袭型曲菌病感染早期，肺部出现结节或肿块状实变影，周围出现晕轮征，即在结节或肿块状病灶周围可见环绕的较低密度区域，其密度介于结节与正常肺组织间，形似晕轮，为周围出血所致小叶性实变或小叶融合性影，多发球形病灶伴空洞形成及肺门淋巴结肿大19BilateralaspergillomasM71,withresidualtuberculosislargecavitiesbilaterallyintheupperlobescontainingfungusballsofdifferentsizes21RadiographyMycetomas:asolid,roundorovalmasswithsoft-tissueopacitywithinalungcavitySeparatedfromthewallofthecavitybyanairspaceofvariablesizeandshape,resultinginthe"aircrescent"signMoveswiththepatientchangesposition22MobileaspergillomawithinapulmonarycysticcavityM43SupineandproneAchangeinthepositionAfumigatuswasdiscoveredatbronchoscopy23Parasites（寄生虫病）OrganismsobtainnourishmentandshelterfromotherorganismsHostmayeitherbeunaffectedorsufferharmfulconsequencesVarywidelyinsizeandcomplexity,fromrelativelysimpleunicellularprotozoans(amebae)tomorecomplexmulticellularorganisms(worms,flukes)Distributedworldwide,ahigherprevalenceindevelopingcountries,inadequatesanitation25CommonhumaninfectionthroughouttheworldEpidemicsofparasiticdiseases(malaria)havedevastatedlargepopulationsandposeaseriousbarriertoprogressinmanydevelopingcountriesEconomicandsocialchangesoverthepastdecadesarestimulatingrural-to-urbanmigrationinmostendemicareas,parasiticdiseasesthataremorecommoninruralareasarenolongerentirelyabsentintheurbanpopulationInindustrializedcountries,riskgroupsforparasiticdiseasesincludestravelers,recentimmigrants,andpatientswithAIDSParasites26肺包虫病肺棘球蚴病，为细粒棘球绦虫或多房棘球绦虫之幼虫（即棘球蚴）感染人体所致，在人体寄生的棘球蚴病称为包虫囊肿传染源多为狗，寄生于狗肠内的细粒棘球绦虫虫卵随粪便排出污染牲畜皮毛、水源及牧草等，病人多因食入污染的食物或水而感染，虫卵也可经呼吸道吸入而发生感染29发病过程棘球蚴虫卵在十二指肠内孵化为六钩蚴，进入肠壁的毛细血管，并经门脉至肝脏，再经肝静脉、下腔静脉、右心、肺动脉到达肺六钩蚴周围有大单核细胞和嗜酸性粒细胞浸润，并逐渐长成棘球蚴的囊状体，有的可形成巨大的囊肿包虫囊肿的壁分为两层，外层为角质层，较坚韧，起保护和营养胚层的作用；内层为胚层（或称为生发层），能分泌液体，具有繁殖作用，液体内有毛钩和头节，头节脱落则形成子囊囊肿破裂，囊液溢出，头节可在邻近形成新的囊肿肺包虫囊肿可破入支气管及继发感染30症状咳嗽、咯血、胸痛及发热破入胸腔引起气胸和胸腔积液破入支气管时咳出大量囊液较小的包虫囊肿可无症状嗜酸性粒细胞增多皮试及血清学试验有助诊断31X线单发或多发的圆形或类圆形影，1～10cm密度均匀，囊状，边缘光滑清楚，可环形钙化外囊破裂，并与支气管相通，少量气体进入内外囊之间，在囊肿上部形成新月形透亮影内外囊同时破裂，并与支气管相通，部分囊内的内容物咳出，空气进入囊内形成气液平面内外囊同时破裂后，若内囊塌陷，漂浮于液平面上形成凹凸不平的形态，称为“水上浮莲”征肺表面的囊肿破裂可形成气胸或液气胸32CT囊肿1cm以下时，边缘模糊的片状影。≥2cm，轮廓清楚的类圆形囊性影，分叶状。边缘光整，密度均匀，CT值为液体密度囊壁薄厚不一，囊肿与胸膜或纵隔相邻处变平囊肿衰老呈不规则状，似实质性肿瘤，但密度仍较低合并感染时边缘模糊，类似肺脓肿破裂可形成支气管瘘，咳出部分囊液且空气进入囊内后出现气液面破入支气管后，若外囊有细小裂口而内囊未破，可有少量气体进入内外囊之间，呈现新月形或镰刀状气体影空气进入外囊内，内囊塌陷并漂浮于液面，“水上浮莲征”33LifeCycleofEgranulosusThedefinitivehostisusuallyadog(orothercarnivore)Theadultwormlivesintheproximalsmallbowelofthedefinitivehost,attachedbyhookletstothemucosaEggsarereleasedintothehost'sintestineandexcretedinthefecesSheeparethemostcommonintermediatehosts.TheyingesttheovumwhilegrazingoncontaminatedgroundTheovumlosesitsprotectivechitinouslayerasitisdigestedintheduodenumThereleasedhexacanthembryo,oroncosphere,passesthroughtheintestinalwallintotheportalcirculationanddevelopsintoacystwithintheliver34LifeCycleofEgranulosusWhenthedefinitivehosteatsthevisceraoftheintermediatehost,thecycleiscompletedHumansmaybecomeintermediatehoststhroughcontactwithadefinitivehost(usuallyadomesticateddog)oringestionofcontaminatedwaterorvegetablesOnceinthehumanliver,cystsgrowto1cmduringthefirst6monthsand2–3cmannuallythereafter,dependingonhosttissueresistance35Lifecycle(dog-sheepcycle)ofEgranulosusDiagramshowsthemostprevalentlifecycleofEgranulosus,inwhichadogandsheepserveasthedefinitiveandintermediatehosts,respectively36ThreelayersOuterpericyst,composedofmodifiedhostcellsthatformadenseandfibrousprotectivezoneMiddlelaminatedmembrane,isacellularandallowsthepassageofnutrientsInnergerminallayer,thescolices(thelarvalstageoftheparasite)andthelaminatedmembraneareproducedMiddlelaminatedmembraneandthegerminallayerformthetruewallofthecyst37HydatidCystStructureDaughtervesicles(broodcapsules)aresmallspheresthatcontaintheprotoscolicesandareformedfromrestsofthegerminallayerBeforebecomingdaughtercysts,thesedaughtervesiclesareattachedbyapedicletothegerminallayerofthemothercystAtgrossexamination,thevesiclesresembleabunchofgrapesDaughtercystsmaygrowthroughthewallofthemothercyst,particularlyinbonedisease38MultivesicularcystPhotographofahumankidneybesectionedalongthemidcoronalplaneAlargecystwiththetypical"bunchofgrapes"appearanceduetodaughtercysts(→)ureter39HydatidCystCystfluidisclearorpaleyellow,hasaneutralpH,andcontainssodiumchloride,proteins,glucose,ions,lipids,andpolysaccharidesThefluidisantigenicandmayalsocontainscolicesandhookletsWhenvesiclesrupturewithinthecyst,scolicespassintothecystfluidandformawhitesedimentknownashydatidsand40HydatidDiseaseinhumansOncetheparasitepassesthroughtheintestinalwalltoreachtheportalvenoussystemorlymphaticsystem,theliveractsasthefirstlineofdefenseandisthereforethemostfrequentlyinvolvedorganHydatiddiseaseinvolvestheliverin75%ofcases,thelungin15%,andotherorgansin10%Thelungsarethesecondmostfrequentsiteofhematogenousspreadinadultsandprobablythemostcommonsiteinchildren41HematogenousDisseminationCompressibleorganssuchasthelungorbrainfacilitatethegrowthofthecystMostcystsareacquiredinchildhood,remainasymptomaticforalongperiodoftime,andarelaterdiagnosedincidentallyatchestradiographyCystsaremultiplein30%ofcases,bilateralin20%,andlocatedinthelowerlobesin60%Calcificationinpulmonarycystsisveryrare,althoughitmaybeseeninpericardial,pleural,andmediastinalcysts42PulmonaryhydatidcystM3Awell-circumscribed,masslikelesionwithapolycyclicconfigurationintheleftlowerlobeThereisobliterationoftheleftcostophrenicangle43PulmonaryhydatidcystSuddencoughingattacks,hemoptysis,andchestpainarethemostcommonsymptomsAftercystrupture,expectorationofcystfluid,membranes,andscolicesmayoccurRuptureintothepleuralcavitymayoccurBacterialinfectionofthecystisthemostseriouscomplicationcommonlyseenafterrupture44PulmonaryhydatidcystWell-definedmasses,usuallyround,peripheralcystsmaybeovalorpolycyclicAircollectionappearsasathin,radiolucentcrescentintheupperpartofthecystandisknownasthecrescentsignormeniscussignAsaircontinuestoenterthisspace,thetwolayersseparatecompletelyandthecystshrinksandruptures,allowingthepassageofairintotheendocyst45PulmonaryhydatidcystAnair-fluidlevelinsidetheendocystandairbetweenthepericystandtheendocystwithan"onionpeel"appearanceconstitutetheCumbosignAfterpartialexpectorationofthecystfluidandscolices,thecystemptiesandthecollapsedmembranescanbeseeninsidethecyst(serpentsign).Whenithascompletelycollapsed,thecrumpledendocystfloatsfreelyinthecystfluid(waterlilysign)Ifthefluidisentirelyevacuatedbyexpectoration,theremainingsolidcomponentswillfalltothemostdependentpartofthecavity("masswithinacavity")46OpencystsAchildwithfever,cough,andexpectorationLeftlateraldecubituspositionAlargecavitarylesionwithanair-fluidlevelintheinferiorleftlungAirisseenbetweenthepericystandthelaminatedmembraneofthecystPulmonaryinfiltrateadjacenttothecystPleuraleffusionduetosuperimposedbacterialinfection47AchildwithpreviousepisodesofcoughandexpectorationLateralchestradiographAnintracysticserpentinestructurerepresentingcollapsedmembranes48OpenlungcystM20,experiencedasuddencoughingattackfollowedbyexpectorationofclearfluidleftlateraldecubituspositionAcavitarylesionintherightupperlobewithsolidcontentsthathavesettledinthemostdependentpartofthecavityThesolidcomponentrepresentsthedetached,crumpledendocyst49Pulmonaryhydatiddisease,EgranulosusM43,AlargecystintherightlowerlungF32,Ahypoattenuatingcrescentsign(meniscussign)50AlveolarEchinococcosisandPolycysticEchinococcosisCausedbyEmultilocularisandEvogeliHaveasimilarclinicopathologiccourseandareacquiredthroughthesamemechanism,similartothatdescribedforEgranulosusTheparasitegrowsfromthemetacestode(larva)intheliverand,resemblinganeoplasmLunginvolvementislessfrequentthaninunilocularcysticechinococcosis,resultsfrommetastaticdisseminationordirectextension51AlveolarandPolycysticEchinococcosisInfectionbecomessymptomaticafter5–15yearssecondarytolocalcompressionordysfunctionoftheaffectedorgan,usuallytheliverNonspecificsymptomssuchasfatigue,weightloss,cough,andhemoptysiscanbepresentAmassoffibroustissuecontainingseveralscatteredcavitiesofwidelyvaryingdiameterswithnecroticareasisfrequentlyseen,ascalcifications52AlveolarandPolycysticEchinococcosisDiagnosiscanbemadewithimmunohistochemicalandhistologicanalysis,serologictestsCTandMRIaretheimagingmodalitiesofchoiceforbetterdefiningthelocationandextentofpulmonarydiseaseCalcificationsmaydevelopasthediseaseprogresses(33%–100%ofcases)Secondarylungcompromisebydirectextensionmaymimicalungcancer53PolycysticechinococcosisM25ChestradiographMultipleperipheralroundareasofsoft-tissueopacity54PolycysticechinococcosisCTclearlydefinedcapsulewitharelativelyhypoattenuatingcenter,afindingthatreflectsthecysticnatureofthelesionsEvogeliwasidentifiedatpathologicanalysisastheetiologicagent55PolycysticechinococcosisofthechestwallfromEvogeliM13Cysticthickeningofthepleurawithchestwallinvolvement.56Schistosomiasis（血吸虫病）Shematobium,Smansoni,andSjaponicumSmansoniisendemictoAfrica,SaudiArabia,Brazil,Madagascar,Venezuela,andPuertoRicoSjaponicumismorefrequentlyseenineastAsiaInfectionisacquiredthroughexposureoftheskintowatercontaminatedwithcercariaeexcretedbysnails,whichhavetheabilitytopenetratetheskinortheintestinalwall,thenmigratetothelungandafterwardtotheliver,wheretheparasitecontinuesitslifecycleThesecondmostcommoncauseofmortalityamongparasiticinfectionsaftermalaria,affecting150–200millionpeopleandcausing500,000deathseachyear57lifecycleofSchistosomaspecies58GeographicdistributionofSchistosomaspecies59PulmonaryschistosomiasisEarlypulmonaryschistosomiasis(3–8weeksafterparasiticpenetration)resultsfromimmunologicreaction,inwhicheosinophilsaresequesteredinthelungsSymptoms：shortnessofbreath,wheezing,anddrycough60EarlypulmonaryschistosomiasisThediagnosisissuggestedinpatientswholiveinorhavetraveledtoendemicareasandwhopresentwitheosinophiliaMayhavebothclinicalandradiologicmanifestationsaftertheonsetofsymptomsAssociatedurticaria,arthralgia,hepatosplenomegaly,hepatitis,eosinophilia61EarlypulmonaryschistosomiasisSmallnodularlesionswithill-definedbordersor,lesscommonly,areticulonodularpatternorbilateraldiffuseareasofground-glassincreasedopacityorhyperattenuationatradiographyandCTAsymptomaticcasesthatmanifestwithabnormalradiologicfindingsmayalsobeseenSensitivityislowfortheexaminationofstoolandurineforeggsinthisstageofinfection62EarlypulmonaryschistosomiasisM28hadtraveledtoMaliInitially,hadfeverandurticaria,afterwhichexperienceddrycough,predominantlyatnightCTshowsmultiplenodularlesionswithill-definedbordersinthelowerlobes.HistologicanalysisrevealedSmansoni

63Resultsfromgranulomatousreactiontoeggsdepositedinthepulmonaryvasculature,whichleadstointimalfibrosis,pulmonaryhypertension,andcorpulmonaleOftenprecededbyliverinvolvementbyportalhypertension,whichallowstheeggstoshuntfromtheportalsystemintothepulmonaryvasculatureDyspnea,chestpain,fatigue,palpitations,cough,and,lately,right-sidedheartfailureChronicpulmonarydisease64ChronicpulmonarydiseaseRadiographicandCTfindingsarealsoconsistentwiththeseclinicalfindingsandincludecardiomegalyandpulmonaryarterialenlargementDiagnosisismadebyidentifyingeggsinstoolorurinesamplesoratrectalbiopsySerologictestsarenotveryhelpfulbecausetheycannothelpdifferentiateaformerinfectionfromcurrentdisease65七律二首送瘟神1958.07.01绿水青山枉自多，华佗无奈小虫何！千村薜荔人遗矢，万户萧疏鬼唱歌。坐地日行八万里，巡天遥看一千河。牛郎欲问瘟神事，一样悲欢逐逝波。春风杨柳万千条，六亿神州尽舜尧。红雨随心翻作浪，青山着意化为桥。天连五岭银锄落，地动三河铁臂摇。借问瘟君欲何往，纸船明烛照天烧

66毛泽东诗词《送瘟神》鉴赏1958年7月1日，读6月30日人民日报，余江县消灭了血吸虫。浮想联翩，夜不能寐。微风拂煦，旭日临窗。遥望南天，欣然命笔当毛泽东得知江西余江县消灭了为害极广的的血吸虫病时，作为共和国的缔造者，一个时刻系念着人民的领袖，他激动不已，彻夜难眠，感慨和热忱化作了这两首七律领袖的爱国爱民之情，闪射出了灿烂的艺术光辉67第一首，诗人回顾过去，描述了瘟神给中国带来的无穷灾难。首联“绿水青山枉自多，华佗无奈小虫何”，抒发了诗人的悲愤心情祖国的南方，向来以鱼米之乡著称，这里青山绿水、风景秀丽。可是，一个小小的血吸虫竟使大好河山萧杀黯淡，就连华佗这样的名医奈之不何“绿水青山”与“枉自多”对举，“华佗”与“无奈”相联，强烈的反差、对比，寄寓了诗人多么深厚的感情，又饱含了人民大众多少苦楚！“千村薜荔人遗矢，万户萧疏鬼唱歌”，“千村”“万户”极言受灾地域之广，受灾人数之多鉴赏268“坐地日行八万里，巡天遥看一千河”道出人民寻求解脱灾祸的强烈呼声随着地球的自转和公转，人们寻遍长天，看过无数的星河然而，年年岁岁惨况依然，苦难依旧，人们到哪里去寻求帮助他们解脱疾病、消灭瘟君的救星呢？鉴赏369鉴赏4通过“坐地”“巡天”的超凡想象，诗的尾联引出了神话传说中天河边的牛郎：“牛郎欲问瘟神事，一样悲欢逐逝波”牛郎是劳动人民的化身神，他当然关心着人民的疾苦，要问“瘟神”肆虐之“事”。如何回答呢？诗人的答词是：一切悲欢离合都随着时光的流逝而成为过去了这样，人间天上浑然一体，极大地开拓了诗词包容的时空和思想蕴含，写出了旧中国带给人民的灾祸，那是天怒人怨，世所难容70第二首情绪热烈、语调高亢，与第一首感情抑郁、语义哽咽形成了鲜明的对比首连“春风杨柳万千条”二句即是一幅意气飞扬的画面。在经历了冰封雪裹的严冬之后，新忠告大地万物复苏，一片欣欣向荣。如今的南方春天，千万条杨柳随风飘拂，景象格外优美。孟子说“人皆可以为尧舜。”但在封建社会，这对于地位极其低下的民众来说，只不过是一种幻想。即使是那些认识到“民可载舟，民可覆舟”的明君圣主，也仍是站在历史的对立面，把民众当成负载自己功业的工具鉴赏571集领袖与诗人与一身的毛泽东，从历史唯物主义的高度，认识到人民的力量及其创造历史的作用，因而写出了“六亿神州尽舜尧”的诗句。表达了毛泽东对人民群众的期待与歌颂，也表达了毛泽东真正民主的人本思想。解放了的人民，确定了社会主人的地位，本质力量得到了淋漓的发挥，让高山地头，令河水让路，将扼住人们命运的瘟神彻底消灭，这样的人民是真正的神、真正的舜尧。诗人用一颗热爱人民、服务人民的心，唱出了热情澎湃的心声，表达了无产阶级革命领袖对人民的关怀、推崇72鉴赏6“红雨随心翻作浪，青山着意化为桥”景物完全化为了情思，自然景物变得通人心、随人意，人与美丽的景色交融一体。暮春的落花飘入水中，随人的心意翻着锦浪，一座座青山相互连同，就象专为人们搭起的凌波之桥，整个中国呈现出一派兴盛的气象此时的水和山，仍然是从前的“绿水青山”，可在旧时代，山河被瘟神糟蹋，虽多亦枉然。到了新时代，人人成为舜尧，山水也焕发青春，大地在日新月异地改变着面貌73鉴赏7“天连五岭银锄落，地动山河铁臂摇”，歌颂了人民群众改天换地的威力。“五岭”绵延在南方，“三河”奔腾于北国，这两个地名，代表了整个中国。祖国到处皆是银锄齐挥、铁臂同摇，人民群众的凌云之志，山河动容诗人以高妙的艺术手笔，概括了当时社会主义建设的雄伟场面，令人叹服。同时，诗句中还滲透了诗人“力拔山兮”的伟岸精神和自力更生的进取意识。诗人“人定胜天”的思想，化成美妙的诗句，闪射出了动人心魄的魅力74鉴赏8全诗名为“送瘟神”，但第二首的前六句却不见瘟神的影子，只在尾联点出“借问瘟君欲何往，纸船明烛照天烧。”，这是为什么呢？实际上，在前六句中，诗人对此已作了暗示。正是由于消灭了瘟神，人民才可以着么扬眉吐气，河山才这样妖娆动人可以想象，六亿人民皆成舜尧，意气风发，改天换地，完成了许多前人所不敢想象的事业，对付小小的血吸虫当然不在话下，瘟神必然逃脱不了灭亡的下场75鉴赏9诗人称瘟神为“瘟君”，实乃一种讽刺戏谑的口吻，充分显示了人民的信心和力量，辛辣嘲笑瘟神（一切反动派）的无能和无奈“照天烧”三字，是全诗的结穴，象征中国人民不仅能消灭血吸虫病，同时也能改变“东亚病夫”和贫穷落后的形象，也能扫除一切的瘟神和一切害人虫，自立于世界民族之林76鉴赏毛泽东是具有革命浪漫主义气质的诗人，《送瘟神》二首便是其革命浪漫主义的杰作之一。在诗中，诗人的内心世界随着神奇的想象、多变的画面得到了多方面的展示。既有理想，又有现实；既有科学，又有神话；既有对旧时代人民苦难生活的叹息，又有为新时代人民壮举的喝彩。情致高昂，想象丰富。诗人的才情得到了极致的展现，诗作的审美情趣也得到了极大的丰富

77Paragonimiasis（肺吸虫病）CausedbythetrematodeParagonimuswestermaniorotherParagonimusspeciesthroughtheingestionofraworpartiallycookedfreshwatercrabsorcrayfishinfectedwiththemetacercariaThemainendemicareasareeastAsia,SoutheastAsia,LatinAmerica(primarilyPeru),andAfrica(primarilyNigeria)78GeographicdistributionofParagonimusspecies79肺吸虫病囊蚴寄生在中间宿主石蟹及喇蛄等体内，当生食或食入未煮熟的石蟹、喇蛄而感染后，幼虫在肠道内脱囊后穿过肠壁进入腹腔，1～2周后经膈进入胸腔及肺而引起感染在肺内由幼虫发育为成虫，在虫体周围肺组织充血并发生炎性反应。虫体在肺内可随意穿行，形成隧道样腔隙或囊肿。增生的纤维组织包裹虫体则形成囊肿样病变，当囊肿样病变内的成虫死亡或脱落后病变可吸收或缩小，也可纤维化或钙化80LifecycleofParagonimusspecies81ParagonimiasisThelungisthetargetorganFever,chestpain,respiratorysymptomssuchaschroniccoughandhemoptysisConfirmedbydetectingparasiteeggsinthesputum,pleuralfluid,orfecesLarvaeoftenbefoundatbronchialbrushingIntradermalandserologictestsarealsoavailable82临床表现咳嗽、咳痰、咯血、胸痛、气短等呼吸道症状，咳果酱样粘痰为特征性表现疲乏及体重减轻，如无混合感染也可不发热痰中可找到肺吸虫虫卵、嗜酸性粒细胞和夏科雷登结晶83X线肺内浸润阴影，斑片状、圆形或椭圆形，1～3cm，边缘模糊，密度低，为肺吸虫引起的肺内出血及组织破坏所致，中、下肺多见浸润阴影内可见单发或多发囊状透明区，多位于肺门附近及下肺野，为肺吸虫在肺内随意穿行而形成的隧道及囊肿圆形或椭圆形结节阴影，单发或多发，其边界清楚，中心可见透亮影，周围有条索状影，为肉芽组织及纤维组织增生硬结和钙化阴影，呈结节、条索状，密度高，边缘清楚为病变吸收愈合的表现可有肺纹理增多、紊乱，胸膜增厚、粘连84ParagonimiasisRadiologicfindingscorrelatewellwiththestageofthediseaseThepenetrationofjuvenilewormsthroughthediaphragmintothepleuralcavitycancausepleuraleffusionorpneumothoraxOncetheparasitesgettothelung,patchyairspaceconsolidationcanoccur,aphenomenonthatreflectsthepresenceofanexudativeorhemorrhagicpneumoniawhichcancavitate85CT斑片状病灶、结节病灶及空洞斑片状病灶的边缘模糊结节病灶边缘清楚空洞壁厚薄不一，其内可见条状高密度虫体上述表现可并存，也可单独出现病灶常多发，可在肺任何部位，以两下叶常见有时见胸腔积液和胸膜肥厚86ParagonimiasisE+CTshowhypoattenuatingfluid-filledcystssurroundedbyhyperattenuatingconsolidationintheadjacentlungLinearareasofincreasedopacityorhyperattenuationindicateperipheralatelectasisorwormmigrationWormcystsrangefrom0.5to1.5cm,arebettervisualizedaftertheconsolidationresolvesandmanifestaseithersolitaryormultiplenodulesorgas-filledcystsdependingontheircontentandtheircommunicationwiththeairway87RadiographicandCTfindingsAringshadowusuallylessthan3mmthickAcrescent-shapedareaofincreasedopacityHyperattenuationwithinthecystthatrepresentswormsattachedtothewallComplicationsofcystsincludepleuraleffusion,empyema,andpneumothorax88PulmonaryparagonimiasisM35Alveolarareasofincreasedopacity,predominantlyintheleftlung89Pulmonaryparagonimiasisbilateralill-definedareasofconsolidationandareasofground-glassattenuationassociatedwithleftpneumothoraxEggsofPwestermaniwerefoundatbronchoalveolarlavage90PulmonaryparagonimiasisM27cavitatedareasofincreasedopacityinthemiddlelobeandleftupperlobe91PulmonaryparagonimiasisAcavitatedareaofconsolidationinthemiddlelobeandhelpedconfirmthepresenceofacavitatednoduleintheleftupperlobe(notshown)EggsofPwestermaniwerefoundatbronchoalveolarlavage92Pulmonaryparagonimiasis

M43Asoft-tissuenoduleinmiddlelobeCTclearlyrevealsthenoduleHistopathologicanalysisperformedaftersurgicalresectiondemonstratedPwestermani93特发性肺间质纤维化原因不明的弥漫性纤维性肺泡炎又称Hamman-Rich综合征为肺泡壁损伤所引起的非感染性炎性反应近认为系免疫性疾病，可能与遗传有关94病理急性期：肺泡内皮细胞和基底膜受损，肺泡和间质内蛋白样物质渗出，伴透明膜形成，继而淋巴细胞和单核细胞渗出。肺泡内皮细胞再生覆盖在渗出物表面并使其整合入肺间质，肺泡壁增厚，胶原纤维扭曲、紊乱而机化。病变发展，间质纤维化加重晚期：肺泡壁、小叶间隔及胸膜下广泛纤维化，肺体积缩小变硬，毛细血管网和气道的终末部分被破坏。在范围较大的纤维化区域，可有终末气道的代偿性扩张，形成直径数mm至2cm的囊样含气腔隙95Hamman-RichSyndrome多见于中年，男、女无差别多起病隐匿，初期无症状进行性呼吸困难和干咳进展速度因人而异：快者1～2年内出现发绀和杵状指，并发肺心病慢者可数年甚或十几年不出现明显缺氧症状，但最终出现缺氧及肺心病易合并肺部感染，反复感染可加快肺纤维化的发展肺功能检查呈限制性通气障碍及低氧血症96胸部X线平片早期正常，或仅见两肺中下野细小网织阴影病变发展，出现不对称性、弥漫性网状、条索状及结节状阴影，可扩展至上肺野晚期，结节状阴影增大，并伴有广泛厚壁囊状阴影，形似蜂窝状，故称为蜂窝肺并发阻塞性肺气肿时，肺野透亮度增强囊肿破裂可发生自发性气胸肺纤维化严重时可发生肺动脉高压和肺心病97Idiopathicpulmonaryfibrosis早期发现肺间质纤维化并准确了解病变的分布CharacteristiconCT磨玻璃样影及实变影，内见含气支气管影，支气管血管数增粗Ground-glassattenuation与胸膜面垂直的细线形影，长1-2cm，宽约1mm，多见于两肺下叶，也见于其他部位两肺中内带小叶间隔增厚表现为分支状细线形影Reticularattenuationwithinterlobularseptalthickening胸膜下0.5cm内与胸壁内面弧度一致的弧线状影，长5-10cm，边缘较清或略模糊，见于两下肺后外部98Idiopathicpulmonaryfibrosis蜂窝状影，数mm至2cm大小不等的圆形或椭圆形含气囊腔，壁薄而清楚，与正常肺交界面清楚。分布于两肺基底部胸膜下区.Ahoneycombpatternpredominantlybasalandperipheralindistribution小结节影，边缘较清楚，为纤维条索病变在横断面的表现，或相互交织而成小叶中心性肺气肿：散在、直径2-4mm的圆形低密度区，无明确边缘，多见于肺外围部，病变发展可渐见于肺中央部。有时胸膜下见1-2cm大圆形或类圆形肺气囊中小支气管扩张，多柱状，伴支气管扭曲、并拢Architecturaldistortionwithassociatedtractionbronchiectasisandbronchiolectasis99IdiopathicpulmonaryfibrosisF47GGO:peripheraldistributionInterlobularseptalthickeningIrregularityofthefissuresBronchiectasisEarlyinterstitialpneumonia22mlater,progressionofinterstitialpneumoniaDiffuseGGO,interlobularseptalthickeningAhoneycombpattern100鉴别诊断肺类风湿性病的广泛性肺间质纤维化，最后发展为蜂窝肺，与HRS相似。但前者有渐进性坏死结节即肉芽肿及胸腔积液表现，有别于HRS红斑狼疮的胸部表现以心肌炎所致的心脏增大、间质性肺炎、节段性盘状肺不张和胸腔积液等所见为特征，与HRS不同硬皮病的肺间质纤维化发展至晚期可出现蜂窝肺，如有皮肤的改变以及在食管造影见其张力减低或狭窄等表现，则有助于硬皮病的诊断101结节病（Sarcoidosis）原因不明的多系统肉芽肿性疾病，良性经过，可累及淋巴结、肺、胸膜、皮肤、骨、眼、脾、肝、腮腺及扁桃体等病理特征为非干酪性肉芽肿淋巴结大，但不融合。肺门LN易受累，次为气管旁和AA旁肺内病变沿支气管血管周围结缔组织鞘及小叶间隔发展蔓延，肺内肉芽肿主要分布在间质，小，直径在0.4mm以下，胸膜下肺间质内肉芽肿更密集。小肉芽肿可融合成大结节急性发病者肉芽肿大多经治疗消退或自行消退。慢性发病者常导致进行性肺纤维化102Sarcoidosis见于任何年龄，20～40岁多见，女性多病程缓慢，轻者无症状症状与影像学表现常不相称，本病特点之一咳嗽，咳少量粘痰、乏力、低热、盗汗、纳差及胸闷等。肝脾肿大、皮肤结节、关节疼痛、腮腺肿大、外周淋巴结肿大及眼部病变症状实验室检查Kveim试验阳性，ACE（血管紧张素转化酶）升高，血、尿钙值升高103胸部X线平片纵隔、肺门淋巴结肿大，半数为唯一异常多组淋巴结肿大，两肺门对称性淋巴结肿大，状如土豆，为典型表现肺门淋巴结肿大的程度比其他部位更加显著少有纵隔淋巴结而无肺门淋巴结者淋巴结肿大一般在6-12个月期间可自行消退，恢复正常；或在肺部出现病变过程中，开始缩小或消退；或不继续增大，为结节病的发展规律104Sarcoidosis肺部病变多发生在淋巴结病变之后两肺弥漫性网状结节影，但肺尖或肺底少或无。结节大小不一，多为1-3mm大小，轮廓尚清楚肺内圆形病变，直径约1.0-1.5cm，密度均匀，边缘较清楚，单发者类似肺内良性病变或周围型肺癌，多发者酷似肺转移瘤节段性或小叶性浸润，类似肺部炎性病变，一般伴或不伴胸腔内淋巴结病变少数为单纯粟粒状，似急性粟粒型结核105Sarcoidosis以纤维性病变为主者，不易与其他原因所致的肺纤维化区别，且可引起多种继发性改变胸膜渗液可能为胸膜脏、壁层广泛受累所致。肥厚的胸膜为非干酪性肉芽肿骨病变约占10%。损害一般限于手、足的短管状骨，显示小囊状骨质缺损并伴有末节指（趾）的骨质吸收，变细、变短106CT纵隔、肺门淋巴结肿大，密度均匀，边缘清楚，周围脂肪界面存在。增强扫描呈均匀强化肺内可见大小结节影或块状影晚期支气管血管束扭曲、聚拢或变形，叶间裂、血管支气管移位，支气管扩张和不同程度肺气肿支气管血管束增厚，边缘不规则或结节状，周围可有大小不等的结节状影；小叶间隔增厚和细小蜂窝影，见于胸膜下区胸膜初期为胸腔积液，可自然吸收，少数可发展为胸膜肥厚107鉴别诊断肺门结核：年轻，有轻度中毒症状。气管旁、支气管旁淋巴结肿大，可有钙化。结素反应阳性，痰中找到结核杆菌霍奇金病：常先有颈部、锁骨上淋巴结肿大，然后出现不对称性双侧或单侧纵隔淋巴结肿大，前纵隔较后纵隔多见。纵隔淋巴结肿大的程度常较肺门淋巴结肿大显著非霍奇金淋巴瘤：多为单侧纵隔淋巴结肿大，即使双侧纵隔淋巴结肿大亦不对称。后纵隔多于前纵隔淋巴结肿大，晚期才有肺门淋巴结肿大。纵隔淋巴结多大于肺门淋巴结未分化型小细胞肺癌：多为单侧纵隔或（和）肺门分叶状淋巴结肿大，双侧纵隔淋巴结肿大较少见。部分伴有不同程度的阻塞性肺炎或肺不张。病程发展迅速间质性病变：当病变发展至纤维化期则需与癌性淋巴管炎、间质性肺炎、嗜酸性肉芽肿等鉴别108SarcoidosisAsystemicdisorderofunknowncauseCharacterizedbynoncaseatinggranulomaswithproliferationofepithelioidcellsAffectsyoungandmiddle-agedpatients,withaslightlyhigherprevalenceinwomenHasdistinctgeographicandracialpredilections,withAfrican-Americans,Swedes,andDanesappearingtobemostcommonlyaffected109SarcoidosisSymptomsandsignsarenonspecific,halfasymptomaticFatigue,weightloss,generalmalaise,feverBilateralhilarlymphadenopathyisthemostcommonradiologicfindingAdenopathyintherightparatrachealnodes,leftaortic-pulmonarywindow,andsubcarinalnodescanalsobeseen,oftenwithassociatedpulmonaryinfiltratesExtrathoracicinvolvementcanbeaninitialmanifestationinone-halfofsymptomaticpatientsSkinandocularlesionsarecommon,theliver,spleen,lymphnodes,parotidglands,CNS,genitourinarysystem,muscles,andbonesmayalsobeinvolved110LaboratoryAngiotensinconvertingenzyme(ACE)levelelevatedandmaycorrelatewithactivityTheCD4:CD8ratioiscommonlydecreasedHypercalcemiaduetoincreasedintestinalabsorptionofcalcium,resultingfromactivationofvitaminDbymacrophagesinsarcoidgranulomas111ClinicalCourseandPrognosisMaycorrelatewiththemodeofonsetandtheextentofdiseaseAcuteonsetwitherythemanodosumorasymptomaticbilateralhilarlymphadenopathyusuallyportendsaself-limitingcoursewithspontaneousresolutionInsidiousonset,especiallywithlunginvolvementormultipleextrapulmonarylesions,maybefollowedbyprogressivefibrosisofthelungandotherorgansDirectcauseofdeathin5%(4%fromcardiacinvolvement,1%frompulmonarycomplications)112TreatmentCorticosteroidsareeffectivelyusedfortreatmentSomerespondrapidly,othersmayrequirelong-termtherapyIncasesofaggressivediseaseorfrequentrecurrence,immunosuppressivedrugssuchasmethotrexateandcyclophosphamidemayberequired113HilaradenopathyM27TypicalbilateralhilaradenopathyAdenopathyintherightparatrachealandleftaortic-pulmonarywindownodes114HilaradenopathyE+CTclearlydepictsthebilateralhilaradenopathy115MediastinalLymphNodesBilateralhilaradenopathyRightparatrachealadenopathyLeftparatrachealandaortic-pulmonarywindownodesarealsocommonlyenlargedCalcificationoccursinaffectednodes，Itcanbeamorphous,punctate,oreggshell-like;itiscloselyrelatedtothedurationofthediseaseandsuggestsachroniccondition116MediastinaladenopathyM26SeverebackpainEnlargedrightparatrachealnodesLeftaortic-pulmonarywindownodeswithassociatedminimalhilarinvolvementarealsoseen117MediastinaladenopathyMediastinaladenopathy,60MCalcificationintheaffectedhilarnodes,hugesubcarinallymphnodesAnunusualfindinginothergranulomatousdiseasessuchastuberculosis118PulmonarysarcoidosisLunginvolvementin20%ofpatientsHasastrongpredilectionfortheupperlungDyspneaanddrycougharecommonmanifestations,whereashemoptysisisrareAthistologicanalysis,sarcoidgranulomasinthelungaretypicallydistributedalongthelymphaticvessels,whichrunwithintheinterstitialtissuesofbronchovascularbundlesandthesubpleuralandperilobularspaces119PulmonarysarcoidosisMultiplesmallnodulesinaperivasculardistribution,alongwithirregularthickeningofbronchovascularbundlesandinterlobularseptaUpperlungpredominance,andcoexistenceofmediastinallymphadenopathy,distinguis