病理学英文版教学课件：11 Infectious disease

Infectiousdisease

传染病病因：病原微生物（Pathogen)

引起疾病有传染性，流行性 地方性，季节性入侵门户：特定病原体—特定的入侵门户—

特定播散方式—特定组织和器官和力—特定病变定位发病机理：细菌：内/外毒素 病毒：细胞/体液免疫传染病

共同特点

传染病

共同特点

基本病理变化 炎症（急/慢性） 宿主——病原致病力，两者决定疾病过程临床经过，典型： 潜伏期：感染—出现症状 前驱期：出现非特异性症状 发病期：出现疾病的典型症状 愈复期：病情渐趋缓解转归痊愈：永久或暂时性免疫慢性复发死亡自然动物病三类病毒性动物病：出血热、鹦鹉热、狂犬病、SARS、

birdflu.立克次体病细菌病、螺旋体病、莱什曼病、布鲁氏病举例20世纪30年代苏联大规模森林脑炎森林脑炎病毒森林修铁路工人

80年代上海食用毛蚶38.5万甲肝病人野鹿、狼自然动物病90年代耐药性结核（美国）从野猴、血貂、海龟身上传来21世纪初

SARS：动物源性冠状病毒(RNA病毒)Birdflu:H5N1型其它著名的病例有：中世纪鼠疫大流行blackdeath

艾滋病、口蹄疫、炭疽、埃博拉病毒、疯牛病美国12变种香港6变种授课内容结核神经系统传染病

流行性乙型脑炎

流行性脑膜炎麻风梅毒伤寒细菌性痢疾Tuberculosis

结核IntroductionAchronicinfectiousdiseaseMycobacteriumTuberculosis☆PulmonaryTBisthemostcommontype.involveallorgans(rareinthyroid,pancreasandmyocardium)Characteristicchanges:

tuberculousgranuloma+caseousnecrosis结核结节干酪样坏死TuberculosisEpidemiologyHistory☆“痨病”Worldwide

1.7billioninfected8-10millionnewcases3milliondeathsChina0.55billioninfected0.13milliondeathsTuberculosisPredisposingfactorssocialfactors:poverty,crowding,agingchronicdebilitatingdisease:diabetesmellitus,Hodgkindisease,pulmonarysilicosis,alcoholism,etalimmunitydeficiency:HIV

TuberculosisEtiologyRobertKoch24th,March“世界防治结核病日”Pathogenspecies:

M.hominis(人型）M.bovine(牛型）M.avium(鸟型）M.piscium(鱼型)M.murium(鼠型)

humanTuberculosisHIVinfectedhostEtiologyPathogenicity

Lipid:mycolicacid（分枝菌酸）cordfactor（索状因子）WaxD（蜡质D）phospholipid（磷脂）mycosides（分枝菌糖苷脂）

Protein：Tuberculin结核菌素/纯蛋白衍生物（PPD）GlycogenTuberculosis分支菌酸(mycolicacid)--抗酸染色TransmissionRespiratorytract(pulmonaryT.B):inhaletheairborneorganismsexposetocontaminatedsecretionsDigestivetract(intestinalT.B):

drinkinginfectedmilkSkininjury:

CongenitalBCG:nonpathogenic,livingT.B,undergoing230passages,13yrs）

mother PlacentaAmnioticfluidFetusTuberculosisPathogenesis

infection≠disease★Onlyasmallfractionofthosewhocontractaninfectiondevelopactivedisease.

TuberculosisPrimaryinfection(non-specificimmunity)hyperemia,edema,neutrophils,TandBcells,MΦphagocytosed,butnotkilledN-RAMP1:naturalresistance-associatedmacrophageprotein1MostpatientsatthisstageareasymptomaticorhaveamildflulikeillnessTuberculosisPathogenesis2–3wkslaterspecificimmunityandallergyoccursOT/PPDSecondaryinfection:(specificimmunity)Kochphenomena:immunityaccompaniedwithallergyTuberculosisPathogenesisPPDtest

false-negativefalse-positiveTuberculosisPathogenesisKochphenomenon:cellmediatedimmunity(CMI)accompaniedwithdelayedtissuehypersensitivity(DTH)TuberculosisCMIandDTHaredifferentimmunoreactionsDifferentantigensDifferentTcellsubtypesTheamountoforganismsorantigenandTh1/Th2excursionDifferentCKsDifferentmethodstokillorganismsPathologicalchangesExudationdominantchanges渗出病变happenedinearlystageofinfectionordeteriorationofDis.

Predisposingfactors:

suppressedimmunity,plentyofmycobacteriumT.BhighvirulenceandstrongDTHchanges:serousinflammation,serous-fibrinousinflammationlocation:pleura,meninges,peritoneumTuberculosisTuberculosisPathologicalchangesExudationdominantchanges:

development:unstableabsorbedwithoutanychangeschangeintoproliferationdominantornecrosisdominantchangeseasytofindorganismsTuberculosisPathologicalchangesProliferationdominantchange(Tubercleformation,granuloma)肉芽肿性病变

Predisposingconditions:strongimmunityfewmycobacteriumlowvirulence

TuberculosisPathologicalchangesProliferationdominantchange(Tubercleformation,granuloma)

Changes:EpithelioidcellsLanghan’sgiantcellsLymphocytesdifficulttofindorganismsTuberculosisTubercle结核结节PathologicalchangesNecrosisdominantchangePredisposingfactors:weakenedimmunity,severehypersensitivitylargeamountofmycobacteriumT.B.highvirulenceChanges:caseousnecrosis（干酪样坏死)

Gross:granular,cheesyappearance(richinlipid)

LM:acidophiliagranularmaterialswithoutstructure

TuberculosiscaseousnecrosisPathologicalchangesNecrosisdominantchangeeasytofindorganismsDevelopment:

Existforlong→timingbombTheamountofmycobacteriumwillincreasesharplywhenthediseasedeteriorateFibrosisTuberculosisPathologicalchangesexudationchangesgranulomalesioncaseousnecrosisTuberculosisBasicchangesHostBacterialImmunityAllergyAmountpathogenexudationlowstrongerlargestronggranulomahigherweakerfewlownecrosislowstrongestlargestrongTuberculosis愈合

病灶小：渗出性病灶吸收消散 增生性病灶纤维化 干酪坏死灶，吸收消散，纤维化-------------"吸收好转期" 病灶大：

纤维化 钙化（20%钙化灶内有活菌）

-------------"硬结钙化期"ConsequenceTuberculosis恶化

1.病灶扩大病灶周围渗出

结核结节及干酪样坏死模糊的云絮状阴影阴影密度增高"浸润进展期"ConsequenceTuberculosis恶化2、溶解、播散与空洞形成坏死、液化——天然腔道排出----空洞“开放性肺结核”播散

天然腔道：支气管---肺

“溶解播散期”

消化道——肠

输尿管——膀胱淋巴道：淋巴结血道：远处器官ConsequenceTuberculosisPulmonaryTuberculosis

肺结核

PrimarypulmonaryT.B.SecondarypulmonaryT.B.TuberculosisPreviouslyunexposedMostinchildren,agedorimmunosuppressdpersons(HIV)ExogenousorganismPathologicalchange:

GhonComplex（原发复合征)1-1.5-cmareaofgray-whiteinflammatoryconsolidation(lowerpartofupperlobeorupperpartoflowerlobe)TuberculouslymphatitisRegionalnodeinvolvement,oftenwithcaseatePrimaryPulmonaryTuberculosisTuberculosisGhonComplexTuberculosisPrimaryPulmonaryTuberculosisTuberculosisPrimaryPulmonaryTuberculosis

绝大多数无明显的症状

5%患者有倦怠，盗汗，消瘦等1、98%好转，机体产生免疫力，病灶吸收，纤维化，钙化

Ranke复合征(Rankecomplex)2、恶化进展血道播散淋巴道播散支气管播散Consequence转归TuberculosisPrimaryPulmonaryTuberculosis血道播散acutemiliaryT.B.

（急性粟粒性结核）大量细菌一次进入肺静脉

全身（肝、脾、脑膜、肾、骨髓）肺动脉

肺抵抗力极差或用大量激素、免疫抑制剂或细胞毒药后TuberculosisPrimaryPulmonaryTuberculosis粟粒性肺结核大小一致、分布均匀、灰白色圆形镜下：结核结节TuberculosisPrimaryPulmonaryTuberculosisTuberculosisPrimaryPulmonaryTuberculosissubacuteorchronicmiliaryT.B.（亚急性或慢性全身粟粒性结核病） 少量多次进入血循环，病灶大小、新旧和性质不一致secondaryorextrapulmonaryT.B.

（继发性肺结核或肺外器官结核病）肺、骨关节、脑、肾、输卵管、附睾等处痊愈或潜伏下来日后复发血道播散TuberculosisPrimaryPulmonaryTuberculosis

锁骨上下LN颈LN肺门LN 支气管、气管LN

纵隔LN

腹膜后LN

结核结节形成伴淋巴组织增生干酪样坏死与软组织粘连，甚至经久不愈的窦道

淋巴道播散TuberculosisPrimaryPulmonaryTuberculosis支气管播散少见。LN肿大将小儿薄壁气管压瘪

TuberculosisPrimaryPulmonaryTuberculosisSecondaryPulmonaryT.B.

继发性肺结核PreviouslyinfectedAdulttypePathogenesis<5%exogenous>95%endogenousseedingTuberculosis1.Location:apexoflobelowarterialbloodpressure,lessMΦ,lessventilation,highO2pressure2.Changes:caseousnecrosis---proliferationfocuslocalizationlesslymphaticandvascularspreadingmorebronchialdissemination3.Longcourseofdisease,complexchangesTuberculosisSecondaryPulmonaryTuberculosisPrimaryPT.BSecondaryPT.B

InfectionpreviouslyuninfectedpreviouslyinfectedPatientchildrenadultSpecialCMIandDTHoccurinthecoursepreviouslyhadPathologicalchangesGhoncomplexvariouschanges,localization,cavityBeginningfocuslowerpartofupperlobeapexoflobeupperpartoflowerlobeCharacterofchangesexudation,necrosisproliferation,necrosisDisseminationlymphaticandbloodvesselbronchialCourseofdiseaseshort,self-controllong,fluctuant,clinicaltreatmentcomparisonTuberculosis原发性肺结核继发性肺结核结核杆菌感染初染再染发病人群儿童成人特异性免疫力和过敏性先无，在病程中发生有病理特征原发复合征病变多样，新旧病灶并存起始病灶下叶上部、上叶下部近胸膜处肺尖病变性质渗出坏死为主肉芽肿形成和坏死为主播散方式淋巴道、血道播散多为支气管，趋于肺内演变病程短，大多自愈长，波动性，需治疗PathologicalchangesFocallesion:(局灶型）1.location:1~2cmbeneathapexoflobe2.modality:lessthan2cmindiametersingleormultiplefocusesproliferationdominantcaseousnecrosisincentralandfibrosisaround3.development:healingbyfibrosisorcalcificationfewbecomeinfiltrativelesionTuberculosisSecondaryPulmonaryTuberculosisTuberculosisSecondaryPulmonaryTuberculosisPathologicalchangesInfiltrativelesion（浸润型）:1.source:focallesion2.location:apexorsubclavicalarea(subclavicularinfiltration)3.modality:exudationdominant,caseousnecrosisincentral4.clinicalsymptoms

TuberculosisPrimaryPulmonaryTuberculosisTuberculosisPrimaryPulmonaryTuberculosisPathologicalchangesInfiltrativelesion（浸润型）:5.development:healingbyabsorb,fibrosis，calcificationdiseaseprogresses,acutecavitationmayoccurcaseouspneumoniaspontaneouspneumothoraxtuberculouspyopneumothoraxchronicfibro-cavitativetypeTuberculosisPrimaryPulmonaryTuberculosisChronicfibro-cavitativelesion(慢性纤维空洞型)1.source:infiltrativetypewithacutecavity2.Characters:☆singleormultiplechroniccavitiesthreelayers----inner:caseousnecroticmaterialsmid:tuberculousgranulationtissueouter:fibrousscar☆diversefoci☆fibrosis(cirrhoticpulmonarytuberculosis)PathologicalchangesTuberculosisPrimaryPulmonaryTuberculosisTuberculosisPrimaryPulmonaryTuberculosisTuberculosisPrimaryPulmonaryTuberculosisChronicfibro-cavitativelesion(慢性纤维空洞型)

3.clinicalsymptoms

openT.B.(mycobacteriuminsputum)emptysis,laryngealT.B.,IntestinalT.B.,corpulmonale4.developmenthealing:smallcavity→scarhealinglargecavity→openhealingPathologicalchangesTuberculosisPrimaryPulmonaryTuberculosisTuberculosisPrimaryPulmonaryTuberculosisCaseousPneumonia(干酪样肺炎）

1.source:infiltrativelesionbronchialspreadingofacuteorchroniccavity2.modality:lobularorlobarcaseouspneumoniaacutecavity(localliquefaction).LM:caseousnecrosiswithserous-fibrinousexudate3.Poorprognosis(百日痨or奔马痨)PathologicalchangesTuberculosisPrimaryPulmonaryTuberculosisTuberculosisPrimaryPulmonaryTuberculosisTuberculoma（结核球)1.source:fibrosisofcaseousnecrosisininfiltrativetypebronchiaclosureleadstocaseousmaterialsfillinthecavitycombinationofseveraltubercular2.modality:caseouslesionwithfibrouscapsule2-5cmindiameter3.prognosis:stabledeteriorationPathologicalchangesTuberculosisPrimaryPulmonaryTuberculosisTuberculosisPrimaryPulmonaryTuberculosisTuberculouspleuritis:wetanddrywettype----Exudativepleuritis：MostinyoungpeopleSource:mycobacteriadisseminationfromprimaryfocusorhilarlymphnodsDTHinducedbyproteinofmycobacteriainpleuraPathologicalchanges:serous-fibrinousinflammationClinicalsymptomsPrognosis:1.absorb2.richinfibrinmaycauseadhesionofpleuraPathologicalchangesTuberculosisPrimaryPulmonaryTuberculosisTuberculosisPrimaryPulmonaryTuberculosisdrytype----proliferativepleuritis：T.B.focusbeneathpleuraextendtopleuraMostinapexoflobe,localpleuraadhesionandthickeningCaseouspleuritisrare

PathologicalchangesTuberculosisPrimaryPulmonaryTuberculosisSystemicsymptoms

responsetoT.B.“toxic”components

Localmanifestations:

coughhemoptysischestpainlowerrespiratoryfunctionCPCmalaise,weary,nightsweat,lowfeverintheafternoon,hecticrosycheeks,lossofappetiteTuberculosisPrimaryPulmonaryTuberculosisHematogenictuberculosisResultfromPrimarytuberculosisorSecondarytuberculosisTuberculosisTuberculosisPrimaryPulmonaryTuberculosisExtrapulmonaryTuberculosisInvolveallorgansReactivationoflatentfociPathologicalchangesandcharacteroforgansarecorrelativeTuberculosisIntestinalTuberculosisSourceofMycobacterium

primary:drinkinginfectedmilksecondary:

swollenmycobacteriumcontainedsputumLocation:

anysegmentofintestinemostcommonatileocecalsegment:1.richinlymphtissue,easytoinvade2.longtimeforfoodtostayinthissegmentTuberculosisUlcerativeintestinalT.B.

TuberclesinlymphtissuefusednecrosisulcerationFeaturesofulcer:

1.longaxisoftheulcerisverticaltolongaxisofintestine,becauseofthecircularlymphaticsofintestine

2.irregularmarginoftheulcer(rat-bite-like),caseousbaseandtuberculargranulationtissuebeneath,fibrinexudateandmiliarytuberclesinserosaIntestinalTuberculosisTuberculosisUlcerativeintestinalT.B.3.IntestinalstraitnessafterulcerhealingFibrosisleadstoaadhesionamongserosaandadjacenttissuesHemorrhageandperforationareuncommonClinicalsymptoms:

chronicabdominalpain,intermittentdiarrheaandconstipation,tubuculartoxicsymptomsTuberculosisIntestinalUlcerativeT.B.TuberculosisProliferativeintestinalT.B.

proliferativechangesdominant,causingthickeningofintestine,polyposis,leadingtoabdominalmassand/orileus※※※※※※※※IntestinalT.B.MesenteryT.B.Tuberculousperitonitiswettypeperitonealtuberclegreenishyelloworhematicascitesdrytype