呼吸次常见病诊断.pptx

1肺隔离症wPulmonary sequestrationw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w肺叶内型肺隔离症肺叶内型肺隔离症：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w肺叶外型肺隔离症肺叶外型肺隔离症：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23Pulmonary sequestration45Pulmonary sequestration6Pulmonary sequestration78肺真菌病w肺霉菌病，因人体抵抗力低下而真菌侵入引起w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w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w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w机体抵抗力降低w口腔卫生不佳w生活和职业中接触较多被真菌孢子污染的物质w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w长期应用激素使机体的免疫功能低下w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w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w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w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w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w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1.散在性小结节：大小不一，密度均匀、边缘较清楚的圆形阴影2.斑片状影：多在两肺中下部，形态大小不一，边缘清楚或模糊，病灶可融合呈地图状，伴有肺纹理增多增强3.肺段或肺叶实变：斑片状影可发展融合为密度高、范围大的实变影，侵犯一个肺段或肺叶，似肺段性或大肺叶炎表现12肺真菌病的影像学表现4.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5.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6.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w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w以下几点有助于提示肺真菌病的诊断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wAspergillosis w又称肺笰状菌病，肺部最常见的真菌病w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w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w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 病理w发于肺内空洞或空腔，繁殖过程中，菌丝、纤维素、细胞碎屑及粘液混合形成曲菌球w发生于支气管者则因过敏反应，分泌物增多，曲菌菌丝又使粘液变稠而不易排出，滞留于支气管内，在支气管内形成粘液嵌塞w侵袭型为曲菌引起的肺部炎症、化脓及肉芽肿性病变，病变范围可较广泛16肺曲菌病 临床w与吸入曲菌量有关，也与机体对曲菌发生的变态反应有关w无症状w有的起病急，有发热、咳嗽、咳痰、咯血等症状，酷似急性肺炎w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w肺空洞或空腔内的圆形或类圆形致密阴影w34cm，密度较均匀，边缘较光整w可有钙化，呈斑点钙化或边缘钙化w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w曲菌球易发于肺结核空洞，两上肺尖后段多见，洞壁多较薄w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w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w曲菌球处于近地位，呈软组织密度，有时见钙化，无强化w支气管粘液嵌塞表现为柱状致密影w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w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 19Microscopic features of A fumigatuswHigh-power photomicrograph wconidiophores with the characteristic head appearance and minute sporeswMedium-power photomicrographwseptate hyphae branching at an angle of approximately 4520Bilateral aspergillomaswM71,with residual tuberculosiswlarge cavities bilaterally in the upper lobes containing fungus balls of different sizes 21Radiography wMycetomas:a solid,round or oval mass with soft-tissue opacity within a lung cavitywSeparated from the wall of the cavity by an airspace of variable size and shape,resulting in the air crescent signwMoves with the patient changes position22Mobile aspergilloma within a pulmonary cystic cavitywM43wSupine and pronewA change in the positionwA fumigatus was discovered at bronchoscopy23AspergillomaswOften associated with thickening of the cavity wall and adjacent pleuraw10%of mycetomas resolve spontaneouslywThickening of the cavity wall and pleura is due to a hypersensitivity reaction wReversibility of the pleural thickening corresponding to the resolution of intracavitary fungal material24Parasites（寄生虫病）wOrganisms obtain nourishment and shelter from other organismswHost may either be unaffected or suffer harmful consequenceswVary widely in size and complexity,from relatively simple unicellular protozoans(amebae)to more complex multicellular organisms(worms,flukes)wDistributed worldwide,a higher prevalence in developing countries,inadequate sanitation25wCommon human infection throughout the worldwEpidemics of parasitic diseases(malaria)have devastated large populations and pose a serious barrier to progress in many developing countrieswEconomic and social changes over the past decades are stimulating rural-to-urban migration in most endemic areas,parasitic diseases that are more common in rural areas are no longer entirely absent in the urban populationwIn industrialized countries,risk groups for parasitic diseases includes travelers,recent immigrants,and patients with AIDS Parasites26Hydatid Disease（包虫病）wA worldwide zoonosis produced by the larval stage of the Echinococcus tapewormwTwo main types of hydatid disease are caused by E granulosus and E multiloculariswThe former is commonly seen in the great grazing regions of the worldwthe Mediterranean region,Africa,South America,the Middle East,Australia,and New Zealand,and is the most frequently encountered type of hydatid disease in humans 27wGeographic distribution of hydatid diseasewendemic due to the transmission of E granulosus by means of the dog-sheep cycle(solid red areas).Red stripes indicate areas where transmission occurs by means of alternative life cycles in which carnivores such as wolves and foxes serve as definitive hosts and goats,camels,and horses serve as intermediate hosts28肺包虫病w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w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w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w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w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w囊肿破裂，囊液溢出，头节可在邻近形成新的囊肿w肺包虫囊肿可破入支气管及继发感染30症状w咳嗽、咯血、胸痛及发热w破入胸腔引起气胸和胸腔积液w破入支气管时咳出大量囊液w较小的包虫囊肿可无症状w嗜酸性粒细胞增多w皮试及血清学试验有助诊断31X线w单发或多发的圆形或类圆形影，110cmw密度均匀，囊状，边缘光滑清楚，可环形钙化w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w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w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w肺表面的囊肿破裂可形成气胸或液气胸32CTw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w囊壁薄厚不一，囊肿与胸膜或纵隔相邻处变平w囊肿衰老呈不规则状，似实质性肿瘤，但密度仍较低w合并感染时边缘模糊，类似肺脓肿w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w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w空气进入外囊内，内囊塌陷并漂浮于液面，“水上浮莲征”33Life Cycle of E granulosuswThe definitive host is usually a dog(or other carnivore)wThe adult worm lives in the proximal small bowel of the definitive host,attached by hooklets to the mucosawEggs are released into the hosts intestine and excreted in the feceswSheep are the most common intermediate hosts.They ingest the ovum while grazing on contaminated groundwThe ovum loses its protective chitinous layer as it is digested in the duodenumwThe released hexacanth embryo,or oncosphere,passes through the intestinal wall into the portal circulation and develops into a cyst within the liver34Life Cycle of E granulosuswWhen the definitive host eats the viscera of the intermediate host,the cycle is completedwHumans may become intermediate hosts through contact with a definitive host(usually a domesticated dog)or ingestion of contaminated water or vegetableswOnce in the human liver,cysts grow to 1 cm during the first 6 months and 23 cm annually thereafter,depending on host tissue resistance35Life cycle(dog-sheep cycle)of E granulosuswDiagram shows the most prevalent life cycle of E granulosus,in which a dog and sheep serve as the definitive and intermediate hosts,respectively 36Three layersOuter pericyst,composed of modified host cells that form a dense and fibrous protective zoneMiddle laminated membrane,is acellular and allows the passage of nutrientsInner germinal layer,the scolices(the larval stage of the parasite)and the laminated membrane are producedMiddle laminated membrane and the germinal layer form the true wall of the cyst37Hydatid Cyst StructurewDaughter vesicles(brood capsules)are small spheres that contain the protoscolices and are formed from rests of the germinal layerwBefore becoming daughter cysts,these daughter vesicles are attached by a pedicle to the germinal layer of the mother cystwAt gross examination,the vesicles resemble a bunch of grapeswDaughter cysts may grow through the wall of the mother cyst,particularly in bone disease38Multivesicular cystwPhotograph of a human kidneywbe sectioned along the midcoronal planewA large cyst with the typical bunch of grapes appearance due to daughter cystsw()ureter 39Hydatid CystwCyst fluid is clear or pale yellow,has a neutral pH,and contains sodium chloride,proteins,glucose,ions,lipids,and polysaccharideswThe fluid is antigenic and may also contain scolices and hookletswWhen vesicles rupture within the cyst,scolices pass into the cyst fluid and form a white sediment known as hydatid sand 40Hydatid Disease in humanswOnce the parasite passes through the intestinal wall to reach the portal venous system or lymphatic system,the liver acts as the first line of defense and is therefore the most frequently involved organwHydatid disease involves the liver in 75%of cases,the lung in 15%,and other organs in 10%wThe lungs are the second most frequent site of hematogenous spread in adults and probably the most common site in children41Hematogenous DisseminationwCompressible organs such as the lung or brain facilitate the growth of the cystwMost cysts are acquired in childhood,remain asymptomatic for a long period of time,and are later diagnosed incidentally at chest radiographywCysts are multiple in 30%of cases,bilateral in 20%,and located in the lower lobes in 60%wCalcification in pulmonary cysts is very rare,although it may be seen in pericardial,pleural,and mediastinal cysts 42Pulmonary hydatid cystwM3wA well-circumscribed,masslike lesion with a polycyclic configuration in the left lower lobewThere is obliteration of the left costophrenic angle 43Pulmonary hydatid cystwSudden coughing attacks,hemoptysis,and chest pain are the most common symptomswAfter cyst rupture,expectoration of cyst fluid,membranes,and scolices may occurwRupture into the pleural cavity may occurwBacterial infection of the cyst is the most serious complication commonly seen after rupture 44Pulmonary hydatid cystwWell-defined masses,usually round,peripheral cysts may be oval or polycyclicwAir collection appears as a thin,radiolucent crescent in the upper part of the cyst and is known as the crescent sign or meniscus signwAs air continues to enter this space,the two layers separate completely and the cyst shrinks and ruptures,allowing the passage of air into the endocyst45Pulmonary hydatid cystwAn air-fluid level inside the endocyst and air between the pericyst and the endocyst with an onion peel appearance constitute the Cumbo signwAfter partial expectoration of the cyst fluid and scolices,the cyst empties and the collapsed membranes can be seen inside the cyst(serpent sign).When it has completely collapsed,the crumpled endocyst floats freely in the cyst fluid(water lily sign)wIf the fluid is entirely evacuated by expectoration,the remaining solid components will fall to the most dependent part of the cavity(mass within a cavity)46Open cystswA child with fever,cough,and expectoration wLeft lateral decubitus positionwA large cavitary lesion with an air-fluid level in the inferior left lungwAir is seen between the pericyst and the laminated membrane of the cyst wPulmonary infiltrate adjacent to the cystwPleural effusion due to superimposed bacterial infection47A child with previous episodes of cough and expectorationwLateral chest radiographwAn intracystic serpentine structure representing collapsed membranes48Open lung cystwM20,experienced a sudden coughing attack followed by expectoration of clear fluidwleft lateral decubitus positionwA cavitary lesion in the right upper lobe with solid contents that have settled in the most dependent part of the cavitywThe solid component represents the detached,crumpled endocyst 49Pulmonary hydatid disease,E granulosuswM43,A large cyst in the right lower lungwF32,A hypoattenuating crescent sign(meniscus sign)50Alveolar Echinococcosis and Polycystic EchinococcosiswCaused by E multilocularis and E vogeliwHave a similar clinicopathologic course and are acquired through the same mechanism,similar to that described for E granulosuswThe parasite grows from the metacestode(larva)in the liver and,resembling a neoplasmwLung involvement is less frequent than in unilocular cystic echinococcosis,results from metastatic dissemination or direct extension 51Alveolar and Polycystic EchinococcosiswInfection becomes symptomatic after 515 years secondary to local compression or dysfunction of the affected organ,usually the liverwNonspecific symptoms such as fatigue,weight loss,cough,and hemoptysis can be presentwA mass of fibrous tissue containing several scattered cavities of widely varying diameters with necrotic areas is frequently seen,as calcifications52Alveolar and Polycystic EchinococcosiswDiagnosis can be made with immunohistochemical and histologic analysis,serologic testswCT and MRI are the imaging modalities of choice for better defining the location and extent of pulmonary diseasewCalcifications may develop as the disease progresses(33%100%of cases)wSecondary lung compromise by direct extension may mimic a lung cancer53Polycystic echinococcosiswM25wChest radiograph wMultiple peripheral round areas of soft-tissue opacity54Polycystic echinococcosiswCT clearly defined capsule with a relatively hypoattenuating center,a finding that reflects the cystic nature of the lesionswE vogeli was identified at pathologic analysis as the etiologic agent55Polycystic echinococcosis of the chest wall from E vogeliwM13wCystic thickening of the pleura with chest wall involvement.56Schistosomiasis（血吸虫病）wS hematobium,S mansoni,and S japonicumwS mansoni is endemic to Africa,Saudi Arabia,Brazil,Madagascar,Venezuela,and Puerto RicowS japonicum is more frequently seen in east AsiawInfection is acquired through exposure of the skin to water contaminated with cercariae excreted by snails,which have the ability to penetrate the skin or the intestinal wall,then migrate to the lung and afterward to the liver,where the parasite continues its life cyclewThe second most common cause of mortality among parasitic infections after malaria,affecting 150200 million people and causing 500,000 deaths each year 57life cycle of Schistosoma species58Geographic distribution of Schistosoma species59Pulmonary schistosomiasiswEarly pulmonary schistosomiasis(38 weeks after parasitic penetration)results from immunologic reaction,in which eosinophils are sequestered in the lungswSymptoms：shortness of breath,wheezing,and dry cough60Early pulmonary schistosomiasiswThe diagnosis is suggested in patients who live in or have traveled to endemic areas and who present with eosinophiliawMay have both clinical and radiologic manifestations after the onset of symptomswAssociated urticaria,arthralgia,hepatosplenomegaly,hepatitis,eosinophilia 61Early pulmonary schistosomiasiswSmall nodular lesions with ill-defined borders or,less commonly,a reticulonodular pattern or bilateral diffuse areas of ground-glass increased opacity or hyperattenuation at radiography and CTwAsymptomatic cases that manifest with abnormal radiologic findings may also be seenwSensitivity is low for the examination of stool and urine for eggs in this stage of infection62Early pulmonary schistosomiasiswM28whad traveled to MaliwInitially,had fever and urticaria,after which experienced dry coug