1、1,各位专家、老师们好！,2,肺真菌病影像表现,天津医科大学总医院放射科叶 宁,3,真菌感染 多见于免疫功能低下者或接受HSCT者粒细胞减少是最主要的危险因素曲霉菌是为最常见的病原菌，其它真菌： 念珠菌、隐球菌、毛霉菌等等以肺部感染多见,4,肺曲菌病,侵袭性：急性出血性坏死性肺炎 粒细胞减少、广谱抗菌素应用中、激素、免疫抑制者变应性支气管肺曲菌病 渗出性细支气管炎、粘液嵌塞、支气管中心性肉芽肿 支气管近端的囊性扩张、肺实变 嗜酸性粒细胞肺炎、哮喘曲菌球：发生在已存在的肺内腔内 结核、支扩、肺囊肿、结节病、组织胞浆菌病 AS 、肺癌、胸膜腔内、咯血,5,观察 伏立康唑 治疗血液病患者并发侵袭性真
2、菌感染(IFI)的临床疗效及安全性93例血液病患者并发IFI感染部位以 肺 部为主(87例,占93.5%)出现影像学改变者71例(76.3%) 磨玻璃影最多(44例), 多发斑片状阴影(13例) 不规则多发结节高密度影5例, 有晕征者4例, 有空洞形成者2例,天津医科大学总医院血液肿瘤科,6,观察卡泊芬净治疗血液病患者侵袭性真菌感染(IFI)的疗效和安全性80例血液病并发IFI患者,感染部位以肺部为主，62例 (77.5%)其他部位18例,包括胃肠道、口腔、鼻面部等胸部影像学改变 新月征1例,余为磨玻璃密度影或多发斑片状影,天津医科大学总医院血液肿瘤科,7,肺部真菌感染影像表现,实变阴影 沿支
3、气管分布的小片状影磨玻璃密度影单发或多发结节、肿块可有浅分叶 多位于肺中外带,8,consolidation in lobar pneumonia,9,10,The ground-glass opacity is defined as a hazy increase in attenuation without obscuration of the underlying vesselsThis sign is seen in avariety of hemorrhagic,TB ，inflammatory, and neoplastic nodules,11,Centrilobular nod
4、ules Nodules are positioned 5 to 10 mm from costal and visceral pleural surfaces and interlobular septaRandom nodules They are found in relation to the visceral pleura, interlobular septa, and center of the lobule roughly equally,12,小叶中心结节与胸膜面、叶间裂、小叶间隔 有数毫米的距离围绕或遮盖了小动脉，可见细支气管影,13,15-year-old boy wit
5、h Aspergillus infection 133 days after bone marrow trans-plantation. large nodule with irregular margins in lingula and several small nodules. Some small nodules are centrilobular (curved arrows), and some are in a random distribution (straight arrow).,14,围绕结节或肿块周围的磨玻璃密度为侵袭性曲霉菌病灶 周围出血征象不具特异性，可见于其他类型
6、的结节的出血，或肿瘤的肺浸润 （如腺癌）,15,边界模糊的低密度影小叶中心性结节亚急性过敏性肺泡炎,16,multiple bilateral nodules of variable sizes, some of them with surrounding ground-glass attenuation,17,aspergillosis,18,Primary tuberculosis in a 45-year-old woman with neutropenia following bone marrow transplantationA: consolidation and adjacen
7、t ground-glass opacity in the left upper lobe B: Photomicrograph of wedge biopsy specimen from the left upper lobe demonstrates lung microabscesses (A) surrounded by a layer (arrows) of epithelioid histiocytes, the two components of the granulomatous inflammatory reaction of tuberculosis. Also note
8、fibrinous exudates (arrowheads) in alveolar spaces surrounding necrotic granulomas,19,肺部真菌感染影像表现,曲菌球 游离、与洞壁间有新月形间隙空洞 厚壁洞外缘模糊，“晕征” 薄壁洞外缘较清楚支扩 多在两肺门附近其它 肺门、纵隔淋巴结肿大 胸腔积液，骨破坏,20,空洞内曲菌球形成 洞内肿块可移动,随体位改变而移动近地侧,22,Fungus ball (aspergilloma). a thick-walled cyst (arrow) with a round intracavitary mass. The c
9、avity was pre-existing, representing a pneumatocele following treatment of staphylococcal pneumonia.,23,空气新月征 air cresent sign感染后2、3周出现标志中性粒细胞恢复、预后好,24,一种新月形气体蓄积， 将空洞壁与洞内肿块分开原有空洞内曲霉菌的寄生(aspergillus colonization)或 血管侵袭性曲霉菌病时 梗死肺回缩的特征表现其它：结核、韦格肉芽肿、空洞内出血、肺癌、足分支菌病,25,26,Angioinvasive pulmonary aspergill
10、osis6 days after (A) with recovery from neutropenia demonstrates air crescent (arrows) within area of airspace consolidationa 30-year-old man with acute myelogenous leukemia,27,当外周血白细胞1000/mm3 时发生，侵袭性肺曲霉病是免疫功能受损者的常见感染类型平片：发现早期病变困难 单/多发局灶阴影、实变，外周分布CT：血管侵袭型、（侵袭性曲霉菌病通常指血管侵袭型）气道侵袭型,曲霉菌病（aspergillosis）,2
11、8,29,30,Bilateral upper lobe aspergillomas,aspergillomas with surrounding air crescent a 65-year-old man who had previously had TB,31,Lower lobe aspergillomaair-crescent signa 55-year-old man with idiopathic pulmonary fibrosis,32,33,halo sign，晕征，早期征象病理为出血性梗死该征也见于： 念珠菌、巨细胞病毒感染、Wegener肉芽肿、 转移性血管肉瘤等,34
12、,The halo sign consists of a nodule or focal area of consolidation surrounded by a halo of ground-glass attenuation This sign is seen in a variety of hemorrhagic, inflammatory, and neoplastic nodules,35,28-year-old woman with invasive aspergillosis 104 days after bone marrow transplantationlarge nod
13、ule surrounded by ground-glass attenuation CT： halo sign,36,Invasive pulmonary aspergillosis in a 39-year-old manwith acute myelogenous leukaemia and neutropenia. multiple nodules surrounded by a halo of ground glass opacity in both upper lobes.,37,38,Chronic necrotizing aspergillosis (semi-invasive
14、 aspergillosis)53-year-old man with diabetes and emphysema,39,反晕征 reversed halo sign,局限性类圆形磨玻璃密度灶，周围有完整或不完整实变环, 少见，最初报道认为是 COP 的特异征象，随后也被描述在 副球孢子菌病(paracoccidioidomycosis)与晕征相似，随着在其他疾病中被识别出，将失去其特异性,40,肺孢子菌感染,41,免疫受损者常见并发症， 尤见于白血病治疗后迁延粒细胞减少者临床表现为发热、咳嗽、进行性呼吸困难， 病死率达60，存活依赖于早期诊断和治疗病理表现分两型：血管侵袭型：菌丝栓塞中至大
15、管径动脉， 致感染性梗死气道侵袭型：相对少见，约占30， 侵犯气道，深达基底膜,侵袭性曲霉菌病（Invasive aspergillosis）,42,HRCT： 结节或肿块周围磨玻密度（晕征） 亚段或段性实变 空气新月征 小血管影增粗鉴别诊断： 巨细胞病毒、单纯疱疹肺炎、 Wegener肉芽肿、转移性血管肉瘤、 Kaposi肉瘤,血管侵袭型,43,较少见平片：支气管肺炎 CT： 小叶中心性结节 支气管周围实变均不具特征性,气道侵袭型,44,HRCT支气管周围实变（曲霉菌性 支气管肺炎）小叶中心性结节（曲霉菌性 细支气管炎）,气道侵袭型,45,Invasive bronchiolar asper
16、gillosis in a patient who underwent bone marrow transplantation(a) peripheral branching structures (arrow) associated with focal areas of consolidation(b) Corresponding photograph of the autopsy specimenshows multiple yellowish acinar nodules (arrows). (c) Photomicrograph of a lung biopsy specimen s
17、hows complete destruction of the bronchiolar wall (arrowheads) by Aspergillus organisms (arrow).,47,48,Allergic bronchopulmonary aspergillosiscentral bronchiectasis (arrows) , small nodules (arrowheads)a 33-year-old asthmatic man with chronic cough,49,中央性支气管扩张， 典型的呈广泛分布粘液栓线样和分支状结节（树芽）周围部实变或弥漫性磨玻璃影马赛
18、克灌注、呼气时空气潴留,变应性支气管肺曲菌病,50,Aspergillosis in a 52岁 with a chronic cough a 23-mm poorly defined nodular ground-glass opacity several peripheral solid portions (arrows) a subtle groundglass opacity (arrowhead),51,52,小气道疾病的直接征象 小叶中心结节曲霉菌沿着小气道播散,53,Inflammation of the bronchiolar wall and intraluminal exu
19、date results in linear opacities The combination of centrilobular branching linear and nodular opacities is known as the tree-in-bud pattern,54,Progression of bronchopneumonia,55,56,树芽征 小叶中心细支气管扩大，管腔被黏液液体或脓液嵌塞，常伴细支气管周围炎 见于 过敏性支气管肺曲菌病 小气道疾病、细支气管扩张、结核 偶见于肺泡癌,57,58,bronchiolitis tree-in-bud pattern,59,
20、BronchiolitisExtension of the inflammatory process into the parenchyma results in 4 to 10 mm diameter centrilobular nodular opacities,60,树芽征 哮喘、细支气管炎小结节伴分枝，提示细支气管扩张，有脓液或粘液,61,支气管囊肿（ bronchocele ）,管状或Y形、V形分支状结构类似戴着手套的手指黏液一般呈软组织密度， 但依其成分可有变化，如 过敏性支气管肺曲霉菌病 时呈高密度先天性支气管闭锁，因通气和灌注减少，周围肺密度可减低,62,Allergic br
21、onchopulmonary aspergillosis,2-1,63,Allergic bronchopulmonary aspergillosis,multifocal bilateral consolidation and poorly defined nodular opacitiesparenchymal consolidation, bronchiectasis, mucus plugging (arrows), bilateral small centrilobular nodule,tree-in-bud patternspecimen: mucus plug containi
22、ng mucin and numerous eosinophilsa 41-year-old asthmatic man with chronic cough, fever, and dyspnea,2-2,64,支气管扩张中的曲菌感染,65,支气管囊肿（ bronchocele ）,管状或Y形、V形分支状结构类似戴着手套的手指黏液一般呈软组织密度， 但依其成分可有变化，如 变应性支气管肺曲霉菌病 时呈高密度先天性支气管闭锁， 因通气和灌注减少，周围肺密度可减低,66,Osteomyelitis owing to aspergillus infection in a 15-year-old b
23、oy with acute myelogenous leukemia. a large low-attenuation extrapleural abscess (A) extending into the chest wall ( arrows ）,67,例1,56岁，男性，急性髓系白血病，右上叶后段节段性实变 GGO；光镜（HE100)显示慢性出血性梗死（Radiology,1998; 208:777-782）,例2,58岁女性，急性髓系白血病 Halo sign; 约4周后，Air-crescent sign，标志进入感染恢复期，与白细胞计数恢复相一致 （Radiology 2001;
24、218:230232）,例3,33岁，女性骨髓移植术后发生侵袭性肺曲霉菌病a. 左上叶结节并晕征; b. 四周后复查出现空气新月征,a,b,例4,男，49岁，白血病治疗中出现发热、咯血。痰培养：烟曲霉菌,白血病 骨髓移植术后， 细支气管侵袭性曲霉菌病：实变、小叶中心性结节、树丫征 (RadioGraphics 2001; 21:825837),半侵袭性肺曲霉菌病（Semi-IPA）,慢性坏死性肺曲霉菌病， 易发生于轻度免疫抑制或存在慢性疾病者危险因素 糖尿病、酗酒、尘肺、胶原性血管病、COPD、 放疗史、营养不良、心肌梗死及小剂量激素； 结构性肺病变（structural lung disea
25、se） 增加感染的危险性病程数月，与患者免疫抑制程度有关； 空洞形成一般在感染后5-7月 出现咳嗽、咳痰、发热及白细胞增高； 可有反复咯血,男性、68岁，慢性支气管炎，反复少量咯血双上肺多发实变，空洞尸检标本照片见边缘不规则空洞性病变，呈褐色，由坏死物质及曲霉菌感染所致（RadioGraphics 2001; 21:825837）,75,指免疫功能正常患者 在没有任何肺原发病症和结构异常的情况下 形成的肺内慢性或亚急性真菌感染性 随健康体检的普及而增多多表现为孤立性结节，少数 多发结节 极易误诊为肺癌、 肺结核,原发肺真菌性肉芽肿,76,肺部真菌感染主要鉴别,支气管炎-肺炎 血管炎性肉芽肿 肺结核 肺部转移瘤、原发性肿瘤,77,pneumatocele,肺气囊 肺内薄壁的含气囊腔 常并发于急性肺炎， 几乎都是一过性的HRCT上 肺气囊和肺囊肿，肺大泡相似根据HRCT表现难以鉴别 若和急性肺炎并发提示为肺气囊,谢谢,
