AIDS相关胸部疾病的影像诊断

艾滋病相关胸部疾病的影像诊断ImagingofthethoraxinAIDS上海复旦大学附属公共卫生临床中心Shanghaiaffiliatedpublichealthcentre施裕新张志勇王桂龙shiyuxinzhangzhiyongwangguilong背景Background发病率：大多数，新AIDS50%Morbidity:50%ofnewAIDSpresentation意义:致病率和死亡率的重要原因Meaning:importantcauseofmorbidityandmortality新特点:1.治疗抗病毒和预防性抗生素Newfeature:Tharapycombinationanti-retroviraltherapyandtheuseofprophylacticantibiotics2.病原体传统(PJP),少见（巨毒及鸟分菌)Pathogentradition(PJP),lesscommon(CMVandMAC)3.人群妇女、儿童Populationcharacteristicswomenandchildren背景Background4.影像:多样,重叠Radiologicalappearances:varietyandoverlap5.影像结合临床:Imagingbeinterpretedinconjuctionwithclinicalinformation获得背景，并发症，CD4+细胞数，治疗缓急程度血氧分析和痰菌培养NatureofHIVacquisition,previousinfectionsornon-infectionscomplications,CD4+cellcount,currentdrugtherapy,andacutenessofonsetandseverityoftheillness,pulseoximetryandsputummicroscopyCD4细胞计数与肺部并发症CD4细胞计数（×106个/L）肺部病原体(种类、表现)200细菌性肺炎结核（继发性）肺癌50－200细菌性肺炎结核（原发性）肺癌肺孢子虫肺炎Kaposi肉瘤淋巴瘤真菌感染弓形体病杆菌性血管瘤病50细菌性肺炎结核（非典型）肺癌肺孢子虫肺炎Kaposi肉瘤淋巴瘤真菌感染弓形体病杆菌性血管瘤病鸟型分枝杆菌巨细胞病毒RelationshipbetweendecliningCD4+countandonsetofHIV-associatedpathologiesCD4+cellcount(×10-6cellsI-1)Pulmonarypathology＞200BacterialpneumoniaTB(re-infection)Lungcarcinoma50–200BacterialpneumoniaTB(primary)LungcarcinomaPCPKSLymphomaFungalinfectionsToxoplasmosisBacillaryangiomatosis＜50BacterialpneumoniaTB(atypicalappearances)LungcarcinomaPCPKSLymphomaFungalinfectionsToxoplasmosisBacillaryangiomatosisMACCMVTB,Tuberculosis;PCP,Pneumocystiscariniipneumonia;KSKaposi’ssarcoma;MAC,Mycobacteriumaviumcomplex;CMV,cytomegalovirus.影像价值TheroleofCTl确定病变Confirmingsuspectedchestdiseasel鉴别诊断Differentialdiagnosisl活检或胸腔引流Advisingonandperformingthoracicinterventionssuchasbiopsyorchestdrainagel疗效检测及随访MonitoringtheresponsetotherapyfollowingdiagnosisCTCT普通胸片CTissuperiortoplainchestradiographyCT确诊率不高,约50%AccuracyofCTinthediagnosisofthoraciccomplicationsofAIDSlow,about50%确定病变，胸片-/Confirmingsuspectedchestdisease定性诊断Clarificationofabnormalitiesidentifiedonplainchestradiographs病变范围和形态Theextentofdiseaseandthepatternofparenchymalchange纵隔异常Evaluationofmediastinalabnormalities肿瘤分期或随访Stagingofmalignantdiseaseorre-stagingposttherapy指导活检、胸腔积液和气胸引流Biopsyplanning,drainingofloculatedpleuralfluidcollections卡氏肺孢子菌肺炎(Pneumocystisjirovecipneumonia)PJP是最常见呼吸道感染PJPwasthecommonestrespiratorytractinfectiontooccurintheAIDSpopulation预防用药提高预期寿命，细菌性肺炎Prophylacticpreventativetherapyincreaselifeexpectancy，bacterialpneumoniasuperseded进行性咳嗽和发热、低氧表现Historyofcoughandfever，hypoxicdevelopingoverseveraldays痰标本、活检Inducedsputumsample,BAL,transbronchialbiopsyX线典型：Chestradiograph:两侧肺门分布毛玻璃或网格状浸润Bilateralground-glassorreticularinfiltratesmostmarkedinaperihilardistribution卡氏肺孢子菌肺炎(Pneumocystiscariniipneumonia)CT（1）肺门周围毛玻璃样浸润，地图样分布Perihilarground-glassinfiltrat,geographicaldistribution（2）线状或网格状伴有小叶间隔增厚——吸收较慢Alinearorreticularinterstitialpatternwiththickeningoftheinterlobularseptae--slowesttoresolve卡氏肺孢子菌肺炎(Pneumocystiscariniipneumonia)不典型：局部实变、肿块、多发结节、胸腔积液、气胸、空洞、淋巴结增大和偶结节钙化Lesstypicalradiographicpatterns:focalareasofconsolidation,masslesions,multiplelungnodules,pleuralfluid,pneumothorax,cavitation,lymphnodeenlargementandoccasionalnodalcalcification与细菌性肺炎和分支杆菌鉴别Difference:bacterialpneumoniasandtypicaloratypicalmycobacterialinfection喷他咪叮预防--PJP局限于上叶或以上叶病变为主。Pentamidineprophylaxis--isolatedtoorpredominantintheupperlobes肺门周的毛玻璃样浸润，呈地图样分布，累及肺组织被正常肺实质分开吸收较慢线状或网格状小叶间隔增厚其他表现卡氏肺孢子菌肺炎(Pneumocystiscariniipneumonia)10%-38%肺囊肿或气胸10–38%ofcasespulmonarycystsorpneumatocoeles典型：充气气囊，薄壁，内外壁光整Typicallythinwalled,withsmoothinnerandoutermargins不典型：厚壁空洞，外形规则或不规则，不含有液体或其他物质Regularorirregularinshape,donotcontainfluidorothermaterial毛玻璃样+囊腔或气胸-PCPGGO+Cysts--PJP气胸和纵隔气肿是肺囊肿并发症PneumothoraxandpneumomediastinumarerecognizedasfurthercomplicationsHRCT评价非典型有价值HRCTishelpfulinatypicalcases肺囊肿或气胸10%-38%病例细菌性肺炎（Bacterialpneumonia）CD4+低高CD4+low＞high细菌性肺炎五倍，败血症100倍TheincidenceofbacterialpneumoniaapproximatelyfivetimesgreaterthaninanotherwisesimilarbutHIVnegativepopulation,thedevelopmentofpneumococcalsepticaemiais100timesgreaterthaninthegeneralpopulation临床表现和过程相同，但进展、空洞、双肺渗出和脓肿形成快TheclinicalpresentationofpneumoniaisgenerallythesameasintheHIV-negativepopulation,thetendencytorapidprogression,cavitation,parapneumoniceffusionandempyemaformationgreater细菌性肺炎（Bacterialpneumonia）病原体多数类似Theorganismsencounteredsametogeneral少数免疫抑制后期：罗卡利马体菌，马红球菌，空洞性肺炎+纵隔淋巴结肿大Opportunisticbacterialinfectionsencounteredinthelaterstagesonimmunosuppression,includingRochalimaeasp.AndRhodococcusequi,whichusuallycausesacavitatorypneumoniaoftenwithassociatedmediastinallymphadenopathy细菌性肺炎（Bacterialpneumonia）叶、段实变多Lobarorsegmentalconsolidationtheusualradiographicfindings空洞和胸膜病变Cavitationandpleuralcomplications间质渗出、小结节、树芽征、马赛克样密度---支气管炎，细支气管炎和支气管扩张Interstitialinfiltrate,multiplesmallnodules,treeinbud,mosaicattenuation--bronchitis,bronchiolitisandbronchiectasis叶或段实变细菌性感染支气管炎细支气管炎和支气管扩张治疗前后结核分支杆菌（Mycobacteriumtuberculosis）正常人群几百倍,更易发生在免疫抑制后期，类似细菌性肺炎。PPD无反应。病原学诊断尤为重要，早期诊断可提高生存期TheincidenceseveralhundredtimesgreaterintheAIDSpopulati