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Case52ina46-year-oldmanwithafeverandproductivecough发热咳嗽Thenoduledistributionis结节分布方式:(a)perilymphatic淋巴管周围分布(b)random随机分布(c)centrilobular小叶中心性分布centrilobularCorrect.Thispatientshowsacentrilobularpattern小叶中心分布.Subpleuralnodulesarenotvisible胸膜下结节未见,andsomenodulesareclearlyrelatedtosmallairwaysorcontainacentrallucency中心透亮,representingacentrilobularbronchiole小叶中心细支气管.小叶中心透亮区Largerareasofopacity大不透亮区,havingapatchydistributionarevisibleinthelungbases在肺底部不均分布.Theserepresentlobularareasofconsolidation肺小叶,somecontainingacentralairbronchogram(i.e.thecentrilobularbronchiole).Diagnosis:Bacterial细菌的bronchopneumonia支气管肺炎withperibronchial支气管周围andlobularareasofconsolidation肺小叶.肺小叶Case53ina57-year-oldwomanwithprogressiveshortnessofbreathoverseveralweeks憋气几周以上,anonproductive非生产性咳嗽cough,andlow-gradefever低热Multipleill-definedlungnodulesofground-glassopacityarevisible多发边界不清磨玻璃密度结节.Thenoduledistributionis分布方式:(a)perilymphatic淋巴管周围分布(b)random随机分布(c)centrilobular小叶中心性分布centrilobularCorrect.Thispatientshowsacentrilobularpattern小叶中心分布.Subpleuralnodulesarenotseen胸膜下结节未见,andthemostperipheralnodules外围结节visiblerange可见区from5to10mmfromthepleuralsurfaceandmajorfissure.Overall,thenodulesappeardiffuseindistributionandevenlyspaced弥漫均匀分布.Abnormal异常bronchiandfrankconsolidationarenotseen.外围结节Additionalhistoryrevealedthatthepatientlivedwithseveralbirds患者有养鸟史.Inpatientswithahistoryofexposure,thisappearanceishighlysuggestiveofhypersensitivitypneumonitis高度暗示过敏性肺炎.Diagnosis:Hypersensitivitypneumonitis,subacutestage亚急性期,withcentrilobularnodules.过敏性肺炎1.斑片状边缘模糊影：肺泡腔内空气被浆液渗出物取代—肺泡炎。2.弥漫分布粟粒影：鸽子肺。3.线、网状、粟粒状影：为间质性渗出性改变。Case54,ina78-year-oldmanwithprogressiveshortnessofbreath进行性喘憋Multipleill-definedlungnodulesarevisible许多边界不清的肺结节.Thenoduledistributionis分布方式:(a)perilymphatic淋巴管周围分布(b)random随机分布(c)centrilobular小叶中心分布centrilobularCorrect.Thispatientshowsacentrilobularpattern小叶中心分布.Themostperipheralnodulesarecentered5-10mmfromthepleuralsurface外围结节胸膜下5-10MM.Althoughthelargestnodulesintheposteriorlungtouchthepleuralsurface尽管后部接胸膜面,nonodulesappeartoariseatthepleuralsurface.Overall,thenodulesappeardiffuseindistributionandevenlyspaced弥漫分布均匀间隔.Noabnormalbronchiarevisible.Thisappearanceisnonspecific该表现无特殊性.Bronchoscopyyieldedbronchioloalveolarcarcinoma支气管镜检为肺泡癌.Diagnosis:Bronchioloalveolarcarcinoma,diffusenodularform,withcentrilobularnodulesBronchioloalveolarcarcinoma细支气管肺泡癌(BAC)canresultin:1)asolitarynoduleormass单发结节或肿块(40%ofpatients);2)focalordiffuseconsolidation(30%);or3)diffuseill-definednodules弥漫(30%).Whenmultiplenodulesarepresent,theymaybecentrilobular,asinthiscase,duetoendobronchialspread气道播散,ormaymimic模仿theappearanceofhematogenousmetastasis血行转移.Case55,ina35-year-oldmanwithafeverandproductive生产性的coughMultipleill-definedlungnodules多发边界不清的肺结节,ofvaryingsize大小不一,arevisible.Thenoduledistributionis分布方式:(a)perilymphatic淋巴管周围分布(b)random随机分布(c)centrilobular小叶中心分布centrilobularCorrect.Thispatientshowsacentrilobularpattern(Figure1).Subpleuralnodulesarenotvisible胸膜下结节未见.Someofthesubpleuralopacitieshaveanirregularbranchingappearance胸膜下可见树芽征.Thisappearance,mimickingabranchingtree,istermedtree-in-bud.“tree-in-bud.”树芽征Whatisthemostlikelydiagnosis最可能的诊断?(a)Infection感染(b)Bronchioloalveolarcarcinoma细支气管肺泡癌(c)Hypersensitivitypneumonitis过敏性肺炎InfectionCorrect.Bronchoscopyrevealed镜检显示infection感染withHemophilusinfluenza流感.Diagnosis:Bacterial细菌的bronchopneumonia支气管肺炎withacentrilobularpattern小叶中心分布and“tree-in-bud.”树芽征（为细支气管内粘液栓）Case56ina53-year-oldwomanwitharightlungtransplantation肺移植foremphysema肺气肿andproductive生产性的cough咳嗽Theleftlungshowstypicalfindingsofpanlobularemphysema左肺为典型的全小叶型肺气肿.Multiplesmall,well-defined明确的centrilobularnodules小叶中心结节(Figure1)arevisibleinthetransplantedrightlung移植的右肺.Subpleuralnodulesarenotvisible胸膜下结节未见.Tree-in-budisvisibleintherightlowerlobe树芽征右下叶可见.左侧全小叶型肺气肿树芽征Diagnosis:Bacterial细菌的bronchopneumonia支气管肺炎withtree-in-bud.DISCUSSION：Identifyingthepresenceof“tree-in-bud”isveryimportantinthedifferentialdiagnosisofcentrilobularopacities识别树芽征在小叶中心鉴别诊断很重要,asitstronglysuggeststhepresenceofinfection暗示感染的存在.Tree-in-budismostcommonwithbacterial细菌andmycobacterial分支杆菌infections感染,butcanalsobeseenwithfungal真菌orviral滤过性毒菌infections.Case57ina58-year-oldmanwithfeverandproductive生产性的coughAcentrilobularpatternofnodulesisvisible,associatedwithbronchialwallthickening支气管壁厚,andmildbronchiectasis轻度支扩.Istree-in-budpresent树芽征存在?(a)Yes(b)NoYesCorrect.Treeinbudisvisibleinmanylocations在许多的位置.Diagnosis:Bronchiectasis支扩,bacterialbronchitisandbronchiolitis细菌性支气管炎、细支气管炎,withtree-in-bud.DISCUSSION：Tree-in-budisoftenvisibleinpatientswithchronicairwaysdisease树芽征在慢性气道阻塞常见,particularly独特的bronchiectasis支扩,wheninfectionispresent感染存在.Inthispatient,treeinbudisassociatedwithbronchiectasis与支扩是关联的.Case58ina28-year-oldwomanwithcoughandnightsweats盗汗Severalnodularopacitiesarevisibleintherightupperlobe上叶多个结节,withfocal焦点cavitation空洞andseveralareasof“tree-in-bud.”Theappearanceoftree-in-budstronglysuggestsendobronchialinfection末细支气管.Thisappearanceinassociationwithafocalapicalopacitysuggests上叶支持TB.树芽征空洞Diagnosis:Acti