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成年人巨细胞病毒性肺炎——影像学及病理学表现胸组读片2010-03-02刘晶华Case•Name：MePing•Sex：Female•Age：46•PNo.：P10044471Case•ExamineDate2009-08-17•Thin-section(1-mmcollimation)computedtomographic(CT)scanshowsBilateraldiffuseground-glassattenuationwiththickenedinterlobularsepta,andAlobulardistribution,segmentalconsolidationwiththe“inflatedbronchia”sign.Thereareseverallymphnodesinthemediastina.Nopleuraleffusion.Theheart,liver,spleenandotherscannedareasarenormal.Case•Diagnosis:Bilateraldiffuselesionoflung,consideredasinfection.•DifferentiateDiagnosis：(1)Viralpneumonia(CMV,EBV)(2)PCP(3)Chlamydiapneumonia成年人病毒性肺炎•流感病毒、麻疹病毒、汉坦病毒、腺病毒、单纯疱疹病毒、水痘-带状疱疹病毒、巨细胞病毒以及EB病毒等多种病毒能够引起成年人下呼吸道感染。•成年人病毒性肺炎可分为两种类型：发生于健康宿主的非典型性肺炎；发生于免疫缺陷宿主的病毒性肺炎。免疫正常及免疫缺陷患者常见的病毒感染•免疫正常患者流感病毒汉坦病毒EB病毒腺病毒•免疫缺陷患者单纯疱疹病毒水痘-带状疱疹病毒巨细胞病毒麻疹病毒腺病毒成年人病毒性肺炎•影像学表现多种多样且相互重叠。•患者年龄、免疫状况、社区性爆发、起病状况、严重程度及持续时间、有无发疹等临床信息对于诊断具有重要帮助。•实验室检查常见的病理学表现•病毒能够引起：气管支气管炎，细支气管炎，肺炎。•上皮细胞及相邻间质组织学改变最为显著。常见的病理学表现•气管支气管炎：气道壁充血，管腔内单核细胞浸润，上皮细胞变性、脱落。•细支气管炎：儿童常见，上皮细胞坏死，管腔内嗜中性粒细胞渗出，气道壁内单核细胞为主的炎性细胞浸润。常见的病理学表现•实质受累（肺炎）：终末及呼吸性细支气管相邻肺组织首先受累，可进展至整个肺叶。•老年及免疫缺陷患者可发生快速进展的肺炎。•组织学上，双肺弥漫性肺泡破坏（间质淋巴细胞浸润，气腔内出血，水肿及纤维蛋白渗出，2型肺泡上皮增生，透明膜形成）Photomicrograph(originalmagnification,×100;hematoxylin-eosinstain)ofalungbiopsyspecimenfroma36-year-oldmanwithpneumoniaduetoherpessimplexvirustype1showsafibrousexudate(largearrows)alongthealveolarwalls.Notetheinterstitialthickeningduetofibroblasticproliferation(smallarrows).常见的影像学表现•气管支气管炎：急性期很少出现异常影像学改变，但多年后粘膜破坏可表现为支气管扩张。•细支气管炎：气道阻塞常为不完全性，影像学上表现为过度通气及边界不清的结节灶。常见的影像学表现病毒性肺炎：•边界不清的结节（4-10mm的气腔内结节）。•细支气管周围斑片状磨玻璃密度及气腔实变。•常伴有过度通气。•快速进展型肺炎：实变区快速融合，引起弥漫性肺泡损害（均一性或斑片状单侧或双侧气腔内实变，以及磨玻璃密度灶或界限不清的小叶核心结节）。Photomicrograph(originalmagnification,×100;hematoxylin-eosinstain)ofalungbiopsyspecimenfroma36-year-oldmanwithpneumoniaduetoherpessimplexvirustype1showsafibrousexudate(largearrows)alongthealveolarwalls.Notetheinterstitialthickeningduetofibroblasticproliferation(smallarrows).Photomicrograph(originalmagnification,×100;hematoxylin-eosinstain)ofalungbiopsyspecimenfroma36-year-oldmanwithpneumoniaduetoherpessimplexvirustype1showsafibrousexudate(largearrows)alongthealveolarwalls.Notetheinterstitialthickeningduetofibroblasticproliferation(smallarrows).Photomicrograph(originalmagnification,×100;hematoxylin-eosinstain)ofalungbiopsyspecimenfroma36-year-oldmanwithpneumoniaduetoherpessimplexvirustype1showsafibrousexudate(largearrows)alongthealveolarwalls.Notetheinterstitialthickeningduetofibroblasticproliferation(smallarrows).Pneumoniaduetoinfluenzavirus(typeC)ina46-year-oldmanwithdyspnea.Initialchestradiographshowsdiffusereticulonodularareasofincreasedopacityinbothlungs.Pneumoniaduetoinfluenzavirus(typeC)ina46-year-oldmanwithdyspnea.Follow-upchestradiographobtained15dayslatershowsprogressionoftheextentofdiseasewithdiffuseconsolidationthroughoutbothlungs.Pneumoniaduetoinfluenzavirus(typeC)ina46-year-oldmanwithdyspnea.(a)Initialchestradiographshowsdiffusereticulonodularareasofincreasedopacityinbothlungs.(b)Follow-upchestradiographobtained15daysafterashowsprogressionoftheextentofdiseasewithdiffuseconsolidationthroughoutbothlungs.(c)Thin-section(1-mmcollimation)computedtomographic(CT)scanobtained16daysafteraattheleveloftheaorticarchshowsdiffuseground-glassattenuationwithsomeirregularlinearareasofincreasedattenuationinbothlungs.(CasecourtesyofDrJungHwaHwang,SoonchunhyangUniversitySeoulHospital,Korea.)Pneumoniaduetoinfluenzavirus(typeC)ina46-year-oldmanwithdyspnea.(a)Initialchestradiographshowsdiffusereticulonodularareasofincreasedopacityinbothlungs.(b)Follow-upchestradiographobtained15daysafterashowsprogressionoftheextentofdiseasewithdiffuseconsolidationthroughoutbothlungs.(c)Thin-section(1-mmcollimation)computedtomographic(CT)scanobtained16daysafteraattheleveloftheaorticarchshowsdiffuseground-glassattenuationwithsomeirregularlinearareasofincreasedattenuationinbothlungs.(CasecourtesyofDrJungHwaHwang,SoonchunhyangUniversitySeoulHospital,Korea.)Pneumoniaduetoinfluenzavirus(typeC)ina46-year-oldmanwithdyspnea.(a)Initialchestradiographshowsdiffusereticulonodularareasofincreasedopacityinbothlungs.(b)Follow-upchestradiographobtained15daysafterashowsprogressionoftheextentofdiseasewithdiffuseconsolidationthroughoutbothlungs.(c)Thin-section(1-mmcollimation)computedtomographic(CT)scanobtained16daysafteraattheleveloftheaorticarchshowsdiffuseground-glassattenuationwithsomeirregularlinearareasofincreasedattenuationinbothlungs.(CasecourtesyofDrJungHwaHwang,SoonchunhyangUniversitySeoulHospital,Korea.)Pneumoniaduetoinfluenzavirus(typeC)ina46-year-oldmanwithdyspnea.Thin-section(1-mmcollimation)computedtomographic(CT)scanobtained1dayafterthesecondchestradiographattheleveloftheaorticarchshowsdiffuseground-glassattenuationwithsomeirregularlinearareasofincreasedattenuationinbothlungs.成年人巨细胞病毒性肺炎巨细胞病毒：•DNA病毒•疱疹病毒的一种•免疫缺陷患者严重症状的肺炎。成年人巨细胞病毒性肺炎致病机制组织病理学特点同种异体移植受体T细胞介导抗原-抗体反应。即使抑制病毒复制时也可发生严重的坏死性肺炎。坏死性炎症显著感染巨细胞病毒的细胞相对较少AIDS患者免疫缺陷更严重巨细胞病毒的细胞致病作用引起肺损害。弥漫肺泡损害常较不患有AIDS的患者常见。大量巨细胞病毒包涵体。成年人巨细胞病毒性肺炎常见CT表现：•磨玻璃密度影•实变•结节灶•边界不清的小叶核心结节•支气管扩张•小叶间隔增厚成年人巨细胞病毒性肺炎•Kangetal报告了10例患巨