肺炎的X线表现和鉴别诊断

肺炎的X线表现和鉴别诊断何来昌南昌大学第一附属医院影像科▶引起肺部急性炎症的病原有细菌、病毒、真菌、原虫、寄生虫，其他病因有过敏、理化因素及放射线等。▶根据X线及病理大体形态，肺炎分为大叶性肺炎、支气管肺炎（小叶性肺炎）和间质性肺炎。▶由于各种肺炎有时有其特征性表现，因此需要了解不同原因肺炎的影像表现。肺炎的分类X线平片是诊断肺炎的主要方法，其价值为：▶可确定肺部有无病变▶可确定部位▶可确定范围▶了解病变的动态变化▶了解有无合并症▶观察治疗效果和判断预后影像学检查在肺炎诊疗中的作用价值▶肺炎主要采用X线平片检查。▶CT检查主要用于肺炎合并症的诊断以及X线诊断困难的病例。▶肺炎的病原诊断需根据临床及病原学检查▶影像检查可以提供鉴别诊断的可能范围▶数字化的影像技术具有较高的应用价值（CR、DR）可提高图像的质量、可防止交叉感染入院时入院3天后人禽流感肺炎的影像表现▶人禽流感未引起肺部病变时X线胸片所见正常。▶当引起肺炎时出现胸部异常影像：（1）病变形态：人禽流感肺炎的基本影像表现是肺内片状影像，病变形态可表现为斑片状、大片状及斑片融合影像，边缘模糊。病变密度呈肺实变或磨玻璃密度，可见“空气支气管征”。肺纹理增粗模糊。（2）病变部位：病变位于一侧或两侧肺部，上、下肺野均可有病变，多以双下肺为重。常为两肺弥漫性分布。（3）病变的范围：早期病变为局限性片状阴影，进展后呈多灶性或弥漫性分布，可累及一个或多个肺段、肺叶，也可位于一侧肺或双肺。但一般不按肺叶或肺段分布。病灶进展快，重症患者很快出现双肺弥漫性病变。（4）动态变化：胸部影像表现变化较快。重症患者肺内病变进展迅速，短期内病灶明显增多，从小片到大片，从单侧到双侧。病变密度也发生明显的变化。在恢复过程中肺内病变的吸收也较快。（5）合并症：易发生急性呼吸窘迫综合征(ARDS)合并ARDS时两肺出现广泛实变影像。辅助通气治疗的患者可发生气胸和纵隔气肿。少数可合并胸腔积液。（6）影像与临床的联系：临床表现严重时，肺部影像改变也最为广泛。当临床状况好转时，肺部影像也逐渐吸收。但也有报道肺部影像正常及病变较轻者而死亡的病例。Casereport1PatientN.L.Hg.female,18y/olivinginThaiBinhprovince.Admittedon13/01/04,diedon23/01/04.Historyofcontacttofluchicken.Butshewithanothersistertogetherlookedafterherbrotherwhohaddiedwithdiagnosisofacuteatypicpneumonia(nosamplecollected)just3daysbefore.Maincomplains:Highsuddenfever,drycough,headache,noshortnessofbreath.Physicalexamination:temp39.90C,pulse90,BP110/60,RR20/min.Oxygensaturation98%.Othersignswerenormal.Labfindingsonadmission:WBC4.8G/L,(67%neutrophils),platelets139G/L,BUN3.3mmol/l.ChestX-ray:“noremarkablechanges”.12.01.0414.01.04Case1Case119.01.0416.01.0421.Jan.o4Case123.Jan.o4Casereport2•PatientN.L.Hh.female,23y/olivinginThaiBinhprovince.•Admittedon13/01/04,diedon23/01/04.•Shewasoldersisterofthecase1.•Maincomplainsonadmission:Fever,drycoughanddiarrhea,noshortnessofbreath.•Physicalexamination:temp39.60C,pulse100,BP100/60,RR20/min,noralesinbothlungs.Oxygensaturation99%.Othersignswerenormal.•Labfindingsonadmission:WBC5.6G/L,(69%neutrophils),platelets131G/L,BUN3.4mmol/l.•ChestX-ray:noremarkablechanges.•Clinicalcourse:Onthe4thday:Becameworsewithcontinuousfever390C,coughing,shortnessofbreathRR40/min,crackleralesinbothlungs,SaO2was86%.BP100/60.WBC3.5G/l.GOT77,GPT40U/l.AdditiontreatmentwithoxygentherapybymaskandantibioticsAxepim（头孢吡肟），Tavanic,ZithromaxandSolumedrol（甲强龙），Butitseemedtobeuneffected.13.01.04Case214.01.0416.01.04Case219.01.04Case221.01.0420.01.04Casereport3•PatientP.T.B.female,30y/olivinginHaNamprovince.•Admittedon05/01/04,diedon09/01/04.•Havinghistoryofcontactwithfluchicken.Shelookedafterherdaughterwhohaddiedofacuteatypicpneumonia(H5N1confirmed)atthePediatricsHospitaljust2daysbefore.•Maincomplains:Feelingfatigue,fever,chestdiscomfortandshortnessofbreath.ShewenttoprovincialhospitalandCXRwasperformedbutnochangeonfilm.However,onthe3rdoftheillness,respiratorydistressquicklydevelopedandshewasreferedtoNICRTM.•Onadmission:temp380C,pulse90,BP80/40,RR30/min.Oxygensaturation64%.•Labfindings:WBC1.7G/L,(63.5%neutrophils),platelets66G/L,BUN14.3mmol/l.•ChestX-ray:changeswithopacitiesunclearboundaryinfiltrationsover2lungs.•Management:Oxygentherapywithmaskbutnoeffect,BiPAPventilationwasapplied.SaO2wasaround83-90%.AntibioticsAxepim（头孢吡肟）,Solumedrol，TequinandDopamin（多巴胺）wereministeredalso.Case3Case3Case3•PatientT.V.Cmale,19y/olivinginBacGiangprovince.•Admittedon16/01/04.Dischargedon30/01/04.•Havingnohistoryofcontactwithfluchicken..Butmanyillchickendiedaroundareawherepatientwasliving.•Presenthistory:5daysofillnessathome.Highfever,sputumcoughingandshortnessofbreath.HeAdmittedtoBacGiangprovincialhospital,CXRshowedseriouslesions.Thenextday,conditionbecamemorecriticalwithdifficultyinbreathandhewasreferedtoNICRTM.•Onadmission:temp38.50C,pulse84,BP110/70,RR54/min,crackleralesinboth2sidesoflung.SaO282%.•Labfindings:WBC3.9G/L,(75.5%neutrophils),platelets127G/L,BUN6.6mmol/l.•ChestX-ray:Opacitieswithunclearboundaryover2lungs.•Management:Oxygentherapywithmask,Tamiflu,Axepim（头孢吡肟）Solumedrol.SaO2wasimproved91-95%.•Clinicalcourse:After2daysoftreatment:Conditionwasimproved.Nolongerfeverorshortnessofbreath.SaO295-99%.Labfindings:WBC10.8G/l,GOT148,GPT194,LDH1014.+Dischargedonthedayof14th.Casereport4Case4Case4Case4Casereport5•PatientL.T.Hfemale,20y/olivinginBacNinhprovince.•Admittedon16/01/04.Dischargedon11/02/04.•Havinghistoryofcontactwithfluchicken..Manyillchickendiedaroundareawherepatientwasliving.•Presenthistory:7daysofillnessathome.Highfever,sputumcoughingandshortnessofbreath.•Onadmission:temp38.20C,pulse120,BP100/60,RR58/min,crackleralesinboth2sidesoflung.SaO280%.•Labfindings:WBC7.2G/L,(87.3%neutrophils),platelets211G/L,BUN3.7mmol/l.•ChestX-ray:Opacitieswithunclearboundaryover2lungs.•Management:Oxygentherapywithmask,Tamiflu；Axepim（头孢吡肟）•Solumedrol（甲强龙），SaO2wasimproved91-95%.•Clinicalcourse:After3daysoftreatment:Conditionwasimproved.Nolongerfeverorshortnessofbreath.SaO295-99%.Labfindings:WBC10.8G/l,GOT37,GPT84+Dischargedonthedayof26th.Case5Case5Case5小结：◆人禽流感肺炎的基本影像表现是肺内①片状影像，一般不按肺单元分布，病变密度呈肺实变或磨玻璃密度，可见“空气支气管征”。◆重症病例影像表现的突出之处在于，肺内影像呈②弥漫分布◆肺部影像③进展迅速（速度超过SARS的肺炎）◆易合并④ARDS，可合并胸腔积液，一般无空洞人禽流感肺炎的鉴别诊断人禽流感肺炎需要与其他原因的肺炎鉴别诊断：肺炎双球菌肺炎一般的病毒性肺炎流感肺炎传染