支原体肺炎病例讨论支原体肺炎病例讨论 临床资料临床资料n n患者：女，患者：女，2323岁岁n n主诉：间断发热、咳嗽、咳痰主诉：间断发热、咳嗽、咳痰6 6天天n n现病史：患者于现病史：患者于6 6天前无明显诱因出现发热伴恶心、呕吐，天前无明显诱因出现发热伴恶心、呕吐，为胃内容物，体温达为胃内容物，体温达39.639.6摄氏度，伴头疼、全身肌肉关节摄氏度，伴头疼、全身肌肉关节疼痛，伴轻微寒战、咳嗽、咳痰，黄色粘痰，量较多，自疼痛，伴轻微寒战、咳嗽、咳痰，黄色粘痰，量较多，自服解热止痛药未见退热，遂去医大二院给予清开灵、地红服解热止痛药未见退热，遂去医大二院给予清开灵、地红霉素、东松等消炎退热治疗仍不见好转，后去下瓦房医院霉素、东松等消炎退热治疗仍不见好转，后去下瓦房医院予阿奇霉素静脉点滴予阿奇霉素静脉点滴2 2日后，体温波动于日后，体温波动于373739.839.8摄氏度摄氏度之间。来我院查胸之间。来我院查胸CTCT示右肺炎。自发病以来曾上肢红色皮示右肺炎。自发病以来曾上肢红色皮疹后自行消退，食欲欠佳，大小便正常，体重无著变疹后自行消退，食欲欠佳，大小便正常，体重无著变临床资料临床资料n n既往史：否认肝炎、结核等传染病史，无外伤手术史，无既往史：否认肝炎、结核等传染病史，无外伤手术史，无过敏史，预防接种史不详过敏史，预防接种史不详n n个人史：无外地久居史，无疫区接触史，无吸烟室，无饮个人史：无外地久居史，无疫区接触史，无吸烟室，无饮酒史酒史n n家族史：无遗传性家族病史家族史：无遗传性家族病史临床资料临床资料n n入院查体：入院查体： T: 39.6 P: 110bpm R: 28bpm Bp: 116/67mmHgT: 39.6 P: 110bpm R: 28bpm Bp: 116/67mmHg 患者年轻女性，既往体健，发育正常，营养中等，面患者年轻女性，既往体健，发育正常，营养中等，面容安静，意识清楚，皮肤粘膜无黄染、出血点，浅表淋巴容安静，意识清楚，皮肤粘膜无黄染、出血点，浅表淋巴结未及肿大，头颅五官端正，气管居中，咽红，胸廓对称，结未及肿大，头颅五官端正，气管居中，咽红，胸廓对称，右肺第右肺第4 4肋间叩浊音，余叩诊清音，双肺呼吸音略粗，未肋间叩浊音，余叩诊清音，双肺呼吸音略粗，未闻及干、湿性啰音。心律齐，心音有力。腹平坦，肝脾不闻及干、湿性啰音。心律齐，心音有力。腹平坦，肝脾不大。生理反射存在，病理反射未引出。大。生理反射存在，病理反射未引出。临床资料临床资料n n辅助检查辅助检查: :l l入院血常规：血红蛋白入院血常规：血红蛋白 137g/L137g/L，红细胞，红细胞4.14104.14101212/L/L，白细胞白细胞6.6106.6109 9/L/L，中性粒细胞，中性粒细胞90.6%90.6% ，淋巴细胞，淋巴细胞6.5%6.5%，单核细胞，单核细胞2.9%2.9% l l血沉：血沉：53mm/1h53mm/1hl l血清结核抗体试验：血清结核抗体试验：TB-IgGTB-IgG（）（）l l血生化：血生化：TP 61g/LTP 61g/L，GLO 23g/LGLO 23g/L，ALP 39/LALP 39/Ll lCRPCRP：17.8mg/dL 17.8mg/dL PCT:4.00ng/mL PCT:4.00ng/mL n n（1212月月3030日）日） 尿尿RBCRBC：166/HPF166/HPF ，尿尿WBCWBC：85/HPF85/HPF 临床资料临床资料l l细小病毒细小病毒B19 IgGB19 IgG抗体（）抗体（）l l细小病毒细小病毒B19 IgMB19 IgM抗体（）抗体（）l l嗜肺军团菌抗体（）嗜肺军团菌抗体（）l l巨细胞病毒巨细胞病毒IgMIgM抗体（）抗体（）l l血培养血培养+ +药敏：无菌落发育药敏：无菌落发育l l痰细菌培养痰细菌培养+ +药敏：肺炎克雷白氏菌（药敏：肺炎克雷白氏菌（+ +）铜绿假单胞菌）铜绿假单胞菌（+ +）恶臭假单胞菌（）恶臭假单胞菌（+ +）l l痰真菌培养：无真菌生长痰真菌培养：无真菌生长l lHIVHIV抗体（），梅毒抗体（）抗体（），梅毒抗体（）临床资料临床资料( (危重期危重期):):l l心肌酶心肌酶 LDH:587U/LLDH:587U/L ，CK:462U/LCK:462U/L ，HBDH:389U/LHBDH:389U/L l l心肌功能心肌功能 ASTAST：70U/L 70U/L , CK, CK：590U/L 590U/L , LDH:788U/L , LDH:788U/L l lUREAUREA：12.8mmol/L 12.8mmol/L , CREA, CREA：189.0umol/L 189.0umol/L （1212月月2727日）日） CA-testCA-test（冷凝集试验（冷凝集试验）：（）：（） MP- IgMMP- IgM（肺炎支原体抗体（肺炎支原体抗体IgMIgM）：（）：（）（1 1月月4 4日）日） MP- IgMMP- IgM：阳性阳性 1 1：320320胸部胸部CT平扫平扫（2010-12-28）胸部胸部CT平扫平扫（2010-12-28）CT检查报告检查报告n n1.1.右肺及左下叶多发实变及斑片状磨玻璃密度影，考虑感右肺及左下叶多发实变及斑片状磨玻璃密度影，考虑感染性病变。右中下叶支气管管腔变窄，远端闭塞。右下肺染性病变。右中下叶支气管管腔变窄，远端闭塞。右下肺门显示不清门显示不清n n2.2.右侧胸腔积液右侧胸腔积液n n3.3.双侧肾实质密度不均匀性减低双侧肾实质密度不均匀性减低其他检查其他检查n nECGECG：窦性心动过速：窦性心动过速n nBUSBUS： 1.1.右侧胸腔积液（于仰卧位难以定位穿刺）右侧胸腔积液（于仰卧位难以定位穿刺） 2.2.左侧胸腔及腹腔未见明显液性暗区左侧胸腔及腹腔未见明显液性暗区n n2424小时脑电监测报告：记录期间除心电及电极伪差外，小时脑电监测报告：记录期间除心电及电极伪差外，ECGECG可见全导无反应性、失节律性、超低幅（小于可见全导无反应性、失节律性、超低幅（小于3uv3uv）杂散可凝电活动，脑电趋于电静息水平，杂散可凝电活动，脑电趋于电静息水平，2424小时未见改善小时未见改善迹象迹象治疗及抢救经过治疗及抢救经过n n患者主因肺感染予抗感染治疗后于患者主因肺感染予抗感染治疗后于12.2912.29出现呼吸衰竭，出现呼吸衰竭，12.3012.30早上行气管插管和呼吸机辅助，呼衰持续不缓解，早上行气管插管和呼吸机辅助，呼衰持续不缓解，于于12.3012.30下午行下午行ECMOECMO植入术，术后转入植入术，术后转入SICUSICU，予呼吸机辅，予呼吸机辅助助ECMOECMO支持治疗，密切监测并抗炎及对症支持治疗，左胸支持治疗，密切监测并抗炎及对症支持治疗，左胸腔闭式引流。后查体发现患者双侧瞳孔散大，腔闭式引流。后查体发现患者双侧瞳孔散大，5:5mm5:5mm，呼，呼吸循环不稳定，肝肾功能不全，病情危重，家属放弃治疗。吸循环不稳定，肝肾功能不全，病情危重，家属放弃治疗。于于20112011年年1 1月月6 6日日19:0119:01分宣布临床死亡分宣布临床死亡n n死亡原因：多脏器功能衰竭死亡原因：多脏器功能衰竭n n死亡诊断：死亡诊断：1.1.多脏器功能衰竭多脏器功能衰竭 2.2.重症肺炎重症肺炎肺炎支原体肺炎肺炎支原体肺炎mycoplosma pneumoniae pneumoniamycoplosma pneumoniae pneumonia，MPPMPP n n社区获得性肺炎最常见类型之一，常见于健康年轻人、儿童社区获得性肺炎最常见类型之一，常见于健康年轻人、儿童n n病理学特征：病理学特征：急性细胞性细支气管炎、支气管壁水肿和溃急性细胞性细支气管炎、支气管壁水肿和溃 疡灶；支气管血管周围间质浸润；小叶性肺炎；严重病例可进疡灶；支气管血管周围间质浸润；小叶性肺炎；严重病例可进展为展为DADDADn n胸片：胸片：片状气腔阴影（实变、片状气腔阴影（实变、GGOGGO）和）和/ /或网状间质浸润，不具或网状间质浸润，不具特征性特征性n nCT/HRCTCT/HRCT：GGOGGO(78(788686) )，常呈小叶性分布；常呈小叶性分布；支气管壁或支支气管壁或支气管血管束斑片状实变气管血管束斑片状实变(61(617979) )、增厚增厚(40(408181) )和和小叶中心小叶中心性结节性结节(78(788989)(p)(p均均0.00010.0001) )为特征表现；单或双侧或多叶，为特征表现；单或双侧或多叶，下肺分布多；进展性病变呈双侧弥漫性下肺分布多；进展性病变呈双侧弥漫性 其他：小叶间隔增厚其他：小叶间隔增厚(10(10) )、网状线影网状线影(27(27) )、淋巴腺病、淋巴腺病(10(102323) )、胸膜渗出、胸膜渗出(7(72020) )影像学表现反映病理改变影像学表现反映病理改变AB40-year-old woman with Mycoplasma pneumoniae pneumonia.A, Chest radiograph reveals patchy areas of nonsegmental air-space opacification in both lower lobes.B, HRCT (1.5-mm collimation) shows focal areas of air-space consolidation in nonsegmental distribution and multiple, partly confluent air-space nodules in centrilobular distribution.30-year-old man with Mycoplasma pneumoniae pneumonia.A, Chest radiograph reveals coarse reticulation and thickening of bronchovascular bundles in right lower lobe.B, HRCT (1.5-mm collimation) shows nonsegmental subpleural air-space consolidation (curved arrow), centrilobular nodules(straight arrow), extensive areas of ground-glass attenuation, and interlobular septal thickening.AB17-year-old boy with M. pneumoniae pneumonia. HRCT(1.0-mm collimation) reveals nodules smaller than 10mm in diameter (arrows) in predominantlycentrilobular distribution and areas of GGO. Note sharp demarcation between normal and abnormal secondary pulmonary lobules, consistent with lobular pneumonia.55-year-old man with M. pneumoniae pneumonia. HRCT (1.0-mm collimation) at level of right upper (A) and lower (B) lobes show poorly defined nodular and branching opacity with predominantly centrilobular distribution (straight arrow, B) and bronchial wall thickening (curved arrow,A and B).AB30-year-old woman with M. pneumoniae pneumonia. CT shows bronchial wall thickening (arrows). Lobular areas of consolidation and GGO are also seen.BMC Medical Imaging 2009, 9:7 BMC Medical Imaging 2009, 9:7 doi:10.1186/1471-2342-9-7 (1)doi:10.1186/1471-2342-9-7 (1)24-year-old man with M. pneumoniae pneumonia. CT shows centrilobular nodules (tree-in-bud, arrows), bronchial wall thickening is also seen.BMC Medical Imaging 2009, 9:7 BMC Medical Imaging 2009, 9:7 doi:10.1186/1471-2342-9-7 (2)doi:10.1186/1471-2342-9-7 (2)Radiology : Volume 238 : Number 1Radiology : Volume 238 : Number 1January 2006 (5)January 2006 (5)Thin-section CT scan demonstrates M.pneumoniae bronchopneumonia in 23-year-old man. Branching centrilobular nodules (tree-in-bud , arrowheads) are seen on a background of faint GGO. Bronchial wall thickening (arrow) is also noted.影像学鉴别诊断影像学鉴别诊断 肺炎链球菌肺炎：炎症主要在肺泡腔，呈大片实变，段性支 气管很少进展性病变，少见支气管壁增厚和树芽征金葡菌肺炎：密集的气腔实变，呈小叶性分布或融合成大 片，多发，空洞干酪性肺炎、支气管内膜结核：虫蚀样空洞、多发播散灶巨细胞病毒性肺炎：双侧无数小结节，多见于免疫受损患者卡氏肺孢子菌病：双肺斑片状或大片GGO，呈地图样分布，边 界常清楚，多见于免疫受损患者肺炎衣原体肺炎：小叶中心性结节，支气管扩张、壁增厚， 带状实变；难鉴别结节病： 广泛支气管血管周围结节样增厚细菌性肺炎细菌性肺炎（bacterial pneumonia）n n肺炎链球菌肺炎肺炎链球菌肺炎（streptococcus pneumoniae pneumoniastreptococcus pneumoniae pneumonia）发发生在任何年龄，是最常见的社区获得性肺炎，也是最常见生在任何年龄，是最常见的社区获得性肺炎，也是最常见的医源性肺炎（约的医源性肺炎（约40%40%）n n金黄色葡萄球菌肺炎金黄色葡萄球菌肺炎（staphylococcal pneumoniastaphylococcal pneumonia）是相对是相对不常见的社区获得性肺炎，很多医源性原因是由耐青霉素不常见的社区获得性肺炎，很多医源性原因是由耐青霉素导致的，特别是监护室的病人导致的，特别是监护室的病人n n细菌性肺炎是通过痰培养或血培养，以及细菌性肺炎是通过痰培养或血培养，以及BALBAL灌洗液确诊灌洗液确诊n n肺炎链球菌肺炎炎症主要在肺泡腔，呈大片实变，段性支气管肺炎链球菌肺炎炎症主要在肺泡腔，呈大片实变，段性支气管很少进展性病变，少见支气管壁增厚和树芽征很少进展性病变，少见支气管壁增厚和树芽征n nImaging features of S.pneumoniae pneumonia:Imaging features of S.pneumoniae pneumonia:（1 1）Lobar(part or all)consolidation most frequent manifestationLobar(part or all)consolidation most frequent manifestation（2 2）Consolidation may be multilobar or sphericalConsolidation may be multilobar or spherical（3 3）Cavitation and pneumatocele formation relatively uncommonCavitation and pneumatocele formation relatively uncommon（4 4）Lymphadenopathy frequent(on CT)Lymphadenopathy frequent(on CT)（5 5）Accompanying pleural effusion frequent(50%)and often infected(empyema)Accompanying pleural effusion frequent(50%)and often infected(empyema)n n金葡菌肺炎多表现为密集的气腔实变，呈小叶性分布或融合成金葡菌肺炎多表现为密集的气腔实变，呈小叶性分布或融合成大片，多发，空洞等大片，多发，空洞等n nImaging features of S.aureus pneumonia:Imaging features of S.aureus pneumonia:（1 1）Patchy or bronchopneumonic consolidation-unilateral or bilateralPatchy or bronchopneumonic consolidation-unilateral or bilateral（2 2）Acinar nodules(up to 1 cm diameter)frequentAcinar nodules(up to 1 cm diameter)frequent（3 3）Tree-in-bud and centrilobular nodules identifiable on CTTree-in-bud and centrilobular nodules identifiable on CT（4 4）Abscess formation within consolidation commonAbscess formation within consolidation common（5 5）Pneumatoceles more frequent in children than in adultsPneumatoceles more frequent in children than in adults（6 6）Pneumothorax and pleural effusions(empyema)are common complicationsPneumothorax and pleural effusions(empyema)are common complications39-year-old man with S. pneumoniae pneumonia. CT shows air-space consolidation in left lower lobe.BMC Medical Imaging 2009, 9:7 BMC Medical Imaging 2009, 9:7 doi:10.1186/1471-2342-9-7 doi:10.1186/1471-2342-9-7 (3)(3)n n支气管血管束管壁支气管血管束管壁增厚、支气管周围性增厚、支气管周围性结节或小叶中心性结结节或小叶中心性结节出现比例远小于肺节出现比例远小于肺炎支原体肺炎和肺炎炎支原体肺炎和肺炎衣原体肺炎衣原体肺炎A 49-year-old man with S. pneumoniae pneumonia. HRCT (1-mm collimation) reveals non-segmental air-space consolidation involving the right lower lobe. GGO is only detected around areas of air-space consolidation (arrows)Eur RadiolEur Radiol (2003) 13:515 (2003) 13:515 521521DOI 10.1007/s00330-002-1490-3 (1)DOI 10.1007/s00330-002-1490-3 (1)Thin-sectionCT scan demonstrates S.pneumoniae pneumonia in 54-year-old man.Segmental consolidation with air bronchograms (arrows) is seen in right middle lobe. Focal area of GGO (arrowhead) is noted in right lower lobe.Radiology : Volume 238 : Number 1Radiology : Volume 238 : Number 1January 2006January 2006 (4)(4)Axial CT image shows bilateral consolidation and ground-glass densities in a 61-year-old bone marrow recipient with myelodysplastic syndrome. Staphylococcus aureus was cultured from bronchoalveolar lavage.Diagn Interv Radiol 2008;14:75-82Diagn Interv Radiol 2008;14:75-82A 38-year-old man with Staphylococcus aureus pneumonia. HRCT scan (1-mm collimation) shows patchy areas of air-space consolidation, consistent with bronchopneumoniaEur RadiolEur Radiol (2003) 13:515 (2003) 13:515 521521DOI 10.1007/s00330-002-1490-3 (4)DOI 10.1007/s00330-002-1490-3 (4)31-year-old man with severe M. pneumoniae pneumonia with respiratory failure requiring mechanical ventilation. CT shows bilateral air-space consolidation and pleural effusion.BMC Medical Imaging 2009, 9:7 BMC Medical Imaging 2009, 9:7 doi:10.1186/1471-2342-9-7 (4)doi:10.1186/1471-2342-9-7 (4)31-year-old man with severe M. pneumoniae pneumonia with respiratory failure requiring mechanical ventilation. CT shows bilateral air-space consolidation and pleural effusion.BMC Medical Imaging 2009, 9:7 BMC Medical Imaging 2009, 9:7 doi:10.1186/1471-2342-9-7 (4)doi:10.1186/1471-2342-9-7 (4)浸润性肺结核浸润性肺结核（infiltrative pulmonary tuberculosis） n n共同点：都可出现小叶中心性分布的病灶，结节状或小斑片共同点：都可出现小叶中心性分布的病灶，结节状或小斑片状气腔实变影及树芽征状气腔实变影及树芽征, , 都很少出现间质纤维化改变都很少出现间质纤维化改变n n不同点：浸润性肺结核多见于年长儿，结核中毒症状较重。不同点：浸润性肺结核多见于年长儿，结核中毒症状较重。多位于肺上叶，呈多样性，肺内播散灶为边界清晰的多发点多位于肺上叶，呈多样性，肺内播散灶为边界清晰的多发点状、小结节状阴影，变化缓慢，吸收后仍留有痕迹，即影像状、小结节状阴影，变化缓慢，吸收后仍留有痕迹，即影像学可见新旧病灶并存，出现钙化，少见学可见新旧病灶并存，出现钙化，少见GGOGGO MPPMPP短期内病变范围迅速扩大，且一般在治疗短期内病变范围迅速扩大，且一般在治疗1 12 2周可以明显吸收或完全吸收。周可以明显吸收或完全吸收。鉴别主要还是通过痰涂片和实验室检查。鉴别主要还是通过痰涂片和实验室检查。 Axial CT image shows consolidation and ill-defined nodules in the posterior segment of right upper lobe in a neutropenic patient with tuberculous infection.Diagn Interv Radiol 2008;14:75-82Diagn Interv Radiol 2008;14:75-82巨细胞病毒性肺炎巨细胞病毒性肺炎（cytomegalovirus pneumonia, CMP） n n病原体病原体CMVCMV属疱疹病毒属疱疹病毒 亚科，为双链亚科，为双链DNADNA病毒，可通过病毒，可通过体液传播体液传播 n nCMPCMP是免疫抑制患者最常见的致命性并发症之一，常见于是免疫抑制患者最常见的致命性并发症之一，常见于免疫缺陷患者，例如器官移植患者、免疫缺陷患者，例如器官移植患者、AIDSAIDS患者及服用过患者及服用过免疫抑制药物的患者，也可发生于各种年龄的血液病患者免疫抑制药物的患者，也可发生于各种年龄的血液病患者n nCMPCMP的主要病理表现为弥漫性肺泡损伤及局灶性间质性肺的主要病理表现为弥漫性肺泡损伤及局灶性间质性肺炎。炎。CMPCMP的影像学表现主要以病理学改变为基础的影像学表现主要以病理学改变为基础n nGGOGGO是是CMPCMP最常见的影像学表现最常见的影像学表现 n nCMVCMV的典型影像表现的典型影像表现 ：双侧弥漫性分布的微小结节，直：双侧弥漫性分布的微小结节，直径径1-5mm1-5mm，边缘光滑或不规则，磨玻璃密度边缘光滑或不规则，磨玻璃密度，为间质性肺为间质性肺炎的表现炎的表现 n n常见胸腔积液及淋巴结肿大常见胸腔积液及淋巴结肿大Axial CT image shows bilateral centrilobular nodules and pleural effusion in Cytomegalovirus infection in a 38-year-old bone marrow recipient.Diagn Interv Radiol 2008;14:75-82Diagn Interv Radiol 2008;14:75-82A 31-year-old woman with cytomegalovirus pneumonia after bone marrow transplantation. HRCT scan (1.5-mm collimation) demonstrates numerous small nodules (arrows)Eur RadiolEur Radiol (2003) 13:515 (2003) 13:515 521521DOI 10.1007/s00330-002-1490-3 (5)DOI 10.1007/s00330-002-1490-3 (5)24-year-old man with M. pneumoniae pneumonia. CT shows centrilobular nodules (tree-in-bud appearance,arrows). Bronchial wall thickening is also seen.BMC Medical Imaging 2009, 9:7 BMC Medical Imaging 2009, 9:7 doi:10.1186/1471-2342-9-7 (4)doi:10.1186/1471-2342-9-7 (4)Pneumonia due to cytomegalovirus in a 45-year-old man who underwent liver transplantation.(a) Chest radiograph obtained 4 weeks after liver transplantation shows patchy air-space consolidation in both lungs.An endotracheal intubation tube, a pigtail drainage catheter in the right pleural space, a chest tube in the left pleural space, and a central venous catheter are seen. (b) Thin-section (1-mm collimation) CT scan obtained at the level of the right upper lobe bronchus 2 days before a shows multifocal patchy ground-glass attenuation in both lungs. Note the consolidation (white arrow) and the small, poorly defined nodules (black arrows). There are associated bilateral pleural effusions.卡氏肺孢子肺炎卡氏肺孢子肺炎（pneumocystis carinii pneumonia,PCP） n n肺孢子虫属真菌，形态上类似原虫，可寄生于正常人体肺肺孢子虫属真菌，形态上类似原虫，可寄生于正常人体肺部部。正常机体可通过细胞免疫和单核吞噬细胞系统将其清正常机体可通过细胞免疫和单核吞噬细胞系统将其清除，因此对健康宿主不致病除，因此对健康宿主不致病n n对免疫抑制患者对免疫抑制患者( (如如HIVHIV感染、器官移植术后及放、化疗或感染、器官移植术后及放、化疗或免疫抑制剂治疗者免疫抑制剂治疗者) )，由于免疫功能极度低下，机体防御，由于免疫功能极度低下，机体防御机制破坏严重，从而对其清除能力明显下降，此时，肺孢机制破坏严重，从而对其清除能力明显下降，此时，肺孢子虫大量繁殖即可引发子虫大量繁殖即可引发PCP PCP n n临床表现可有干咳、呼吸困难和低烧临床表现可有干咳、呼吸困难和低烧 n nPCPPCP的影像学改变以两肺间质性和肺泡性病变这两种类型的影像学改变以两肺间质性和肺泡性病变这两种类型为基础为基础 n n典型影像表现为双肺典型影像表现为双肺，特别肺门周围的和弥漫性轮廓不清特别肺门周围的和弥漫性轮廓不清的、孤立的、不对称的的、孤立的、不对称的GGOGGO斑片，呈斑片，呈“碎石路碎石路”分布，边分布，边界常清楚，可伴有小叶间隔增厚界常清楚，可伴有小叶间隔增厚等间质性炎症等间质性炎症，进展，进展3 34 4天后可发展为肺泡性实变天后可发展为肺泡性实变 A 28-year-old man with AIDS and Pneumocystis carinii pneumonia. HRCT scan (1.5-mm collimation) reveals extensive bilateral areas of GGO in a geographic distribution with sharp demarcation between normal and abnormal lungEur RadiolEur Radiol (2003) 13:515 (2003) 13:515 521521DOI 10.1007/s00330-002-1490-3 (2)DOI 10.1007/s00330-002-1490-3 (2)P carinii pneumonia in a 32-year-old man with acquired immunodeficiency syndrome. High-resolution CT scan shows areas of ground-glass attenuation with intralobular lines. 1512 November-December 2003 RG f Volume 23 Number 61512 November-December 2003 RG f Volume 23 Number 6RadioGraphicsRadioGraphics肺炎衣原体肺炎肺炎衣原体肺炎（chlamydia pneumoniae pneumonia,CPP） n nCPPCPP是由衣原体引起的肺炎，衣原体有沙眼衣原体是由衣原体引起的肺炎，衣原体有沙眼衣原体（chlamydia chlamydia trachomatis,CTtrachomatis,CT）、）、肺炎衣原体肺炎衣原体（chlamydia psittaci,CPchlamydia psittaci,CP）、）、鹦鹉鹦鹉热衣原体和家蓄衣原体。与人类关系密切的为热衣原体和家蓄衣原体。与人类关系密切的为CTCT和和CPCP，偶见鹦，偶见鹦鹉热衣原体肺炎鹉热衣原体肺炎n n非典型肺炎。发病率占社区获得性肺炎的非典型肺炎。发病率占社区获得性肺炎的6%6%12%12%，是继肺，是继肺炎链球菌肺炎和炎链球菌肺炎和MPPMPP之后第三大社区获得性肺炎之后第三大社区获得性肺炎 n nCPPCPP临床症状及影像表现均无特异性，与临床症状及影像表现均无特异性，与MPPMPP鉴别较困难，确鉴别较困难，确诊有赖于实验室诊断诊有赖于实验室诊断n n微量免疫荧光试验微量免疫荧光试验(MIF)(MIF)是目前国际上标准的且是最常用的是目前国际上标准的且是最常用的CPCP血清学诊断方法血清学诊断方法n n文献总结出三条临床鉴别要点：文献总结出三条临床鉴别要点：（1 1）MPPMPP会发生中枢神经系统并发症，例如脑膜炎或脊髓会发生中枢神经系统并发症，例如脑膜炎或脊髓炎；炎；CPPCPP患者很少有此并发症；患者很少有此并发症；（2 2）仅）仅CPPCPP患者与冠状动脉疾病相关联；患者与冠状动脉疾病相关联；（3 3）CPPCPP经常发生再感染，或携带经常发生再感染，或携带CPPCPP抗体且偶尔需要一段抗体且偶尔需要一段长期的药物治疗去根除疾病的患者的慢性感染长期的药物治疗去根除疾病的患者的慢性感染 n n影像上，肺实变、磨玻璃密度、小叶中心性结节、支气管血管束增粗影像上，肺实变、磨玻璃密度、小叶中心性结节、支气管血管束增粗在肺炎衣原体肺炎及支原体肺炎中都较常见。但肺炎衣原体肺炎患者在肺炎衣原体肺炎及支原体肺炎中都较常见。但肺炎衣原体肺炎患者中肺间质改变、支气管扩张和肺气肿较支原体肺炎患者常见，慢性阻中肺间质改变、支气管扩张和肺气肿较支原体肺炎患者常见，慢性阻塞性肺病更偏向于出现在肺炎衣原体肺炎塞性肺病更偏向于出现在肺炎衣原体肺炎 Transverse thin-section CT scan demonstrates C.pneumoniae pneumonia with GGO predominance in 23-year-old man.Extensive areas of GGO are seen in the left lower lobe, which demonstrates thickened bronchovascular bundles(arrows) and fine reticular framework(ie,crazy-paving appearance).Radiology : Volume 238 : Number 1Radiology : Volume 238 : Number 1January 2006 (1)January 2006 (1)Thin-section CT scan demonstrates C. pneumoniaebronchopneumonia in 66-year-old man. Centrilobular nodules (arrows) and lobular consolidation with bilateral airway dilatation (arrowheads). Note the associated areas of linear opacity.Radiology : Volume 238 : Number 1Radiology : Volume 238 : Number 1January 2006 (1)January 2006 (1)胸内结节病胸内结节病n n结节病结节病( (sarcoidosissarcoidosis) )是一种多系统多器官受累的肉芽肿是一种多系统多器官受累的肉芽肿性疾病，病因未明，是未知抗原与机体细胞免疫和体液免性疾病，病因未明，是未知抗原与机体细胞免疫和体液免疫功能相互抗衡的结果疫功能相互抗衡的结果n n常侵犯肺、双侧肺门淋巴结，临床上常侵犯肺、双侧肺门淋巴结，临床上90%90%以上有肺的改变以上有肺的改变 n n胸内结节病临床表现约胸内结节病临床表现约50%50%患者早期常无明显症状和体征患者早期常无明显症状和体征，25%25%患者主诉咳嗽和呼吸困难患者主诉咳嗽和呼吸困难 ，可有乏力、发热、盗汗、可有乏力、发热、盗汗、食欲减退、体重减轻等食欲减退、体重减轻等，25%25%的患者有胸腔外症状，经常的患者有胸腔外症状，经常累及皮肤和眼睛累及皮肤和眼睛 n n异常的胸部影像表现常是结节病的首要发现异常的胸部影像表现常是结节病的首要发现，占，占90%90%以上以上n n胸内淋巴结增大是结节病最常见的影像表现胸内淋巴结增大是结节病最常见的影像表现，占，占85%85%以上以上 n n双肺门区淋巴结增大伴或不伴有纵隔淋巴结增大发生于双肺门区淋巴结增大伴或不伴有纵隔淋巴结增大发生于95%95%的累及淋巴结的病人的累及淋巴结的病人 n n两侧肺门淋巴结对称性增大时结节病的较为特征性改变，两侧肺门淋巴结对称性增大时结节病的较为特征性改变，仅有仅有1%1%3%3%的患者出现单侧肺门淋巴结增大的患者出现单侧肺门淋巴结增大 51-year-old man with CT finding of nodular peribronchovascular interstitial thickening (arrow). Results of transbronchial biopsy were positive for multiple epithelioid granuloma in alveolar parenchyma and bronchial wall, suggesting sarcoidosis. Results of special stains for acid-fast bacilli and fungi were negative.AJR:191, October 2008 (3)AJR:191, October 2008 (3)Sarcoidosis in a 25-year-old asymptomatic man. High-resolution CT scan shows scattered bilateral areas of ground-glass attenuation associated with inter and intralobular lines. 1512 November-December 2003 RG f Volume 23 Number 61512 November-December 2003 RG f Volume 23 Number 6RadioGraphicsRadioGraphicsHilar adenopathy in a 27-year-old man with Heerfordt syndrome. (a) Chest radiograph demonstrates typical bilateral hilar adenopathy. Adenopathy in the right paratracheal and left aortic-pulmonary window nodes (arrowheads)is also identified. (b) Contrast materialenhanced computed tomographic (CT) scan clearly depicts the bilateral hilar adenopathy (arrowheads).RG f Volume 24 Number 1RG f Volume 24 Number 1儿童肺炎支原体肺炎 儿童（儿童（1818岁岁）影像表现常与细菌性肺炎类似：）影像表现常与细菌性肺炎类似：n n叶、段性实变叶、段性实变（100100）n n胸膜渗出（肺炎旁积液胸膜渗出（肺炎旁积液）（）（8080）n n肺门、纵隔淋巴结增大肺门、纵隔淋巴结增大（8080）n n肺容积轻度减少肺容积轻度减少（7373）Fig. a, b 1-year-old girl with M. pneumoniae pneumonia.a. Axial contrast-enhanced CT scan (5-mm collimation) shows a lobar consolidation in the left upper lobe with pleural effusion (arrowheads). Mild mediastinal shifting suggests mild volume decrease of the left lung. Note another subsegmental consolidation in the right upper lobe (arrow). b. 18 months after a shows complete resolution of the previously noted consolidations. A focal region of mosaic oligemia is seen in the right upper lobe (arrows), suggestive of constrictive bronchiolitis. The entire left upper lobe also shows diffuse regions of lucency with oligemia, suggestive of Swyer-James syndrome. Note a linear atelectasis inthe left upper lobe (arrowhead)Eur RadiolEur Radiol (2006) 16: 719 (2006) 16: 719 725725DOI 10.1007/s00330-005-0026-DOI 10.1007/s00330-005-0026-z zFig. a, b 2-year-old girl with M. pneumoniae pneumonia.a. Axial contrast-enhanced CT scan (5-mm collimation) shows a lobar consolidation in the left lower lobe. The air bronchogram within the consolidation shows diffuse mild narrowing (white arrow). Small subpleural areas of low attenuation are seen within the otherwise homogeneous consolidation, suggestive of focal necrosis (black arrows). Note a moderate-sized, ipsilateral pleuraleffusion with diffuse enhancing pleural thickening (arrowheads).b. CT image obtained at a higher level to a shows an enlarged hilar lymph node (arrow)Eur RadiolEur Radiol (2006) 16: 719 (2006) 16: 719 725725DOI 10.1007/s00330-005-0026-DOI 10.1007/s00330-005-0026-z zFig. a, b 14-year-old boy with M. pneumoniae pneumonia.a. Axial contrast-enhanced CT scan (5-mm collimation) shows a segmental consolidation in the right lower lobe with a small amount of pleural effusion. The air bronchogram is well delined within the consolidation. b. Lung window image of HRCT (1-mm collimation) shows patchy lobular consolidations with centrilobular and acinar nodules (arrows) around the segmental consolidationEur RadiolEur Radiol (2006) 16: 719 (2006) 16: 719 725725DOI 10.1007/s00330-005-0026-DOI 10.1007/s00330-005-0026-z z小小 结结n n薄层薄层CTCT或或HRCTHRCT表现为单表现为单/ /双侧支气管壁、支气管血管束双侧支气管壁、支气管血管束增厚（浸润、水肿），边界不清的小叶中心性结节（细支增厚（浸润、水肿），边界不清的小叶中心性结节（细支气管炎），斑片状实变或气管炎），斑片状实变或GGOGGO常呈小叶性分布（支气管肺常呈小叶性分布（支气管肺炎），具有相对特征性。炎），具有相对特征性。支气管壁增厚和小叶中心性结节支气管壁增厚和小叶中心性结节同时出现时高度提示诊断同时出现时高度提示诊断。n n平片显示细节差，缺乏特征性平片显示细节差，缺乏特征性n n主要需与其他感染性炎症鉴别，确诊需结合临床和实验室主要需与其他感染性炎症鉴别，确诊需结合临床和实验室检查检查