晕征与反晕征晕征与反晕征 halo sign and reversed halo sign1 CTCTCTCT表现：致密影表现：致密影表现：致密影表现：致密影 直径直径直径直径5mm5mm5mm5mm称微结节称微结节称微结节称微结节 （2 2 2 23mm3mm3mm3mm粟粒结节）粟粒结节）粟粒结节）粟粒结节） 直径直径直径直径5 5 5 5 10mm10mm10mm10mm称称称称小结节小结节小结节小结节 10mm10mm10mm10mm者统称结节者统称结节者统称结节者统称结节 一般将小于等一般将小于等3cm3cm者称为结节，者称为结节，大于大于3cm3cm者称为者称为肿块。肿块。基本概念基本概念2 是指肺部是指肺部CTCT或薄层或薄层CTCT上，肺密度轻度增加，支气管上，肺密度轻度增加，支气管和血管轮廓可见，形似磨玻璃，称磨玻璃密度影。和血管轮廓可见，形似磨玻璃，称磨玻璃密度影。意义意义非特异，任何使肺实变、远端气腔内空气含量减少非特异，任何使肺实变、远端气腔内空气含量减少而又不使肺泡全部闭塞的因素都可产生磨玻璃影。而又不使肺泡全部闭塞的因素都可产生磨玻璃影。基本概念基本概念3 晕征晕征CTCT表现表现在在CTCT上肺内结节或肿块周围的晕状上肺内结节或肿块周围的晕状磨玻璃密度影，低于中央结节，但高于正常肺磨玻璃密度影，低于中央结节，但高于正常肺组织，形似日晕。组织，形似日晕。4 分类分类一、出血性肺结节一、出血性肺结节 ( (一一) )感染性疾病中的出血性结节感染性疾病中的出血性结节 ( (毛霉菌病、念珠菌病、结核病、病毒毛霉菌病、念珠菌病、结核病、病毒性肺炎、侵袭性曲菌病性肺炎、侵袭性曲菌病) ) ( (二二) )非感染性疾病中的出血性结节（韦格纳肉非感染性疾病中的出血性结节（韦格纳肉芽肿病，芽肿病，KabosiKabosi肉瘤，）肉瘤，）二、肿瘤细胞浸润性结节（细支气管肺泡癌，淋二、肿瘤细胞浸润性结节（细支气管肺泡癌，淋巴瘤、肺泡内肿瘤生长）巴瘤、肺泡内肿瘤生长）三、非出血性结节（肉状瘤病，机化性肺炎）三、非出血性结节（肉状瘤病，机化性肺炎）5 晕征病因晕征病因Arch Bronconeumol. 2008;44(7):386-926 免疫功能不全免疫功能不全侵袭性曲霉菌、毛霉菌、念珠菌及隐球菌侵袭性曲霉菌、毛霉菌、念珠菌及隐球菌一晕征一晕征-感染性疾病感染性疾病-真菌真菌7 一晕征一晕征-感染性疾病感染性疾病-真菌真菌Kuhlman JE 1985 Invasive pulmonary aspergillosis. A: Computed tomography (CT) scan of a patient with acute lymphoid leukemia and neutropenia showing a nodule surrounded by a halo in the right upper lobe, with adjacent acinar involvement (arrows). B: Macroscopic sagittal slice of another patients lung showing a round necrotic lesion (asterisk) surrounded by a hemorrhagic halo (arrowheads), corresponding to invasive pulmonary aspergillosis. C: Microscopic image of the margin of the lesion described in B, with visible pulmonary necrosis and hemorrhage. The image also shows the hyphae of Aspergillus fumigatus (arrows), which are of regular caliber, septate, and branching at acute angles (hematoxylin-eosin, magnification 2).8 中国CT和磁共振杂志 2014年6月 12卷 3期一晕征一晕征-感染性疾病感染性疾病-真菌真菌9 免疫功能不全免疫功能不全常见单纯疱疹病毒、巨细胞病毒、常见单纯疱疹病毒、巨细胞病毒、 水痘带状疱疹病毒及粘病毒水痘带状疱疹病毒及粘病毒一晕征一晕征-感染性疾病感染性疾病-病毒病毒10 slow-resolving bacterial pneumonia slow-resolving bacterial pneumonia ( (吸收延迟性肺炎吸收延迟性肺炎) )放线菌放线菌结核分枝杆菌结核分枝杆菌一晕征一晕征-感染性疾病感染性疾病-细菌细菌11 1.641.64岁男，退休，咳嗽、间断咯血岁男，退休，咳嗽、间断咯血2 2月来诊。吸烟，既往健月来诊。吸烟，既往健康，痰涂片革兰阴性菌，培养：卡他布兰汉菌；康，痰涂片革兰阴性菌，培养：卡他布兰汉菌；2.452.45岁，岁，既往心梗，吸烟，咳嗽既往心梗，吸烟，咳嗽1 1月间断咯血月间断咯血1010天，痰培养：流感嗜天，痰培养：流感嗜血杆菌血杆菌中国实用内科杂志 2009 7月 29卷 增刊1一晕征一晕征-感染性疾病感染性疾病-细菌细菌12 立克次体立克次体寄生虫寄生虫一晕征一晕征-感染性疾病感染性疾病-其他其他13 肾上腺嗜铬细胞瘤肾上腺嗜铬细胞瘤血管肉瘤转移瘤血管肉瘤转移瘤肾细胞癌肾细胞癌绒毛膜癌绒毛膜癌肺血管肉瘤肺血管肉瘤KaposiKaposi肉瘤肉瘤二晕征二晕征-肿瘤性疾病肿瘤性疾病-出血性瘤结节出血性瘤结节14 Hemorrhagic metastasis in a patient with choriocarcinoma（绒毛膜癌）（绒毛膜癌） who presented with massive hemoptysis. A: Computed tomography scan of the chest shows multiple hemorrhagic pulmonary nodules with a halo sign that have coalesced in the posterior segments of the right lung. B: Macroscopic lung slice showing several round hemorrhagic lesions. C: Macroscopic image of nodules containing hemorrhagic areas, fibrin, and tumor cells (hematoxylin-eosin,magnification 10).二晕征二晕征-肿瘤性疾病肿瘤性疾病-出血性瘤结节出血性瘤结节15 细支气管肺泡癌细支气管肺泡癌消化系、胰腺、肺腺癌消化系、胰腺、肺腺癌淋巴瘤淋巴瘤二晕征二晕征-肿瘤性疾病肿瘤性疾病-瘤细胞浸润瘤细胞浸润16 Bronchioloalveolar carcinoma in a patient with chronic cough. A:Computed tomography scan of the chest shows nodules with a halo sign in the right lung, with some pseudocavitation (arrow). Also visible is a considerable area of consolidation in the left lung. B: Microscopic image showing thickened alveolar walls (asterisks) due to infiltration by tumor cells (arrows) ematoxylin-eosin ,magnification 10).二晕征二晕征-肿瘤性疾病肿瘤性疾病-瘤细胞浸润瘤细胞浸润17 Pulmonary lymphoma in a 73-year-old patient who visited the emergency service with dyspnea. A: An axial scan of the lower pulmonary lobes shows multiple pulmonary nodules with a halo sign and a tendency to coalesce in the posterior segments. There is also bilateral pleural effusion, somewhat greater on the right side. The patient died 3 weeks after admission. B: Low magnification image of pulmonary nodule showing mainly peribronchovascular tumor cell infiltration and marked necrosis (hematoxylin-eosin, magnification 4). C: A higher-magnification image of the periphery of the nodule shows the infiltration of tumor cells along the alveolar walls (arrows) (hematoxylineosin,magnification 10).18 出血性结节出血性结节非出血性结节非出血性结节三晕征三晕征-非感染性疾病非感染性疾病19 三晕征三晕征-非感染性疾病非感染性疾病-出血性结节出血性结节韦格纳肉芽肿韦格纳肉芽肿子宫内膜异位症子宫内膜异位症活检活检20 Wegener granulomatosis. A: Computed tomography scan showing 2 pulmonary nodules surrounded by a halo (arrows) and an area of consolidationin the left lower lobe (asterisk), also with a halo sign. The patient, whose first symptom was hemoptysis, also had rapidly progressing glomerulonephritis肾肾小球肾炎小球肾炎B: Microscopic image showing inflammatory infiltration of the arterial wall with a multinucleated giant cell (arrow) and endothelial destruction (arrowheads)(hematoxylin-eosin, magnification 20).三晕征三晕征-非感染性疾病非感染性疾病 出血性结节出血性结节21 结节病结节病机化性肺炎机化性肺炎闭塞性细支气管炎闭塞性细支气管炎嗜酸细胞肺炎嗜酸细胞肺炎肺淀粉样变肺淀粉样变三晕征三晕征-非感染性疾病非感染性疾病 非出血性结节非出血性结节22 反晕征反晕征是是CT肺窗，中心为磨玻璃样密度影，周围肺窗，中心为磨玻璃样密度影，周围是高密度新月形或环形条带，与晕征的周是高密度新月形或环形条带，与晕征的周围稍低密密度磨玻璃影相反，称反晕征。围稍低密密度磨玻璃影相反，称反晕征。Voloudaki et al 1996 cop23 反晕征病因反晕征病因24 一反晕征一反晕征-感染性疾病感染性疾病-真菌真菌肺曲菌肺曲菌接合菌属（接合菌属（Zygomycetes Zygomycetes 包括根霉和毛霉）包括根霉和毛霉）地方性真菌感染（南美芽生菌病地方性真菌感染（南美芽生菌病- -拉丁美洲拉丁美洲- -巴西）巴西）隐球菌隐球菌早期征象早期征象25 Invasive pulmonary aspergillosis in a 54-year-old female with multiple myeloma and secondary plasma cell leukaemia who had undergone chemotherapy. (a) High-resolution CT image at the lung base shows a right lower-lobe pulmonary nodule (arrow) and the reversed halo sign (RHS) in the left lower lobe (curved arrow) with adjacent ground-glass opacities. (b) CT image with mediastinal window settings shows the peripheral consolidation of the RHS (asterisks). Note a small right pleural effusion.26 Pulmonary zygomycosis in a 22-year-old male with precursor B-cell acute lymphocytic leukaemia. (a) CT image shows the reversed halo sign (RHS) in the left upper lobe (arrows). (b) CT scan performed 2 months later shows interval development of cavitation (air crescent sign). The presence of RHS in an immunosuppressed patient is highly suggestive of pulmonary zygomycosis, especially if the patient is receiving prophylaxis for aspergillosis.27 Paracoccidioidomycosis in a 49-year-old male,resident of a rural area in Brazil. CT image shows reversed halo sign (RHS) lesions (arrows) and bilateral small poorlymarginated pulmonary nodules. The presence of RHS in a patient from an endemic region for fungal infection should raise concern for that specific fungal infection.28 一反晕征一反晕征-感染性疾病感染性疾病-结核结核Tuberculosis in a 59-year-old female. High-resolution CT image shows bilateral small centrilobular nodules, tree-in-bud opacities and areas of reversed halo sign (RHS). Note the nodular appearance of the ring of consolidation of the RHS lesions (arrows), which may be helpful in the differentiation between active granulomatous disease and cryptogenic organising pneumonia. The presence of associated centrilobular nodules and tree-in-bud opacities should raise suspicion of tuberculosis.29 二反晕征二反晕征-机化性肺炎（机化性肺炎（19%）Organising pneumonia in a 53-year-old male with graft-vs-host disease after stem cell transplantion for treatment of acute myelogenous leukaemia. CT scan shows bilateral peripheral and peribronchovascular consolidative opacities with the reversed halo sign (arrows). Open-lung biopsy showed organising pneumonia. The patient was treated with steroids with resolution of the lesions.30 二反晕征二反晕征-机化性肺炎机化性肺炎47-yr-old female was referred to a tertiary centre (St Michaels Hospital,Toronto, Canada) for further evaluation of chronic cough, fever, progressive exertional dyspnoea and fatigue. Coronal chest computed tomography scan showing multiple areas of central ground-glass opacity, surrounded by ring or crescentic-shape, dense airspace consolidation, mainly in the left lower lobe and the right upper lobe. Transbronchial biopsy showing organising pneumonia31 三反晕征三反晕征-非特异性间质性肺炎非特异性间质性肺炎The British Journal of Radiology, May 2011A 52-year-old female presented with a cough and New York Heart Association (NYHA) class 2 dyspnoea of 4 months duration，CT images show a central ground-glass opacity surrounded by crescent or ring-shaped areas of consolidation, showing the reversed halo sign. (e) 6 days and (f) 6 months of steroid therapy, both showed improvement.32 四反晕征四反晕征-结节病结节病Sarcoidosis in a 44-year-old female. High-resolution CT image shows bilateral nodular opacities with the reversed halo sign (RHS) (arrows) and small pulmonary nodules with predominant perilymphatic distribution. Thepresence of the RHS associated with nodules in perilymphatic distribution and mediastinal and hilar lymphadenopathy (not shown) should raise suspicion of sarcoidosis.33 五反晕征五反晕征-肺栓塞肺栓塞Acute pulmonary embolism with pulmonary infarction in a 64-year-old female. (a) CT image shows the reversed halo sign in the superior segment of the right lower lobe. (b) CT image (mediastinal window settings) shows a clot in the distal right main pulmonary artery extending to the superior segmental branch of the right lower lobe pulmonary artery. (c) 2 month follow-up CT scan shows cavitation of the infarcted pulmonary parenchyma.34 Multifocal pulmonary adenocarcinoma in a 70-year-old female. CT image shows bilateral ulmonarynodules with the reversed halo sign (black arrows) and ground-glass pulmonary nodules (white arrows).六反晕征六反晕征-肿瘤肿瘤35 Metastatic renal cell carcinoma in a 73-year-old male. The CT scan shows multiple bilateral lesions with reversed halo sign (RHS), biopsy proven to represent metastatic renal cell carcinoma in a background of fibrosis and necrosis. In patients with a known primary malignancy, RHS lesions may represent atypical presentation of metastatic disease. The main differential diagnosis is organising pneumonia, which can be related to drug toxicity if the patient is receiving chemotherapy.六反晕征六反晕征-肿瘤肿瘤36 Reversed halo sign (RHS) following radiofrequency ablation (RFA) of a pulmonary adenocarcinoma in a 64-year-old female. (a) CT image shows the adenocarcinoma in the left lower lobe. (b) CT scan performed 1 month after RFA of the tumour shows development of the RHS. When present shortly after RFA, the RHS should not be confused with recurrence of disease.七反晕征七反晕征-射频消融术后改变射频消融术后改变37 放疗相关肺疾病急性期放疗相关肺疾病急性期肿瘤坏死肿瘤坏死炎症反应，肺组织坏死炎症反应，肺组织坏死继发性机化性肺炎继发性机化性肺炎八反晕征八反晕征-放疗后改变放疗后改变38 八反晕征八反晕征-放疗后改变放疗后改变Reversed halo sign (RHS) following proton radiation therapy for a poorly differentiated squamous（鳞癌）（鳞癌） cell carcinoma in a 71-yearold male. (a) CT image shows the primary tumour in the left peri-hilar region. (b) CT scan performed 4 months after radiation therapy shows development of the RHS in the region of the tumour consistent with necrosis.39 Reversed halo sign (RHS)following radiation therapy for ametastatic non-small cell lung cancerin a 59-year-old female. (a) CTimage shows the primary tumour inthe left upper lobe. (b) Positronemission tomography CT axialfusion image shows fludeoxyglucose(FDG) avid metastasis in the leftscapula (arrow). (c) CT scan 1 monthafter chemotherapy and palliativeradiation therapy to the left scapulashows development of the RHS inthe left lung apex (arrow) adjacentto the primary tumour, consistentwith radiation pneumonitis. (d) Afollow-up CT scan performed 4months after (c) shows developmentof cavitation in the region of theRHS. When present within the radiationfield shortly after radiationtherapy, the RHS should not beconfused with infection or recurrenceor disease.40 “同影异病、同病异影同影异病、同病异影”41 42 43 44 45 46 Add your company slogan Add your company slogan 47