经可弯曲气管镜治疗阻塞型气道侵袭性曲霉病并呼吸衰竭二例

阻塞型气道侵袭性曲霉病是气道侵袭性曲霉病的一种亚型,主要以气管、支气管感染为主,故又称曲霉性气管、支气管炎[1].曲霉菌在气道管腔内呈团块状生长,导致管腔狭窄、阻塞,临床上主要表现为进行性呼吸困难,随时有窒息的危险,死亡率高.近期对收治的2例阻塞型气道侵袭性曲霉病并呼吸衰竭患者紧急进行了呼吸介入治疗、局部应用抗真菌药冲洗滴注并全身应用抗真菌药,取得了良好效果,挽救了患者生命,现报道如下.     

支气管结核的CT表现及动态观察

目的 分析支气管结核的CT及支气管镜表现，探讨支气管结核的影像特征及其病理基础。方法 收集痰菌、病理及临床证实的支气管结核50例，均做胸部CT及支气管镜检查，将CT及支气管表现对照分析。对有多次CT检查的病例，分析各次检查的动态变化。结果 支气管结核CT表现有以下特点：（1）支气管病变范围广泛；（2）多数病例可见肺内播散病变；（3）支气管狭窄、阻塞不伴有肺门部肿块；（4）病变管壁内可见点状或线状钙化。CT与支气管镜表现对照分析显示：管腔狭窄主要由支气管粘膜充血、水肿及溃疡引起，支气管阻塞多由肉芽肿和陈旧斑痕造成。治疗后，动态观察多数病例肺内播散病灶明显吸收。结论 CT是诊断及鉴别支气管结核的有效手段，也可评价病变的动态变化。     

新型支气管镜检查技术在肺外周病变诊断中的应用进展

肺外周病变一般包括肺外周三分之一的结节、肿块和浸润病灶,缺乏特定的影像学表现,很容易被误诊或漏诊.常规支气管镜对大气道可视病变的诊断非常有效,但对肺外周病变无法直视和准确定位,致使肺外周病变的诊断率偏低.新型支气管镜检查技术包括超细支气管镜(UTB)检查技术、径向支气管内超声(R-EBUS)检查技术、导航支气管镜(NB...     

侵袭性肺曲霉病1例并文献复习

目的提高对侵袭性肺曲霉病的临床、胸部影像学、病原学和病理改变的认识。方法对1例经病理证实的侵袭性肺曲霉病患者的职业、临床表现、胸部X线、CT、气管镜和病理资料并结合文献进行回顾性分析。结果侵袭性肺曲霉病的临床表现缺乏特异性，典型的影像学检查显示胸膜下单发或多发结节状或斑片状阴影，并呈动态变化。GM试验用于诊断侵袭性肺曲霉病具快速灵敏的特点；侵袭性肺曲霉病的病理可见由大小规范，呈两分叉（Y形）的分隔菌丝引起的特征性的血管侵害，也可以表现为局限性肉芽肿或广泛化脓性肺炎。结论侵袭性肺曲霉病的临床表现和影像学改变非常复杂，在诊断中需要综合患者的各种临床资料（包括临床症状、放射学、血清学检查和病理）。     

侵袭性肺曲霉病49例临床分析

目的 通过分析侵袭性肺曲霉病(IPA)病例,提高IPA临床诊治水平.方法 回顾性分析49例IPA患者的人口学资料、宿主因素、基础疾病、胸部CT表现、微生物检验、组织病理学检查、治疗和转归.结果 49例IPA患者确诊19例(38.8%),临床诊断30例(61.2%).3例(6.1%)无宿主因素,与1PA相关的宿主因素和基础疾病25例(51.0%),关系不肯定的基础疾病2l例(42.9%).胸部CT表现:结节29例次,斑片影15例次,团块12例次,实变10例次,空洞34例次,晕征19例次,支气管充气征18例次,新月征6例次,双肺影33例次,多发病灶38例次.痰真菌培养阳性率为26.5%(13/49),支气管肺泡灌洗液真菌培养阳性率为66.7%(10/15),曲霉半乳甘露聚糖试验阳性率为30.6%(11/36),肺组织病理检查阳性率为90.5%(19/21).烟曲霉为主要病原菌81.0%(17/21).抗真菌药物初始治疗有效率为50%(21/42).结论 IPA患者胸部影像学表现以双肺、多发、结节影、空洞为主,晕征、新月征少见.侵袭性诊断技术具有较好的诊断价值.     

原发性肺非霍奇金淋巴瘤三例影像学表现

目的　提高对原发性肺非霍奇金恶性淋巴瘤影像学表现的认识。方法　 3例经病理、临床证实的原发性肺非霍奇金恶性淋巴瘤 ,结合文献对其影像学 (胸部CT及X线片 )特征及病理进行分析讨论。结果　 3例患者均经CT导引肺穿刺切割肺活检获得标本并最终获得病理和免疫组织化学诊断 ,所有 3例在胸片和CT上存在着不同范围的肺实变 ,在所有实变病灶中见空气支气管征。其中 1例除了多个肺叶的实变外 ,在右下肺有一大小为 3.5cm× 3.0cm的肿块 ,在其它肺叶还有多个大小不等的结节 ,并且在肿块及部分结节中见空气支气管征。毛玻璃样改变或间质结构增厚所致的网格条索样改变在大多数肿块、结节和实变的边缘或其它部位存在。所有病灶中无坏死、空洞及钙化存在。无胸膜增厚及胸液。无明显的肺门及纵隔淋巴结肿大。结论　原发性肺非霍奇金恶性淋巴瘤影像学表现具有一定的特征 ,影像学表现有助于该疾病的诊断。经皮穿刺肺活检可有效的获得病理结果。     

AIDS肺孢子菌肺炎的支气管镜和胸部CT特点

目的探讨艾滋病(AIDS)相关肺孢子菌肺炎(PCP)电子支气管镜检查与胸部CT影像学表现的特点。方法对152例艾滋病相关肺孢子菌肺炎病人的胸部CT及电子支气管镜检查等资料进行回顾性分析。结果 152例病人中,CT影像学表现为双肺网格/粟粒/结节样改变40例(26.3%),磨玻璃样改变108例(71.1%),斑片/条索/实变90例(59.2%);支气管镜下主要表现为轻至中度充血136例(89.5%),无明显水肿142例(93.4%),管腔内少量分泌物128例(84.2%),以透明、泡沫样分泌物为主,共125例(97.7%)。支气管肺泡灌洗液六胺银染色镜检肺孢子菌阳性103例(67.8%),阴性49例(32.2%);阳性组及阴性组在CT影像学表现方面差异无统计学意义(P0.05)。结论电子支气管镜支气管肺泡灌洗液六胺银染色病原学检查,在肺孢子菌肺炎诊断方面的意义不优于CT影像学检查,作为艾滋病常见的机会性感染,肺孢子菌肺炎可以依据症状、体征及胸部CT影像学表现等积极进行临床诊断和治疗。     

支气管镜在气管支气管结核诊断中的临床价值

目的探讨支气管镜检查在气管支气管结核诊断中的临床应用价值,以用于气管支气管结核早期诊治。方法收集唐都医院呼吸内科2013年11月1日至2015年10月31日诊断的气管支气管结核212例住院患者临床资料,分析支气管镜检查结果及临床特点。结果 212例患者中,经电子支气管镜检查确诊为气管、支气管结核患者,其中痰菌阳性患者151例(71.2%),合并肺结核者195例,合并其他肺外结核者17例,具有结核中毒症状者182例,支气管镜下溃疡坏死型最多(29.7%)。由于气管支气管结核临床表现不特异,临床误诊率高,本组212例患者中,误诊率高达25.9%,误诊时间最长为8个月,临床危害大。结论支气管镜检查在气管支气管结核诊断中具有重要的临床价值。     

并殖吸虫病患者不同临床时期的胸部CT表现及其临床意义

目的 探讨并殖吸虫病不同临床时期的胸部CT表现及其临床意义.方法 收集2000年11月至2007年12月上海市肺科医院实验室检查证实为并殖吸虫病的患者48例,男30例,女18例.年龄9～66岁,平均31.4岁.均行胸部CT平扫,部分加增强扫描.结果 48例并殖吸虫病患者的胸部CT表现为支气管周围炎样改变9例;肺浸润性改变13例,胸部CT表现为单侧或双侧斑片状影,边缘模糊,部位及形态易变,少数病例可见特征性的"隧道"征;结节和肿块11例;囊状影及空洞6例;胸腔积液9例.并殖吸虫病患者不同临床阶段的胸部CT表现不同,感染早期表现为支气管周围炎样及浸润性改变,并出现胸腔积液;中期表现为结节、肿块、囊肿及空洞;稳定期表现为附壁结节、空腔、胸膜增厚或钙化.结论 并殖吸虫病患者不同时期的胸部CT表现不同.并殖吸虫病的诊断需密切结合临床资料和CT表现.     

CT引导下经皮肺穿刺活检对侵袭性肺真菌感染的诊断价值

目的探讨CT导向下经皮肺穿刺活检对侵袭性肺真菌感染的诊断价值。方法回顾性分析32例侵袭性肺真菌感染的病例资料,所有病例均行痰涂片、胸X线检查、胸部CT检查、纤维支气管镜检查、CT引导下经皮肺穿刺活检术,检出物送病理检查。结果 7例患者痰培养真菌阳性,纤维支气管镜检查肺泡灌洗液真菌培养均阴性,肺CT及胸X线表现为多发实变、结节状阴影、新月征、斑片状阴影、空洞征等。32例患者均经CT引导下经皮肺穿刺活检术（PCNB）,其中28例检出物病理检查确诊为真菌感染。穿刺后无严重并发症。结论对肺部难以确诊的侵袭性肺真菌病,CT引导下经皮肺穿刺活检是一种安全有效的方法。     

Computed tomography halo sign in pulmonary nodules: frequency and diagnostic value

On computed tomography (CT) scanning, a ground-glass opacity zone surrounding a pulmonary nodule has been named the computed tomography (CT) halo sign. To investigate the frequency and diagnostic value of the CT halo sign, the authors reviewed the CT examinations of 305 patients with proven diseases producing solitary or multiple nodules. The CT halo sign was seen in 22 patients (7%). Eleven patients had a solitary nodule; five patients had multiple nodules; and six patients had nodules associated with areas of pulmonary consolidation, or ground-glass opacity, or both. Solitary nodules were the result of bronchioloalveolar carcinoma (n = 5), tuberculoma (n = 2), squamous cell carcinoma, non-Hodgkin lymphoma, myxovirus infection, and metastasis (n = 1 each). Multiple nodules were the result of metastasis (n = 2), Kaposi sarcoma (n = 2), and Wegener granulomatosis (n = 1). Nodules associated with areas of consolidation or ground-glass opacity were the result of metastasis (n = 2), bronchioloalveolar carcinoma, bronchiolitis obliterans organizing pneumonia, eosinophilic pneumonia, and invasive pulmonary aspergillosis (n = 1 each). The data showed that the CT halo sign is a nonspecific finding. It is known that in immunocompromised patients the CT halo sign should suggest invasive pulmonary aspergillosis, Kaposi sarcoma, and lymphoproliferative pulmonary disorders. However, in immunocompetent patients, the authors found that a solitary nodule with the CT halo sign and pseudocavitations has a high likelihood of being a bronchioloalveolar carcinoma.     

Pulmonary invasive aspergillosis and candidiasis in immunocompromised patients: a comparative study of the high-resolution CT findings

The purpose of this study was to compare the high-resolution computed tomography (HRCT) findings of pulmonary invasive aspergillosis and candidiasis in immunocompromised patients. The study included 54 immunocompromised patients (32 men, 22 women; 10 to 68 years of age, median 40 years) with a diagnosis of Aspergillus (n=32) or Candida (n=22) pulmonary infection obtained by sputum culture, bronchoalveolar lavage culture, transbronchial biopsy, surgical biopsy, or autopsy. High-resolution CT images were assessed for the presence and distribution of nodules, consolidation and ground-glass opacities. Presence of the CT halo sign and cavitation was also recorded and the overall distribution of abnormalities was assessed. Comparison was made using the Fisher exact test. Nodules were the most common finding, present in 84% (27 of 32) of patients with aspergillosis and 95% (21 of 22) of patients with candidiasis (P>0.3, Fisher exact test). Centrilobular nodules were more common in patients with aspergillosis (26 of 27, 96%) than in those with candidiasis (11 of 21, 52%) (P<0.001) and random nodules more common in candidiasis (10 of 21, 48%) than in aspergillosis (1 of 27, 4%) (P<0.001). Presence of the CT halo sign, cavitation, and ground-glass opacities was similar in both groups. In summary, pulmonary aspergillosis and candidiasis in immunocompromised patients manifest with similar high-resolution CT findings. Centrilobular nodules and consolidation are more common in aspergillosis. The presence of halo sign or cavitation is not helpful in the differential diagnosis.     

Invasive pulmonary aspergillosis in solid organ transplant recipients

To discuss diagnosis, risk factors, clinical and radiologic manifestations of invasive pulmonary aspergillosis (IPA) that is accepted as an important mortality factor in organ transplant recipients. We retrospectively evaluated seven IPA cases who were diagnosed among 207 patients that had undergone organ transplantation surgery in our center between 1998-2001. Of seven patients, four was renal and three was liver recipients. Diagnosis was made histopathologically (three post-mortem, one transbronchial lung biopsy) in four patients while culture positivity (sputum and tracheal aspiration material) with clinical and radiological evaluation was the diagnostic criteria for three patients. The most common respiratory symptoms were fever, productive cough and dyspnea. The most common fiberoptic bronchoscopic findings were mucosal fragility, hemorrhage. In one patient plaque formation was found. One liver recipients had been on hemodialysis because of renal insufficiency (serum creatine was 2.6 mg/dL). All liver and kidney recipients had allograft failure. One liver and two kidney recipients had neutropenia, two liver and one kidney recipients had thrombocytopenia. Six patients had received amphotericin-B and/or itraconazole therapy. Four of the five exitus were receiving antifungal treatment. Three of them were lost in a short time while only one non-survivor had received itraconazole for three weeks. The most frequent CT findings were patchy infiltrations and nodule formation with or without cavitation. Five patients were lost in two months (mortality, 71.4 %), two survivors are under follow up. These findings showed, IPA should be thought in the differential diagnosis of pulmonary infections after organ transplantation.     

Community-acquired methicillin-resistant Staphylococcus aureus pneumonia: radiographic and computed tomography findings

OBJECTIVE: The aim of our study was to review the radiologic findings of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) pneumonia. MATERIALS AND METHODS: The hospital infection control computer database was used to identify patients who had a CA-MRSA infection with organisms isolated from blood, bronchoalveolar lavage fluid, or pleural fluid samples. Criteria for CA-MRSA pneumonia were consolidation seen on chest radiography or computed tomography (CT), growth of MRSA from sputum and/or sterile pulmonary site, clinical complaints of cough and/or shortness of breath. Chest radiographs and CT scans for 9 patients (5 men, mean age 45 y, range 35 to 71 y) were retrospectively reviewed by 2 chest radiologists. RESULTS: The most common chest radiographic finding was consolidation, which was bilateral in 7 patients and unilateral in 2 patients. The consolidation was patchy and nonsegmental in 5 and segmental in 4 patients. Two patients had cavitation evident on the chest radiograph. The most common CT scan findings were bilateral (n=8), often symmetric (n=5) consolidation, bilateral septal lines (n=7), and multiple nodules (n=5). Cavitation was present in 5 patients, either in regions of consolidation (n=5) or in large nodules (n=3). Five patients with CA-MRSA pneumonia had rapid clinical deterioration requiring ventilatory support. Two patients died. CONCLUSIONS: CA-MRSA pneumonia is characterized by extensive bilateral consolidation and frequent cavitation and is commonly associated with rapid progression and clinical deterioration. CT is superior to radiography in demonstrating the presence of cavitation.     

Invasive pulmonary aspergillosis in nonimmunocompromised, nonneutropenic hosts

Invasive pulmonary aspergillosis occurs predominantly in individuals who are neutropenic or who have severe defects in cell-mediated immunity. The isolation of Aspergillus from respiratory secretions of normal hosts usually signifies tracheobronchial colonization, not disease. Recent experience with three nonimmunocompromised patients who had invasive pulmonary aspergillosis, each of whom had Aspergillus isolated from respiratory secretions early in his illness, led to a reassessment of the significance of the isolation of Aspergillus from tracheobronchial secretions. Two of 10 nonimmunocompromised, nonleukopenic individuals who had pulmonary infiltrates and whose sputum yielded Aspergillus had invasive pulmonary aspergillosis, whereas two of five individuals who had pulmonary infiltrates and whose bronchial washings grew Aspergillus had invasive disease. These findings indicate that invasive pulmonary aspergillosis should be considered when Aspergillus is isolated from the respiratory secretions of anyone who has pneumonia, regardless of host defense status.     

Nodular pulmonary opacities in patients with rheumatoid arthritis. A diagnostic dilemma

Nodular opacities are a well-known pulmonary manifestation of rheumatoid arthritis (RA), occurring most often in seropositive men who smoke and have subcutaneous nodules. In the past 15 years two cases of lung carcinoma presenting as pulmonary nodules have been reported in patients with rheumatoid disease. We present seven patients with seropositive RA and subcutaneous nodules who had new pulmonary nodule(s) noted on chest roentgenograms. All but one were current smokers. Carcinoma was found in all patients at bronchoscopy or thoracotomy. Four patients had solitary nodules (one was cavitary); the remaining three patients had multiple bilateral nodules that cavitated in one case. All patients had interstitial abnormality (peribronchial/vascular thickening) with basal predominance in three, and there was evidence of pleural thickening/fluid in three patients. These results strongly suggest that histologic proof of presumed rheumatoid pulmonary nodules be obtained.     

溺水后侵袭性曲霉病三例并文献复习

目的 提高临床医生对溺水后侵袭性曲霉病（invasive aspergillosis IA）的认识。方法收集2005年10月至2010年8月南京军区南京总医院收治的3例,结合文献报道的8例溺水后IA的临床症状、病程及影像资料进行分析。结果 3例溺水后IA中女2例,男1例,年龄为18、32和72岁。溺水前均无免疫功能缺陷的临床表现。2例因车祸溺水,1例意外跌入污水池。3例溺水后均出现呼吸衰竭,并接受气管插管机械通气和广谱抗生素治疗;1例出现一过性白细胞减少,2例接受糖皮质激素治疗。3例均在溺水后9～11d出现病情加重,2例痰培养曲霉阳性。3例胸部CT均见双肺多发结节、实变及空洞影。1例发生颅内曲霉感染,头颅核磁共振检查示多发性脑脓肿。1例死亡,尸检确诊曲霉侵袭肺、脑、心肌及肾脏;2例为临床诊断,曲霉仅侵袭肺脏,经治疗好转出院。文献报道溺水后IA较少。以“near-drowning”和“aspergillosis”为检索词,未设定时间限制,搜索Pubmed数据库,共获得7例溺水后IA的病例报道;以“溺水”和“侵袭性肺曲霉病”为检索词检索中国期刊网全文数据库、万方数据库和中国医院数字图书馆期刊全文数据库,获得1篇国内溺水后IA的病例报道[11]。8篇报道中,最早发表于1984年,最近的发表于2010年,其中5例为确诊病例,3例为临床诊断病例。结论 免疫功能正常的宿主溺水后可罹患IA。曲霉感染多发生在溺水后1～2周,合并中枢神经系统的IA患者预后差。     

Comparison of CT features of Aspergillus and bacterial pneumonia in severely neutropenic patients

PURPOSE: To establish whether a relationship exists between computed tomography features of lung opacities in severely neutropenic patients and their Aspergillus or bacterial etiology. METHODS: Computed tomography scans of 124 patients with lung opacities larger than 5 mm occurring during severe (neutrophils <500/mm) and prolonged (>7 d) neutropenia-induced by bone marrow transplantation and/or high-dose chemotherapy for hematologic malignancies-were reviewed. Invasive pulmonary aspergillosis or bacterial pneumonia were assessed by means of bronchoalveolar lavage, bronchial washing, trans-bronchial biopsy or (for bacteria only) blood cultures. Pulmonary opacities were classified as nodules or as consolidations. The presence of a perinodular ground-glass halo, the similarity of consolidations to a pulmonary infarction and the presence of cavitation (crescent-shaped or not) were recorded. RESULTS: Invasive pulmonary aspergillosis was diagnosed in 68 patients; bacterial pneumonia in 56. Nodules (85) were more common than consolidations (39); their distribution among the patients with aspergillosis (52 nodules and 16 consolidations) and those with bacterial pneumonia (33 nodules and 23 consolidations) was even. Out of the 19 nodules surrounded by a halo 17 were due to aspergillosis. Nine consolidations (3 due to aspergillosis) were infarctionlike shaped. Cavitation appeared during 22/68 aspergillosis and 31/56 bacterial pneumonias; an air-crescent in 6 patients with aspergillosis and in 24 with bacterial pneumonia. CONCLUSIONS: Although rare enough, the perinodular halo is highly specific for invasive aspergillosis. The nodular pattern of lung opacities, their similarity to a pulmonary infarction, the occurrence of cavitation and the air-crescent are not related to aspergillosis.     

Importance of open lung biopsy in the diagnosis of invasive pulmonary aspergillosis in patients with hematologic malignancies

Invasive pulmonary aspergillosis is a serious infectious complication in immunocompromised patients. Recent reports indicate its favorable clinical outcomes by early diagnosis with chest computed tomography scan. We retrospectively analyzed our experiences with histopathological evaluation by open lung biopsy in 31 patients (32 cases) with hematologic malignancies, suspected of having invasive pulmonary aspergillosis clinically and radiologically. Although the initial computed tomography findings of all cases were highly indicative of invasive pulmonary aspergillosis by demonstrating nodules or masses with a halo sign (16 cases), segmental area of consolidation with ground-glass attenuation (7 cases), both nodules or masses with a halo sign and segmental area of consolidation with ground-glass attenuation (7 cases) and poorly defined centrilobular nodules (2 cases), we could histopathologically confirm invasive fungal infections only in 17 cases (53.1%) by open lung biopsy. There were 13 cases of invasive pulmonary aspergillosis, two cases of aspergilloma, and two cases of mucormycosis. No fungal hyphae were found in the other 15 cases: organizing pneumonia in seven cases, pulmonary hemorrhage in three cases, brochiolitis obliterans with organizing pneumonia in two cases, and CMV pneumonia, pulmonary tuberculosis, candida pneumonia in one case each, respectively. We could perform open lung biopsy without mortality and significant morbidity. In view of the low positive predictive value of chest computed tomography scan and the very low morbidity of open lung biopsy, this procedure is recommendable for the diagnosis of invasive pulmonary aspergillosis and determination of its treatment.