第189课 病例探析（037）—肺曲霉菌病

上期试题：关于骨肿瘤好发部位，下列描述错误的是E

A．血管瘤：椎体、颅骨

B．软骨瘤：手的短管状骨

C．骨样骨瘤、尤文肉瘤：长骨骨干

D．成骨肉瘤：长骨干骺端

E．骨巨细胞瘤：扁骨

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女，42岁，间断性咯血一年。

      肺曲菌病(pulmonary aspergillosis，PA)属霉曲菌感染，曲菌是条件致病菌，当曲菌孢子侵人人体后，健康人对曲菌有很强的抵抗力，一旦机体免疫力减退或抵抗力下降时可大量繁殖而致病。

     aspergillus lung disease (pulmonary aspergillosis, PA) belong to the bad music bacterium infection, aspergillus is conditional pathogenic bacteria, after the music bacterium spores of shooting the human body, a healthy person to music bacterium has a strong resistance, once decreased immunity or resistance can multiply and cause disease.

     曲霉菌在整个自然界无处不在，当吸入真菌时，可以导致易感宿主发病。人类感染最主要的曲霉菌是烟曲霉。这个病原体，以菌丝体的形式存在，菌丝在角度为45°时有特征性的分枝，在整个在自然界中均可发现。其他重要的曲霉菌物种还有土曲霉。

      Aspergillus is everywhere in nature, and when inhaled, it can lead to the onset of susceptible hosts. The most important aspergillus in human infection is aspergillus. The pathogens, in the form of mycelium, hyphae in the Angle of 45 ° characteristic of the branch, in the whole can be found in nature. Other important aspergillus species have aspergillus Niger.

烟曲霉引起的感染传统学上分为4种不同的形式：

1、侵袭性曲霉菌

2、半侵袭性曲霉菌（即慢性坏死性曲霉菌）

3、过敏性曲霉菌

4、曲霉球

艾滋病患者曲霉菌感染的一种罕见表现为阻塞性支气管曲霉病。

There are four different types of infection that are caused by aspergillus Niger:

1. Invasive aspergillus.

2. Semi-invasive aspergillus (chronic necrotic aspergillus)

3. Allergic aspergillus.

4. Aspergillus

A rare manifestation of aspergillus infection in AIDS patients is obstructive bronchial aspergillosis.

      当易感性宿主吸入病原体时发生曲霉菌感染。烟曲霉感染有各种高位因素，与感染的不同形式有关。

     Aspergillosis occurs when the susceptible host inhales the pathogen. Aspergillus Niger infection has various high - level factors, which are related to different forms of infection.

     曲菌在组织中主要引起急性化脓性炎和坏死性炎，PA早期的基本病理变化是出血性肺梗死引起的凝固性坏死，相邻肺泡出血使病灶周围可见出血性边缘，其影像表现为“晕征”。因坏死组织的部位、范围、形态不同而影像表现各异。曲菌球病理学上由空洞(空腔)内的曲菌丝、纤维、黏液混合而成团块。

     aspergillus in the organization the main cause of acute suppurative inflammation and necrotizing inflammation, PA early is the basic pathological changes of coagulation necrosis caused by hemorrhagic pulmonary infarction, adjacent alveolar hemorrhage make visible hemorrhagic lesions around edges, the images show the 'halo sign'. The image of necrotic tissue varies according to its location, range and morphology. In the pathophysiology of aspergillus, it is a mixture of hyphae, fiber and mucus in the cavity.

影像学特点

Imaging features.

1、肺部炎症样改变：CT表现为胸膜下楔形、不规则片状致密影，边缘模糊，可累及多个肺叶及肺段，可与结节灶同时存在。胸膜下楔形实变影对曲菌病的诊断有重要价值，与其出血性肺梗死的表现一致。

1. Pulmonary inflammatory changes: the CT findings are subpleural cuneiform, irregular patchy dense shadows, blurred edges, and multiple pulmonary and pulmonary segments, which can coexist with the nodules. The diagnosis of aspergillosis in the subpleural wedge is of great value and is consistent with that of hemorrhagic pulmonary infarction.

2、单发或多发结节：大多位于肺的中外带，结节大小不一，在CT图像上，其边缘可见略低于结节密度而又高于肺实质的环形“磨玻璃”样改变，称为“晕征”或“环征”。结节+晕征是肺曲菌病较特征的早期表现。CT检查可发现早期肺内较小的结节影。肿块样浸润指病灶直径大于75px的软组织块影，无分叶及毛刺，周围可出现“晕征”。

2, single or multiple nodules: mostly in the lung and band, nodule size, on the CT image, the edge is slightly below the nodes density and higher than the ring 'ground glass' change of lung parenchyma, referred to as the 'halo sign' or 'ring'. Nodules + halos are early manifestations of pulmonary aspergilloma. CT examination revealed small nodules in the early lung. Mass infiltration refers to a soft tissue block with a diameter greater than 75px, without leaves and burrs, and can appear 'halo' around.

3、曲菌球：一般寄生在肺部慢性疾病所致的空洞或空腔内，常见的有结核空洞、支气管扩张、先天性肺囊肿等。空洞大小不等、洞壁薄厚不一，其内曲菌球一般呈圆形或卵圆形，密度均匀，边界光整，在洞内处于游离状态，可随体位改变而移动，曲菌球与洞壁之问形成一新月形的含气腔隙。曲菌球具有特征性的诊断价值。

3. Aspergillus globule: commonly parasitic in the cavity or cavity caused by chronic diseases of the lungs, commonly found in nodules, bronchiectasis, congenital pulmonary cyst, etc. Have different hole size, width, thick, its aspergillus ball generally assumes the circular or ovoid, uniform density, boundary finishing, in the free state within the hole, can change with position and movement, music bacterium ball and asked to form a crescent of the width of gas-bearing lacuna. The aspergillus ball has characteristic diagnostic value.

4、支气管扩张：肺部及气道反复感染，可引起黏液嵌塞及支气管扩张，常以肺门近侧的段及亚段支气管扩张为明显，CT图像上为条索状高密度灶内可见低密度“裂隙”影，HRCT能清楚显示该征象，此为本病的另一特点。

4, bronchiectasis, lung and repeated infection of the airway, can cause mucous plug and bronchiectasis, often in the lung near side of the period and the period of bronchiectasis is apparent, CT images can be seen in the article for the funicular high-density focal low density shadow 'crack', HRCT can clearly show the sign, this is another feature of the disease.

5、其他改变：当曲菌侵犯胸膜时，可引起胸腔积液、胸膜增厚粘连；曲菌感染经淋巴管蔓延时，可见肺门及纵隔淋巴结肿大。

5. Other changes: when aspergillus invaded the pleura, it could cause pleural effusion, pleural thickening and adhesion; When aspergillus infection is spread through lymphatic vessels, it can be seen that hilar and mediastinal lymph nodes are enlarged.

本期试题：真菌性肺炎最常见的病原菌是？

A.白假丝酵母菌

B.曲霉菌

C.毛霉菌

D.新型隐球菌

E.卡氏肺孢菌