第214课继发性肺结核secondary tuberculosis of lung（二）

zskyteacher 2019-08-16

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本题解析出自上期（第213课）内容：浸润性肺结核是较常见的继发性肺结核表现类型，多见于成年人。该病具有相对好发的部位，即两肺上叶的尖段、后段（约占80%）和两肺下叶背段（约占15%），少数亦可发生于肺下叶的基底段或其他部位；病变可以局限，也可累及多个肺段或双侧肺。

Invasive pulmonary tuberculosis is a common type of secondary pulmonary tuberculosis, mostly seen in adults. The disease occurs relatively well in the apical and posterior segments of the upper lobe of both lungs (about 80%) and the dorsal segment of the lower lobe of both lungs (about 15%). Lesions may be limited or may involve multiple lung segments or both lungs.

这期讲以干酪样病变为主的继发性肺结核；以干酪样病变为主的继发性肺结核主要包括干酪样肺炎和结核球（这块我们下期讲）。干酪样肺炎是指累及肺段以上的大范围的干酪样坏死性炎症。

This episode is about the secondary tuberculosis mainly caused by cheese - like lesions. The primary secondary pulmonary tuberculosis with caselike lesions mainly includes caselike pneumonia and tuberculous pellets (we will discuss next time). Caseous pneumonia refers to a wide range of caseous necrotic inflammation that extends beyond the lung.

干酪样肺炎又称结核性大叶性肺炎，是继发性肺结核中最为急重的一种类型。常在大量结核分枝杆菌侵入、毒力强、机体变态反应增高和免疫力低下的情况下发生，常易引起单发或多发小空洞以及支气管播散病灶。早期干酪样肺炎的实变区密度均匀或浓淡不均，无空洞及支气管播散病灶，痰菌多阴性，与肺炎鉴别困难。待病情进展时，结核性实变病灶随即发生干酪样坏死和液化溶解，其密度呈现浓淡不均，可出现多发低密度区。X线平片上，表现为肺段或肺叶的致密实变影，轮廓较模糊，与大叶性肺炎的表现类似，但病灶密度更高，其内常可见大小不等、形态不整的透亮区，即虫蚀样空洞或无壁空洞，常采用高电压摄影或体层摄影才能显示的更为清晰，有时在病灶的内侧或对侧肺野可见结节或斑片状支气管播散病灶。

Caseous pneumonia, also known as tuberculous lobar pneumonia, is the most serious type of secondary tuberculosis. Often in a large number of tuberculosis mycobacterium invasions, virulence is strong, airframe allergy is heighten and immune force is low circumstance happens, often cause single or multiple small cavity and bronchus to spread a disease focus easily. Early caselike pneumonia had uniform density or uneven density, no cavity and bronchial disseminated lesions, and sputum bacteria were mostly negative, which was difficult to differentiate from pneumonia. When the disease progresses, caseous necrosis and liquefaction of the tuberculous solid lesions occur immediately. The density of the lesions is uneven, and multiple low-density areas can appear. X-ray plain film, is manifested as pulmonary segments or consolidation of the lung density shadow outline is fuzzy, similar to the performance of lobar pneumonia, but higher density of lesions, which often can be seen the bright area of the size, shape is not the whole, the worm hole or without hole wall corrosion samples, often using high voltage photography or ct can show more clear, sometimes in the inside of the lesions or the contralateral lung nodules are visible or patchy endobronchial spread lesions.

↑ 两肺大叶性肺炎并发干酪样肺炎

左图为感染初期X线胸片，两肺弥漫大叶性实变影，密度均匀

右图为长期抗感染治疗后复查X线胸片，呈干酪样、空洞及纤维化影

↑ 左上肺干酪样肺炎：左图为X线平片，右图为体层摄影片。可见左上肺大片状致密影，其内可见多发大小不等、形态不整的类似虫蚀样空洞。

CT扫描更有助于显示干酪样病变累及的范围、病灶内部的多发虫蚀样空洞以及其他肺叶的支气管播散病灶等改变。小叶性干酪样肺炎多呈小叶性分布，以上肺多见，周边有时可见磨玻璃密度影，大叶性干酪样肺炎可累及肺段或整个大叶的范围，其内可出现多发类似虫蚀样的无壁空洞，代表干酪样坏死的多灶性来源，与普通大叶性肺炎相似，有时亦可见到空支气管征，但可伴有实变区内支气管扩张、狭窄和中断，类似枯树枝样改变，提示气道发生不可逆损坏。肺结核干酪样病灶进展过程中出现空洞意味着播散的开始，也就是说在干酪样坏死物排空时结核分枝杆菌就已经发生了支气管播散，一般沿支气管树呈节段性分布，多发生在干酪样病灶的周围，也可发生于对侧肺野，但一般患侧多于健侧，上肺先于下肺。CT上表现为节段性分布的直径2-4mm的小叶中心结节和分支状结构影，即树芽征，或直径为5-8mm，边缘模糊的结节影。CT上发现支气管播散病灶对肺结核的诊断与活动性判定具有重要的作用，此时患者痰涂片亦多呈阳性。重症干酪样肺炎由于出现大面积干酪样坏死，经抗结核治疗很难吸收，CT表现以肺实变病灶机化、患病肺体积缩小和肺叶变形为特点，是毁损肺形成的主要原因之一，此时胸廓可有不同程度的塌陷。

CT scan is more helpful to show the range of involvement of cheese - like lesions, polyphasic cavity in the lesion, and other bronchospread lesions in the pulmonary lobes. Lobular caseous pneumonia are distributed in many lobular, lung, above ground glass density around sometimes visible, lobar caseous pneumonia can be affected lung segment or the scope of the whole big leaf, it can appear more like insect damage without walls empty, on behalf of the multifocal source of caseous necrosis, similar to ordinary lobar pneumonia, sometimes also can see air bronchogram, but may be accompanied by bronchiectasis, narrow and consolidation area interruption, like dead change, prompted the airway irreversible damage occurs. Tuberculosis cavity appeared in the process of cheese lesion progress means the beginning of the spread, that is to say, in the caseous necrosis when emptying of mycobacterium tuberculosis has happened endobronchial spread, general segmental distribution along the bronchial tree, tend to occur around cheese lesion, can also occur in the contralateral lung field, but in general than the contralateral side, on pulmonary ahead of the lung. On CT, the central nodules and branching structures of the lobule with a diameter of 2-4mm and segmental distribution were shown, that is, tree buds, or nodules with a diameter of 5-8mm and indistinct edges. It was found on CT that bronchial disseminated lesions had an important role in the diagnosis and determination of pulmonary tuberculosis, at which time the sputum smear of the patient was mostly positive. Severe caselike pneumonia is difficult to be absorbed by anti-tuberculosis treatment due to the large area of caselike necrosis. CT findings are characterized by the institutionalization of pulmonary solid lesions, the reduction of diseased lung volume and the deformation of lung lobes, which is one of the main reasons for the formation of damaged lung. At this time, the thoracic cavity may have different degrees of collapse.

↑ 小叶性干酪样肺炎：

左上肺多发小叶性范围致密实变影，中央密度很高，周边伴磨玻璃密度影

右上肺多发小叶实变影，伴病灶周围磨玻璃阴影

↑ 肺段分布的干酪样肺炎：CT显示左上肺后段干酪样实变影，密度不均，其内可见虫蚀样空洞

↑ 大叶性干酪样肺炎：CT扫描显示左下肺大叶范围干酪样实变影，其内可见多发虫蚀样空洞影及斑点状钙化影

以干酪样病灶为主的继发性肺结核，在MRI上的形态学表现与CT类似、一般来说，干酪样坏死病灶在T1WI上呈中等或略低信号，T2WI上呈不均匀高信号，如周边伴有纤维或肉芽组织可出现强化，而干酪样坏死物质无强化，如伴有较大的钙化灶可显示低信号。此外，MRI显示干酪样病灶内的虫蚀样空洞较为敏感。

Is given priority to with cheese lesion of secondary pulmonary tuberculosis, morphology on the MRI manifestations and CT is similar, in general, caseous necrosis lesions were middle or slightly low signal on T1WI, T2WI in the heterogeneous high signal, such as surrounding with fiber or granulation tissue can appear reinforcement, and caseous necrosis material without reinforcement, such as with larger calcifications can show low signal. In addition, MRI showed that the wormlike cavity in the cheese - like lesions was more sensitive.