S1-HIV感染肺炎.ppt

pneumonia in hiv, approached by specific diseases 通過(guò)特定疾病考察 hiv感染肺炎,causes of pulmonary disease associated with human immunodeficiency virus infection 與人類(lèi)hiv感染有關(guān)的肺部疾病的病因,mandell, douglas, and bennetts principals and practice of infectious disease. sixth edition. 傳染性疾病的要點(diǎn)與實(shí)踐：第六版,最常見(jiàn)病因 細(xì)菌 肺炎鏈球菌 流感嗜學(xué)血桿菌 未發(fā)現(xiàn)微生物，但對(duì)抗細(xì)菌藥物有反應(yīng) 分枝桿菌 結(jié)核分枝桿菌 真菌 肺囊蟲(chóng)肺炎 不常見(jiàn)但在某些場(chǎng)合可具有重要臨床意義 細(xì)菌 綠膿桿菌 金黃色葡萄球菌 腸桿菌科 軍團(tuán)菌 奴卡菌 馬紅球菌 分枝桿菌 坎沙西分枝桿菌 鳥(niǎo)型分枝桿菌復(fù)合物 真菌 新型隱球菌 莢膜組織胞漿菌 厭酷球孢子 曲霉菌 皮炎芽生菌 馬爾尼菲青霉菌,病毒 流感病毒 巨細(xì)胞病毒 單純皰疹病毒 腺病毒 呼吸道合胞病毒 副流感病毒 寄生蟲(chóng) 剛地弓形蟲(chóng) 糞類(lèi)圓線蟲(chóng) 微孢子蟲(chóng) 微小隱孢子蟲(chóng) 非感染性 卡波濟(jì)肉瘤 非何杰金淋巴瘤 肺癌 原發(fā)肺動(dòng)脈高壓 充血性心力衰竭 淋巴細(xì)胞性（或淋巴樣）間質(zhì)肺炎 肺氣腫 阿巴卡韋過(guò)敏,distribution of aids cases by five opportunistic infections in thailand, (data as of september 1984-march 2004) 泰國(guó)按5種機(jī)會(huì)性感染分類(lèi)的aids病例組成情況， （1984年9月-2004年3月數(shù)據(jù)）,3.3%,14.7%,4.6%,25.6%,18.7%,bureau of epidemiology, cdc , moph,mycobacterium infection - mycobacterium tuberculosis (m. tb) - mycobacterium avium complex (mac) fungal infection - pneumocystis jirovecii - cryptococcus neoformans bacterial infection - nocardia spp. - rhodococcus equi - miscellaneous,key opportunistic organisms for pneumonia in hiv+ patients hiv陽(yáng)性患者肺炎主要機(jī)會(huì)性致病性微生物,分枝桿菌感染 - 結(jié)核分枝桿菌 (m. tb) - 鳥(niǎo)分枝桿菌復(fù)合物 (mac) 真菌感染 - 肺囊蟲(chóng)肺炎 - 新型隱球菌 細(xì)菌感染 - 諾卡氏菌 - 馬紅球菌 - 其它細(xì)菌,mycobacterium tuberculosis 結(jié)核分枝桿菌 (m. tb),結(jié)核-hiv的聯(lián)合流行分布,impact of tb on hiv,leading aids-related oi enhance hiv replication might accelerate the natural progression of hiv infection drug interaction between rmp vs. arv,結(jié)核對(duì)hiv的影響,結(jié)核是首要的艾滋病相關(guān)機(jī)會(huì)性感染 結(jié)核可增強(qiáng)hiv復(fù)制 結(jié)核有可能加速hiv感染的自然病程 利福平與抗逆轉(zhuǎn)錄藥物的相互作用,impact of hiv on tb,high rate of primary tb and reactivation increase incidence of extrapulmonary and disseminated tb increase incidence of paradoxical reaction might need longer treatment course more adverse drug reactions increase incidence of mdr-tb high mortality rate,hiv對(duì)結(jié)核的影響,原發(fā)結(jié)核的高發(fā)病率和再激活 增加肺外結(jié)核和播散性結(jié)核的發(fā)病率 增加異常反應(yīng)的發(fā)生率 可能需要延長(zhǎng)療程 增加藥物不良反應(yīng) 增加耐多藥性結(jié)核病的發(fā)生率 高死亡率,clinical manifestations of active tb in early versus late hiv infection hiv感染早期和晚期活動(dòng)性結(jié)核的臨床表現(xiàn),for practical purposes , early and late may be defined as cd4+cell counts 300 cells/mm and 300 個(gè)細(xì)胞/mm a和 200個(gè)細(xì)胞/mm,a,a,radiographic pictures of tb/hiv,cd4 300 - patchy or nodular infiltration - location in apical or subapicoposterior segment of upper lobe or superior segment of lower lobe - dry, thick wall cavitation (50%), air-fluid level is uncommon - lymphadenopathy is unusual - pleural effusion could be found,“typical radiographic pattern of ptb”,結(jié)核/hiv的放射學(xué)檢查圖象,cd4 300 - 斑片或結(jié)節(jié)浸潤(rùn)影 - 定位于肺尖或上葉尖下后段或下葉上段 - 干性厚壁空洞 (50%)，氣液平不常見(jiàn) - 淋巴腺病不常見(jiàn) - 可見(jiàn)胸膜滲出,“肺結(jié)核的典型放射線表現(xiàn)”,radiographic pictures of tb/hiv,cd4 200 - alveolar infiltration, diffuse interstitial infiltration, or mixed infiltration - location in any segments or lobes - common enlarged lymphadenopathy - common extrapulmonary involvement - normal cxr (14-20%) in advanced aids (cd450),“non-specific radiographic pattern”,結(jié)核/hiv的放射學(xué)檢查圖象,cd4 200 - 肺泡浸潤(rùn)，彌漫間質(zhì)浸潤(rùn)或混合浸潤(rùn) - 定位于任何肺段或肺葉 - 一般化增大的淋巴結(jié) - 一般化的肺外受累 - 晚期艾滋病患者(cd450)可有正常的x線表現(xiàn) (14-20%),“非特異放射線表現(xiàn)”,afb stain; acid-fast bacilli 抗酸桿菌染色； 抗酸桿菌,gram stain; ghost bacilli 革蘭氏染色； 血影桿菌,h&e stain 蘇木素和伊紅染色,afb stain 抗酸桿菌染色,mycobacterium avium complex 鳥(niǎo)分枝桿菌綜合癥 (mac),mac infection in non-hiv,prior history of underlying lung pathology middle-age to old man typical radiographic pictures - upper lobe fibronodular lesion, associated with pleural thickening - cavitations tend to be higher than tuberculosis (60-90% vs. 50%) and more likely to be thin-wall, quite large - pleural effusion is common,“pulmonary disease”,非hiv感染者的mac感染,有基礎(chǔ)肺疾病史 從中年到老年均可發(fā)生 典型放射線表現(xiàn) - 上葉纖維結(jié)節(jié)病灶，與胸膜增厚有關(guān) - 空洞的發(fā)生比結(jié)核多（分別為60-90%和50%），更多見(jiàn)大的薄壁空洞 - 胸膜滲出常見(jiàn),“肺部疾病”,mac infection in a 52-year-old copd man, with history of prolong fever, weight loss, cough, intermittent hemoptysis, and dyspnea 某52歲慢阻肺患者的mac感染，持續(xù)發(fā)熱，體重下降，咳嗽，間斷性咯血和呼吸困難,mandell, douglas, and bennetts principals and practice of infectious disease. sixth edition.,mac infection in aids-patients,cd4 50 the most common organs involved; - spleen, liver, intestines, colon, lymph nodes, bone marrow the less common organs involved; - lung (10%), adrenal glands, stomach, central nervous system (cns) radiographic pictures, simulating tb; - alveolar/interstitial infiltration - nodules/cavitations are uncommon - adenopathy is not dominant,“disseminated disease”,艾滋病患者的mac感染,cd4 50 最常受累的器官： - 脾，肝，小腸，結(jié)腸，淋巴結(jié)，骨髓 最少受累的器官： - 肺 (10%)，腎上腺，胃，中樞神經(jīng)系統(tǒng) (cns) 放射線表現(xiàn)類(lèi)似于結(jié)核： - 肺泡/間質(zhì)浸潤(rùn) - 結(jié)節(jié)/空洞不常見(jiàn) - 腺病不是主要的,“播散性疾病”,pneumocystis jirovecii (carinii) （卡氏）肺囊蟲(chóng)肺炎,您可以預(yù)防卡氏肺囊蟲(chóng)肺炎： hiv感染者指南,pcp in non-hiv,immunocompromised host at risk for pneumocystosis - hematological malignancies and solid tumors - solid organ/bone marrow transplant recipients - collagen vascular disorders - use of cytotoxic/immunosuppressive therapy especial corticosteroids insidious onset of progressive dyspnea on exertion, fever, + dry cough and cyanosis in 1-2 weeks,非hiv感染者的卡氏肺囊蟲(chóng)肺炎,免疫受損宿主易發(fā)生肺囊蟲(chóng)肺炎 - 血液系統(tǒng)惡變和實(shí)體腫瘤 - 實(shí)體器官/骨髓移植接受者 - 膠原血管異常 - 使用細(xì)胞毒/免疫抑制治療，尤其是皮質(zhì)激素 緩慢發(fā)作的勞力性進(jìn)展性呼吸困難，發(fā)熱， +干咳，紫紺（1-2周）,radiographic pictures of pcp,typical pattern: - normal cxr (10-39%) in early disease - diffuse bilateral infiltration (ground-glass appearance) atypical pattern: - thin-wall cyst, bleb - - risk for pneumothorax - unilateral infiltration, nodules, cavitations lymphadenopathy, pleural effusion,卡氏肺囊蟲(chóng)肺炎放射線表現(xiàn),典型表現(xiàn): - 早期疾病可有正常胸部x線表現(xiàn) (10-39%) - 彌漫性雙側(cè)浸潤(rùn)（毛玻璃樣表現(xiàn)） 非典型表現(xiàn): - 薄壁囊，氣泡 - - 發(fā)生氣胸風(fēng)險(xiǎn) - 單側(cè)浸潤(rùn)，結(jié)節(jié)，空洞，淋巴腺病，胸膜滲出,pcp in aids-patients,cd4 200 disease burden is higher but severity is less symptoms; lasting from weeks to months extrapulmonary pneumocystosis; in advanced aids without pcp prophylasis or only aerosolized pentamidine cxr; cavitations, lymphadenopathy and pleural effusion are unusual,“cavity, adenopathy and pleural effusion are unusual”,艾滋病患者卡氏肺囊蟲(chóng)肺炎,cd4 200 疾病負(fù)荷更高，但嚴(yán)重度較小 癥狀：持續(xù)數(shù)周到數(shù)月 肺外肺囊蟲(chóng)肺炎：可見(jiàn)于不做pcp預(yù)防治療或僅做戊烷脒霧化治療的進(jìn)展期艾滋病患者 胸部x線表現(xiàn)：空洞、淋巴腺病、胸膜滲出不常見(jiàn),“空洞、腺病和胸膜滲出不常見(jiàn)”,gms stain; cluster of round or cup shaped cysts gms染色； 成堆的圓形或杯狀囊,h frothy eosinophilic honeycombed material filling alveolar space 蘇木素和伊紅染色； 空泡化嗜酸粒蜂窩樣物質(zhì)充填于肺泡間隙,cryptococcal neoformans 新型隱球菌,cryptococcal infection in non-hiv,susceptible hosts symptoms range; - asymptomatic colonization of the airway to life- threatening pneumonia (depend on immune status) radiographic characteristics include; - well-defined noncalcified single/multiple nodules, mass-like infiltration or dry thin-wall cavitations the two common sites are lung and cns,非hiv感染者的新型隱球菌感染,易感宿主 癥狀范圍： - 從氣道的無(wú)癥狀聚集到威脅生命的肺炎都可能發(fā)生（取決于免疫狀態(tài)） 放射線特點(diǎn)包括： - 分界清楚的非鈣化單發(fā)/多發(fā)結(jié)節(jié)，腫塊樣浸潤(rùn)或干性薄壁空洞 兩個(gè)常見(jiàn)部位為肺和中樞神經(jīng)系統(tǒng),mandell, douglas, and bennetts principals and practice of infectious disease. sixth edition.,hiv感染 淋巴增生異常 肉瘤 皮質(zhì)激素治療 高-igm綜合征 高-ige綜合征 單克隆抗體（如英利昔單抗） 系統(tǒng)性紅斑狼瘡* hiv陰性cd4+ t淋巴細(xì)胞減少癥 糖尿病# 器官移植* 腹膜透析 肝硬化 * 免疫抑制治療可能導(dǎo)致易感性。 # 糖尿病長(zhǎng)期以來(lái)就被認(rèn)為是新型隱球菌感染的危險(xiǎn)因素。但由于糖尿病是一個(gè)很常見(jiàn)的疾病，因此不能確定糖尿病就是新型隱球菌感染的危險(xiǎn)因素。 摘自 casadevall a, perfect jr.新型隱球菌，華盛頓：asm press；1998:410,表261-1：已知或可能與新型隱球菌感染有關(guān)的情形,mandell, douglas, and bennetts principals and practice of infectious disease. sixth edition.,cryptococcal infection in aids-patients,cd4 100 more cns and extrapulmonary infections for cns infection; - high rate of +india ink, +cryptococcal ag, +blood culture, and few csf inflammatory cells for lung infection (only 5-25% of cases); - coinfection have been reported with tb, pcp, nocardiosis,“l(fā)imited pneumonia is uncommon and coinfection is considered”,艾滋病患者的新型隱球菌感染,cd4 100 更多的中樞神經(jīng)系統(tǒng)和肺外感染 中樞神經(jīng)系統(tǒng)感染： - 高陽(yáng)性率的印度墨汁染色，新型隱球菌抗原，血培養(yǎng)和腦脊液炎性細(xì)胞 肺感染（發(fā)生率只有5-25%）： - 曾見(jiàn)于結(jié)核、卡氏肺囊蟲(chóng)肺炎、諾卡菌病的聯(lián)合感染,“限制性肺炎不常見(jiàn)，此時(shí)要考慮聯(lián)合感染”,cryptococcal pneumonia in aids-patients,radiographic pictures; - diffuse bilateral interstitial infiltration (mimic pcp) - focal/nodular infiltration, consolidation, dry thin-wall cavitations - lymphadenopathy - pleural involvement is unusual,“radiographic patterns often mimic pcp”,艾滋病患者的新型隱球菌肺炎,放射線表現(xiàn)： - 彌漫雙側(cè)間質(zhì)浸潤(rùn)（酷似卡氏肺囊蟲(chóng)肺炎） - 局灶/結(jié)節(jié)浸潤(rùn)，實(shí)變，干性薄壁空洞 - 淋巴腺病 - 胸膜受累不常見(jiàn),“放射線表現(xiàn)常酷似卡氏肺囊蟲(chóng)肺炎”,afb stain; encapsulated yeast cells and acid-fast bacilli 抗酸桿菌染色; 包囊化酵母細(xì)胞和抗酸桿菌,wright stain; encapsulated yeast cells 萊特染色； 包囊化酵母細(xì)胞,nocardia spp. 諾卡氏菌,nocardiosis,preexisting immunocompromised host; - alcoholism - diabetes mellitus - organ transplantation/lymphoreticular neoplasm - long-term corticosteroid usage - chronic lung disease - aids 3 forms; 1. progressive cutaneous/lymphocutaneous disease 2. pulmonary disease 3. disseminated infection: cns, eye, skin, bone&joint, heart, lung and kidney,諾卡菌病,存在免疫受損的宿主： - 酗酒 - 糖尿病 - 器官移植/淋巴網(wǎng)狀系統(tǒng)腫瘤 - 長(zhǎng)期應(yīng)用皮質(zhì)激素 - 慢性肺疾病 - 艾滋病 3種形式： 1. 進(jìn)展性皮膚/淋巴皮膚疾病 2. 呼吸疾病 3. 播散感染：中樞神經(jīng)系統(tǒng)，眼，皮膚，骨/關(guān)節(jié)，心臟，肺和腎,nocardiosis,radiographic pictures; - irregular nodules, mass-like condolidation, abscesses, reticulonodular infiltration - pleural effusion/empyema - contiguous extension to deep structures and surface nocardiosis in aids-patients; - cd4 200 - overall incidence in aids-patient is low!,“clinical clues to suspected nocardiosis” spread to contiguous structures, especially soft tissue swellin