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单击此处编辑母版标题样式,编辑母版文本样式,第二级,第三级,第四级,第五级,2016/2/27,#,非结核分支杆菌病影像学NTM修改,非结核分枝杆菌肺病的发病率逐年上升。,因临床、影像表现与其他疾病相似，极易误诊为其他疾病。,非,结核分枝杆菌,（,nontuberculous,mycobacteria,，,NTM,）,指除,结核分枝杆菌（,MTB,）复合群和麻风分枝杆菌以外的一大类分枝,杆菌。,NTM,感染,指感染,了,NTM,，,但未,发病。,NTM,病,指感染,了,NTM,，,并引起相关组织、脏器的,病变。,一、什么是非结核分支杆菌,二、细菌学分类,1.,伯杰细菌分类系统（生长速度）,.,快速生长型,.,缓慢生长型,2.,Runyon,分类,.,光产色菌（,eg.,堪萨斯分枝杆菌,、海分枝杆菌）,.,暗产色菌（,eg.,瘰疬分枝杆菌）,.,不产色菌（,eg.,鸟,-,胞内分枝杆菌复合菌组（,MAC,）,、嗜血分枝杆菌）,.,快速生长分枝杆菌（,eg.,脓肿分枝杆菌,、龟分枝杆菌、偶发分枝杆菌）,三、,NTM,流行病学,传播途径：,自然环境（主要为水和土壤），潮热地带为主，尚未发现动物,人及人,人间传播证据。,台湾地区,MAC,（,30%,）、脓肿分枝杆菌（,17.5%,）、偶发分枝杆菌（,13.0%),上海,龟分枝杆菌（,26.7%,）、偶发分枝杆菌（,15.4%,）、堪萨斯分枝杆菌（,14.2%,）、,MAC,（,13.1%,）,东亚地区,MAC,（,67%,）、快速生长分枝杆菌（,16%,）,我国,NTM,发病率呈上升 趋势,1990,年（,4.9%,）,2010,年（,22.9%,）,四、发病机制,（与,MTB,类似）,感染途径：呼吸道、消化道、皮肤等，为,条件致病菌。,致病过程：中性粒灭杀巨噬细胞吞噬、溶酶体酶溶解抗原及菌体成分转运至局部淋巴结激活效应细胞、释放细胞因子,CD+T,细胞（释放,-,干扰素和,IL-12,等）等介导免疫反应和迟发型变态反应。,肿瘤坏死因子,-,（,TNF-,）：激活其他细胞因子、上调黏附分子表达、促进巨噬细胞活化、,参与肉芽肿形成、导致组织坏死和空洞形成,，,TNF-,拮抗剂英夫利昔和可溶性受体依那西普可能使,NTM,感染发展为活动性,NTM,病。,NTM,肺病常发生于结构性肺部疾病基础上（如,COPD,、支扩、肺,TB,、囊性纤维化、尘肺等）。,具有某些表型特征，如绝经期、脊柱侧弯、漏斗胸、二尖瓣脱垂和关节伸展过度等，可对,NTM,易感。,五、病理变化,菌体成分及抗原与,MTB,有共性，,毒力较,MTB,弱，干酪样坏死较少，机体组织反应较弱,1.NTM,肺病,病理反应：渗出性反应：淋巴细胞、巨噬细胞浸润、干酪样坏死,；,增殖性反应：类上皮细胞、朗汉斯巨细胞肉芽肿形成,；,硬化性反应：细胞萎缩、胶原纤维增生。,组织学分型：纤维空洞或类结核型、支气管扩张型、结节型及其他（肺纤维化、肺气肿和肺不张等）。,坏死和空洞形成,，,常,多发或多房性，侵及,双肺,，位于,胸膜下,，,薄壁,为主，空洞坏死层较厚且稀软。,2.NTM,淋巴结病,早期,：肉芽肿形成，淋巴结粘连、质,韧；晚期,：纤维化、钙化，或迅速干酪样坏死及软化、破溃形成慢性,窦道。,3.,皮肤,NTM,病,最易侵犯,真皮和皮下脂肪组织,，其次为,深层,肌肉组织；,主要病理表现：,肉芽肿性病变，非特异性慢性化脓性炎症,早期,：急性炎症反应、,渗出,晚期,：硬结、脓肿、窦道,形成,4.,播散性,NTM,病,最常侵犯,肝脏、淋巴结和胃肠道,，亦可累及,肺、,骨髓、,心和肾,肉眼观：,肝、脾、,淋巴结肿大，可见,柠檬色,肉芽肿,镜下：弥漫性肉芽肿，由特征性,纹状组织细胞,组成，仅少数为典型,肉芽肿。,六,、临床及影像学表现,1.NTM,肺病（最为常见）,-,影像上需要鉴别！,主要致病菌种：,MAC,、脓肿分枝杆菌、偶发分枝杆菌。,女性患病率高于男性，老年人居多，尤其是,绝经期妇女,最为常见，大多已有基础肺部疾病。,大多为,缓慢起病,，临床症状表现差别较大。,症状和体征：与肺结核相似，,全身中毒症状较轻。,影像学：胸片：多为炎性病灶及单发或多发薄壁空洞，多累及,上叶尖段和前段；,胸部,CT:,通常以,多种形态病变,混杂存在，如：结节影、斑片及小斑片样实变影、空洞影、支扩、树芽征、磨玻璃影、线状及纤维条索影、胸膜肥厚粘连等。,肺功能：通气功能减退较肺结核更为明显。,2.NTM,淋巴结病,（儿童中最常见,）,-,影像上需要鉴别！,主要致病菌种：,MAC,、嗜血分枝,杆菌。,多见于儿童，,1-5,岁最常见，,10,岁以上少见，男：女为,1,：,1.3-2.0,。,最常累及上颈部和下颌下淋巴结，其次为耳部、腹股沟和腋下淋巴结，单侧多,见。,多无全身症状体征，仅有局部表现，无或轻度压痛，迅速软化、破溃形成慢性,窦道。,PPD,试验多呈弱阳性，,NTM,抗原皮试为强,阳性。,超声或,CT,：非对称,性淋巴结肿大，,周围炎症反应较,轻，对此可酌情选择,MRI,检查评价。,3.NTM,皮肤病,-,临床上易忽视的！,主要致病菌种：偶发分枝杆菌、脓肿分枝杆菌,等。,可引起皮肤及皮下软组织,病变。,局部脓肿,常见，多位于,针刺伤口、开放性伤口或骨折处,，往往迁延不,愈。,亦可为,皮肤感染（,Buruli,溃疡）、游泳池肉芽肿、类孢子丝菌病、皮肤播散性和多中心,结节灶。,4.,播散性,NTM,病,-,临床上易忽视！,主要致病菌种：,MAC,、堪萨斯分枝杆菌、脓肿分枝杆菌,等。,见于,免疫功能,受损者，多,见于,HIV,感染，,亦可,见于,脏器,移植,、长期应用,皮质,激素,和白血病等。,可有淋巴结病、骨病、肝病、胃肠道疾病、心内膜炎、心包炎和脑膜炎,等。,临床表现多种多样，最常见为不明,原因持续性,或间歇性发热，多有进行,性体重,减轻、夜间盗汗,可有轻度腹痛甚至持续性腹痛、腹泻、消化不良、肝脾肿大、皮下多发性结节或脓肿,等。,实验室检查：全血细胞减少，,CD4+T,细胞降低，血清碱性磷酸酶和乳酸脱氢酶升高，肝功能异常，体液或分泌物涂片、培养抗酸染色多为阳性。,5.,其他,NTM,病,-,临床上易忽视！,主要致病菌种：海分枝杆菌、,MAC,。,可引起手或腕部滑膜慢性病变、化脓性关节病、牙龈病变、泌尿,生殖系、眼、,胃肠道疾病,等。,八、诊断,1.NTM,感染,的诊断：皮肤试验阳性，缺乏组织、器官侵犯证据。,2.,疑似,NTM,病,（,具备上述,7,项之一,即可考虑为疑似,NTM,病）,痰抗酸染色阳性，临床表现与肺结核不相符；,痰液显微镜发现异常分枝杆菌；,痰或其他标本分枝杆菌培养阳性，菌落形态及生长与,MTB,不相符；,正规抗结核无效而且反复排菌，肺部病灶以支扩、多发性小结节及薄壁空洞为主；,支气管卫生净化处理后痰分枝杆菌未能转阴；,有免疫功能缺陷，但已除外肺结核者；,医源性或非医源性软组织损伤，或外科术后伤口长期不愈而不明原因者。,3.NTM,病,（,无论,NTM,肺病还是肺外,NTM,病，或是播散性,NTM,病，均需进行,NTM,菌种,鉴定）,NTM,肺病,：,呼吸和,（或）全身症状,+,胸部,影像,+,排除其他疾病,+NTM,培养和,（或）病理学,特征改变；,肺外,NTM,病,：局部和（或）全身症状,+,排除其他疾病,+NTM,培养；,播散性,NTM,病,：,相关症状,+,肺或肺,外病变,+,血培养,NTM,阳性和（或）骨髓、,肝脏,等,穿刺,物,NTM,培养。,九、治疗,1.,治疗原则,治疗前药敏试验；,根据药敏试验结果和用药史，,5-6,种,药物联合治疗，,强化期,6-12,个月，巩固期,12-18,个月,，,NTM,培阳,阴转后继续治疗,12,个月以上,；,不同,NTM,病用药种类、疗程不同；,不建议对疑似,NTM,病患者行经验性治疗；, NTM,肺病慎用外科手术治疗。,2.,治疗药物,新型大环内酯类：克拉霉素（巨噬细胞和组织内浓度较高）、阿奇霉素；,利福霉素类,:,利福平、利福他汀（肝代谢酶诱导作用较弱）；,乙胺丁醇：最常用的基本,药物；,氨基糖苷类：链霉素、阿米卡星（主要针对,MAC,）、妥布霉素（主要针对龟分枝杆菌）；,氟喹诺酮类：,DC-159a,、氧氟沙星、环丙沙星、左氧氟沙星、加替沙星和莫西沙星（主要针对,MAC,、偶发分枝杆菌,）；,头孢西丁：主要针对快速生长分枝杆菌（对,99%,脓肿分枝杆菌敏感,）；,其他：主要为针对快速生长分枝杆菌的药物，如四环素类（多西环素、米诺环素、替加环素）、磺胺类（磺胺甲恶唑、复方磺胺甲恶唑）、碳青霉烯类（伊米培南,/,西司他丁）、利奈唑,胺。,NTM,感染肺部影像解读,NTM,影像表现,：,小叶中心结节,NTM,影像学表现：树芽征,NTM,影像学表现：肺实变,NTM,影像,学表现,：多中心肺,实变,NTM,影像学表现：多灶性磨玻璃影,鸟胞内分枝杆菌,（,MAC,）感染肺部,空洞及空腔,Jong Woon Song,，,et al,AJR 2008; 191:W160W166,鸟胞内分枝杆菌（,MAC,）感染肺部结节影,Jong Woon Song,，,et al,AJR 2008; 191:W160W166,鸟胞内分枝杆菌（,MAC,）支气管扩张,Jong Woon Song,，,et al,AJR 2008; 191:W160W166,鸟胞内分枝杆菌复合体（,MAC,）支气管扩张,Jong Woon Song,，,et al,AJR 2008; 191:W160W166,Pulmonary,Nontuber-culous Mycobacterial Infection,:,Radiologic Manifestations,Jeremy J,et,al,RadioGraphics 1999; 19:14871503,Pulmonary M avium-intracellulare infection in a 50-year-old woman with a chronic cough. (a) Posteroanterior chest radiograph shows heterogeneous areas of increased opacity in the right upper lobe with volume loss. The patient responded poorly to antimycobacterial therapy and underwent right upper lobe resection. (b) Posteroanterior chest radio-,graph,obtained 3 years after resection shows consolidation in the upper aspect of the,right lung,and new areas of increased opacity in the left lung. The diagnosis of recurrent M,aviumintracellulare,infection was confirmed with transbronchial lung biopsy. The infection,responded,poorly to antimycobacterial therapy, and right pneumonectomy was performed.,Persistent infection resulted in chronic empyema in the right pleural space. (c),Posteroanterior,chest radiograph obtained 1 year later shows air in the right pleural space, a finding,consistent,with a bronchopleural fistula from chronic M avium-intracellulare infection.,Note the,scattered heterogeneous areas of increased opacity in the left lung.,鸟胞内分枝杆菌,（,MAC,）感染,女，,50,岁。慢性咳嗽。,A),右上肺高密度伴体积缩小。对抗分支杆菌治疗不敏感。,B,）,3,年后，右上叶实变，左侧肺出现病灶。活检证实,MAC,感染，药物治疗不敏,感，行右上肺切除术。右侧胸腔持续感染而导致脓胸。,C,）一年后，支气管胸膜瘘。,Pulmonary M avium-intracellulare infection in a 72-year-old woman with a chronic cough,. M,avium-intracellulare was cultured from the sputum. (a) Posteroanterior chest radiograph,shows scattered, bilateral, pulmonary areas of increased opacity with focal consolidation in the lingula.,There is,right paratracheal adenopathy (arrows). (b) Posteroanterior chest radiograph obtained 5 years,later after,long-term antituberculous drug therapy shows progressive volume loss in the upper lobes, in-,creased paratracheal adenopathy (arrow), and improvement in the areas of increased opacity in,the right,upper lobe and lingula. New areas of increased opacity have developed in the middle lobe (,arrowhead,).,女，,72,岁，肺,MAC,感染，慢性咳嗽。,MAC,痰培养阳性。,胸,片可见双侧肺散在局灶高密度影，右侧纵隔淋巴结增大。经长期抗结核治疗，,5,年后胸片显示上叶气管旁淋巴结体积渐缩小，右上叶和左侧舌叶密度增高影改善。右侧肺中叶新增病灶。,Pulmonary M,avium-intracellulare infection,in a 58-year-old woman with a history,of chronic,cough and recent onset of shortness,of breath,and fatigue. Posteroanterior chest,radiograph,shows thin-walled cavities in the right,upper,lobe and a well-defined nodule in the left,upper,lobe (arrow). There are scattered,heterogeneous,and small nodular areas,of increased opacity,bilaterally,女性，,58,岁。肺,MAC,感染，慢性咳嗽、近来呼吸短促、疲乏。胸片显示右上叶薄壁空洞，左上叶边界清楚的结节灶。双侧肺多发性高密度结节灶。,Pulmonary,MAC,infection in a 43-year-old man with chronic,obstructive lung,disease, digital clubbing, and a chronic productive cough. Bronchial washings were positive for,MAC.,(a) C,hest,radiograph shows heterogeneous linear and,nodular areas,of increased opacity in the left lung. There is marked destruction of the right lung with,architectural,distortion and an air-fluid level in the superior segment of the right lower lobe. The patient,was poorly,compliant with antituberculous therapy and presented 20 months later with progressive,weight loss,and hemoptysis. (b) C,hest,radiograph shows progressive destruction of the,upper lobes,with a large bulla in the right upper lobe. Heterogeneous areas of increased opacity are,present in,the left upper lobe (arrows), and there is associated architectural distortion and traction,bronchiectasis,(arrowheads). (c) Left bronchial arteriogram shows a bronchial arterypulmonary artery,fistula (,arrows).,The,patient died after massive hemoptysis.,男，,43,岁，慢阻肺，肺,MAC,感染，杵状指、慢性咳嗽；支气管灌洗液,MAC,阳性。,a),胸片：左肺不均匀线样、结节样高密度影，右肺结构显著破坏，并右下叶背段可见气液平；,20,个月期间抗痨治疗不规则，伴进行性体重减轻及咯血。,b),胸片：右上叶进行性破坏伴右上叶肺大泡；左肺上叶不均匀密度增高灶（箭），伴肺结构破坏及牵拉性支扩（箭头）。,C),左肺支气管动脉造影显示支气管动脉,-,肺动脉瘘（箭）。病人大咯血后死亡。,Pulmonary M avium-intracellulare infection in a 50-year-old man with a,history of,resected nonsmall cell lung cancer and recent onset of weight loss and hemoptysis,. (,a) Posteroanterior chest radiograph obtained 4 years before admission shows sutures (,arrow,) and scarring in the right upper lobe from partial pulmonary resection. (b),Posteroanterior,chest radiograph obtained at admission shows progressive volume loss, more areas of,increased,opacity around the sutures, and adjacent pleural thickening. M avium-,intracellulare was,cultured from bronchial washings. No malignant cells were found, and the,patient,s condition,improved with appropriate antimycobacterial therapy.,男，,50,岁，肺,MAC,感染，既往有非小细胞癌病史，进来消瘦、咯血。,a),入院前,4,年胸片显示右上叶切除后的缝合（箭）和瘢痕。,b),入院时胸片显示病变肺体积缩小加重、,更,致密，邻近胸膜增厚。支气管灌洗液培养,MAC,阳性，没有恶性细胞，经抗分支杆菌治疗后，症状改善。,Pulmonary M avium-intracellulare infection in a 64-year-old man with a,historyof chronic,weight loss, cough,and occasional,hemoptysis. (a) Posteroanterior chest,radiograph,shows scattered nodular areas of increased opacity and volume loss in both,upper lobes,. Note the cavity in the right upper lobe with an air-fluid level and biapical pleural,thickening,. (b) Coronal,(FDG) positron emission,tomographic,scan shows marked increased FDG uptake in the upper lobes and in the wall of,the right,upper lobe cavity. Although increased FDG uptake is usually indicative of malignancy, false-positive,studies can occur with NTMB infection. C = normal cardiac activity, H =,hepatic,activity, M = mediastinal activity.,男，,64,岁，肺,MAC,感染。咳嗽、体重减轻、偶有咯血。,a),胸片：双上肺体积缩小、其中见散在分布的结节样高密度区；右上空洞气液面及胸膜增厚,.,b)PET,冠状图示双上叶病变、,右上叶空洞,壁明显高摄取。这种易误认为恶性肿瘤的高摄取同样可见于,NTMB,感染。,Pulmonary M kansasii,infectionin,a 28-year-old woman with a history,of surgically,treated tricuspid atresia who,presented,with weight loss, fever, and a cough,. (,a) Posteroanterior chest radiograph,shows heterogeneous,areas of increased,opacity in,the right upper lobe. (b, c) CT scans,show a,large upper lobe cavity (b) and small,nodular, tree-in-bud areas of increased,opacity (,c) in the dependent portion of the,right lung, which are due,to endobronchial spread,of infection.,女，,28,岁，肺堪萨斯分支杆菌感染。外科治疗三尖瓣闭锁术后，消瘦、咳嗽、发热。,a),、胸片示右上叶密度不均匀病灶。,b,、,c),、,CT,示右上叶大的空洞（,b,）和由于支气管播散所致的高密度小结节、“树芽征”（,c,）,Pulmonary M avium-intracellulare infection in a 67-year-old woman. The infection,was proved,with resection of the lingula. Close-up CT scans of the right lung show mild cylindrical,bronchiectasis,(arrow) and small centrilobular nodules in the middle lobe (arrowhead in a).,女，,67,岁，舌叶切除标本证实,肺,MAC,感染。,CT,扫描图：,右肺中叶轻度柱状支扩（箭）；小叶中心结节（,a,图箭头）,Pulmonary M avium-intracellulare infection in a 70-year-old white woman with a chronic cough, malaise, and weight loss. M avium-intracellulare was cultured from bronchial washings. Thin-section CT scans (,1-mm collimation) show atelectasis and bronchiectasis bilaterally, more severe in the middle lobe and lingula,. Note,the small, peripheral, tree-in-bud areas of increased opacity (arrow in a) and the 1.5-cm-diameter nodule,in the,left lower lobe (arrow in b).,女，,70,岁，慢性咳嗽、不适及体重减轻，支气管灌洗液培养证实肺,MAC,感染。薄层,CT,扫描示双侧肺散在不张及支扩，以右肺中叶及左肺舌叶著。,注：外周区树芽征（,a,图箭）、左下叶,1.5cm,结节（,b,图箭）。,Pulmonary M avium-intracellulare infection in a 60-year-old,asymptomatic,woman. (a) Close-up posteroanterior chest radiograph of the right lung,shows scattered, small, heterogeneous areas of increased opacity and a thin-walled cavity,in the right upper lobe (arrowheads). (b) Close-up thin-section CT scan of the,right lung,shows the thin-walled cavity in the right upper lobe, as well as a,communicating,bronchus (arrowheads) and small centrilobular nodules (arrows).,60,岁，女。肺,MAC,感染，无症状。,胸片示右上肺片状高密度影伴薄壁空洞。,薄层,CT,显示薄壁空洞及引流支气管（箭头）；小叶中心结节（箭）,Pulmonary M,aviumintracellulare,infection in a,42-yeold,woman with a chronic cough,. Sputum,cultures were negative.,M avium-intracellulare,infection,was diagnosed,with transbronchial,lung biopsy,. Thin-section CT scan (,1-mm collimation,) shows cylindrical,bronchiectasis, bronchial wall thickening, and,tree-in-bud areas of,increased opacity,女，,42,岁。慢性咳嗽，痰培养阴性，内镜活检证实,MAC,感染。薄层,CT,显示柱状支扩、支气管壁增厚、树芽征。,Pulmonary M chelonae,infection in,a 45-year-old asymptomatic woman.,Close up,posteroanterior chest radiograph of the,right lower lobe shows a well-defined,noncalcified, 1-cm-diameter nodule (arrow). M,chelonae,infection was diagnosed at resection.,Pulmonary M avium-intracellulare infection in a 29-year-old man with AIDS.,(a) Close-up posteroanterior chest radiograph of the upper right lung shows a mass in,the apex,of the lung (arrows) without hilar or paratracheal adenopathy. (b) CT scan shows a,heterogeneous,soft-tissue mass (M) in the right upper lobe abutting the mediastinum and,chest wall,. Biopsy revealed granulomatous inflammation, and a culture was positive for M,aviumintracellulare,.,女，,45,岁，龟分枝杆菌感染，无症状。非钙化性结节灶,29,岁，男性，艾滋病人。右肺尖肿块，,不伴肺门和纵隔淋巴结增大。活检为炎性肉芽肿，细菌培养：,MAC,阳性,Disseminated M avium-intracellulare infection in a,35-year-old,man with AIDS who presented with a cough and,fever.,Sputum cultures were,negative,. M avium-intracellulare infection was diagnosed with,bronchoscopy and transbronchial,biopsy. Posteroanterior chest,radiograph shows,masslike areas of increased opacity and smaller, scattered,nodular,areas of increased opacity in the upper lobes. There is no hilar,or mediastinal,adenopathy.,男，,35,岁。艾滋病，咳嗽、发热。痰培养阴性，内镜活检为,MAC,。胸片双上肺块状高,密度影，呈结节状分布。没有肺门、纵隔淋巴结增大。,Disseminated M,avium intracellulare,infection in a,33-year-old,man with AIDS who,presented with,weight loss, pyrexia, and,back pain,. (a) Posteroanterior chest,radiograph,shows diffuse small,nodules with,basal predominance. There is,no hilar or mediastinal adenopathy,. (,b) Chest CT scan also shows small, discrete,nodules. Transbronchial,biopsy,was positive for M,avium-intracellulare,. (c) CT scan of the,abdomen shows,a right psoas abscess (arrow,). Needle,aspiration was positive for,M avium-intracellulare,.,男，,33,岁，艾滋病人。胸片弥漫性小结节，,CT,见散在结节；右侧腰大肌脓肿，活检均为非结核分支杆菌感染（,MAC,）。,女，,36,岁。体检发现肺部病变，体温低热，咳嗽，有痰，既往年幼时即发生过肺感染，以后间断发生并抗感染治疗,后,缓解。,2016,年,网络,会诊病例,抗痨治疗后症状缓解,该病例,10,年前的,CT,检查,此例显然符合在原肺部疾病基础上感染,NTM,E N D,
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