肺炎的X线表现和鉴别诊断

Case report 1





Patient N.L.Hg. female, 18 y/o living in Thai Binh province. Admitted on 13/01/04, died on 23/01/04. History of contact to flu chicken. But she with another sister together looked after her brother who had died with diagnosis of acute atypic pneumonia (no sample collected) just 3 days before. Main complains: High sudden fever, dry cough, headache, no shortness of breath. Physical examination: temp 39.90C, pulse 90, BP 110/60, RR 20/min. Oxygen saturation 98%. Other signs were normal. Lab findings on admission: WBC 4.8 G/L, (67% neutrophils), platelets 139 G/L, BUN 3.3mmol/l. Chest X-ray :“ no remarkable changes”.
（3）病变的范围：早期病变为局限性片状阴影， 进展后呈多灶性或弥漫性分布，可累及一个或 多个肺段、肺叶，也可位于一侧肺或双肺。但 一般不按肺叶或肺段分布。 病灶进展快 ，重症 患者很快出现双肺弥漫性病变。 （4）动态变化：胸部影像表现变化较快。重症 患者肺内病变 进展迅速 ，短期内病灶明显增多， 从小片到大片，从单侧到双侧。病变密度也发 生明显的变化。在恢复过程中肺内病变的 吸收 也较快。
影像学检查在肺炎诊疗中的作用价值
X线平片是诊断肺炎的主要方法，其价值为： ▶可确定肺部有无病变 ▶可确定部位 ▶可确定范围 ▶了解病变的动态变化 ▶了解有无合并症 ▶观察治疗效果和判断预后
▶肺炎主要采用X线平片检查。
▶ CT检查主要用于肺炎合并症的诊断以及X线
诊断困难的病例。
▶肺炎的病原诊断需根据临床及病原学检查
Case 3
Case 3
Case 3
Case report 4
• Patient T.V.C male, 19 y/o living in Bac Giang province. • Admitted on 16/01/04. Discharged on 30/01/04. • Having no history of contact with flu chicken.. But many ill chicken died around area where patient was living. • Present history: 5 days of illness at home. High fever, sputum coughing and shortness of breath. He Admitted to Bac Giang provincial hospital, CXR showed serious lesions. The next day, condition became more critical with difficulty in breath and he was refered to NICRTM. • On admission: temp 38.50C, pulse 84, BP 110/70, RR 54/min, crackle rales in both 2 sides of lung. SaO2 82%. • Lab findings : WBC 3.9 G/L, (75.5% neutrophils), platelets 127 G/L, BUN 6.6mmol/l. • Chest X-ray : Opacities with unclear boundary over 2 lungs. • Management: Oxygen therapy with mask, Tamiflu, Axepim（头孢吡肟） Solumedrol. SaO2 was improved 91-95%. • Clinical course: After 2 days of treatment: Condition was improved. No longer fever or shortness of breath. SaO2 95-99%. Lab findings: WBC 10.8 G/l, GOT 148, GPT 194, LDH 1014. + Discharged on the day of 14th.
Case 1
12.01.04
14.01.04
Hale Waihona Puke Baidu
Case 1
16.01.04
19.01.04
Case 1
21.Jan.o4
23.Jan.o4
Case report 2
• • • • • Patient N.L.Hh. female, 23 y/o living in Thai Binh province. Admitted on 13/01/04, died on 23/01/04. She was older sister of the case 1. Main complains on admission: Fever, dry cough and diarrhea, no shortness of breath. Physical examination: temp 39.60C, pulse 100, BP 100/60, RR 20/min, no rales in both lungs. Oxygen saturation 99%. Other signs were normal. Lab findings on admission: WBC 5.6 G/L, (69% neutrophils), platelets 131 G/L, BUN 3.4mmol/l. Chest X-ray : no remarkable changes. Clinical course: On the 4th day : Became worse with continuous fever 390C, coughing, shortness of breath RR 40/min, crackle rales in both lungs, SaO2 was 86%. BP 100/60. WBC 3.5 G/l. GOT 77, GPT 40 U/l. Addition treatment with oxygen therapy by mask and antibiotics Axepim（头孢吡肟）， Tavanic, Zithromax and Solumedrol（甲强龙），But it seemed to be uneffected.
（ 5 ）合并症：易发生急性呼吸窘迫综合征 (ARDS) 合并ARDS时两肺出现广泛实变影像。 辅助通气治疗的患者可发生气胸和纵隔气肿。少 数可合并胸腔积液。
（ 6 ）影像与临床的联系：临床表现严重时，肺部 影像改变也最为广泛。当临床状况好转时，肺部影 像也逐渐吸收。但也有报道肺部影像正常及病变较 轻者而死亡的病例。
肺炎的X线表现和鉴别诊断
何 来 昌
南昌大学第一附属医院影像科
肺炎的分类
▶引起肺部急性炎症的病原有细菌、病毒、真菌、 原虫、寄生虫，其他病因有过敏、理化因素及放 射线等。
▶根据X线及病理大体形态，肺炎分为大叶性肺炎、 支气管肺炎（小叶性肺炎）和间质性肺炎。 ▶由于各种肺炎有时有其特征性表现，因此需要了 解不同原因肺炎的影像表现。
▶影像检查可以提供鉴别诊断的可能范围
▶数字化的影像技术具有较高的应用价值（CR、
DR）可提高图像的质量、可防止交叉感染
入院时
入院3天后
人禽流感肺炎的影像表现
▶人禽流感未引起肺部病变时X线胸片所见正常。 ▶当引起肺炎时出现胸部异常影像： （ 1 ）病变形态：人禽流感肺炎的基本影像表现是 肺内片状影像，病变形态可表现为斑片状、大片状 及斑片融合影像，边缘模糊。病变密度呈肺实变或 磨玻璃密度，可见“空气支气管征”。肺纹理增粗 模糊。 （ 2 ）病变部位：病变位于一侧或两侧肺部，上、 下肺野均可有病变，多以双下肺为重。常为两肺弥 漫性分布。
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Case 2
13.01.04
14.01.04
Case 2
16.01.04
19.01.04
Case 2
20.01.04
21.01.04
Case report 3
• Patient P.T.B. female, 30 y/o living in Ha Nam province. • Admitted on 05/01/04, died on 09/01/04. • Having history of contact with flu chicken. She looked after her daughter who had died of acute atypic pneumonia (H5N1 confirmed) at the Pediatrics Hospital just 2 days before. • Main complains: Feeling fatigue, fever, chest discomfort and shortness of breath. She went to provincial hospital and CXR was performed but no change on film. However, on the 3rd of the illness, respiratory distress quickly developed and she was refered to NICRTM. • On admission: temp 380C, pulse 90, BP 80/40, RR 30/min. Oxygen saturation 64%. • Lab findings : WBC 1.7 G/L, (63.5% neutrophils), platelets 66 G/L, BUN 14.3mmol/l. • Chest X-ray : changes with opacities unclear boundary infiltrations over 2 lungs . • Management: Oxygen therapy with mask but no effect, BiPAP ventilation was applied. SaO2 was around 83-90%. Antibiotics Axepim （头孢吡肟）, Solumedrol，Tequin and Dopamin（多巴胺） were ministered also.
Case 4
Case 4
Case 4
Case report 5
• Patient L.T.H female, 20 y/o living in Bac Ninh province. • Admitted on 16/01/04. Discharged on 11/02/04. • Having history of contact with flu chicken.. Many ill chicken died around area where patient was living. • Present history: 7 days of illness at home. High fever, sputum coughing and shortness of breath. • On admission: temp 38.20C, pulse 120, BP 100/60, RR 58/min, crackle rales in both 2 sides of lung. SaO2 80%. • Lab findings : WBC 7.2 G/L, (87.3% neutrophils), platelets 211 G/L, BUN 3.7mmol/l. • Chest X-ray : Opacities with unclear boundary over 2 lungs. • Management: Oxygen therapy with mask, Tamiflu； Axepim（头孢吡肟） • Solumedrol（甲强龙） ，SaO2 was improved 91-95%. • Clinical course: After 3 days of treatment: Condition was improved. No longer fever or shortness of breath. SaO2 95-99%. Lab findings: WBC 10.8 G/l, GOT 37, GPT 84+ Discharged on the day of 26th.