树芽征-省放射年会.ppt
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1、肺部CT 树芽征的诊断价值,甘肃省张掖市人民医院影像中心 主任医师 黄宝生,树芽征(Tree-in-Bud Pattern),树芽征是指病变累及细支气管以下的小气道,由于小气道的扩张和管腔内炎性物质的填充,在肺部薄层CT(thin-section computed tomography)或HRCT上表现为直径2mm4mm的小叶中心软组织密度结节影和与之相连的分支线状影,状如树芽而得名。,The tree-in-bud pattern is commonly seen at thin-section computed tomography (CT) of the lungs. It consis
2、ts of small centrilobular nodules of soft-tissue attenuation connected to multiple branching linear structures of similar caliber that originate from a single stalk,树芽征,最早由Im等描述为结核杆菌沿支气管内播散的CT表现, Paslawski等则认为树芽征是细支气管炎的典型HRCT征象,其形成基础是小叶中心支气管内脓液、粘液、肉芽肿或炎性细胞充填所致。Pipavath等也认为树芽征和小叶中心结节为细支气管炎的直接征象。,病因,本
3、征可见于累及小气道的多种肺疾病,包括周围性气道感染(细菌、病毒、霉菌或寄生虫感染)、先天性疾病、特发性疾病(闭塞性细支气管炎、弥漫性泛细支气管炎)、吸入性肺炎、毒气吸入、免疫性疾病、结缔组织病、周围性肺血管病(如肿瘤性栓塞)和肿瘤支气管内转移等 。 树芽征是由多种影响小气道的病变所引起的一种非特异性征象。,病因,感染(Infection) 先天性病变(Congenital Disorders) 特发性疾病(Idiopathic Disorders) 异物吸入 毒气吸入 结缔组织病 免疫性疾病 肿瘤(Neoplasms),(一) 感染(Infection),1、细菌性感染(Bacterial I
4、nfection),树芽征常见于结核杆菌沿支气管内播散的患者,该征的出现高度提示结核具有活动性。,HRCT表现,通常表现为2mm4mm大小的小叶中心结节和分支样线状影,合并表现有支气管壁增厚,伴有或不伴有支气管扩张、气腔实变影、空洞、血行播散所致的边缘清楚小结节影、胸腔积液、淋巴结肿大(伴有中心坏死)等。Kashyap 等认为树芽征和小叶中心结节是支气管内结核的特征性HRCT表现。 (Kashyap S, Mohapatra PR, Saini V. Endobronchial tuberculosisJ. Indian J Chest Dis Allied Sci. 2003;45(4):2
5、47-256. ),Postprimary active tuberculosis in a 66-year-old woman with a chronic cough. High-resolution CT scans of the right lung show peripheral, poorly defined, small (24-mm-diameter) centrilobular nodules and branching linear opacities of similar caliber originating from a single stalk (the tree-
6、in-bud pattern) in the lower lobe (arrow). These findings represent endobronchial spread of tuberculosis.,Postprimary active tuberculosis in a 34-year-old man with weight loss and a chronic cough. (a) High-resolution CT scan of the left lung shows a thick-walled cavity and multiple peripheral small
7、nodules and branching linear structures (arrows). Note the thickening of the bronchial walls (arrowhead).,Photomicrograph (original magnification, x400; hematoxylin-eosin stain) shows impacted caseous material (*) in small peripheral airways (arrow).,男性,33岁。咳嗽、咳痰2月。,女性,35岁,咳嗽咳痰午后低热 1月,男性,34岁,咳嗽发热2周。
8、,肺部非结核性分支杆菌(nontuberculous mycobacteria),或称非典型分枝杆菌(atypical mycobacteria)感染主要由鸟胞内分支杆菌(M avium-intracellulare complex,MAIC)和Kansasii分支杆菌致病。 典型放射学表现类似于继发性肺结核(包括树芽征在内)。,CT表现,Jeong等报告1组,其薄层CT扫描最常见表现有双肺小结节(100%)、静脉曲张型支气管扩张(91%)、树芽征(77%),相关的病理组织学表现为细支气管扩张、细支气管壁增厚、伴有或不伴有肉芽肿的细支气管及其周围炎症。 -Jeong YJ, Lee KS, K
9、oh WJ, et al. Nontuberculous mycobacterial pulmonary infection in immunocompetent patients: comparison of thin-section CT and histopathologic findings.RadiologyJ, 2004 ,231(3):880-886.,Infection with M avium-intracellulare complex in a 44-year-old woman with malaise and a chronic cough. High-resolut
10、ion CT scans of the right lung show multiple peripheral small nodules connected to branching linear opacities and a thick-walled cavity in the superior segment of the lower lobe. Note the thickening of the bronchial walls, bronchial dilatation, and mucus impaction. The diagnosis was confirmed with b
11、ronchoalveolar lavage.,细支气管其他细菌感染,如金黄色葡萄球菌、流行性嗜血杆菌感染的细支气管炎也可表现为周围分布的树芽征,其病理学基础为细支气管壁的炎性细胞浸润和管腔内炎性渗出物充填所致。 AIDS患者马红球菌(Rhodococcus equi)肺部感染CT扫描也可见树芽征表现。 医源性绿脓假单胞菌肺炎(nosocomial Pseudomonas aeruginosa Pneumonia, PAP)有50%患者CT表现有结节影,其中1/3可见树芽征,,S aureus bronchiolitis in a 32-year-old man with acquired im
12、munodeficiency syndrome (AIDS). (a) High-resolution CT scan shows small peripheral centrilobular nodules and branching linear opacities, resulting in the tree-in-bud pattern.,2、霉菌感染(Fungal Infection),气道侵袭性曲菌病是由曲菌孢子引起的真菌病,临床常见于免疫妥协中性粒细胞减少患者和AIDS患者。主要临床表现包括急性气管-支气管炎、细支气管炎和支气管肺炎,气管受累者占14%-34%。,CT表现,HRC
13、T表现为支气管周围的实变和小叶中心结节,细支气管炎薄层CT扫描的特征性表现为小叶中心结节和分支状线样影(即树芽征),其他HRCT表现有肺实变影合并周围毛玻璃密度影(halo,晕征),因此在免疫妥协患者或AIDS患者肺部HRCT显示晕征结节和树芽征可提出肺曲菌病的诊断。,Invasive bronchiolar aspergillosis in a patient who underwent bone marrow transplantation. (a) High-resolution CT scan (lung window) shows peripheral branching struc
14、tures (arrow) associated with focal areas of consolidation in the right lower lobe.,病毒感染(Viral Infection),巨细胞病毒感染主要见于免疫缺陷患者,临床症状有发热、干咳、气短和低氧血症。CT表现常无特征性,为散在分布或广泛分布的磨玻璃密度影、肺实变影及边缘模糊的结节影伴有晕征,少见表现有支气管血管束增粗和树芽征。 组织病理学上小叶中心结节为细支气管及其周围有巨噬细胞、红细胞和纤维蛋白聚集所致。,呼吸道合胞病毒(RSV)也可引起下呼吸道感染,所致的细支气管炎和支气管肺炎最常见于婴幼儿和儿童,在成人
15、也可引起肺炎。HRCT表现有磨玻璃密度影、气腔实变影、支气管壁增厚和扩张以及树芽征,有时还可见空气潴留. Ko JP, Shepard JA, Sproule MW, et al. CT manifestations of respiratory syncytial virus infection in lung transplant recipientsJ. J Comput Assist Tomogr, 2000,24(2):235241. ,Cytomegalovirus pneumonia in a 51-year-old man with chronic myelogenous le
16、ukemia who underwent bone marrow transplantation. (a) Thin-section CT scan of the right lung shows centrilobular ground-glass opacities in addition to nodules and tree-in-bud opacities (arrow).,59-year-old man with adenovirus infection after hematopoietic stem cell transplantation for Hodgkins disea
17、se. Transverse thin-section (1-mm collimation, lung window) CT scan obtained at level of lower pulmonary veins shows branching distal structures (tree-in-bud pattern) (arrow).,(二)先天性病变 (Congenital Disorders),1、囊性纤维化(Cystic fibrosis),囊性纤维化是一种以外分泌腺功能异常、粘液栓形成为特征的常染色体隐性遗传性多系统疾病,为相对常见的影响上下呼吸道、胰腺、肝脏、胆囊、肠道
18、和生殖道的先天性病变。以外分泌腺功能异常和粘性物的分泌为特征,与水和盐的细胞运转缺陷有关,发生率为1/2000,主要发生于白种人。,CT表现,本病的最常见的CT表现为支气管壁增厚、支气管周围间质增厚、支气管扩张、细支气管扩张、指套状高密度粘液栓影并肺不张或肺实变,尽管典型病例可累及所有肺叶,但病变早期主要累及肺上叶尖后段。树芽征可能是病变的一个早期征象,这主要是由于细支气管内有大量的粘性分泌物停留所致。 Oikonomou A, Manavis J, Karagianni P,et al. Loss of FEV1 in cystic fibrosis: correlation with HR
19、CT featuresJ.Eur Radiol, 2002,12(9):2229-2235. ,Cystic fibrosis in a 17-year-old boy with a chronic cough. High-resolution CT scan shows dilated thick-walled bronchi and diffuse tree-in-bud patterns (arrow).,2、Kartagener 综合症,原发性纤毛运动功能障碍综合症是包括纤毛功能和结构异常的一组遗传性疾病,Kartagener 综合症是其一个亚型,包括内脏转位、鼻窦炎和支气管扩张三联症
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