S1-HIV感染肺炎.ppt
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1、Pneumonia in HIV, approached by specific diseases 通过特定疾病考察 HIV感染肺炎,Causes of Pulmonary Disease Associated with Human Immunodeficiency Virus Infection 与人类HIV感染有关的肺部疾病的病因,Mandell, Douglas, and Bennetts Principals and Practice of Infectious Disease. Sixth edition. 传染性疾病的要点与实践:第六版,最常见病因 细菌 肺炎链球菌 流感嗜学血杆菌
2、 未发现微生物,但对抗细菌药物有反应 分枝杆菌 结核分枝杆菌 真菌 肺囊虫肺炎 不常见但在某些场合可具有重要临床意义 细菌 绿脓杆菌 金黄色葡萄球菌 肠杆菌科 军团菌 奴卡菌 马红球菌 分枝杆菌 坎沙西分枝杆菌 鸟型分枝杆菌复合物 真菌 新型隐球菌 荚膜组织胞浆菌 厌酷球孢子 曲霉菌 皮炎芽生菌 马尔尼菲青霉菌,病毒 流感病毒 巨细胞病毒 单纯疱疹病毒 腺病毒 呼吸道合胞病毒 副流感病毒 寄生虫 刚地弓形虫 粪类圆线虫 微孢子虫 微小隐孢子虫 非感染性 卡波济肉瘤 非何杰金淋巴瘤 肺癌 原发肺动脉高压 充血性心力衰竭 淋巴细胞性(或淋巴样)间质肺炎 肺气肿 阿巴卡韦过敏,Distributio
3、n of AIDS cases by five opportunistic infections in Thailand, (Data as of September 1984-March 2004) 泰国按5种机会性感染分类的AIDS病例组成情况, (1984年9月-2004年3月数据),3.3%,14.7%,4.6%,25.6%,18.7%,Bureau of Epidemiology, CDC , MOPH,Mycobacterium Infection - Mycobacterium tuberculosis (M. TB) - Mycobacterium avium Complex
4、(MAC) Fungal Infection - Pneumocystis jirovecii - Cryptococcus neoformans Bacterial Infection - Nocardia spp. - Rhodococcus equi - Miscellaneous,Key Opportunistic Organisms for Pneumonia in HIV+ Patients HIV阳性患者肺炎主要机会性致病性微生物,分枝杆菌感染 - 结核分枝杆菌 (M. TB) - 鸟分枝杆菌复合物 (MAC) 真菌感染 - 肺囊虫肺炎 - 新型隐球菌 细菌感染 - 诺卡氏菌 -
5、 马红球菌 - 其它细菌,Mycobacterium tuberculosis 结核分枝杆菌 (M. TB),结核-HIV的联合流行分布,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,结核对HIV的影响,结核是首要的艾滋病相关机会性感染 结核可增强HIV复制 结核有可能加速HIV感染的自然病程 利福平与抗逆转录药物的相
6、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对结核的影响,原发结核的高发病率和再激活
7、 增加肺外结核和播散性结核的发病率 增加异常反应的发生率 可能需要延长疗程 增加药物不良反应 增加耐多药性结核病的发生率 高死亡率,Clinical manifestations of active TB in early versus late HIV infection HIV感染早期和晚期活动性结核的临床表现,For practical purposes , early and late may be defined as CD4+cell counts 300 cells/mm and 300 个细胞/mm a和 200个细胞/mm,a,a,Radiographic Pictures
8、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 pa
9、ttern of PTB”,结核/HIV的放射学检查图象,CD4 300 - 斑片或结节浸润影 - 定位于肺尖或上叶尖下后段或下叶上段 - 干性厚壁空洞 (50%),气液平不常见 - 淋巴腺病不常见 - 可见胸膜渗出,“肺结核的典型放射线表现”,Radiographic Pictures of TB/HIV,CD4 200 - alveolar infiltration, diffuse interstitial infiltration, or mixed infiltration - location in any segments or lobes - common enlarged l
10、ymphadenopathy - common extrapulmonary involvement - normal CXR (14-20%) in advanced AIDS (CD450),“Non-specific radiographic pattern”,结核/HIV的放射学检查图象,CD4 200 - 肺泡浸润,弥漫间质浸润或混合浸润 - 定位于任何肺段或肺叶 - 一般化增大的淋巴结 - 一般化的肺外受累 - 晚期艾滋病患者(CD450)可有正常的X线表现 (14-20%),“非特异放射线表现”,AFB stain; acid-fast bacilli 抗酸杆菌染色; 抗酸杆菌,
11、Gram stain; ghost bacilli 革兰氏染色; 血影杆菌,H&E stain 苏木素和伊红染色,AFB stain 抗酸杆菌染色,Mycobacterium avium Complex 鸟分枝杆菌综合症 (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 thick
12、ening - 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,有基础肺疾病史 从中年到老年均可发生 典型放射线表现 - 上叶纤维结节病灶,与胸膜增厚有关 - 空洞的发生比结核多(分别为60-90%和50%),更多见大的薄壁空洞 - 胸膜渗出常见,“肺部疾病”,MAC infection in a 5
13、2-year-old COPD man, with history of prolong fever, weight loss, cough, intermittent hemoptysis, and dyspnea 某52岁慢阻肺患者的MAC感染,持续发热,体重下降,咳嗽,间断性咯血和呼吸困难,Mandell, Douglas, and Bennetts Principals and Practice of Infectious Disease. Sixth edition.,MAC infection in AIDS-patients,CD4 50 The most common orga
14、ns 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
15、 not dominant,“Disseminated disease”,艾滋病患者的MAC感染,CD4 50 最常受累的器官: - 脾,肝,小肠,结肠,淋巴结,骨髓 最少受累的器官: - 肺 (10%),肾上腺,胃,中枢神经系统 (CNS) 放射线表现类似于结核: - 肺泡/间质浸润 - 结节/空洞不常见 - 腺病不是主要的,“播散性疾病”,Pneumocystis jirovecii (carinii) (卡氏)肺囊虫肺炎,您可以预防卡氏肺囊虫肺炎: HIV感染者指南,PCP in Non-HIV,Immunocompromised host at risk for Pneumocysto
16、sis - 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
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