病理呼吸系統(tǒng)一肺炎

1、Southern Medical University,南方醫(yī)科大學(xué)病理學(xué)系,,呼吸系統(tǒng)疾病病理學(xué),病理學(xué)系 周軍,Flu symptom,Are we ready to meet bird flu challenge?,SARS-the mystery illness,Pneumonia-how common it is!,Pulmonary tuberculosis-old disease Continuing,Waging wa

2、r on lung cancer,呼吸系統(tǒng)組成：,上呼吸道:,下呼吸道:,鼻、咽、喉,氣管、支氣管和肺,以喉環(huán)狀軟骨為界,,,導(dǎo)氣部：支氣管、葉支氣管、段支氣管、小支氣管、細(xì)支氣管、終末細(xì)支氣管、呼吸部：呼吸性細(xì)支氣管、肺泡管、肺泡囊、肺泡,呼吸系統(tǒng)的解剖組織學(xué)結(jié)構(gòu),肺小葉：3~5個終末細(xì)支氣管連同它的各級分支和肺泡組成，包括15~25個肺腺泡。,肺小葉,肺 腺 泡,呼吸性細(xì)支氣管及其遠(yuǎn)端所屬的肺組織；I型肺泡上皮： I型肺泡上皮

3、、基底膜、毛細(xì)血管內(nèi)皮細(xì)胞共同組成肺泡毛細(xì)血管膜，組成氣血屏障，是肺進(jìn)行氣血交換的場所；II型肺泡上皮：分泌肺表面活性物質(zhì)，降低肺泡表面張力，防止呼氣末肺萎陷，維持小氣道的通暢。 肺的基本功能單位,Microscopic structure of the alveolar wall. Note that the basement membrane (yellow) is thin on o

4、ne side and widened where it is continuous with the interstitial space. Portions of interstitial cells are shown.,肺臟是空氣可以進(jìn)出體內(nèi)的唯一器官,粉塵微粒、病原體,黏附在氣道黏膜的黏液層上,纖毛-黏液排送系統(tǒng),肺泡巨噬細(xì)胞,吞噬、降解,,,,,,,肺泡腔,,肺組織學(xué),氣管和支氣管的組織結(jié)構(gòu)：分粘膜、粘膜下和外膜三層，粘膜

5、上皮含三種細(xì)胞；粘膜上皮中含假復(fù)層或單層纖毛柱狀上皮，杯狀細(xì)胞、刷細(xì)胞、基細(xì)胞、Clara細(xì)胞和神經(jīng)內(nèi)分泌細(xì)胞；粘膜下層：混合性腺；外膜：軟骨、平滑肌,細(xì)支氣管：上皮成分，不含軟骨和腺體,肺泡上皮：分I型和II型.,粘膜層,粘膜下層,外膜層,bronchiole,pulmonary alveoli,感染性疾病阻塞性肺病肺間質(zhì)疾病腫瘤,呼吸系統(tǒng)疾病：,肺 炎pneumonia,肺的急性滲出性炎癥，呼吸系統(tǒng)常見病和多發(fā)病,

6、分類：,,感染性（細(xì)菌性、病毒性…）,理化性（放射性、吸入性 和類脂性）,變態(tài)反應(yīng)性（過敏性和風(fēng)濕）,2、根據(jù)部位的不同分肺泡性和間質(zhì)性,3、根據(jù)病變性質(zhì)可分為漿液性、纖維素性、化膿性、出血性等等,1、根據(jù)病因分類,引起肺炎的病原體有哪些？,細(xì)菌：肺炎鏈球菌、肺炎桿菌、流感嗜血桿菌、溶血性球菌、葡萄球菌、結(jié)核桿菌、非典型分枝桿菌、綠膿桿菌、大腸桿菌、變形桿菌、軍團(tuán)菌病毒：流感病毒、呼吸道合胞病毒、腺病毒、副流

7、感病毒、麻疹病毒、單純皰疹病毒、巨細(xì)胞病毒、冠狀病毒、禽流感病毒支原體：肺炎支原體衣原體：沙眼認(rèn)原體、鸚鵡熱衣原體真菌：新型隱球菌、曲霉菌、毛霉菌、念珠菌放線菌立克次體：伯納特立克次體→Q fever 寄生蟲：弓形體、卡氏肺囊蟲、血吸蟲幼蟲、肺吸蟲,大葉性肺炎 lobar pneumonia,主要由肺炎球菌引起的以肺泡內(nèi)彌 漫性纖維素滲出為主的炎癥，常累及肺葉的大部或全部。,Diffuse fibri

8、nous inflammation in alveoliYoung to middle aged persons Clinical manifestations: Rapid; chill, high fever, chest pain, cough, rusty sputum, dyspnea; consolidation of lung; WBC↑Natural course of disease: 5

9、-10 days,Introduction,漿液性滲出物,,細(xì)菌在肺泡中繁殖,肺泡孔,呼吸細(xì)支氣管,,帶菌滲出液,大葉間蔓延,葉支氣管,,鄰近肺組織,機(jī)體抵抗力↓呼吸道防御能力↓→細(xì)菌感染(肺炎球菌)→ 變態(tài)反應(yīng)→血管擴(kuò)張，通透性↑→漿液、纖維素滲出,肺炎鏈球菌（1,2,3,7型）,金黃色葡萄球菌,溶血性鏈球菌,90％,病因和發(fā)病機(jī)制,Mostly lateral lung，inferior lobe of left or

10、right lungAlso more than two pulmonary lobesFour stages，5-10 days,Pathological changes,(一)充血水腫期（1－2天） ★,肉眼：腫大 重量增加 暗紅鏡下：肺泡壁毛細(xì)血管擴(kuò)張、充血 肺泡腔大量漿液,少紅、中性粒、巨 噬細(xì)胞,大量細(xì)菌,,高熱、咳嗽，毒血癥濕性啰音、淡薄陰影,Gr

11、am Stain of a film of sputum,(二)紅色肝樣變期（3－4天） ★,肉眼：大、質(zhì)實(shí)、灰紅鏡下：肺泡壁毛細(xì)血管擴(kuò)張充血，肺泡腔 大量RBC滲出，少數(shù)WBC、纖維素,,發(fā)紺、咳嗽、鐵銹色痰、胸痛、支氣管呼吸音、濕性羅音、致密陰影,(2)紅色肝樣變期(3-4天),(三)灰色肝樣變期(5-6天) ★,肉眼：大、重量↑、灰白、實(shí) 鏡下：肺泡腔 纖維蛋白滲出↑ 中性粒

12、細(xì)胞↑ 纖維素連成網(wǎng)、細(xì)菌少 肺泡壁 毛細(xì)血管受壓,,,Typical appearance of right lobar Pneumonia,發(fā)紺↓、咳膿痰、胸痛 大片致密陰影,,(3)灰色肝樣變期(5-6天),(四)溶解消散期（一周左右） ★,肉眼：質(zhì)軟鏡下：白細(xì)胞變性壞死→蛋白溶解酶→ 纖維素溶解→咳出、淋巴管吸收,,體溫降、痰多、捻發(fā)音 陰影漸退

13、→消失,Four stages (5-10 days),Lobar pneumonia,,,,臨床病理聯(lián)系,充血水腫期 毒血癥 、濕性啰音、X-ray紅色肝樣變期 實(shí)變、呼吸音、 X-ray、痰灰色肝樣變期 實(shí)變、呼吸音、 X-ray、痰溶解消散期 呼吸音、 X-ray,現(xiàn)今，典型的大葉性肺炎的四期病變少見。,Upper right lobe pneumonia,Outcome and complication,敗血癥，感

14、染性休克（休克/中毒型肺炎）,肺肉質(zhì)變(機(jī)化性肺炎),多數(shù)可恢復(fù)正常,纖維素性胸膜炎肺膿腫、膿胸,病灶,,,,侵犯胸膜,金葡菌,細(xì)菌入血,,(1)肺肉質(zhì)變 (pulmonary arnification),Early organization of intra-alveolar exudate, seen in areas to be streaming through the pores of Kohn (arrow).,,,肺

15、肉質(zhì)變,(2)化膿性胸膜炎及膿胸(3)肺膿腫(4)敗血癥或膿毒敗血癥(5)感染性休克,肺膿腫,,lung abscess with complete destruction of underlying parenchyma within the focus of involvement,Abscess formation,,小葉性肺炎 lobular pneumonia,以細(xì)支氣管為中心的急性化膿性炎癥。,Acute pur

16、ulent inflammation Often localization to the bronchioles and surrounding, also called Bronchopneumonia infants, elderly Often complication of other diseases,Introduction,Etiology : many kinds of bacteria

17、 mixed infectionPathogenesis: Defense of airway↓Induced factors→body resistance↓→bacteria proliferation

18、 Bronchitis Lobular pneumonia,,,Pathological changes ★,肉眼：大小不等、0.5-1cm、不規(guī)則、灰黃； 散布兩肺各葉，以下葉和背側(cè)多見； 可融合（融合性支氣管肺炎）,,,Conflu

19、ent lobular pneumonia,鏡下: ● 細(xì)支氣管粘膜充血、水腫，上皮壞死、脫落，腔內(nèi)大量膿性滲出 ● 周圍肺泡壁血管擴(kuò)張充血，肺泡腔膿性滲 出，代償肺氣腫、肺不張,Low power view shows patchy peribronchiolar distribution of pneumonia,,,Normal alveolar,,,,,Acute purulent exudate fills br

20、onchioles and adjacent alveoli.,White cell--,,--Bacterial cenobium,Clinical relations,Clinical characters: Coughing, fever, sputum, chest pain Not obvious of lung consolidationMoist ralesX ray,Outcome and complica

21、tion,呼吸衰竭心力衰竭肺膿腫, 膿胸支氣管擴(kuò)張膿毒血癥,病 毒 性 肺 炎,Viral Pneumonia,,基本病變：急性間質(zhì)性肺炎,Introduction,Common virus: flu virus, adenovirus, syncytial virus, measles virus, cytomegalovirusClinical characters: children, diversity,

22、Toxicemia＋refractory coughing or short breath,Pathological changes,肉眼：病變不明顯、輕度增大鏡下：間質(zhì)性肺炎 充血、水腫 間質(zhì) 淋巴細(xì)胞、單核細(xì)胞浸潤 肺泡間隔明顯增寬 肺泡腔 無或少量漿液 　 支氣管上皮細(xì)胞或肺泡上皮內(nèi)包涵體,,Interstit

23、ial pneumonitis with alveolar walls widened by mononuclear cells, but no intra-alveolar exudate,透明膜：流感、麻疹、冠狀病毒、腺病毒肺炎,多核巨細(xì)胞：麻疹病毒（支氣管、肺泡上皮增生）,病毒包涵體性狀： 約紅細(xì)胞大小，常呈嗜酸性紅染，其周圍有透明暈。,病毒包涵體位置：在增生的上皮細(xì)胞中 僅在細(xì)胞漿：呼吸道合胞病

24、毒 胞漿和胞核：麻疹病毒 僅在細(xì)胞核：單純皰疹病毒 巨細(xì)胞病毒、腺病毒,Syncytial cell pneumonia,Cytomegalovirus distinct nuclear cytoplasmic inclusions in the lung,Cells from the blister in showing glassy i