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1、Pneumonia in HIV,approached by specific diseases通过特定疾病考察通过特定疾病考察HIV感染肺炎感染肺炎 Mandell,Douglas,and Bennetts Principals and Practice of Infectious Disease.Sixth edition.传染性疾病的要点与实践：第六版传染性疾病的要点与实践：第六版最常见病因最常见病因细菌肺炎链球菌流感嗜学血杆菌未发现微生物，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
2、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3.3%3.3%14.7%14.7%4.64.6%25.6%25.6%18.7%18.7%Bureau of Epidemiology,CDC,MOPH Mycobacterium Infection-Mycobacterium tube
3、rculosis(M.TB)-Mycobacterium avium Complex(MAC)Fungal Infection-Pneumocystis jirovecii-Cryptococcus neoformansBacterial Infection-Nocardia spp.-Rhodococcus equi-Miscellaneous 分枝杆菌感染分枝杆菌感染-结核分枝杆菌(M.TB)-鸟分枝杆菌复合物 (MAC)真菌感染真菌感染-肺囊虫肺炎-新型隐球菌 细菌感染细菌感染-诺卡氏菌-马红球菌-其它细菌 leading AIDS-related OI enhance HIV repl
4、ication might accelerate the natural progression of HIV infection drug interaction between RMP vs.ARV 结核是首要的结核是首要的艾滋病艾滋病相关相关机会机会性感染性感染 结核可增强结核可增强HIV复制复制 结核有可能加速结核有可能加速HIV感染的自感染的自然病程然病程 利福平与抗逆转录药物的相互利福平与抗逆转录药物的相互作用作用 high rate of primary TB and reactivationincrease incidence of extrapulmonary and dis
5、seminated TBincrease incidence of paradoxical reactionmight need longer treatment coursemore adverse drug reactionsincrease incidence of MDR-TB high mortality rate 原发结核的高发病率和再激原发结核的高发病率和再激活活 增加肺外结核和播散性结核增加肺外结核和播散性结核的发病率的发病率 增加异常反应的发生率增加异常反应的发生率 可能需要延长疗程可能需要延长疗程 增加药物不良反应增加药物不良反应 增加耐多药性结核病的发生增加耐多药性结核病
6、的发生率率 高死亡率高死亡率 For practical purposes,early and late may be defined as CD4+cell counts 300 cells/mm and 300 个细胞个细胞/mm a和和 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
7、is uncommon-lymphadenopathy is unusual-pleural effusion could be found “Typical radiographic pattern of PTB”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肺结核的典型放射线表现现”CD4 200-alveolar infiltration,diffuse interstitial infiltration,or mixed infiltration-location in a
8、ny segments or lobes-common enlarged lymphadenopathy-common extrapulmonary involvement-normal CXR(14-20%)in advanced AIDS(CD450)“Non-specific radiographic pattern”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%)“非特异放射线表现非特异放射线表现”AFB stain;acid-fast bacilli抗酸杆菌染色
9、；抗酸杆菌染色；抗酸杆菌Gram stain;ghost bacilli革兰氏染色；革兰氏染色；血影杆菌H&E stain苏木素和伊苏木素和伊红染色红染色AFB stain抗酸杆菌染色抗酸杆菌染色Mycobacterium avium Complex鸟分枝杆菌综合症鸟分枝杆菌综合症(MAC)Prior history of underlying lung pathologyMiddle-age to old manTypical radiographic pictures-upper lobe fibronodular lesion,associated with pleural thicke
10、ning-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”有基础肺疾病史有基础肺疾病史 从中年到老年均可发生从中年到老年均可发生 典型放射线表现典型放射线表现-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“肺部疾病肺部疾病”MAC infection in a 52-year
11、-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.CD4 50The most common organs involved;-spleen,liver,intestines,colon,lymph
12、nodes,bone marrowThe 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 not dominant“Disseminated disease”CD4 50最常受累的器官：最常受累的器官：-脾，肝，小肠，结肠，淋巴结，
13、骨髓 最少受累的器官：最少受累的器官：-肺(-risk for pneumothorax-unilateral infiltration,nodules,cavitations lymphadenopathy,pleural effusion 典型表现典型表现:-早期疾病可有正常胸部X线表现(10-39%)-弥漫性双侧浸润（毛玻璃样表现）非典型表现非典型表现:-薄壁囊，气泡-发生气胸风险-单侧浸润，结节，空洞，淋巴腺病，胸膜渗出CD4 200Disease burden is higher but severity is lessSymptoms;lasting from weeks to m
14、onthsExtrapulmonary pneumocystosis;in advanced AIDS without PCP prophylasis or only aerosolized pentamidineCXR;cavitations,lymphadenopathy and pleural effusion are unusual“Cavity,adenopathy and pleural effusion are unusual”CD4 200疾病负荷更高，但严重度较小疾病负荷更高，但严重度较小症状：症状：持续数周到数月肺外肺外肺囊虫肺炎：肺囊虫肺炎：可见于不做PCP预防治疗或仅做
15、戊烷脒雾化治疗的进展期艾滋病患者胸部胸部X线表现线表现：空洞、淋巴腺病、胸膜渗出不常见“空洞、腺病和胸膜渗空洞、腺病和胸膜渗出不常见出不常见”GMS stain;cluster of round or cup shaped cystsGMS染色染色；成堆的圆形或杯状囊成堆的圆形或杯状囊H&E stain;frothy eosinophilic honeycombed material filling alveolar space苏木素和伊红染色；苏木素和伊红染色；空泡化嗜酸粒蜂窝样物空泡化嗜酸粒蜂窝样物质充填于肺泡间隙质充填于肺泡间隙Susceptible hostsSymptoms rang
16、e;-asymptomatic colonization of the airway to life-threatening pneumonia(depend on immune status)Radiographic characteristics include;-well-defined noncalcified single/multiple nodules,mass-like infiltration or dry thin-wall cavitationsThe two common sites are lung and CNS 易感宿主易感宿主 症状范围：症状范围：-从气道的无症状聚集到威胁生命的肺炎都可能发生（取决于免疫状态）放射线放射线特点包括：特点包括：-分界清楚的非钙化单发/多发结节，肿块样浸润或干性薄壁空洞 两个常见部位为肺和中枢神两个常见部位为肺和中枢神经系统经系统Mandell,Douglas,and Bennetts Principals and Practice of Infectious Disease.Sixth edition.HIV感染淋巴增生异
