高分辨CT结合支气管肺泡灌洗液在结缔组织疾病合并间质性肺病诊断中的作用

The roles of high-resolution computer tomography and bronchoalveolar lavage in the diagnosis of connective tissue diseases associated with interstitial lung disease.

目的探讨高分辨CT（HRCT）与支气管肺泡灌洗液（BALF）在结缔组织疾病合并间质性肺病（CTD—ILD）诊断中的作用。方法回顾性分析1997年1月至2007年12月在北京大学第一医院住院，确诊为CTD—ILD的96例患者HRCT、BALF的临床资料。结果①共获得46例患者的胸部HRCT资料：寻常型间质性肺炎（UIP）样改变占41．3％（19／46），小叶间隔及小叶内间隔增厚占39．1％（18／46）。UIP样改变共19例，ANCA相关性血管炎（AASV）及类风湿关节炎（RA）比例分别为8／17及5／9；机化性肺炎（OP）样改变、淋巴细胞性间质性肺炎（LIP）样改变在多发性肌炎／皮肌炎（PM／DM）及干燥综合征（SS）中分别为2／4、2／4。②32例支气管肺泡灌洗（BAL）检查显示：AASV-ILD均有中性粒细胞比例（10／10）增高，其他CTD—ILD中淋巴细胞比例（14／22，63．6％）和中性粒细胞比例增加（18／22，81．8％）者基本相当，且多为淋巴细胞比例和中性粒细胞比例同时增加（12／22，54．5％）；其中13例淋巴细胞比例增高者进行的淋巴细胞亚群分析显示：13例中10例表现为CD4／CD8降低，3例表现为CD4／CD8增高，均与SS有关。③15例同时进行了HRCT和BAL检查，影像学表现为UIP样改变者7例均有BALF中性粒细胞比例增高，非UIP样改变者8例中5例以淋巴细胞比例增高为主。结论①UIP样改变和小叶及小叶内间隔增厚是CTD-ILD最常见的两种影像学表现，前者在AASV及RA中最常见，OP及LIP样改变分别主要见于PM／DM及SS。②AASV-ILD BALF以中性粒细胞比例增加为主，而其他CTD-ILD BALF中中性粒细胞和淋巴细胞增加者的比例相当；CTD—ILD淋巴细胞亚群分析主要表现为CD4／CD8比例降低，CD4／CD8比例增高者与SS-LIP有较强的相关性。③影像学表现为UIP样改变病例均有中性粒细胞比例升高，而非UIP样改变则以淋巴细胞比例升高为主。

Objective To evaluate the roles of high-resolution computer tomography （HRCT） and bronchoalveolar lavage （BALF） in the diagnosis of connective tissue diseases associated with interstitial lung disease （CTD-ILD）. Methods Clinical data of chest HRCT and BALF of patients with CTD-ILD from January 1997 to December 2007 in in-patient department of Peking University First Hospital, were retrospectively analyzed. Results ①Among 46 cases with the picture of chest HRCT, 19（41.3% ）showed usual interstitial pneumonia（UIP） -like pattern and 18 （39.1% ）showed lobular and interlobular septa thickening. 8 （8/17） of ANCA vasculitis （AASV） and 5 （5/9）of rheumatoid arthritis （RA） manifested as UIP -like patterns respectively. In polymyositis/dermatomyositis（PM/DM） and Sjogren＇s syndrome （SS） patients, the organizing pneumonia（OP）-like pattern and lymphocytic interstitial pneumonia（LIP）-like pattern were 2/4 and 2/4 respectively. ②Among 32 cases undergoing BAL, 10/10 patients with AASV-ILD all showed that neutrophils were dominant in BALF, while, the other 22 patients showed that the ratio of neutrophils elevation （14/22, 63.6% ）and the ratio of lymphocytes elevation （18/22, 81.8 % ）were comparable, and there were 12/22 （54.5 % ）patients with both types of cell elevation. Among 13 cases with lymphocytes elevation in BALF who performed analysis of sub-type lymphocytes, 10/13 cases showed decreased CD4/CD8 ratio, 3/13 cases showed increased CD4/CD8 ratio which were all related with SS.③Among 15 patients undertaken HRCT and BALF detection together, 7/7 UIP-like cases showed the ratio of neutrophils elevation in BALF. While in non-UIP-like cases, 5/8 showed the ratio of lymphocytes elevation. Conclusion ①UIP-like patterns and patterns of lobular and interlobular septa thickening are the most common imaging features of HRCT in CTD-ILD, the former are mostly seen in AASV and RA. OP-like patterns and LIP-like patterns are commonly seen in PM/DM and SS respectively. ②The increased neutrophil percentage is dominant in BAL fluid of patients with AASV- ILD, while the others show that the ratio of neutrophil and lymphocyte elevation are comparable, lymphocytes subtype analysis shows decreased CD4/CD8 ratio is dominant in CTD-ILD patients with lymphocytes increased. There is a significant relationship between increased CD4/CD8 ratio and SS-LIP. ③All of the cases with UIP-like patterns show the ratio of neutrophils elevation in BALF. While the ratio of lymphocytes elevation is dominant in non-UIP-like cases.