过敏性肺炎的临床病理特征分析

Clinicopathological diagnosis of hypersensitivity pneumonitis

目的探讨过敏性肺炎（HP）的临床、影像学和病理学特征，提高对HP的认识和诊断水平。方法回顾性分析2009年2月至2011年9月卫生部北京医院收治的6例HP患者的临床资料，其中男2例，女4例；年龄38～61岁，平均51．5岁。临床主要表现为咳嗽、气促，有2例表现为呼吸困难。病程1～8个月。其中5例有饲鸽等接触史。3例为经支气管肺穿刺，3例为开胸肺活检。活检肺组织全部取材、石蜡包埋，行HE、抗酸等其他组织化学染色及免疫组织化学染色研究。结果6例患者中亚急性4例，慢性2例。3例亚急性患者经支气管穿刺活检、1例亚急性和2例慢性患者经开胸肺活检。高分辨率CT表现为弥漫的沿支气管、小叶中心分布的磨玻璃和斑片影，以中上肺为主，典型的可见马赛克征；肺组织病理学检查可见松散的非干酪坏死的肉芽肿结节。慢性HP临床病史隐匿、影像学表现复杂，可见肺间质纤维化；病理学检查可表现为普通型间质性肺炎样或细支气管周边纤维化型；病变主要围绕支气管分布或出现桥性纤维化，合并细支气管周围肺泡的细支气管上皮化生，间质中可见少量松散的肉芽肿和多核巨细胞，其中1例见Schaumann小体。结论HP有复杂的临床、影像学和病理学特征，易与其他弥漫性肺间质性疾病相混淆，综合分析有益于明确诊断。

Objective To enhance the understandings of clinical, radiological and pathological features of hypersensitivity pneumonitis （HP）. Methods Six HP cases with pathological data, clinical and radiological data were retrospectively analyzed during the period from February 2009 to September 2011 at Beijing Hospital of Ministry of Health. There were 2 males and 4 females with a mean age of 51.5 years （range ： 38 - 61 ）. Clinically, the patients presented with chronic cough, shortness of breath and dyspnea （n- 2）. The disease course was 1 -8 months. Five cases had fed pigeons and other contact histories. Specimens obtained by transbronchial lung biopsy （ n = 3 ） and open lung biopsy （ n = 3 ） were paraffin embedded and stained by hematoxylin and eosin, special stains and immunohistochemistry. Results Four cases had subacute HP and 2 cases chronic HP. Three cases of subacute HP underwent transbronchial lung biopsy. One case of subaeute HP and 2 cases of chronic HP were diagnosed by open lung biopsy. High- resolution computed tomography of lungs showed diffuse ground glass and patch shadow along the bronchial and centrilobular distributions. There was a predominance of upper half zone. Typical visible mosaic syndrome was present. There was poorly formed granuloma without cheesy necrosis. With an insidious medical history and complicated radiological features, chronic HP cases were characterized by pulmonary interstitial fibrosis. There were usual interstitial pneumonitis （UIP）-like fibrosis and fibrosis with an airway- centered distribution type. The lesions were distributed around bronchioles. Continuous bridge fibrosis might be present. There were bronchiolar metaplasia of peribronchiolar alveoli, poorly formed granuloma and multinucleated giant ceils in interstitium. Schaumann body was identified in 1 case. Conclusions Because of its diverse clinical, radiological and pathological features, HP may be easily confused with other interstitial lung diseases. Aggregate analyses yield a definite diagnosis.