24例过敏性肺炎的临床、影像学及病理分析

Clinical,Radiological and Pathological Features of Hypersensitivity Pneumonitis: 24 Cases Analysis

目的提高临床医生对过敏性肺炎的临床、影像学及病理特点的认识。方法回顾性分析南京大学医学院附属鼓楼医院2005年2月至2013年2月诊治的24例过敏性肺炎患者的临床资料,总结其临床、影像学及病理特征。结果 24例患者中男15例,女9例;平均年龄(48±13)岁;急性2例,亚急性17例,慢性5例。主要的临床症状为呼吸困难、咳嗽、咳痰、发热、体重减轻,血气分析示低氧血症,肺功能检查显示限制性通气功能障碍及弥散功能障碍。胸部高分辨率CT主要表现为双肺弥漫性磨玻璃影、斑片影、小叶中心性结节影、马赛克征和网格影或伴蜂窝肺。支气管肺泡灌洗液(BALF)细胞分类示肺泡淋巴细胞增加,经支气管镜肺活检(TBLB)病理表现为淋巴细胞浸润为主的肺泡炎、非干酪性坏死性肉芽肿及间质性肺炎。所有病例避免抗原暴露及经糖皮质激素治疗后症状明显缓解,胸部影像学改变明显好转。结论过敏性肺炎诊断困难,大部分病例(急性、亚急性)根据相关抗原的暴露、影像学、BALF的细胞学改变及TBLB病理检查作出诊断。对于不典型病例(慢性),需要进行外科肺活检而做出临床-影像学-病理的综合诊断。

Objective To improve clinicians＇ knowledge of hypersensitivity pneumonitis （HP）. Methods We retrospectively analyzed the clinical data of 24 HP patients who were diagnosed in the Affiliated Drum Tower Hospital of Nanjing University Medical School during February 2005 to February 2013. The clinical, radiological and pathological features of those patients were summarized. Results Among those 24 patients, 15 were male and 9 were female, with mean age of （48 ±13 ） years. All patients had a history of environmental exposure. Two patients showed acute clinical manifestations, and there were 17 subacute and 5 chronic cases. The main clinical manifestations were dyspnea, cough, sputum, fever and weight loss with hypoxemia via blood gas analysis. Restrictive ventilatory impairment was the most frequent functional pattern, and the carbon monoxide diffusing capacity was decreased. Pulmonary function test showed restrictive ventilatory defect and gas interchange disturbance. The features of chest HRCT included diffuse ground-glass attenuation and/or patchy consolidation, centrilobular micronodules, mosaic sign, reticular and/or honeycombing lesions. Bronchoalveolar lavage fluid （BALF） demonstrated an increase of total cell counts with predominant lymphoeytosis. The transbronchoscopic lung biopsy （TBLB） pathological examination revealed lymphocytic alveolitis, noncaseating granuloma, and interstial pneumonia. All patients were treated by eorticosteroid and avoided antigen exposure and showed significant clinical and radiological improvement. Conclusions The diagnosis of HP is difficult. In most cases （acute and subacute HP） , a diagnosis can be made by combination history of exposure, chest HRCT manifestations, cell classification of BALF and pathological examination of TBLB. For atypical cases （ chronic HP）, a surgery lung biopsy is needed for multi-disciplinary diagnosis including pathologist, radiologist and pulmonologists.