免疫正常与抑制患者原发性肺隐球菌病的CT征象分析

CT manifestations analysis of primary pulmonary cryptococcosis in immunocompetent or immunosuppressive patients

目的 分析免疫正常与抑制患者原发性肺隐球菌病（primary pulmonary cryptococcosis,PPC）的CT征象特点,以提高对本病的认识及诊断水平.方法 搜集我院2008年2月至2015年2月收治的CT引导下经皮肺穿刺活检术或手术病理证实的43例PPC患者的临床及CT资料,分别对免疫正常和免疫抑制患者的CT征象进行分析.结果 免疫正常或免疫抑制患者CT影像表现分5种：（1）单发结节、肿块型分别为10、3例（共计13例）.（2）多发结节、肿块型分别为10、5例（共计15例）.（3）斑片实变型分别为4、2例（共计6例）.（4）混合型均为免疫抑制者,7例.（5）混合型伴纵隔淋巴结异常增大均为免疫正常者,2例.此型淋巴结融合并坏死且发病年龄为儿童.结节与肿块型、斑片实变型单侧发生率较高[85.3％ （29/34）],肺叶分布上肺或下肺发生率分别为38.2％（13/34）、44.1％（15/34）.以混合型为主双侧发生率较高[77.8％（7/9）],上、下肺均累及发生率较高[77.8％,（7/9）].5种类型均无明显肺叶分布倾向.免疫正常组以外周分布为主,发生率为77.8％（21/27）;免疫抑制组以外周、随机分布多见,发生率为37.5％（6/16）、50％（8/16）.其中磨玻璃状影、晕征、支气管气象（air bronchogram）的发生率较高,分别为39.5％（17/43）、41.8％（18/43）、67.4％（29/43）,空洞发生率较低（13.9％,6/43）.这些征象在免疫正常组发生率分别为38.4％（10/27）、38.4％（10/27）、55.5％（15/27）,免疫抑制组发生率分别为43.7％（7/16）、50％（8/16）、87.5％（14/16）,磨玻璃状影、晕征发生率在两组间无明显差别,支气管气象在免疫抑制组发生率更高.结论 PPC的CT表现多样化,免疫正常者以结节或肿块型、外周簇状分布为主;免疫抑制者以混合型、外周、随机分布为主.儿童中发现混合型伴纵隔淋巴结增大、融合并坏死,需高度考虑隐球菌病可能.磨玻璃状影、晕征、支气管气象对诊断有一定提示意义.

Objective To analyse CT image features of primary pulmonary cryptococcosis （PPC） in immu nocornpetent or immunosuppressive patients in order to improve its cognitive and diagnostic level. Methods We analyzed retrospectively 43 cases with primary pulmonary cryptococcosis （PPC） from our hospital during February 2008 to February 2015. All the cases were confirmed diagnosis by pathology through surgery or CT-guided percutaneous lung biopsy. CT manifestations of the two groups （immunocompetence and imrnunosuppression） were analyzed. Results Imaging characteristics on CT were divided into 5 types： （1） solitary nodule/mass in 13 cases, 10 in immunocompetent patients and 3 in immunosuppressive patients respectively; （2）multiple nodules/masses in 15 cases, 10 in immunocompetent patients and 5 in immunosuppressive patients; （3） patchy or solid appearance in 6 cases, 4 in immunocompetent patients and 2 in immunosuppressive patients; （4） mixed type in 7cases, all in immunosuppressive patients; （5） mixed type accompanying with abnormal lymphadenectasis in mediastinum in 2 cases, both in immunocompetent children patients and the lymph nodes showed fusion, and necrosis. 85.3%（29/34） of nodule, mass and patchy solid types appeared unilaterally, 38. 2% （13/34） in the upper lobe and 44. 1% （15/34） in the lower lobe. Mixed type always be found bilaterally and both in upper and lower lobe the proportion was 77.8%（7/9）. There was no significant difference in the lobe distribution of the 5 types. In immunocompetent group, it was mainly periphery distributed of 77.8% （21/27）, however, in the immunosuppressive group, it always showed periphery and random distribution of 37.5 % （6 / 16） and 50% （8/16） respectively. Ground glass opacity, hato sign, and air bronchogram were common to see, and the rates were 39.5% （17/43）, 41.8% （18/43）, 67.4% （29/43） respectively, and the cavity sign was rare （13.9%, 6/43）. These signs rates found in immunocompetent patients were 38.4% （10/27）, 38. 4% （10/27）, 55.5% （15/27） and were 43.7% （7/16）, 50%（8/16）, 87.5%（14/16） in immunosuppressive group. Ground glass opacity and hato sign showed no significant difference in the two groups, while bronchogram sign likely occurred in the mmunosuppressive group. Conclusion The CT imaging is diverse in PPC. Lesions in immunocompetent patients show mainly nodule/lump types and peripheral areatus distribution, and show mixed type, prehperal and random distribution in immunosuppressive patients. Mixed type accompanying with abnormal enlargement, fusion, and necrosis of mediastinal lymph nodes in children should be highly concerned about PPC. Ground glass opacity,hato sign,and air bronchogram indicate this disease.