肺结核结节性病灶不同传播方式的HRCT表现

2022-09-17 放射沙龙 中国中西医结合影像学杂志

血行播散肺结核可以伴有少量的支气管播散病灶,Hong等总结的一组血行播散性肺结核患者中,16%的患者在HRCT上可见支气管播散病灶。

结核结节(结核瘤)在HRCT上表现为大小不等的结节灶,这些病灶可以是血行播散而来,也可以是支气管播散所致。常规X线胸片对这些结节灶播散来源的鉴别,主要依据其在肺野内的大致分布规律。双肺对称性分布,且为大小均匀的粟粒样病灶(即所谓三均匀)被认为是血行播散性;局灶性分布被认为是沿支气管播散的病灶。HRCT图像上,这些结节的分布是否与支气管分支相关;是否累及细支气管、小叶间隔以及小叶内间质对于鉴别病灶的播散方式都有着重要的意义。因此,我们应认真分析HRCT图像上肺内结节性病灶的分布规律,以帮助判断结核灶的来源。

1、血行播散性病灶的HRCT形态及分布特点

血行播散性肺结核是结核菌经由血管到肺内后发病的类型。血行播散途径可以是由于肺内结核菌由肺静脉进入体循环,再进入肺循环导致的结核杆菌在肺内播散;可以是肺门淋巴结内的结核杆菌经淋巴管进入血液系统;也可以是干酪样坏死的淋巴结直接侵犯血管所致。由于主要表现为双肺弥漫性分布的粟粒样结节,又称粟粒性肺结核。血行播散性肺结核可以是原发,也可以是继发性。1.1随机分布的粟粒样结节是血行播散肺结核的分布特点

血性播散性肺结核的主要病理改变是大量直径较小的结核结节的形成,这些结核结节的直径大都在1~5 mm。由于是经血管播散,结核结节的分布以血管走行分布为特点,称为随机分布。最常见的是两肺对称性分布,有时也可见到单侧肺或单侧肺叶内的分布。这些粟粒样病灶可以边缘锐利(肉芽肿为主)(见图1,2),也可以边缘模糊(干酪样坏死为主)。 图1 急性血行播散性肺结核。HRCT可见随机分布的粟粒样病灶

图2 右肺上叶亚急性血行播散性肺结核。右肺上叶随机分布的边缘锐利、体积略大的类圆形结节灶

1.2 HRCT对血行播散肺结核中肺间质增厚和胸膜结节的显示有明显优势

由于HRCT的高空间分辨力,对于肺问质改变有很高的敏感性和特异性。血行播散性肺结核常侵犯肺间质,在HRCT上表现为小叶间隔增厚(大网格样改变)(见图3)和/(或)小叶内问质增厚(细网格样改变)。血性播散性肺结核也累及胸膜,HRCT上表现为胸膜下粟粒样结节灶和叶间胸膜的粟粒样结节。(见图4)。


图3 血行播散性肺结核中的小叶问隔增厚。两上肺内除了随机分布的粟粒样结节外,还可见到大网格状改变的小叶间隔增厚
图4 血行播散性肺结核中的胸膜下结节灶。右肺斜裂和水平裂以及胸壁的胸膜下可见多发的粟粒样结节灶

1.3 血行播散性肺结核也可见磨玻璃样改变

由于HRCT的高敏感性,很多文献报道粟粒性肺结核患者的HRCT图像上,可以看到不同大小、不同形态和不同分布的磨玻璃样改变区域(见图5)。当这些磨玻璃样改变面积较大时,多伴有呼吸困难,甚至出现呼吸窘迫综合征。

图5 血行播散性肺结核并发肺内渗出。双肺随机分布的粟粒样结节灶,右肺下叶片状磨玻璃样密度病灶

2、支气管播散结核灶的HRCT形态及分布特点

支气管播散是肺结核最常见的播散方式之一,是指肺结核的原发病灶继发地沿支气管播散形成的病灶,这些病灶无疑与支气管走行有联系密切。支气管播散的典型表现为结节及分支样线形结构(树芽征)的小叶中心病灶,支气管壁增厚和小叶实变。

2.1 多发“簇”状分布的小叶中心结节是支气管播散的分布特点

病理学上小叶中心结节表现为于酪样坏死环绕或位于呼吸性细支气管内,有时位于肺泡管。多发“簇”状分布的小叶中心结节是支气管播散病灶的特征性表现之一。所谓“簇”状,实际上是沿小的支气管走行为单位分布的多个结节灶,大小随受累支气管所属分支的多少而不同。或者表现为大的“簇”,或者表现为小的“簇”。“簇”与“簇”之间往往有正常肺组织间隔。支气管播散的结节灶可以较小,与血行播散结节灶相似,也可以直径明显大于血行播散病灶(见图6,7)。

图6 支气管播散性结核灶。右肺中下叶多发“簇”状沿支气管走行分布的粟粒样结节灶.“簇”与“簇”之间有正常肺间隔
图7支气管播散性肺结核。双肺多发”簇”状沿支气管走行分布的粟粒样结节灶,互相之间有正常肺间隔

2.2 分支样线性结构是支气管播散的HRCT典型表现之一

HRCT上的分支样线性结构在病理上表现为气道壁由于干酪样坏死而增厚,多与“簇”状分布的结节灶同时出现。

2.3 支气管播散病灶的进展

小叶中心结节生长和互相融合可以形成小叶实变,HRCT表现为小叶分布的片状高密度,肺窗图像上遮盖了肺纹理,纵隔窗可以看到高密度改变。如果中心肉芽肿包绕干酪样坏死,则形成较大的结核瘤,HRCT表现为有强化边缘、内部不强化的低密度病灶。如果小叶中心的边缘产生非特异性炎性反应,产生的炎性渗出则大多表现为片状磨玻璃样密度病灶。如果多个小叶中心空洞融合.则会形成大的空洞。空洞壁由干酪样坏死组织、上皮细胞及多核巨细胞、肉芽组织和纤维囊壁组成(见图8)。

图8 气管播散肺结核并融合呈实变。双肺多发“簇”状沿支气管走行分布的结节灶,左肺下叶内前基底段可见结核结节融合后的实变区域

3 血行播散病灶与支气管播散病灶的鉴别诊断血行播敞病灶与较小的、较密集分布的支气管播散病灶郁表现为结节样病灶,即使住HRCT图像上.二者有时也容易混淆.以下几点有助于二者的鉴别诊断:

①分布模式不同。血行播散性结节灶为随机分布,而支气管播散则是“簇”状分布的小叶中心结节,前者体现了血行传播的特点,后者则表明是沿支气管走行分布的特点。

②血行播散结节灶可以发生在胸膜下.支气管播散则不会。

③血行播散性肺结核容易侵犯肺间质,常伴有小叶问隔和/(或)小叶内问质增厚的表现(大网格或者细网格改变)。

另外。血行播散肺结核可以伴有少量的支气管播散病灶,Hong等总结的一组血行播散性肺结核患者中,16%的患者在HRCT上可见支气管播散病灶。

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    认真学习~~

    0

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