病理學(xué)英文版教學(xué)課件：11 Infectious disease

Infectiousdisease

傳染病病因：病原微生物（Pathogen)

引起疾病有傳染性，流行性 地方性，季節(jié)性入侵門戶：特定病原體—特定的入侵門戶—

特定播散方式—特定組織和器官和力—特定病變定位發(fā)病機理：細菌：內(nèi)/外毒素 病毒：細胞/體液免疫傳染病

共同特點

傳染病

共同特點

基本病理變化 炎癥（急/慢性） 宿主——病原致病力，兩者決定疾病過程臨床經(jīng)過，典型： 潛伏期：感染—出現(xiàn)癥狀 前驅(qū)期：出現(xiàn)非特異性癥狀 發(fā)病期：出現(xiàn)疾病的典型癥狀 愈復(fù)期：病情漸趨緩解轉(zhuǎn)歸痊愈：永久或暫時性免疫慢性復(fù)發(fā)死亡自然動物病三類病毒性動物病：出血熱、鸚鵡熱、狂犬病、SARS、

birdflu.立克次體病細菌病、螺旋體病、萊什曼病、布魯氏病舉例20世紀30年代蘇聯(lián)大規(guī)模森林腦炎森林腦炎病毒森林修鐵路工人

80年代上海食用毛蚶38.5萬甲肝病人野鹿、狼自然動物病90年代耐藥性結(jié)核（美國）從野猴、血貂、海龜身上傳來21世紀初

SARS：動物源性冠狀病毒(RNA病毒)Birdflu:H5N1型其它著名的病例有：中世紀鼠疫大流行blackdeath

艾滋病、口蹄疫、炭疽、埃博拉病毒、瘋牛病美國12變種香港6變種授課內(nèi)容結(jié)核神經(jīng)系統(tǒng)傳染病

流行性乙型腦炎

流行性腦膜炎麻風(fēng)梅毒傷寒細菌性痢疾Tuberculosis

結(jié)核IntroductionAchronicinfectiousdiseaseMycobacteriumTuberculosis☆PulmonaryTBisthemostcommontype.involveallorgans(rareinthyroid,pancreasandmyocardium)Characteristicchanges:

tuberculousgranuloma+caseousnecrosis結(jié)核結(jié)節(jié)干酪樣壞死TuberculosisEpidemiologyHistory☆“癆病”Worldwide

1.7billioninfected8-10millionnewcases3milliondeathsChina0.55billioninfected0.13milliondeathsTuberculosisPredisposingfactorssocialfactors:poverty,crowding,agingchronicdebilitatingdisease:diabetesmellitus,Hodgkindisease,pulmonarysilicosis,alcoholism,etalimmunitydeficiency:HIV

TuberculosisEtiologyRobertKoch24th,March“世界防治結(jié)核病日”Pathogenspecies:

M.hominis(人型）M.bovine(牛型）M.avium(鳥型）M.piscium(魚型)M.murium(鼠型)

humanTuberculosisHIVinfectedhostEtiologyPathogenicity

Lipid:mycolicacid（分枝菌酸）cordfactor（索狀因子）WaxD（蠟質(zhì)D）phospholipid（磷脂）mycosides（分枝菌糖苷脂）

Protein：Tuberculin結(jié)核菌素/純蛋白衍生物（PPD）GlycogenTuberculosis分支菌酸(mycolicacid)--抗酸染色TransmissionRespiratorytract(pulmonaryT.B):inhaletheairborneorganismsexposetocontaminatedsecretionsDigestivetract(intestinalT.B):

drinkinginfectedmilkSkininjury:

CongenitalBCG:nonpathogenic,livingT.B,undergoing230passages,13yrs）

mother PlacentaAmnioticfluidFetusTuberculosisPathogenesis

infection≠disease★Onlyasmallfractionofthosewhocontractaninfectiondevelopactivedisease.

TuberculosisPrimaryinfection(non-specificimmunity)hyperemia,edema,neutrophils,TandBcells,MΦphagocytosed,butnotkilledN-RAMP1:naturalresistance-associatedmacrophageprotein1MostpatientsatthisstageareasymptomaticorhaveamildflulikeillnessTuberculosisPathogenesis2–3wkslaterspecificimmunityandallergyoccursOT/PPDSecondaryinfection:(specificimmunity)Kochphenomena:immunityaccompaniedwithallergyTuberculosisPathogenesisPPDtest

false-negativefalse-positiveTuberculosisPathogenesisKochphenomenon:cellmediatedimmunity(CMI)accompaniedwithdelayedtissuehypersensitivity(DTH)TuberculosisCMIandDTHaredifferentimmunoreactionsDifferentantigensDifferentTcellsubtypesTheamountoforganismsorantigenandTh1/Th2excursionDifferentCKsDifferentmethodstokillorganismsPathologicalchangesExudationdominantchanges滲出病變happenedinearlystageofinfectionordeteriorationofDis.

Predisposingfactors:

suppressedimmunity,plentyofmycobacteriumT.BhighvirulenceandstrongDTHchanges:serousinflammation,serous-fibrinousinflammationlocation:pleura,meninges,peritoneumTuberculosisTuberculosisPathologicalchangesExudationdominantchanges:

development:unstableabsorbedwithoutanychangeschangeintoproliferationdominantornecrosisdominantchangeseasytofindorganismsTuberculosisPathologicalchangesProliferationdominantchange(Tubercleformation,granuloma)肉芽腫性病變

Predisposingconditions:strongimmunityfewmycobacteriumlowvirulence

TuberculosisPathologicalchangesProliferationdominantchange(Tubercleformation,granuloma)

Changes:EpithelioidcellsLanghan’sgiantcellsLymphocytesdifficulttofindorganismsTuberculosisTubercle結(jié)核結(jié)節(jié)PathologicalchangesNecrosisdominantchangePredisposingfactors:weakenedimmunity,severehypersensitivitylargeamountofmycobacteriumT.B.highvirulenceChanges:caseousnecrosis（干酪樣壞死)

Gross:granular,cheesyappearance(richinlipid)

LM:acidophiliagranularmaterialswithoutstructure

TuberculosiscaseousnecrosisPathologicalchangesNecrosisdominantchangeeasytofindorganismsDevelopment:

Existforlong→timingbombTheamountofmycobacteriumwillincreasesharplywhenthediseasedeteriorateFibrosisTuberculosisPathologicalchangesexudationchangesgranulomalesioncaseousnecrosisTuberculosisBasicchangesHostBacterialImmunityAllergyAmountpathogenexudationlowstrongerlargestronggranulomahigherweakerfewlownecrosislowstrongestlargestrongTuberculosis愈合

病灶小：滲出性病灶吸收消散 增生性病灶纖維化 干酪壞死灶，吸收消散，纖維化-------------"吸收好轉(zhuǎn)期" 病灶大：

纖維化 鈣化（20%鈣化灶內(nèi)有活菌）

-------------"硬結(jié)鈣化期"ConsequenceTuberculosis惡化

1.病灶擴大病灶周圍滲出

結(jié)核結(jié)節(jié)及干酪樣壞死模糊的云絮狀陰影陰影密度增高"浸潤進展期"ConsequenceTuberculosis惡化2、溶解、播散與空洞形成壞死、液化——天然腔道排出----空洞“開放性肺結(jié)核”播散

天然腔道：支氣管---肺

“溶解播散期”

消化道——腸

輸尿管——膀胱淋巴道：淋巴結(jié)血道：遠處器官ConsequenceTuberculosisPulmonaryTuberculosis

肺結(jié)核

PrimarypulmonaryT.B.SecondarypulmonaryT.B.TuberculosisPreviouslyunexposedMostinchildren,agedorimmunosuppressdpersons(HIV)ExogenousorganismPathologicalchange:

GhonComplex（原發(fā)復(fù)合征)1-1.5-cmareaofgray-whiteinflammatoryconsolidation(lowerpartofupperlobeorupperpartoflowerlobe)TuberculouslymphatitisRegionalnodeinvolvement,oftenwithcaseatePrimaryPulmonaryTuberculosisTuberculosisGhonComplexTuberculosisPrimaryPulmonaryTuberculosisTuberculosisPrimaryPulmonaryTuberculosis

絕大多數(shù)無明顯的癥狀

5%患者有倦怠，盜汗，消瘦等1、98%好轉(zhuǎn)，機體產(chǎn)生免疫力，病灶吸收，纖維化，鈣化

Ranke復(fù)合征(Rankecomplex)2、惡化進展血道播散淋巴道播散支氣管播散Consequence轉(zhuǎn)歸TuberculosisPrimaryPulmonaryTuberculosis血道播散acutemiliaryT.B.

（急性粟粒性結(jié)核）大量細菌一次進入肺靜脈

全身（肝、脾、腦膜、腎、骨髓）肺動脈

肺抵抗力極差或用大量激素、免疫抑制劑或細胞毒藥后TuberculosisPrimaryPulmonaryTuberculosis粟粒性肺結(jié)核大小一致、分布均勻、灰白色圓形鏡下：結(jié)核結(jié)節(jié)TuberculosisPrimaryPulmonaryTuberculosisTuberculosisPrimaryPulmonaryTuberculosissubacuteorchronicmiliaryT.B.（亞急性或慢性全身粟粒性結(jié)核?。? 少量多次進入血循環(huán)，病灶大小、新舊和性質(zhì)不一致secondaryorextrapulmonaryT.B.

（繼發(fā)性肺結(jié)核或肺外器官結(jié)核?。┓巍⒐顷P(guān)節(jié)、腦、腎、輸卵管、附睪等處痊愈或潛伏下來日后復(fù)發(fā)血道播散TuberculosisPrimaryPulmonaryTuberculosis

鎖骨上下LN頸LN肺門LN 支氣管、氣管LN

縱隔LN

腹膜后LN

結(jié)核結(jié)節(jié)形成伴淋巴組織增生干酪樣壞死與軟組織粘連，甚至經(jīng)久不愈的竇道

淋巴道播散TuberculosisPrimaryPulmonaryTuberculosis支氣管播散少見。LN腫大將小兒薄壁氣管壓癟

TuberculosisPrimaryPulmonaryTuberculosisSecondaryPulmonaryT.B.

繼發(fā)性肺結(jié)核PreviouslyinfectedAdulttypePathogenesis<5%exogenous>95%endogenousseedingTuberculosis1.Location:apexoflobelowarterialbloodpressure,lessMΦ,lessventilation,highO2pressure2.Changes:caseousnecrosis---proliferationfocuslocalizationlesslymphaticandvascularspreadingmorebronchialdissemination3.Longcourseofdisease,complexchangesTuberculosisSecondaryPulmonaryTuberculosisPrimaryPT.BSecondaryPT.B

InfectionpreviouslyuninfectedpreviouslyinfectedPatientchildrenadultSpecialCMIandDTHoccurinthecoursepreviouslyhadPathologicalchangesGhoncomplexvariouschanges,localization,cavityBeginningfocuslowerpartofupperlobeapexoflobeupperpartoflowerlobeCharacterofchangesexudation,necrosisproliferation,necrosisDisseminationlymphaticandbloodvesselbronchialCourseofdiseaseshort,self-controllong,fluctuant,clinicaltreatmentcomparisonTuberculosis原發(fā)性肺結(jié)核繼發(fā)性肺結(jié)核結(jié)核桿菌感染初染再染發(fā)病人群兒童成人特異性免疫力和過敏性先無，在病程中發(fā)生有病理特征原發(fā)復(fù)合征病變多樣，新舊病灶并存起始病灶下葉上部、上葉下部近胸膜處肺尖病變性質(zhì)滲出壞死為主肉芽腫形成和壞死為主播散方式淋巴道、血道播散多為支氣管，趨于肺內(nèi)演變病程短，大多自愈長，波動性，需治療PathologicalchangesFocallesion:(局灶型）1.location:1~2cmbeneathapexoflobe2.modality:lessthan2cmindiametersingleormultiplefocusesproliferationdominantcaseousnecrosisincentralandfibrosisaround3.development:healingbyfibrosisorcalcificationfewbecomeinfiltrativelesionTuberculosisSecondaryPulmonaryTuberculosisTuberculosisSecondaryPulmonaryTuberculosisPathologicalchangesInfiltrativelesion（浸潤型）:1.source:focallesion2.location:apexorsubclavicalarea(subclavicularinfiltration)3.modality:exudationdominant,caseousnecrosisincentral4.clinicalsymptoms

TuberculosisPrimaryPulmonaryTuberculosisTuberculosisPrimaryPulmonaryTuberculosisPathologicalchangesInfiltrativelesion（浸潤型）:5.development:healingbyabsorb,fibrosis，calcificationdiseaseprogresses,acutecavitationmayoccurcaseouspneumoniaspontaneouspneumothoraxtuberculouspyopneumothoraxchronicfibro-cavitativetypeTuberculosisPrimaryPulmonaryTuberculosisChronicfibro-cavitativelesion(慢性纖維空洞型)1.source:infiltrativetypewithacutecavity2.Characters:☆singleormultiplechroniccavitiesthreelayers----inner:caseousnecroticmaterialsmid:tuberculousgranulationtissueouter:fibrousscar☆diversefoci☆fibrosis(cirrhoticpulmonarytuberculosis)PathologicalchangesTuberculosisPrimaryPulmonaryTuberculosisTuberculosisPrimaryPulmonaryTuberculosisTuberculosisPrimaryPulmonaryTuberculosisChronicfibro-cavitativelesion(慢性纖維空洞型)

3.clinicalsymptoms

openT.B.(mycobacteriuminsputum)emptysis,laryngealT.B.,IntestinalT.B.,corpulmonale4.developmenthealing:smallcavity→scarhealinglargecavity→openhealingPathologicalchangesTuberculosisPrimaryPulmonaryTuberculosisTuberculosisPrimaryPulmonaryTuberculosisCaseousPneumonia(干酪樣肺炎）

1.source:infiltrativelesionbronchialspreadingofacuteorchroniccavity2.modality:lobularorlobarcaseouspneumoniaacutecavity(localliquefaction).LM:caseousnecrosiswithserous-fibrinousexudate3.Poorprognosis(百日癆or奔馬癆)PathologicalchangesTuberculosisPrimaryPulmonaryTuberculosisTuberculosisPrimaryPulmonaryTuberculosisTuberculoma（結(jié)核球)1.source:fibrosisofcaseousnecrosisininfiltrativetypebronchiaclosureleadstocaseousmaterialsfillinthecavitycombinationofseveraltubercular2.modality:caseouslesionwithfibrouscapsule2-5cmindiameter3.prognosis:stabledeteriorationPathologicalchangesTuberculosisPrimaryPulmonaryTuberculosisTuberculosisPrimaryPulmonaryTuberculosisTuberculouspleuritis:wetanddrywettype----Exudativepleuritis：MostinyoungpeopleSource:mycobacteriadisseminationfromprimaryfocusorhilarlymphnodsDTHinducedbyproteinofmycobacteriainpleuraPathologicalchanges:serous-fibrinousinflammationClinicalsymptomsPrognosis:1.absorb2.richinfibrinmaycauseadhesionofpleuraPathologicalchangesTuberculosisPrimaryPulmonaryTuberculosisTuberculosisPrimaryPulmonaryTuberculosisdrytype----proliferativepleuritis：T.B.focusbeneathpleuraextendtopleuraMostinapexoflobe,localpleuraadhesionandthickeningCaseouspleuritisrare

PathologicalchangesTuberculosisPrimaryPulmonaryTuberculosisSystemicsymptoms

responsetoT.B.“toxic”components

Localmanifestations:

coughhemoptysischestpainlowerrespiratoryfunctionCPCmalaise,weary,nightsweat,lowfeverintheafternoon,hecticrosycheeks,lossofappetiteTuberculosisPrimaryPulmonaryTuberculosisHematogenictuberculosisResultfromPrimarytuberculosisorSecondarytuberculosisTuberculosisTuberculosisPrimaryPulmonaryTuberculosisExtrapulmonaryTuberculosisInvolveallorgansReactivationoflatentfociPathologicalchangesandcharacteroforgansarecorrelativeTuberculosisIntestinalTuberculosisSourceofMycobacterium

primary:drinkinginfectedmilksecondary:

swollenmycobacteriumcontainedsputumLocation:

anysegmentofintestinemostcommonatileocecalsegment:1.richinlymphtissue,easytoinvade2.longtimeforfoodtostayinthissegmentTuberculosisUlcerativeintestinalT.B.

TuberclesinlymphtissuefusednecrosisulcerationFeaturesofulcer:

1.longaxisoftheulcerisverticaltolongaxisofintestine,becauseofthecircularlymphaticsofintestine

2.irregularmarginoftheulcer(rat-bite-like),caseousbaseandtuberculargranulationtissuebeneath,fibrinexudateandmiliarytuberclesinserosaIntestinalTuberculosisTuberculosisUlcerativeintestinalT.B.3.IntestinalstraitnessafterulcerhealingFibrosisleadstoaadhesionamongserosaandadjacenttissuesHemorrhageandperforationareuncommonClinicalsymptoms:

chronicabdominalpain,intermittentdiarrheaandconstipation,tubuculartoxicsymptomsTuberculosisIntestinalUlcerativeT.B.TuberculosisProliferativeintestinalT.B.

proliferativechangesdominant,causingthickeningofintestine,polyposis,leadingtoabdominalmassand/orileus※※※※※※※※IntestinalT.B.MesenteryT.B.Tuberculousperitonitiswettypeperitonealtuberclegreenishyelloworhematicascitesdrytype