Pneumonia Definition • Pneumonia is an acute infection of the parenchyma of the lung(肺实质), caused by bacteria, fungi(真菌）, virus, parasite（寄生虫） etc. • Pneumonia may also be caused by.
Download ReportTranscript Pneumonia Definition • Pneumonia is an acute infection of the parenchyma of the lung(肺实质), caused by bacteria, fungi(真菌）, virus, parasite（寄生虫） etc. • Pneumonia may also be caused by.
Pneumonia Definition • Pneumonia is an acute infection of the parenchyma of the lung(肺实质), caused by bacteria, fungi(真菌）, virus, parasite（寄生虫） etc. • Pneumonia may also be caused by other factors including X-ray, chemical, allergen Epidemiology The morbidity and mortality of pneumonia are high especially in old people. Etiology There are two factors involved in the formation of pneumonia , including pathogens and host defenses. Classification Classification of anatomy Classification of pathogen Classification of acquired environment Ⅰ.Classification by pathogen Pathogen classification is the most useful to treat the patients by choosing effective antimicrobial agents Bacterial pneumonia (1) Aerobic Gram-positive bacteria,such as streptococcus pneumoniae, staphylococcus aureus, Group A hemolytic streptococci (2) Aerobic Gram-negative bacteria, such as klebsiella pneumoniae, Hemophilus influenzae, Escherichia coli (3) Anaerobic bacteria Atypical pneumonia Including Legionnaies pneumonia , Mycoplasmal pneumonia ,chlamydia pneumonia. Fungal pneumonia Fungal pneumonia is commonly caused by candida(念珠菌) and aspergilosis(曲菌). pneumocystis jiroveci（肺孢子虫） Viral pneumonia Viral pneumonia may be caused by adenoviruses, respiratory syncytial virus, influenza, cytomegalovirus, herpes simplex Pneumonia caused by other pathogen Rickettsias (a fever rickettsia), (立克次体） parasites(寄生虫) protozoa（原虫） Ⅱ.Classification by anatomy 1. Lobar（大叶性）: Involvement of an entire lobe 2. Lobular（小叶性）: Involvement of parts of the lobe only, segmental or of alveoli contiguous to bronchi (bronchopneumonia). 3. Interstitial（间质性） Lobar pneumonia Lobular pneumonia Interstitial pneumonia Classification by acquired environment Community acquired pneumonia，CAP （社区获得性肺炎） Hospital acquired pneumonia，HAP ，NP （医院获得性肺炎） Nursing home acquired pneumonia,NHAP (护理院获得性肺炎） Immunocompromised host pneumonia,(ICAP) (免疫宿主低下肺炎） Diagnosis（诊断步骤） Give a definite diagnosis of pneumonia To evaluate the degree of the pneumonia To definite the pathogen of the pneumonia Diagnosis History and physical examination(5W) X-ray examination Pathogen identification Differentiation Pulmonary tuberculosis Lung cancer Acute lung abecess Pulmonary embolism Noninfectious pulmonary infiltration Pathogen identification Sputum: More than 25 white blood cells (WBCs) and less than 10 epithelial cells. Nasotracheal suctioning BAL, ETA, PSB, LA Blood culture or pleural effusion culture Serologic testing (immunological testing) Molecular Techniques The principal of therapy Select antibiotics According to guideline Therapy The therapy should always follow confirmation of the diagnosis of pneumonia and should always be accompanied by a diligent effort to identify an etiologic agent. Empiric therapy,(4-8h) Combined empiric therapy to target therapy It is important to evaluate the severity degree of pneumonia The critical management decision is whether the patient will require hospital admission. It is based on patient characteristics, comorbid illness, physical examinations, and basic laboratory findings. The diagnostic standard of sever pneumonia Altered mental status Pa02<60mmHg. PaO2/FiO2<300, needing MV Respiratory rate>30/min Blood pressure<90/60mmHg Chest X-ray shows that bilateral infiltration, multilobar infiltration and the infiltrations enlarge more than 50% within 48h. Renal function: U<20ml/h, and <80ml/4h CAP (社区获得性肺炎） CAP refers to pneumonia acquired outside of hospitals or extended-care facilities . Streptococcus pneumoniae remains the most commonly identified pathogen. Other pathogens include Haemophilus influenzae, mycoplasma pneumoniae, Chlamydophilia pneumoniae, Moraxella catarrhalis and ects. Drug resistance streptococcus pneumoniae(DRSP) Clinical manifestation The onset is accute Respiratory symptoms Extrapulmonary symptoms signs Consolidation signs Moist rales Respiratory rate or heart rate Laboratory examination WBC X-ray features Diagnosis Clinical diagnosis Pathogen diagnosis Evaluate the severity degree of pneumonia Therapy Antiinfectious therapy(Combined empiric therapy to target therapy) Supportive therapy Empiric therapy (1) Outpatient<60 years old and no comorbid diseases Common pathogens: S pneumoniaes, M pneumoniae, C pneumoniae, H influenzae and viruses A new generation macrolide A beta-lactam: the first generation cephlosporin A fluoroquinolone Empiric therapy (2) Outpatient>65 years old or having comorbid diseases or antibiotic therapy within last 3 months Common pathogens: S pneumoniae(drugresistant), M pneumoniae, C pneumoniae, H pneumoniae, H influenzae, Viruses, Gram-negative bacilli and S aureus A fluoroquinolone A beta-lactam / betalactamase inhibitor The second generation cephalosporin or combination of a macrolide Empiric therapy (3) Inpatient : Not severely ill. Common pathogen:S pneumoniae, H influenzae, polymicrobial, Anaerobes, S aureus, C pneumoniae, Gramnegative bacilli. The second or third generation cephalosporin plus A macrolide A betalactam/betalactamase inhibitor. A newer fluoroquinolone Empiric therapy (4) Inpatient severely ill Common pathogens:S pneumoniae, Gramnegative bacilli, M pneumoniae, S aureus and viruses The second or third generation cephalosporin plus A macrolide A betalactam/betalactamase inhibitor. A newer fluoroquinolone Vancomycin Empiric therapy (5) Patients in ICU without Pneudomonas aeruginosa infection The second or third generation cephalosporin plus A macrolide A betalactam/betalactamase inhibitor. A newer fluoroquinolone Vancomycin Empiric therapy (6) Patients in ICU with Pneudomonas aeruginosa infection A antipneudomonas aeruginosa betalactam/betalactamase inhibitor plus fluoroquinolone prognosis preventive HAP（医院获得性肺炎） HAP refers to pneumonia acquired in the hospital setting. Enteric Gram-negative organisms, S. aureus, Pneudomonas aeruginosa, ects. The pathogen of HAP Gram-negative bacteria (GNB) account for 55% to 85% of HAP infections gram-positive cocci account for 20% to 30% and some other pathogens. EPIDEMIOLOGY General risk factors for developing HAP include age more than 70 years, serious comorbidities, malnutrition, impaired consciousness, prolonged hospitalization, and chronic obstructive pulmonary diseases. EPIDEMIOLOGY HAP is the most common infection occurring in patients requiring care in an intensive care unit (ICU), with incidence rates ranging from 6% up to 52%, much higher than the 0.5% to 2% incidence reported for hospitalized patients as a whole. This increased incidence is due to the fact that patients located in an ICU often require mechanical ventilation, and mechanically ventilated patients are 6 to 21 times more likely to develop HAP than are nonventilated patients. Mechanical ventilation is associated PATHOGENESIS Aspiration :Microaspiration of contaminated oropharyngeal secretions seems to be the most important of these factors, as it is the most common cause of HAP. Inhalation Contamination Clinical manifestations The onset is acute or insidious Respiratory symptoms Physical signs Laboratory examinations Chest X-ray diagnosis Clinical diagnosis Pathogen diagnosis Evaluate the severity degree of pneumonia Treatment (1) Antibiotic therapy: antimicrobial therapy begin promptly because delays in administration of antibiotics have been associated with worse outcomes. The initial selection of an antimicrobial agent is almost always made on an empiric basis and is based on factors such as severity of infection, patient-specific risk factors, and total number of days in hospital before onset. Treatment (2) All empiric treatment regimens should include coverage for a group of core organisms that includes aerobic gram negative bacilli (Enterobacter spp, Escherichia coli, Klebsiella spp, Proteus spp, Serratia marcescens, and Hemophilus influenzae) and gram-positive organisms such as Streptococcus pneumoniae and Staphylococcus aureus. Treatment (3) In patients with mild or moderate infections and no specific risk factors for resistant or unusual pathogens, monotherapy with a second-generation cephalosporin such as cefuroxime; a nonpseudomonal third-generation cephalosporin such as ceftriaxone; or a beta-lactam/betalactamase inhibitor such as ampicillin/sulbactam, ticarcillin/clavulanate, or piperacillin/tazobactam may be appropriate. For patients in this low-risk category who have an allergy to penicillin, it is appropriate to initially use a fluoroquinolone Treatment (4) Patients with severe infections with specific risk factors should have broadened empiric coverage. Combination therapy should be employed in these cases because of the high rate of acquired resistance among these organisms. Appropriate combinations for this group of patients include an aminoglycoside or ciprofloxacin in addition to a beta-lactam with antipseudomonal coverage. Additionally, vancomycin should be considered if the patient has risk factors that suggest methicillin-resistant Staphylococcus aureus could be a pathogen. Prevention Release aspiration Washing hands vaccination ICHP (免疫低下宿主肺炎) Pneumonia in an immunocompromised host describes a lung infection that occurs in a person whose ability to fight infection is greatly impaired. (Non-HIV-ICH) Causes, incidence, and risk factors Immunosuppression can be caused by HIV infection, leukemia, organ transplantation, bone marrow transplant, and medications to treat cancer. Microorganisms include all kinds of bacteria and virus(CMV), candida(念珠菌) and aspergilosis(曲菌). pneumocystis carinii（PCP,卡氏肺孢子虫） Symptoms The onset is incidous , but clinical Symptoms are severe. Fever Nonproductive (dry) cough or cough with mucus-like, greenish, or pus-like sputum PCP Fungal infection Diagnosis Earlier finding and diagnosis Pathogen diagnosis Chest x-ray Sputum gram stain, other special stains, and culture Arterial blood gases Bronchoscopy Chest CT scan, Tissue diagnosis Treatment Antimicroorganism therapy The goal of treatment is to get rid of the infection with antibiotics or antifungal agents. The specific drug used will depend on what kind of organism is causing the problem. One drug may kill one type of organism, but not another. Respiratory treatments (to remove fluid and mucus) and oxygen therapy are often needed. Pneumococcal pneumonia Abstraction • Pneumococcal pneumonia is produced by streptococcal pneumoniae • It is the most commonly occurring bacterial pneumonia Etiology • Streptococcus pneumonia are encapsulated, gram-positive cocci that occur in chains or pairs • The capsule which is a complex polysaccharide has specific antigenicity • Type 3 is the most virulent, usually causing severe pneumonia in adults, but type 6,14,19 and 23 are virulents is children Bacteria are introduced into the lungs by the four routes Source Route colonization aspiration Air Non-pulmonary infection Contiguous infection inhalation blood stream direct extention Response lung defenses Outcome pneu. pathogenesis Pneumococci usually reach the lungs by inhalation or aspiration. They lodge in the bronchioles, proliferation and initiate an inflammatory process. Pathology Congestion red hepatization grey hepatization resolution) Pathology Red hepatilization ◆ All of the four main stages of the inflammatory reaction described above may be present at the same time ◆ In most cases, recovery is complete with restoration of normal pulmonary anatomy Clinical manifestations Clinical manifestations (1) • Many patients have had an upper respiratory infection for several days before the onset of pneumonia • Onset usually is sudden, half cases with a shaking chill • The temperature rises during the first few hours to 39-40℃ Clinical manifestations (2) Typically, patients have the symptoms of high fever , shaking chill, sharp chest pain, cough, dyspnea and blood-flecked sputum. But in some cases, especially those at age extremes symptoms may be more insidious. Clinical manifestations (3) • The pulse accelerates • Sharp pain in the involved hemi thorax • The cough is initially dry with pinkish or blood-flecked sputum • Gastrointestinal symptoms such as, anorexia, nausea, vomiting abdominal pain, diarrhea may be mistaken as acute abdominal inflammation Signs 1 • The acutely ill patient is tachypneic, and may be observed to use accessory muscles for respiration, and even to exhibit nasal flaring • Fever and tachycardia are present, frank shock is unusual, except in the later stages of infection or DIC Signs 2 • Auscultation of the chest reveals bronchovesicular or tubular breath sounds and wet rales over the involved lung • A consolidation occurs, vocal and tactile fremitus are increased Laboratory examinations Laboratory examinations (1) • The peripheral white blood cell (WBC) count • Before using antibiotic, the culture of blood and of expectorated purulent sputum between 24-48 hours can be used to identify pneumococci • Colony counts of bacteria from bronchoalveolar lavage washings obtained during endoscopy are seldom available early in the course of illness • Use of the PCR may amplify pneumococcal DNA and improve potential for detection X-ray examination • Chest radiographs is more sensitive than physical examination • PA and lateral chest radiographs are invaluable to detect pneumonia X-ray examination • Usually lobar or segmental consolidation suggests a bacterial cause for pneumonia • If blunting of the costophrenic angle is noted, pleural effusion may be exist. The features of CT Air-bronchogram sign Complications In 5% to 10% of patients, infection may extend into the pleural space and result in an empyema （脓胸） In 15% to 20% of patients, bacteria may enter the blood stream (bacteremia) via the lymphatics and thoracic dust. Invasion of the blood stream by pneumococci may lead to serious metastatic disease at a number of extra pulmonary sites (meningitis, arthritis, pericarditis, endocarditis, peritonitis, ostitis media etc). Complications sepsis （脓毒性休克） lung abscess（肺脓疡） or empyema pleural effusion（胸腔积液） pleuritis ARDS（急性呼吸窘迫综合征） ARF（急性呼吸衰竭） pneumothorax（气胸） Extrapulmonary infections Diagnosis According to history, the clinical signs , physical examinations, laboratory examinations and radiographic features it is not difficult to make the diagnosis Differential diagnosis • pulmonary tuberculosis • Other microbial pneumonias: klebsiella pneumonia, staphylococal pneumonia, pneumonias due to G (-) bacilli, viral and mycoplasmal • Acute lung abscess • Bronchogenic carcinoma • Pulmomary infarction Treatments Antibiotics Support therapy Therapy of complications Antibiotic therapy (1) • All patients with suspected pneumococcal pneumonia should be treated as promptly as possible with penicillin G • The dose and route of delivery may have to be on the basis of patients status adverse reaction or complication that occur Antibiotic therapy (2) • For patients who are believed to be allergic to penicillin, one may select the first or second generation cephalosporin or advanced macrolide+ β -lactam or respiratory fluoroquinolone alone. For patients with PRSP, one may select the second and third generation cephalosporin or advanced macrolide+ β -lactam or respiratory fluoroquinolone alone. In some cases, vancomycin may be used. Antibiotic therapy • Treatment with any effective agent should be given for at least 5 to 7 day or after the patients have been afebrile for 2-3 days Supportive measure Supportive measure are generally used in the initial management of acute pneumo coccal pneumonia, such measures include • Bed rest • Monitoring vital signs and urine output • Administering an occasional analgesic to relieve pleuritic pain • Replacing fluids, if the patient is dehydrated • Correcting electrolytes • Oxygen therapy Treatment of complications • Empyema develops in appoximately 5% of patients with pneumococcal pneumonia, although pleural effusion commonly develop in 10%- 20% patients • Chest X-ray with lateral decubitus films are often useful in the early recognition of pleural effusion, pleural fluid that is removed should be subjected to routing examination • If pneumococcal bacteremia occurs, extra pulmonary complications such as arthritis, endocarditis must be excluded, because the therapy requires higher dosages • Treatment of infections shock Prognosis Prognosis is much better Any of the following factors makes the prognosis less favorable and convalescence more prolonged elderly: • involvement of 2 or more lobes • underlying chronic diseases (heart lung kidney) normal temperature and WBC count <5000 • immunodeficiency with severe complication Prevention The most important preventive tool available is using a poly valent pneumococcal vaccine in those with chronic lung diseases, chronic liver diseases, splenectomy, diabetes mellitus and aged Staphylococcus pneumonia • Staphylococcal pneumonia is usually caused by staphylococcus aureus • It is often a complication of influenza, but may be primary, particularly in infants and the aged • It occurs in immunocompromissed patients such as diabetes mellitus hematologic disease ( leukemia, lymphoma, leukopenia ) AIDS, liver disease, malnutrition, alcoholism • Staphylococcal bacteremia complicating infections at other sites (furuncles, carbuncles) may cause hematogenous pulmonary involvement (due to blood spread) • Some or all of the symptoms of pneumococcal pneumonia (high fever, shaking chill, pleural pain, productive cough) may be present, sputum may be copious and salmon-colored • Prostration is often marked • According the symptoms, signs of pneumonia, leukocytosis and a positive sputum or blood culture, the diagnosis can be made • Gram stain of the sputum provides earliest diagnostic clue • Chest X-ray early in the disease shows many small round areas of densities that enlarge and coalesce to from abscess, and leave evidence of multiple cavities • Until the sensitivity results are know, a penicillinase–resistant penicillin or a cephalosporin should be given • Therapy is continued for 2 weeks after the patient has become afebrile and the lungs have shown signs of clearing • Vancomycin is the drug of choice for patients allergic to penicillin and cephalosporin and for those not responding to other antistaphylococcal drugs, mainly used in MRSA. Pneumonia caused by klebsiella Klebsiella pneumonia ( also named Friedlander pneumonia) is an acute lung infection, caused by Klebsiella pneumoniae 1, it occurs much more in aged, malnutrition, chronic alcoholism, and in whom with bronchial pulmonary disease • This pneumonia is most likely to be found in man with middle age, onset usually is sudden, with high fever, cough, pleuritic pain, abundant sputum, cyanosis, tachycardia my be present, half cases with a shaking chill • Shock appears in early stage • Clinical manifestations are similar to sever pneumococcal pneumonia • The sputum is viscid and “ropy”, and may be “brick red” in color • Chest X-ray shows a downward curve of the horizontal interlobar fissure, if the right upper lobe is involved • Areas of increased radiance whithin dense consolidation suggest cavitation • It constitutes 2% of bacterial pneumonia, but mortality may be as high as 30% • When an elderly patient suffered from acute pneumonia with sever toxic symptom, viscid and “brick red”, sputum must consider this disease • The diagnosis is determined by bacterial examination of sputum • Early using antimicrobial therapy is important for patients with survivable illillnesses, aminoglycoside (Kanamycin, Amikacin, Gentamycin ) and the third generation cephalosporin are often used. Mycoplasmal pneumonia • Mycoplasmal pneumonia is caused by Mycoplasmal pneumoniae • Mycoplasmal pneumoniae is one of the smallest organisms 125-150 μm capable of replication in cell-free media • Infection is spread form person to person by respiratory secretions expelled during bouts of coughing, causing epidemic • It commonly occurs in children, adolescent, mainly in fall and winter • It constitutes more than 1/3 of non bacterial pneumonias, or 10% of pneumonias from all cause • Cellular infiltrate around bronchioles, and in alveolar interstitium, consists mostly of mononuclear elements Clinical findings • The illness begins insidiously with constitutional symptomatology: malaise, sore throat, cough, fever, myalgia • Half of cases have no symptom • Chest X-ray Chest X-ray findings are manifold • Most patients have unilateral lower lobe segmental abnormalities • The earliest signs are an interstitial accentuation of marking with subsequent patch air space consolidation and thickened bronchial shadows • The pneumonia may persist for 3-4 weeks a slight leukocytosis is seen, with a normal differential count • The diagnosis is generally proved by a single antibody titer of 1:32 or greater, a titer of cold agglutinins of 1:32 or greater a single Ig M determination • The most promising in terms of speed, sensitivity and specificity is PCR although cost and lack of general availability limit its routine use Therapy A definite clinical response is seen to erythromycin and some other newer macrolide Legionnaies Pneumonia Legionella can be an opportunistic pathogen. Patients with immunosuppression are at increased risk for infection. But sometimes outbreaks do occur in previously healthy individuals. Legionellae are small, gram-negative, obligately aerobic baclli. . Legionnaires’ disease is acquried by inhaling aerosolized water containing Legionella organisms or possibly by pulmonary aspiration of contaminated water. The contaminated water are derived from humidifiers, shower heads, respiratory therapy equipment, industrail cooling water. Because of the frequently use of air conditioner, Legionnaies pneumonia is also seen in CAP Clinical manifestations The onset of L.pneumonia is sometimes severe. High fever, rigors, and significant hypoxemia are usually seen in patients with L.pneumonia. Failure to rapidly appropriate therapy in these cases is likely to result in a poor outcome. Common signs include cough, dyspnea, pleuritic chest pain, gastrointestinal symptoms, especially diarrhea or localized abdominal pain, nausea, vomitting are a prominent finding in 20% to 40% of patients with L.pneumonia. Physical examination Physical finding are often similar to other pneumonias. Rales are usually present over involved areas Pulse rate is not coincide to the body temperate. Chest X-ray No diagnostic features on the chest X-ray distinguish it from other pneumonia Infiltrates can be unilateral, bilateral, patchy, or dense, and can spread very quickly to involve the entire lung, pleural effusion, usually Laboratory examination Serologic testing is the most often used for establishing a diagnosis. A fourfold or greater rise in antibody is considered definitively exist for Legionella. Diagnosis According to history, clinical signs, X-ray features and serologic testing, we can diagnose it. Therapy Erythromycin is considered the drug of choice.It should be given until clinical improvement is seen.It usually lasts 2-3 weeks. Candidiasis Candidiasis is an opportunistic disease, it is caused by candida. Clinical signs Respiratory signs: fever,cough, sputum production, dyspnea. X-ray shows no specific.It is similar to acute pneumonia. diagnosis Mainly according to sputum culture or biopsy of lung. Therapy Nystatin or various azole drugs Aspergillosis Aspergillosis refers to infection with any of species of the genus Aspergillus Clinical signs The disease generally occurs in immunosuppressed and anticancer therapy patients. There are four types of pulmonary aspergillosis. Clinical signs of Pulmonary aspergillosis Presents as chronic productive cough, hemoptysis, dyspnea, weight loss, fatigue, chest pain, or fever Sometimes patients with pulmonary aspergillosis accompany with prior chronic lung disease. Typical picture of an aspergilloma is a fungus ball in a cavity in an upper lobe The sputum culture is positive in most patients. Diagnosis The repeated isolation of Aspergillus from sputum or the demonstration of hyphae in sputum or BALF suggests endobronchial infection. Treatment With intravenous amphotericin B (1.0 to 1.5 mg/kg daily) Patients with severe hemoptysis due to fungus ball of lung may benefit from lobectomy Therapy to Infectious Shock Treatment in intensive care units cardiac rhythm, blood pressure, cardiac performance, oxygen delivery, and metabolic derangements can be monitored Adequate oxygenation and ventilatory support (sometimes mechanical ventilation) Effective antibiotic therapy Maintain blood pressure, including maintain circulation blood volume, use of dopamine Summary 1.肺炎的定义 2.肺炎的分类 3.CAP和HAP的定义和常见的病原体 4.肺炎球菌肺炎的典型的临床表现和影象 特点及其治疗原则 5.各种病原体肺炎的治疗原则 6.感染性休克的治疗原则 Questions 1.What is the differences between CAP and HAP? 2.What is the standard of sever pneumonia? 3.what are the principals of antibiotic therapy of various of pneumonias? Case report 患者,男性,32岁 主诉:发热伴咳嗽6天 现病史:患者于6天前劳累后出现发热,体温最高 达39℃,稍有畏寒,自服退热药后热退,之后体温 又上升,达38℃,伴有咳嗽,痰为白色黏液样,偶呈 黄脓性,遂于我院就诊,胸部X线显示:左下肺片 状高密度影,外周血白细胞6.0*109 /L,N66.2%,在 门诊予与亚星和左克抗感染3天,体温不退,行胸 部CT检查示:左下肺片状密度增高影。故收入 院进一步诊治。 入院体检 神清，一般可，T：38℃，P90次/分， R18次/分，BP110/70mmHg，口唇无紫绀， 全身浅表淋巴结未及肿大，颈软，两肺 呼吸音粗，未及干湿罗音，腹软，无压 痛，双下肢无浮肿，NS(-) 辅助检查 血支原体抗体IgM１：160 胸片 胸部CT 胸片 胸部CT case2 患者，男性，50岁 主诉:咳嗽伴咳黄痰二十余天 现病史:患者于入院前二十余天开始无明显诱因下出现 咳嗽,咳黄脓痰,量中,无咯血,胸痛和呼吸困难等其他呼 吸系统症状。四天后出现发热一次，体温未测，自服 安乃近后热平，但一直有夜间出汗较多伴乏力，遂于 当地医院就诊，胸片示两肺多发阴影，拟肺炎后于次 日来我院行CT（见CT结果），为进一步诊治入院。 追问病史患者于入院约半年前确诊天疱仓，遂开始服 用强地松片30mg/d,后因病情反复增加用量，并于入院 前２月加用硫唑嘌呤２片／d 入院体检、辅助检查 体检无特殊阳性体征 胸部ＣＴ检查 How do we diagnose? 选择题 1．男性，58 岁，有慢性咳嗽、咯痰史 15 年， 1 周来高热、咯红砖色胶冻样痰，伴气急紫绀， 谵妄，本 例可能性最大的诊断是：B A、肺炎球菌肺炎 B、克雷白杆菌肺炎 C、浸润型肺结核 D、病毒性肺炎 E、支原体肺炎 2．男性，35 岁，发热、寒颤 3 天，体温 39 度， 胸片示右上肺大片阴影，痰涂片见较多革兰氏 阳性成对 或短链状球菌，这时治疗首选 ？C A、头孢唑啉 B、丁胺卡那霉素 C、青霉素 D、氟哌酸 E、红霉素 3．肺炎球菌肺炎在病变消散后肺组织结 构：E A、纤维组织增生 B、有小空洞残留 C、肺泡壁水肿 D、局部支气管扩张 E、肺泡壁无损坏 4．男，20 岁，低热咽痛，咳嗽半月入院，咳嗽甚剧， 为刺激性干咳，体检：T37.8 度，咽充血，心肺无 阳 性体征，化验：WBC：8＊10^9/L，中性 70％，X 线 胸片示右下肺间质性炎变，间有小片状阴影，以下哪 项检查对明确诊断意义较大？E A、痰细菌培养 B、咽拭子细菌培养 C、痰查抗酸杆菌 D、结核菌素试验 E、冷凝集试验 5．患者，25 岁，女性，咽痛，咳嗽，乏力，四肢肌肉 疼痛，中等发热，双肺呼吸音稍粗，未闻罗音，白 细 胞 9.6＊10^9/L，中性 86％，胸片示：左下肺部斑片状 浸润阴影，血清冷凝集试验：1：64 阳性，最好 应选 择的治疗药物是：E A、抗结核药 B、青霉素 C、头孢菌素 D、氨基甙类抗生素 E、红霉素 6.军团菌肺炎首选的抗生素是:A A.红霉素 B.青霉素 C.头孢菌素 D.丁胺卡那霉素 E.氯霉素 7．肺炎球菌致病力的主要因素是 E A．肺炎球菌内毒素 B．肺炎球菌外毒素 C．肺炎球菌菌体蛋白质 D. 肺炎球菌迅速繁殖 E．肺炎球菌含高分子多糖体荚膜对组织 的侵袭力 8．治疗肺炎球菌肺炎首选抗生素是B A 红霉素 B．青霉素 C．丁胺卡那霉素 D．氯霉素 E．羧苄青霉素 9．男性，25岁，因受凉后突起畏寒、发热 (39.2度)。左 侧胸痛伴咳嗽，咯少量铁锈色痰，胸部X线摄 片见左下肺野大片淡薄阴影。其最可能的诊断 是：C A.金黄色葡萄球菌肺炎 B．结核性胸膜炎 C．肺炎球菌肺炎 D原发性支气管肺癌合并阻塞性肺炎 E．急性原发性肺脓疡 9．肺炎球菌肺炎患者在抗生素治疗下体 温接近正常后反又升高，白细胞增高， 首先考虑：E A．细菌产生耐药 B．抗生素用量不足 C．药物热 D．加用退热药 E．出现并发症 10.肺炎球菌肺炎的炎症发展最高峰是： A A.灰色肝样变期 B.消散期 C.红色肝样变期 D.病变组织的机化 E.充血期