艾滋病免疫重建炎性综合征并发结核感染影像学表现

发布时间：2018-05-27 22:16

本文选题：艾滋病 + 免疫重建炎性综合征　；参考：《复旦大学》2014年硕士论文

【摘要】：背景和目的截至2013年9月30日,全国共报告现存活艾滋病病毒感染者和艾滋病病人约43.4万例,接受抗病毒治疗的患者累计约26万例。从1996年起,广泛应用高效抗反转录病毒疗法(highly active antiretroviral therapy, HAART)或者是ART(antiretroviral therapy)来治疗艾滋病感染患者,但是治疗后的艾滋病病毒(HIV)感染或艾滋病(AIDS)患者,在免疫系统重建恢复(CD4细胞增加、病毒载量降低)的同时,部分病人病情出现反复、恶化,甚至直接引发患者死亡,通常将这种征象称之为免疫重建炎性综合征(immune reconstitution inflammatory syndrome, IRIS)或者免疫重建疾病(immune reconstitution disease, IRD)(后文统称为IRIS)。国内已经有不少文献对于IRIS的发病机制、免疫学特征等问题进行探究,但是鲜有文章系统性的对艾滋病免疫重建患者影像学表现进行讨论,尤其是神经系统系统IRIS后发生的影像学改变,根据人群研究,IRIS多发生隐性感染,最常见的病原体是结核,所以本文主要对艾滋病IRIS合并结核感染患者的影像学以及一般资料进行研究,旨在探讨上海地区艾滋病IRIS合并结核的高危因素、影像特点以及影像学诊断对于临床的价值。方法收集上海市公共卫生临床中心2004年12月-2013年12月所有艾滋病合并结核患者,根据HIV相关IRIS研究国际网络组织(International Network for the Study of HIV—associated IRIS,INSHI)的IRIS诊断标准,筛选IRIS合并结核感染患者,收集并分析中枢神经系统、呼吸系统以及其他系统结核感染的影像学表现与一般资料,并与非IRIS的艾滋病合并结核感染患者进行对比。对征象进行统计分析,使用STATA10.0系统,如P0.05,认为差异具有统计学意义。结果收集我院艾滋病合并IRIS并发结核感染患者51例,其中男性33例,女性18例,平均年龄为33.63±7.32岁,其中合并神经系统病变14例,出现免疫重建时间为84.07±16.52天,合并呼吸系统及其他系统病变41例,免疫重建时间为37.92±10.67天,HAART治疗前结核感染者11例,治疗前CD4计数平均为80.67±95.34/ul,治疗后CD4计数增高平均为406.25±149.27/ul,出现头疼头昏患者24例,憋喘、咳嗽、咳痰36例,腹痛或软组织疼痛5例。非IRIS艾滋病合并结核患者,共收集确诊病例183例,其中男性112例,女性71例,平均年龄为40.67±10.93岁,神经系统、呼吸系统受累及分别为36例、147例,治疗前CD4计数为110±120.34/ul,治疗后CD4计数增高计数为327.38±110.65/ul,出现头昏、头痛68例,憋喘、咳嗽、咳痰132例。1、神经系统：(1)艾滋病合并结核主要影像学表现：①脑膜强化；②结核瘤多发或者单发；③病变周围水肿；④脑积水；⑤结核性脑脓肿。(2)艾滋病合并IRIS组以及非IRIS组在脑膜强化、病灶强化,占位效应等影像学征象,未见明显具有统计性差异的征象(P0.05)；(3)IRIS组与基线影像学资料(发生IRIS前的影像学资料)进行对比,病变均进展,结核瘤,脑膜强化具有统计学差异(P0.05)：2、呼吸系统：(1)艾滋病主要影像学表现：①粟粒性肺结核；②结节、斑片灶；③实变；④树芽征；⑤病变累及范围以多肺叶为主；⑥淋巴结肿大、坏死或融合；⑦心包积液或胸腔积液；⑧支气管充气或者支气管扩张。(2)IRIS组在粟粒性肺结核、心包积液,淋巴结肿大、内部坏死以及融合等影像学征象比非IRIS组出现率明显增高(P0.05)；IRIS组不出现空洞及钙化,以及包裹性胸腔积液。(3) IRIS组与基线影像学资料对比,患者病变明显进展,粟粒性结核,纵膈淋巴结改变以及心包积液等具有统计学差异(P0.05)。3、其他：非呼吸系统及中枢神经系统病变多伴随呼吸系统病变出现,这类结核无特异性影像学表现。结论1、艾滋病合并IRIS患者多为青壮年,男性居多,60%的患者CD4计数小于50/ul, HAART治疗后,80.4%的患者CD4计数升高超过400/ul,IRIS的出现时间多在3个月内,神经系统IRIS的出现平均时间为其他系统的2倍。2、艾滋病合并IRIS组与非IRIS组结核感染患者影像学比较：(1)中枢神经系统影像学改变IRIS组与非IRIS组影像学表现相似；(2)在呼吸系统中,IRIS组呈浸润性改变,粟粒性肺结核、心包积液、淋巴结的肿大内部坏死等比例明显增加,艾滋病非IRIS合并肺结核可出现病变钙化、空洞以及包裹性胸腔积液,而IRIS组未出现此征象；非呼吸系统及中枢神经系统病变多伴随呼吸系统病变出现,这类结核无特异性影像学表现。3、IRIS组与基线影像学资料比较,病变均出现进展或出现新病灶,如粟粒性肺结核、胸腔及心包积液、纵膈出现淋巴结病变等,在HAART以及抗结核治疗后,病变先进展后吸收的影像学变化,具有特异性,有助于IRIS的诊断。
[Abstract]:Background and objectives as of September 30, 2013, about 434 thousand cases of living AIDS and AIDS patients were reported, and about 260 thousand patients received antiretroviral treatment. From 1996, highly active antiretroviral therapy (HAART), or ART (antiretroviral ther), was widely used. Apy) to treat AIDS infected patients, but after the treatment of HIV (HIV) infection or AIDS (AIDS) patients, in the immune system reconstruction recovery (CD4 cells increase, viral load reduction), some patients have repeated, worsened, and even direct the death of the patient, usually called the immune reconstructive inflammatory complex. Immune reconstitution inflammatory syndrome (IRIS) or immune reconstitution disease (IRD) (immune reconstitution disease, IRD) (later referred to as IRIS). There have been a lot of literature on the pathogenesis and immunological characteristics of IRIS, but there are few articles on the imaging of AIDS immune reconstruction patients. The manifestations were discussed, especially the imaging changes of the nervous system IRIS. According to the population study, the most common pathogen of IRIS was tuberculosis. Therefore, this article mainly studied the imaging and general data of AIDS IRIS with tuberculosis infection, aimed at exploring the IRIS merger of AIDS in Shanghai area. The high risk factors, imaging features, and imaging diagnosis for the clinical value of tuberculosis. Methods collects all AIDS patients with tuberculosis in the Shanghai public health clinic in December -2013 December 2004. According to the HIV related IRIS Research International Network Organization (International Network for the Study of HIV - associated IRIS) Diagnostic criteria, screening IRIS with patients with tuberculosis infection, collecting and analyzing the imaging manifestations and general information of the central nervous system, respiratory system and other system tuberculosis infection, and comparing with non IRIS AIDS patients with tuberculosis infection. Statistical analysis of the signs, using the STATA10.0 system, such as P0.05, considered the difference. Results 51 cases of IRIS complicated with tuberculosis infection in our hospital were collected, including 33 males and 18 females, with an average age of 33.63 + 7.32 years, including 14 cases of nervous system lesions, 84.07 + 16.52 days of immune reconstruction, 41 cases of respiratory system and other systemic lesions, and 37.92 + 10.6 reconstruction time. On the 7 day, 11 cases of tuberculosis infection before HAART treatment. The average CD4 count was 80.67 + 95.34/ul before treatment, and the average CD4 count was 406.25 + 149.27/ul after treatment. There were 24 cases of headache and dizziness, 36 cases of cough, expectoration, abdominal pain and 5 cases of soft tissue pain. There were 183 cases of non IRIS AIDS combined with tuberculosis, of which the male was 112. Of them 112 men were 112. Of them 112 men were 112. For example, 71 women, the average age was 40.67 + 10.93 years old, the nervous system and respiratory system were involved in 36 cases and 147 cases respectively. The CD4 count was 110 + 120.34/ul before treatment. The increase count of CD4 count was 327.38 + 110.65/ul, dizziness, headache 68, cough, expectoration, 132.1, nervous system: (1) the main imaging of AIDS combined tuberculosis. Performance: (1) meningeal enhancement; (2) multiple or single tuberculoma; (3) edema around the lesion; (4) hydrocephalus; (5) tuberculous brain abscess. (2) the image of the IRIS group and the non IRIS group in the meningeal enhancement, the focus enhancement, the occupying effect, and so on, there was no apparent difference (P0.05); (3) the IRIS group and the baseline image Study data (before IRIS imaging data) were compared, the lesions were progressing, tuberculoma, and meningeal enhancement had statistical difference (P0.05):2, respiratory system: (1) the main imaging manifestations of AIDS: (1) miliary pulmonary tuberculosis; (2) tuberous pulmonary tuberculosis; (2) nodules, patch foci; (3) real changes; tree bud sign; (5) lesions involving multiple lobes; (6) drenching (2) the imaging signs of miliary pulmonary tuberculosis, pericardial effusion, lymph node enlargement, internal necrosis and fusion were significantly higher in IRIS group than in non IRIS group (P0.05); group IRIS did not appear cavities, calcification, and inclusions in group IRIS. Pleural effusion (3) compared with the baseline imaging data in group IRIS, the patients' lesions were progressed significantly, miliary tuberculosis, mediastinal lymph node changes and pericardial effusion were statistically different (P0.05).3, the other: non respiratory system and central nervous system lesions were associated with respiratory diseases, and the nodules had no specific imaging findings. 1, AIDS combined with IRIS patients were mostly young, male and 60% of the patients were less than 50/ul. After HAART treatment, 80.4% of patients increased the CD4 count more than 400/ul, the occurrence time of IRIS was more than 3 months, the average time of IRIS in the nervous system was 2 times.2 in other systems, and AIDS combined IRIS and non IRIS group tuberculosis infection. Imaging comparison: (1) the imaging changes of IRIS group and non IRIS group were similar in the central nervous system, and (2) in the respiratory system, the IRIS group showed invasive changes. The proportion of miliary pulmonary tuberculosis, pericardial effusion, and lymph node enlargement was significantly increased. Parcels of pleural effusion were not found in group IRIS; non respiratory system and central nervous system lesions were associated with respiratory diseases, and this kind of tuberculosis had no specific imaging findings of.3. Group IRIS and baseline imaging data showed that the lesions were progressed or emerging of new lesions, such as miliary pulmonary tuberculosis, pleural and pericardial effusion, and mediastinum. Lymph node lesions and so on, after HAART and anti tuberculosis treatment, the imaging changes of advanced lesions after the disease are specific, which is helpful for the diagnosis of IRIS.
【学位授予单位】：复旦大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R512.91;R52

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