胸心外科

NEJM精品案例:支气管镜下取出引起支气管阻塞的支气管结石

作者:佚名 来源: SIFIC感染官微 日期:2017-07-28
导读

          一名68岁女子来急症科就诊,气短加重,喘息,干咳,发烧和发冷三天的病史。当她呼吸环境空气时,氧饱和度为96%。肺部听诊:左下肺叶可及啰音。胸部CT显示左下叶支气管腔被支气管结石阻塞(图A,红色虚框内,白色箭头所示,骨窗设置),支气管旁毛玻璃和斑片状实变阴影(图B,红色虚框内,肺窗设置)。支气管镜下可见正阻塞左下叶近端支气管的松动的支气管结石(图C)。支气管结石1.00×1.45cm(图D),被抓住并轻轻地取出。

关键字:  支气管结石 

原文翻译:

        一名68岁女子来急症科就诊,气短加重,喘息,干咳,发烧和发冷三天的病史。当她呼吸环境空气时,氧饱和度为96%。肺部听诊:左下肺叶可及啰音。胸部CT显示左下叶支气管腔被支气管结石阻塞(图A,红色虚框内,白色箭头所示,骨窗设置),支气管旁毛玻璃和斑片状实变阴影(图B,红色虚框内,肺窗设置)。支气管镜下可见正阻塞左下叶近端支气管的松动的支气管结石(图C)。支气管结石1.00×1.45cm(图D),被抓住并轻轻地取出。

        支气管结石通常由支气管旁淋巴结形成,钙化并迁移到支气管腔内。淋巴结钙化可以在慢性肉芽肿感染后发展而成,如组织胞浆菌病或结核病。本例患者支气管肺泡灌洗液的培养物、分枝杆菌、细菌和真菌均阴性。γ干扰素释放试验(用于测试以前有结核病暴露的证据)为阴性,组织胞浆菌病的血清学检测为阴性。患者接受抗生素治疗阻塞后的肺炎,其症状得到缓解。

病例特点小结:

        1、患者,老年女性;

        2、气短加重、喘息、干咳、发热和畏寒为表现;

        3、胸部CT显示左下叶支气管腔被支气管结石阻塞,支气管旁毛玻璃和斑片状实变阴影。支气管镜下可见支气管结石。

        4、镜下取出支气管结石明确,并经抗生素治疗后症状缓解。

读片贴士:

        支气管结石,是指在支气管腔或支气管壁内出现的钙化或骨化影。常见原因如下:

        1、淋巴结钙化。

        2、异物或感染灶的钙化。

        3、软骨钙化后脱落。

        上述原因中以淋巴结钙化最常见。不是所有的钙化淋巴结都是结石,只有少数钙化的淋巴结在不断呼吸运动的推动下逐渐侵蚀、穿透支气管壁进入到腔内,形成结石。支气管结石使支气管狭窄、扭曲并压迫管壁引起肺气肿、肺炎、肺不张、支气管扩张、出血等。钙化的淋巴结和支气管结石我们可以通过螺旋CT来鉴别,CT下可以清晰的显示结石的位置、大小。

        部分低密度的支气管异物给自己穿上了“隐身衣”,可以逃脱X线的检查,当它钙化变成结石时就“束手就擒”了!

        本病例胸部CT的图A左肺下叶支气管内正常透亮影消失,被三角形结石影取代。左肺下叶背段支气管开口处位置偏高,部分阻塞,气体入多出少,故左肺下叶背段透亮度增强,肺纹理稀疏,形成阻塞性肺气肿。

附原文:

        A 68-year-old woman presented to the emergency department with a 3-day history of worsening shortness of breath, wheezing, dry cough, fevers, and chills. Her oxygen saturation was 96% while she was breathing ambient air. Pulmonary examination revealed crackles in the left lower lobe. Computed tomography of the chest showed an obstructing broncholith in the bronchus of the left lower lobe (arrow in Panel A, bone-window setting) with peribronchial ground-glass and patchy consolidation (Panel B, lung-window setting). Flexible bronchoscopy revealed a loose broncholith that was obstructing the proximal bronchus of the left lower lobe (Panel C). The broncholith, which measured 1.00 by 1.45 cm (Panel D), was grasped and gently retracted. Broncholiths are most commonly formed by peribronchial lymph nodes that calcify and migrate into the lumen of the bronchus. Lymphatic calcification can develop after chronic granulomatous infection, such as histoplasmosis or tuberculosis. Cultures of bronchoalveolar lavage fluid were negative for mycobacterial, bacterial, and fungal organisms. An interferon-gamma release assay to test for evidence of previous tuberculosis exposure was negative, and serologic testing for histoplasmosis was negative. The patient was treated with antibiotics for postobstructive pneumonia, and her symptoms resolved.

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