病理學(xué)課件 傳染病和寄生蟲-2016 May-liugy

InfectiousDiseases

劉國元gyliu@PathologyDepartment,SchoolofBasicMedicalSciences,FudanUniversityEtiology:pathogenicmicrobes

parasite

epidemiologysourceofinfectionrouteoftransmissionSusceptiblepopulation

Pathogenesisentrycelltoxin/enzyme,vesselinjuryimmuneresponseInfectiousDisease

CommonFeaturesLeprosy(麻風(fēng))

Syphilis(梅毒)

Typhoidfever(傷寒)

Bacillarydysentery（細(xì)菌性痢疾）傳染病

Leprosy(麻風(fēng))Leprosy,HansendiseaseSlowlyprogressiveMycobacteriumleprae麻風(fēng)桿菌AffectingtheskinandperipheralnervesResultinginparalysedskinlesion,rigidandswollennerves,disablingdeformities.

麻木性皮膚損害、周圍神經(jīng)粗大、手足殘廢和畸形IntroductionHistoryEpidemiology熱帶地區(qū)較多

Harm

EtiologyM.lepraeOneoftheoldestpathogenthatafflicthumansDiscoveredinNorwayin1873byDr.ArmauerHansenAcid-fastobligateintracellularbacterium

抗酸桿菌、胞內(nèi)寄生SimilartomycobacteriumtuberculosisEtiologydoesnotgrowinculturebutcanbegrowninthearmadillo(犰狳).Preferlowtemperature(32to34℃)

andgrowslowlyvirulenceisbasedonpropertiesofitscellwall麻風(fēng)菌素

HumanbeingseemstobetheonlyvictimTransmissionContainedinsecretionRespiratorypathway呼吸道Abrasionorwounds破損的皮膚Takenupbymacrophagesdisseminatesthroughtheblood大約95％的人具有自然免疫力

PathogenesisLatentperiod:2-4yearsCellularimmunityHumeralimmunityLepromintest麻風(fēng)菌素注射于皮膚，局部出現(xiàn)

遲發(fā)型變態(tài)反應(yīng)，菌體的熱休克蛋

白可誘發(fā)細(xì)胞免疫所致

PathogenesisAbipolardisease

根據(jù)細(xì)胞免疫強(qiáng)弱，分成截然不同的兩種類型

tuberculoidleprosy結(jié)核樣型麻風(fēng)(T-cellmediatedimmuneresponse，細(xì)胞免疫強(qiáng))

lepromatousleprosy瘤型麻風(fēng)

(Immunityanergic免疫無反應(yīng)性，體液免疫，

抗體+++)

Typesaccordingtopathologicalchanges分型Tuberculoidleprosy70%Lepromatousleprosy20%Borderlineleprosy中間界線類少見Indeterminateleprosy未定類麻風(fēng)很少見Tuberculoidleprosy(60-70%)Intactcellularimmuneresponse Slowcourse,spanningdecades Limitedlesions

FewbacilliwithinthelesionMainlyinvolveskinandnervesClinicalfeature:lepromintest(+) lowinfectivity goodprognosisTuberculoidleprosy

Granuloma

resembleshardtuberclesepithelioidmacrophagesgiantcellswithoutcaseousnecrosisPeripheral:CD4+Th1IL-2&IFN-γfewsurvivingmycobacteriaTuberculoidleprosy

Skinlesions:maculaorpapula斑疹或丘疹gross:flatandredirregularshapeswithindurated,elevated,hyperpigmentedmarginsanddepressedpalecenters好發(fā)于面部、臀部、軀干四肢伸面SkinlesionsLM: tuberculoidgranuloma結(jié)核樣結(jié)節(jié)enclosebloodvessels,cutaneousappendagesandnervesextendtothebasalcellsofepidermisTuberculoidleprosyTuberculoidleprosyPeripheralneuropathy:rigidandswollennerves神經(jīng)變硬、不規(guī)則增粗，如繩索 Fromsmalldermalnervestonervetrunk N.auricularismagnus(耳大)

N.auricularisposterior(耳后) LM：

GranulomatousinflammatoryreactionsenclosedneuronandmaydestroyitFibrosis,absenceofnervesNervedegeneration,destruction,fibrosis

ClinicalpathologicconferenceAnesthesia感覺障礙,atrophy(失神經(jīng)營養(yǎng)),paralysis,liabletotrauma,autoamputationoffingersortoes(肢體自動(dòng)脫落),disablingdeformities,indolentskinulcers,keratitis角膜炎,cornealulcerations.Tuberculoidleprosy鷹爪手Lepromatousleprosy(20%)anergicimmunity細(xì)胞免疫反應(yīng)弱lepromintest(-)Largeamountsofbacilliinfectious傳染性強(qiáng)Acutedeteriorate,poorprognosis,

伴麻風(fēng)反應(yīng)：高熱、神經(jīng)痛Generallyinvolvedtheskin,peripheralnerves,anterioreye,upperairways,testes,lymphnode,visceral,etcLepromatousleprosylargeaggregatesoflipidladenmacrophages(leprosycells),oftenfilledwithmassesofacid-fastbacilli

麻風(fēng)細(xì)胞:巨噬細(xì)胞吞噬大量的麻風(fēng)桿菌，胞質(zhì)內(nèi)有大量類脂空泡，呈泡沫狀lymphocytesinfiltratedLackCD4+TH1cellsatthemarginsbutinsteadcontainmanyCD8+suppressorTcellsLepromatousleprosySkinlesions:

Macular斑疹,papular丘疹,ornodularlesionsform結(jié)節(jié)、麻風(fēng)瘤

ontheface,ears,back,extremitiesWithprogression,thenodularlesionscoalescetoyieldadistinctiveleoninefaces(獅面).SkinlesionshypoestheticoranestheticLepromatousleprosySkinlesions:LM:largeamountsoflepracellsandafewlymphcytesinfiltrationenclosevesselsandappendages

真皮深層聚集大量麻風(fēng)細(xì)胞Clearline無浸潤帶病灶和表皮之間的真皮淺層有無細(xì)胞浸潤帶，又稱為自由帶

LepromatousleprosyPeripheralnerves：resembletuberculoidleprosyLossofsensationandatrophicchanges.Nose

糜爛或潰瘍，鼻中隔穿孔Spleenandliver成堆泡沫細(xì)胞Lymphnodes

泡沫細(xì)胞Testes

精液中帶菌Thevitalorgansandcentralnervoussystemarerarelyaffected.

TuberculoidtypeLepromatoustypeIncidence70%20%ImmuneresponseIntenseSubduedSkinlesionMaculaorpapula,tuberculoid,fewbacilliProtuberant,largeamountofbacilliLepromintest(+)(-)Humoralantibody(+/-)(+++)InvolvedtissueLimitedtoskinandnervesExtendtootherorgansProcessDevelopslowlyRelativefastInfectivityWeakStrongComparisonSexuallyTransmittedDisease

性傳播性疾病（STD）

VenerealDiseases,VDFiveclassicvenerealdiseasesSyphilis梅毒Gonorrhea淋病Chancroid軟下疳granulomainguinale腹股溝肉芽腫lymphogranulomavenereum性病淋巴肉芽腫SexuallyTransmittedDisease,STDInthepastdecade,thespectrumofsexuallytransmitteddisease(STD)haswidenedconsiderablyClassificationofImportantSTDCausalAgentDiseaseManifestationsExclusivelyorRegularlyTransmittedbySexualcontactViralHIV-1,HIV-2HSV-1,HSV-2PapillomavirusesAIDSHerpeslesions生殖器皰疹Condyloma,cervicalneoplasiaChlamydial,MycoplasmalChlamydiatrachomatis(Ltype)ChlamydiatrachomatisUreaplasma

urealyticumLymphogranuloma

venereum性病淋巴肉芽腫Nongonorrhea

urethritis,cervicitisNongonorrheal

urethritis,cervicitisBacterialNeisseria

gonorrhoeaeTreponema

pallidumHaemophilus

ducreyiCalymmatobacterium

donovaniGonorrhea淋病Syphilis(lues

venerea)梅毒Chancroid軟下疳Granuloma

inguinale腹股溝肉芽腫ProtozoalTrichomonasvaginalisTrichomoniasis

滴蟲ByArthropodPhthiruspubisPediculosispubis(crab)陰虱病TransmissibleSexuallyorbyOtherMeansViralCytomegalovirus,hepatitisBvirus,Epstein-Barrvirus,molluscum

contagiosumvirusHepatitis,mononucleosis,wartsBacterialGroupBstreptococci;gram-negativebacilliNeonatalsepsis,cystitisFungalCandidaThrush,vaginitisPotozoalEntamoeba

histolyticaColitis,liverabscessSyphilis(Lues)梅毒AnimportantSTDMultipleclinicalpresentations(thusdesignatedthegreatimposter)chronicandslowlyprogressiveinvolvemanyvitalorgansinlateperiod

EtiologyPathogen:

SpirocheteTreponemapallidum

梅毒螺旋體cannotbecultureddetectablebysilverstainsdarkfieldexaminationTransmissionMode:

Sexualintercourse(>95%)Acquiredsyphilis后天性(獲得性)梅毒

TransplacentaltransmissionCongenitalsyphilis先天性梅毒Pathogenesis

TraverseabradedskinandmucosaEnterlymphcirculation

TravelthroughbloodandreachvariousorgansandtissueLatentperiod:10-90days,averageat21daysPathogenesisScarceproteinonsurface(Weakantigenicity) Down-regulationofTH1cells

InadequatecellularandhumoralimmuneresponseRelapsesyphilisandtertiarysyphilisLatentsyphilis隱性梅毒血清反應(yīng)陽性，而無病變無癥狀MorphologyMayaffectnearlyanyorganortissueinthebodyTwomorphologicpatternsoftissueinjuryObliterativeendarteritis

閉塞性小動(dòng)脈內(nèi)膜炎Gumma樹膠樣腫病原體引發(fā)的遲發(fā)性超敏反應(yīng)Morphology1

Proliferativeendarteritis增生性動(dòng)脈內(nèi)膜炎

Obliterativeendarteritis Perivascularinflammation

小血管周圍炎

concentricendothelialandfibroblasticproliferativethickeningofthesmallvessels asurroundingmononuclear(principallyplasmacell)inflammatoryinfiltrate,knownascuffing血管周圍套病變周圍組織發(fā)生缺血性細(xì)胞壞死和纖維化，見于各期梅毒Morphologylatelesionoccurredinanysite(liver,bone,testes)Varyinsize小的肉眼不能見到，大的直徑達(dá)3-4cmgray,toughandrubbery,likegumAbsorbed,fibrosis,scared后期可被吸收、纖維化、疤痕形成Scarcelycalcification絕少鈣化最后導(dǎo)致病變組織破壞和瘢痕攣縮2.

Gumma(syphiloma梅毒瘤)發(fā)生于晚期梅毒，大小不一，灰白色，質(zhì)地韌有彈性似樹膠，稱樹膠樣腫。Morphologyacenterofcoagulativenecrosissurroundedbymanymononuclearleukocytesadmixedwithmacrophages(someresemblingepithelioidcells)中央為凝固性壞死，但不如結(jié)核干酪樣壞死徹底，彈力纖維尚保存壞死灶周圍有許多單核細(xì)胞（淋巴細(xì)胞、漿細(xì)胞)、上皮樣細(xì)胞(巨噬細(xì)胞）Gumma:resemblethelesionoftuberculosis.鏡下頗似結(jié)核結(jié)節(jié)Acquiredsyphilis

ThreedistinctstagesPrimarySecondaryTertiaryEarlystage(contagious)LatestagePrimarysyphilis一期梅毒Chancre硬下疳

直徑為1cm大小有淺表潰瘍的無痛性硬塊Afterlatentperiod(about3weeks)Atthesiteofinoculation,penis,vulvaorcervixindurated,button-likepapuleatfirstErodesAsingle,painless,copper-colored,Clean-based,shallowulcer,withelevatedandinduratedmargin單個(gè)、無痛性、紅銅色、邊界隆起、潰瘍基底干凈PrimarysyphilisChancreAccompaniedbylymphadenopathy淋巴結(jié)腫大LM: obliterativeendarteritis

perivascularplasmacellcuffingDarkfieldexaminationoftheexudate

滲出液檢查可找到螺旋體Spontaneoushealing自愈Secondarysyphilis二期梅毒Mucocutaneousrash梅毒疹1-3monthsaftertheprimarysyphilisWidespreadpatchyordiffuse廣泛Bilateral,symmetric,maculopapular,

red-blown對稱分布斑丘疹Condylomatalata梅毒扁平濕疣LM:typicalvasculitisNonspecificlymphadenopathy

腫大淋巴結(jié)為非特異性炎癥SecondarysyphilisFever,malaise,weightlossSerologictest(+)Spontaneoushealingafter1-3monthsRelapse復(fù)發(fā)梅毒疹，疹量較少Latentsyphilis隱性梅毒 asymptomatic

serologictests(+)Tertiarysyphilis三期梅毒Afteralatencyperiodof10-20yearsMayaffectanypartofthebodyCardiovascularsystem(80-90%)Centralnervoussystem(5-10%)Liver,bone,testes,etc.Gummaandscartissueformation皮膚黏膜損害

結(jié)節(jié)型梅毒疹好發(fā)于頭皮、肩胛、背部及四肢的伸側(cè)。樹膠樣腫常發(fā)生在小腿部，為深潰瘍形成，萎縮樣瘢痕TertiarysyphilisSyphiliticaortitis梅毒性主動(dòng)脈炎

80-90%Confinedtothoracicaorta胸主動(dòng)脈升部和根部Obliterativeendarteritisofnutrientarteries

閉塞性滋養(yǎng)小動(dòng)脈炎wrinklingor“treebarking”oftheintimalsurface內(nèi)膜樹皮狀皺縮

Secondaryatheroscleroticplaques彈力纖維染色，顯示大動(dòng)脈中層彈力纖維破壞

Syphiliticaneurysm梅毒性主動(dòng)脈瘤Aorticinsufficient主動(dòng)脈瓣關(guān)閉不全梅毒性主動(dòng)脈瘤TertiarysyphilisNeurosyphilis神經(jīng)梅毒5%-10%Meningovascularsyphilis腦膜血管性梅毒TabesDorsalis脊髓癆Generalparesis麻痹性癡呆Braingumma腦樹膠樣腫TertiarysyphilisBone:septalperforation(saddlenose)

鼻中隔穿孔（馬鞍鼻）骨膜炎、骨髓炎、骨炎導(dǎo)致骨硬化（象牙化）Liver肝梅毒TestesCongenitalsyphilis先天性梅毒OnsetafterthefourthmonthofpregnancyEarlycongenitalsyphilis(perinatalperiod)

早期胎傳梅毒MucocutanouslesionRashes(vesicularorbullous水皰、大皰)Extensivedesquamationoftheskin廣泛性皮膚脫屑Diffuseinterstitialinflammation,prominentfibrosisLung,liver,spleen,pancreas,etc.Osteochondritisandperichondritis骨軟骨炎及骨膜炎Saddlenose,sabershins馬刀脛骨Congenitalsyphilis口角放射狀疤痕梅毒疹（大皰）馬刀脛骨馬鞍鼻CongenitalsyphilisLatecongenitalsyphilis>2y

Hutchinson三聯(lián)癥Hutchinson’steethNervedeafness神經(jīng)性耳聾Interstitialkeratitis間質(zhì)性角膜炎Mayremainlatentuntiladolescence鋸齒形門牙ClinicalStagesandFeaturesTyphoidFever

(傷寒)

張仲景《傷寒論》

吳有性《瘟病論》Conception

Anacuteinfectiousdiseasecausedby

Salmonellatyphi.傷寒桿菌Characterizedbyulcerationofthesmallintestine小腸潰瘍systemicreticuloendothelialcellshyperplasia單核巨噬細(xì)胞增生

Mainmanifestations:fever,leukopenia,delirium,abdominalpain,diarrhea,rosespots,andsplenomegalyintestinalbleedingandperforation.Epidemic貴州、云南、廣西、浙江、江蘇和新疆

Etiology

Typhoidbacillusgram-negativerodbacteriaEndotoxinflagellar(H)antigencellwall(O)lipopoysaccharideantigenpolysaccharidevirulence(Vi)antigenlocatedinthecellcapsule.Astory:TyphoidMarryHealthycarrierSourceoftransmissionillpersonsfeces,urine,vomitus,andoralsecretionsChroniccarriersfecesPathogenesisStomach,smallintestinemononuclearphagocytes

ilealPeyer’spatchesandmesentericlymphnodeschills,fever,rosespots,etcfeces,urineofpatientsorcarrierflyFoodandwatermouthbacteremiaToxemia,septicemiamononuclearphagocyteshyperplasiahepatomegaly,splenomegaly,lymphdenopathyPathogenesisMorphologyCharacteristicsofpathologicalchanges:Aninflammation-proliferationofreticulo-endothelialsystemtyphoidcell:large,richincytoplasm,oftencontainsingestedbacteria,celldebris,anderythrocytetyphoidgranuloma傷寒肉芽腫,傷寒細(xì)胞聚集成團(tuán)Diagnosticvalue巨噬細(xì)胞增生，并有極強(qiáng)的吞噬能力。病灶內(nèi)無中性粒細(xì)胞滲出。Morphology:typhoidnoduleMorphology1. 1stweek(髓樣腫脹期)Gross:sharplydelineated,plateau-likeelevationsupto8cmindiameter,withenlargementofdrainingmesentericlymphnodesLM:typhoidgranuloma,edema,hyperemiaCF:Highfever,bradycardia,splenomegaly,rosespots

IntestinePayer’spatchesintheileum回腸

isthemostaffectedpart淋巴濾泡增生、腫脹，似“腦回”

Intestine髓樣腫脹期2.2ndweek

Necrosis:壞死期

Gross:thelesionofPeyer’spatchisnecroticandstainedbybile.LM:StructurelesseosinophilicsubstanceCF:bacteremia,toxemia濾泡中心/表層壞死，邊緣腫脹LM:嗜酸性無結(jié)構(gòu)物質(zhì)Intestine3.3rdweekUlceration:潰瘍期

Necrotictissueisdissolvedbyenzymeovalulcerswiththeirlongaxisinthedirectionofbowelflowulcermaybeverydeep CF:bleeding,perforation穿孔,abdominalpain,diarrhea腹瀉

，

全身中毒癥狀緩和Intestine

Intestine潰瘍期潰瘍長軸與腸長軸平行，較深，易引起腸穿孔、出血4.Healing:愈合期 4th–5thweek Granulationtissueformswithsmallscarformation CF:symptomssubsideanddisappear, widal’stest(+)潰瘍底部肉芽組織長入，粘膜再生

不形成瘢痕，不造成腸腔狹窄IntestineorgansrelatedtoreticuloendothelialsystemMesentericlymphnode:IntheterminalileumTyphoidcell,TyphoidgranulomaSpleen:

enlarged,softandcherryredincolorprominentsinushistocytosisandreticuloendothelialproliferation質(zhì)軟，脾髓組織可用刀背刮下organsrelatedtoreticuloendothelialsystemLiver:enlargedandswellingwithtensecapsuleandroundedgestyphoidcell,typhoidgranulomasmall,randomlyscatteredfociofparenchymalnecrosisBonemarrow:typhoidgranulomawithscatteredfociofnecrosisFailureofnormalhematopoiesis造血功能Salmonellatyphi.(+)骨髓培養(yǎng)陽性率可高達(dá)90%OthersCholecystitis

膽囊炎，細(xì)菌在膽汁中繁殖，傳染源CNS

小血管內(nèi)膜炎，膠質(zhì)細(xì)胞增生，嗜睡、傷寒面容OthersMyocardium

心肌細(xì)胞渾濁腫脹，重脈，相對緩脈Skinandmuscle毛細(xì)血管細(xì)菌栓塞，橫紋肌臘樣壞死。玫瑰疹、肌痛Typhoidsepticemia傷寒?dāng)⊙YComplicationandprognosis4-5weeksChloramphenicol氯霉素remainstobeeffectivesinceitsintroductionin1942Complications:intestinalhemorrhage腸出血perforationandperitonitis腸穿孔、腹膜炎lobularpneumonia

臨床病理聯(lián)系初期菌血癥、毒血癥、單核巨噬細(xì)胞系統(tǒng)增生壞死期敗血癥，稽留熱、神志不清、嗜睡、譫妄潰瘍期機(jī)體抵抗力占優(yōu)勢，菌血癥消失癥狀緩和愈合期機(jī)體占絕對優(yōu)勢，體溫階梯下降，恢復(fù)BacillaryDysentery

(細(xì)菌性痢疾)IntroductionAnacuteinflammationofthecolon,causedbyshigella.Summer,autumnMorphologicalfeatures:pseudomembranousinflammationand

irregularsuperficialulcerationsMainclinicalmanifestations:fever,abdominalpain,diarrhea,pus-mucin-bloodmixedstool

粘液膿血便EtiologyandepidemiologyCausativeagent:Shigella,gram-negativefacultativeanaerobes

Shigelladysenteriae

ShigellaFlexneri ShigellaBoydii ShigellaSonneiInfectonlyhumansTransmissionSource:Carrier,patientRoute: Fecal-oral ContaminatedfoodorwaterPathogenesisInvadetheintestinalmucosalcells,butdonotusuallygobeyondthelaminapropria固有層Proliferationwithintheepithelialcells,destroyhostcellsEndotoxin:Shigatoxincauseshemorrhagiccolitis hemolytic-uremicsyndrome溶血-尿毒癥綜合征Shigelladysenteriae:extrotoxinneurotoxicantcytotoxicenterotoxinTypesAcutebacillarydysentery1-2weeksChronicbacillarydysentery>2monthsToxicbacillarydysenteryAcutebacillarydysenteryA.Colon:Mucoidcatarrhinfl.Pseudo-membranousinfl.糠皮樣假膜

Ulcerformation淺表不規(guī)則潰瘍

Hyperemic,edematous,PMN中性粒腹痛、腹瀉、里急后重、粘液稀便mucosanecrosis,fibrinogenexudation,hemorrhage粘液膿血便necrotictissueshedoffrectum,sigmoidflexureGross:Pseudomembranousinflammation ulcerformation(irregularandsuperficial)糠皮樣假膜、淺表潰瘍MucosaofColon,esp.leftAcutebacillarydysenteryLM: Psuedomembrane纖維蛋白性炎Infiltrationofinflammatorycells中性粒細(xì)胞

NecrotictissueFibrinexudationRedbloodcellsAcutebacillarydysenteryB.Lymphdenopathyofmesenterymildsplenomegaly

C.Otherorgans:heart,liver,kidney

cellulardegenerationornecrosisAcutebacillarydysenteryClinicalmanifestation:Toxemia:fever,headache,fatigue,leukocytosisIntestinallesion:abdominalpain,diarrheawithtenesmus里急后重, pus-mucus-bloodmixedstool,dehydration,etc.AcutebacillarydysenteryPrognosisMostlycuredColonicperforation(rare)ScarcelycolonichemorrhageAfewdevelopintochronicperiodChronicbacillarydysentery慢性細(xì)菌性痢疾ChronicbacillarydysenteryOccurswhengeneralconditionispoorortreatedimproperlyatacutestageImportanttransmissionsources:chroniccarrier病程超過2個(gè)月ChronicbacillarydysenteryCharacteristics:Associatedwithspeciesofshigellae:FlexneriPersistseveralyearspathology:Chroniculcerformation;variedinsizeanddepth;Fibrosis,thewallofcolonisthickenedInfiltratedbylymphocytes,monocytesandplasmacellsSometimestheepithelialcellsmayalsoproliferateandformpolyps急性菌痢轉(zhuǎn)變而來，福氏菌、耐藥菌株病情起伏，可有急性發(fā)作病理—新舊潰瘍混雜（較深，多達(dá)肌層，邊緣粘膜可有過度增生息肉形成）大量肉芽組織、纖維瘢痕—腸壁增厚腸腔狹窄臨床病理聯(lián)系：—病程延長表現(xiàn)起伏腹痛、腹瀉、便秘與腹瀉交替慢性菌痢急性發(fā)作，表現(xiàn)和急性菌痢相似慢性帶菌者(重要傳染源)慢性細(xì)菌性痢疾Toxicbacillarydysentery中毒性菌痢ToxicbacillarydysenteryCharacteristics:toxemiaisveryseverebutthemorphologicalchangesarenotenlargementofthelymphoidfollicles“follicularenteritis”Thenatureoftheinflammationis“serous”,oftenassociatedwithtoxicshock2-5yearsoldShigellaFlexneri,ShigellaSonnei起病急驟：全身中毒癥狀嚴(yán)重（中毒性休克、呼吸循環(huán)衰竭）endotoxinInjuryofendothelialcellofbloodvesselDICSpasmofbloodvesselHypoxiaDilatationofcapiBloodvolshockIncreaseofpermeabilityedemaThemechanismoftoxicshockandDICPlatelet,neutrophilsvasoactive

substancesParasitosis寄生蟲病

2010Jun.ClassificationProtozoaldiseaseTrematodiasisTeniasisNematodosis原蟲病阿米巴病黑熱病瘧疾吸蟲病肝吸蟲病肺吸蟲病血吸蟲病絳蟲病囊蟲病包蟲病線蟲病鉤蟲病蛔蟲病絲蟲病Amoebiasis

阿米巴病病原：溶組織內(nèi)阿米巴原蟲寄生部位：結(jié)腸（尤其右半結(jié)腸）

腸外

(肝、肺、腦等）流行現(xiàn)狀：

熱帶、亞熱帶地區(qū)，我國南方多見。世界10%人口攜帶，無任何國家幸免感染。

近年多為散發(fā)慢性、不典型病例及帶蟲者。EntamoebahistolyticaHumans(largebowel)Ingestionofcysts(persontoperson)Trophozoites,cystsinfecesCystssurviveinfood,waterEntamoebahistolytica溶組織內(nèi)阿米巴原蟲Sourceofinfectionchronicpatientandparasitecarrierkilledbydesiccation干燥,temperaturesabove55℃spreadbythefecal-oralrouteRoutesofinfection生活史：滋養(yǎng)體、包囊兩期成熟包囊小滋養(yǎng)體(食物、水)

（小腸下段）

大滋養(yǎng)體(致病型)小滋養(yǎng)體

（結(jié)腸腸壁）包囊前期成熟包囊（感染型）食物、水

（結(jié)腸腸腔）抵抗力結(jié)腸功能正常>90%Exopathicfactor

contact-mediatedcytolysis接觸性細(xì)胞溶解(膜結(jié)合磷脂酶A)excretemanyfactors分泌多種因子channel-formingproteincysteineproteinase

pseudopodialmovementandphagocytosis

偽足運(yùn)動(dòng)及吞噬作用免疫抑制和逃避Internalfactorsusceptibilityofhost宿主易感性intestinaldysfunction腸道功能紊亂intestinal

concurrentinfection腸道合并感染Pathogenesisamebicdysentery腸阿米巴病(阿米巴痢疾）Sites：Cecum盲腸Ascendingcolon升結(jié)腸SigmoidRectumAppendix分期：急性慢性腸內(nèi)氧分壓較低，腸內(nèi)容物生理性滯留有關(guān)acuteamebicdysentery急性阿米巴痢疾Amoebiasisofintestine結(jié)腸阿米巴病

Gross

flask-shapedulcer(燒瓶狀潰瘍)口小底寬急性期粘膜有多個(gè)圓形隆起，中央有點(diǎn)狀壞死潰瘍MorphologicChange結(jié)腸阿米巴病潰瘍間粘膜正常病變擴(kuò)展期，潰瘍在粘膜下相互溝通，形成隧道樣病變，粘膜壞死脫落，呈破絮狀嚴(yán)重者潰瘍深達(dá)肌層并侵及血管，甚至漿膜層Microscopically

mainlyinvolvingthemucosaandsub-mucosaanecroticprocesswithminimalinflammatoryexudate Lymphocytesandplasmacells炎癥反應(yīng)輕微Trophozoites

滋養(yǎng)體scatteredattheperipheryMorphologicchange阿米巴滋養(yǎng)體bloodydiarrhea果醬樣，腐敗腥臭味intestinalpaintrophozoite(+)全身癥狀輕微，無發(fā)熱Clinicalfeatures99%

achievedacompletecureasmallproportionofcasesperforationhemorrhageprogressiontochronicinflammationsecondarybacterialinfectionpurulentLesionprogressesruptureintoadjacentstructuresPrognosis2chronicamebicdysentery慢性阿米巴痢疾ComplexTissueregenerationLesionprogressMucosaatrophyInflammatorypolypsamoeboma（阿米巴瘤）腸壁肉芽組織增生過多，形成局限性包塊MorphologicChangeIntermittentbellyache間歇性腹痛diarrhea腹瀉intestinalobstruction

腸梗阻malnutritionClinicalfeaturesamebicdysentery急性

病理：組織溶解壞死燒瓶狀潰瘍，邊緣滋養(yǎng)體

臨床：痢疾樣癥狀，果醬樣便，滋養(yǎng)體（+）慢性

病理：病變復(fù)雜“阿米巴瘤”

臨床：輕度腸道功能紊亂癥狀，腸梗阻，營養(yǎng)不良等。

大便包囊體（+）

腸外阿米巴病阿米巴性肝膿腫阿米巴性肺膿腫阿米巴性腦膿腫amebicliverabscess阿米巴肝膿腫amebicliverabscess腸阿米巴病最常見的合并癥MorphologicChangeGrosssingletherightlobe(80%)theabscesscontentsischocolate-colored

“巧克力膿腫”膿腫壁破絮狀膿腔內(nèi)容物呈棕褐色，由壞死肝組織和陳舊性血液混合而成，果醬樣。Microscopically

extensiveliquefactivenecrosisascantinflammatoryreactionattheirmargins

TrophozoitesscatteredattheperipheryashaggyfibrinliningUsuallyprognosisisgood Metronidazole甲硝唑SecondarybacterialinfectionpurulentLesionprogressesruptureintoadjacentstructuresPrognosisamebicpulmonaryabscesssingleInferiorlobeofrightlungAnextensionofahepaticabscessAmebicbrainabscessthroughbloodstream

multiplecerebralcortex

Schistosomiasis

血吸蟲病Schistosomajaponicum日本血吸蟲

ChinaandAsiaSchistosomamansoni曼氏血吸蟲

LatinAmerica,centralAfrica,theMiddleEast

schistosomahaematobium埃及血吸蟲

northernAfricaPathogens流行狀況

75個(gè)國家流行：2+億人感染，5-6億人受威脅我國：長江中下游13個(gè)省市流行

解放初期：1+億人受威脅，病人1千萬

五十年代：血防運(yùn)動(dòng)，70%流行區(qū)消滅

八十年代：1+億人受威脅，有螺面積33.8億m2Endemicparasitoses(地方性寄生蟲病)Zoonoticinfections(人畜共患)

human,ox,horse,goat,etcMajorpathologicmanifestation

granulomasandfibrosis

成蟲:門靜脈系統(tǒng)主要危害:蟲卵嚴(yán)重后果:肝匯管區(qū)纖維化、慢性腸道病變SchistosomajaponicumDioecism(雌雄異體)MaleoralsuckerventralsuckerFemaleheme-derivedpigmentsEggsinfeces(passedintowater)Hatchedlarvae毛蚴

penetratefreshwatersnail(intermediatehost)Developmentofotherlarvalstagesinsnail（母包蚴、子包蚴）CercariaepenetrateskinofhumansCercariae尾蚴emergefromsnail(water)HUMANS

adultwormsinblood(veins)Lifecycleofschistosomes釘螺病原與傳染途徑

血吸蟲卵

毛蚴

胞蚴尾蚴

童蟲

成蟲

蟲卵

腸腔

糞便排出

肝臟

腸壁

蟲卵結(jié)節(jié)

部分糞便排出入水釘螺中間宿主入水（疫水）鉆入皮膚粘膜腸系膜V（病人畜糞便）經(jīng)粘膜潰瘍（16%）（大腸50%，小腸<10%）順血流（23%）逆血流PathogenesisMechanicaldamage各階段均可見ImmunologicaldamageAllkindsofantigens(solubleeggantigens,SEA,可溶性蟲卵抗原)Cellularimmunity產(chǎn)生肉芽腫病變1L-2,IFN-γ,IL-4,1L-5,etcMorphologicchanges血吸蟲發(fā)育的不同階段，尾蚴、童蟲、成蟲和蟲卵均可對宿主引起不同的損害和復(fù)雜的免疫病理反應(yīng)由于各期致病因子的不同，宿主受累的組織、器官和機(jī)體反應(yīng)性也有所不同，引起的病變和臨床表現(xiàn)亦具有相應(yīng)的特點(diǎn)和階段性causedbywormscausedbyeggsCercaria:dermatitis(itching,localedema)尾蚴性皮炎Schistosomulum童蟲:angitis,spothemorrhage(lung)allergicreaction血管炎、血管周圍炎、超敏反應(yīng)Adultworms成蟲:Local:endophlebitis,periphlebitis

靜脈內(nèi)膜炎、靜脈周圍炎Totalbody:anemia,allergicreaction

貧血、發(fā)熱、蕁麻疹、血象中嗜酸性粒細(xì)胞增多等PathologycausedbywormsPathologycausedbyeggsImmatureeggs:atypicalchronicgranulomas

毛蚴不成熟，無毒性分泌物Matureeggs:acuteeosinophilicabscesschronic

granulomas可溶性蟲卵抗原Acuteeggnodule:Eosinophilicabscess嗜酸性膿腫Egg(yellowrefractingeggshellandapear-likemyracidium)Hoeppliphenomenon(redradiatingflame-likesubstance)急性蟲卵結(jié)節(jié)（嗜酸性膿腫）中央：1-2個(gè)成熟蟲卵，Hoeppli現(xiàn)象

周圍：大量變性壞死的嗜酸性粒細(xì)胞浸潤

肉眼：灰黃色粟粒至綠豆大小結(jié)節(jié)急性肺血吸蟲病蟲卵結(jié)節(jié)嗜酸性膿腫Pseudotubercle假結(jié)核結(jié)節(jié)Fibrousnodule纖維化蟲卵結(jié)節(jié)Someeggnodulesarechronicattheverybeginning,withoutexperiencingtheacutestage.Chroniceggnodule蟲卵內(nèi)毛蚴死亡

pseudotubercleeggssurroundedbyradiatingeosinophilicmaterialEosinophils,epithelioidcells,multinucleatedgiantcellslymphocytes,granulationtissue(scarce)假結(jié)核結(jié)節(jié)蟲卵巨噬細(xì)胞類上皮細(xì)胞、異物多核巨細(xì)胞周圍：淋巴細(xì)胞、少量肉芽組織假結(jié)核結(jié)節(jié)纖維鈣化蟲卵結(jié)節(jié)

eggsdestroyedandcalcified

granulomatousinflammationreplac