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Thursday, March 29, 2007

Pulmonary infection

画像診断 2007 Vol.27 No.4

○細菌性肺炎と非定型肺炎の鑑別に用いる項目
1 60歳未満
2 基礎疾患がないあるいは軽微
3 頑固な咳がある
4 胸部聴診上所見に乏しい
5 喀痰がないあるいは迅速診断法で原因が証明されない
6 末梢血白血球数が 10.000/μL 未満である
3/5一致で非定型肺炎を考える。マイコプラズマの90%、クラミジアの70%で3/5を満たす。Sens 77%, Spec 93% Ishida T et al. Respirol 12:104-11, 2007.


市中肺炎の重症度判定項目
A (age) M 70歳以上、F75歳以上
D (Dehydration) BUN 21mg/dl 以上
R(Respiration) SpO2 90%以下
P (blood Pressure)SBP 90mmHg以下

(日本呼吸器学会市中肺炎ガイドライン 2007)

結核菌特異蛋白刺激性遊離インターフェロン-γ測定(準用先区分 D023「4」)(区分E-3)
製品名:クオンティフェロン

平成18 年1 月1 日より適用:血漿蛋白免疫学的検査
保険点数:410点             定量試験
製品名:クオンテイフェロンTB-2G
製造元:Cellestis Ltd. (Australia)
販売元:(株)日本ビーシージーサプライ  電話:03-5800-5311
総輸入発売元:(株)ニチレイ       電話:03-3248-2208
測定方法:酵素免疫測定(EIA)法     192テスト(40検体分)/キット
結果が出るまでの時間:21時間       自動化:不可
検体:全血
同時再現性:15%以下           測定範囲:0.05~15.0 IU/mL
カットオフ値:0.35 IU/mL

【特徴】本法は、結核菌特異抗原と全血を共培養することにより、活性化された全血中のTリンパ球から産出された培養上清中のINF-γを酵素免疫測定(EIA)法を用いて測定する。
本キットを用いた結核患者群とBCG接種健常人群を対象とした成績からはその有病正診率は89.0%(105/118)、無病正診率は92.2% (200/217)と高かった。また、本キットとツ反検査を比較したところ、本キットの有病正診率は92.2%(71/77)、無病正診率は92.2% (200/217)であるのに対し、ツ反検査では各々90.9%(70/77)、16.6%(36/217)であり、本法が特異性の点で格段に優れていた。この結果はツ反検査がBCG既接種の影響を受けるのに対し、本キットは影響を受けないことを示した。
日本臨床検査専門医会のサイトより
新結核用語集・QFT-2G
Table 1. ddx of focal consolidation/ggo
A. Infection
bacterial pneumonia, mycoplasma pneumoniae pneumonia, Chlamydophila pneumoniae pneumonia, Legionnaire pneumonia, Viral infection, Tuberculosis, ATM, pulmonary fungal infection.

B. Non-infectious diseases
1) Neoplastic diseases
Obstructive pneumonia, mucin producing cancer, MALT lymphoma.
2) Vascular diseases
Pulmonary infarction, hemorrhage, edema, vasculitis.
3) Miscellaneous
Chronic eosinophilic pneumonia, cryptogenic organizing pneumonia, focal organizing pneumonia (delayed pneumonia).

Table 2. ddx. of diffuse consolidation/ggo.
A. Infection
CAP; bacterial pneumonia other than legionnaire, Chramydia psitacci, influenza virus, adenovirus, Legionnaire pneumonia.
HAP; GNR, invasive aspergillosis, Pneumocystis jiroveci, CMV, herpes virus.

B. Non-infectious diseases
Pulmonary edema, diffuse pulmonary hemorrhage, COP, ARDS/AIP/UIP acute exacerbation, hypersensitivity pneumonitis, CEP/AEP, drug-induced pulmonary injury.

Table 3. ddx. of diffuse miliary lesions
A. Infection
Miliary tuberculosis, viral (VZV, Measles, CMV), fungal infections (PCP, Candida, cryptococcus, aspergillus, coccioidmycosis, histoplasma), Mycoplasma.

B. Non-infectious
1) Peripheral airway inflammatory diseases
DPB, DAB, exposure to chemical substances, bronchiolitis associated with RA, obstructive bronchiolitis after BMT, HTLV-I related DPB like lesion.
2) Pneumoconiosis
Silica, Mixed dust pneumoconiosis, Coal workers lung, iron/Talk/Beryllium lung.
3) Granulomatous diseases
Sarcoidosis, LCH.
4) Allergic diseases
HP
5) Neoplastic lesions
Hematogenous metastases (thyroid/lung/melanoma/breast/choriocarcionoma), transbronchial spread (BAC).
6) Miscellaneous
Pulmonary alveolar microlithiasis.

Table 4. ddx of SPN
A. Infection
Satellite lesion of tuberculosis: central calcification, cavity, low or no enhancement, ring-like enhancement.
Aspergillosis: meniscus sign, low or no enhancement.
Cryptococcosis: Satellite nodules, broad-base pleural attachment, multiple nodules within the same lobe, cavity.
Pulmonary abscess: cavity, low or no enhancement.
Pulmonary paragonimiasis: cavity, low or no enhancement.
Pulmonary dirofilariasis: No calc., no pleural lesion

B. Non-infectious
1) Neoplastic lesions
Bronchogenic carcinoma, solitary metastasis (can be no enhancement), lymphoma, hamartoma, sclerosing hemangioma.
2) Vascular lesions
AVM, pulmonary infarction (wedge-shaped subpleural lesion), hematoma.
3) Miscellaneous
Sequestration, bronchial artesia (focal emphysema)

Table 5. ddx of Multiple nodules/masses
A. Infection
Fungal, Mycobacterium, Nocardiosis, Actinomycosis, Pulmonary Abscess, Viral, parasite.

B. Non-infectious
1) Neoplastic
Metastases, BAC, lymphoma, benign metastasizing leiomyoma, epithelioid hemangioendothelioma.
2) Vascular
Septic embolus, AVM
3) Traumatic
Hematoma
4) Granulomatous
Sarcoidosis, Wegeners granulomatosis, Pneumoconiosis.

Table 6. ddx of cyst/cavitary lesions.
A. Infection

Pulmonary abscess, pneumatocele, septic embolus, infected bulla, tuberculosis, fungal infection, Pneumocystis pneumonia, Parasitic infection.

B. Non-infectious
1) Neoplastic lesions
Bronchogenic carcinoma, metastases (H&N cancer, uterine cervical cancer), benign tumor (sclerosing hemangioma)
2) Airway disease
Bulla/bleb, emphysema, bronchiectasis.
3) Embolic disease
Pulmonary infarcation, septic eomblus.
4) Autoimmune diseases
Rheumatoid nodule, Wegener's granulomatosis.
5) Congenital lesions
CCAM, bronchogenic cyst, pulmonary sequestration, Wilson-Mikity syndrome, bronchopulmonary atresia.
6) Trauma
Pulmonary laceration, traumatic pulmonary cyst
7) Miscellaneous
Sarcoidosis, LCH, LAM.

Table 7. ddx of atelectasis
A. Obstructive atelectasis
Tumor, mucous plug, foreign body, amyloidosis, Wegener's granulomatosis, Bronchial trauma, broncholithiasis, CF, tracheobronchomalacia.

B. Compression atelectasis (passive atelectasis)
Pleural effusion, pneumothorax, bulla, cardiomegaly, aneurysm, SOL.
C. Adhesive atelectasis
Pulmonary infarciton, acute radiation pneumonitis, plate atelectasis, infantile respiratory distress syndrome (infant RDS),
D. Cicatrizing atelectasis
Bronchiectasis, middle lobe syndrome, secondary tuberculosis, pulmonary fibrosis, asbestosis.
E. Miscellaneous
Rounded atelectasis, gravity-dependent atelectasis.

Table 8. ddx of mediastinal/hilar lymph node enlargement
A. Infectious
Tuberculous lymphadenitis, miliary tuberculosis, mycoplasma pneumonia of pediatric patients, C. psittaci, pertussis, anthrax, plague, tularemia, rickettsia, viral infection (measles, IM, VZV, echovirus), fungal infection (histoplasmosis, coccidioidomycosis, sporotrichosis).

B. Non-infectious
1) Neoplastic
bronchogenic carcinoma, lymph node metastases, lymphoma, leukemia.
2) Miscellaneous
Respiratory infection in immunocompromised patients, sarcoidosis, Castleman disease, Silicosis, berylliosis, amyloidosis, Wegener's granulomatosis, drug-induced lymphadenopathy.
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