Hava yolu invaziv aspergillozu

Özet

Hava yolu invaziv aspergillozu (AWIA), Aspergillus'un trakeobronşiyal duvara veya küçük hava yollarına invazyonuyla gelişir ve çoğunlukla immün sistemi baskılanmış hastalarda düşünülür. BT'de bronş duvarı kalınlaşması, lümen daralması, peribronşiyal konsolidasyon ve bronşioler tomurcuklanan ağaç paterni değişen kombinasyonlarda görülebilir. Anjioinvaziv hastalıktaki halo işareti bulunmayabilir; bu nedenle sadece nodül çevresi buzlu cam aramak hava yolu formunu kaçırabilir. Hava yolu tıkanması, distal atelektazi ve ilerleyen parankim tutulumu hastalığın klinik önemini artırır; BT görünümü mikolojik doğrulamanın yerini almaz.

Faz ve pencere

HRCT tanısal

Kontrastsız ince kesitlerde trakea ve bronş duvarı kalınlaşması, lümen düzensizliği/daralması, bronş çevresi konsolidasyon, sentrilobüler nodüller ve tomurcuklanan ağaç aranır. İnce kesitli BT görüntülerinde bronş duvarı kalınlaşması ve bronşioler bulgular değerlendirilebilir.

Önerilen pencereler: Akciğer (G 1500 / M -600), Mediasten (G 350 / M 50).

BT bulguları

• Trakeobronşiyal duvar kalınlaşması — trakea veya ana bronş duvarında düzensiz, çoğu kez çevresel kalınlaşma hava yolu invazyonunu düşündürür.
• Bronş lümeninde daralma — lobar veya segmental bronş boyunca kısa segmentli düzensizlik, tıkaç ya da stenoz görülebilir.
• Mukus tıkacı — bronş lümeninde mukoid impaksiyon görülebilir; bronşiollerde tıkanmış mukus lümen genişlemesiyle birlikte izlenebilir.
• Peribronşiyal konsolidasyon — bronş çevresini kılıflayan hava boşluğu opasitesi, invaziv bronşiyal yayılımın parankimal karşılığı olabilir.
• Bronşektazi — lobar veya segmental bronşlarda bronşektazi ve duvar kalınlaşması AWIA'da görülebilir.
• Tomurcuklanan ağaç paterni distal bronşioler tutulumu düşündürür; tüberkülozda da görülebildiğinden Aspergillus'a özgü değildir.
• Küçük kavite veya yamalı periferik odak — bronşiol ve parankim tutulumunun ilerlediği hastalarda eşlik edebilir.

Ölçütler ve sınıflamalar

Bir retrospektif serideki BT morfoloji tipleri (evreleme değil)

Tek retrospektif seride tanımlanan morfolojik gruplar evrensel kabul görmüş klinik evreleme değildir: Tip I trakea/ana bronş tutulumu; Tip II lobüler/segmental bronş tutulumu (erken duvar kalınlaşmasını izleyerek IIa bronşektazi veya IIb peribronşiyal konsolidasyon); Tip III bronşiol-parankim tutulumu (tomurcuklanan ağaç, asiner nodüller, yamalı opasite ve küçük kavite).

Normalde

AWIA serilerinde trakea veya ana bronş duvar kalınlaşması seyrek; lobar ve segmental bronşlarda lümen darlığı ve duvar kalınlaşması ise sık bildirilen BT bulgularındandır. AWIA şüphesinde bronş duvar kalınlaşması ve lümen darlığını, distal bronşiollerde tomurcuklanan ağaç bulgusuyla birlikte değerlendirin.

Ayırıcı tanı

Bakteriyel bronşiyolit veya bronkopnömoni

tomurcuklanan ağaç ve peribronşiyal konsolidasyon yapabilir; invaziv mantar için konak riski ve mikoloji gerekir.

Tüberküloz veya atipik mikobakteri enfeksiyonu

bronşioler nodüller ve bronş duvarı değişikliğiyle benzer görünür; dağılım, kavite ve laboratuvar verileri ayrımda yardımcıdır.

Mukus tıkacı ve astım

endobronşiyal dolum, hava hapsi ve atelektazi yapabilir; invaziv duvar değişikliği ve klinik immünsüpresyon yoksa alternatif düşünülür.

Endobronşiyal tümör

fokal, kitle benzeri duvar/lümen lezyonu ve distal atelektazi oluşturabilir; bronş boyunca yaygın inflamatuvar örüntüden ayrılır.

Relapsing polichondrit

trakeobronşiyal daralma ve trakeomalasi oluşturabilir; kartilaj tutulumu ve sistemik inflamatuvar bulgular değerlendirilir.

Tuzaklar

• Tomurcuklanan ağaç Aspergillus'a özgü değildir; nötropeni/transplantasyon gibi konak özellikleri yoksa enfeksiyon etkenini görüntüden çıkarmayın.
• Hava yolu invaziv aspergillozunda tomurcuklanan ağaç paterni nodül çevresinde halo işareti olmadan da görülebilir; bronşiyal ve bronşioler bulguları da sistematik inceleyin.
• Atelektaziyi yalnız mukus tıkacına bağlamayın; bronş lümeninde daraltıcı duvar lezyonu veya endobronşiyal kitle olup olmadığını araştırın.

Kendini dene

1. Transplant alıcısında segment bronş duvarı kalın, lümen dar ve distalinde sentrilobüler dallanan nodüller var. En uygun olasılık hangisidir?

   • Hava yolu invaziv aspergillozu
   • Santral akciğer embolisi
   • Pulmoner ödem
   • Plevral mezotelyoma
   Cevabı göster

   Hava yolu invaziv aspergillozu. İmmünsüprese konakta bronş duvarı/lümen değişikliğiyle distal bronşioler nodüllerin birlikteliği AWIA'yı düşündürür. AWIA’da sık görülen BT bulguları arasında lobar ve segmental bronş lümen darlığı ve duvar kalınlaşması ile tomurcuklanan ağaç işareti bulunur.

2. Bronş çevresindeki konsolidasyon ve tomurcuklanan ağaç tek başına hangi sonucu kanıtlamaz?

   • Aspergillus etkenini
   • Hava yolu tutulumunu
   • Bronşioler yayılımı
   • Enfeksiyon olasılığını
   Cevabı göster

   Aspergillus etkenini. Bu örüntüler hava yolu merkezli enfeksiyonla uyumludur ancak Aspergillus'a özgül değildir; mikolojik ve klinik doğrulama gerekir. Diğer seçenekler görüntüde tarif edilen dağılımı ifade eder.

İlgili konular

• İnvaziv pulmoner aspergilloz

Kaynaklar

Bu sayfadaki 38 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla tek tek karşılaştırıldı; 2 cümle bu karşılaştırmada düzeltildi (2026-10-09).

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