Pulmoner gangren

Özet

Pulmoner gangren, ağır nekrotizan akciğer enfeksiyonunda bir lobun ya da segmentin geniş ölçekte canlılığını yitirdiği, nadir fakat yaşamı tehdit eden tablodur. Kontrastlı toraks BT, hastalığın yaygınlığını ve pulmoner damar trombozunu değerlendirmeye yardımcı olur; lobun yarısından fazlasını tutan nekroz ve büyük damar trombozu pulmoner gangreni nekrotizan pnömoniden ayıran özellikler arasındadır. Büyük damar tıkanıklığı ile geniş nekrozun birlikte görülmesi, akciğer dokusunun yaygın destrüksiyonunu düşündürür. Yaygın nekroz ve perfüzyon kaybı geliştiğinde antimikrobiyal tedavi hastalık ilerlemesini durduramaz; bu durum hızla kötüleşen klinik tablo ve aşırı yüksek mortalite ile sonuçlanır.

Faz ve pencere

BTPA tanısal

Kontrastlı toraks BT, nekrozun yaygınlığını ve pulmoner arterlerde tromboz olup olmadığını değerlendirmeye yardımcı olur; pulmoner gangrende büyük damar trombozu görülebilir.

Kontrastsız

Pulmoner gangrende çoklu kaviteleşmeler görülebilir; pulmoner vasküler beslenmenin değerlendirilmesi için kontrastlı toraks BT önerilir.

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

BT bulguları

• Lobar konsolidasyon içinde çevreye göre belirgin azalmış ya da kaybolmuş kontrastlanma
• Nekrotik parankimde geniş alanlara yayılan çok sayıda mikrosiyahap ve bunların birleşerek büyük boşluklar oluşturması beklenir.
• Birden fazla kavitasyonun büyük tek bir boşlukta birleşmesi ve eşlik eden yaygın parankim destrüksiyonu.
• Etkilenen segment veya lobu besleyen pulmoner arter dallarında ani kalibrasyon kaybı ya da oklüzyon
• Kavite içinde nekrotik doku parçası ve çevresinde hava hilali görünümü oluşabilmesi
• Plevral kalınlaşma ve kontrastlanan ampiyem duvarı veya loküle plevral sıvı
• Komşu bronşta inflamatuvar daralma, tıkanma veya bronkoplevral fistüle eşlik edebilen plevral hava

Ölçütler ve sınıflamalar

Gangren lehine yaygın lob nekrozu

Nekroz etkilenen lobun %50'sinden fazlasını tutar.

Normalde

Konsolide alanda kontrastlı toraks BT ile pulmoner vasküler beslenmeyi değerlendir.

Ayırıcı tanı

Nekrotizan pnömoni

çoklu küçük nekroz odakları ve mikroapseler vardır; geniş lob nekrozu ile bölgesel büyük damar oklüzyonu birlikteliği daha az belirgindir.

Akciğer apsesi genellikle tek kaviter lezyonla seyreder; pulmoner gangrende ise nekroz daha geniş bir alanı tutar ve büyük damar trombozu görülebilir.

Sağ taraflı endokarditle ilişkili septik pulmoner emboliler, bilateral periferik kaviter nodüller şeklinde görülebilir.

Pulmoner infarkt çoğunlukla tromboemboliye bağlı gelişebilir ve sonrasında ikincil enfeksiyona zemin hazırlayabilir.

Tuzaklar

• Pulmoner arterlerin yetersiz opasifikasyonu, özellikle periferik dalların değerlendirilmesini güçleştirebilir; damar oklüzyonu yorumlanırken kontrastlanma kalitesi dikkate alınmalıdır.
• Nekrotizan pnömonideki çoklu küçük kaviter lezyonlar birleşerek geniş tek bir boşluk oluşturabilir; bu durum geniş lob nekrozunu değerlendirmede önemlidir.
• Pulmoner gangren kaviteleşmeyle birlikte hidropnömotoraks ve plevral efüzyonla da görülebileceğinden, plevral koleksiyonlar ayrıca değerlendirilmelidir.

Kendini dene

1. Ağır pnömonide lobun büyük bölümü kontrastlanmıyor; iç içe kavitelere ek olarak besleyici arter dalı sonlanıyor. En olası tablo hangisidir?

   • Pulmoner gangren
   • Akciğer apsesi
   • Septik emboli
   • Kavite yapan tümör
   Cevabı göster

   Pulmoner gangren. Geniş perfüzyon kaybı, lob içinde yaygın nekroz ve pulmoner arter dalı oklüzyonu gangreni destekler. Apse genellikle sınırlı tek boşluktur; septik emboli çoklu periferik nodüller yapar, tümör ise bu akut enfeksiyöz damar-parankim paternini açıklamaz.

2. BT'de etkilenen lobun yarısından fazlasını tutan nekroz ve büyük damar trombozu birlikte görülüyor. En olası tanı hangisidir?

   • Pulmoner gangren
   • Akciğer apsesi
   • Septik pulmoner emboli
   • Pulmoner infarkt
   Cevabı göster

   Pulmoner gangren. Pulmoner gangrende nekroz etkilenen lobun yarısından fazlasını tutabilir ve nekrotizan pnömoniye kıyasla daha büyük damar trombozu görülür.

İlgili konular

• Pulmoner infarkt

Kaynaklar

Bu sayfadaki 34 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla otomatik olarak karşılaştırıldı; 10 cümle bu karşılaştırmada düzeltildi (2026-10-09).

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