Pulmoner histoplazmoz BT bulguları

Özet

Histoplasma mikrokonidilerinin solunması asemptomatik enfeksiyon, akut kendini sınırlayan pnömoni veya yapısal akciğer hastalığı olanlarda kronik kaviter forma uzanan farklı klinik tablolara yol açabilir. Toraks BT, akciğer nodüllerini ve hiler-mediastinal düğümleri daha detaylı göstererek, kalsifiye iyileşme bulgularının saptanmasında radyografiden daha etkindir. Nodül ve düğüm görünümü özgül değildir; özellikle tek spiküle nodül maligniteyi, üst lob kavitesi ise tüberkülozu taklit edebilir. Kalsifiye düğümün bronşa geçişi fark edilmezse bronkolit ve bunun gerisindeki havalanma kaybı gözden kaçabilir.

Faz ve pencere

Kontrastsız tanısal: Toraks BT, akciğer nodüllerinin boyut ve kalsifikasyon paternlerini, hiler-mediastinal lenfadenopatiyi ve kavitasyonları radyografiden daha hassas göstererek tanıya katkı sağlar.

Önerilen pencereler: Akciğer (G 1500 / M -600), Mediasten (G 350 / M 50), Kemik (G 1800 / M 400).

BT bulguları

Tek veya çok sayıda, düzgün ya da spiküle konturlu solid nodül; nodül çevresinde ince buzlu cam halosu bulunabilir
Histoplazma nodülleri santral, diffüz veya laminer kalsifikasyon gösterebilir; santral kalsifikasyonlu nodül histoplazmom olarak adlandırılır ve hedef lezyonu andırabilir.
Akut/subakut hastalıkta pulmoner opasitelere eşlik eden hiler ya da mediastinal lenf düğümü büyümesi
İyileşme döneminde hiler ve mediastinal düğümlerde belirgin kalsifikasyon; akciğerde eşlik eden kalsifiye granülomlar
Akut enfeksiyonda iki taraflı yamalı konsolidasyon veya buzlu camla birlikte belirsiz sınırlı sentriasiner opasiteler
Bağışıklığı baskılanmış hastada her iki akciğere rastgele dağılmış milimetrik nodüller; miliyer yayılım paterni
Kronik kaviter hastalıkta üst lob apikal-posterior segmentlerinde ilerleyici konsolidasyon, kalın duvarlı kavite ve çevresel plevral kalınlaşma
Bronş lümenine erozyonla açılan kalsifiye peribronşiyal düğüm (bronkolit); tıkalı bronşun distalinde atelektazi veya bronşektazi görülebilir.

Normalde

Akut enfeksiyon sırasında hiler ve mediastinal lenf düğümleri büyüklüğü sıklıkla artarken, kronik kaviter hastalıkta lenfadenopati nadirdir. Normal akciğer parankimi yerine, hastalıkta yamalı konsolidasyonlar, buzlu cam opasiteleri veya nodüler lezyonlar gelişebilir. Kalsifiye lenf düğümlerinin bronş lümenine erozyonu bronkolitiyazise neden olabilir; bu durum distalde atelektazi, bronşektazi veya rekürren enfeksiyon gibi obstrüktif komplikasyonlara yol açabilir.

Normal BT ile kıyasla

Aynı bölgenin, kaynak veri setinde patoloji içermediği belirtilen bir BT incelemesini kesit kesit kaydırın; organ sınırlarını açarak anatomiyi hasta görüntüsüyle karşılaştırın. Küçük rastlantısal bulgular tümüyle dışlanmamıştır.

Kaynak: TotalSegmentator v2.01 veri seti (Wasserthal ve ark., Radiology: Artificial Intelligence 2023), CC BY 4.0, vaka s1278; organ sınırları veri setinin otomatik segmentasyonundan, birleştirilerek sadeleştirildi. Görüntüler 2,5 mm kesit aralığına yeniden örneklendi.

Ayırıcı tanı

Postprimer tüberküloz: üst lob kavitesi ve fibrotik hacim kaybı örtüşür; aktif endobronşiyal yayılımda kavite çevresinde sentrilobüler ağaç-tomurcuk opasiteleri görülebilir.
Sarkoidoz: bilateral hiler lenfadenopati en sık bulgudur; atipik formlarda bazal-periferik fibrotik fenotiple öne çıkabilir.
Primer akciğer kanseri: tek büyüyen spiküle lezyon ve bronş kesilmesi şüphe uyandırır; histoplazma nodülü de spiküle olabileceği için BT tek başına ayırıcı değildir.
Tüberküloz dışı mikobakteri enfeksiyonu: tüberküloz ve kronik histoplazmoz gibi kavitasyon ve yuvarlak nodüllerle kendini gösterir; kalsifiye granülom-düğüm birlikteliği histoplazmoz lehine ayırt edicidir.
Akciğer malignitesi: nodüler histoplazmom hem BT hem de PET'te maligniteyi taklit edebilir; yoğun FDG tutulumu granülomatöz hastalıkta da görülebilir, kesin tanı için doku örneği gereklidir.

Tuzaklar

Spiküle sınır histoplazma nodülünü dışlamaz; büyüme, önceki incelemeler ve malignite riski değerlendirilmeden yalnız kontura göre etiket koymayın.
Yoğun kalsifikasyonlu hiler düğümün bronşa bakan kenarını atlamayın; lümene taşan kalsifiye parça bronkolit olabilir ve distal havalanma bozukluğu eşlik edebilir.
Üst lob kavitesi Histoplasma için tek başına ayırt ettirici değildir; tüberküloz ve kronik mantar enfeksiyonu görüntüde örtüşebilir.
PET'te nodül veya düğüm FDG tutulumu malignite kanıtı sayılmaz; granülomatöz histoplazmoz da metabolik olarak aktif görünebilir.

Kendini dene

Kalsifiye sağ hiler düğümün bir parçası bronş lümeninde izleniyor; distal segmentte hacim kaybı var. Bu kombinasyon en çok neyi düşündürür?
Cevabı göster
Bronkolitiyazis. Kalsifiye lenf düğümünün bronşa erozyonu bronkolit oluşturabilir; distal atelektazi bu mekanik tıkanmayı destekler. Karsinoid yumuşak doku kitlesi olarak bronşu daraltır, mukus kalsifiye düğümle süreklilik göstermez, atrezi ise doğuştan bronş gelişim bozukluğudur.
Endemik bölgede yaşamış, belirti vermeyen bir kişide santral kalsifikasyonlu akciğer nodülü ve kalsifiye hiler düğümler var. En olası açıklama nedir?
Cevabı göster
İyileşmiş histoplazmoz. Santral kalsifikasyonlu granülomlarla kalsifiye hiler düğümlerin birlikteliği geçirilmiş histoplazmoz için uyumlu bir sekeldir. Malignite nodüllerinde kalsifikasyon nadirdir; sarkoidozda simetrik hiler düğüm ve perilenfatik nodül dağılımı tipiktir; NTM hastalığında ise kavitasyon ve yuvarlak nodüller öne çıkar.

Kaynaklar

Bu sayfadaki 38 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla tek tek karşılaştırıldı; 12 cümle bu karşılaştırmada düzeltildi (2026-10-08).

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