病理学教学课件：Infectious Diseases

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1、Infectious Diseases 1.Etiology:u pathogenic microbes u parasite 2.epidemiologyvsource of infectionvroute of transmission vSusceptible population 3.Pathogenesis ventry cellvtoxin/enzyme,vessel injuryvimmune response Infectious DiseaseCommon FeaturesLeprosy (麻风麻风)Syphilis(梅毒梅毒)Typhoid fever(伤寒伤寒)Bacil

2、lary dysentery（细菌性痢疾）（细菌性痢疾）传染病传染病Leprosy (麻风麻风)Leprosy,Hansen diseaseSlowly progressive Mycobacterium leprae 麻风杆菌麻风杆菌Affecting the skin and peripheral nervesResulting in paralysed skin lesion,rigid and swollen nerves,disabling deformities.麻木性皮肤损害、周围神经粗大、手足残废和畸形IntroductionHistoryEpidemiology热带地区较多热

3、带地区较多HarmEtiologynM.leprae One of the oldest pathogen that afflict humans Discovered in Norway in 1873 by Dr.Armauer Hansen Acid-fast obligate intracellular bacterium 抗酸杆菌、胞内寄生抗酸杆菌、胞内寄生 Similar to mycobacterium tuberculosis Etiology does not grow in culture but can be grown in the armadillo(犰狳犰狳).Pr

4、efer low temperature(32 to 34)and grow slowly virulence is based on properties of its cell wall 麻风菌素麻风菌素 Human being seems to be the only victimEpidemiologyu传染源传染源 麻风病人是本病的唯一传染源麻风病人是本病的唯一传染源，瘤，瘤型型和界线类病人传染性最强。和界线类病人传染性最强。u 传播途径传播途径 麻风杆菌主要是通过破损的皮肤和麻风杆菌主要是通过破损的皮肤和呼吸道进入人体。呼吸道进入人体。u 人群易感性人群易感性 人类对麻风杆菌的易感

5、性很不一致，人类对麻风杆菌的易感性很不一致，一般儿童较成人易感，而病例多为一般儿童较成人易感，而病例多为20岁以上的成岁以上的成人，男性病例多于女性病例人，男性病例多于女性病例。大约大约95的人的人具有具有自然自然免疫力免疫力TransmissionuContained in secretionuRespiratory pathway呼吸道呼吸道 Abrasion or wounds破损的皮肤破损的皮肤uTaken up by macrophagesudisseminates through the bloodPathogenesisnLatent period:2-4 years nCell

6、ular immunitynHumeral immunitynLepromin test 麻风菌素麻风菌素注射于皮肤，局部出现注射于皮肤，局部出现 迟发型变态反应，菌体的热休克蛋迟发型变态反应，菌体的热休克蛋 白可诱发细胞免疫所致白可诱发细胞免疫所致PathogenesisnA bipolar disease 根据细胞免疫强弱，分成截然不同的两种类型根据细胞免疫强弱，分成截然不同的两种类型 u tuberculoid leprosy 结核样型麻风结核样型麻风(T-cell mediated immune response，细胞免疫强，细胞免疫强)u lepromatous leprosy瘤型麻

7、风瘤型麻风(Immunity anergic 免疫无反应性，体液免疫，免疫无反应性，体液免疫，抗体抗体+)Types according to pathological changes分型分型nTuberculoid leprosy 70%nLepromatous leprosy 20%nBorderline leprosy 中间界线类中间界线类 少见少见nIndeterminate leprosy未定类麻风未定类麻风 很少见很少见Tuberculoid leprosy (60-70%)nIntact cellular immune responseSlow course,spanning d

8、ecadesLimited lesionsFew bacilli within the lesionnMainly involve skin and nervesnClinical feature:lepromin test(+)low infectivity good prognosisTuberculoid leprosyGranuloma resembles hard tubercles epithelioid macrophagesgiant cells without caseous necrosisPeripheral:CD4+Th1 IL-2&IFN-few surviving

9、mycobacteriaTuberculoid leprosySkin lesions:macula or papula斑疹或丘疹斑疹或丘疹gross:flat and red irregular shapes with indurated,elevated,hyperpigmented margins and depressed pale centers 好发于面部、臀部、躯干四肢伸面好发于面部、臀部、躯干四肢伸面Skin lesionsLM:tuberculoid granuloma结核样结节结核样结节n enclose blood vessels,cutaneous appendages

10、 and nerves n extend to the basal cells of epidermis Tuberculoid leprosyTuberculoid leprosyPeripheral neuropathy:rigid and swollen nerves神经变硬、不规则增粗，如绳索神经变硬、不规则增粗，如绳索From small dermal nerves to nerve trunkN.auricularis magnus(耳大耳大)N.auricularis posterior(耳后耳后)LM：Granulomatous inflammatory reactions e

11、nclosed neuron and may destroy it Fibrosis,absence of nervesNerve degeneration,destruction,fibrosisClinical pathologic conferenceAnesthesia感觉障碍感觉障碍,atrophy(失神经营养失神经营养),paralysis,liable to trauma,autoamputation of fingers or toes(肢体自动脱落肢体自动脱落),disabling deformities,indolent skin ulcers,keratitis角膜炎角膜

12、炎,corneal ulcerations.Tuberculoid leprosy鹰爪手鹰爪手Lepromatous leprosy (20%)细胞免疫反应弱细胞免疫反应弱nlepromin test(-)nLarge amounts of bacilli infectious传染性强传染性强n Acute deteriorate,poor prognosis,伴伴麻风反应：高热、神经痛麻风反应：高热、神经痛nGenerally involved the skin,peripheral nerves,anterior eye,upper airways,testes,lymph node,vi

13、sceral,etcLepromatous leprosynlarge aggregates of lipid laden macrophages(leprosy cells),often filled with masses of acid-fast bacilli 麻风细胞麻风细胞:巨噬细胞吞噬大量的麻巨噬细胞吞噬大量的麻风杆菌，胞质内有大量类脂空泡，风杆菌，胞质内有大量类脂空泡，呈泡沫状呈泡沫状nlymphocytes infiltratedLack CD4+TH1 cells at the margins but instead contain many CD8+suppressor

14、T cellsLepromatous leprosySkin lesions:Macular斑疹斑疹,papular丘疹丘疹,or nodular lesions form结节、麻风瘤结节、麻风瘤 on the face,ears,back,extremitiesWith progression,the nodular lesions coalesce to yield a distinctive leonine faces(狮面狮面).Skin lesions hypoesthetic or anestheticLepromatous leprosySkin lesions:LM:large

15、 amounts of lepra cells and a few lymphcytes infiltration enclose vessels and appendages 真皮深层聚集大量麻风细胞真皮深层聚集大量麻风细胞Clear line无浸润带无浸润带病灶和表皮之间的真皮浅层病灶和表皮之间的真皮浅层有无细胞浸润带，又称为自由带有无细胞浸润带，又称为自由带Lepromatous leprosyPeripheral nerves：resemble tuberculoid leprosyLoss of sensation and atrophic changes.Nose 糜烂或溃疡，鼻中

16、隔穿孔糜烂或溃疡，鼻中隔穿孔Spleen and liver 成堆泡沫细胞成堆泡沫细胞Lymph nodes 泡沫细胞泡沫细胞Testes 精液中带菌精液中带菌nThe vital organs and central nervous system are rarely affected.Tuberculoid typeLepromatous typeIncidence70%20%Immune response IntenseSubduedSkin lesionMacula or papula,tuberculoid,few bacilli Protuberant,large amount o

17、f bacilliLepromin test(+)(-)Humoral antibody(+/-)(+)Involved tissueLimited to skin and nervesExtend to other organsProcessDevelop slowlyRelative fastInfectivityWeakStrongComparisonSexually Transmitted Disease性传播性疾病（性传播性疾病（STD）Venereal Diseases,VDnFive classic venereal diseases Syphilis 梅毒梅毒Gonorrhea

18、 淋病淋病Chancroid 软下疳软下疳granuloma inguinale 腹股沟肉芽肿腹股沟肉芽肿lymphogranuloma venereum 性病淋巴肉芽肿性病淋巴肉芽肿Sexually Transmitted Disease,STDnIn the past decade,the spectrum of sexually transmitted disease(STD)has widened considerablyViralHIV-1,HIV-2HSV-1,HSV-2PapillomavirusesAIDSHerpes lesions生殖器疱疹Condyloma,cervica

19、l neoplasiaChlamydial,MycoplasmalChlamydia trachomatis(L type)Chlamydia trachomatisUreaplasma urealyticumLymphogranuloma venereum性病淋巴肉芽肿性病淋巴肉芽肿Nongonorrhea urethritis,cervicitisNongonorrheal urethritis,cervicitisBacterialNeisseria gonorrhoeaeTreponema pallidumHaemophilus ducreyiCalymmatobacterium do

20、novaniGonorrhea淋病淋病Syphilis(lues venerea)梅毒梅毒Chancroid软下疳软下疳Granuloma inguinale腹股沟肉芽肿腹股沟肉芽肿ProtozoalTrichomonas vaginalisTrichomoniasis 滴虫By ArthropodPhthirus pubisPediculosis pubis(crab)阴虱病Syphilis(Lues)梅毒梅毒An important STDMultiple clinical presentations(thus designated the great imposter)chronic a

21、nd slowly progressive involve many vital organs in late periodEtiologynPathogen:Spirochete Treponema pallidum 梅毒螺旋体梅毒螺旋体ncan not be cultured ndetectable by silver stainsndark field examination TransmissionnMode:Sexual intercourse(95%)p Acquired syphilis 后天性后天性(获得性获得性)梅毒梅毒Transplacental transmissionp

22、 Congenital syphilis 先天性梅毒先天性梅毒PathogenesisTraverse abraded skin and mucosaEnter lymph circulation Travel through blood and reach various organs and tissueLatent period:10-90 days,average at 21 daysPathogenesisScarce protein on surface(Weak antigenicity)Down-regulation of TH1 cells Inadequate cellul

23、ar and humoral immune responseRelapse syphilis and tertiary syphilisnLatent syphilis 隐性梅毒隐性梅毒 血清反应阳性，而无病变无症状血清反应阳性，而无病变无症状MorphologynMay affect nearly any organ or tissue in the bodynTwo morphologic patterns of tissue injuryObliterative endarteritis 闭塞性小动脉内膜炎闭塞性小动脉内膜炎Gumma 树胶样肿树胶样肿病原体引发的迟发性超敏反应病原体引发

24、的迟发性超敏反应Morphology1 Proliferative endarteritis 增生性动脉内膜炎增生性动脉内膜炎 Obliterative endarteritis Perivascular inflammation 小血管周围炎小血管周围炎concentric endothelial and fibroblastic proliferative thickening of the small vessels a surrounding mononuclear(principally plasma cell)inflammatory infiltrate,known as cuf

25、fing血管周围套血管周围套 病变周围组织发生病变周围组织发生缺血性细胞缺血性细胞坏死和纤维化坏死和纤维化，见于各期梅毒，见于各期梅毒late lesion occurred in any site(liver,bone,testes)Vary in size 小的肉眼不能见到，大的直径达小的肉眼不能见到，大的直径达3-4cmgray,tough and rubbery,like gumAbsorbed,fibrosis,scared后期可被吸收、纤维化、疤痕形成后期可被吸收、纤维化、疤痕形成Scarcely calcification 绝少钙化绝少钙化最后导致病变组织破坏和瘢痕挛缩最后导致病

26、变组织破坏和瘢痕挛缩2.Gumma(syphiloma梅毒瘤梅毒瘤)发生于晚期梅毒，大小不一，灰发生于晚期梅毒，大小不一，灰白色，质地韧有弹性似树胶，称白色，质地韧有弹性似树胶，称树胶样肿树胶样肿。la center of coagulative necrosis lsurrounded by many mononuclear leukocytes ladmixed with macrophages(some resembling epithelioid cells)中央为凝固性坏死，但不如结核干酪中央为凝固性坏死，但不如结核干酪样坏死彻底，弹力纤维尚保存样坏死彻底，弹力纤维尚保存坏死灶周围有

27、许多单核细胞（淋巴细坏死灶周围有许多单核细胞（淋巴细胞、浆细胞胞、浆细胞)、上皮样细胞、上皮样细胞(巨噬细胞）巨噬细胞）Gumma:resemble the lesion of tuberculosis.镜下镜下颇似结核结节颇似结核结节Acquired syphilisThree distinct stagesnPrimarynSecondarynTertiaryEarly stage(contagious)Late stagePrimary syphilis一期梅毒一期梅毒nChancre硬下疳硬下疳 直径为直径为1cm大小有浅表溃疡的无痛性硬块大小有浅表溃疡的无痛性硬块nAfter lat

28、ent period(about 3 weeks)nAt the site of inoculation,penis,vulva or cervixnindurated,button-like papule at firstnErodespA single,painless,copper-colored,Clean-based,shallow ulcer,with elevated and indurated margin 单个、无痛性、红铜色、边界隆起、溃疡基底干净单个、无痛性、红铜色、边界隆起、溃疡基底干净Primary syphilisnChancreAccompanied by lym

29、phadenopathy 淋巴结肿大淋巴结肿大LM:obliterative endarteritis perivascular plasma cell cuffingDark field examination of the exudate 渗出液检查可找到螺旋体渗出液检查可找到螺旋体Spontaneous healing 自愈自愈Secondary syphilis二期梅毒二期梅毒nMucocutaneous rash梅毒疹梅毒疹n1-3 months after the primary syphilisnWidespread patchy or diffuse 广泛广泛nBilatera

30、l,symmetric,maculopapular,red-blown 对称分布斑丘疹对称分布斑丘疹nCondylomata lata 梅毒扁平湿疣梅毒扁平湿疣LM:typical vasculitisnNonspecific lymphadenopathy 肿大淋巴结为非特异性炎症肿大淋巴结为非特异性炎症Secondary syphilisnFever,malaise,weight lossnSerologic test(+)nSpontaneous healing after 1-3 monthsnRelapse 复发梅毒疹复发梅毒疹，疹量较少疹量较少nLatent syphilis隐性梅

31、毒隐性梅毒 asymptomaticserologic tests(+)Tertiary syphilis 三期梅毒三期梅毒nAfter a latency period of 10-20 yearsnMay affect any part of the bodyCardiovascular system(80-90%)Central nervous system(5-10%)Liver,bone,testes,etc.nGumma and scar tissue formation皮肤黏膜损害皮肤黏膜损害 结节型梅毒疹好发于头皮、肩胛、背部及四肢的伸侧。树胶样肿常发生在小腿部，为深溃疡形成，

32、萎缩样瘢痕Tertiary syphilisnSyphilitic aortitis梅毒性主动脉炎梅毒性主动脉炎 80-90%Confined to thoracic aorta 胸主动脉升部和根部胸主动脉升部和根部Obliterative endarteritis of nutrient arteries 闭塞性滋养小动脉炎闭塞性滋养小动脉炎wrinkling or“tree barking”of the intimal surface 内膜树皮状皱缩内膜树皮状皱缩 Secondary atherosclerotic plaques弹力纤维染色，显示大动脉中层弹力纤维染色，显示大动脉中层弹力

33、纤维破坏弹力纤维破坏u Syphilitic aneurysm 梅毒性主动脉瘤梅毒性主动脉瘤u Aortic insufficient 主动脉瓣关闭不全主动脉瓣关闭不全梅毒性主动脉瘤梅毒性主动脉瘤Tertiary syphilisnNeurosyphilis 神经梅毒神经梅毒 5%-10%Meningovascular syphilis 脑膜血管性梅毒脑膜血管性梅毒Tabes Dorsalis 脊髓痨脊髓痨General paresis 麻痹性痴呆麻痹性痴呆Brain gumma 脑树胶样肿脑树胶样肿Tertiary syphilisnBone:septal perforation(saddl

34、e nose)鼻中隔穿孔鼻中隔穿孔（马鞍鼻）（马鞍鼻）骨膜炎、骨髓炎、骨炎导致骨硬化（象牙化）骨膜炎、骨髓炎、骨炎导致骨硬化（象牙化）nLiver 肝梅毒肝梅毒nTestesCongenital syphilis先天性梅毒先天性梅毒nOnset after the fourth month of pregnancynEarly congenital syphilis(perinatal period)早期早期胎传梅毒胎传梅毒nMucocutanous lesionuRashes(vesicular or bullous水疱、大疱水疱、大疱)uExtensive desquamation of

35、the skin广泛性皮肤脱屑广泛性皮肤脱屑nDiffuse interstitial inflammation,prominent fibrosis uLung,liver,spleen,etc.nOsteochondritis and perichondritis骨软骨炎及骨膜炎骨软骨炎及骨膜炎uSaddle nose,saber shins 马刀胫骨马刀胫骨口角放射状疤痕口角放射状疤痕梅毒疹（大疱）梅毒疹（大疱）马刀胫骨马刀胫骨马鞍鼻马鞍鼻Congenital syphilisnLate congenital syphilisn 2y Hutchinson三联症三联症uHutchinso

36、ns teethuNerve deafness 神经性耳聋神经性耳聋uInterstitial keratitis 间质性角膜炎间质性角膜炎nMay remain latent until adolescence锯齿形门牙锯齿形门牙Clinical Stages and FeaturesTyphoid Fever(伤寒伤寒)张仲景张仲景伤寒论伤寒论吴有性吴有性瘟病论瘟病论ConceptionnAn acute infectious disease caused by Salmonella typhi.伤寒杆菌伤寒杆菌nCharacterized by ulceration of the sma

37、ll intestine 小肠溃疡小肠溃疡systemic reticuloendothelial cells hyperplasia单核巨噬细胞增生单核巨噬细胞增生 nMain manifestations:fever,leukopenia,delirium,abdominal pain,diarrhea,rose spots,and splenomegaly intestinal bleeding and perforation.nEpidemic贵州、云南、广西、浙江、江苏和新疆贵州、云南、广西、浙江、江苏和新疆 Etiology nTyphoid bacillus ngram-nega

38、tive rod bacterianEndotoxin flagellar(H)antigen cell wall(O)lipopoysaccharide antigen polysaccharide virulence(Vi)antigen located in the cell capsule.A story:Typhoid MarrynHealthy carrierSource of transmission ill persons feces,urine,vomitus,and oral secretionsChronic carriers fecesPathogenesisStoma

39、ch,small intestinemononuclear phagocytes ileal Peyers patches and mesenteric lymph nodeschills,fever,rose spots,etcfeces,urine of patients or carrierflyFood and watermouthbacteremiaToxemia,septicemiamononuclear phagocytes hyperplasia hepatomegaly,splenomegaly,lymphdenopathyPathogenesisMorphologyChar

40、acteristics of pathological changes:An inflammation proliferation of reticulo-endothelial systemtyphoid cell:large,rich in cytoplasm,often contains ingested bacteria,cell debris,and erythrocytetyphoid granuloma伤寒肉芽肿伤寒肉芽肿,伤寒细胞聚集成团伤寒细胞聚集成团 Diagnostic value巨噬细胞增生，并有极强的巨噬细胞增生，并有极强的吞噬能力吞噬能力。病灶内无中性粒病灶内无中性

41、粒细胞渗出。细胞渗出。Morphology:typhoid noduleMorphology1.1st week(髓样肿胀期髓样肿胀期)Gross:sharply delineated,plateau-like elevations up to 8 cm in diameter,with enlargement of draining mesenteric lymph nodes LM:typhoid granuloma,edema,hyperemiaCF:High fever,bradycardia,splenomegaly,rose spots IntestinePayers patche

42、s in the ileum回肠回肠 is the most affected part淋巴滤泡增生、肿胀，似淋巴滤泡增生、肿胀，似“脑回脑回”Intestine 髓样肿胀期髓样肿胀期2.2nd week Necrosis:坏死期坏死期Gross:the lesion of Peyers patch is necrotic and stained by bile.LM:Structureless eosinophilic substanceCF:bacteremia,toxemia滤泡中心滤泡中心/表层坏死，边缘肿胀表层坏死，边缘肿胀LM:LM:嗜酸性无结构物质嗜酸性无结构物质Intestin

43、e3.3rd week Ulceration:溃疡期溃疡期pNecrotic tissue is dissolved by enzymepoval ulcers with their long axis in the direction of bowel flow pulcer may be very deepCF:bleeding,perforation穿孔穿孔,abdominal pain,diarrhea腹泻腹泻，全身中毒症状缓和全身中毒症状缓和IntestineIntestine 溃疡期溃疡期溃疡长轴与肠长轴平行，较深，易引起肠穿孔、出血溃疡长轴与肠长轴平行，较深，易引起肠穿孔、出血4

44、.Healing:愈合期愈合期4th 5th week Granulation tissue forms with small scar formationCF:symptoms subside and disappear,widals test(+)溃疡底部肉芽组织长入，粘膜再生溃疡底部肉芽组织长入，粘膜再生不形成瘢痕，不造成肠腔狭窄不形成瘢痕，不造成肠腔狭窄Intestineorgans related to reticuloendothelial systemMesenteric lymph node:In the terminal ileumTyphoid cell,Typhoid g

45、ranulomaSpleen:enlarged,soft and cherry red in color prominent sinus histocytosis and reticuloendothelial proliferation 质软，脾髓组织可用刀背刮下质软，脾髓组织可用刀背刮下organs related to reticuloendothelial systemLiver:enlarged and swelling with tense capsule and round edgestyphoid cell,typhoid granuloma small,randomly sc

46、attered foci of parenchymal necrosis Bone marrow:typhoid granuloma with scattered foci of necrosis Failure of normal hematopoiesis 造血功能造血功能 Salmonella typhi.(+)骨髓培养阳性率可高达90%OthersnCholecystitis 胆胆囊炎，细菌在胆汁中繁殖，传染源囊炎，细菌在胆汁中繁殖，传染源nCNS 小血管内膜炎，胶质细胞增生，嗜睡、伤寒面容小血管内膜炎，胶质细胞增生，嗜睡、伤寒面容OthersnMyocardium 心肌心肌细胞浑浊肿

47、胀，重脉，相对缓脉细胞浑浊肿胀，重脉，相对缓脉nSkin and muscle 毛细血管细菌栓塞，横纹肌腊样坏死。玫瑰疹、肌痛毛细血管细菌栓塞，横纹肌腊样坏死。玫瑰疹、肌痛nTyphoid septicemia 伤寒败血症伤寒败血症Complication and prognosisn4-5 weeksnChloramphenicol 氯霉素氯霉素remains to be effective since its introduction in 1942nComplications:intestinal hemorrhage肠出血肠出血 perforation and peritonitis肠

48、穿孔、腹膜炎肠穿孔、腹膜炎 lobular pneumonia临床病理联系临床病理联系n初期初期 菌血症、毒血症、单核巨噬细胞系统增生菌血症、毒血症、单核巨噬细胞系统增生 n坏死期坏死期 败血症，稽留热、神志不清、嗜睡败血症，稽留热、神志不清、嗜睡、谵妄、谵妄n溃疡期溃疡期 机体抵抗力占优势，菌血症消失机体抵抗力占优势，菌血症消失 症状缓和症状缓和n愈合期愈合期 机体占绝对优势，体温阶梯下降机体占绝对优势，体温阶梯下降，恢复，恢复Bacillary Dysentery(细菌性痢疾细菌性痢疾)IntroductionnAn acute inflammation of the colon,caus

49、ed by shigella.nMorphological features:andnMain clinical manifestations:fever,abdominal pain,diarrhea,pus-mucin-blood mixed stool 粘液脓血便粘液脓血便 Etiology and epidemiologynCausative agent:Shigella,gram-negative facultative anaerobes Shigella dysenteriae Shigella Flexneri Shigella Boydii Shigella SonneinI

50、nfect only humansnTransmission Source:Carrier,patient Route:Fecal-oral Contaminated food or waterPathogenesisnInvade the intestinal mucosal cells,but do not usually go beyond the lamina propria固有层固有层nProliferation within the epithelial cells,destroy host cellsnEndotoxin:Shiga toxin causes hemorrhagi

51、c colitis hemolytic-uremic syndrome溶血溶血-尿毒症综合征尿毒症综合征nShigella dysenteriae:extrotoxin neurotoxicant cytotoxic enterotoxin TypesnAcute bacillary dysentery 1-2weeksnChronic bacillary dysentery 2monthsnToxic bacillary dysenteryAcute bacillary dysenteryA.Colon:Mucoid catarrh infl.Pseudo-membranous infl.糠

52、皮样假膜糠皮样假膜Ulcer formation浅表不规则溃疡浅表不规则溃疡 Hyperemic,edematous,PMN中性粒腹痛、腹泻、里急后重、粘液稀便mucosa necrosis,fibrinogen exudation,hemorrhage粘液脓血便necrotic tissue shed offrectum,sigmoid flexureGross:Pseudomembranous inflammation ulcer formation(irregular and superficial)糠皮样假膜、浅表溃疡Mucosa of Colon,esp.leftAcute baci

53、llary dysenteryLM:Psuedomembrane 纤维蛋白性炎 Infiltration of inflammatory cells 中性粒细胞中性粒细胞Necrotic tissueFibrin exudationRed blood cellsAcute bacillary dysenteryB.Lymphdenopathy of mesentery mild splenomegaly C.Other organs:heart,liver,kidney cellular degeneration or necrosisAcute bacillary dysenteryClin

54、ical manifestation:uToxemia:fever,headache,fatigue,leukocytosisuIntestinal lesion abdominal pain,diarrhea with tenesmus里急后重,pus-mucus-blood mixed stool,dehydration,etc.Acute bacillary dysenteryPrognosisMostly curedColonic perforation(rare)Scarcely colonic hemorrhageA few develop into chronic periodC

55、hronic bacillary dysentery慢性细菌性痢疾慢性细菌性痢疾Chronic bacillary dysenterynOccurs when general condition is poor or treated unproperly at acute stagenImportant transmission sources:chronic carrier 病程超过病程超过2个月个月Chronic bacillary dysenteryCharacteristics:nAssociated with species of shigellae:FlexnerinPersist

56、 several years npathology:Chronic ulcer formation;varied in size and depth;Fibrosis,the wall of colon is thickenedInfiltrated by lymphocytes,monocytes and plasma cellsSometimes the epithelial cells may also proliferate and form polypsn急性菌痢转变而来，福氏菌、耐药菌株急性菌痢转变而来，福氏菌、耐药菌株n病情起伏，可有急性发作病情起伏，可有急性发作n病理病理新旧溃

57、疡混杂新旧溃疡混杂 （较深，（较深，多达肌层，边缘粘膜可有过度增生多达肌层，边缘粘膜可有过度增生 息肉形成）息肉形成）大量肉芽组织、纤维瘢痕大量肉芽组织、纤维瘢痕肠壁增厚肠壁增厚 肠腔狭窄肠腔狭窄n临床病理联系临床病理联系：病程延长病程延长 表现起伏表现起伏 腹痛、腹泻、便秘与腹泻交替腹痛、腹泻、便秘与腹泻交替 慢性菌痢急性发作，慢性菌痢急性发作，表现和急性菌痢相似表现和急性菌痢相似 慢性带菌者慢性带菌者(重要传染源重要传染源)慢性细菌性痢疾慢性细菌性痢疾Toxic bacillary dysentery中毒性菌痢中毒性菌痢Toxic bacillary dysenteryCharacteri

58、stics:utoxemia is very severe but the morphological changes are notuenlargement of the lymphoid follicles “follicular enteritis”uThe nature of the inflammation is“serous”,often associated with toxic shocku2-5 years olduShigella Flexneri,Shigella Sonnei起病急骤起病急骤 ：全身中毒症状严重：全身中毒症状严重（中毒性休克、呼吸循环衰竭）（中毒性休克、

59、呼吸循环衰竭）endotoxinInjury of endothelial cell of blood vesselDICSpasm of blood vesselHypoxiaDilatation of capiBlood volshockIncrease of permeabilityedemaThe mechanism of toxic shock and DICPlatelet,neutrophilsvasoactive substances 思考题思考题n试从病因、传播途径、发病机理、基本病试从病因、传播途径、发病机理、基本病变、并发症等方面来比较肠道传染病。变、并发症等方面来比较肠

60、道传染病。Parasitosis寄生虫病寄生虫病 2010 Jun.ClassificationProtozoal diseaseTrematodiasisTeniasisNematodosis原虫病 阿米巴病阿米巴病 黑热病黑热病 疟疾疟疾吸虫病 肝吸虫病肝吸虫病 肺吸虫病肺吸虫病 血吸虫病血吸虫病绦虫病 囊虫病囊虫病 包虫病包虫病线虫病 钩虫病钩虫病 蛔虫病蛔虫病 丝虫病丝虫病Amoebiasis阿米巴病阿米巴病病原病原：溶组织内阿米巴原虫溶组织内阿米巴原虫寄生部位寄生部位：结肠（尤其右半结肠）结肠（尤其右半结肠）肠外肠外 (肝、肺、脑等）肝、肺、脑等）流行现状流行现状：热带、亚热带地区，

61、我国南方多见。热带、亚热带地区，我国南方多见。世界世界10%人口携带，无任何国家幸免感染。人口携带，无任何国家幸免感染。近年多为散发慢性、不典型病例及带虫者。近年多为散发慢性、不典型病例及带虫者。Entamoeba histolyticaHumans(large bowel)Ingestion of cysts(person to person)Trophozoites,cysts in fecesCysts survive in food,waterEentamoeba histolytica溶组织内阿米巴原虫溶组织内阿米巴原虫Source of infectionu chronic pat

62、ient and parasite carrieru killed by desiccation干燥干燥,temperatures above 55u spread by the fecal-oral routeRoutes of infection生活史：滋养体、包囊两期成熟包囊成熟包囊 小滋养体小滋养体(食物、水食物、水)（小肠下段）（小肠下段）大滋养体大滋养体(致病型致病型)小滋养体小滋养体 （结肠肠壁）（结肠肠壁）包囊前期包囊前期 成熟包囊成熟包囊（感染型感染型）食物、水食物、水 （结肠肠腔）（结肠肠腔）抵抗力抵抗力结肠功能正常结肠功能正常90%Exopathic factor con

63、tact-mediated cytolysis接触性细胞溶解接触性细胞溶解(膜结合磷脂酶A)excrete many factors 分泌多种因子分泌多种因子channel-forming proteincysteine proteinase pseudopodial movement and phagocytosis 伪足运动及吞噬作用伪足运动及吞噬作用免疫抑制和逃避免疫抑制和逃避Internal factorsusceptibility of host 宿主易感性宿主易感性intestinal dysfunction 肠道功能紊乱肠道功能紊乱intestinal concurrent in

64、fection 肠道合并感染肠道合并感染Pathogenesis1.amebic dysentery 肠阿米巴病肠阿米巴病(阿阿米巴痢疾）米巴痢疾）Sites：Cecum 盲肠盲肠Ascending colon 升结肠升结肠Sigmoid RectumAppendix分期：分期：急性急性 慢性慢性肠内氧分压较低，肠内容物生理性滞留有关肠内氧分压较低，肠内容物生理性滞留有关1.acute amebic dysentery急性阿米巴痢疾急性阿米巴痢疾Amoebiasis of intestine结肠阿米巴病结肠阿米巴病 Gross flask-shaped ulcer(烧瓶状溃疡烧瓶状溃疡)口小底

65、宽口小底宽急性期粘膜有多个圆形隆起，中央有点状坏死溃疡急性期粘膜有多个圆形隆起，中央有点状坏死溃疡Morphologic Change结肠阿米巴病结肠阿米巴病溃疡间粘膜正常溃疡间粘膜正常病变扩展期，溃疡在粘膜下相互沟通，形成病变扩展期，溃疡在粘膜下相互沟通，形成隧道样隧道样病变，粘膜坏死脱落，呈破絮状病变，粘膜坏死脱落，呈破絮状严重者严重者溃疡深达肌层并侵及血管，溃疡深达肌层并侵及血管，甚至浆膜层甚至浆膜层Microscopically mainly involving the mucosa and sub-mucosaa necrotic process with minimal infla

66、mmatory exudate Lymphocytes and plasma cells炎症反应轻微炎症反应轻微Trophozoites 滋养体滋养体scattered at the peripherymorphologic change阿米巴滋养体阿米巴滋养体nbloody diarrhea 果酱样果酱样，腐败腥臭味，腐败腥臭味nintestinal painntrophozoite(+)n全身症状轻微，无发热全身症状轻微，无发热Clinical featuresu99%achieved a complete cureua small proportion of cases perforationhemorrhageprogression to chronic inflammation secondary bacterial infection purulent Lesion progresses rupture into adjacent structuresPrognosis2 chronic amebic dysentery慢性阿米巴痢疾慢性阿米巴痢疾nComplexu Tis