Inflammation 白求恩医学院病理学系 李 伟 炎 症 ( 三）

Major events in inflammation 纤维素性炎 浆液性炎 化脓性炎 出血性炎 慢性炎症

Locus: mucous membrane, serosa, loose connective tissue, skin Manifestation: inflammatory edema, blister, cavity effusion, serous catarrh Sequel: absorption Morphologic types of inflammation Serous inflammation 浆液性炎 accumulation of excessive serous fluid (clear watery fluid) with variable protein content (plasma)

a friction blister of the skin Serous inflammation

serous effusion clear, pale yellow appearance of the fluid right pleural effusion in a baby Serous inflammation

Definition : The inflammation exudate contains plentiful fibrinogen, then forms fibrin. Cause: severe vascular injury—bacterial toxin ， Hg, urea Locus: mucous membrane, serosa, lung Manifestation: Pseudo-membranous inflammation--dysentery, diphtheria rheumatic pericarditis---Hairy heart （绒毛心） lobar pneumonia Fibrinous inflammation 纤维素性炎 Morphologic types of inflammation 以纤维蛋白原渗出为主，继而形成纤维蛋白，即纤维素

Diphtheria 白喉 伪膜性炎 Pseudo-membranous inflammation Fibrinous inflammation 纤维素性炎 纤维素性炎发生于粘膜时，渗出的纤 维蛋白、坏死组织和中性粒细胞共同 形成伪膜

bacillary Dysentery 细菌性痢疾 Fibrinous inflammation 纤维素性炎

绒毛心 Fibrinous inflammation 纤维素性炎 Hairy heart Shaggy heart Cor villosum

绒毛心 Fibrinous inflammation 纤维素性炎 Hairy heart

fibrinous pericarditis 纤维素性心包炎 normal

lobar pneumonia 大叶性肺炎 Fibrinous inflammation 纤维素性炎

Outcome  Absorption: lobar pneumonia  Organization and adherence -- pericarditis- -armored heart( 盔甲心 ) --Pulmonary Carnification( 肺肉质变）  Pseudo-membrane: detach—ulcer, bleeding trachea diphtheria—asphyxia Fibrinous inflammation 纤维素性炎

心包腔闭锁 心包壁层和脏层发生纤维性粘连 Fibrinous inflammation 纤维素性炎 Pulmonary Carnification 肺肉质变

Suppurative inflammation 化脓性炎 Morphologic types of inflammation 以中性粒细胞渗出为主，伴不同程度组织坏死和脓液形成 The presence of large number of neutrophils and varying degrees of tissue necrosis and pus formation. The presence of large number of neutrophils and varying degrees of tissue necrosis and pus formation. Pus—purulent exudation Purulent cells—degenerated and necrotic neutrophils Causes: pyogenic bacteria superficial suppuration and Empyema （表面化脓和积脓） Phlegmonous inflammation （蜂窝织炎） Abscess （脓肿） superficial suppuration and Empyema （表面化脓和积脓） Phlegmonous inflammation （蜂窝织炎） Abscess （脓肿）

Superficial Suppuration Location: mucosal or serosa surface Features: Pus formation, Suppurative Catarrh Features: Pus formation, Suppurative Catarrh Empyema a collection of pus in a hollow viscus, e. g. in the gall- bladder or fallopian tube, serous cavity Superficial Suppuration Superficial Suppuration and Empyema 表面化脓和积脓 Types of suppurative inflammation

化脓性脑膜炎 acute meningitis Superficial Suppuration 表面化脓性炎

Superficial Suppuration 表面化脓性炎 化脓性腹膜炎 purulent peritonitis

心包腔积脓 purulent exudate in pericardial cavity Empyema 积脓 输卵管积脓 pyosalpinx

Definition: wide-spread purulent inflammation in loose tissue Locus: skin, muscle and appendix Causes: hemolytic streptococci 溶血性链球菌：透明质酸酶，链激酶 Phlegmonous inflammation 蜂窝织炎 Types of suppurative inflammation 疏松结缔组织的弥漫的化脓性炎

Phlegmonous inflammation: in loose tissue Phlegmonous inflammation 蜂窝织炎

acute appendicitis 急性阑尾炎 Phlegmonous inflammation 蜂窝织炎

Erysipelas( 丹毒） An acute disease of the skin and subcutaneous tissue caused by a species of hemolytic streptococcus and marked by localized inflammation and fever An acute disease of the skin and subcutaneous tissue caused by a species of hemolytic streptococcus and marked by localized inflammation and fever Also called: Saint Anthony's fire Also called: Saint Anthony's fire Types of suppurative inflammation 丹毒是皮肤及其网状淋巴管的急性化脓性真皮炎。病原菌是 A 族乙型溶血性链球菌，好发于下肢和面部。其临床表现为 起病急，局部出现界限清楚之片状红疹，颜色鲜红，并稍隆 起，压之褪色。皮肤表面紧张炽热，迅速向四周蔓延，有烧 灼样痛。伴高热畏寒等。皮炎

Types of suppurative inflammation Abscess 脓肿 Focal localized collections of purulent  Definition -- Focal localized collections of purulent inflammatory tissues caused by suppuration buried inflammatory tissues caused by suppuration buried in a tissue, an organ, or a confined space. in a tissue, an organ, or a confined space.  Locus-- skin, lung, brain, liver, kidney 局限性化脓性炎症，其主要特征是组织发生溶解坏死，形 成充满脓液的腔  Causes— Staphylococcus aureus 毒素 → 组织坏死 →PMN 浸润 →PMN 崩解释放蛋白水解酶 → 坏死组织液化 血浆凝固酶 → 纤维蛋白原转变为纤维素 → 病变局限 层粘连蛋白受体 → 迁徙性脓肿 金黄色葡萄球菌

Abscess 脓肿 Liver abscess

Renal abscess Abscess 脓肿

Lung abscess

Localized suppurative inflammation of haircyst, sebaceous gland & surrounding tissues. 疖 Furuncle Fusion of quite a few furuncles. 痈 Carbuncle: 痈 Carbuncle 疖 Furuncle

Inflammation associated with conspicuous haemorrhage as a result of vascular damage. Haemorrhage inflammation 出血性炎 炭疽性脑膜炎 血管损伤重，大量红细胞漏出 epidemic hemorrhagic fever ） 流行性出血热（ epidemic hemorrhagic fever ） 钩端螺旋体病 ( leptospirosis ) 鼠疫 ( plague ) 炭疽 ( anthrax )

损伤与抗损伤斗争结果既为炎症的结局 : 抗损伤 > 损伤 → 炎症痊愈（大多数） 损伤 > 抗损伤 → 炎症蔓延扩散（极少数） 抗损伤 = 损伤 → 炎症迁延不愈，转为慢性（少数） 痊愈 Healing 迁延为慢性 Delay and Persistence Spreading 蔓延扩散 Spreading 局部蔓延 local 淋巴道蔓延 Lymphatic 血道蔓延 Blood vessels outcome of acute Inflammation

1.Return to normal vascular permeability 2.Removal of fluid and protein 3.Macrophage pinocytosis 4.Phagocytosis by neutrophils 5.Necrotic debris by macrophages 6.Eventual exodus by macrophages Events in the complete resolution of inflammation

皮肤或粘膜深在的组织坏死脱落 后所留下的组织缺损 Local spreading 溃疡 Ulcer 窦道 Sinus 瘘管 Fistula 深部脓肿一端穿破皮肤，另一端穿 破自然管道或有腔脏器，在组织内 形成两端相通的病理性管道 深部脓肿如向体表或自然管道穿破，在 组织内形成一个有盲端的病理性管道 空洞 cavity 空腔脏器的组织坏死随自然管道排 出体外后留下的腔洞 炎症局部蔓延 (local spreading)

溃疡 Ulcer 炎症局部蔓延 (local spreading)

肛门直肠周围脓肿伴窦道、瘘管形成 Sinus and Fistula

 Local spreading  Lymphatic spreading ： 淋巴管炎 lymphangitis ， 淋巴结炎 lymphnoditis  Blood spreading 菌血症 Bacteremia: organisms→ blood 毒血症 Toxemia: toxin→ blood 败血症 Septicemia: ① + ② 脓毒败血症 Pyaemia: pyogenic organisms Course & outcome of Inflammation

炎症血道蔓延的后果 发生机制 临床表现 菌血症细菌入血无中毒症状 + 血液细菌（＋） 毒血症细菌毒性产物或毒素入血中毒症状 败血症 细菌入血 + 繁殖 + 产生毒素中毒症状 + 病理变化 + 血液病菌（＋） 脓毒 败血症 化脓菌入血 + 繁殖 + 产生毒素败血症表现 + 多发性栓塞性脓肿 ** 栓塞性脓肿（迁徙性脓肿，转移性脓肿） —— 脓肿中央或毛细血管、 小血管内有细菌菌落，由栓塞于毛细血管的化脓菌引起。

肾栓塞性小脓肿 血道蔓延 -- 脓毒败血症 Pyaemia

 好转 1. 吸收消散 2. 纤维化、纤维包裹或钙化  恶化进展 1. 浸润进展 2. 溶解播散 ①经血道 → 全身或肺粟粒性结核 ②经淋巴道 → 淋巴结结核 ③经自然管道 Example --- 肺结核病的结局

Lymphatic spreading ： 淋巴管炎 lymphangitis ， 淋巴结炎 lymphnoditis 结核性淋巴结炎 原发灶 结核性淋巴管炎 肺结核 原发综合征

原发性肺结核扩散途径

女， 23 岁， 20 天前鼻旁粉刺，后红肿，头部变黄，挤压后红肿， 并扩大至面部， 14 天前开始发热（ 38.5 ℃）， 8 天前因出现头痛， 呕吐而入院。查体：神志尚清楚，嗜睡。体温 39.2 ℃ ， P92 次 / 分， 血压 10.6/13.6kpa ， 皮肤粘膜多数小出血点，表浅淋巴结轻度肿 大，脾左肋缘下 2cm ，救治无效死亡。 1 、病变诊断： 14 天前， 8 天前，死亡时 2 、尸检所见：脸、脾、肝、脑 病 例 摘 要 -1

1 、疖 → 痈 → 菌血症 （粉刺感染 → 疖，上唇周围和鼻部是 “ 危险三角区 ” ， 疖如被挤压或挑刺，炎症蔓延，经静脉入血 → 沿内眦静 脉和眼静脉进入颅内，引起化脓性脑膜炎 危险三角区 病理诊断： 3 、败血症 2 、化脓性脑膜炎 皮下脓肿，化脓性脑膜炎 病原菌毒素可引起组织器官发生水肿、变性和坏死。 病菌引起的迁徙性脓肿可见于肺、肝、肾等 毛细血管损伤造成皮肤和粘膜淤点和皮疹。 单核 — 吞噬细胞增生活跃，肝、脾、淋巴结可肿大 尸检所见 ：

Chronic inflammation spread Blood vessel regionalLymphatic Acute inflammation healing Injur y Course & outcome of Inflammation

Section 3 chronic inflammation

Causes of chronic inflammation  supervening on acute 继发于急性炎症之后  due to repeated bouts of an acute 急性炎症反复发作  at beginning: persistent infection by intracellular microorganisms (tubercule bacilli-- Granulomatous inflammation ) Prolonged exposure to nondegradable but potentially toxic substances (silicosis in the lung) Immune reactions perpetuated against the individual’s own tissues (rheumatoid arthritis ， SLE)

Types of Chronic inflammation  Non –specific chronic inflammation 一般慢性炎症  Chronic Granulomatous inflammation 慢性肉芽肿性炎症

Pathologic features of general chronic inflammation  Exudation: manifest of active inflammation  Inflammatory cells: macrophage, lymphocytes, and plasma cells.  Alteration: Tissue destruction-- mainly caused by inflammatory cells  Proliferation: parenchymal cells, vessels and connective tissues Non-special chronic inflammation

Chronic bronchitis 慢性支气管炎

Here is chronic cervicitis Here is chronic cervicitis.Appearance of more mononuclear cells. In this case the inflammation is severe enough to produce mucosal damage with hemorrhage. Non-special chronic inflammation

炎性息肉 — 鼻息肉 Chronic inflammation 炎性息肉（ inflammatory polyp ） ：由局部粘膜上皮、腺体及肉芽 组织增生所致。常见于鼻、子宫颈、肠  Polypoid lesion of mucosa result from Chronic inflammation composed of mucosal glands, granulation tissue, and inflammatory cells.  Commonly seen in nasal, cervical & colorectal mucosa.

Chronic inflammation 炎性假瘤（ inflammatory pseudotumor ）：炎性增生形成的肉眼和 Ⅹ线观察上与肿瘤相似的团块。常见于眼眶、肺 炎性假瘤  Tumor-like proliferation of local tissues (parenchymal, stromal, even inflammatory cells) resulting from chronic inflammation  It is not a real tumor  Occur in the orbit, lung, liver and spleen lung, liver and spleen

Chronic granulomatous inflammation 慢性肉芽肿性炎 慢性肉芽肿性炎是以肉芽肿形成为特点的特殊慢性炎症。肉 芽肿是由巨噬细胞及其衍生细胞局部增生构成的境界清楚的 结节状病灶。 A form of chronic inflammation is characterized by granulomas-small nodular collections of activated macrophages. Special type of chronic inflammation Distinctive pattern (granuloma) Aggregation of macrophages (derived cell) Diameter 0.5-2mm Special type of chronic inflammation Distinctive pattern (granuloma) Aggregation of macrophages (derived cell) Diameter 0.5-2mm

causes of granulomas  Infective granuloma  Foreign body’s granuloma  Agnogenic : Bacteria— 结核，麻风 treponema 螺旋体 — 梅毒 fungi 真菌 parasite 寄生虫

Two conditions : Conditions of granulomas formation 1.Durable chronic stimulation 异物肉芽肿 2. Cellular immune response 结核

TuberculosisTuberculosis Caseous necrosisCaseous necrosis Epitheloid cells and Langhans giant cellEpitheloid cells and Langhans giant cell LymphocytesLymphocytes fibrosisfibrosis Caseous necrosisCaseous necrosis Epitheloid cells and Langhans giant cellEpitheloid cells and Langhans giant cell LymphocytesLymphocytes fibrosisfibrosis Infective granuloma

Langhans giant cells and epitheloid cells

Features: foreign bodies Foreign body giant cells: seen in association with particulate insoluble material. Nuclei scattered throughout cytoplasm. Foreign body’s granuloma

Here is a foreign body type giant cell at the upper left of center adjacent to a segment of vegetable material aspirated into the lung Foreign body’s granuloma

Two foreign body giant cells are seen just to the right of center where there is a bluish strand of suture material from a previous operation Foreign body’s granuloma

Two types of granulomas Infection granulomas Foreign body granulomas

Causes and outcomes of acute and chronic inflammation

病 例 摘 要 -2 女， 59 岁，无意中发现颈部肿块 1 天。 B 超及 CT 检查显示左侧颈部实性包块，大小 2x2cm ，界 限清楚。 考虑  （ 1 ）转移癌 ；（ 2 ）恶性淋巴瘤 等。 1 、该患者有哪些疾病的可能？ 2 、各疾病特点，如何鉴别？ 3 、进一步确诊需做哪些检查？

可能诊断 : 1. 颈部淋巴结炎 2. 淋巴结结核 3. 转移癌 4. 恶性淋巴瘤 5. 甲状腺疾病 1. 体格检查 2. 影像学检查 3. 实验室检查 : PPD, 血清学检查 ( 抗结核抗体、 CA125 和 CEA 等） 4. 针吸细胞学检查 5. 病理活检 质地较硬，不易活动、固定者要考虑恶性的可能； 质地较软，有明显压痛并可活动者考虑为炎性 呈串珠样改变、质软、有肺结核史者考虑颈部淋巴结结核 随吞咽上下移动无明显疼痛者可能是甲状腺瘤 进行性无痛性增大的淋巴结恶性淋巴瘤的可能； 伴有鼻涕中带血及耳闷的病人要首先排除鼻咽癌的可能； 有声音嘶哑及痰中带血要检查喉部，排除喉癌的可能 伴胸痛、咳嗽者要警惕肺癌的可能

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