CT征象联合外周血嗜酸性粒细胞对鉴别儿童胸肺型并殖吸虫病与结核性胸膜炎的价值研究

doi:10.19982/j.issn.1000-6621.20220229

摘要/Abstract

摘要：

目的探讨胸部CT征象联合外周血嗜酸性粒细胞百分比对鉴别儿童胸肺型并殖吸虫病与结核性胸膜炎的价值。方法: 回顾性收集昆明市第三人民医院2019年1月至2021年12月首次确诊的儿童胸肺型并殖吸虫病患者及结核性胸膜炎患者,其中儿童胸肺型并殖吸虫病患者58例(吸虫组),结核性胸膜炎患者45例(结核组)。分析其临床症状、胸部CT影像学表现及实验室检查结果;利用二元logistic回归建立CT征象的影像模型和结合CT征象与嗜酸性粒细胞的联合模型,计算及对比两个诊断模型的鉴别诊断效能。结果: 利用CT征象建立的影像模型显示,出现包裹性胸腔积液(OR=5.11,95%CI:1.64~15.97)和肺部结节(OR=12.33,95%CI:2.51~60.65)时,诊断为结核性胸膜炎的可能性更高,而出现胸膜钙化(OR=0.17,95%CI:0.04~0.68)和隧道征(OR=0.01,95%CI:0.00~0.15)时,诊断为结核性胸膜炎的可能性更低;通过绘制受试者工作特征曲线(ROC),曲线下面积(AUC)为0.850(95%CI:0.777~0.922),敏感度为79.3%(95%CI:66.6%~88.8%),特异度为75.6%(95%CI:60.5%~87.1%)。利用CT征象和嗜酸性粒细胞百分比建立联合模型显示,出现肺部结节(OR=11.56,95%CI:1.76~75.71)时,诊断为结核性胸膜炎的可能性更高,而出现隧道征(OR=0.02,95%CI:0.00~0.48)和嗜酸性粒细胞百分比升高(OR=0.02,95%CI:0.01~0.08)时,诊断为结核性胸膜炎的可能性更低;通过绘制ROC曲线,AUC为0.934(95%CI:0.885~0.982),敏感度为89.7%(95%CI:78.8%~96.1%),特异度为88.9%(95%CI:75.9%~96.3%)。联合模型鉴别诊断效能高于影像模型,其AUC差异有统计学意义(Z=-2.401,P=0.016)。结论: 对于儿童胸肺型并殖吸虫病与结核性胸膜炎的鉴别,联合模型鉴别诊断效能高于影像模型;出现肺部结节、嗜酸性粒细胞百分比未升高时更倾向于诊断儿童结核性胸膜炎。

关键词: 结核, 胸膜, 并殖吸虫病, 诊断, 鉴别, 体层摄影术, X线计算机

Abstract:

Objective: To investigate the value of chest CT signs combined with peripheral blood eosinophil percentage in identifying pleuropulmonary paragonimiasis and pleural tuberculosis in children. Methods: Pediatric patients with pleuropulmonary paragonimiasis and pleural tuberculosis in children first diagnosed from January 2019 to December 2021 in The Third People’s Hospital in Kunming were retrospectively collected, including 58 pediatric patients with pleuropulmonary paragonimiasis (PG group) and 45 pediatric patients with pleural tuberculosis (TB group). The clinical symptoms, chest CT manifestations and laboratory test results were analyzed; an imaging model of CT signs and a combined model combining CT signs and eosinophils were established using binary logistic regression, the differential diagnostic efficacy of the two diagnostic models was calculated and compared. Results: The imaging model of CT signs showed that, encapsulated effusion (OR=5.11, 95%CI: 1.64-15.97) and pulmonary nodules (OR=12.33, 95%CI: 2.51-60.65) were more likely to be diagnosed as pleural tuberculosis, while pleural calcification (OR=0.17, 95%CI: 0.04-0.68) and tunnel sign (OR=0.01, 95%CI: 0.00-0.15) was less likely to be diagnosed as pleural tuberculosis. According to the ROC curve, when AUC=0.850 (95%CI: 0.777-0.922), the sensitivity was 79.3% (95%CI: 66.6%-88.8%), and the specificity was 75.6% (95%CI: 60.5%-87.1%). The combined model of CT signs and eosinophil percentage showed that, when pulmonary nodules (OR=11.56, 95%CI: 1.76-75.71) was found, pleural tuberculosis was more likely to be diagnosed, while tunnel signs (OR=0.02, 95%CI: 0.00-0.48) and elevated eosinophil percentage (OR=0.02, 95%CI: 0.01-0.08) were found, pleural tuberculosis was less likely to be diagnosed, and the ROC curve was plotted with AUC=0.934 (95%CI: 0.885-0.982), sensitivity of 89.7% (95%CI: 78.8%-96.1%), and specificity of 88.9% (95%CI: 75.9%-96.3%). The combined model had higher differential diagnostic efficacy than the imaging model, with a statistically significant difference in AUC (Z=-2.401, P=0.016). Conclusion: For the differentiation of pleuropulmonary paragonimiasis and pleural tuberculosis in children, the combined model have higher differential diagnostic efficacy than the imaging model; when there are pulmonary nodules and the percentage of eosinophils is not increased, the children are more likely to be diagnosed of tuberculous.

Key words: Tuberculosis, pleural, Paragonimiasis, Diagnosis, differential, Tomography, X-ray computed

中图分类号:

李翔, 付旭文, 许艳玲, 干玮, 杞敏, 黄瑛. CT征象联合外周血嗜酸性粒细胞对鉴别儿童胸肺型并殖吸虫病与结核性胸膜炎的价值研究[J]. 中国防痨杂志, 2023, 45(1): 38-44. doi: 10.19982/j.issn.1000-6621.20220229

Li Xiang, Fu Xuwen, Xu Yanling, Gan Wei, Qi Min, Huang Ying. The value of CT signs combined with peripheral blood eosinophils in differentiating pleuropulmonary paragonimiasis from pleural tuberculosis in children[J]. Chinese Journal of Antituberculosis, 2023, 45(1): 38-44. doi: 10.19982/j.issn.1000-6621.20220229

图/表 8

表1

图1~2

图3~5

图6~7

表2

表3

影像模型的二元logistic回归分析

特征	β值	s $x ˉ$ 值	Wald χ²值	P值	OR值	95%CI值
肺部结节	2.512	0.813	9.550	0.002	12.33	2.51~60.65
隧道征	―4.482	1.312	11.662	0.001	0.01	0.00~0.15
胸膜钙化	―1.753	0.696	6.341	0.012	0.17	0.04~0.68
包裹性胸腔积液	1.632	0.581	7.894	0.005	5.11	1.64~15.97
常量	―2.671	0.967	7.627	0.006	0.07	-

表3

表4

联合模型的二元logistic回归分析

特征	β值	s $x ˉ$ 值	Wald χ²值	P值	OR值	95%CI值
肺部结节	2.448	0.959	6.515	0.011	11.56	1.76~75.71
隧道征	―3.672	1.498	6.008	0.014	0.02	0.00~0.48
嗜酸性粒细胞百分比升高	―3.840	0.704	29.730	0.000	0.02	0.01~0.08
常量	1.800	0.546	10.847	0.001	6.05

表4

图8

参考文献 20

[1]	郑晓燕, 王非, 王磊, 等. 12例误诊为肺结核的胸肺型并殖吸虫病临床特点分析. 热带医学杂志, 2019, 19(6): 731-734. doi:10.3969/j.issn.1672-3619.2019.06.015. doi: 10.3969/j.issn.1672-3619.2019.06.015.
[2]	谢益兵, 周永飞, 洪加林, 等. 胸肺型并殖吸虫病早期感染期的CT诊断价值. 中华地方病学杂志, 2018, 37(8): 668-670. doi:10.3760/cma.j.issn.2095-4255.2018.08.016. doi: 10.3760/cma.j.issn.2095-4255.2018.08.016.
[3]	中华人民共和国卫生部. WS 380—2012 并殖吸虫病的诊断. 2012-06-04.
[4]	中华人民共和国卫生和计划生育委员会. WS 288—2017 肺结核诊断. 2017-11-09.
[5]	Hansell DM, Bankier AA, MacMahon H, et al. Fleischner Society: glossary of terms for thoracic imaging. Radiology, 2008, 246(3): 697-722. doi:10.1148/radiol.2462070712. doi: 10.1148/radiol.2462070712 pmid: 18195376
[6]	周永飞, 洪加林, 许崇永, 等. 肺型并殖吸虫病的CT诊断. 中国人兽共患病学报, 2009, 25(8): 819-821. doi:10.3969/j.issn.1002-2694.2009.08.027. doi: 10.3969/j.issn.1002-2694.2009.08.027.
[7]	Moy MP, Levsky JM, Berko NS, et al. A new, simple method for estimating pleural effusion size on CT scans. Chest, 2013, 143(4): 1054-1059. doi:10.1378/chest.12-1292. doi: S0012-3692(13)60216-0 pmid: 23632863
[8]	杨振兴, 周本江. 云南省并殖吸虫虫种分类与分布研究进展. 国际医学寄生虫病杂志, 2010, 37(4): 254-258. doi:10.3760/cma.j.issn.1673-4122.2010.04.014. doi: 10.3760/cma.j.issn.1673-4122.2010.04.014.
[9]	胡杨红, 詹学. 肺吸虫病的诊治进展. 中华临床医师杂志(电子版), 2017, 11(5): 849-854. doi:10.3877/cma.j.issn.1674-0785.2017.05.031. doi: 10.3877/cma.j.issn.1674-0785.2017.05.031.
[10]	黄莉, 陈田木, 杨云斌, 等. 应用SARIMA模型预测肺结核发病趋势. 现代预防医学, 2019, 46(5): 794-797, 803.
[11]	李翔, 付旭文, 耿鹏, 等. 云南省儿童并殖吸虫病临床与影像学特征分析. 热带病与寄生虫学, 2021, 19(6): 316-318, 347. doi:10.3969/j.issn.1672-2302.2021.06.005. doi: 10.3969/j.issn.1672-2302.2021.06.005.
[12]	盛利平, 孔宪炳, 邓友松, 等. 30例卫氏并殖吸虫病患者临床及影像学特征. 中国血吸虫病防治杂志, 2019, 31(2): 200-203. doi:10.16250/j.32.1374.2017244. doi: 10.16250/j.32.1374.2017244.
[13]	贺伟, 吕平欣, 吕岩, 等. 非活动性结核性胸膜炎与活动性结核性胸膜炎的CT扫描影像特征分析. 中国防痨杂志, 2022, 44(4): 315-321. doi:10.19982/j.issn.1000-6621.20210728. doi: 10.19982/j.issn.1000-6621.20210728.
[14]	DePew ZS, Wigle D, Mullon JJ, et al. Feasibility and safety of outpatient medical thoracoscopy at a large tertiary medical center: a collaborative medical-surgical initiative. Chest, 2014, 146(2): 398-405. doi:10.1378/chest.13-2113. doi: S0012-3692(15)48829-4 pmid: 24577099
[15]	Yamamoto J, Nishiura M, Ohata T, et al. Tuberculous Pleurisy Diagnosed by Thoracoscopic Lung Biopsy. Kyobu Geka, 2018, 71(3):169-172.
[16]	王起, 方喆, 蒋源, 等. 内科胸腔镜联合深部热疗对包裹性结核性胸膜炎患者血清调节性T淋巴细胞相关细胞因子和趋化因子的影响. 临床内科杂志, 2021, 38(3): 202-204. doi:10.3969/j.issn.1001-9057.2021.03.018. doi: 10.3969/j.issn.1001-9057.2021.03.018.
[17]	王岩, 赵顺英, 于彤, 等. 基于CT分型方法的儿童肺结核临床特征分析. 中国防痨杂志, 2018, 40(9): 940-943. doi:10.3969/j.issn.1000-6621.2018.09.006. doi: 10.3969/j.issn.1000-6621.2018.09.006.
[18]	Naranje P, Bhalla AS, Sherwani P. Chest Tuberculosis in Children. Indian J Pediatr, 2019, 86(5):448-458. doi:10.1007/s12098-018-02847-7. doi: 10.1007/s12098-018-02847-7 pmid: 30762202
[19]	刘晓芳, 焦洋, 范洪伟, 等. 寄生虫感染致外周血嗜酸性粒细胞增多的临床特点. 协和医学杂志, 2016, 7(6): 432-435. doi:10.3969/j.issn.1674-9081.2016.06.006. doi: 10.3969/j.issn.1674-9081.2016.06.006.
[20]	李银月, 舒敏, 李雪, 等. 伴嗜酸性粒细胞增多的儿童寄生虫病与结核病的临床特点分析. 实用医院临床杂志, 2021, 18(2):46-49. doi:10.3969/j.issn.1672-6170.2021.02.013. doi: 10.3969/j.issn.1672-6170.2021.02.013.

特征	吸虫组(58例)		结核组(45例)		χ²值	P值
特征	例数	发生率(%)	例数	发生率(%)	χ²值	P值
症状
咳嗽	36	62.1	24	53.3	0.795	0.373
咳痰	24	41.4	12	26.7	2.413	0.120
胸痛	16	27.6	25	55.6	8.273	0.004
胸闷	13	22.4	17	37.8	2.898	0.089
盗汗	18	31.0	7	15.6	3.303	0.069
发热	26	44.8	29	64.4	3.919	0.048
咯血	4	6.9	1	2.2	1.199	0.274
胸部CT征象
实变	46	79.3	39	86.7	0.951	0.330
空洞	4	6.9	2	4.4	0.278	0.598
肺部结节	7	12.1	19	42.2	12.209	<0.001
隧道征	19	32.8	1	2.2	15.101	<0.001
肺部累及部位
右肺上叶	18	31.0	14	31.1	<0.001	0.993
右肺中叶	19	32.8	15	33.3	0.004	0.951
右肺下叶	22	37.9	24	53.3	2.432	0.119
左肺上叶	22	37.9	13	28.9	0.924	0.337
左肺下叶	32	55.2	20	44.4	1.167	0.280
胸腔积液量
少量	31	53.4^a	24	53.3^a	0.000	0.991
中等量	24	41.4^a	17	37.8^a	0.137	0.711
大量	3	5.2^a	4	8.9^a	0.553	0.457
双侧胸腔积液	20	34.5	5	11.1	7.530	0.006
包裹性胸腔积液	30	51.7	35	77.8	7.388	0.007
胸膜钙化	16	27.6	5	11.1	4.237	0.040
淋巴结增大	8	13.8	17	37.8	7.931	0.005

指标	吸虫组(58例)	结核组(45例)	Z值	P值
外周血白细胞总数(×10⁹/L)	13.60(9.80,17.82)	6.28(4.72,7.38)	―7.520	<0.001
外周血中性粒细胞计数(×10⁹/L)	3.30(2.77,4.47)	3.68(2.40,4.77)	―0.110	0.913
外周血淋巴细胞计数(×10⁹/L)	3.20(2.61,4.50)	1.64(1.30,2.04)	―7.291	<0.001
外周血嗜酸性粒细胞计数(×10⁹/L)	4.72(2.18,8.21)	0.09(0.04,0.17)	―8.024	<0.001
中性粒细胞百分比(%)	27.55(17.31,42.21)	57.36(50.68,67.23)	―7.008	<0.001
淋巴细胞百分比(%)	23.68(19.99,31.29)	27.98(22.22,34.73)	―1.300	0.194
嗜酸性粒细胞百分比(%)	34.93(21.09,53.73)	1.57(0.81,2.70)	―7.926	<0.001
血红细胞沉降率(mm/1h)	35.00(24.50,44.50)	35.00(16.00,40.00)	―0.748	0.455
血清总蛋白(g/L)	75.10(69.28,78.95)	67.20(64.60,71.50)	―4.575	<0.001
血清白蛋白(g/L)	35.75(32.85,38.48)	36.00(32.10,38.80)	―0.173	0.863
血清球蛋白(g/L)	37.85(33.15,44.05)	32.40(28.00,36.40)	―4.172	<0.001
血清白球比	0.93(0.75,1.09)	1.08(0.96,1.32)	―3.098	0.002