常规超声联合超声造影在胸膜下肺结核与细菌性肺炎鉴别诊断中的价值

doi:10.3969/j.issn.1000-6621.2019.08.004

摘要/Abstract

摘要：

目的探讨常规超声联合超声造影在胸膜下肺结核与细菌性肺炎鉴别诊断中的应用价值。方法搜集2019年1—5月就诊于上海市肺科医院并经病理学、细菌学或诊断性治疗确诊为肺结核患者(结核组)35例,细菌性肺炎患者(肺炎组)16例。对比分析两组病灶常规超声及超声造影图像,比较病灶大小、位置、形态、回声,以及超声造影增强模式、开始增强时间、达峰时间、消退速度、坏死发生率及特征等。结果 (1)常规超声显示的病灶形态:结核组28例(80.00%)呈楔形,5例(14.29%)呈类圆形,2例(5.71%)呈不规则形。肺炎组10例(62.50%)呈楔形,6例(37.50%)呈类圆形,两组间差异无统计学意义(χ²=4.109,P=0.128)。病灶深部与正常肺组织间可见高回声,其中呈“碎片征”者结核组11例(31.43%),肺炎组13例(81.25%),两组间差异有统计学意义(χ²=10.940,P=0.001);呈“瀑布征”者结核组22例(62.86%),肺炎组3例(18.75%),两组间差异有统计学意义(χ²=8.548,P=0.003)。(2)超声造影的特征:病灶开始增强时间结核组为[8.43(4.79,10.83)]s,肺炎组为[7.80(5.51,12.26)]s,差异无统计学意义(U=0.721,P=0.471);病灶与正常肺组织开始增强时间差结核组为[1.47(0.56,2.01)]s,肺炎组为[2.00(1.28,2.67)]s,差异无统计学意义(U=1.453,P=0.146);病灶增强峰值强度结核组为(-41.89±5.72)dB,肺炎组为(-44.89±5.72)dB,差异无统计学意义(t=1.738,P=0.089);病灶增强强度减半时间结核组为[153.33(124.02,180.00)]s,肺炎组为[138.45(128.70,147.09)]s,差异无统计学意义(U=1.326,P=0.185)。结核组29例(82.86%)病灶出现坏死,肺炎组5例(31.25%)出现坏死,前者明显高于后者(χ²=13.160,P=0.000)。在坏死区形态方面,结核组中15例(51.72%,15/29)表现为病灶内多个不相互连续的筛孔样坏死,11例(37.93%,11/29)表现为形态规则、内壁规整的大片状坏死,3例(10.35%,3/29)表现为病灶内部几乎全坏死仅存残留活性边缘的环状增强。肺炎组中1例表现为形态规则、内壁规整的大片状坏死(1/5),4例表现为形态规则、内壁规整的小片状坏死(4/5),两组间差异有统计学意义(χ²=26.692,P=0.000)。结论常规超声中细菌性肺炎病灶后方具有特征性的“不规则碎片样”高回声表现,超声造影显示肺结核病灶坏死发生率明显高于细菌性肺炎,且呈“筛孔样”及“规则大片状”坏死特点,可为两者的鉴别提供一定的诊断依据。

关键词: 结核, 肺, 肺炎, 细菌性, 超声检查, 评价研究, 超声造影

Abstract:

Objective To investigate the value of conventional ultrasound combined with contrast-enhanced ultrasonography in the differential diagnosis of pleural-based pulmonary tuberculosis and bacterial pneumonia.Methods A total of 35 patients with pulmonary tuberculosis (tuberculosis group) and 16 cases with bacterial pneumonia (pneumonia group) diagnosed by pathology, bacteriology or diagnostic therapy in Shanghai Pulmonary Hospital from January to May 2019 were enrolled. Conventional and contrast-enhanced ultrasound images of lesions between the two groups were analyzed, and the size, location, shape, echogenicity, enhancement pattern, arrival time, time to peak, clearance speed, incidence and characteristics of necrosis were compared.Results (1) Conventional ultrasound showed 28 cases (80.00%) with wedge shape, 5 cases (14.29%) with round-like shape, and 2 cases (5.71%) with irregular shape in the tuberculosis group; and 10 cases (62.50%) with wedge shape, and 6 cases (37.50%) with round-like shape in the pneumonia group, without significant difference between the two groups (χ²=4.109, P=0.128). There was hyperechoic between the deep lesion and the normal lung tissue, among which, “fragment sign” appeared 11 cases (31.43%) in the tuberculosis group and 13 cases (81.25%) in the pneumonia group, with the significant difference between the two groups (χ²=10.940, P=0.001); “Waterfall sign” appeared in 22 cases (62.86%) in the tuberculosis group and 3 cases (18.75%) in the pneumonia group, with the significant difference between the two groups (χ²=8.548, P=0.003). (2) Contrast-enhanced ultrasonography showed that arrival time of lesions was (8.43 (4.79,10.83)) s in the tuberculosis group and (7.80 (5.51,12.26)) s in the pneumonia group, without the significant difference between the two groups (U=0.721, P=0.471); arrival time difference between lesion and lung tissue was (1.47 (0.56,2.01)) s in the tuberculosis group and (2.00 (1.28,2.67)) s in the pneumonia group, without the significant difference between the two groups (U=1.453, P=0.146); peak intensity was (-41.89±5.72) dB in the tuberculosis group and (-44.89±5.72) dB in the pneumonia group, without the significant difference between the two groups (t=1.738, P=0.089); half time of intensity descent was (153.33 (124.02,180.00)) s in the tuberculosis group and (138.45 (128.70,147.09)) s in the pneumonia group, without the significant difference between the two groups (U=1.326, P=0.185). Necrosis occurred in 29 cases (82.86%, 29/35) in the tuberculosis group and 5 cases (31.25%, 5/16) in the pneumonia group, with the significant difference between the two groups (χ²=13.160, P=0.000). In terms of the characteristics of necrosis, 15 cases (51.72%, 15/29) presented with multiple non-interconnected sieve-like necrosis, 11 cases (37.93%, 11/29) presented with large patchy necrosis with regular shape and regular inner wall, and 3 cases (10.35%, 3/29) presented with almost total necrosis with circular enhancement of residual active margin in the tuberculosis group; 1 case (1/5) presented with large patchy necrosis with regular shape and regular inner wall, and 4 cases (4/5) presented with small patchy necrosis with regular shape and regular inner wall in the pneumonia group. There was significant difference between the two groups (χ²=26.692, P=0.000).Conclusion Conventional ultrasound shows the characteristic of “irregular fragment-like” hyperechoic behind the lesions of bacterial pneumonia. Contrast-enhanced ultrasonography shows that the incidence of necrosis in pulmonary tuberculosis is significantly higher than that in bacterial pneumonia, with the characteristics of “sieve-like” and “regular large patch” necrosis. These founds can provide diagnostic basis for the differential diagnosis.

Key words: Tuberculosis, pulmonary, Pneumonia, bacterial, Ultrasonography, Evaluation studies, Contrast-enhanced ultrasound

武楷文,毕珂,张怡,沈梦君,丛阳,王茵. 常规超声联合超声造影在胸膜下肺结核与细菌性肺炎鉴别诊断中的价值[J]. 中国防痨杂志, 2019, 41(8): 822-827. doi: 10.3969/j.issn.1000-6621.2019.08.004

Kai-wen WU,Ke BI,Yi ZHANG,Meng-jun SHEN,Yang CONG,Yin WANG. The value of conventional ultrasound combined with contrast-enhanced ultrasonography in the differential diagnosis of pleural-based pulmonary tuberculosis and bacterial pneumonia[J]. Chinese Journal of Antituberculosis, 2019, 41(8): 822-827. doi: 10.3969/j.issn.1000-6621.2019.08.004

图/表 6

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表1

胸膜下肺结核及细菌性肺炎超声造影各项定量指标在两组患者间的比较

指标	结核组(35例)	肺炎组(16例)	统计值	P值
正常肺组织开始增强时间[s,M(Q₁,Q₃)]	6.69(3.90,8.92)	5.47(4.07,10.65)	U=0.223	0.823
病灶开始增强时间[s,M(Q₁,Q₃)]	8.43(4.79,10.83)	7.80(5.51,12.26)	U=0.721	0.471
病灶与正常肺组织开始增强时间差[s,M(Q₁,Q₃)]	1.47(0.56,2.01)	2.00(1.28,2.67)	U=1.453	0.146
病灶增强强度减半时间[s,M(Q₁,Q₃)]	153.33 (124.02,180.00)	138.45 (128.70,147.09)	U=1.326	0.185
病灶增强峰值强度(dB, $x ˉ$ ±s)	-41.89±5.72	-44.89±5.72	t=1.738	0.089
病灶60s增强强度(dB, $x ˉ$ ±s)	-47.80±7.28	-49.38±4.49	t=0.799	0.428
病灶120s增强强度(dB, $x ˉ$ ±s)	-53.06±7.62	-55.80±4.37	t=1.623	0.111
病灶180s增强强度(dB, $x ˉ$ ±s)	-58.64±6.33	-60.93±3.94	t=1.329	0.190

表1

参考文献 16

[1]	张志军, 邱民泽, 范瀚宇 . 肺下叶结核误诊为肺炎38例临床分析. 中国防痨杂志, 2006,28(3):182-183.
[2]	郑浈浈, 董琼雄, 黄映宏 , 等. 不典型肺结核的影像学误诊分析. 中华全科医学, 2009,7(1):91-92.
[3]	Choo JY, Lee KY, Kim MY , et al. Pulmonary Tuberculosis Confirmed by Percutaneous Transthoracic Needle Biopsy: Analysis of CT Findings and Review of Correlations with Underlying Lung Disease. Balkan Med J, 2014,31(3):208-213.
[4]	Agostinis P, Copetti R, Lapini L , et al. Chest ultrasound findings in pulmonary tuberculosis. Trop Doct, 2017,47(4):320-328.
[5]	Görg C, Bert T, Görg K . Contrast-enhanced sonography for differential diagnosis of pleurisy and focal pleural lesions of unknown cause. Chest, 2005,128(6):3894-3899.
[6]	农恒荣, 苏楠 . 艾滋病相关周边型肺结核超声影像分析. 中华超声影像学杂志, 2018,27(5):427-430.
[7]	舒霁欣, 王茵 . 超声新技术在肺结核诊断中的应用进展. 第二军医大学学报, 2018,39(10):1092-1095.
[8]	Bai J, Yang W, Wang S , et al. Role of Arrival Time Difference Between Lesions and Lung Tissue on Contrast-Enhanced Sonography in the Differential Diagnosis of Subpleural Pulmonary Lesions. J Ultrasound Med, 2016,35(7):1523-1532.
[9]	Montuori M, Casella F, Casazza G , et al. Lung ultrasonography in pulmonary tuberculosis: A pilot study on diagnostic accuracy in a high-risk population. Eur J Intern Med, 2019.pii: S0953-6205(19) 30185-2.
[10]	Stephens MJ, Rho BH, Curran-Everett D , et al. Identification of Nonaggressive Pulmonary Nodules Using an Optimized Scoring System. J Thorac Imaging, 2019,34(3):170-178.
[11]	陈霰, 徐丽伟, 邢恩芳 , 等. 超声造影及介入在周围型肺部病变诊断中的价值. 中国超声医学杂志, 2015,31(12):1080-1082.
[12]	Caremani M, Benci A, Lapini L , et al. Contrast enhanced ultrasonography (CEUS) in peripheral lung lesions: A study of 60 cases. J Ultrasound, 2008,11(3):89-96.
[13]	王茵, 肖和平 . 结核病超声诊断的现状与思考. 第二军医大学学报, 2018,39(10):1065-1070.
[14]	张怡, 毕珂, 汤春红 , 等. 超声造影在胸膜下肺结核与肺癌鉴别诊断中的价值. 第二军医大学学报, 2018,39(10):1071-1076.
[15]	Cao BS, Liang YM, Li XL , et al. Contrast-enhanced sonography of juxtapleural pulmonary tuberculoma. J Ultrasound Med, 2013,32(5):749-756.
[16]	赵丹, 杨高怡, 何宁 , 等. 超声造影模式在诊断颈部淋巴结结核中的应用价值. 中国超声医学杂志, 2015,31(8):683-686.