不同b值弥散加权成像对肺结核分型诊断及对耐多药风险评估的预测

doi:10.19982/j.issn.1000-6621.20240201

摘要/Abstract

摘要：

目的: 探究不同b值弥散加权成像(diffusion weighted imaging, DWI)对肺结核分型诊断及对耐多药风险评估的预测。方法: 选取2020年10月至2023年5月于黑龙江省传染病防治院就诊的110例肺结核患者作为研究对象。对全部患者行不同b值(0、500、800、1000s/mm²)的DWI检查,比较不同b值下DWI诊断肺结核分型的效能。依据患者耐药检测结果,将110例患者分为耐多药组(47例)和药物敏感组(63例),比较两组患者的临床特征资料,通过logistic回归探究表观扩散系数与耐多药肺结核的关系。结果: b值为800s/mm²时,诊断各肺结核分型的漏诊率(1.82%,2/110)和误诊率(3.64%,4/110)明显低于b值为0、500、1000s/mm²时[漏诊率和误诊率分别为11.82%(13/110)和17.27%(19/110),9.09%(10/110)和13.64%(15/110),8.18%(9/110)和10.91%(12/110)],差异均有统计学意义(漏诊:χ²=8.657,P=0.003; χ²=5.641,P=0.018;χ²=4.689,P=0.030。误诊:χ²=10.925,P=0.000;χ²=6.970,P=0.008;χ²=4.314,P=0.038)。b值为800s/mm²时的受试者工作特征曲线下面积、准确率和约登指数最高,分别为0.874、96.35%和0.788,均高于b值为0、500、1000s/mm²时(分别为0.718、82.73%、0.612,0.735、86.36%、0.695,0.862、89.09%、0.724)。校正混杂因素后,表观扩散系数与耐多药风险仍存在独立相关性,表观扩散系数与耐多药风险呈负相关(r=-0.719,P<0.05)。结论: b值为800s/mm²时DWI在肺结核分型鉴别诊断中效果更为显著,具有更高的准确率;表观扩散系数与耐多药风险呈负相关关系。

关键词: 磁共振成像, 弥散, 结核, 肺, 抗药性, 多药, 诊断

Abstract:

Objective: To investigate the diagnostic efficacy of diffusion weighted imaging (DWI) with different b-values in classifying tuberculosis (TB) and predicting multidrug-resistance (MDR) risk. Methods: This study enrolled 110 TB patients admitted to Heilongjiang Provincial Infectious Disease Prevention and Control Hospital between October 2020 and May 2023. All patients underwent DWI with various b-values (0, 500, 800, 1000 s/mm²) to compare the diagnostic accuracy for TB classification at different b-values. Based on drug resistance test results, the 110 patients were divided into an MDR-TB group (47 cases) and a drug-sensitive TB group (63 cases). Clinical data and imaging features of the two groups were compared, and logistic regression was used to explore the relationship between apparent diffusion coefficient (ADC) and MDR-TB. Results: At a b-value of 800 s/mm², the rates of missed diagnosis (1.82%, 2/110) and misdiagnosis (3.64%, 4/110) in diagnosing various classifications of TB were significantly lower than those at b-values of 0, 500, and 1000 s/mm² (the missed diagnosis rate and misdiagnosis rate were 11.82% (13/110) and 17.27% (19/110), 9.09% (10/110) and 13.64% (15/110), 8.18% (9/110) and 10.91% (12/110), respectively), the differences were statistically significant (missed diagnosis: χ²=8.657, P=0.003; χ²=5.641, P=0.018; χ²=4.689, P=0.030; misdiagnosis: χ²=10.925, P=0.000; χ²=6.970, P=0.008; χ²=4.314, P=0.038). The area under the curve, accuracy, and Youden index of the receiver operating characteristic curve with a b-value of 800 s/mm² were the highest (0.874, 96.35%, and 0.788, respectively), all higher than those with b-values of 0, 500, and 1000 s/mm² (0.718, 82.73%, 0.612, and 0.735, 86.36%, 0.695, and 0.862, 89.09%, 0.724, respectively). After adjusting confounding factors, ADC was independently correlated with MDR risk, showing a negative correlation (r=-0.719, P<0.05). Conclusion: DWI with a b-value of 800 s/mm² demonstrates superior efficacy in diagnosing different TB classifications, with higher sensitivity and accuracy. ADC was negatively correlated with MDR risk.

Key words: Diffusion magnetic resonance imaging, Tuberculosis, pulmonary, Drug resistance, multiple, Diagnosis

中图分类号:

刘馨, 于千会. 不同b值弥散加权成像对肺结核分型诊断及对耐多药风险评估的预测[J]. 中国防痨杂志, 2024, 46(11): 1356-1364. doi: 10.19982/j.issn.1000-6621.20240201

Liu Xin, Yu Qianhui. Diffusion weighted imaging with different b-values for the classification diagnosis of pulmonary tuberculosis and prediction of multidrug-resistance risk[J]. Chinese Journal of Antituberculosis, 2024, 46(11): 1356-1364. doi: 10.19982/j.issn.1000-6621.20240201

图/表 6

表1

表2

不同b值下不同分型肺结核ADC值的差异 (×10-3mm2/s, x ˉ±s)

肺结核分型	0s/mm²	500s/mm²	800s/mm²	1000s/mm²	800s/mm² vs. 0s/mm²		800s/mm² vs. 500s/mm²		1000s/mm² vs. 0s/mm²		1000s/mm² vs. 500s/mm²
肺结核分型	0s/mm²	500s/mm²	800s/mm²	1000s/mm²	t值	P值	t值	P值	t值	P值	t值	P值
Ⅰ型肺结核(4例)	1.25±0.26	1.20±0.20	1.12±0.15	1.13±0.14	4.512	<0.001	3.261	0.004	4.435	<0.001	3.198	0.005
Ⅱ型肺结核(12例)	1.02±0.22	1.04±0.15	0.91±0.12	0.90±0.12	6.198	<0.001	6.034	<0.001	6.043	<0.001	5.892	<0.001
Ⅲ型肺结核(68例)	1.23±0.31	1.19±0.24	1.15±0.13	1.13±0.10	3.123	0.042	3.012	0.044	3.245	0.041	3.029	0.043
Ⅳ型肺结核(10例)	1.25±0.28	1.22±0.25	1.18±0.12	1.15±0.09	3.123	0.043	3.226	0.044	3.498	0.039	3.502	0.031
混合型肺结核(16例)	0.93±0.25	0.82±0.16	0.70±0.11	0.69±0.12	6.891	<0.001	5.019	<0.001	7.023	<0.001	5.223	<0.001
Ⅰ型vs. Ⅱ型
t值	2.343	1.710	3.818	3.755
P值	0.033	0.108	0.002	0.002
Ⅰ型vs. Ⅲ型
t值	0.126	0.082	0.594	0.762
P值	0.900	0.935	0.554	0.449
Ⅰ型vs. Ⅳ型
t值	0.000	0.142	0.132	0.323
P值	1.000	0.889	0.897	0.752
Ⅰ型vs.混合型
t值	2.274	4.062	7.453	6.949
P值	0.035	0.001	<0.001	<0.001
Ⅱ型vs. Ⅲ型
t值	3.098	2.088	5.959	7.128
P值	0.003	0.040	<0.001	<0.001
Ⅱ型vs. Ⅳ型
t值	2.910	2.089	5.255	5.429
P值	0.008	0.049	<0.001	<0.001
Ⅱ型vs.混合型
t值	0.110	3.697	6.392	4.583
P值	0.913	0.001	<0.001	<0.001
Ⅲ型vs. Ⅳ型
t值	0.193	0.367	0.687	0.597
P值	0.848	0.714	0.494	0.552
Ⅲ型vs.混合型
t值	3.600	5.854	12.795	15.234
P值	0.001	<0.001	<0.001	<0.001
Ⅳ型vs.混合型
t值	3.034	4.997	10.459	10.401
P值	0.006	<0.001	<0.001	<0.001

表2

表3

表4

耐多药组和药物敏感组患者临床资料的比较

临床资料	耐多药组(47例)	药物敏感组(63例)	统计检验值	P值
年龄(岁, $x ˉ$ ±s)	48.23±2.49	47.96±2.54	t=0.556	0.579
BMI( $x ˉ$ ±s)	21.87±3.52	23.85±3.46	t=2.947	0.004
平均收缩压(mmHg, $x ˉ$ ±s)	129.54±11.75	129.43±10.98	t=0.050	0.960
平均舒张压(mmHg, $x ˉ$ ±s)	84.72±8.94	85.02±9.24	t=0.171	0.865
心率(次/min, $x ˉ$ ±s)	105.86±9.85	106.14±10.23	t=0.144	0.886
性别[例(构成比,%)]			χ²=8.019	0.005
男性	40(85.11)	38(60.32)
女性	7(14.89)	25(39.68)
婚姻情况[例(构成比,%)]			χ²=0.014	0.905
已婚	37(78.72)	49(77.78)
未婚	2(4.26)	3(4.76)
离异/丧偶	8(17.02)	11(17.46)
居住方式[例(构成比,%)]			χ²=0.026	0.872
独居	8(17.02)	10(15.87)
与家人居住	39(82.98)	53(84.13)
受教育水平[例(构成比,%)]			χ²=0.052	0.820
本科及以上	9(19.15)	11(17.46)
高中/专科	24(51.06)	32(50.79)
初中及以下	14(29.79)	20(31.75)
家庭月收入[例(构成比,%)]			χ²=9.660	0.002
<2000元	20(42.55)	10(15.87)
2000~5000元	23(48.94)	39(61.91)
>5000元	4(8.51)	14(22.22)
吸烟史[例(构成比,%)]			χ²=0.001	0.978
是	23(48.94)	31(49.21)
否	24(51.06)	32(50.79)
饮酒史[例(构成比,%)]			χ²=0.001	0.980
是	26(55.32)	35(55.56)
否	21(44.68)	28(44.44)
高血压史[例(构成比,%)]			χ²=0.006	0.937
是	19(40.43)	25(39.68)
否	28(59.57)	38(60.32)
合并糖尿病[例(构成比,%)]			χ²=3.996	0.046
是	16(34.04)	11(17.46)
否	31(65.96)	52(82.54)
冠心病史[例(构成比,%)]			χ²=0.026	0.872
是	8(17.02)	10(15.87)
否	39(82.98)	53(84.13)
高血脂史[例(构成比,%)]			χ²=0.000	0.987
是	12(25.53)	16(25.40)
否	35(74.47)	47(74.60)
慢性咳嗽史[例(构成比,%)]			χ²=5.988	0.014
是	17(36.17)	10(15.87)
否	30(63.83)	53(84.13)
不规则治疗[例(构成比,%)]			χ²=12.644	<0.001
是	20(42.55)	8(12.70)
否	27(57.45)	55(87.30)
肺结核患者密切接触史[例(构成比,%)]			χ²=0.016	0.900
是	2(4.26)	3(4.76)
否	45(95.74)	60(95.24)
肺结核分型[例(构成比,%)]			χ²=0.405	0.525
Ⅰ型	1(2.13)	3(4.76)
Ⅱ型	5(10.64)	7(11.11)
Ⅲ型	29(61.70)	39(61.90)
Ⅳ型	4(8.51)	6(9.52)
混合型	8(17.02)	8(12.71)
累及肺叶数[例(构成比,%)]			χ²=0.000	0.987
1个	12(25.53)	16(25.40)
2个	10(21.28)	13(20.63)
3个	9(19.15)	12(19.05)
4个	6(12.77)	8(12.70)
5个	10(21.27)	14(22.22)
磨玻璃影[例(构成比,%)]	7(14.89)	9(14.29)	χ²=0.008	0.929
实变[例(构成比,%)]	23(48.94)	31(49.21)	χ²=0.001	0.978
树芽征[例(构成比,%)]	39(82.98)	37(58.73)	χ²=7.412	0.006
空洞[例(构成比,%)]			χ²=7.021	0.008
0个	20(42.55)	32(50.79)
1个	10(21.28)	14(22.22)
2个	5(10.64)	7(11.11)
3个	4(8.51)	6(9.52)
4个	3(6.38)	4(6.36)
≥5个	5(10.64)	0(0.00)
结核球[例(构成比,%)]	10(21.28)	13(20.63)	χ²=0.007	0.935
纤维化[例(构成比,%)]	35(74.47)	47(74.60)	χ²=0.000	0.987
钙化[例(构成比,%)]	16(34.04)	21(33.33)	χ²=0.006	0.938
肺毁损[例(构成比,%)]	11(23.40)	14(22.22)	χ²=0.021	0.884
支气管扩张[例(构成比,%)]	18(38.30)	23(36.51)	χ²=0.037	0.848
肺气肿[例(构成比,%)]	12(25.53)	16(25.40)	χ²=0.000	0.987
淋巴结肿大[例(构成比,%)]	15(31.91)	20(31.75)	χ²=0.000	0.985
淋巴结钙化[例(构成比,%)]	7(14.89)	9(14.29)	χ²=0.008	0.929
胸膜增厚粘连[例(构成比,%)]	40(85.11)	54(85.71)	χ²=0.008	0.929
胸腔积液[例(构成比,%)]	10(21.28)	12(19.05)	χ²=0.084	0.772
壁形态不均匀[例(构成比,%)]	35(74.47)	46(73.02)	χ²=0.029	0.864
最大层面长径(mm, $x ˉ$ ±s)	30.29±4.23	26.78±5.34	t=1.631	0.106
最大层面短径(mm, $x ˉ$ ±s)	20.47±2.76	21.77±4.98	t=1.613	0.110
最大层面长短径比值( $x ˉ$ ±s)	1.50±0.35	1.28±0.22	t=4.037	<0.001
内壁长径(mm, $x ˉ$ ±s)	20.64±4.32	19.93±3.87	t=0.906	0.367
内壁短径(mm, $x ˉ$ ±s)	13.45±2.96	13.21±2.65	t=0.447	0.656
内壁长短径比值( $x ˉ$ ±s)	1.53±0.43	1.49±0.39	t=0.509	0.612
MRI信号强度
T₁WI	0.98±0.22	1.00±0.24	t=0.448	0.655
T₂WI	1.42±0.36	1.39±0.31	t=0.469	0.640
ADC(×10^-3mm²/s, $x ˉ$ ±s)	0.73±0.12	1.17±0.25	t=11.137	<0.001

表4

表5

表6

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类别	确诊	0s/mm²	500s/mm²	800s/mm²	1000s/mm²
Ⅰ型肺结核	4(3.64)	1(0.91)	2(1.82)	3(2.73)	3(2.73)
Ⅱ型肺结核	12(10.91)	7(6.36)	9(8.18)	12(10.91)	10(9.09)
Ⅲ型肺结核	68(61.82)	75(68.18)	72(65.45)	70(63.64)	72(65.45)
Ⅳ型肺结核	10(9.09)	16(14.55)	13(11.82)	10(9.09)	11(10.00)
混合型肺结核	16(14.55)	5(4.55)	6(5.45)	13(11.82)	11(10.00)
误诊	-	13(11.82)	10(9.09)	2(1.82)	9(8.18)
漏诊	-	19(17.27)	15(13.64)	4(3.64)	12(10.91)

b值(s/mm²)	AUC	95%CI值	敏感度(%)	特异度(%)	准确率(%)	约登指数
0	0.718	0.703~0.736	81.30	87.50	82.73	0.612
500	0.735	0.714~0.758	77.42	95.00	86.36	0.695
800	0.874	0.841~0.907	91.70	89.50	96.35	0.788
1000	0.862	0.832~0.897	89.25	89.70	89.09	0.724

变量	未校准模型	模型1	模型2	模型3	模型4	模型5
ADC(×10^-3mm²/s,95%CI)	0.57 (0.32~0.76)	0.55 (0.33~0.75)	0.54 (0.34~0.78)	0.53 (0.33~0.77)	0.53 (0.35~0.79)	0.52 (0.35~0.74)
ADC二分类(×10^-3mm²/s,95%CI)^a
≤1.00	1	1	1	1	1	1
>1.00	0.55 (0.31~0.74)	0.47 (0.26~0.68)	0.46 (0.28~0.69)	0.46 (0.25~0.60)	0.45 (0.27~0.59)	0.45 (0.26~0.60)

影响因素	弥散加权成像
影响因素	β(95%CI)值	P值
体质量指数	-0.637(-0.865~1.345)	0.095
男性	-0.829(-0.974~2.013)	0.147
家庭月收入	-0.698(-0.927~1.184)	0.086
合并糖尿病	-0.982(-1.089~2.018)	0.123
慢性咳嗽史	-0.087(-0.142~0.546)	0.215
不规则治疗	-0.134(-0.902~0.361)	0.139
树芽征	-0.645(-0.985~-0.260)	0.027
空洞个数	-0.523(-0.851~-0.317)	0.035
最大层面长短径比值	-0.882(-0.903~-0.029)	0.008