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新型冠状病毒肺炎(corona virus disease 2019, COVID-19)是由新发现的β属RNA病毒引起的以肺部炎性病变为主的急性呼吸道传染病[1];由于其传染性较强且目前没有特效的治疗方法,该病已被纳入《中华人民共和国传染病防治法》规定的乙类传染病,并按甲类传染病管理。新型冠状病毒感染后潜伏期长,传染性强,临床表现无特异性,如不能早期发现并隔离患者,大范围的传播会对人民的生命健康造成严重威胁[2]。根据国家卫生健康委员会印发的新型冠状病毒肺炎防控方案(第六版)[3],COVID-19的诊断标准需结合流行病学、临床表现、CT 表现和病毒核酸检测等结果。其中,核酸检测是COVID-19诊断的“金标准”,但由于采样方式等问题其检测阳性率有限[4]。CT检查较快捷且阳性率高,能清晰显示COVID-19常见的淡薄磨玻璃病灶,并对病变的范围、程度和病程演变进行定量评估[5]。因此,本研究通过对比评估COVID-19的临床表现、CT特征和核酸检测结果,探讨CT对该病的诊断价值及其与核酸检测结果的相关性,以期提高对COVID-19的认识,为其临床早期诊断和病程演变评估提供参考。
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164例患者中,有发热、咳嗽、乏力和肌痛等相关临床症状者146例(89.0%),无临床症状者18例(11.0%);核酸检测最终确诊阳性76例,阳性率为46.3%;CT诊断阳性143例,阳性率为87.2%;确诊患者中无临床症状者8例,疑似患者中无临床症状者10例。
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164例患者的CT表现和核酸检测的对比结果见表1。CT诊断的灵敏度为96.1%、特异度为20.5%、阳性预测值为51.0%、阴性预测值为85.7%和准确率为55.5%。在 <60岁的患者中,CT诊断的灵敏度为96.4%、特异度为21.2%、阳性预测值为50.5%、阴性预测值为87.5%和准确率为54.9%;在≥60岁的患者中,CT诊断的灵敏度为95.2%、特异度为18.2%、阳性预测值为52.6%、阴性预测值为80.0%和准确率为57.1%。CT诊断的灵敏度(χ2=0.051,P=0.822)、特异度(χ2=0.414,P=0.520)、阳性预测值(χ2=0.052,P=0.820)、阴性预测值(χ2=0.175,P=0.676)和准确率(χ2=0.063,P=0.802)在<60岁和≥60岁患者之间的差异均无统计学意义。88例疑似COVID-19患者中,CT诊断阳性率为79.5%(70/88)。
CT表现 核酸诊断 合计 阳性 阴性 阳性 73 70 143 阴性 3 18 21 合计 76 88 164 注:表中,COVID-19:新型冠状病毒肺炎;CT:计算机体层摄影术 表 1 164例确诊和疑似COVID-19患者的CT表现与核酸 检测结果的比较(例)
Table 1. Comparison of CT and nucleic acid testing results for patients confirmed or suspected to have COVID-19 (case)
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76例确诊患者初诊时,68例(89.5%)有相关临床症状,8例(10.5%)为无症状亚临床期患者(因有流行病史来院筛查发现)。69例(90.8%)患者初诊时CT有阳性表现,主要影像学征象为磨玻璃密度(46例)、实性密度(17例)和混合磨玻璃密度(6例)病灶,其中46例磨玻璃密度病灶中有8例合并铺路石征;7例(9.2%)初诊时CT无阳性表现,复查过程中4例CT出现阳性征象,另3例持续阴性。65例(85.5%)患者核酸初检结果为阳性;11例(14.5%)核酸初检结果为阴性,复查过程中转为阳性,其中9例初诊时CT有阳性表现。
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76例确诊患者的4~8 d后随访CT和核酸检测结果:11例(14.5%)核酸初检阴性患者转为阳性,其中7例CT显示肺炎进展(图1);28例(36.8%)CT显示肺炎较初次CT吸收缓解,其中14例核酸检测结果由阳性转为阴性、14例核酸检测结果持续阳性;另37例(48.7%)CT显示肺炎进展,其中8例核酸检测结果由阳性转为阴性,29例核酸检测结果持续阳性。61例确诊患者的9~12 d后随访CT和核酸检测结果:46例(75.4%)CT显示肺炎较上次吸收缓解,其中31例核酸检测结果由阳性转为阴性(图2),15例核酸检测结果持续阳性;另15例(24.6%)CT显示肺炎进展,其中4例核酸检测结果由阳性转为阴性,11例核酸检测结果持续阳性(图3)。
图 1 确诊COVID-19患者(男性,49岁)的CT图
Figure 1. CT images of patient (male, 49 years old) confirmed to have COVID-19
CT与核酸检测对新型冠状病毒肺炎诊断及病程演变的对比分析
Assessment of CT findings and nucleic acid testing in the diagnosis and the disease course of COVID-19: a comparative study
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摘要:
目的 对比评估CT与核酸检测对新型冠状病毒肺炎(COVID-19)的诊断效能和病程演变特征。 方法 回顾性分析2020年1月20日至3月5日郑州大学第一附属医院收治的164例确诊和疑似COVID-19患者的临床资料、CT和核酸检测结果,其中,确诊COVID-19患者76例[男性40例、女性36例,年龄25~83岁]、疑似COVID-19患者88例[男性47例、女性41例,年龄21~75岁]。将所有受检者按年龄分为<60岁组(122例)和≥60岁组(42例)。以咽拭子取样核酸检测结果为“金标准”,评估CT对COVID-19的诊断效能。不同年龄组间各诊断效能的比较采用独立样本卡方检验。分析确诊患者自就诊以来的多次CT图像和核酸检测结果,对比COVID-19患者病程演变过程中的临床表现、CT和核酸检测结果的转变规律。 结果 164例患者中,核酸检测最终确诊阳性76例,阳性率为46.3%;CT诊断阳性143例,阳性率为87.2%。CT诊断的灵敏度、特异度、阳性预测值、阴性预测值和准确率分别为96.1%(73/76)、20.5%(18/88)、51.0%(73/143)、85.7%(18/21)、55.5%(91/164)。CT的各诊断效能在<60岁和≥60岁患者之间的差异均无统计学意义(χ2=0.051~0.414,均P>0.05)。88例疑似COVID-19患者中,CT诊断阳性率为79.5%(70/88)。76例确诊患者初诊时,8例(10.5%)为无症状亚临床期,7例(9.2%)CT无阳性表现,11例(14.5%)核酸检测结果为阴性[其中9例(81.8%)CT诊断有阳性表现,CT肺炎进展期核酸检测结果转为阳性]。病程演变过程中,CT能清晰显示肺炎的进展和缓解程度,4~8 d后复查,28例CT表现为缓解期的患者中有14例(50.0%)核酸检测结果转阴;9~12 d后复查,46例CT表现为缓解期的患者中有31例(67.4%)核酸检测结果转阴。 结论 CT在早期COVID-19的筛查和诊断中较核酸检测更灵敏,且能更早地评估COVID-19的病程演变,可作为COVID-19临床诊疗过程中的重要辅助手段。 -
关键词:
- 体层摄影术,X线计算机 /
- 新型冠状病毒肺炎 /
- 核酸检测
Abstract:Objective To evaluate and compare the diagnostic values of CT findings and nucleic acid testing in the corona virus disease 2019 (COVID-19) and investigate their features in the disease course. Methods The retrospective analysis was performed on the data of patients who received chest CT and nucleic acid testing from January 20, 2020 to March 5, 2020 in the First Affiliated Hospital of Zhengzhou University. This study involved 164 patients, including 76 confirmed (40 males and 36 females, aged 25−83 years old) and 88 suspected (47 males and 41 females, aged 21−75 years old) cases. The patients were divided into <60 years old group (122 cases) and ≥60 years old group (42 cases). The performance of CT in diagnosing COVID-19 was assessed using nucleic acid testing results as the gold standard. For confirmed patients with multiple CT images and nucleic acid tests, the CT findings and nucleic acid testing results were analyzed comparatively from the beginning of the disease to the progress and turnover of the disease. Results Of 164 patients, 46.3% (76/164) had positive nucleic acid testing results, and 87.2% (143/164) had positive CT findings. Considering the nucleic acid testing results as standard, the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of CT in diagnosing COVID-19 were 96.1% (73/76), 20.5% (18/88), 51.0% (73/143), 85.7% (18/21), and 55.5% (91/164), respectively. There was no significant difference in CT diagnostic efficiency between <60 years old group and ≥60 years old group (χ2=0.051−0.414, all P>0.05). In patients with negative nucleic acid testing results, 79.5% (70/88) had positive CT findings. In patients with positive nucleic acid testing results, 10.5% (8/76) had no symptom, 9.2% (7/76) had negative CT findings, and 14.5% (11/76) had negative nucleic acid testing results when first examined. Among the 11 patients with initially negative nucleic acid testing results, 81.8% (9/11) had positive CT findings, and the nucleic acid testing results changed from negative to positive during the follow-up period. In the course of disease development, the CT could present progress and improvement. The nucleic acid testing results of 50.0% (14/28) of cases with CT finding improvement changed from positive to negative in the follow-up at 4 to 8 days, and the nucleic acid testing results of 67.4% (31/46) cases changed from positive to negative in the follow-up at 9 to 12 days. Conclusion CT had higher sensitivity for the diagnosis of COVID-19 compared with the initial nucleic acid testing and could show condition improvement earlier than the nucleic acid testing results, it is an important supporting means in clinical practice . -
Key words:
- Tomography, X-ray computed /
- COVID-19 /
- Nucleic acid testing
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表 1 164例确诊和疑似COVID-19患者的CT表现与核酸 检测结果的比较(例)
Table 1. Comparison of CT and nucleic acid testing results for patients confirmed or suspected to have COVID-19 (case)
CT表现 核酸诊断 合计 阳性 阴性 阳性 73 70 143 阴性 3 18 21 合计 76 88 164 注:表中,COVID-19:新型冠状病毒肺炎;CT:计算机体层摄影术 -
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