成都市公共卫生临床医疗中心 610000
【摘要】目的:探讨不同临床分型的新型冠状病毒肺炎(corona virus disease 2019,COVID-19)胸部CT表现特征和凝血功能的特点,提高对COVID-19的认识和诊治水平。方法:对成都市公共卫生医疗中心收治的89例COVID-19患者的胸部CT资料、以及凝血功能进行回顾性对照分析。 结果:普通型COVID-19患者多累及肺外带(93.10%),以磨玻璃影(91.38%)为主;重型COVID-19患者多累及中外带(100%),以磨玻璃影为主(94.12%),伴较多亚实变(64.71%);危重型内、中、外带不同程度受累,伴较多实变及亚实变,小叶间隔明显增厚(90%)及纤维化(70%),并伴有不同程度的胸膜增厚(60%)及胸腔积液(50%)。危重型患者纤维蛋白(原)高于重型、普通型患者(8.4000±10.8989μg/ml vs 3.0333±1.4121 vs 2.8069±2.5653μg/ml, P=0.001);危重型患者D-二聚体明显高于重型、普通型患者(3.5262±5.5756g/ml vs 0.9067±0.5775g/ml vs 0.8822±0.9205g/ml,P=0.001);危重型患者活化部分凝血活酶时间长于重型、普通型患者(30.2385±12.6672s vs 30.2611±5.0694s vs 28.0655±3.4433s,P=0.016);危重型患者凝血酶时间长于重型、普通型患者(19.7385±16.7784s vs 14.6722±0.8252s vs 14.7586±0.8461s, P=0.035);不同临床分析患者的凝血酶原时间及纤维蛋白原差异无统计学意义(均P>0.05)。结论:不同临床分型COVID-19患者双肺均受累,普通型以外带为主,重型及危重型逐渐侵及中内带;各型患者均有不同程度磨玻璃影像,但随着疾病的严重程度,伴有不同程度的亚实变及实变,危重症患者常常合并小叶间隔及胸膜增厚、以及胸腔积液;纤维蛋白(原)降解产物、D-二聚体、活化部分凝血酶时间和凝血酶时间测定对COVID-19患者的临床分型有一定的临床意义。
【关键词】新型冠状病毒肺炎;体层摄影术,X线计算机;CT;凝血
【Abstract】Objective: To investigate the characteristics of chest CT features and coagulation function of novel coronavirus pneumonia (COVID-19) with different clinical types, and to improve the understanding and diagnosis and treatment of COVID-19. Methods: A retrospective control analysis was performed on chest CT data and coagulation function of 89 patients with COVID-19, who were admitted in Chengdu Public Health Medical Center. Results: Patients with COVID-19 in common group are mostly affected Extra-pulmonary bands (93.10%), mainly with ground glass shadow (91.38%). Patients with COVID-19 in severe group mainly affected mid-external bands (100%) and ground-glass shadow (94.12%) ), and with more sub-solidification (64.71%). Patients with COVID-19 in critically ill group critically are affected inner, middle, and outer belts in varying degrees, with more consolidation and sub-solidification, and the leaflet spacing is significantly thickened (90%) and fibrosis (70%), and with varying degrees of pleural thickening (60%) and pleural effusion (50%); both lungs were affected in each clinical analysis. Fibrin (original) in critically ill group patients was higher than that patients in severe and common group (8.4000 ± 10.8989μg / ml vs 3.0333 ± 1.4121 vs 2.8069 ± 2.5653μg / ml,
P = 0.001); D-dimer was significantly higher in critically ill group patients than patients in severe and ordinary group (3.5262 ± 5.5756g / ml vs 0.9067 ± 0.5775g / ml vs 0.8822 ± 0.9205g / ml, P = 0.001); activate thromboplastin in patients with critically ill longer than severe and ordinary group patients (30.2385 ± 12.6672s vs 30.2611 ± 5.0694s vs 28.0655 ± 3.4433s, P = 0.016); thrombin time in critically ill group patients is longer than severe and ordinary group patients (19.7385 ± 16.7784s vs 14.6722 ± 0.8252s vs 14.7586 ± 0.8461s, P = 0.035) ; there was no significant difference in thrombin time and fibrinogen between patients in different clinical type groups (all P> 0.05). Conclusion: Patients with different clinical types of COVID-19 are affected by both lungs. The common type is mainly affected the outer band, and the severe and critically type also affected the middle and inner band. Each type of patients has different degrees of ground glass imaging, with different degrees of subconsolidation and consolidation, critically ill patients often combine lobular septum and pleural thickening, and pleural effusion; fibrin (pro) degradation products, D-dimer, activated partial thrombin time, and the measurement of thrombin time has certain clinical significance for the clinical classification of patients with COVID-19.
Keywords: new coronavirus pneumonia; tomography, X-ray computer; CT; coagulation
新型冠状病毒肺炎(COVID-19)至今为止已造成我国近8万余人确诊感染,4千多人死亡[1]。CHEN等[2]报道武汉金银滩医院早期收治COVID-19患者死亡率高达11%。因此,早期判断、检出重症及危重症患者对患者的分层诊断有着非常重要的价值。
1 材料与方法
1研究对象
搜集成都市公共卫生临床医疗中心2020年1月-2月间收治的确诊COVID-19患者89例,符合新型冠状病毒感染的肺炎诊疗方案(试行第六版)[3]。
1.2实验室检查
患者新型冠状病毒核酸阳性,全部采集凝血功能指标检测。
1.3胸部CT检查
所有患者均采用GE-BrightSpeed螺旋CT扫描。
1.4统计学方法
采用SPSS 18.0软件,采用单因素方差分析,组间两两比较采用LSD法,p<0.05表示差异有统计学意义。
2结果
2.1 临床表现及合并症
根据纳入及排除标准,共纳入普通型58例,危重型13例。
2.2 胸部CT影像学表现
胸部CT影像学表现见表1及图1-2。
2.3凝血功能检查
凝血功能检查请见表2。
三 讨论
胸部HRCT对初级肺小叶及肺间质等细微结构进行良好显示[4,5],在第五版新型冠状病毒感染的肺炎诊疗方案[6]已经作为湖北省的临床诊断依据。COVID-19病例特征与SARS和中东呼吸综合征(Middle East respiratory syndrome,MERS)冠状病毒引起的病例特征相似
[7]。冠状病毒累及双肺时,大致病理改变为细支气管炎及其周围炎和间质性炎变,渗出明显[8]。COVID-19早期以双肺散在多发小片状及结节状磨玻璃改变[9],随着病程进展,双肺迅速出现多发磨玻璃影、浸润影,病灶明显增多、范围增大,部分病灶变密实,呈亚实性改变,磨玻璃影与实变影或条索影共存[10]。本研究证实COVID-19和既往病毒性肺炎肺部侵犯类似,多累及双肺多叶、多段、中外带明显,病程早期病灶局限、以渗出灶为主,随着病程时间延长,出现危重症的几率越大。危重型组入院时亚实变、实变明显高于普通型组,入院时重型组、危重型组小叶间隔增厚及纤维化的比例远远高于普通型组,危重型组患者伴随胸膜增厚、胸腔积液也更明显,提示危重型组患者急性期病情更加严重。
严重炎症所致的缺氧和内毒素作为启动因子,机体的微血管内皮损伤,从而导致微血管内血栓形成,血液粘滞度异常,血小板聚集和小动脉痉挛,并干扰抗凝系统,引起纤溶功能亢进、凝血功能异常[11,12]。本次研究中部分凝血指标在正常范围之内。纤维蛋白原测定、纤维蛋白(原)降解产物、D-二聚体有延长,以危重型组明显,尤其是后两者,提示危重型患者存在明显继发性纤溶亢进,机体内部血液呈现高凝状态[13]。D-二聚体及纤维蛋白(原)降解产物明显升高的患者,特别是临床感染中毒症状表现不明显及一些具有深静脉血栓栓塞症危险因素的患者,尤其需要高度警惕肺栓塞发生的可能。危重组患者年龄普遍偏高,也是导致高凝的危险因素之一[14]。
综上所述,由于炎症和凝血之间的上述关系,在COVID-19中检测血浆FDP、D-二聚体水平,并结合胸部影像学表现,能在一定程度上早期判断COVID-19患者病情的严重程度,同时对疾病转归起到一定的提示作用。
参考文献
[1] 卫生应急办公室. 截至12月10日24时新型冠状病毒肺炎疫情最新情况[R/OL].(2020-12-10) [2020-12-10].http://www.nhc.gov.cn/xcs/yqfkdt/202012/9c71024c45bf43548469204f9e9e064b.shtml
[2] CHEN N, ZHOU M, DONG X,et la.Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan,China:A descriptive study[J].Lancet,2020,395(10223):507-513.doi:10.1016/S0140-6736(20)30211-7.
[3] 国家卫健委, 关于印发新型冠状病毒肺炎诊疗方案(试行第六版)的通知, 2020-02-19,
http://www.gov.cn/zhengce/zhengceku/2020-02/19/content_5480948.htm
[4] 吴展陵. 原发性间质性肺炎的HRCT特征及诊断分析[J].中国CT和MRI杂志,2016,14(4):62-64
[5] 贺明礼,刘莲花,赖华.儿童间质性肺疾病低剂量容积数据高分辨率CT随访观察[J].实用放射学杂志,2017,33(11):1802-1804
[6] 国家卫健委, 关于印发新型冠状病毒肺炎诊疗方案(试行第五版)的通知, 2020-02-04,http://www.gov.cn/zhengce/zhengceku/2020-02/05/content_5474791.htm
[7] XU Z, SHI L, WANG Y,et al.Pathological findings of COVID-19 associated with acute respiratory distress syndrome[J].Lancet Respir Med,2020.doi:10.1016/S2213-2600(20)30076-X.
[8] 刘茜,王荣帅,屈国强,等. 新型冠状病毒肺炎死亡尸体系统解剖大体观察报告[J].医法学杂志,2020,36(1):1-3.
[9] 刘晓龙,于珊珊,李萍. 中东呼吸综合征的影像学研究进展[J].医学影像学杂志,2016,26(1):109-111.
[10] AJLAN AM, AHYAD RA,JAMJOOM LG, et al. Middle East respiratory syndrome coronavirus (MERS-COV) infection: chest CT findings[J].AJR,2014,203(4):782-787.DOI:10.2214/AJR.14.13021
[11] 杨亚娟,郭萍. 老年重症肺炎患者凝血功能的变化研究[J].齐齐哈尔医学院学报,2015,36(24):3669-70.
[12] 王瑞珠,席艳丽,郭斌,等.儿童肺炎支原体感染致坏死性肺炎的影像特点及血-C反应蛋白,D-二聚体的评价[J].实用放射学杂志,2019,35(6):952-955 DOI:10.3969/j.issn.1002G1671.2019.06.024
[13]傅中明,顾霄. 老年重症肺炎患者细胞炎症因子、凝血功能和肺功能变化及危险因素[J]. 中国老年学杂志,2018,38(19):4663-4666 DOI:10.3969/j.issn.1005-9202.2018.19.021
[14] 吴海涛,鲍海咏,侯明. 老年重症肺炎患者凝血功能的变化及临床意义[J].中国老年医学杂志,2014,34(10):2702-2704.DOI:10.3969/j.issn.1005-9202.2014.10.043
图1 a b 男,49岁,普通型COVID-19患者,发热咳嗽3天入院,胸部CT显示右肺中叶外侧段、右肺下叶后基底段、外基底段、左肺下叶背段散在磨玻璃影,边缘模糊,病灶主要位于肺部外带、邻近胸膜下(箭头)。
图2 女,65岁,重型COVID-19患者,咳嗽、咯痰、畏寒、乏力、全身酸痛5天入院摄片 a)双肺外带弥漫分布亚实变、磨玻璃影(箭头) b)亚实变病灶内见小叶间隔增厚 c)局部亚实变区域邻近胸膜轻度增厚(箭头)