上海地区重型及危重型新型冠状病毒肺炎临床特点与胸部计算机断层扫描表现

Clinical characteristics and chest computed tomography findings of severe and critical coronavirus disease 2019 in Shanghai,China

目的总结重型及危重型新型冠状病毒肺炎(COVID-19)患者的临床特点与胸部CT表现,探讨病情好转的影响因素,为临床诊治重型及危重型COVID-19提供经验。方法收集2020年1月23日至2020年3月5日在我院诊治的25例重型及危重型COVID-19病例资料。回顾性分析患者临床资料,比较治愈出院患者与未治愈患者的临床及实验室检查特点,并进一步分析治愈出院患者在进展期和恢复期实验室指标的变化。观察患者胸部CT基本表现,并使用基于CT影像的智能化肺炎病灶定量分析软件定量病灶体积百分比,评估肺部病灶随病程变化的演变特点。结果25例(3例死亡)COVID-19患者中男19例、女6例,年龄为65(63,75)岁,BMI为25.60(23.51,28.65)kg/m^2,22例有明确流行病学史,首发症状以发热(22例)、咳嗽(14例)最常见,18例合并基础疾病。12例治愈出院(中位住院时间为25.5 d)、13例未治愈(死亡3例、住院时间>25 d且病情未缓解者10例)。与未治愈患者相比,治愈出院患者的BMI较低,从发病至进展为重型或危重型的时间较长,CD4^+T淋巴细胞计数较高,差异均有统计学意义(P均<0.05)。多因素logistic回归分析结果显示,CD4^+T淋巴细胞计数高是重型及危重型COVID-19患者治愈出院的独立保护因素(P=0.031)。12例治愈出院患者恢复期淋巴细胞绝对值、CD4^+T淋巴细胞计数均高于进展期,CRP水平、红细胞沉降率(ESR)、降钙素原水平均低于进展期,差异均有统计学意义(P均<0.01)。21例患者于进展期行胸部CT检查,均表现为双肺多肺叶以外周带及背侧分布为主的磨玻璃影与实变影,其中胸膜增厚20例,双侧少量胸腔积液9例,纵隔淋巴结肿大8例;12例治愈出院患者恢复期均复查胸部CT,均表现为病灶不同程度吸收好转,部分形成不规则纤维网格影或条索影,胸膜增厚及双侧少量胸腔积液均有不同程度吸收。由定量分析病灶体积随病程变化的曲线图可见,12例治愈出院COVID-19患者病灶体积百分比在进展期明显增高,吸收期降低,呈倒V形;未治愈患者病灶体积百分比在进展期(≥2次CT检查者9例)呈快速上升型。结论上海地区重型及危重型COVID-19患者多年龄较大、BMI偏高、合并基础疾病。重型及危重型COVID-19患者BMI低、病情进展慢、CD4^+T淋巴细胞计数高有利于其病情恢复。胸部CT主要表现为以肺外周带及背侧分布为主的多发磨玻璃影与实变影,多累及胸膜。淋巴细胞绝对值、CRP、CD4^+T淋巴细胞计数、ESR和降钙素原等实验室指标及胸部CT影像学检查对COVID-19的诊断、病情监测与预后判断有重要作用。

Objective To sum up the clinical characteristics and chest computed tomography(CT)findings of severe and critical coronavirus disease 2019(COVID-19)patients,and to explore the factors affecting the outcomes,so as to provide experience for the clinical diagnosis and treatment of severe and critical COVID-19.Methods The data of 25 severe and critical COVID-19 patients,who were treated in our hospital from Jan.23,2020 to Mar.5,2020,were collected.The clinical characteristics were retrospectively analyzed,and the clinical and laboratory indexes were compared between cured patients and uncured patients.The laboratory indicators of cured patients were further compared between the progressive and recovery stages.The chest CT findings of the patients were observed,and the lesion volume was quantified to assess the evolution of lung lesions using the CT image-based intelligent pneumonia lesion quantitative analysis software.Results There were 19 male and six female COVID-19 patients,and there were three deaths.The median age of 25 patients was 65(63,75)years old,and the body mass index(BMI)was 25.60(23.51,28.65)kg/m^2.Twenty-two patients had a clear epidemiological history.Fever(22 cases)and cough(14 cases)were the most common first symptoms,and 18 patients had underlying diseases.Twelve patients were cured and discharged(median hospital stay was 25.5 d),and 13 patients were not cured,including three deaths and 10 cases with hospital stay>25 d with no remission.Compared with the uncured patients,the cured patients had significantly lower BMI,longer time from onset to progression to severe or critical illness,and higher CD4^+T lymphocyte counts(all P<0.05).Multivariate logistic regression analysis showed that high CD4^+T lymphocyte count was an independent protective factor for the cure and discharge of severe and critical COVID-19 patients(P=0.031).Compared with those in the progressive stage,the lymphocyte count and CD4^+T lymphocyte count of 12 cured patients were significantly higher in the progression stage,and the C-reactive protein(CRP)level,erythrocyte sedimentation rate(ESR)and procalcitonin level were significantly lower(all P<0.01).Twenty-one patients received chest CT examination in the progressive stage;and all of them had multiple ground-glass opacities and consolidation shadows of the multiple-lobe lateral band and the dorsal side of bilateral lungs,20 cases had pleural thickening,9 cases had a small amount of bilateral pleural effusion,and 8 cases had mediastinal lymphadenopathy.The 12 cured patients received CT examination during the recovery period,and their lesions were all improved to different extents;some patients had irregular fiber grid shadows and stripe shadows;and the pleural thickening and pleural effusion were reduced to different extents.The quantitative analysis curves showed that lesion volume in the 12 cured patients obviously increased in the progressive stage and reduced in the absorption stage,showing an inverted V shape;and lesion volume in the uncured patients(nine cases received CT examination for two or more times)showed a rapid increase in the progressive stage.Conclusion Most severe and critical COVID-19 patients in Shanghai are older,with higher BMI and underlying diseases.Low BMI,slow disease progression,and high CD4^+T lymphocyte count are beneficial to the improvement of COVID-19.The main findings of chest CT include multiple ground-glass opacities and consolidation shadows,mainly distributing in the lateral band and the dorsal side of lungs and mostly involving the pleura.The laboratory indexes,including the lymphocyte,CRP,CD4^+T lymphocyte,ESR and procalcitonin,and chest CT examination play an important role in the diagnosis,disease monitoring and prognosis assessment of COVID-19.