【作者】 王萍；

【导师】 王静；

【作者基本信息】 青岛大学 ， 免疫学， 2022， 硕士

【摘要】 目的探讨外周血中超敏C反应蛋白(High sensitivity C-reactive protein,hs-CRP)、血清淀粉样蛋白A(Serum amyloid A,SAA)、降钙素原(Procalcitonin,PCT)、白介素-6(Interleukin-6,IL-6)联合检测在儿童肺炎支原体感染及其合并细菌、病毒感染中的辅助鉴别诊断价值。方法收集2021年7月-2021年10月在淄博市第一医院儿科收治的肺炎支原体肺炎(Mycoplasma pneumoniae pneumonia,简称MPP)患儿370例,其中根据呼吸道病原学检测结果将患儿分为单纯肺炎支原体感染组(简称MP组,113例)、肺炎支原体合并病毒感染组(简称合并病毒组,118例),以及肺炎支原体合并细菌感染组(简称合并细菌组,139例),并随机选取同期于淄博市第一医院进行健康体检的儿童50例作为对照组。对研究对象分组及检测如下:(1)在入院初期均留取咽拭子,采用聚合酶链反应(polymerase chain reaction,PCR)进行肺炎支原体核酸检测,同时进行甲乙型流感病毒核酸、呼吸道合胞病毒核酸、巨细胞病毒核酸、EB病毒核酸检测,肺炎支原体核酸检测结果阳性作为患儿纳入研究对象的确定依据,呼吸道任何一种病毒阳性,分组到合并病毒组,单纯肺炎支原体核酸阳性分组到单纯肺炎支原体组;(2)留取患儿痰液标本,进行一般细菌培养、鉴定、药敏试验和涂片革兰染色镜检,细菌培养阳性患儿分组到合并细菌组;(3)留取患儿血清标本,采用间接免疫荧光法定性检测抗呼吸道病原体(包括流感病毒A+B,副流感病毒,腺病毒,呼吸道合胞病毒等)Ig M抗体,任何一种病毒抗体阳性分组到合并病毒组。(4)留取上述四组血清标本,采用电化学发光法定量检测PCT、IL-6水平。(5)留取上述四组全血样本,采用免疫散射比浊法定量检测hs-CRP、SAA水平。相关数据均使用EXCEL2010软件进行整理,使用统计软件SPSS 22.0进行统计学分析及ROC曲线绘制,经正态性检验,资料不符合正态分布,结果以中位数和四分位数间距[M(P25,P75]表示。组间两两比较采用Mann-Whitney U检验,以P<0.05表示差异有统计学意义。利用Med Calc软件计算各检测指标ROC曲线下面积(AUC)、尤登指数及最佳诊断cut-off值。结果(1)外周血中PCT、IL-6和SAA水平,三组观察组与对照组相比,均明显升高,合并细菌组浓度最高,差异均具有统计学意义(P均<0.05)。MP组、合并细菌组和合并病毒组三组之间进行两两比较,差异均具有统计学意义(P均<0.05)。(2)外周血中hs-CRP水平,三组观察组与对照组相比,均明显升高,合并细菌组浓度最高差异具有统计学意义(P均<0.05)。MP组、合并细菌组、合并病毒组三组进行组间两两比较,MP与合并细菌组hs-CRP有统计学差异(P<0.05),与合并病毒组没有统计学差异(Z=-0.992,P=0.321),合并细菌组和合并病毒组hs-CRP浓度有统计学差异(P<0.05)。(3)SAA/hs-CRP比值,三组观察组与对照组比,SAA/hs-CRP比值均明显升高,合并病毒组的SAA/hs-CRP比值最高,差异有统计学意义(P均<0.01)。MP组、合并细菌组、合并病毒组三组进行组间两两比较,MP与合并病毒组间有统计学差异(P<0.05),合并细菌组和合并病毒组间有统计学差异(P<0.05),MP与合并细菌组间无统计学差异(Z=-1.634,P=0.102)。(4)五项指标检测对鉴别诊断MPP合并细菌感染的ROC曲线显示:hs-CRP、SAA、SAA/hs-CRP、PCT和IL-6单独检测对鉴别诊断MPP合并细菌感染的ROC曲线下面积(AUC)分别为0.749、0.757、0.571、0.887和0.894。单独检测时,IL-6检测效能最好,在鉴别诊断支原体肺炎患儿合并细菌感染方面价值较高;五项指标联合检测对鉴别诊断MPP合并细菌感染的AUC为0.941,敏感度和特异性分别为84.89%和86.55%;而IL-6和PCT联合检测对鉴别诊断MPP合并细菌感染的AUC为0.935,敏感度和特异性分别为84.89%和87.39%,敏感度没有降低,特异性略高于五项指标联合检测,考虑到患儿经济和身体因素,建议使用PCT和IL-6两项联合检测,辅助鉴别诊断MPP是否合并细菌感染。(5)五项指标检测对鉴别诊断MPP合并病毒感染的ROC曲线显示:hs-CRP、SAA、SAA/hs-CRP、PCT和IL-6单独检测对鉴别诊断MPP合并病毒感染的ROC曲线下面积(AUC)分别为0.537、0.641、0.650、0.578、0.605。单独检测时,SAA/hs-CRP检测效能最好,在鉴别诊断支原体肺炎患儿合并病毒感染方面价值较高;五项指标的联合检测在鉴别诊断MPP合并病毒感染的AUC为0.695,敏感度和特异性分别为84.75%和48.67%;而SAA和SAA/hs-CRP两项指标联合检测在鉴别诊断MPP合并病毒感染的AUC为0.650,略低于五项联合检测的AUC,敏感度和特异性分别为77.97%和48.67%,敏感度略有降低,特异性没有改变,考虑到患儿经济和身体因素,建议用SAA和SAA/hs-CRP两项联合检测,辅助鉴别诊断MPP是否合并病毒感染。结论(1)外周血中SAA、PCT和IL-6水平可用于MPP患儿合并其他病原体感染的辅助诊断。(2)外周血中SAA、SAA/hs-CRP联合检测可作为鉴别诊断MPP患儿合并病毒感染的指标。(3)外周血中PCT和IL-6联合检测可作为鉴别诊断MPP患儿合并细菌感染的指标。更多还原

【Abstract】 Objective To explore the value of combined detection of high sensitivity C-reactive protein(hs-CRP),serum amyloid A(SAA),procalcitonin(PCT)and interleukin-6(IL-6)in the differential diagnosis of mycoplasma pneumoniae infection in children and whether it is complicated with bacterial and viral infection.Methods A total of 370 children with mycoplasma pneumoniae pneumonia(MPP)treated in pediatrics of Zibo first hospital from August 2021 to November 2021 were collected.According to the results of respiratory tract etiology,the children were divided into simple mycoplasma pneumoniae infection group(113 cases)and mycoplasma pneumoniae combined with virus infection group(118 cases),and mycoplasma pneumoniae combined with bacterial infection group(referred to as combined bacteria group,139 cases),and 50 children who underwent physical examination in Zibo first hospital in the same period were randomly selected as the control group.The children in MP group,combined with virus infection group and combined with bacteria infection group were tested as follows:(1)pharyngeal swabs were taken at the beginning of admission,and the nucleic acid of mycoplasma pneumoniae was detected by polymerase chain reaction(PCR),as well as influenza A and B virus nucleic acid,respiratory syncytial virus nucleic acid,cytomegalovirus nucleic acid and EB virus nucleic acid;(2)Sputum samples from children were collected for general bacterial culture,identification,drug sensitivity test and Gram staining microscopic examination of smears;(3)The serum samples of children were taken and the levels of PCT and IL-6 were quantitatively detected by electrochemiluminescence method;Indirect immunofluorescence assay was used to detect anti mycoplasma pneumoniae Ig M antibody.(4)The levels of PCT and IL-6were detected quantitatively by electrochemiluminescence.(5)The above four groups of whole blood samples were taken and the levels of hs-CRP and SAA were quantitatively detected by immune scattering turbidimetry.The relevant data were sorted out by Excel2010 software,and the statistical software SPSS 22.0 was used for statistical analysis and ROC curve drawing.Through the normality test,the data did not conform to the normal distribution,and the results were expressed by the median and interquartile spacing [M(P25,P75)].Mann-Whitney U test was used for pairwise comparison between groups,and P<0.05 showed that the difference was statistically significant.The area under ROC curve(AUC),Youden index and the best cut-off value of diagnosis were calculated by Med Calc software.Results(1)The levels of PCT,IL-6 and SAA in peripheral blood in the observation group were significantly higher than those in the control group,and the concentration in the combined bacteria group was the highest,the difference was statistically significant(P <0.05).There were significant differences among the MP group,bacteria combined group and virus combined group(P<0.05).(2)The level of hs-CRP in peripheral blood of the three groups was significantly higher than that of the control group,and the concentration of hs-CRP in the combined bacteria group was the highest,the difference was statistically significant(P < 0.05).There was significant difference in the hs-CRP between the MP group,the bacteria group and the virus group(P<0.05),but there was no significant difference between the MP group and the virus group(z=-0.992,P = 0.321).There was statistical difference in hs-CRP concentration between bacteria group and virus group(P< 0.05).(3)The serum samples of the children were taken,and the Ig M antibodies against respiratory pathogens(including influenza virus A+B,parainfluenza virus,adenovirus,respiratory syncytial virus,etc.)were detected by indirect immunofluorescence.Any virus antibody positive group was divided into combined virus group.(4)The ROC curve of the five indexes for differential diagnosis of MPP complicated with bacterial infection showed that the area under the ROC curve(AUC)of hs-CRP,SAA,SAA / hs-CRP,PCT and IL-6 for differential diagnosis of MPP complicated with bacterial infection were0.749,0.757,0.571,0.887 and 0.894 respectively;The AUC of the combined detection of five indexes for the differential diagnosis of MPP complicated with bacterial infection was 0.941,and the sensitivity and specificity were 84.89% and 86.55% respectively;The AUC of combined detection of IL-6 and PCT for differential diagnosis of MPP complicated with bacterial infection was 0.935,and the sensitivity and specificity were84.89% and 87.39% respectively.The sensitivity did not decrease,and the specificity was slightly higher than that of combined detection of five indicators.Considering the economic and physical factors of children,it is recommended to use combined detection of PCT and IL-6 to assist in differential diagnosis of MPP complicated with bacterial infection.(5)The ROC curve of five indexes for differential diagnosis of MPP complicated with virus infection showed that the AUC of hs-CRP,SAA,SAA / hs-CRP,PCT and IL-6 for differential diagnosis of MPP complicated with virus infection were0.537、0.641、0.650、0.578、0.605 respectively.When tested alone,SAA/hs-CRP has the best detection efficiency,the ROC curve is located at the top left,and the corresponding AUC is the largest.It is of high value in the differential diagnosis of mycoplasma pneumonia children with viral infection,followed by SAA,with the corresponding AUC of 0.641,slightly lower than SAA/hs-CRP.The AUC of the combined detection of the five indexes in the differential diagnosis of MPP complicated with virus infection was0.695,and the sensitivity and specificity were 84.75% and 48.67% respectively.The AUC of the combined detection of SAA and SAA/hs-CRP in the differential diagnosis of MPP complicated with virus infection was 0.650,slightly lower than the AUC of the five combined detection.The sensitivity and specificity were 77.97% and 48.67% respectively.The sensitivity was slightly reduced,and the specificity did not change.Considering the economic and physical factors of children,it is recommended to use the combined detection of SAA and hs-CRP to assist in the differential diagnosis of MPP complicated with virus infection.Conclusion(1)The levels of SAA,PCT and IL-6 in peripheral blood can be used for the auxiliary diagnosis of MPP children complicated with other pathogen infection.(2)The combined detection of SAA and SAA/hs-CRP in peripheral blood can be used as an index for differential diagnosis of MPP children complicated with virus infection.(3)The combined detection of PCT and IL-6 in peripheral blood can be used as an index for differential diagnosis of MPP children with bacterial infection.更多还原