目的 分析重症恙虫病患者的临床特征,以期提高临床医师对重症恙虫病的诊治能力.方法采用病例报告表(CRF)收集2017年1月1日至2018年12月31日云南省各家医院收治恙虫病患者的临床资料,记录年龄、性别、入院时临床症状,入院第1天的白细胞计数(WBC)、嗜酸粒细胞计数(EO)、红细胞计数(RBC)、血小板计数(PLT)、血红蛋白(Hb)、血细胞比容(HCT)、白蛋白(ALB)、丙氨酸转氨酶(ALT)、天冬氨酸转氨酶(AST)、总胆红素(TBil)、乳酸脱氢酶(LDH)、尿素氮(BUN)、血肌酐(SCr)、尿酸(UA)和临床结局.根据重症恙虫病的诊断标准将患者分为非重症组和重症组,对比两组患者临床表现、实验室检查、影像学检查及预后等;将单因素分析中差异有统计学意义的变量进行多因素Logistic回归分析;并绘制LDH、UA鉴别诊断重症恙虫病的受试者工作特征曲线(ROC).结果 最终入选2017年1月1日至2018年12月31日云南省15个地州市37家医院收治的408例恙虫病患者,临床诊断385例,实验室诊断23例;非重症组265例,重症组143例;共死亡8例,其余400例患者均好转出院.① 与非重症组比较,重症组患者年龄大,头晕、咳嗽、咳痰、全身酸痛、呼吸困难、心悸、腹痛、腹泻、球结膜充血、胸腔积液、腹腔积液、心包积液、肝肿大、脾肿大的发生率以及WBC、ALT、AST、LDH、TBil、BUN、SCr、UA水平显著升高,淋巴结肿大发生率显著降低,EO、PLT和ALB水平显著降低,而两组间其他指标比较差异无统计学意义.② 多因素Logistic回归分析显示:年龄增高,伴有呼吸困难、心悸,LDH、UA升高和ALB降低为重症恙虫病的危险因素,β值分别为0.040、-2.147、-1.414、0.002、0.005、-0.132,优势比(OR)分别为1.041、0.117、0.243、1.002、1.005、0.877(均P<0.01).③ ROC曲线分析显示, UA、LDH鉴别诊断重症恙虫病的准确性较好(均P<0.01),ROC曲线下面积(AUC)分别为0.693〔95%可信区间(95%CI)=0.633~0.754〕、0.819(95%CI=0.776~0.862).UA最佳诊断值为306.2 μmol/L时,敏感度为60.8%,特异度为77.4% ;LDH最佳诊断值为485.5 U/L时,敏感度为74.8%,特异度为74.7%.UA与LDH联合可进一步提高诊断价值,AUC为0.832,敏感度为69.9%,特异度为85.3%.结论 临床医师可以根据年龄较大,伴有呼吸困难、心悸、低蛋白血症、UA>306.2 μmol/L、LDH>485.5 U/L早期识别重症恙虫病患者.
To analyze the clinical characteristics of severe tsutsugamushi disease, and to improve the ability of clinicians to recognize severe cases. Methods The clinical data of patients with tsutsugamushi disease from January 1st, 2017 to December 31st, 2018 in hospitals of Yunnan Province were retrospectively collected by the Case Report Form (CRF). The age, gender, clinical symptoms at admission; white blood cell (WBC), eosinophil count (EO), red blood cell (RBC), platelet count (PLT), hemoglobin (Hb), hematocrit (HCT), albumin (ALB), alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin (TBil), lactate dehydrogenase (LDH), blood urea nitrogen (BUN), serum creatinine (SCr), uric acid (UA) on the first day of admission; and clinical outcomes were recorded. The patients were divided into the non-critical group and the critical group according to the diagnostic criteria, the data of clinical manifestation, laboratory examination, imaging examination and prognosis were compared between the two groups. Multivariate Logistic regression analysis was performed on the variables with statistical significance. The receiver operating characteristic (ROC) curve of LDH and UA for differential diagnosis of severe tsutsugamushi disease were drawn. Results From January 1st, 2017 to December 31st, 2018, 408 patients with tsutsugamushi disease were enrolled in 37 hospitals in 15 prefectures and municipalities of Yunnan Province. 385 cases were clinically diagnosed and 23 cases were laboratory diagnosed. There were 265 cases in non-critical group and 143 cases in critical group. A total of 8 cases died and the remaining 400 cases were discharged from hospital. ① Compared with the non-critical group, age of the critical group was older, the incidence of dizziness, cough, expectoration, general soreness, dyspnea, palpitation, abdominal pain, diarrhea, bulbar conjunctival congestion, pleural effusion, peritoneal effusion, pericardial effusion, hepatomegaly, splenomegaly, and the levels of WBC, ALT, AST, LDH, TBil, BUN, SCr, UA were significantly increased, the incidence of lymph node enlargement and the levels of EO, PLT and ALB were significantly decreased, and there was no significant difference in other indicators between the two groups.② Multivariate Logistic regression analysis showed that age, dyspnea, palpitations, LDH, UA, ALB were risk factors for severe tsutsugamushi disease, βvalue was 0.040,-2.147,-1.414, 0.002, 0.005 and-0.132 respectively, and the odds ratio (OR) was 1.041, 0.117, 0.243, 1.002, 1.005 and 0.877 respectively (all P < 0.01). ③ROC curve analysis showed that UA and LDH had better accuracy in differential diagnosis of severe tsutsugamushi disease (both P < 0.01), and the area under ROC curve (AUC) was 0.693 [95% confidence interval (95%CI) = 0.633-0.754], 0.819 (95%CI = 0.776-0.862), respectively. When the cut-off of UA was 306.2 μmol/L, the sensitivity was 60.8%, and the specificity was 77.4%. When the cut-off of LDH was 485.5 U/L, the sensitivity was 74.8%, and the specificity was 74.7%. The diagnostic value of UA combined with LDH was higher, AUC was 0.832, the sensitivity was 69.9%, and the specificity was 85.3%. Conclusion Severe tsutsugamushi disease can be diagnosed at an early stage according to age, respiratory distress, palpitations, hypoalbuminemia, UA >306.2 μmol/L, and LDH > 485.5 U/L.