早期识别和迅速诊断对于预防传播和及时提供支持性治疗至关重要。
所有出现发热和/或急性呼吸道疾患的患者,临床高度可疑 COVID-19 感染;但是,需知晓的是,部分患者可能无发热性呼吸道疾病征象或症状。
应在地方、区域和国家各层级为疑似或确诊 COVID-19 者建立 COVID-19 诊疗路径。根据病例定义和症状评估,在卫生系统第一接触点筛查患者,并将疑似或确诊病例纳入路径。[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
疑似病例应保留于该路径中,直到被证实为阴性。
立即将所有疑似和确诊病例进行隔离,实施恰当的感染防控规程。 使用标准分诊工具对患者进行分诊,并对患者进行评估,以估计疾病严重性。
COVID-19 为法定报告传染病。
Best Practice 临床实践目前已发布一个针对 COVID-19 合并症管理的独立专题。
BMJ Best Practice: Management of co-existing conditions in the context of COVID-19
Opens in new window
关键建议
立即隔离所有疑似或确诊病例。使用标准分诊工具对患者进行分诊,并评估疾病严重性。遵循当地感染防控指南。[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
所有出现发热和/或急性呼吸道疾患的患者,临床高度可疑。具有传播高风险或社区传播高风险地区居住/工作/旅行史,且与可能病例和确诊病例产生接触者,感染风险升高。[184]World Health Organization. Public health surveillance for COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications/i/item/who-2019-nCoV-surveillanceguidance-2020.7
出现新发持续咳嗽、发热或味觉、嗅觉改变的患者,可建立疑似诊断。[383]Department of Health and Social Care. Everyone in the United Kingdom with symptoms now eligible for coronavirus tests. 2020 [internet publication].
https://www.gov.uk/government/news/everyone-in-the-united-kingdom-with-symptoms-now-eligible-for-coronavirus-tests
患者还可能出现呼吸困难、乏力、肌痛/关节痛、咽痛、头痛、鼻塞或流涕、痰液产生、胸闷或胃肠道症状(例如恶心、呕吐、腹泻)。[384]Struyf T, Deeks JJ, Dinnes J, et al. Signs and symptoms to determine if a patient presenting in primary care or hospital outpatient settings has COVID-19 disease. Cochrane Database Syst Rev. 2020 Jul 7;(7):CD013665.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD013665/full#CD013665-abs-0002
http://www.ncbi.nlm.nih.gov/pubmed/32633856?tool=bestpractice.com
进行实时逆转录聚合酶链反应(reverse transcription polymerase chain reaction, RT-PCR)以确认诊断。首选上呼吸道和下呼吸道样本。某些情境中血清学检测可能会有所帮助。[385]World Health Organization. Diagnostic testing for SARS-CoV-2: interim guidance. 2020 [internet publication].
https://www.who.int/publications/i/item/diagnostic-testing-for-sars-cov-2
结果应根据疾病验前概率加以解读。
对出现急性胃肠道症状和心肌炎症征象的儿童和青少年,保持高度警惕。迄今为止的证据表明儿童病程较轻或无明显症状。[386]Liguoro I, Pilotto C, Bonanni M, et al. SARS-COV-2 infection in children and newborns: a systematic review. Eur J Pediatr. 2020 Jul;179(7):1029-46.
https://link.springer.com/article/10.1007/s00431-020-03684-7
http://www.ncbi.nlm.nih.gov/pubmed/32424745?tool=bestpractice.com
然而,一种少见的多系统炎性疾病,伴川崎病和中毒性休克综合征相似的部分特征,暂被认为与儿童和青少年 COVID-19 发病相关。[387]World Health Organization. Multisystem inflammatory syndrome in children and adolescents temporally related to COVID-19: scientific brief. 2020 [internet publication].
https://www.who.int/news-room/commentaries/detail/multisystem-inflammatory-syndrome-in-children-and-adolescents-with-covid-19
对住院患者进行以下实验室检查:全血细胞计数、生化全项、动脉血气、血糖水平、凝血筛查、炎症标志物、心脏生物标志物、血清肌酸激酶,以及其他病原体血液和痰液培养。脉搏血氧测定可提示氧饱和度过低。
疑似肺炎的重症患者应优先进行胸部 X 线检查。如果胸部 X 线检查呈不确定或正常,考虑进行计算机体层成像。[388]British Society of Thoracic Imaging. Thoracic imaging in COVID-19 infection: guidance for the reporting radiologist - version 2. 2020 [internet publication].
https://www.bsti.org.uk/media/resources/files/BSTI_COVID-19_Radiology_Guidance_version_2_16.03.20.pdf
查阅当地指南。
向当地卫生部门上报所有疑似或确诊病例。COVID-19 为法定报告传染病。
完整详情和指南,参见以下信息。
病史
采集详细病史,以确定 COVID-19 感染风险水平,并评估其他病因可能性,包括旅行史和危险因素评估。
对于以下人群需怀疑诊断:[184]World Health Organization. Public health surveillance for COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications/i/item/who-2019-nCoV-surveillanceguidance-2020.7
美国疾病预防控制中心将密切接触定义为症状发作前 2 天(或无症状患者接受检测前 2 天内),24 小时内在距感染者 2 米(6 英尺)范围内停留时间总计达 15 分钟以上者。[185]Centers for Disease Control and Prevention. Coronavirus disease 2019 (COVID-19): contact tracing. 2020 [internet publication].
https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/contact-tracing.html
成人临床表现
约 15% 患者出现发热、咳嗽和呼吸困难症状三联征,而 90% 患者出现一种以上症状。[5]Chen N, Zhou M, Dong X, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet. 2020 Feb 15;395(10223):507-13.
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30211-7/fulltext
http://www.ncbi.nlm.nih.gov/pubmed/32007143?tool=bestpractice.com
部分患者可能症状轻微或无症状,而其他患者可能出现严重的肺炎或并发症,例如急性呼吸道综合征、脓毒性休克、急性心肌梗死、静脉血栓栓塞或多器官功能衰竭。
最常见的症状包括:
较不常见的症状包括:
肌痛或关节痛
疲乏
痰液产生
胸闷
胃肠道症状
咽痛
头痛
头晕
神经系统症状
眼部症状
皮肤症状
流涕/鼻塞
胸痛
咯血。
发热性呼吸系统疾病的征象和症状,可能不具备建立早期疑似诊断所必需的敏感性。[389]Yang BY, Barnard LM, Emert JM, et al. Clinical characteristics of patients with coronavirus disease 2019 (COVID-19) receiving emergency medical services in King County, Washington. JAMA Netw Open. 2020 Jul 1;3(7):e2014549.
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2767993
http://www.ncbi.nlm.nih.gov/pubmed/32639570?tool=bestpractice.com
一项 Cochrane 评价发现,至少半数患者出现咳嗽、咽痛、发热、肌痛/关节痛、乏力或头痛。发热、肌痛/关节痛、乏力和头痛的出现,显著增加 COVID-19 诊断可能性。咳嗽和咽痛在无 COVID-19 者中十分常见,因此仅有此类症状,对诊断并无过多帮助。该项评价性研究未指出任何单一症状或征象可准确诊断 COVID-19,作者得出的结论为,缺乏或存在征象或症状,均无法准确得出疾病诊断或排除疾病诊断。[384]Struyf T, Deeks JJ, Dinnes J, et al. Signs and symptoms to determine if a patient presenting in primary care or hospital outpatient settings has COVID-19 disease. Cochrane Database Syst Rev. 2020 Jul 7;(7):CD013665.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD013665/full#CD013665-abs-0002
http://www.ncbi.nlm.nih.gov/pubmed/32633856?tool=bestpractice.com
非呼吸道症状可能在发热症状和下呼吸道症状出现之前即已呈现。[390]Centers for Disease Control and Prevention. Ten clinical tips on COVID-19 for healthcare providers involved in patient care. 2020 [internet publication].
https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-tips-for-healthcare-providers.html
临床表现在不同地理位置略有不同。美国病例的初步印象表明,临床表现可能比中国和意大利所观察到的更为广泛,胸痛、头痛、精神状态改变和胃肠道症状均可见于首发症状。还观察到严重肝肾功能不全致使肺部不适。[391]Sommer P, Lukovic E, Fagley E, et al. Initial clinical impressions of the critical care of COVID-19 patients in Seattle, New York City, and Chicago. Anesth Analg. 2020 Jul;131(1):55-60.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7172559/
http://www.ncbi.nlm.nih.gov/pubmed/32221172?tool=bestpractice.com
来自纽约市首批住院患者的数据显示,尽管最常见的首发症状为发热、咳嗽、呼吸困难和肌痛,但似乎胃肠道症状比中国更为常见。[392]Goyal P, Choi JJ, Pinheiro LC, et al. Clinical characteristics of Covid-19 in New York City. N Engl J Med. 2020 Jun 11;382(24):2372-4.
https://www.nejm.org/doi/full/10.1056/NEJMc2010419
http://www.ncbi.nlm.nih.gov/pubmed/32302078?tool=bestpractice.com
严重程度
根据一项欧洲研究,轻中症患者最普遍症状为头痛、嗅觉丧失、鼻塞、咳嗽、乏力、肌痛、流涕、味觉障碍和咽痛。较少诉发热。症状平均持续时间为 11.5 天。临床表现随年龄发生变化,年轻患者通常出现耳、鼻和咽喉不适,而老年患者则通常出现发热、乏力和食欲丧失。[393]Lechien JR, Chiesa-Estomba CM, Place S, et al. Clinical and epidemiological characteristics of 1,420 European patients with mild-to-moderate coronavirus disease 2019. J Intern Med. 2020 Apr 30 [Epub ahead of print].
https://onlinelibrary.wiley.com/doi/10.1111/joim.13089
http://www.ncbi.nlm.nih.gov/pubmed/32352202?tool=bestpractice.com
重症患者更为常见症状包括发热、呼吸困难和厌食。[132]Xie Y, Wang Z, Liao H, et al. Epidemiologic, clinical, and laboratory findings of the COVID-19 in the current pandemic: systematic review and meta-analysis. BMC Infect Dis. 2020 Aug 31;20(1):640.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7457225/
http://www.ncbi.nlm.nih.gov/pubmed/32867706?tool=bestpractice.com
孕妇
孕妇临床特征与非孕妇成人临床特征相似。[394]Matar R, Alrahmani L, Monzer N, et al. Clinical presentation and outcomes of pregnant women with COVID-19: a systematic review and meta-analysis. Clin Infect Dis. 2020 Jun 23 [Epub ahead of print].
https://academic.oup.com/cid/article/doi/10.1093/cid/ciaa828/5861636
http://www.ncbi.nlm.nih.gov/pubmed/32575114?tool=bestpractice.com
孕妇最常见的症状是发热和咳嗽。但是,与未妊娠育龄女性相比,孕妇更少表现发热和肌痛。[395]Allotey J, Stallings E, Bonet M, et al. Clinical manifestations, risk factors, and maternal and perinatal outcomes of coronavirus disease 2019 in pregnancy: living systematic review and meta-analysis. BMJ. 2020 Sep 1;370:m3320.
https://www.bmj.com/content/370/bmj.m3320
http://www.ncbi.nlm.nih.gov/pubmed/32873575?tool=bestpractice.com
重要的是要注意,由于妊娠生理适应或不良妊娠事件,发热、呼吸困难、消化道症状和乏力等症状可能会与其交叠。[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
非典型表现
可能出现非典型表现,尤其是老年和免疫功能低下患者(例如跌倒、谵妄/意识模糊、功能下降、运动能力下降、晕厥、持续性呃逆、无发热)。老年患者和存在合并症患者可能表现为轻症症状,但具有较高的恶化风险。[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
COVID-19 患者已有腮腺炎(可能与腮腺内淋巴结炎相关)、口腔粘膜大疱类疾病、视网膜病变和雄激素性脱发等病例报道;然而,尚不清楚此类发现是否与严重急性呼吸综合征冠状病毒 2(severe acute respiratory syndrome coronavirus 2, SARS-CoV-2)感染有关。[396]Lechien JR, Chetrit A, Chekkoury-Idrissi Y, et al. Parotitis-like symptoms associated with COVID-19, France, March-April 2020. Emerg Infect Dis. 2020 Jun 3;26(9).
https://wwwnc.cdc.gov/eid/article/26/9/20-2059_article
http://www.ncbi.nlm.nih.gov/pubmed/32491984?tool=bestpractice.com
[397]Martín Carreras-Presas C, Amaro Sánchez J, López-Sánchez AF, et al. Oral vesiculobullous lesions associated with SARS-CoV-2 infection. Oral Dis. 2020 May 5 [Epub ahead of print].
https://onlinelibrary.wiley.com/doi/full/10.1111/odi.13382
http://www.ncbi.nlm.nih.gov/pubmed/32369674?tool=bestpractice.com
[398]Marinho PM, Marcos AAA, Romano AC, et al. Retinal findings in patients with COVID-19. Lancet. 2020 May 23;395(10237):1610.
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31014-X/fulltext
http://www.ncbi.nlm.nih.gov/pubmed/32405105?tool=bestpractice.com
[399]Wambier CG, Vaño-Galván S, McCoy J, et al. Androgenetic alopecia present in the majority of hospitalized COVID-19 patients: the "Gabrin sign". J Am Acad Dermatol. 2020 May 21;83(2):680-2.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7242206/
http://www.ncbi.nlm.nih.gov/pubmed/32446821?tool=bestpractice.com
同时感染
SARS-CoV-2 阳性患者中,病毒和非典型细菌混合感染的汇总流行率为 11.6%(在对 100% 患者进行共病原体检测的研究中,该比例为 16.8%)。[400]Davis B, Rothrock AN, Swetland S, et al. Viral and atypical respiratory co-infections in COVID-19: a systematic review and meta-analysis. J Am Coll Emerg Physicians Open. 2020 Jun 19 [Epub ahead of print].
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7323310/
http://www.ncbi.nlm.nih.gov/pubmed/32838380?tool=bestpractice.com
据报道,7% 的住院患者存在细菌性混合感染,而在重症监护病房中这一比率则为 14%。最常见的细菌为肺炎支原体、铜绿假单胞菌、流感嗜血杆菌和肺炎克雷伯菌。真菌病原体和病毒(例如呼吸道合胞病毒、甲型流感病毒)混合感染的报道不甚常见。[401]Lansbury L, Lim B, Baskaran V, et al. Co-infections in people with COVID-19: a systematic review and meta-analysis. J Infect. 2020 May 27 [Epub ahead of print].
https://www.journalofinfection.com/article/S0163-4453(20)30323-6/pdf
http://www.ncbi.nlm.nih.gov/pubmed/32473235?tool=bestpractice.com
混合感染在重症患者中更为常见。[402]Langford BJ, So M, Raybardhan S, et al. Bacterial co-infection and secondary infection in patients with COVID-19: a living rapid review and meta-analysis. Clin Microbiol Infect. 2020 Jul 22 [Epub ahead of print].
https://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(20)30423-7/fulltext
http://www.ncbi.nlm.nih.gov/pubmed/32711058?tool=bestpractice.com
若不及早发现和治疗,混合感染可能与呼吸道症状迁延、长期接受重症诊疗,以及病率和死亡率相关。[403]Gayam V, Konala VM, Naramala S, et al. Presenting characteristics, comorbidities, and outcomes of patients coinfected with COVID-19 and Mycoplasma pneumoniae in the USA. J Med Virol. 2020 May 25 [Epub ahead of print].
https://onlinelibrary.wiley.com/doi/full/10.1002/jmv.26026
http://www.ncbi.nlm.nih.gov/pubmed/32449972?tool=bestpractice.com
流感病毒混合感染患者与单纯 COVID-19 患者表现为相似的临床特征。[404]Ding Q, Lu P, Fan Y, et al. The clinical characteristics of pneumonia patients co-infected with 2019 novel coronavirus and influenza virus in Wuhan, China. J Med Virol. 2020 Mar 20 [Epub ahead of print].
https://onlinelibrary.wiley.com/doi/epdf/10.1002/jmv.25781
http://www.ncbi.nlm.nih.gov/pubmed/32196707?tool=bestpractice.com
[405]Cuadrado-Payán E, Montagud-Marrahi E, Torres-Elorza M, et al. SARS-CoV-2 and influenza virus co-infection. Lancet. 2020 May 16;395(10236):e84.
https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(20)31052-7.pdf
http://www.ncbi.nlm.nih.gov/pubmed/32423586?tool=bestpractice.com
儿童临床表现
征象和症状可能与其他常见病毒性呼吸道感染和其他儿童期疾病相似,因此对于儿童需要高度怀疑 COVID-19。
严重程度
33% 儿童表现为轻度疾病
51% 儿童表现为中度疾病
7% 儿童表现为重症
5% 儿童表现为危重症
20% 儿童表现为无症状疾患。[406]Cui X, Zhao Z, Zhang T, et al. A systematic review and meta-analysis of children with coronavirus disease 2019 (COVID-19). J Med Virol. 2020 Aug 6 [Epub ahead of print].
https://onlinelibrary.wiley.com/doi/abs/10.1002/jmv.26398
http://www.ncbi.nlm.nih.gov/pubmed/32761898?tool=bestpractice.com
迄今为止的证据表明,约 95% 儿童病程较轻微或无症状,但对于该两类患儿,均可能有证据表明其肺部存在放射影像学改变。常见症状包括发热、咳嗽、咽痛、鼻塞和流涕。与成人相比,儿童发热、咳嗽和呼吸困难不甚常见。与成人相比,儿童更易出现胃肠道症状,尤其是新生儿和婴幼儿,其可能为唯一症状。[386]Liguoro I, Pilotto C, Bonanni M, et al. SARS-COV-2 infection in children and newborns: a systematic review. Eur J Pediatr. 2020 Jul;179(7):1029-46.
https://link.springer.com/article/10.1007/s00431-020-03684-7
http://www.ncbi.nlm.nih.gov/pubmed/32424745?tool=bestpractice.com
热性惊厥较少报道。[20]Garazzino S, Montagnani C, Donà D, et al. Multicentre Italian study of SARS-CoV-2 infection in children and adolescents, preliminary data as at 10 April 2020. Euro Surveill. 2020 May;25(18).
https://www.eurosurveillance.org/content/10.2807/1560-7917.ES.2020.25.18.2000600
http://www.ncbi.nlm.nih.gov/pubmed/32400362?tool=bestpractice.com
与甲型流感感染相比,5 岁以下年龄儿童临床表现似乎较轻。[407]Li Y, Wang H, Wang F, et al. Comparison of hospitalized patients with pneumonia caused by COVID-19 and influenza A in children under 5 years. Int J Infect Dis. 2020 Jun 11;98:80-3.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7289729/
http://www.ncbi.nlm.nih.gov/pubmed/32535301?tool=bestpractice.com
儿童罕见重症病例报道。[386]Liguoro I, Pilotto C, Bonanni M, et al. SARS-COV-2 infection in children and newborns: a systematic review. Eur J Pediatr. 2020 Jul;179(7):1029-46.
https://link.springer.com/article/10.1007/s00431-020-03684-7
http://www.ncbi.nlm.nih.gov/pubmed/32424745?tool=bestpractice.com
[408]Cook J, Harman K, Zoica B, et al. Horizontal transmission of severe acute respiratory syndrome coronavirus 2 to a premature infant: multiple organ injury and association with markers of inflammation. Lancet Child Adolesc Health. 2020 Jul;4(7):548-51.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7237364/
http://www.ncbi.nlm.nih.gov/pubmed/32442422?tool=bestpractice.com
美国一项针对 48 名危重症婴儿和儿童进行的横断面研究发现,与成人相比,其临床病程和住院结局更佳。与成人类似的一点是,80% 的危重症儿童患有合并症,最常见的如免疫抑制/癌症、心脏疾病、肥胖和糖尿病。[409]Shekerdemian LS, Mahmood NR, Wolfe KK, et al. Characteristics and outcomes of children with coronavirus disease 2019 (COVID-19) infection admitted to US and Canadian pediatric intensive care units. JAMA Pediatr. 2020 May 11 [Epub ahead of print].
https://jamanetwork.com/journals/jamapediatrics/fullarticle/2766037
http://www.ncbi.nlm.nih.gov/pubmed/32392288?tool=bestpractice.com
[410]Williams N, Radia T, Harman K, et al. COVID-19 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in children and adolescents: a systematic review of critically unwell children and the association with underlying comorbidities. Eur J Pediatr. 2020 Sep 10 [Epub ahead of print].
https://link.springer.com/article/10.1007%2Fs00431-020-03801-6
http://www.ncbi.nlm.nih.gov/pubmed/32914200?tool=bestpractice.com
值得注意的是,与 1 岁以上儿童相比,1 岁以下儿童危重症报道频率更高,该年龄段人群呕吐更为常见。[406]Cui X, Zhao Z, Zhang T, et al. A systematic review and meta-analysis of children with coronavirus disease 2019 (COVID-19). J Med Virol. 2020 Aug 6 [Epub ahead of print].
https://onlinelibrary.wiley.com/doi/abs/10.1002/jmv.26398
http://www.ncbi.nlm.nih.gov/pubmed/32761898?tool=bestpractice.com
重症儿童中正出现一种相关的炎症综合症,越来越引发关注。更多信息,请参阅并发症章节。
新生儿
新生儿中已有 COVID-19 病例报道。呼吸困难是新生儿最常见征象。尽管疾病通常为轻症,但已有危重症报道,包括迟发型新生儿脓毒症和脑炎病例。与年龄较大的儿童相比,新生儿危重症略加更为常见。婴儿可能出现易激惹、哭闹、进食困难、沉默性低氧和神经系统症状。[386]Liguoro I, Pilotto C, Bonanni M, et al. SARS-COV-2 infection in children and newborns: a systematic review. Eur J Pediatr. 2020 Jul;179(7):1029-46.
https://link.springer.com/article/10.1007/s00431-020-03684-7
http://www.ncbi.nlm.nih.gov/pubmed/32424745?tool=bestpractice.com
[411]Lorenz N, Treptow A, Schmidt S, et al. Neonatal early-onset infection with SARS-CoV-2 in a newborn presenting with encephalitic symptoms. Pediatr Infect Dis J. 2020 Aug;39(8):e212.
http://www.ncbi.nlm.nih.gov/pubmed/32404789?tool=bestpractice.com
[412]Chacón-Aguilar R, Osorio-Cámara JM, Sanjurjo-Jimenez I, et al. COVID-19: fever syndrome and neurological symptoms in a neonate. An Pediatr (Engl Ed). 2020 Apr 27;92(6):373-4.
https://www.sciencedirect.com/science/article/pii/S2341287920300661?via%3Dihub
http://www.ncbi.nlm.nih.gov/pubmed/32341945?tool=bestpractice.com
[413]Sinelli MT, Paterlini G, Citterio M, et al. Early neonatal SARS-CoV-2 infection manifesting with hypoxemia requiring respiratory support. Pediatrics. 2020 Jul;146(1):e20201121.
https://pediatrics.aappublications.org/content/early/2020/04/30/peds.2020-1121.long
http://www.ncbi.nlm.nih.gov/pubmed/32366612?tool=bestpractice.com
同时感染
混合感染在儿童中可能更为常见。[414]Xia W, Shao J, Guo Y, et al. Clinical and CT features in pediatric patients with COVID-19 infection: different points from adults. Pediatr Pulmonol. 2020 May;55(5):1169-74.
https://onlinelibrary.wiley.com/doi/full/10.1002/ppul.24718
http://www.ncbi.nlm.nih.gov/pubmed/32134205?tool=bestpractice.com
美国和意大利研究中,6% 儿童出现混合感染,最常见病原体为呼吸道合胞病毒、鼻病毒、EB 病毒、甲型流感、非 SARS 冠状病毒和肺炎链球菌。[20]Garazzino S, Montagnani C, Donà D, et al. Multicentre Italian study of SARS-CoV-2 infection in children and adolescents, preliminary data as at 10 April 2020. Euro Surveill. 2020 May;25(18).
https://www.eurosurveillance.org/content/10.2807/1560-7917.ES.2020.25.18.2000600
http://www.ncbi.nlm.nih.gov/pubmed/32400362?tool=bestpractice.com
[214]DeBiasi RL, Song X, Delaney M, et al. Severe COVID-19 in children and young adults in the Washington, DC metropolitan region. J Pediatr. 2020 Aug;223:199-203.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7217783/
http://www.ncbi.nlm.nih.gov/pubmed/32405091?tool=bestpractice.com
体格检查
进行体格检查。如果可能,应避免使用听诊器,因其存在病毒污染风险。患者可出现发热(伴或不伴寒战/畏寒),并出现明显咳嗽和/或呼吸困难。肺炎或呼吸窘迫患者胸部听诊可闻及吸气湿啰音、啰音和/或支气管呼吸音。呼吸窘迫患者可伴随缺氧出现心动过速、呼吸急促或紫绀。一项小型队列研究中,注意到轻中度疾病患者出现心动过缓。[415]Ikeuchi K, Saito M, Yamamoto S, et al. Relative bradycardia in patients with mild-to-moderate coronavirus disease, Japan. Emerg Infect Dis. 2020 Jul 1;26(10).
https://wwwnc.cdc.gov/eid/article/26/10/20-2648_article
http://www.ncbi.nlm.nih.gov/pubmed/32610036?tool=bestpractice.com
脉搏血氧测量
脉搏血氧测定可发现低氧饱和度(SpO₂ <90%)。 临床医生应意识到,COVID-19 患者可出现“沉默性低氧”:他们的血氧饱和度可能降至低水平,并引发急性呼吸衰竭,但却无明显呼吸窘迫症状。仅有一小部分患者出现其他器官功能障碍,这意味着在急性恶化初始阶段之后,对于进一步恶化的传统识别方法(例如英国国家早期预警评分 2 [National Early Warning Score 2, NEWS2] 评分)可能对于哪些患者将进展至呼吸衰竭无法进行预测。[416]Xie J, Tong Z, Guan X, et al. Critical care crisis and some recommendations during the COVID-19 epidemic in China. Intensive Care Med. 2020 May;46(5):837-40.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7080165/
http://www.ncbi.nlm.nih.gov/pubmed/32123994?tool=bestpractice.com
虽然 NEWS2 仍被建议用于 COVID-19 患者,但英国皇家内科医师学院目前建议,若此类患者需氧量增加,应请示能力更强的上级临床决策者,并将观察频率初步增加到至少每小时一次,直到进行全面临床评估。[417]Royal College of Physicians. NEWS2 and deterioration in COVID-19. 2020 [internet publication].
https://www.rcplondon.ac.uk/news/news2-and-deterioration-covid-19
初步实验室检查
所有重症患者均应进行以下实验室检查:
最常见的实验室异常为淋巴细胞减少、白细胞增多、白细胞减少、血小板减少、低白蛋白血症、心脏生物标志物升高、炎症标志物升高、D-二聚体升高以及肝肾功能异常。[392]Goyal P, Choi JJ, Pinheiro LC, et al. Clinical characteristics of Covid-19 in New York City. N Engl J Med. 2020 Jun 11;382(24):2372-4.
https://www.nejm.org/doi/full/10.1056/NEJMc2010419
http://www.ncbi.nlm.nih.gov/pubmed/32302078?tool=bestpractice.com
[418]Li LQ, Huang T, Wang YQ, et al. COVID-19 patients' clinical characteristics, discharge rate, and fatality rate of meta-analysis. J Med Virol. 2020 Jun;92(6):577-83.
https://onlinelibrary.wiley.com/doi/epdf/10.1002/jmv.25757
http://www.ncbi.nlm.nih.gov/pubmed/32162702?tool=bestpractice.com
[419]Zhu J, Zhong Z, Ji P, et al. Clinicopathological characteristics of 8697 patients with COVID-19 in China: a meta-analysis. Fam Med Community Health. 2020 Apr;8(2).
https://fmch.bmj.com/content/8/2/e000406
http://www.ncbi.nlm.nih.gov/pubmed/32371463?tool=bestpractice.com
[420]Zhang ZL, Hou YL, Li DT, et al. Laboratory findings of COVID-19: a systematic review and meta-analysis. Scand J Clin Lab Invest. 2020 May 23:1-7.
https://www.tandfonline.com/doi/full/10.1080/00365513.2020.1768587
http://www.ncbi.nlm.nih.gov/pubmed/32449374?tool=bestpractice.com
实验室异常(特别是淋巴细胞减少、白细胞异常和其他全身性炎症标志物)在儿童中较为少见。[386]Liguoro I, Pilotto C, Bonanni M, et al. SARS-COV-2 infection in children and newborns: a systematic review. Eur J Pediatr. 2020 Jul;179(7):1029-46.
https://link.springer.com/article/10.1007/s00431-020-03684-7
http://www.ncbi.nlm.nih.gov/pubmed/32424745?tool=bestpractice.com
[421]Wu H, Zhu H, Yuan C, et al. Clinical and immune features of hospitalized pediatric patients with coronavirus disease 2019 (COVID-19) in Wuhan, China. JAMA Netw Open. 2020 Jun 1;3(6):e2010895.
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2766670
http://www.ncbi.nlm.nih.gov/pubmed/32492165?tool=bestpractice.com
[422]Henry BM, Benoit SW, de Oliveira MHS, et al. Laboratory abnormalities in children with mild and severe coronavirus disease 2019 (COVID-19): a pooled analysis and review. Clin Biochem. 2020 Jul;81:1-8.
https://www.sciencedirect.com/science/article/pii/S0009912020303313?via%3Dihub
http://www.ncbi.nlm.nih.gov/pubmed/32473151?tool=bestpractice.com
多数无症状患者(62%)表现为正常的实验室检查指标。实验室检查异常者中,白细胞减少、淋巴细胞减少、乳酸脱氢酶升高和 C 反应蛋白升高为最常见表现。[423]Kronbichler A, Kresse D, Yoon S, et al. Asymptomatic patients as a source of COVID-19 infections: a systematic review and meta-analysis. Int J Infect Dis. 2020 Jun 17 [Epub ahead of print].
https://www.ijidonline.com/article/S1201-9712(20)30487-2/pdf
http://www.ncbi.nlm.nih.gov/pubmed/32562846?tool=bestpractice.com
采集重症或危重症患者血液和痰液标本进行培养,以排除引起下呼吸道感染和脓毒症其他病因,尤其是具有不典型流行病史的患者。如果可能,应在开始使用经验性抗菌药物之前采集标本。[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
分子检测
需要进行分子检测以确认诊断。条件允许时,应始终对疑似感染患者针对 SAR-CoV-2 进行核酸扩增检测(详见“诊断标准”部分),如实时逆转录聚合酶链反应(reverse-transcription polymerase chain reaction, RT-PCR)。[385]World Health Organization. Diagnostic testing for SARS-CoV-2: interim guidance. 2020 [internet publication].
https://www.who.int/publications/i/item/diagnostic-testing-for-sars-cov-2
检测应根据当地卫生部门发布的指南进行,并遵循恰当的生物安全规范。
需要检测谁
应基于临床和流行病学因素做出哪些人应进行检测的决策。[385]World Health Organization. Diagnostic testing for SARS-CoV-2: interim guidance. 2020 [internet publication].
https://www.who.int/publications/i/item/diagnostic-testing-for-sars-cov-2
在英国,推荐对以下人群进行检测:[383]Department of Health and Social Care. Everyone in the United Kingdom with symptoms now eligible for coronavirus tests. 2020 [internet publication].
https://www.gov.uk/government/news/everyone-in-the-united-kingdom-with-symptoms-now-eligible-for-coronavirus-tests
[424]Public Health England. COVID-19: investigation and initial clinical management of possible cases. 2020 [internet publication].
https://www.gov.uk/government/publications/wuhan-novel-coronavirus-initial-investigation-of-possible-cases/investigation-and-initial-clinical-management-of-possible-cases-of-wuhan-novel-coronavirus-wn-cov-infection
在美国,建议对以下人群进行检测:[425]Centers for Disease Control and Prevention. Overview of testing for SARS-CoV-2 (COVID-19). 2020 [internet publication].
https://www.cdc.gov/coronavirus/2019-ncov/hcp/testing-overview.html
美国儿科学会建议对症状与 COVID-19 一致的儿童,与可能或确诊感染个体产生密切接触的儿童,以及计划进行侵入性医学操作的儿童,给予检测。检测决定不因儿童年龄而异。不建议对不具相同症状的其他疾病(例如尿路感染、蜂窝织炎)或与受感染个体产生密切接触的儿童进行检测,除非密切接触者本身的后续检测呈阳性。[426]American Academy of Pediatrics. COVID-19 testing guidance. 2020 [internet publication].
https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/covid-19-testing-guidance/
应询问当地卫生部门以获取指南,因为检测优先级取决于地方建议和可用资源。
样本
用于检测的最佳样本取决于患者临床表现和症状持续时间。世界卫生组织(World Health Organization, WHO)推荐如下样本。[385]World Health Organization. Diagnostic testing for SARS-CoV-2: interim guidance. 2020 [internet publication].
https://www.who.int/publications/i/item/diagnostic-testing-for-sars-cov-2
上呼吸道样本:早期感染时的推荐选择,尤其是在无症状或轻度病例中。鼻咽拭子的检测结果比口咽拭子更为可靠;联合使用鼻咽拭子和口咽拭子能进一步提高信度。
下呼吸道样本:推荐用于晚期感染患者或强烈怀疑感染但上呼吸道样本检测阴性的患者。合适的样本包括患有更严重呼吸道疾病患者的痰液和/或气管抽吸物或支气管肺泡灌洗液。然而,考虑到收集下呼吸道样本时发生气溶胶传播的高风险 – 不推荐使用通过诱发咳嗽获取的痰样本,因为这会增加气溶胶传播的风险。
其他呼吸道样本:已对口咽和鼻孔/鼻拭子、中鼻甲或下鼻腔或鼻孔拭子或舌拭子进行了研究;但是,需进一步给予评估和验证。收集口腔体液对于某些情况(例如幼儿、老年痴呆患者)也许适用新证据表明,唾液可能是建立诊断的可靠样本。[427]Azzi L, Carcano G, Gianfagna F, et al. Saliva is a reliable tool to detect SARS-CoV-2. J Infect. 2020 Apr 13 [Epub ahead of print].
https://www.journalofinfection.com/article/S0163-4453(20)30213-9/pdf
http://www.ncbi.nlm.nih.gov/pubmed/32298676?tool=bestpractice.com
[428]Williams E, Bond K, Zhang B, et al. Saliva as a non-invasive specimen for detection of SARS-CoV-2. J Clin Microbiol. 2020 Apr 21 [Epub ahead of print].
https://jcm.asm.org/content/jcm/early/2020/04/17/JCM.00776-20.full.pdf
http://www.ncbi.nlm.nih.gov/pubmed/32317257?tool=bestpractice.com
[429]Caulley L, Corsten M, Eapen L, et al. Salivary detection of COVID-19. Ann Intern Med. 2020 Aug 28 [Epub ahead of print].
https://www.acpjournals.org/doi/10.7326/M20-4738
http://www.ncbi.nlm.nih.gov/pubmed/32857591?tool=bestpractice.com
[430]Wyllie AL, Fournier J, Casanovas-Massana A, et al. Saliva or nasopharyngeal swab specimens for detection of SARS-CoV-2. N Engl J Med. 2020 Aug 28 [Epub ahead of print].
https://www.nejm.org/doi/full/10.1056/NEJMc2016359
http://www.ncbi.nlm.nih.gov/pubmed/32857487?tool=bestpractice.com
然而,目前 WHO 不推荐将唾液作为常规临床诊断的唯一样本类型。
粪便样本:当上呼吸道或下呼吸道样本为阴性但临床仍怀疑感染时可考虑使用(可在症状发作第二周以后使用)
不同国家推荐使用的样本类型也可能不同。例如,美国疾病预防控制中心(Centers for Disease Control and Prevention, CDC)推荐下列上呼吸道样本:鼻咽或口咽拭子、鼻部中鼻甲拭子、鼻前孔拭子或鼻咽/鼻部冲洗/抽吸。推荐的下呼吸道样本包括:痰液、支气管肺泡灌洗液、气管抽吸物、胸腔积液和肺活检。[431]Centers for Disease Control and Prevention. Interim guidelines for collecting, handling, and testing clinical specimens for COVID-19. 2020 [internet publication].
https://www.cdc.gov/coronavirus/2019-ncov/lab/guidelines-clinical-specimens.html
在采取了适当感染防控措施的条件下收集样本。
检测结果
RT-PCR 阳性结果可确诊 SARS-CoV-2 感染。如果为阴性结果,但仍临床怀疑感染(例如存在流行病学关联、存在典型 X 线表现、没有其他可能病因),则再次对患者进行取样并重复检测。阳性结果可确诊感染。如果第二次检测仍为阴性,考虑血清学检测(见下方)。[385]World Health Organization. Diagnostic testing for SARS-CoV-2: interim guidance. 2020 [internet publication].
https://www.who.int/publications/i/item/diagnostic-testing-for-sars-cov-2
不推荐将基因组测序作为常规方法,但可能有助研究暴发的动态变化,包括流行病规模随时间的变化、时空上的传播以及对传播途径假设的验证。[385]World Health Organization. Diagnostic testing for SARS-CoV-2: interim guidance. 2020 [internet publication].
https://www.who.int/publications/i/item/diagnostic-testing-for-sars-cov-2
鼻拭子检测并发症
鼻拭子检测相关并发症尚未得到充分描述。不良反应可能包括鼻衄、鼻腔不适、头痛、耳部不适和鼻漏。[432]Gupta K, Bellino PM, Charness ME. Adverse effects of nasopharyngeal swabs: three-dimensional printed versus commercial swabs. Infect Control Hosp Epidemiol. 2020 Jun 11 [Epub ahead of print].
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7308627/
http://www.ncbi.nlm.nih.gov/pubmed/32522313?tool=bestpractice.com
据报道,一名未被诊断出筛窦小窝颅底缺损的女性,在接受 COVID-19 鼻拭子检测后,出现医源性脑脊液渗漏。[433]Sullivan CB, Schwalje AT, Jensen M, et al. Cerebrospinal fluid leak after nasal swab testing for coronavirus disease 2019. JAMA Otolaryngol Head Neck Surg. 2020 Oct 1 [Epub ahead of print].
https://jamanetwork.com/journals/jamaotolaryngology/article-abstract/2771362
http://www.ncbi.nlm.nih.gov/pubmed/33022069?tool=bestpractice.com
其他感染的检测
采集鼻咽拭子进行检测,根据当地指南,有临床指征时,排除其他呼吸道病原体(例如流感、非典型病原体)所致感染。根据当地流行病学和临床症状,酌情检测其他潜在原因,包括疟疾、登革热和伤寒。重要的是,要注意可能出现混合感染,非 COVID-19 病原体的阳性检测结果不能排除 COVID-19。[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
[434]Wu X, Cai Y, Huang X, et al. Co-infection with SARS-CoV-2 and influenza A virus in patient with pneumonia, China. Emerg Infect Dis. 2020 Mar 11;26(6).
https://wwwnc.cdc.gov/eid/article/26/6/20-0299_article
http://www.ncbi.nlm.nih.gov/pubmed/32160148?tool=bestpractice.com
当 SARS-CoV-2 与流感病毒同时传播时,需在所有住院急性呼吸道疾病患者中对这两种病毒进行检测,如果检测结果将改变患者临床管理,则仅对急性呼吸道疾病门诊患者进行流感病毒检测。[3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2020 [internet publication].
https://covid19treatmentguidelines.nih.gov/
分子检测的局限性
应谨慎解读 RT-PCR 检测结果。
使用 RT-PCR 诊断 COVID-19 的证据仍在不断出现,其有效性和准确性尚不确定。在缺乏诊断或排除 COVID-19 的明确参考标准情况下,应谨慎解读对诊断准确性的估计。此外,还需要更多证据,证明在医院环境外,以及在无症状或轻症病例中检测的有效性。[435]Jarrom D, Elston L, Washington J, et al. Effectiveness of tests to detect the presence of SARS-CoV-2 virus, and antibodies to SARS-CoV-2, to inform COVID-19 diagnosis: a rapid systematic review. BMJ Evid Based Med. 2020 Oct 1 [Epub ahead of print].
https://ebm.bmj.com/content/early/2020/09/30/bmjebm-2020-111511.long
http://www.ncbi.nlm.nih.gov/pubmed/33004426?tool=bestpractice.com
很少有研究尝试从人类样本中培养 SARS-CoV-2 活病毒。这是一个待解决的问题,因为病毒培养被认为是金标准检测,所有病毒诊断性指标检测须针对病毒培养进行衡量和校对,以明确该检测的预测性。[436]Centre for Evidence-Based Medicine; Jefferson T, Heneghan C, Spencer EA, et al. Are you infectious if you have a positive PCR test result for COVID-19? 2020 [internet publication].
https://www.cebm.net/covid-19/infectious-positive-pcr-test-result-covid-19/
对参考样本和病毒培养样本进行前瞻性常规检测十分必要,因其可明确 RT-PCR 诊断 COVID-19 的实用性和可靠性,以及前者对于帮助进行感染性预测时,与患者因素(例如症状发作时间和拷贝阈值)的关联。[437]Jefferson T, Spencer E, Brassey J, et al; medRxiv. Viral cultures for COVID-19 infectivity assessment: systematic review. 2020 [internet publication].
https://www.medrxiv.org/content/10.1101/2020.08.04.20167932v1
由于没有适用于 COVID-19 检测的明确“金标准”,因此评估检测结果可能具有挑战性。临床判断基于拭子复查、病史、临床表现和胸部影像学检查,可能是现有最好的“金标准”。[438]Watson J, Whiting PF, Brush JE. Interpreting a covid-19 test result. BMJ. 2020 May 12;369:m1808.
https://www.bmj.com/content/369/bmj.m1808
http://www.ncbi.nlm.nih.gov/pubmed/32398230?tool=bestpractice.com
目前尚不清楚阳性结果是否一定表明存在传染性病毒。
对检测结果的解读取决于检测本身的准确性,以及疾病的验前概率和验后概率。结果的准确性取决于各种因素,包括采样地点和质量、疾病分期、病毒增殖或清除程度,以及患病率。[438]Watson J, Whiting PF, Brush JE. Interpreting a covid-19 test result. BMJ. 2020 May 12;369:m1808.
https://www.bmj.com/content/369/bmj.m1808
http://www.ncbi.nlm.nih.gov/pubmed/32398230?tool=bestpractice.com
灵敏度和特异度:汇总灵敏度估计为 87.8%,特异度估计为 87.7% 至 100%。[435]Jarrom D, Elston L, Washington J, et al. Effectiveness of tests to detect the presence of SARS-CoV-2 virus, and antibodies to SARS-CoV-2, to inform COVID-19 diagnosis: a rapid systematic review. BMJ Evid Based Med. 2020 Oct 1 [Epub ahead of print].
https://ebm.bmj.com/content/early/2020/09/30/bmjebm-2020-111511.long
http://www.ncbi.nlm.nih.gov/pubmed/33004426?tool=bestpractice.com
验前概率:应根据国家和地区数据所反映的当地感染率、患者症状、潜在病例接触、COVID-19 既往史或是否存在抗体,以及其他诊断的可能性,估计验前概率。[438]Watson J, Whiting PF, Brush JE. Interpreting a covid-19 test result. BMJ. 2020 May 12;369:m1808.
https://www.bmj.com/content/369/bmj.m1808
http://www.ncbi.nlm.nih.gov/pubmed/32398230?tool=bestpractice.com
当验前概率低时,应谨慎解读阳性结果,理想情况下应再测试一个样本以进行确认。[439]Surkova E, Nikolayevskyy V, Drobniewski F. False-positive COVID-19 results: hidden problems and costs. Lancet Respir Med. 2020 Sep 29 [Epub ahead of print].
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7524437/
http://www.ncbi.nlm.nih.gov/pubmed/33007240?tool=bestpractice.com
验后概率:指定人群患病率越低,验后概率就越低。[440]Floriano I, Silvinato A, Bernardo WM, et al. Accuracy of the polymerase chain reaction (PCR) test in the diagnosis of acute respiratory syndrome due to coronavirus: a systematic review and meta-analysis. Rev Assoc Med Bras (1992). 2020 Jul;66(7):880-8.
https://www.scielo.br/scielo.php?pid=S0104-42302020000700880&script=sci_arttext&tlng=en
http://www.ncbi.nlm.nih.gov/pubmed/32844930?tool=bestpractice.com
例如,如果使用特异性为 99% 的检测方法对感染可能性为 50% 的高风险有症状人群进行检测,则阳性预测值为 99%。这意味着,每 100 名检测结果阳性者,其中 99 人将呈现 SARS-CoV-2 感染,而 1 名未受感染者将出现假阳性结果。相反,在感染可能性较低(例如 0.05%)的低风险无症状人群中,阳性预测值约为 4.3%。这意味着,每 100 名检测结果阳性者,其中 4 至 5 人将呈现 SARS-CoV-2 感染,而未受感染的 95 至 96 人将出现假阳性结果。[441]Public Health Laboratory Network. PHLN statement on nucleic acid test false positive results for SARS-CoV-2. 2020 [internet publication].
https://www.health.gov.au/resources/publications/phln-statement-on-nucleic-acid-test-false-positive-results-for-sars-cov-2
BMJ Practice Pointer: interpreting a covid-19 tests result
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假阳性结果
假阳性结果可能由于检测误差,或当前和过去暴露于季节性人类冠状病毒感染(例如普通感冒)而形成的抗体发生交叉反应所致。[442]Australian Government Department of Health. COVID-19 testing in Australia: information for health professionals. 2020 [internet publication].
https://www.tga.gov.au/covid-19-testing-australia-information-health-professionals
若 SARS-COV-2 流行程度为中至低度,则假阳性结果可能性更高。[443]US Food and Drug Administration. CDC 2019-novel coronavirus (2019-nCoV) real-time RT-PCR diagnostic panel. 2020 [internet publication].
https://www.fda.gov/media/134922/download
假阳性检测率数据暂缺乏。然而,英国初步估值为 0.8%-4%。[444]Government Office for Science; Scientific Advisory Group for Emergencies. Impact of false-positives and false-negatives in the UK’s COVID-19 RT-PCR testing programme. 2020 [internet publication].
https://www.gov.uk/government/publications/gos-impact-of-false-positives-and-negatives-3-june-2020
由于目前英国人群中感染病毒的患病率较低,这一比率意味着每日假阳性结果的比例很高,从而对检测的阳性预测值产生不利影响。[439]Surkova E, Nikolayevskyy V, Drobniewski F. False-positive COVID-19 results: hidden problems and costs. Lancet Respir Med. 2020 Sep 29 [Epub ahead of print].
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7524437/
http://www.ncbi.nlm.nih.gov/pubmed/33007240?tool=bestpractice.com
假阳性检测结果的潜在后果示例包括:[439]Surkova E, Nikolayevskyy V, Drobniewski F. False-positive COVID-19 results: hidden problems and costs. Lancet Respir Med. 2020 Sep 29 [Epub ahead of print].
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7524437/
http://www.ncbi.nlm.nih.gov/pubmed/33007240?tool=bestpractice.com
不必要的推迟或取消择期手术或治疗
紧急入院期间错误的路径导致潜在的感染暴露
自我隔离造成的经济损失、收入损失和旅行取消
误诊造成的心理伤害,包括害怕感染他人或羞耻感
因封锁和隔离而增多的抑郁或家庭暴力
人群中无症状感染的发病率和程度受到过高估计。
假阴性结果
据报道,假阴性率在 2% 至 29% 之间。[438]Watson J, Whiting PF, Brush JE. Interpreting a covid-19 test result. BMJ. 2020 May 12;369:m1808.
https://www.bmj.com/content/369/bmj.m1808
http://www.ncbi.nlm.nih.gov/pubmed/32398230?tool=bestpractice.com
感染者出现假阴性结果的可能性从感染第 1 天的 100% 降至第 4 天的 67%。中位假阴性率在症状发作当天降至 38%,第 8 天降至 20%,而后从第 9 天起开始再次升高。[445]Kucirka LM, Lauer SA, Laeyendecker O, et al. Variation in false-negative rate of reverse transcriptase polymerase chain reaction–based SARS-CoV-2 tests by time since exposure. Ann Intern Med. 2020 May 13 [Epub ahead of print].
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7240870/
http://www.ncbi.nlm.nih.gov/pubmed/32422057?tool=bestpractice.com
假阴性检测结果的潜在后果示例包括:[438]Watson J, Whiting PF, Brush JE. Interpreting a covid-19 test result. BMJ. 2020 May 12;369:m1808.
https://www.bmj.com/content/369/bmj.m1808
http://www.ncbi.nlm.nih.gov/pubmed/32398230?tool=bestpractice.com
血清学检测
血清学检测不能用作急性 SARS-CoV-2 感染的独立诊断性检测。但可用于多种情境(例如分子检测呈阴性时、诊断延迟就诊或症状持续时间长的患者、用于血清抗体监测)。[385]World Health Organization. Diagnostic testing for SARS-CoV-2: interim guidance. 2020 [internet publication].
https://www.who.int/publications/i/item/diagnostic-testing-for-sars-cov-2
[446]Watson J, Richter A, Deeks J. Testing for SARS-CoV-2 antibodies. BMJ. 2020 Sep 8;370:m3325.
https://www.bmj.com/content/370/bmj.m3325
http://www.ncbi.nlm.nih.gov/pubmed/32900692?tool=bestpractice.com
BMJ practice pointer: testing for SARS-CoV-2 antibodies
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对于强烈怀疑感染且 RT-PCR 结果阴性的患者,WHO 建议采集配对血清样本,即在急性期和 2-4 周后的恢复期各采集一次样本。[385]World Health Organization. Diagnostic testing for SARS-CoV-2: interim guidance. 2020 [internet publication].
https://www.who.int/publications/i/item/diagnostic-testing-for-sars-cov-2
美国 CDC 建议将血清学检测用作一种支持性诊断方法,用于在其他病毒检测方法(例如 RT-PCR、抗体检测)的基础上支持诊断延迟就诊(即症状发作 9-14 天后才就诊)的急性感染患者或就诊时伴有晚期并发症(例如儿童中的小儿炎性多系统综合征)。[447]Centers for Disease Control and Prevention. Interim guidelines for COVID-19 antibody testing. 2020 [internet publication].
https://www.cdc.gov/coronavirus/2019-ncov/lab/resources/antibody-tests-guidelines.html
首选获得了美国食品药品监督管理局紧急使用授权的检测试验。无论检测对象是免疫球蛋白 G(immunoglobulin G, IgG)、IgM+IgG 还是总抗体,检测方法之间不分优劣。
为了优化检测的阳性预测值,应选择高特异性(例如 >99.5%)的检测方法,并对具有高验前概率出现抗体的患者或人群进行检测,或采用正交实验法。应在预期预测值(阳性和阴性)背景下对结果进行解读。
美国传染病学会推荐在以下情况中使用血清学检测:[448]Infectious Diseases Society of America. Infectious Diseases Society of America guidelines on the diagnosis of COVID-19: serologic testing. 2020 [internet publication].
https://www.idsociety.org/practice-guideline/covid-19-guideline-serology/
SARS-CoV-2 的抗体反应通常发生于疾病前 1 至 3 周,IgG 抗体的血清转换时间常早于 IgM 抗体。[449]Long QX, Liu BZ, Deng HJ, et al. Antibody responses to SARS-CoV-2 in patients with COVID-19. Nat Med. 2020 Jun;26(6):845-8.
https://www.nature.com/articles/s41591-020-0897-1
http://www.ncbi.nlm.nih.gov/pubmed/32350462?tool=bestpractice.com
[450]Qu J, Wu C, Li X, et al. Profile of IgG and IgM antibodies against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Clin Infect Dis. 2020 Apr 27 [Epub ahead of print].
https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa489/5825506
http://www.ncbi.nlm.nih.gov/pubmed/32337590?tool=bestpractice.com
一项 Cochrane 评价发现,症状发作后 1 周进行 IgG/IgM 抗体检测,仅检测出 30% COVID-19患者,但在第 2 周检测出 70% 的患者,在第 3 周检测出 90% 以上的患者,从而准确性得到提高。超过 3 周的数据有限。无 COVID-19 的患者中,2% 患者检测得出假阳性结果。该评价发现,症状发作后第 1 周进行的抗体检测敏感性太低,无法在 COVID-19 诊断中起主要作用,但如果在症状发作后 15 天或以上进行检测,则可能对检测既往感染有所作用(尽管超过 35 天的数据很少)。[451]Deeks JJ, Dinnes J, Takwoingi Y, et al. Antibody tests for identification of current and past infection with SARS-CoV-2. Cochrane Database Syst Rev. 2020 Jun 25;(6):CD013652.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD013652/full
http://www.ncbi.nlm.nih.gov/pubmed/32584464?tool=bestpractice.com
血清学检测的局限性
使用抗体检测诊断 COVID-19 的证据仍在不断出现,其有效性和准确性尚不确定。在缺乏诊断或排除 COVID-19 的明确参考标准的情况下,应谨慎解读对诊断准确性的估计。需要更多证据,证明在医院外以及在无症状或轻症病例中检测的有效性。抗体检测的灵敏度估计为 18.4%-96.1%(报告的最低灵敏度来自即时检测,尽管一项实验室检查报告灵敏度 <50%),特异度为 88.9%-100%。[435]Jarrom D, Elston L, Washington J, et al. Effectiveness of tests to detect the presence of SARS-CoV-2 virus, and antibodies to SARS-CoV-2, to inform COVID-19 diagnosis: a rapid systematic review. BMJ Evid Based Med. 2020 Oct 1 [Epub ahead of print].
https://ebm.bmj.com/content/early/2020/09/30/bmjebm-2020-111511.long
http://www.ncbi.nlm.nih.gov/pubmed/33004426?tool=bestpractice.com
目前关于针对 SARS-CoV-2 的抗体应答的知识仍有待研究;因此,必须谨慎使用抗体检测试验,且不能用于确定是否存在急性感染。[385]World Health Organization. Diagnostic testing for SARS-CoV-2: interim guidance. 2020 [internet publication].
https://www.who.int/publications/i/item/diagnostic-testing-for-sars-cov-2
检测结果无法确定目前或过去是否存在过感染,因为 IgM 和 IgG 抗体在发生感染后需要 1-3 周来形成。[447]Centers for Disease Control and Prevention. Interim guidelines for COVID-19 antibody testing. 2020 [internet publication].
https://www.cdc.gov/coronavirus/2019-ncov/lab/resources/antibody-tests-guidelines.html
通常只有在恢复期才有可能得出可靠的诊断,而这时已经错过了治疗和切断传播的机会。[385]World Health Organization. Diagnostic testing for SARS-CoV-2: interim guidance. 2020 [internet publication].
https://www.who.int/publications/i/item/diagnostic-testing-for-sars-cov-2
对于在针对 SARS-CoV-2 的应答中产生的抗体,其抗体持久性的持续时间仍有待研究。[385]World Health Organization. Diagnostic testing for SARS-CoV-2: interim guidance. 2020 [internet publication].
https://www.who.int/publications/i/item/diagnostic-testing-for-sars-cov-2
一些患者在感染后可能不会产生可被检测到的抗体。且在那些会产生抗体的患者体内,抗体水平可能会随时间降至检测不到的水平。[447]Centers for Disease Control and Prevention. Interim guidelines for COVID-19 antibody testing. 2020 [internet publication].
https://www.cdc.gov/coronavirus/2019-ncov/lab/resources/antibody-tests-guidelines.html
存在与 SARS-CoV-2 结合的抗体并不代表它们一定是中和抗体或能提供保护性免疫。[385]World Health Organization. Diagnostic testing for SARS-CoV-2: interim guidance. 2020 [internet publication].
https://www.who.int/publications/i/item/diagnostic-testing-for-sars-cov-2
一些检测可能会显示出与其他冠状病毒(例如导致普通感冒的冠状病毒)的交叉反应,而这会导致假阳性结果。[447]Centers for Disease Control and Prevention. Interim guidelines for COVID-19 antibody testing. 2020 [internet publication].
https://www.cdc.gov/coronavirus/2019-ncov/lab/resources/antibody-tests-guidelines.html
血清学检测不应用于确定个人免疫状况,或用以对居住或收容至集体场所(例如学校、宿舍、监狱)或返岗人群进行分组的决策。[447]Centers for Disease Control and Prevention. Interim guidelines for COVID-19 antibody testing. 2020 [internet publication].
https://www.cdc.gov/coronavirus/2019-ncov/lab/resources/antibody-tests-guidelines.html
快速诊断试验
抗体检测
虽然快速抗体检测试剂盒已获批用于定性检测血清、血浆或全血中 SARS-CoV-2 IgG/IgM 抗体,但由于这些检测尚未得到验证,WHO 不推荐其在研究环境外使用。[452]World Health Organization. Advice on the use of point-of-care immunodiagnostic tests for COVID-19: scientific brief. 2020 [internet publication].
https://www.who.int/news-room/commentaries/detail/advice-on-the-use-of-point-of-care-immunodiagnostic-tests-for-covid-19
血清学即时检测证据尤其薄弱。荟萃分析发现,化学发光免疫测定(chemiluminescent immunoassays, CLIA)对 IgG 或 IgM 总体敏感性约为 98%,酶联免疫吸附测定(enzyme-linked immunosorbent assays, ELISA)敏感性为 84%。然而,作为即时检测技术研发的侧向流免疫测定(lateral flow immunoassays, LFIA)敏感性最低,为 66%。症状发作后 3 周或更长时间,检测敏感性最高。现有证据不支持使用现有的即时血清学检测。[453]Lisboa Bastos M, Tavaziva G, Abidi SK, et al. Diagnostic accuracy of serological tests for covid-19: systematic review and meta-analysis. BMJ. 2020 Jul 1;370:m2516.
https://www.bmj.com/content/370/bmj.m2516
http://www.ncbi.nlm.nih.gov/pubmed/32611558?tool=bestpractice.com
抗原检测
抗体检测基于使用侧向流免疫测定法对鼻拭子和其他呼吸道样本中 SARS-CoV-2 病毒蛋白的直接检测。通常能在 30 分钟内得出结果。虽然抗原试验的敏感性比 RT-PCR 低了不少,但前者提供了一种在适当情境中对大部分感染病例进行快速、廉价且早期检测的可能性。如果要用这种方法,应在症状发作后 5-7 天内进行检测。[454]World Health Organization. Antigen-detection in the diagnosis of SARS-CoV-2 infection using rapid immunoassays: interim guidance. 2020 [internet publication].
https://www.who.int/publications/i/item/antigen-detection-in-the-diagnosis-of-sars-cov-2infection-using-rapid-immunoassays
WHO 建议应仅在无法进行 RT-PCR 或较长的周转时间降低了临床实用性的特定情境中进行抗原检测,因为与 RT-PCR 检测相比,这一检测达到了敏感性 ≥80%、特异性 ≥97% 这一最低效用要求。[454]World Health Organization. Antigen-detection in the diagnosis of SARS-CoV-2 infection using rapid immunoassays: interim guidance. 2020 [internet publication].
https://www.who.int/publications/i/item/antigen-detection-in-the-diagnosis-of-sars-cov-2infection-using-rapid-immunoassays
美国食品药品监督管理局警告称,抗原检测可能会导致假阳性结果,包括检测者不遵循试剂使用说明而产生假阳性结果,而且,假阳性检测结果数量会随着疾病患病率降低而增加。[455]US Food and Drug Administration. Potential for false positive results with antigen tests for rapid detection of SARS-CoV-2: letter to clinical laboratory staff and health care providers. 2020 [internet publication].
https://www.fda.gov/medical-devices/letters-health-care-providers/potential-false-positive-results-antigen-tests-rapid-detection-sars-cov-2-letter-clinical-laboratory
胸部影像学检查
所有影像检查均应根据当地感染防控规程进行,以防止传播。胸部影像学检查被认为对于孕妇较为安全。[456]Poon LC, Yang H, Kapur A, et al. Global interim guidance on coronavirus disease 2019 (COVID‐19) during pregnancy and puerperium from FIGO and allied partners: information for healthcare professionals. 2020 [internet publication].
https://obgyn.onlinelibrary.wiley.com/doi/10.1002/ijgo.13156
所有疑似肺炎患者均需进行胸部 X 线检查。发现 25% 的患者有单侧肺浸润,75% 的患者有双侧肺浸润。[4]Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020 Feb 15;395(10223):497-506.
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30183-5/fulltext
http://www.ncbi.nlm.nih.gov/pubmed/31986264?tool=bestpractice.com
[5]Chen N, Zhou M, Dong X, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet. 2020 Feb 15;395(10223):507-13.
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30211-7/fulltext
http://www.ncbi.nlm.nih.gov/pubmed/32007143?tool=bestpractice.com
[457]Song F, Shi N, Shan F, et al. Emerging coronavirus 2019-nCoV pneumonia. Radiology. 2020 Feb 6:200274.
https://pubs.rsna.org/doi/10.1148/radiol.2020200274
http://www.ncbi.nlm.nih.gov/pubmed/32027573?tool=bestpractice.com
尽管与胸部 CT 相比,胸部 X 线检查敏感性似乎较低,但它具有资源集约更少从而辐射剂量更低,更易于序列重复及更易于转移设备等优势。[458]World Health Organization. Use of chest imaging in COVID-19: a rapid advice guide. 2020 [internet publication].
https://www.who.int/publications/i/item/use-of-chest-imaging-in-covid-19
考虑进行胸部 CT 扫描。CT 在某些国家(例如中国)是首要的影像学检查手段。它有助于作出诊断,指导个体患者的治疗决策,协助进行并发症诊断,或为其他诊断提供线索。但是,它对于 COVID-19 不具诊断性,因此应查阅当地指南,决定是否行 CT扫描。
英国胸科影像学会(British Society of Thoracic Imaging, BSTI)建议对于临床疑似 COVID-19 的重症患者,若胸部 X 线检查无法确定或正常,则进行 CT 影像学检查。若排除 COVID-19 可疑,则放射影像学检查不具特异性,可能代表许多其他的疾病过程。BSTI 与英格兰 NHS 合作开发了一种放射影像学决策支持工具,以帮助临床医生决定是否应进行胸部影像学检查。[388]British Society of Thoracic Imaging. Thoracic imaging in COVID-19 infection: guidance for the reporting radiologist - version 2. 2020 [internet publication].
https://www.bsti.org.uk/media/resources/files/BSTI_COVID-19_Radiology_Guidance_version_2_16.03.20.pdf
BSTI: radiology decision tool for suspected COVID-19
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英国部分医疗机构针对临床高度疑似 COVID-19 的病例推荐了一个更务实的检测方法,即仅在胸部 X 线检查结果正常或两次结果不确定,以及联合 RT-PCR 检测呈阴性之后,才建议行胸部 CT 检查。[459]Tavare AN, Braddy A, Brill S, et al. Managing high clinical suspicion COVID-19 inpatients with negative RT-PCR: a pragmatic and limited role for thoracic CT. Thorax. 2020 Jul;75(7):537-8.
https://thorax.bmj.com/content/early/2020/04/21/thoraxjnl-2020-214916.long
http://www.ncbi.nlm.nih.gov/pubmed/32317269?tool=bestpractice.com
美国放射学会建议为有 CT 特定临床指征的住院有症状患者保留 CT 检查,并强调正常的胸部 CT 并不意味着患者无 COVID-19,而异常的胸部 CT 亦并不对 COVID -19 诊断具有特异性。[460]American College of Radiology. ACR recommendations for the use of chest radiography and computed tomography (CT) for suspected COVID-19 infection. 2020 [internet publication].
https://www.acr.org/Advocacy-and-Economics/ACR-Position-Statements/Recommendations-for-Chest-Radiography-and-CT-for-Suspected-COVID19-Infection
在一项对 50,466 例住院患者进行的荟萃分析中,多达 97% COVID-19 患者报道出现胸部 CT 异常。[461]Sun P, Qie S, Liu Z, et al. Clinical characteristics of hospitalized patients with SARS-CoV-2 infection: a single arm meta-analysis. J Med Virol. 2020 Jun;92(6):612-7.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7228255/
http://www.ncbi.nlm.nih.gov/pubmed/32108351?tool=bestpractice.com
部分患者通过 CT 检查得到肺炎证据的时间可能早于 RT-PCR 检测得到 SARS-CoV-2 阳性结果的时间。[462]Li Z, Yi Y, Luo X, et al. Development and clinical application of a rapid IgM-IgG combined antibody test for SARS-CoV-2 infection diagnosis. J Med Virol. 2020 Feb 27 [Epub ahead of print].
http://www.ncbi.nlm.nih.gov/pubmed/32104917?tool=bestpractice.com
无症状患者可出现 CT 影像学异常。在无症状病例中,胸部 CT 检查阳性率总体估计为 62%,而在出现症状的患者中则为 90%。[463]Tsikala Vafea M, Atalla E, Kalligeros M, et al. Chest CT findings in asymptomatic cases with COVID-19: a systematic review and meta-analysis. Clin Radiol. 2020 Aug 12 [Epub ahead of print].
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7420957/
http://www.ncbi.nlm.nih.gov/pubmed/32861461?tool=bestpractice.com
尽管 RT-PCR 阳性,但某些患者仍可表现为胸部检查结果正常。[464]Yang W, Cao Q, Qin L, et al. Clinical characteristics and imaging manifestations of the 2019 novel coronavirus disease (COVID-19): a multi-center study in Wenzhou city, Zhejiang, China. J Infect. 2020 Apr;80(4):388-93.
https://www.journalofinfection.com/article/S0163-4453(20)30099-2/fulltext
http://www.ncbi.nlm.nih.gov/pubmed/32112884?tool=bestpractice.com
同样,RT-PCR 结果可能呈假阴性,因此有典型 CT 表现的患者应重复接受 RT-PCR 检测以确认诊断。[465]Long C, Xu H, Shen Q, et al. Diagnosis of the coronavirus disease (COVID-19): rRT-PCR or CT? Eur J Radiol. 2020 Mar 25;126:108961.
https://www.ejradiology.com/article/S0720-048X(20)30150-9/pdf
http://www.ncbi.nlm.nih.gov/pubmed/32229322?tool=bestpractice.com
典型特征
最常见的影像学发现是毛玻璃样混浊,无论是孤立还是与其他影像学发现(例如实变、小叶间间隔增厚或铺路石征)共存。最常见分布模式为双侧性、周边/胸膜下、混浊呈后分布,肺叶为主的特征较不明显。广泛/多叶受累合并实变在老年患者和重症患者中更为常见。[466]Ojha V, Mani A, Pandey NN, et al. CT in coronavirus disease 2019 (COVID-19): a systematic review of chest CT findings in 4410 adult patients. Eur Radiol. 2020 May 30 [Epub ahead of print].
https://link.springer.com/article/10.1007%2Fs00330-020-06975-7
http://www.ncbi.nlm.nih.gov/pubmed/32474632?tool=bestpractice.com
毛玻璃样混浊和病毒性肺炎其他特征同时存在,对 COVID-19 检测最具意义(敏感性为 90%,特异性为 89%)。[467]Hossein H, Ali KM, Hosseini M, et al. Value of chest computed tomography scan in diagnosis of COVID-19: a systematic review and meta-analysis. Clin Transl Imaging. 2020 Oct 12:1-13.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7549426/
http://www.ncbi.nlm.nih.gov/pubmed/33072656?tool=bestpractice.com
CT 扫描通常显示,早期随访时段中,毛玻璃样混浊的大小、数量和密度都有所增加,并在 10 至 11 天逐渐进展为毛玻璃样混浊、实变和铺路石征混合病灶,而后逐渐消退或持续呈现片状纤维化。[466]Ojha V, Mani A, Pandey NN, et al. CT in coronavirus disease 2019 (COVID-19): a systematic review of chest CT findings in 4410 adult patients. Eur Radiol. 2020 May 30 [Epub ahead of print].
https://link.springer.com/article/10.1007%2Fs00330-020-06975-7
http://www.ncbi.nlm.nih.gov/pubmed/32474632?tool=bestpractice.com
一项小型比较性研究发现,与其他类型肺炎相比,COVID-19 患者更有可能双侧受累,出现多发斑片影和毛玻璃样混浊。[468]Zhao D, Yao F, Wang L, et al. A comparative study on the clinical features of COVID-19 pneumonia to other pneumonias. Clin Infect Dis. 2020 Mar 12 [Epub ahead of print].
https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa247/5803302
http://www.ncbi.nlm.nih.gov/pubmed/32161968?tool=bestpractice.com
儿童胸部 CT 检查常表现为正常或轻度病变。儿童中最常见征象为斑片状毛玻璃样混浊,非特异性斑片影、区域实变和晕征则不甚常见。异常表现在下叶更为常见,且主要呈单侧。胸腔积液较为罕见。儿童患者症状极少或无症状,但仍可能在胸部影像学检查时显示肺炎征象。[469]Kumar J, Meena J, Yadav A, et al. Radiological findings of COVID-19 in children: a systematic review and meta-analysis. J Trop Pediatr. 2020 Jul 21 [Epub ahead of print].
https://academic.oup.com/tropej/article/doi/10.1093/tropej/fmaa045/5874434
http://www.ncbi.nlm.nih.gov/pubmed/32692815?tool=bestpractice.com
非典型特征
肺血管扩张、小叶间或小叶内间隔增厚、相邻胸膜增厚、空气支气管征、胸膜下线征、铺路石征、支气管扭曲、支气管扩张、液泡回缩征和晕征为非典型特征。胸腔积液、心包积液、空腔、气胸和纵隔淋巴结肿大也较少被报道。[466]Ojha V, Mani A, Pandey NN, et al. CT in coronavirus disease 2019 (COVID-19): a systematic review of chest CT findings in 4410 adult patients. Eur Radiol. 2020 May 30 [Epub ahead of print].
https://link.springer.com/article/10.1007%2Fs00330-020-06975-7
http://www.ncbi.nlm.nih.gov/pubmed/32474632?tool=bestpractice.com
WHO 建议在以下情况中进行胸部影像学检查:[458]World Health Organization. Use of chest imaging in COVID-19: a rapid advice guide. 2020 [internet publication].
https://www.who.int/publications/i/item/use-of-chest-imaging-in-covid-19
当无法进行 RT-PCR,RT-PCR 检测结果延迟回报,或初步 RT-PCR 检测为阴性但临床高度可疑 COVID-19 者(用于诊断)
当前未住院且呈现轻度症状的疑似或确诊 COVID-19 患者(做出住院亦或返家的决定)
当前未住院且呈现中重度症状的疑似或确诊 COVID-19 患者(帮助做出常规收住院亦或收入重症监护病房的决定)
当前已住院且呈现中重度症状的疑似或确诊 COVID-19 患者(治疗管理)。
新兴的检查方法
逆转录环介导等温扩增
逆转录环介导等温扩增(reverse transcription loop-mediated isothermal amplification, RT-LAMP)分析是探查 SARS-CoV-2 病毒 RNA 的新兴检测。尽管该检测简单、快捷,但其使用证据却较少。SARS-CoV-2 检测方法已进行研发,并正在予以评估。[470]Park GS, Ku K, Baek SH, et al. Development of reverse transcription loop-mediated isothermal amplification assays targeting severe acute respiratory syndrome coronavirus 2. J Mol Diagn. 2020 Jun;22(6):729-35.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7144851/
http://www.ncbi.nlm.nih.gov/pubmed/32276051?tool=bestpractice.com
[471]Baek YH, Um J, Antigua KJC, et al. Development of a reverse transcription-loop-mediated isothermal amplification as a rapid early-detection method for novel SARS-CoV-2. Emerg Microbes Infect. 2020 Apr 20:1-31.
https://www.tandfonline.com/doi/full/10.1080/22221751.2020.1756698
http://www.ncbi.nlm.nih.gov/pubmed/32306853?tool=bestpractice.com
[472]Lu R, Wu X, Wan Z, et al. A novel reverse transcription loop-mediated isothermal amplification method for rapid detection of SARS-CoV-2. Int J Mol Sci. 2020 Apr 18;21(8).
https://www.mdpi.com/1422-0067/21/8/2826/htm
http://www.ncbi.nlm.nih.gov/pubmed/32325642?tool=bestpractice.com
肺部超声
在某些中心,肺部超声被用作诊断工具,以替代胸部 X 线检查和胸部 CT。尽管只有确定性极低的证据支持其诊断准确性,但它作为补充或替代性影像检查方式,可有所帮助。[458]World Health Organization. Use of chest imaging in COVID-19: a rapid advice guide. 2020 [internet publication].
https://www.who.int/publications/i/item/use-of-chest-imaging-in-covid-19
它具有诸多优点,包括便携、可床边评估、医务工作者暴露减少、消毒流程更便捷、无电离辐射暴露,以及随访期间的可重复性。资源受限环境中,它也可能更易使用。但是,它亦有某些局限性(例如无法分辨病变是否为长期慢性),因此可能需要结合其他影像学检查。B 线是 COVID-19 患者主要表现,汇总出现频率为 97%。胸膜线异常也很常见,汇总出现频率为 70%。尽管此类发现并非 COVID-19 特异性表现,但在特征性临床表现背景下,它们增加了疾病诊断的可能性。其他发现包括实变、胸膜增厚和胸腔积液。[473]Mohamed MFH, Al-Shokri S, Yousaf Z, et al. Frequency of abnormalities detected by point-of-care lung ultrasound in symptomatic COVID-19 patients: systematic review and meta-analysis. Am J Trop Med Hyg. 2020 Jun 2 [Epub ahead of print].
http://www.ajtmh.org/content/journals/10.4269/ajtmh.20-0371
http://www.ncbi.nlm.nih.gov/pubmed/32500849?tool=bestpractice.com
可对孕妇和儿童加以使用。[474]Moro F, Buonsenso D, Moruzzi MC, et al. How to perform lung ultrasound in pregnant women with suspected COVID-19 infection. Ultrasound Obstet Gynecol. 2020 May;55(5):593-8.
https://obgyn.onlinelibrary.wiley.com/doi/abs/10.1002/uog.22028
http://www.ncbi.nlm.nih.gov/pubmed/32207208?tool=bestpractice.com
[475]Denina M, Scolfaro C, Silvestro E, et al. Lung ultrasound in children with COVID-19. Pediatrics. 2020 Jul;146(1):e20201157.
https://pediatrics.aappublications.org/content/early/2020/04/17/peds.2020-1157
http://www.ncbi.nlm.nih.gov/pubmed/32317309?tool=bestpractice.com
BSTI: lung ultrasound (LUS) for COVID-19 patients in critical care areas
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病毒分离