| Background and Objective:Twinkling artifact is a rapidly changing mixture of red and blue colors behind a strongly reflective medium at color Doppler imaging, and has got wide use in clinical practice with the main aim at diagnosing urinary tract and gallbladder stones. And more over it use had extended to related fields. Tuberculous pleuritis has a high prevalence and characterized by calcification formation on the pleura. So detection of pleural calcification is helpful for the diagnosis of tuberculous pleuritis. Based on the above stated, this study is focused on the clinical use of color Doppler twinkling artifact in diagnosis of tuberculous pleuritis by comparing with computed tomography and gray scale ultrasonography, contributing to exploring its capacity in detection of pleural calcification and extending its use in clinical setting.Meterials and methods:Clinical materials:one hundred and six cases of tuberculous pleuritis and 26 cases of cancerous pleuritis who were admitted to Shandong Provincial Chest Hospital from April 2014 to December 2014 were randomly included in this study. The total patient population included 81 male patients and 51 female patients, the age range is 16～84 years with the average age 47.2±17.2 years. The tuberculous pleuritis population included 64 male patients and 42 female patients, the age range is 16～84 years with the average age 44.4±17.5 years. The cancerous pleuritis group included 17 male patients and 9 female patients, the age range is 38～73 years with the average age 58.7±9.7 years. Among the tuberculous pleuritis group,61 cases got a confirmed diagnosis with bacterial cultivation from the pleural effusion,35 cases were confirmed by needle biopsy pathology of the primary lung disease,10 cases were confirmed by biochemical analysis of the pleural effusion. Among the cancerous pleuritis group,14 cases were confirmed by needle aspiration and cytologic analysis of the pleural effusion,8 cases were confirmed by needle biopsy histology of the primary lung disease, and 4 cases were confirmed by needle aspiration cytology of the primary lung disease.Imaging procedureUSG the ultrasound machine type was GE E9, the transducer frequency was 2.5-5MHz. the parameters of machine was as follows:color gain, gray gain, wall filter, focus depth, pulse repetition frequency, sample frame were identical for all the patients. During the scan, the patient sat with back to the sonographer, the upper body slightly leaning forward, and his/her back adequately exposed. The scan was performed along each intercostals space from the spine to the sternum with a whole range covering from the inlet of the thorax to the lower bound of thoracic cavity.Computed tomography (CT):all patients were scanned with a 16-slice spiral CT scanner (Siemens SOMATOM Sensation 16). All the patients was trained for breath-hold before the scan. The patients took supine and head first position. The scan range covered from the inlet of thorax to the posterior costophrenic angle including the whole thorax. The detailed parameters of the scanning was the following:300mA tube current,120KV tube voltage,5mm collimation,5mm reconstructed slice thickness, the pitch was 1.75, the display matrix was 512x512. The source images was transferred to the integrated workstation and interpreted. Pleural calcification was defined to be dot-like, nodule-like, linear or irregular foci of high density of 80-300HU on the pleura.Image interpretation1. On the CT plain scan, Pleural calcification was defined to be dot-like, nodule-like, linear or irregular foci of high density of 80～300HU on the pleura.2. On the gray scale ultrasonography, calcification was defined as strong echogenic mass with posterior acoustic shadowing.3. Twinkling artifact was defined as a rapidly changing mixture of red and blue colors behind a strongly reflective structure.4. A positive result of combined ultrasound and twinkling artifact was either the presence of a strong echogenic mass with posterior acoustic shadowing or the presence of a rapidly changing mixture of red and blue colors behind a strongly reflective structure.Statistical methodThe number of calcification foci detected at CT and gray scale ultrasonography were recorded. The number of positive foci for color Doppler twinkling artifact was recorded. The detection between each pair of imaging methods was calculated by using McNemar χ2 test for paired nominal scale data. The difference of positive foci detected by combined gray scale and color Doppler twinkling artifact in tuberculous pleuritis and cancerous pleuritis was calculated by using Pearson χ2 test. The statistical software was IBM SPSS 21.0, and P<0.05 was considered to be of statistic significance.Results1. The appearance of tuberculous pleuritis on gray scale ultrasonography can be classified into 5 types:(1) free pleural effusion, the fluid dark area can change in shape with the change of body posture. The fluid dark area was anechoic. This type didn’t demonstrate color Doppler twinkling artifact. (2) free pleural effusion with small amount of echoic areas, and band-like strong echo of fibrinoid tissue may present. (3) free pleural effusion with large amount of echoic foci and exudated fiber, which lead to increased viscosity and increased amount of band-like strong echo interlacing together to form reticulate structure. This type is characteristic of the fixed shape of pleural effusion which can not change in shape with body posture change. (4) encapsulated pleural effusion with internal dot-like low echo or strong echo. (5) pleural thickening without fluid dark area. The visceral pleura and parietal pleura showed focal or diffuse thickening. In some cases there presented small nodular protrusion of hypoecho, isoecho or hyperecho. Echo of calcification of 2～10mm in size could be seen in some cases. Beyond 2-dimensional scan, color Doppler technique was used and except type 1 and 2, all types showed some incidence of twinkling artifact among which type 5 had the highest incidence of 68.9%.2. Taking the CT results of calcification detection as the reference standard, gray scale ultrasonography detected 63.3%(31/49) of the calcification, and color Doppler twinkling artifact detected 83.7%(41/49) of calcification. There was significant difference between gray scale ultrasonography and color Doppler twinkling artifact in calcification detection (P=0.039) and between gray scale ultrasonography combined with color Doppler twinkling artifact and gray scale ultrasonography alone (P=0.002)3. There were 56 cases positive for gray scale ultrasonography combined with color Doppler twinkling artifact and 50 negative cases in the tuberculous pleuritis group, while in the cancerous pleuritis group, there was 1 positive case and 25 negative cases. There difference was significant by using Pearson χ2 test. The odds ratio (OR) and 95% confidence interval (CI) of gray scale ultrasonography combined with color Doppler twinkling artifact for tuberculous pleuritis was 28.00 and 3.66～214.23. |
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