A CT-based deep learning model for the automated risk stratification of refractory Mycoplasma pneumoniae pneumonia in children

BACKGROUND: The accurate identification of children with refractory Mycoplasma pneumoniae pneumonia (RMPP) remains challenging. This study aimed to develop a transformer-based model utilizing clinically indicated chest computed tomography (CT) to stratify pediatric RMPP risk at a critical decision point. METHODS: Non-contrast chest CT data from a multicenter retrospective cohort of 1224 pediatric patients with Mycoplasma pneumoniae pneumonia who underwent clinically indicated CT were used to develop a transformer-based deep learning framework (trans-DLF). The primary cohort comprised training (n = 506), validation (n = 140), and internal testing (n = 139) cohorts, with two independent external cohorts (n = 331 and n = 108) used to evaluate generalizability. Model performance was assessed by the area under the receiver operating characteristic curve (AUC) and compared against a three-dimensional convolutional neural network (3D-CNN), a clinical model, and a multimodal nomogram. Interpretability was examined using gradient-weighted class activation mapping (Grad-CAM). RESULTS: The median age was 6.83 years (interquartile range, 5.0-8.6 years), and 609 (49.8%) were male. The trans-DLF demonstrated strong performance across all cohorts: training (AUC 0.97; 95% confidence interval [CI], 0.96-0.98), validation (0.91; 0.86-0.96), internal testing (0.90; 0.85-0.95), and external testing (0.89; 0.84-0.94 and 0.89; 0.82-0.95). It significantly outperformed the clinical model (p < 0.001), while its AUCs were not significantly different from those of the multimodal nomogram. The model maintained good performance in outpatient settings (AUC 0.87) with good calibration and net clinical benefit. Grad-CAM suggested that predictions were influenced by clinically meaningful features, particularly consolidations. CONCLUSION: The trans-DLF provides a streamlined and efficient approach to RMPP risk assessment in children who have already undergone clinically indicated chest CT and may support timely, evidence-based decision-making without additional tests.