Tongue Image–Based Diagnosis of Acute Respiratory Tract Infection Using Machine Learning: Algorithm Development and Validation

• Published in: JMIR medical informatics Vol. 13; p. e74102
• Main Authors: Che, Qianzi, Leng, Yuanming, Yang, Wei, Cao, Xihao, Wang, Zhongxia, Liu, Lizheng, Xie, Feibiao, Wang, Ruilin
• Format: Journal Article
• Language: English
• Published: Canada JMIR Publications 25.08.2025
• Subjects: Adenovirus Infections, Human - diagnosis; Adenovirus Infections, Human - diagnostic imaging; Adenoviruses; Adult; Aged; Algorithms; Artificial intelligence; Blood diseases; Bronchitis; Clinical Information and Decision Making; Complementary and Alternative Medicine; Computer-Aided Diagnosis; COVID-19; COVID-19 - diagnosis; Diagnosis, Differential; Disease transmission; Fatty liver; Female; Humans; Imaging Informatics; Immunoglobulins; Infectious Diseases (non-STD/STI); Machine Learning; Male; Middle Aged; Original Paper; Pneumonia; Polymerase chain reaction; Respiratory Medicine; Respiratory Tract Infections - diagnosis; SARS-CoV-2; Tongue; Tongue - diagnostic imaging; Tools, Programs and Algorithms; Traditional Chinese medicine; Tumors; Viral infections; COVID-19; traditional Chinese medicine; image feature extraction; tongue diagnosis; machine learning; human adenoviruses
• ISSN: 2291-9694; 2291-9694
• DOI: 10.2196/74102

Human adenoviruses (HAdVs) and COVID-19 are prominent respiratory pathogens with overlapping clinical presentations, including fever, cough, and sore throat, posing significant diagnostic challenges without viral testing. Tongue image diagnosis, a noninvasive method used in traditional Chinese medicine, has shown correlations with specific respiratory infections, but its application remains underexplored in differentiating HAdVs from COVID-19. Advances in artificial intelligence offer opportunities to enhance tongue image analysis for more objective and accurate diagnostics. This study aims to develop and validate artificial intelligence-based predictive models using tongue image features to differentiate COVID-19 from adenoviral respiratory infections, thereby improving diagnostic accuracy and integrating traditional diagnostic methods with modern medical technologies. A total of 280 tongue images were collected from 58 patients with COVID-19, 84 patients with HAdVs, and 30 healthy controls. Deep learning methods were applied to extract tongue features, including color, coating, fissures, papillae, tooth marks, and granules. Four machine learning classifiers, logistic regression, random forest, gradient boosting model, and extreme gradient boosting, were developed to differentiate COVID-19 and HAdV infections. The key features identified by the machine learning algorithms were further visualized in a 2D space. Nine tongue features showed significant differences among groups (all P<.05), including coating color (red, green, and blue), presence of tooth marks, coating crack ratio, moisture level, texture directionality, roughness, and contrast. The extreme gradient boosting model achieved the highest diagnostic performance with an area under the receiver operating characteristic curve of 0.84 (95% CI 0.78-0.90) and an area under the precision-recall curve above 0.70. Shapley additive explanations analysis indicated tongue color, moisture, and texture as key contributors. Our findings demonstrate the potential of tongue diagnosis in identifying pathogens responsible for acute respiratory tract infections at the time of admission. This approach holds significant clinical implications, offering the potential to reduce clinician workloads while improving diagnostic accuracy and the overall quality of medical care.