风湿总论

GeneralIntroduction 2004SpringTeacher 毕黎琦 RheumaticDiseases Rheumatology Section1GeneralIntroduction 总论 ofRheumaticDiseasesRequirements 要求 1 Toknow 了解 thedefinitionofrheumaticdiseasesanditscommonpathology 2 Tobefamiliarwith 熟悉 theclassificationofrheumaticdiseasesandthecommoncharacteristicsofconnectivetissuediseases 3 Tograsp 掌握 thefeaturesofjointmanifestationofrheumaticdiseasesandclinicalimportance 意义 ofauto antibodiesdetection 4 Tobefamiliarwith 熟悉 theclassificationandmechanismof3kindsofanti rheumaticdrugs Definition 1 Rheumatism 风湿 It sdefinedasthechronicpainofjoint peri articulartissues muscleandbone 风湿 是指关节 关节周围软组织 肌肉 骨出现的慢性疼痛 2 Rheumaticdiseases 风湿性疾病 It sadiseaseentityinvolvingjointsandperi articulartissueswithdifferentcauses 风湿性疾病 是指一大类病因各不相同 但均累及关节及其周围组织的疾病 Itencompassesdiffuseconnectivetissuediseases andotherdisordersinvolvingjointsandperi articulartissues includingmuscle tendon ligament etc 它包括 弥漫性结缔组织病及各种病因引起的关节和关节周围软组织 包括肌 肌腱 韧带等的疾病 概念 3 diffuseconnectivetissuedisease 弥漫性结缔组织病 简称结缔组织病 CTD It sthemainkindofrheumaticdiseases Itbelongstoorgannonspecificautoimmunediseases 器官非特异性自身免疫病 It salsocalledcollagenicdisease 胶原病 CommoncharactersofdiffuseCTD 1 pathogenesis autoimmunity 2 pathologicchange chronicinflammationofvesselsandconnectivetissue 3 multisysteminvolvement Heterogeneous 4 course onset remission recurrence remission Lifelongdiseases 5 gluco corticosteroidhormoneandimmuno suppressants 6 Improvedprognosis ThenomenclatureandclassificationofarthritisandrheumaticdiseasesfromAmericansocietyofRheumatologyin1993美国风湿病学学会对关节炎和风湿性疾病的命名和分类 ArthRheum26 1029 1032 1993 一 Diffuseconnectivetissuediseases 弥漫性结缔组织病 1 Rheumatoidarthritis RA 类风湿关节炎 2 Juvenilerheumatoidarthritis JRA 幼年类风湿关节炎 3 Systemiclupuserythematosus SLE 系统性红斑狼疮 4 Systemicsclerosis SSc 系统性硬化病 5 Diffusefasciitis EF 弥漫性筋膜炎 6 Polymyositis Dermatomyositis PM DM 多肌炎 皮肌炎 7 Vasculitis 血管炎 8 Sjogrensyndrome SS 干燥综合征 9 Overlappingsyndrome OS 重叠综合征 10 others Polymyalgiarheumatica 风湿性多肌痛 二 Arthritisassociatedwithspodylitis 并发脊柱炎的关节炎 Seronegativespondyloarthropathies 血清阴性脊柱关节病 1 Ankylosingspondylitis AS 强直性脊柱炎 2 Reitersyndrome RS 赖特综合征 3 Psoriaticarthritis PA 银屑病关节炎 4 Enteropathicarthritis EA 炎性肠病关节炎 三 Osteoarthritis OA 骨性关节炎 四 Infection 感染所致风湿性综合征 1 Reactivearthritis 反应性关节炎 Rheumaticfever Rheumaticaithritis RF 风湿热 2 Directinfection 直接 五 Metabolicandendocrinologicdiseases 伴有风湿性疾病的代谢或内分泌疾病 1 Gout 痛风 2 Pseudogout 假性痛风 六 Others 其他 1 Osteoporosis 骨质疏松 2 Fibromyalgiasyndrome FS 纤维肌痛综合征 3 Palindromicrheumatism PR 复发性风湿病 EpidemiologyofrheumaticdiseasesinChinaTheincidencesomerheumaticdiseases SLE 0 07 RA 0 32 0 36 AS 0 25 pSS 0 3 OA 50 50yearsold Gout increaseddaybydayRheumaticarthritis decreasedmarkedly Historytakingandphysicalexamination 病史采集和体格检查 Historytaking 1 Articularandperi articulartissueinvolvement 关节及其周围组织受累情况 involvedjoint site diseasecourse swelling pain morningstiffness relievingandaggravationfactors reactiontotherapy andsoon 2 Organsysteminvolvement 各器官系统受累情况 Kidney heart brain liver gastro intesting respiratoryandhematologicsystem skin muscle Tab8 1 1 P1029 Historytakingandphysicalexamination 病史采集和体格检查 Physicalexamination thegeneralphysicalexamination一般内科体格检查Muscleexamination myagia myasthenia myotrophy myodynamia 6grades 0 5 2 Skin mucosaexamination rashes mucousmembranelesions 3 Joints site symmetric effusion redness swelling heat tenderness activeandpassivemotionofthejointsandspine DifferentiatingfeaturesofcommonarthritidesRAASOAGoutSLEperipheralarthritisOnsetslow insidiousslow insidiousslow insidiousabruptuncertainFirstmetacarpophalangealkneeknee lumber 1stmetatarso handInvolvedjoint proximalinter hipdistalinter phalangealjointorJointphalangealjoint wristanklephalangealjointjointothersPainpersistentpainpainatseverepainuncertainFeaturepainatrestatrestactivitynightpainSwellingsofttissuesofttissuebonyredness heatlessFeaturehypertrophyswellingcommonDeformitycommonandobviousmostinlessrarerarejointfunctionislimitedhipjointcommonChangessymmetricasymmetricweight bearingrecurrentmultiarthritislowerlimbsjointAxialskeletonoccationalymustpresentlumberhyperplasianonoAnd orsacro jointfunctioncondensingosteitisiliacjointsislimitedlip likechange 常见关节炎的关节特点关节RAASOA痛风SLE周围关节炎起病缓缓缓急骤不定首发MCP膝 髋 膝 腰 大拇趾手关节或PIP 腕踝DIP其他部位痛性质持续性休息后活动后痛剧烈不定休息后加重加重加重夜间重肿性质软组织为主软组织为主骨性肥大红 肿 热少数畸形常见 明显多见于髋小部分少见偶见影响功能演变对称性不对称负重关节反复发作多关节炎下肢大关节症状明显脊柱炎和 或 偶有必有腰椎增生无无骶髂关节病变功能受限唇样变 Laboratorytest实验室检查 1 SpecialexaminationAutoantibodyexamination 1 ANAandANAspectrum 抗核抗体谱 Antids DNASLE 50 highspecificityAnti histonedrug inducedlupus 95 100 SLE 70 RA 30 Anti SmSLE 20 30 markerantibodyAnti U1RNPMCTD 100 SLE SSc etcAnti SSA Ro SS 60 76 SLE 30 40 Anti SSB La SS 50 60 SLE 30 40 Anti Scl 70SSc 15 20 markerantibodyAnti CentromereSSc CREST 80 markerantibodyAnti KuSLE 10 PM SSoverlap 55 AntiJo 1PM 31 markerantibody Laboratorytest实验室检查 2 ANCA antineutrophilcytoplasmicantibody 抗中性粒细胞胞浆抗体 c ANCA cytoplasmic 胞浆染色 proteinase3 PR3 p ANCA perinuclear 核周边染色 MPOdiagnosisofvasculitisc ANCAforWegenergranulomatosis 30 90 sensitivity 98 specificity 3 Antiphospholipidantibodies 抗磷脂抗体 include Anticardiolipinantibody 抗心磷脂抗体 Lupusanticoagulant 狼疮抗凝物 False positiveserologictestforsyphilis 假阳性梅毒血清试验 1 multiplethrombosespositiveAntiphospholipid2 thrombocytopenia anti phospholipidantibodysyndrome3 recurrentspontaneousantibody 抗磷脂综合征 abortion Laboratorytest实验室检查 4 RF Rheumatoidfactor 类风湿因子 80 90 RA HLA B27 90 AS Complement CH50 serumtotalcomplement C3 C4forSLEandvasculitis Analysisofsynovialfluid Commonitems routinetest WBCcountanddifferentialcount biochemistrytest glucose chloride smearandcultureforbacteriatestRFCrystaltestundermicropolariscope 偏振光显微镜 ClassificationanddifferentiationofsynovialeffusionsDiseasesWBCdifferentiationneutrophilmicro countofWBC polariscope1 Normal0 200 102 Non OA1000 2000monocyte inflammationlymphocyte 203 MildSLE2000 5000neutrophil 30inflammation4 SevereRA5000 50000neutrophil 70inflammationGout5000 75000neutrophil 70crystalofurate noninfectious Pseudogout5000 75000neutrophil 70crystalofCPPD CPPD calciumpyrophosphatedihydrate5 SevereinflammationBacterial infectious infections5000 250000neutrophil 90 2 GeneralexaminationBloodroutineforWBC RBC pletletcountUrineroutinetotestWBC RBC castsinurine alsoglucose protein crystal pH gravity bacteria bilirubin urobilinogen etc Hepaticfunctiontest AST ALT Renalfunctiontest BUN blooduricnitrogen creatinine 2 Radiographicstudies1 Plainfilm convenient economic butsamllerosionofjointmaybemissed 2 CT forsacro iliacjoint sacroiliitisinAS forbrain SLE forlung interstitialfibrosis 3 MRI magneticresonanceimaging expensive forbrain spinalcord muscle bone smallerosion 4 Angiography 血管造影 expensiveandtraumatic forvasculitis polyarteritisnodosa Takayasu sarteritis大动脉炎 Pathology 病理 Biopsy renalbiopsy lupusnephritis SLE musclebiopsy myositis PM DM labialmucosa parotidgland cheilitislupusbandtest SLE1 Inflammatoryreaction It smanifestedbyinfiltrationgatheringoflymphocytes macrophagesandplasmacellsduetoimmunologicreaction exce