当类风湿关节炎遇到痛风,会擦出怎样的火花?

2019-04-25 金迪 王玉伟 医学界风湿免疫频道

患者为44岁中国女性,10个月前开始出现多关节肿痛。查体可见患者右手近端和远端指间关节外形呈梭形肿胀,有压痛,双腕关节及膝关节肿胀、压痛,晨僵时间>30min,X线片(见图1)示双侧手腕关节、指间关节间隙缩小。

类风湿性关节炎(RA)和痛风是常见的风湿性疾病。RA是最常见的慢性对称性外周多关节炎疾病,病因不明。在成年人群中,RA的总患病率为0.5%~1%,男女患病率为1:3。同时,痛风是由于单钠尿酸盐晶体沉积所致,患病率占总人群的1%~4%。尽管RA和痛风都很常见,但RA合并痛风却很少有报道。下面与大家分享一例病例报道。

病例简介

患者为44岁中国女性,10个月前开始出现多关节肿痛。查体可见患者右手近端和远端指间关节外形呈梭形肿胀,有压痛,双腕关节及膝关节肿胀、压痛,晨僵时间>30min,X线片(见图1)示双侧手腕关节、指间关节间隙缩小。


图1 患者双手X线片

实验室检测

类风湿因子阳性,抗核抗体1:1000,抗CCP抗体滴度升高,抗SSA抗体(+++),抗Ro52抗体(++),抗RNP抗体(+++),血尿酸水平正常。血沉:47mm/h(正常值<15mm/h),C反应蛋白:20.67mg/L(正常值<10mg/L)。

初步诊断和治疗

根据2010年美国风湿学会/欧洲抗风湿病联盟(ACR/EULAR)RA分类标准,患者诊断为“类风湿性关节炎”,并开始甲氨蝶呤、来氟米特和甲泼尼龙(12mg/d)药物治疗。数天后患者关节肿痛症状明显减轻。然而,患者因出现肝功能异常,停用甲氨蝶呤和来氟米特,并开始使用肿瘤坏死因子(TNF)-α受体拮抗剂,治疗效果较好。

随访情况

出院6个月后,患者出现双膝关节肿痛,温暖的天气症状会加重。患者将甲泼尼龙剂量由4mg/d调整至8mg/d。

实验室检测示:类风湿因子升高,C反应蛋白及血沉升高,血尿酸值为363mmol/L(正常值为178.4~297.4mmol/L)。患者右膝关节彩超(见图2)示:关节积液,滑膜增厚,关节软骨“双轨征”,双侧腘窝囊肿。显微镜下观察到一侧膝关节液中存在尿酸盐晶体(见图3)。


图2 患者右膝关节彩超


图3 镜下可见关节液中的尿酸盐晶体

修正诊断及调整治疗:患者诊断为“RA合并膝关节痛风性关节炎”,开始接受TNF-α受体拮抗剂、秋水仙碱和非布司他药物治疗。随访3年,患者膝关节症状完全消退,未再复发。

病例总结

本病例患者起初血尿酸水平正常,缺乏典型的痛风史,结合其表现和辅助检查初步诊断为RA。经治疗后,患者指间关节和腕关节肿痛症状明显减轻,但膝关节症状反复加重,甚至在使用生物制剂后复发,这个关节表现与RA特征不一致。完善血尿酸检测、膝关节彩超及关节穿刺等辅助检查后,患者最终确诊为RA合并痛风。

本病例为一名中年女性RA患者合并双膝非典型性痛风,国内外少有报道。这个病例提醒我们:如RA患者反复出现关节炎症状,且靶向治疗效果欠佳时,应除外RA合并痛风的可能。

RA合并痛风知多少

RA合并痛风患者多为老年男性,其类风湿因子滴度和血清尿酸水平比仅有RA的患者要明显升高。有关RA合并痛风的发病率研究尚不统一。尿酸盐晶体被认为可以抑制T细胞和B细胞活化,并具有抗氧化和抗吞噬的特性,所以RA合并痛风发病率很低。另外,RA患者体内的白介素(IL)-6可能会减少痛风发作。RA常用药物如来氟米特也有助于降低血尿酸水平。

RA合并痛风病例报道较少,这可能归于以下几个原因:RA患者的多关节炎表现会掩盖非典型痛风的症状;长期使用糖皮质激素、非甾体抗炎药物可以预防痛风发作;患者非典型痛风性关节炎的诊断主要依赖于关节穿刺发现滑膜中存在尿酸盐晶体,这通常很难在小关节中实施。

患者血清尿酸水平轻度升高,可能是因为女性患者体内雌激素和黄体酮促进尿酸排泄。正如接受药物治疗的RA患者,来氟米特通过调节肾上皮细胞中的尿酸转运体促进尿酸排泄,降低血尿酸水平。也有文献报道羟氯喹能够升高细胞质中pH值,促进尿酸盐结晶的排出,从而降低血尿酸水平。另外,类风湿因子可能阻止尿酸晶体的沉积。因此,RA合并痛风患者尿酸水平可能轻度升高,甚至正常。

RA合并痛风的患者大多会出现至少一次急性发作,而上述病例患者最初否认有任何急性痛风发作史,但是双膝关节肿痛症状反复发作,我们容易误诊为治疗未达标。类似这种情况,患者往往不会完全停用糖皮质激素或其他药物。也许,患者未发作痛风的原因是长期服用糖皮质激素和非甾体抗药物等。

此外,我们在上述病例中还可以发现一个有趣的现象:患者双膝关节肿痛加重多发生在温暖的天气。有研究发现3月到7月急性痛风性关节炎的发病率增加,7月份发病率最高,随后开始下降,直到9月份创下最低记录。而且,秋天与急性痛风性关节炎的发病有显著的相关性,这可能与温度变化导致单钠尿酸盐晶体沉积有关。一天之中,患者清晨和夜间痛风发作要比白天更常见,可能是由于皮质醇水平在午夜和凌晨会降至最低水平。因此,如果关节痛与季节、天气和夜晚相关,我们需要考虑到痛风的可能性。

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    2019-04-27 lmm397
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  4. [GetPortalCommentsPageByObjectIdResponse(id=1265959, encodeId=958f12659591f, content=<a href='/topic/show?id=57a53011364' target=_blank style='color:#2F92EE;'>#关节炎#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=21, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=30113, encryptionId=57a53011364, topicName=关节炎)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=f90281, createdName=lmm397, createdTime=Sat Apr 27 14:14:00 CST 2019, time=2019-04-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1334135, encodeId=102c13341357c, content=<a href='/topic/show?id=5306e6164b6' target=_blank style='color:#2F92EE;'>#类风湿#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=42, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=76164, encryptionId=5306e6164b6, topicName=类风湿)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4c37265, createdName=zhaojie88, createdTime=Sat Apr 27 14:14:00 CST 2019, time=2019-04-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1597374, encodeId=3924159e37497, content=<a href='/topic/show?id=fa1710082017' target=_blank style='color:#2F92EE;'>#风湿关节炎#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=31, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=100820, encryptionId=fa1710082017, topicName=风湿关节炎)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=456818510265, createdName=xuruicheng, createdTime=Sat Apr 27 14:14:00 CST 2019, time=2019-04-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=365333, encodeId=06ad3653331f, content=好好好好好好, beContent=null, objectType=article, channel=null, level=null, likeNumber=57, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/08/29/bbc5cc0eed9b8d17623d2fd49dbdf19a.jpg, createdBy=79522135794, createdName=yjs木玉, createdTime=Sat Apr 27 05:53:08 CST 2019, time=2019-04-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=365291, encodeId=5ad33652914e, content=了解一下谢谢, beContent=null, objectType=article, channel=null, level=null, likeNumber=55, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTLbTp9nZtjwVrSZNxAXbAicnKQWnic2eBdJUQYhxO36XdkstSicr7FVF8p5ReH4omtmsbnLdvZLiaJJ1A/132, createdBy=8bff2327056, createdName=kafei, createdTime=Fri Apr 26 09:06:01 CST 2019, time=2019-04-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=365284, encodeId=5a033652848e, content=谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://thirdwx.qlogo.cn/mmopen/vi_32/DYAIOgq83eqYPFHuMA3bhYQrHvycmum7IJoCsLK0FP6X56Eoj9PZAECDke8zLCKxZZvk9q7B6rZmPuFgN5YCfw/132, createdBy=f52d2514454, createdName=SCI我的梦, createdTime=Fri Apr 26 07:43:18 CST 2019, time=2019-04-26, status=1, ipAttribution=)]
    2019-04-27 yjs木玉

    好好好好好好

    0

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    2019-04-26 kafei

    了解一下谢谢

    0

  6. [GetPortalCommentsPageByObjectIdResponse(id=1265959, encodeId=958f12659591f, content=<a href='/topic/show?id=57a53011364' target=_blank style='color:#2F92EE;'>#关节炎#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=21, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=30113, encryptionId=57a53011364, topicName=关节炎)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=f90281, createdName=lmm397, createdTime=Sat Apr 27 14:14:00 CST 2019, time=2019-04-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1334135, encodeId=102c13341357c, content=<a href='/topic/show?id=5306e6164b6' target=_blank style='color:#2F92EE;'>#类风湿#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=42, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=76164, encryptionId=5306e6164b6, topicName=类风湿)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4c37265, createdName=zhaojie88, createdTime=Sat Apr 27 14:14:00 CST 2019, time=2019-04-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1597374, encodeId=3924159e37497, content=<a href='/topic/show?id=fa1710082017' target=_blank style='color:#2F92EE;'>#风湿关节炎#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=31, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=100820, encryptionId=fa1710082017, topicName=风湿关节炎)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=456818510265, createdName=xuruicheng, createdTime=Sat Apr 27 14:14:00 CST 2019, time=2019-04-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=365333, encodeId=06ad3653331f, content=好好好好好好, beContent=null, objectType=article, channel=null, level=null, likeNumber=57, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/08/29/bbc5cc0eed9b8d17623d2fd49dbdf19a.jpg, createdBy=79522135794, createdName=yjs木玉, createdTime=Sat Apr 27 05:53:08 CST 2019, time=2019-04-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=365291, encodeId=5ad33652914e, content=了解一下谢谢, beContent=null, objectType=article, channel=null, level=null, likeNumber=55, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTLbTp9nZtjwVrSZNxAXbAicnKQWnic2eBdJUQYhxO36XdkstSicr7FVF8p5ReH4omtmsbnLdvZLiaJJ1A/132, createdBy=8bff2327056, createdName=kafei, createdTime=Fri Apr 26 09:06:01 CST 2019, time=2019-04-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=365284, encodeId=5a033652848e, content=谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://thirdwx.qlogo.cn/mmopen/vi_32/DYAIOgq83eqYPFHuMA3bhYQrHvycmum7IJoCsLK0FP6X56Eoj9PZAECDke8zLCKxZZvk9q7B6rZmPuFgN5YCfw/132, createdBy=f52d2514454, createdName=SCI我的梦, createdTime=Fri Apr 26 07:43:18 CST 2019, time=2019-04-26, status=1, ipAttribution=)]
    2019-04-26 SCI我的梦

    谢谢分享

    0

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