临床病例评析——多关节炎高尿酸血症右肩肿痛

Polyarthritis,hyperuricemia and right shoulder pain:a report of one case with literature review

目的提高临床对RA合并痛风、感染性关节炎(SA)的鉴别诊断能力。方法报道1例RA合并高尿酸血症、反复右肩肿痛患者的临床特点及诊治经过,并进行分析讨论。结果RA病程10年,血尿酸升高8年,反复右肩发作性肿痛1年的患者,院外诊断RA、痛风、SA,对症治疗后疗效欠佳。近1个月病情加重伴右肩窦道形成,实验室检查:结核T细胞干扰素释放试验(IGRA)、结核菌素(PPD)试验阴性,CD4^(+)细胞计数下降;右肩数字化X线摄影、超声、双能CT、磁共振检查综合分析提示右肩尿酸盐(MSU)沉积伴骨侵蚀、骨破坏、骨髓水肿、关节积液及滑囊、腱鞘、肌腱、肌肉等多部位受累;右肩穿刺液实时荧光定量核酸扩增检测技术(GeneXpert)、宏基因组测序(mNGS)及关节液培养提示结核分枝杆菌复合群,确诊RA、痛风、关节结核(OAT)。予甲氨蝶呤、艾拉莫德、降尿酸、抗结核、关节清创对症治疗后症状缓解。结论RA伴高尿酸血症患者出现反复单关节炎,除考虑合并痛风外,应警惕有无OAT,患者免疫状态、药物因素可能干扰免疫结果判读,需综合患者临床特征、多种影像学、病原学检查以明确诊断,避免漏诊。

Objective To improve the clinical differential diagnosis ability of rheumatoid arthritis(RA)complicated with gout and septic arthritis(SA).Methods The clinical characteristics,diagnosis,and treatment of one RA patient with hyperuricemia and recurrent swelling and pain in right shoulder were reported and discussed.Results A patient,with a history of RA for 10 years,hyperuricemia for 8 years,recurrent swelling and pain in right shoulder for 1 year.RA,gout,and SA were diagnosed before,and the response was poor after symptomatic treatment.In recent 1 month,the symptom was aggravated with the formation of fistula on the right shoulder.The laboratory tests for tuberculosis T cell interferon release test(IGRA)and tuberculin(PPD)test were negative,and the CD4^(+)cell count decreased.The comprehensive analysis of the imaging with right shoulder showed MSU deposition on right shoulder,with bone erosion,bone destruction,bone marrow edema,joint effusion,and multiple sites of connective tissue involvement(synovial bursa,tendon sheath,tendon,and muscle)GeneXpert MTB/RIF(GeneXpert),metagenomic next-generation sequencing(mNGS)of puncture fluid and joint fluid culture prompted Mycobacterium tuberculosis complex group.He was finally diagnosed with RA,gout,and osteoarticular tuberculosis(OAT).Symptoms were relieved after symptomatic treatment.Conclusion RA patients with hyperuricemia have recurrent single arthritis.In addition to considering for gout,the presence of OAT should also be considered.The immune functional status of the patient and drug used may interfere with the interpretation of immune function tests.It is necessary to integrate the clinical characteristics of patients,a variety of imaging examinations,and etiological detection to confirm the diagnosis and avoid misdiagnosis.