中老年风湿性多肌痛31例误诊和漏诊分析

Misdiagnosis and missed diagnosis of 31 middle-aged and elderly patients with rheumatic polymyalgia

目的探讨风湿性多肌痛的误诊和漏诊原因。方法选取2018年3月至2020年7月浙江医院收治的中老年风湿性多肌痛确诊患者31例,分析其首发症状和临床表现、首诊科室、误诊和漏诊情况、治疗和随访情况。结果(1)初诊时主要症状为肩颈痛、双下肢近端肌肉痛、臀区肌肉疼痛、四肢酸痛等。(2)首次就诊于风湿免疫科仅4例,就诊的其他科室为针灸推拿科、全科医学科、中医科、神经内科等。(3)21例确诊前均被误诊为颈椎病、肩周炎、腰椎间盘突出、脊柱关节病、关节炎、感染性疾病等;10例确诊前诊断不明并分布于其他科室。(4)确诊前较为集中的临床表现为肩部疼痛、双下肢肌肉疼痛、骨盆带肌肉疼痛、双上肢上举受限、下蹲起立困难、颈及肩部肌痛等。(5)C反应蛋白水平升高31例,红细胞沉降率(简称血沉)大于40 mm/h 28例。(6)31例患者均经激素治疗后症状缓解,C反应蛋白水平和血沉下降。其中30例随访1~38个月,达到长期临床缓解者18例。结论对于伴颈肩痛和(或)合并下肢肌肉疼痛,且有双上肢上举受限、下蹲起立困难,并伴血沉及C反应蛋白水平升高的中老年人,在排除感染、肿瘤后应考虑有无风湿性多肌痛可能,可及时行血沉、C反应蛋白及自身免疫病相关抗体等的检查,以便早诊断、早治疗。

Objective To investigate the causes of misdiagnosis and missed diagnosis of rheumatic polymyalgia.Methods 31 confirmed patients with middle-aged and elderly rheumatic polymyalgia admitted to Zhejiang Hospital From March 2018 to July 2020 were selected,and their first symptoms,clinical manifestations,misdiagnosis,missed diagnosis,treatment and follow-up were analyzed.Results The main symptoms at the beginning are shoulder and neck pain,proximal muscle pain in the lower extremities,and hip muscles,etc.Only 4 cases went for medical service in the department of rheumatology and immunology for the first time,the other departments visited were acupuncture and massage,general medicine traditional chinese medicine and neurology,etc.21 cases were misdiagnosed as cervical spondylosis,frozen shoulder,lumbar,spondyloarthropathy,arthritis and Infectious diseases,etc.10 cases are unknown diagnosis.The more concentrated clinical manifestations before diagnosis are shoulder pain,pain in the lower axillary muscles,pain in the pelvic band,limited lifting of the upper limbs,difficulty in standing in squatting,neck and shoulder muscle pain.31 cases C-reactive protein level was increased,and 28 cases erythrocyte sedimentation rate(ESR)was greater than 40 mm/h.The symptoms of 31 patients were relieved after hormone therapy,C-reactive protein and blood sedimentation drops.Among them,30 cases were followed up for 1 to 38 months,and 18 cases reached long-term clinical remission.Conclusion For the middle-aged and elderly people with neck and shoulder pain and/or combined with lower limb muscle pain,limited upper limb lifting,difficulty squatting up,elevated blood sedimentation and C-reactive protein levels should consider the possibility of rheumatic polymyalgia after excluding infection and tumor.ESR,C-reactive protein level and autoimmune disease-related antibodies can be screened in time for early diagnosis and treatment.