强直性脊柱炎合并类风湿关节炎一例并文献复习

Coexistence of ankylosing spondylitis and rheumatoid arthritis: report of a single case and literature review

目的探讨强直性脊柱炎(AS)合并类风湿关节炎(RA)的临床特点,以便及时准确的诊断,及时治疗,有效减少漏诊误治。方法在总结我院诊治1例AS合并RA的基础上,分析AS合并RA的临床表现、发病机制、实验室检查、诊断标准、治疗及相关文献复习。结果①AS合并RA典型临床表现以中轴关节病变、肌腱端炎症为首发表现,并伴有慢性多关节滑膜炎为特征。②遗传背景及免疫学异常及易感基因人类白细胞抗原(HLA)-B27、HLA-DR4及其共享表位在AS合并RA的发生中有重要作用。③实验室检查上首选HLA-B27、类风湿因子(RF)、抗环瓜氨酸多肽(CCP)抗体、骶髂关节CT、关节X线或磁共振成像(MRI)检查,有条件者可检测HLA-DR4、DR2。④诊断上,具有AS影像学改变及临床表现,对称性外周关节破坏,抗CCP抗体阳性,外加RA的影像学改变,可诊断AS合并RA。⑤治疗上,首选改善病情抗风湿药物,同时可应用非甾体抗炎药和糖皮质激素。结论临床上AS合并RA患者比较少见,大部分患者是隐匿起病,容易漏诊,当患者出现腰背或腰骶部疼痛或肌腱端炎为首发症状时,同时伴发对称性外周多关节肿痛时,应高度怀疑AS合并RA,并需积极诊治。

Objective To investigate the clinical characteristics of ankylosing spondylitis （AS） with concomitant rheumatoid arthritis （RA）, which is expected to facilitate prompt and accurate diagnosis and timely treatment, thus reducing the rate of misdiagnosis and mistreatment. Methods The clinical manifestations, laboratory test findings, pathogenesis, diagnostic criteria and therapy based on a single case of AS with concomitant RA were analyzed and did a literature review. Results The central-axis joint involvement and enthesopathy were typically the initial manifesta- tions of AS with RA, the chronic involvement of sacroiliac joint could also be noted. Genetic background, immunolog- ical dysfunction and susceptibility gene, i.e. human leukocyte antigen （HLA）-B27, HLA-DR4 and their common epi- topes, may play a crucial role in the pathogenesis of AS with RA. Measurement of HLA-B27, rheumatoid factor （RF）, anti-cyclic citrylinated peptide （CCP） antibody, sacroiliac joint CT and joint X-ray or MRI were preferred, assessment of HLA - DR4 and DR2 could be performed when necessary. The diagnosis of AS with RA could be confirmed by the imaging and clinical manifestations of AS suggesting the presence of symmetric peripheral joint involvement, anti-CCP antibody and coexistence of imaging changes of RA. Disease modifying anti-rheumatic drugs was the first-line therapy, with the addition of non-steroidal anti-inflammatory drugs and glucocorticosteroids. Conclusion AS with RA has been rarely reported, with cryptogenic onset of symptoms in most cases leading to a high rate of misdiagnosis and mistreatment. The diagnosis of AS with RA should be prompted in case of lumbar or lumbosacral region pain, enthesopathy and the presence of multiple symmetric peripheral arthralgias, thus securing treatment in a timely fashion.