变应性鼻炎对全身型幼年特发性关节炎病情的影响

The influence of allergic rhinitis on patients with systemic onset juvenile idiopathic arthritis

目的 探讨变应性鼻炎（AR）对全身型幼年特发性关节炎（SoJIA）病情的影响.方法 收集2008年7月至2013年11月于上海交通大学医学院附属仁济医院儿科住院和门诊就诊的SoJIA患儿44例,分别记录临床及实验室相关资料.通过回顾性队列研究的方法,根据AR的诊断分为AR组16例和非AR组28例,分别比较2组ACR Pedi30/50/70及其他病情指标的变化情况,分析AR组中AR评分与DAS28的相关性.2组再次病情活动时,AR组进行关节炎治疗的同时积极进行鼻喷剂和口服抗组胺药物治疗AR（干预组）,非AR组单纯进行关节炎治疗（非干预组）,分别比较2组SoJIA病情的改善率.计量资料满足正态性和方差齐性条件则采用t检验,否则采用Mann-Whitney U检验;计数资料采用x2检验,相关性分析采用Pearson或Spearman相关检验.结果 ①在回顾性分析中：AR组起病时医师对疾病活动状况的整体评估、患儿/监护人对健康状况的整体评估、活动性关节炎数目、活动受限关节数目、ESR、血清铁蛋白（SF）以及儿童健康评估问卷（CHAQ）评分均高于非AR组[分别为（6.7±1.0）cm与（4.8±1.9） cm;（6.5±1.4） cm与（3.2±1.5）cm;4.1±2.7与2.7±1.7;3.4±2.4与1.4±1.5;（87±35） mm/1 h与（61±40） mm/1 h;（888±1 043） μg/L与（311±324） μg/L;1.6±0.5与0.7±0.3,P均＜0.05];AR组在发病3、6个月达ACR Pedi50、70低于非AR组,而单位体质量糖皮质激素累积剂量高于非AR组,差异均有统计学意义[3个月时分别为38％与71％;13％与46％;（76±35） mg/kg与（43±36） mg/kg;6个月时分别为25％与71％;19％与64％;（127±57） mg/kg与（67±58） mg/kg;P均＜0.05];在AR组中,入组时和3、6个月AR评分和DAS28呈正相关（分别r=0.741;r=0.703;r=0.680;P均＜0.05）.②在前瞻性研究中：2组再次发病时,干预组系统特征评分、医师对疾病活动状况的整体评估、患儿/监护人对健康状况的整体评估、活动性关节炎数目、活动受限关节数目、ESR、SF以及CHAQ评分均高于非干预组[分别为3.8±1.5与2.1±1.1;（5.6±1.5） cm与（4.5±1.6）cm;（4.6±1.9） cm与（3.1±1.5）cm;3.9±1.9与2.5±1.4;2.4±0.9与1.5±1.2;（92±27） mm/1 h与（53±37） mm/1 h;565（339,1 192） μg/L与171（85,284） μg/L;13（0.8,1.6）与0.7（0.5,1）;P均＜0.05];3个月随访时对各项病情活动指标的改善率进行比较发现：干预组3个月时医师对疾病活动状况的整体评估、患儿/监护人对健康状况的整体评估、ESR、活动性关节炎数目、受限关节数目以及CHAQ评分改善率均高于非干预组[分别为71（55,86）％与46（0,75）％;67（45,81）％与28（-4,62）％;92（77,96）％与70（27,88）％;65（48,81）％与0（-17,67）％;100（46,100）％与42（0,100）％;67（49,85）％与37（0,75）％;P＜0.05];干预组治疗6个月后ESR、患儿/监护人对健康状况的整体评估、受限关节数目以及CHAQ的改善率高于非干预组[分别为94（85,96）％与73（33,85）％;89（65,99）％与63（5,85）％;100（100,100）％与100（0,100）％;91（69,100）％与72（11,91）％;P＜0.05].结论 ①SoJIA合并AR可能对其病情控制产生不利影响;②SoJIA合并AR患儿,给予AR干预有利于原发病SoJIA病情的控制。

Objective To explore the influence of allergic rhinitis （AR） on patients with systemic onset juvenile idiopathic arthritis （SoJIA）.Methods The study involved 44 cases with SoJIA from Department of Pediatrics,Renji Hospital affiliated to School of Medicine of Shanghai Jiaotong University from July 2008 to November 2013.The Clinical and laboratory data of all patients were recorded respectively.This was a retrospective cohort study.According to the diagnosis of allergic rhinitis （AR）,children were subdivided into AR group （16 cases） and Non-AR group （28 cases）.ACR Pediatric criteria （ACR Pedi） 30/ 50/70 and related indicators of SoJIA between the two groups were compared.In the AR group,the correlation between AR scores and DAS28 was analyzed.When SoJIA of the two groups relapsed,the AR group （the treatment group） received anti-rheumatism for arthritis as well as nasal spray and oral antihistamines for AR.The non-AR group （control group） only received the anti-rheumatism for arthritis.The improvement of SoJIA between the two groups was analyzed.The continuous variables were analyzed by Student＇s t-test or the MannWhitney U-test as appropriate.Categorical data were compared between different groups by the Chi-square test.Correlations were determined by Pearson or Spearman＇s ranking.Results ① In the retrospective analysis：the physician＇s and patients＇/parents＇ general assessment on a 10 cm visual-analogue scale （VAS）,number of joints with res-triction of movement,number of swollen joints,ESR,serum ferritin（SF） and childhood health assessment questionnaire （CHAQ） score were significantly elevated in the AR group compared with Non-AR group at the disease onset [（6.7±1.0） cm vs （4.8±1.9） cm; （6.5±1.4） cm vs （3.2±1.5） cm; 4.1±2.7 vs 2.7± 1.7; 3.4±2.4 vs 1.4±1.5; （87±35） mm/1 h vs （61±40） mm/1 h; （888±1 043） μg/L vs （311±324） μg/L; 1.6±0.5 vs 0.7±0.3,respectively; all P＜0.05].At the 3 and 6 months follow-up after disease onset,the proportion of patients who reached ACR pedi 50,70 in AR group were lower than the Non-AR group,while the cumulative glucocorticoid dose was higher in the AR group than that of those without AR [at 3 months 38％ vs 71％; 13％ vs 46％; （76±35） mg/kg vs （43±36） mg/kg,respectively; at 6 months 25％ vs 71％; 19％ vs 64％; 127±57 vs 67±58,respectively,all P＜0.05]; In the AR group,at the disease onset,3 and 6 months follow-up after disease onset,the scores of AR was positively correlated with DAS28（r=0.741,0.703,0.680,respectively; all P＜0.05）.② In the prospective study：when SoJIA was relapsed,systemic feature score,the physician＇s and patients＇ /parents＇ general assessment on a l0 cm VAS,number of joints with restriction of movement,number of swollen joints,ESR,SF and CHAQ score were significantly elevated in the treatment group compared with the control group [3.8±1.5 vs 2.1±1.1; （5.6±1.5） cm vs （4.5±1.6） cm; （4.6±1.9） cm vs （3.1±1.5）cm; 3.9±1.9 vs 2.5±1.4; 2.4±0.9 vs 1.5±1.2; 92±27 vs 53±37; 565（339,1 192） μg/L vs 171（85,284） μg/L; 13（0.8,1.6） vs 0.7（0.5,1）; respectively; P＜0.05].The improvement rate of the physician＇s and patients＇/parents＇ general assessment on a 10 cm VAS,number of swollen joints,number of joints with restriction of movement,ESR and CHAQ score at the follow-up 3 months were higher in treatment group than the control group [71（55,86）％ vs 46（0,75）％; 67（45,81）％ vs 28（-4,62）％; 92（77,96）％ vs 70（27,88）％; 65（48,81）％ vs 0（-17,67）％; 100（46,100）％ vs 42（0,100）％; 67（49,85）％ vs 37（0,75）％; P＜0.05].At the follow-up 6 months,the improvement rate of ESR,patients＇/ parents＇ general assessment on a 10 cm VAS,number of joints with restriction of movement and CHAQ score were higher than control group [94（85,96）％ vs 73（33,85）％; 89（65,99）％ vs 63（5,85）％; 100（100,100）％ vs 100（0,100）％; 91（69,100）％ vs 72（11,91）％; respectively,P＜0.05].Conclusion AR may exert an adverse influence on SoJIA.SoJIA patients who are treated with combined with AR may have better outcome than those who are only treated for arthritis.