以关节炎为首发表现的肥大性肺性骨关节病五例患者临床分析

Arthritis as the Initial Manifestation of Hypertrophic Pulmonary Osteoarthropathy: A Clinical Analysis of Five Patients

目的探讨以关节炎为首发表现的肥大性肺性骨关节病(HPOA)的临床特点,以提高认识,减少误诊误治。方法回顾性分析2006—2015年北京积水潭医院诊治的5例以关节炎为首发表现的HPOA患者的临床资料,结合文献复习,总结其临床表现、实验室检查及影像学特点。结果临床资料:5例患者中,男4例、女1例,中位年龄51岁,中位病程6个月。5例均为多关节受累,且呈对称性,均有双侧下肢大关节受累(膝、踝关节)。3例有轻度咳嗽,4例有吸烟史。5例查体均可见杵状指(趾)。5例原发病均为肺癌。实验室检查:3例存在轻度贫血,4例红细胞沉降率(ESR)、C反应蛋白(CRP)水平升高,5例类风湿因子(RF)、抗环瓜氨酸肽(抗CCP)抗体、抗核抗体谱(ANAs)及人类白细胞抗原(HLA)-B27均阴性,4例肿瘤标志物水平升高。影像学:3例X线示双下肢(股骨、胫骨)对称性骨膜反应,4例骨显像示四肢长骨骨皮质放射性分布增高,5例肺CT发现占位性病变。结论以关节炎为首发表现的HPOA虽然少见,但对于中老年患者出现对称性以下肢为主的关节炎、伴杵状指(趾)、存在系统症状、抗风湿治疗效果不佳时应积极行X线及骨扫描检查,一旦诊断HPOA,尽早完善肺部影像学筛查恶性肿瘤。

Objective To investigate the clinical manifestations of hypertrophic pulmonary osteoarthropathy （HPOA） with arthritis as the initial manifestation, and to raise the awareness and reduce misdiagnosis and mistreatment. Methods The clinical data of five HPOA patients, taking arthritis as the initial manifestation and receiving diagnosis and treatment in Beijing Jishuitan Hospital from 2006 to 2015, were retrospectively analyzed. The clinical manifestation, laboratory inspection and imaging characteristics were summarized combined with literature review. Results Clinical data： among the five patients, four male and one female, with a median age of 51 and the median course of disease of 6 months. Multiple joints of five cases were affected and presented symmetry, all of them had large joint of bilateral lower extremity affected （ knee and ankle joints）. Three had mild cough, and four had history of smoking. The five cases presented with visible clubbed fingers （toe）. The primary disease of five patients was lung cancer. Laboratory examination： mild anemia occurred in three cases, erythrocyte sedimentation rate （ESR） and C - reactive protein （CRP） levels of four cases were increased, the rheumatoid factor （ RF）, anti - cyclic citrulline polypeptide （ anti - CCP） antibody, antinuclear antibodies （ANAs） and human leukocyte antigen （HLA） - B27 of five cases were all negative, and levels of tumor markers of four cases were increased. Imaging： X - ray showed symmetrical periosteal reaction of both lower extremities （femur, tibia） in three cases, bone scintigraphy showed increased radioactive distribution of bone cortex of long bone of limbs in four cases, and lung CT of five cases found there were space - occupying lesions. Conclusion Although HPOA with the initial manifestation of arthritis is not commonly seen, when symmetrical arthritis of lower limbs, combining with clubbed fingers （toes）, presence of systemic symptoms, poor anti -rheumatic treatment occur in middle aged and aged patients, X - ray and bone scanning should be performed actively, once the diagnosis of HPOA is made, pulmonary imaging should be improved for screening malignant tumors as early as possible.