误诊脊柱关节炎的结核性骶髂关节炎2例并文献复习

Misdiagnosis of tuberculous sacroiliitis as spondyloarthritis:two cases and a literature review

目的 提高临床医生对结核性骶髂关节炎的认识。方法 总结2例中山大学孙逸仙纪念医院风湿免疫科收治及13例在中英文文献数据库收录的文献(截至2023年7月)中报道的被误诊为脊柱关节炎的结核性骶髂关节炎患者的临床特点。结果 15例患者中女性8例,男性7例,中位年龄27 (23~36)岁,自发病到确诊为结核性骶髂关节炎的中位时间为11 (6~24)个月。临床表现以臀部痛(10例)和腰痛(9例)最常见,其他临床表现包括发热8例、消瘦3例、盗汗2例、咳嗽2例、髋痛2例和腹泻1例。85.7%(12/14)患者红细胞沉降率升高,77.8%(7/9)患者C反应蛋白升高。23.1%(3/13)患者人类白细胞抗原-B27阳性。80.0%(8/10)患者结核菌素纯蛋白衍生物皮试阳性,83.3%(5/6)患者γ干扰素释放试验阳性,80.0%(4/5)患者结核分枝杆菌脱氧核糖核酸检查阳性,60.0%(6/10)患者病变部位组织或关节积液结核分枝杆菌培养阳性。骶髂关节影像学检查显示单侧受累13例,双侧受累2例。10例确诊后予抗结核药物治疗,4例在骨外科行病灶清除术联合抗结核药物治疗,1例仅进行病灶清除术。13例提供随访结果的患者均病情明显好转。结论临床上遇到青壮年起病的腰臀部痛患者,应注意脊柱关节炎与骶髂关节感染尤其是结核的鉴别,及时行相关病原学检查明确诊断,避免误诊误治。

Objective To improve physicians'clinical knowledge regarding tuberculous sacroiliitis.Methods 2 patients who were initially misdiagnosed with spondyloarthritis but subsequently re-diagnosed with tuberculous sacroiliitis were obtained from Department of Rheumatology,Sun Yat-sen Memorial Hospital,Sun Yat-sen University and 13 patients were obtained from relevant literature.Their clinical data were collected and analyzed.Results Among the cohort of 15 cases,8 were female while 7 were male,with a median age of 27 years(range 23-36 years).The median disease duration from the onset of the first symptom to final definitive diagnosis of tuberculous sacroiliitis was 11 months(range 6-24 months).The most prevalent clinical manifestations were buttock pain or lower back pain,observed in 10 and 9 patients respectively.Additional clinical manifestations encompassed fever in 8 patients,weight loss in 3 patients,night sweats in 2 patients,cough in 2 patients,hip pain in 2 patients,and diarrhea in 1 patient.An elevated erythrocyte sedimentation rate was observed in 85.7%(12/14)patients,and elevated C-reactive protein was found in 77.8%(7/9)patients.Positive human leucocyte antigen-B27 was detected in 23.1%(3/13)patients.The purified protein derivative tuberculin skin test was positive in 80.0%(8/10)patients,while theγ-interferon release assay showed positive results in 83.3%(5/6)patients.The tuberculosis deoxyribonucleic acid test showed positive results in 80.0%(4/5)patients,and tuberculosis mycobacterial was successfully cultured in 60.0%(6/10)patients.Radiographic examination of the sacroiliac joints revealed unilateral involvement in 13 cases and bilateral involvement in 2 cases.For the treatment,10 patients were treated with anti-tuberculosis drugs,4 patients underwent lesion debridement of orthopedic surgery combined with anti-tuberculosis drugs,and 1 case underwent lesion debridement alone.All 13 patients who provided follow-up results showed significant improvement.Conclusions Differential diagnosis of spondyloarthritis with tuberculous sacroiliitis should be considered in young patients with lower back or buttock pain.The relevant pathogen tests should be carried out promptly for definitive diagnosis and to avoid misdiagnosis and mistreatment.