不典型强直性脊柱炎误诊原因分析

Causes of Misdiagnosis of Atypical Ankylosing Spondylitis

目的分析强直性脊柱炎(ankylosing sporidylitis,AS)误诊为腰椎间盘突出症、风湿热(rheumatic fever,RF)的原因及防范措施。方法回顾分析2021至2023年收治的AS误诊腰椎间盘突出症1例、RF 1例的病例资料。结果1例为31岁男性,因腰背部及右下肢疼痛伴晨僵3个月就诊,腰椎间盘CT检查示L_(4~5)椎间盘轻度突出,初诊为腰椎间盘突出症,后出现低热,查红细胞沉降率(erythrocyte sedimentation rate,ESR)、C反应蛋白(C reactive protein,CRP)升高、人白细胞抗原B27阳性,骶髂关节CT示双侧骶髂关节面有虫噬样改变,诊断为AS。1例为16岁青少年,因双踝双膝关节肿痛1年余、加重1月余就诊,因抗链球菌溶血素“O”试验(+),合并有多关节疼痛症状,诊断为RF,予苄星青霉素注射后症状好转停用后再发,后行骶髂关节MRI检查示双侧骶髂关节面局部融合,ESR与CRP升高,综合以上排除RF后诊断AS。误诊时间3个月、14个月。2例确诊后均予柳氮磺胺吡啶、甲氨蝶呤、重组人Ⅱ型肿瘤坏死因子受体抗体融合蛋白等治疗后症状消失,随访1~2年病情平稳。结论部分AS患者初期表现不典型,易误诊;加强对AS及相关疾病的认识、诊断及鉴别诊断能力,仔细采集病史,认真查体,早期行骶髂关节影像学检查及人白细胞抗原B27检测,结合临床表现和其他相关检查结果综合分析病情,可避免本病误诊的发生。

Objective To analyze the causes and preventive measures of ankylosing spondylitis(AS)misdiagnosed as lumbar disc herniation(LDH)and rheumatic fever(RF).Methods The case data of 1 patient with AS misdiagnosed as LDH and 1 patient with RF from 2021 to 2023 were retrospectively analyzed.Results A 31-year-old male patient presented with pain in the lower back and right lower extremity accompanied by morning stffness for 3 months.CT examination of lumbar disc showed mild disc herniation at L_(4-5) and was initially diagnosed as LDH.Afterwards,low fever appeared,erythrocyte subsidence rate(ESR)and C-reactive protein(CRP)were elevated,human leukocyte antigen B27(HLA-B27)was positive,and CT scan of the sacroiliac joint showed worm-eaten-like changes on the surface of both sacroiliac joints,which was diagnosed AS.One pa-tient was a 16-year-old adolescent who presented with swelling and pain in both ankles and knees for more than 1 year,which was aggravated for more than 1 month.Due to anti-streptolysin"o"test(+),and the complicated symptoms of multiple joint pain,he was diagnosed with RF.The symptoms improved after Benzathine Penicillin injection and recurred after discontinua-tion.MRI examination of posterior sacroiliac joint showed local fusion of bilateral sacroiliac joint surfaces,with elevated ESR and CRP.Based on this,AS was diagnosed after exclusion of RF.The duration of misdiagnosis was 3 months and 14 months re-spectively.After diagnosis,the symptoms of 2 patients disappeared after treatment with Sulfasalazine,Methotrexate,and recombi-nant human tumor necrosis factor receptor type II antibody fusion protein.They were followed up for 1 to 2 years,and the con-dition was stable.Conclusion Some patients with AS have atypical manifestations in the early stage and are prone to misdiag-nosis.Strengthening the understanding of AS and related diseases,diagnosis and differential diagnosis ability,careful collection of medical history,careful physical examination,early imaging examination of sacroiliac joint and HLA-B27 detection,com-bined with clinical manifestations and other relevant examination results,can help avoid misdiagnosis of this disease.