狼疮性肾炎七例临床误诊分析

Clinical Misdiagnosis of Lupus Nephritis in 7 Patients

目的探讨狼疮性肾炎(LN)的临床特点、诊断及鉴别诊断方法、误诊原因及防范误诊措施。方法回顾性分析2020年3月至2022年6月收治的曾误诊为紫癜性肾炎、类风湿关节炎的7例LN的病例资料。结果7例中男5例、女2例,年龄26~57岁。2例以发热、关节痛、疲乏无力、食欲减退、手足出汗为主要表现,查血白细胞、血小板计数轻微降低,血红蛋白降低,红细胞沉降率增快,X线检查示病变手指关节、膝关节周围软组织稍肿胀、关节间隙轻度狭窄,初诊类风湿关节炎,予抗风湿药物、中药外敷治疗病情无明显缓解,再次来院完善自身抗体检查及肾活检确诊为LN。5例以皮疹、关节痛、下肢水肿、少尿、腰痛为主要表现,查尿常规见蛋白尿、血尿,肾功能异常,初诊紫癜性肾炎,后经肾穿刺病理检查确诊为LN。LN病理分型:Ⅱ型2例、Ⅲ型4例、Ⅳ型1例。7例误诊时间为1~2个月,确诊后予泼尼松联合环磷酰胺及对症支持治疗,病情稳定。结论LN患者临床表现多样,部分患者早期表现不典型,少数患者仅有肾损害表现,在未行自身抗体检查及肾活检前极易误诊;临床医生应加强对LN多系统表现复杂性的认识,加强对本病特点及诊断相关知识的了解,提高警惕性,认真鉴别诊断,及早行自身抗体检查及肾活检,有利于减少本病误诊误治。

Objective To investigate the clinical features,diagnosis and differential diagnosis methods,causes of misdiagnosis and preventive measures of lupus nephritis(LN).Methods The case data of 7 patients with LN who were misdiagnosed as purpura nephritis and rheumatoid arthritis from March 2020 to June 2022 were retrospectively analyzed.Results Among the 7 patients,5 were males and 2 were females,aged 26-57 years.Fever,arthralgia,fatigue and weakness,loss of appetite,and night sweats of hands and limbs were the main manifestations in 2 patients.The white blood cells and platelet counts were slightly decreased,hemoglobin was decreased,and erythrocyte precipitation rate was increased.Xray ex-amination showed slight swelling of soft tissues around the affected joints and slight narrowing of joint space.They were initial-ly diagnosed with rheumatoid arthritis,and the condition did not improve significantly after receiving anti rheumatic drugs and external application of traditional Chinese medicine.Upon further examination of the patient's own antibodies and renal biop-sy,the diagnosis was confirmed as LN.The main manifestations of the 5 patients were rash,arthralgia,lower limb edema,oli-guria,and lumbago.Proteinuria,hematuria,abnormal renal function were found on routine urine examination,purpura nephri-tis was initially diagnosed,and LN was confirmed by pathological examination through renal puncture.The pathological types of LN were 2 cases of typeⅡ,4 cases of typeⅢand 1 case of typeⅣ.The misdiagnosis of 7 patients lasted 12 months.Af-ter diagnosis,all patients were treated with Prednisone combined with Cyclophosphamide and symptomatic supportive treat-ment,showing stable condition.Conclusion The clinical manifestations of LN patients are varied,some of them are atypical in the early stage,and a few of them only show kidney damage,which is more likely to cause misdiagnosis before autoantibody examination and renal biopsy.Clinicians should strengthen the understanding of the complexity of LN's multisystem manifes-tations,strengthen the understanding of the characteristics and diagnostic knowledge of the disease,enhance vigilance,and perform careful differential diagnosis,early autoantibody examination and renal biopsy,which is conducive to reducing the misdiagnosis and mistreatment of the disease.