第八篇结缔组织病和风湿病Eighthconnectivetissuediseasesandrheumatism

1、第八篇 结缔组织病和风湿病（eighth connective tissue diseases and rheumatism）eighth connective tissue diseases and rheumatismthe second chapter rheumatoid arthritislearning points1. to understand the etiology and pathogenesis of rheumatoid arthritis.2. familiar with the pathological changes of rheumatoid arthriti

2、s.3. to master the clinical manifestation, diagnosis, differential diagnosis and treatment of rheumatoid arthritis.key and difficult analysisfirst, etiology: etiology is not clear, may be associated with infection factors, genetic a certain relationship.two, pathogenesis: unknown antigen into the bo

3、dy after the activation of t, b cells and the complement system, the release of cytokines (such as ll1-2, tnf-, 1-6, alpha ll-8) and immunoglobulin (such as rheumatoid factor antibodies) caused by the joint inflammation and destruction. cd4+t lymphocytes play an important role in the pathogenesis of

4、 ra. the abnormal apoptosis of synovial cells leads to the immune response of ra synovitis.three 、 pathologythe pathological change of rheumatoid arthritis is synovitis.1. acute phase: manifested as exudative and cell infiltration, expansion of small blood vessels in the lower synovial layer, swelli

5、ng of endothelial cells, enlargement of intercellular space, interstitial edema and neutrophil infiltration.2. chronic phase: synovial hypertrophy, formation of villous projections, protruding into the joint cavity or invade cartilage, subchondral bone, synovial infiltration of lymphocytes, most of

6、which were cd4+t lymphocytes.3. vasculitis is another pathological change of ra, which can occur in any tissue outside the joint. involvement of small and medium arteries and venous walls, lymphocytic infiltration, fibrosis, and intimal hyperplasia leads to narrowing or occlusion of the lumen. rheum

7、atoid nodules are a manifestation of vasculitis and are common in the extensor portion of the joint. the nodular center is a cellulose like necrotic tissue. around the epithelioid cell infiltration, arranged in a ring, outside with granulation tissue. between granulation tissue are lymphocytes and p

8、lasma cells.four 、 clinical manifestation(1) joint performance1. morning one of ra activity index observation2. joint pain, the earliest symptoms. the most common sites were wrists, metacarpophalangeal joints, and proximal interphalangeal joints. followed by toe, ankle, elbow, shoulder and other lar

9、ge joints. symmetrical, persistent, light, heavy, accompanied by tenderness, brown pigmentation of the skin.3. symmetrical joint swelling.1., late joint spleen shape.2. special features: neck joint involvement, neck pain, limited motion. shoulder and hip joint pain, swelling and limited motion. 1/4

10、patients suffered from temporomandibular joint involvement, speech pain during mastication, and limited mouth opening. in conclusion, ra mainly involves small joints, especially hand joints, which are symmetrical, multiple joints, chronic disease, repeated recurrence.(two) extra articular manifestat

11、ions1. rheumatoid nodules.2. rheumatoid vasculitis.3. pulmonary manifestations, pulmonary interstitial lesions, are the most common pulmonary lesions, nodular changes, pleurisy.1. pericarditis.2. gastrointestinal discomfort, mostly caused by antirheumatic drugs.3. kidney damage, mostly for antirheum

12、atic drugs and complicated amyloidosis, causing abnormal urine.4. nerve system, the cervical vertebra bone joint involvement causes the spinal cord compression or the peripheral nerve, because the synovitis is involved.5. blood system: iron deficiency anemia, fel, ty syndromethe 10. part of patients

13、 with sjogren's syndrome.five 、 laboratory examination(1) hemogram: mild or moderate anemia. white blood count and normal classification. during the active stage, the increase of platelet and esr is the index of the activity and severity of synovitis.(two) c reactive protein: explain ra activity

14、.(three) rheumatoid factor: igg, lg m, lga rf, the routine clinical work detected as lgm rf, the number and the disease activity and severity in proportion, but must be combined with clinical manifestations, except for systemic lupus erythematosus, sjogren syndrome.(four) serum immune complexes and

15、complement the arrow(five) synovial fluid decrease, wbc increases obviously(six) x of the fingers and wrists: stage i: joint end of osteoporosis; stage ii: joint space narrowing; iii joint surface worm cutting destruction; fourth joint subluxation; fibrous and bony ankylosis after joint destruction.

16、six 、 diagnosis of clinical rheumatology clinic in 1987 based on the diagnostic criteria, combined with the auxiliary examination to determine.seven 、 differential diagnosis(a) ankylosing spondylitis: most young and middle-aged men, asymmetric lower limb joint arthritis mainly, rarely involved in ha

17、nd joints. the sacroiliac joint is characterized by typical x ray changes. more than 90% of patients were hla-b27 (+), rf (-).(two) in psoriatic arthritis: skin psoriasis, symmetrical arthritis, involving the distal finger joint is more obvious, and the performance of the joint attachment and finger

18、 end inflammatory arthritis, at the same time, sacral iliac arthritis and spondylitis, rf (1).(three) osteoarthritis is more than 50 years old. the joint pain is mild, mainly after the exercise, and relieved after the rest. there are bony hyperplasia and nodules in the distal finger joints. rf (1).

19、esr does not increase rapidly.(four) systemic lupus erythematosus: joint symptoms are lighter than ra, systemic symptoms such as extra articular butterfly, erythema and alopecia are prominent, serum antinuclear antibody (+), anti double stranded dna antibody (+), early onset of low complement.(five)

20、 rheumatoid arthritis is one of the most common manifestations of rheumatic fever. arthritis is characterized by large, swollen joints and very few deformities. extra articular symptoms are fever, inflammation of the heart, subcutaneous nodules, sore throat, annular erythema. rf (i), strand o test (

21、+).eight, treatment:(1) objective: to reduce and eliminate symptoms, to control development, to prevent and reduce the destruction of joint bones, and to promote the repair of damaged joint bones.(three) measures1. rest, acute phase, joint immobilization. convalescent stage, joint functional exercis

22、e, physical therapy.2. drug treatment (group nsaid): oral administration mainly; gastrointestinal reaction is heavy, long-term use of renal interstitial damage. slow acting antirheumatic drugs: use with nsaid as soon as possible. mtx commonly used drugs, sulfasalazine, preparation, penicillamine, cy

23、clophosphamide, azathioprine tripterygium glycosides, etc. glucocorticoids are suitable for patients with extra articular symptoms or joints who are clearly unable to control nsaid or slow acting antirheumatic drugs. joint replacement or synovectomy.synchronous exercisefirst, the noun explanation1.

24、raynaud's phenomenon, 2. afraid stiff 3., rheumatoid nodules 4. rheumatoid factortwo fill in the blanks1. seronegative arthritis is present,.2. rheumatoid arthritis is more common in sex, good hair, age at age.3. commonly found in morning stiffness. except for the phenomenon of stalemate.4. rheu

25、matoid arthritis, hand joint destruction is serious, will appear, and / or deformity.5. the main treatments for connective tissue disease include,.6. rheumatoid factor is an autoantibody, can be divided into, and clinically commonly used, it is found in about patients serum.7. rheumatoid arthritis i

26、s the main manifestation of the disease. pathological joint.8. rheumatoid joints cause joint destruction, joint deformities, dysfunction of the pathological basis is.9. in patients with rheumatoid arthritis, urinary abnormalities should be considered for renal damage or by the presence of wind assoc

27、iated with the disease.10.95% rheumatoid arthritis patients appear, often as one of the indicators of disease activity.five, jane answer1. what are the diagnostic criteria for rheumatoid arthritis?2. try to describe the functional classification of rheumatoid arthritis.3. what are the common treatme

28、nt options for rheumatoid arthritis?4. rheumatoid arthritis and ankylosing spondylitis identification of what is the point?5. what are the principles of glucocorticoids in the treatment of rheumatoid arthritis?four, medical record analysispatients, female, 32 years old, with distal metacarpophalange

29、al joint swelling and morning stiffness for 2 months with admission. after about 2 hours of questioning disease shi chen stiff, no light allergy, no oral ulcer,check the proximal interphalangeal joint of finger fusiform swelling body finger, serum antinuclear antibody, rheumatoid factor positive, es

30、r, 89mm/h, blood routine is normal, no abnormal urine routine, the patient can understand what is the diagnosis? what is the basis for diagnosis?reference answerfirst, the noun explanation1. a: refers to the primary disease on the basis of hand foot skin appear pale, cyanosis, flushing, three months

31、 of sequential color change. cold and mental stress can be induced.2. answer: the pathological changes of the joints in the stationary after a long period of time stiff, (>1 hours), such as sticky like feeling.3. answer: rheumatoid arthritis is a special manifestation of the skin, mostly located

32、in the joint bulge and compression parts of the subcutaneous, size, symmetry distribution. without tenderness.4, answer: it is a kind of autoantibody that uses denatured 1gg as target antigen.two fill in the blanks1. ankylosing spondylitis, reiter syndrome, psoriatic arthritis, reactive arthritis.2.

33、 female, 35-50 years old.3., rheumatoid arthritis, rheumatoid arthritis, bone and joint disease.the 4. peak deformity, swan neck deformity and ulnar deviation deformity, buttonhole deformity, telescope.5. glucocorticoids, immunosuppressive agents, non steroidal anti-inflammatory drugs.6.igm, rf, 1gg

34、, rf, 1ga, rf, 1gm, rf, 70%.7. peripheral joint, multisystem inflammatory and autoimmune synovitis.8. in the chronic phase formation of villous projections.9. antirheumatic drugs, amyloidosis.10. morning, morning stiffness duration.three, jane answeranswer: the 1. morning stiffness for at least 1 ho

35、urs (per day) for at least 6 weeks duration. there are three or three joints swollen for at least 6 weeks. wrist, metacarpophalangeal joints, swollen joints of the fingers, at least 6 weeks. symmetrical joint swelling for at least 6 weeks. subcutaneous nodules. change the hand x-ray (at least for os

36、teoporosis and joint space narrowing). the positive rheumatoid factor (>1:20, the titer) 7 items in 4 can be diagnosed as rheumatoid arthritis.2. answer: level 1: daily life and work as usual. level ii: general daily life and some kind of professional work. but restrictions on participation in ot

37、her projects are limited. iii. general daily life, but limited to participation in a particular job or other activity. the ability to take care of themselves and to participate in daily work is limited.3. answer: rheumatoid arthritis is currently commonly used treatment options (1), pyramid program

38、(2), step down program (3), 2 kinds of change, disease medicine combination.4. answer: rheumatoid arthritis is more common in 35-50 year old women, small joints of the hands and feet is the predilection site. the lesion was mainly characterized by joint invasion. rheumatoid factor 80% was positive,

39、and hla-b27 was normal. ankylosing spondylitis is more common in men aged 16-30 years, and the predilection sites are in the spine and sacroiliac joints. the main feature of the disease is bone rigidity, 90% hla-b27 (+)5. answers: short term: medium quantity. quick withdrawal.the fourth chapter is s

40、ystemic lupus erythematosuslearning points1. to understand the etiology and pathogenesis of systemic lupus erythematosus.2. master the clinical manifestation and laboratory examination.3. master the standard of diagnosis and differential diagnosis.4. master the treatment.key and difficult analysis(1

41、) etiology: unknown etiology may be related to the following factors.1. genetic factors2. environmental factors such as sunlight, ultraviolet radiation, chemicals and so on3. estrogen.two. pathogenesis: genetic predisposition - environmental factors or sex hormones - abnormal immune responses of t a

42、nd b cells - a large number of immune complexes and pathogenic autoantibodies producing tissue damage.three, clinical manifestations: involving multiple organs, relief and alternating attacks.1. general performance: chronic, low, moderate fever, fatigue, fatigue, weight loss.2. bone, joints and musc

43、les: asymmetry, multi joint pain, intermittent, finger, wrist and knee joints are common. may have myalgia, myositis.3. skin and mucous membranes: facial erythema, erythema, sunburn, macula, photosensitivity, oral ulcers, alopecia.4. kidney: chronic nephritis and nephrotic syndrome are the most comm

44、on. late onset uremia is one of the causes of sle death.fivecardiovascular: pericarditis is most common.6. lungs: lupus pneumonia. fever, cough, shortness of breath, chest x-ray double lung patchy infiltration shadows. pleurisy and interstitial lung disease are not easy to distinguish from miliary t

45、uberculosis.the 7. nerve system: the central nervous system, especially the brain, is the most common. can appear all sorts of mental disorders, seizures, hemiplegia and so on. it is an index of serious illness, poor activity and poor prognosis.8. digestive system: abdominal pain, diarrhea, vomiting

46、, loss of appetite and so on. elevated transaminase, jaundice, and a small number of acute abdominal events are signals of the sie attack.9. blood system: bleeding, anemia, lymphadenopathy, splenomegaly etc.10. sjogren syndrome11. fundus can be bleeding, papillary edema, retinal exudation and other

47、non - characteristic changes.four 、 laboratory examinationesr: ana is the sie screening test, serum titer of more than 1:80 of connective tissue disease diagnosis significance. anti sm antibody is mainly based on the retrospective diagnosis; often anti ssb antibody, anti ssb antibody, anti rnp (posi

48、tive often prompts nervous system damage), antiphospholipid antibodies from other antibodies; anti double stranded dna antibody in diagnosis and judgment of lupus activity in the reference value, the antibody titer increased have kidney damage, complement ch50, c3 and c4 can help reduce diagnosis, p

49、rompt the activity of lupus; lupus band test has positive significance to diagnosis. renal biopsy is valuable in the diagnosis, treatment and prognosis of lupus nephritis.five 、 diagnosis and differential diagnosis1. of the diagnostic criteria for lupus nephritis, 11 of the 4 positive, can be diagno

50、sed as sie.2.sle need to pay attention to and all kinds of dermatitis, epilepsy, mental illness, characteristics of white board reduction purple house: primary glomerulonephritis identification. (the distinction between oral and multiple diseases has been explained in detail).3. determine the severi

51、ty of sie activity to guide and estimate prognosis.three, treatment: treatment principle: active period and severe illness, given strong drug control, remission after disease maintenance treatment.1. light sie symptomatic and low dose corticosteroids.2. heavy sie hormone and cytotoxic agents.3. acut

52、e fulminant critical sie: methylprednisolone + ctx shock therapy + symptomatic treatment.4. general treatment: psychological treatment of acute period of bed rest the timely treatment of infection and found drug induced lupus and avoid using strong sunlight and ultraviolet light to avoid the body to

53、 remission of vaccination, remission for more than one year may consider pregnancy.synchronous exercisefirst, the noun explanation1. systemic lupus erythematosus 2. antiphospholipid syndrome 3. drug induced lupus 4. photosensitivitytwo fill in the blanks1. the etiology of systemic lupus erythematosu

54、s is unknown. it may be related to a variety of factors.2. predisposing factors for systemic lupus erythematosus include,.3. the pathological types of lupus nephritis are mainly,.4.sie is the hallmark antibody, with a positive rate of approximately.5.sie's hematologic abnormalities are most ofte

55、n manifested as.6. systemic lupus erythematosus is different from rheumatoid arthritis,.7. common causes of systemic lupus erythematosus,.three, jane answer1. what is the standard of activity in the diagnosis of systemic lupus erythematosus?2. what is the positive change of immunology in systemic lu

56、pus erythematosus?four, medical record analysisthe patient, aged 20, complained of joint pain, rash, january, edema, oliguria, and fever for 2 days. check t 38.30c, bp12/8kpa, facial edema, facial butterfly erythema, edema of the eyelids, conjunctiva slightly pale, pharynx congestion, tonsil is not,

57、 lungs are coarse and no rales, heart size and heart rate of 90 beats per minute, the law is neat, no noise, and untouched, ascites syndrome (+), double the edema of lower extremity. laboratory examination, routine blood test, wbc 3.1 x 109/l, n60%, l27%, hb, 90g/dl, plt80 * 109/l, esr60mm/h,urine pro+, bld+ rbc1015/hp, anti double stranded dna antibody (+), plasma total protein 50g/l albumin 24g/l, alanine aminotransferase 213u/l aspartate aminotransferase 412u/l, serum creatinine 102 mol/l, what is the basis for the diagnosis of patients with diagnosis of what kind of disea