类风湿关节炎RheumatoidArthritis(RA)

1、 郑州大学第一附属医院 类风湿关节炎类风湿关节炎Rheumatoid Arthritis (RA)By Raoul Dufy (1877-1953)Outline Definition and history Prevalance Etiology,pathogenesis and pathology Clinical features Laboratory findings Imaging Diagnosis and differential diagnosis Management RA定义定义 An autoimmune disorder of unknown etiology char

2、acterized by symmetric, erosive synovitis and, in some cases, extraarticular involvement. Most patients experience a chronic fluctuating course of disease that, despite therapy, may result in progressive joint destruction, deformity, disability, and even premature death-2003, American college of Rhe

3、umatologyMedicine as an artThe holy family with St. Anne(C1633C1635) by Peter Paul Rubens历史历史History :Pierre-Auguste Renoir (1841-1919)On the Terrace (1878)By Pierre-Auguste Renoir历史历史： Erik WaalerErik Erik WaalerWaalerThe occurrence of a factor in human serum activating the specific agglutination o

4、f sheep corpuscles. Acta Pathol Microboil Scand 1940; 1: 172-88.Genetic Factors in RADRB1Virus-infection HypothesisSex Hormone on RARheumatoid Pannus（血管翳）（血管翳）Pannus （血管翳）（血管翳）Rheumatoid Arthritis: Hand, Fusiform Swelling（梭形）（梭形）Ulnar（尺侧）（尺侧） Deviation and Muscle AtrophySwan Neck Deformity and Bouto

5、nnire Deformity钮扣花钮扣花Telescoping SignArthritis Mutilans残毁Arthritis MutilansHypermobility Arthritis MutilansSubcutaneous Nodule, Olecranon鹰嘴鹰嘴Rheumatoid NodulesRheumatoid Nodules in the LungRheumatoid Nodule: PathologyScleromalacia Perforans（穿孔性巩膜软化）（穿孔性巩膜软化）Vasculitis and Gangrene（坏疽）（坏疽）Extensor Te

6、ndon RupturePopliteal Cyst（腘窝囊肿）（腘窝囊肿）Progressive Right PIP3 Erosions in a 60-year Old Lady Suffering From RA3/19893/198911/19903/199211/19931/19956/1996Right Wrist in the Same Patient3/198911/19903/199211/19931/19956/19963/198911/19903/199211/19931/19956/1996Rheumatoid Arthritis: KneesHip, Late Ero

7、sionsProtrusio Acetabuli髋臼突出患病率患病率0.310.61.46.801.1012345678ChinaNorth Am.YupickEskimoInupiatEskimoChippewaIndiansNigeriaEnglandNationalityPrevalence(%)病因病因 遗传因素遗传因素 感染因素感染因素 内分泌因素内分泌因素发病机理发病机理病理病理 Synovitis( (滑膜炎）滑膜炎） Vasculitis Rheumatoid nodules临床表现临床表现 关节表现关节表现 晨僵晨僵Morning stiffness 关节痛关节痛Arthra

8、lgia 和关节压痛和关节压痛 tenderness 关节肿关节肿 Joint swelling 关节变形关节变形 Joint deformity 关节外表现关节外表现A Picture is Worth a Thousand Words关节外表现关节外表现 类风湿结节类风湿结节 Rheumatoid nodule 类风湿血管炎类风湿血管炎 Rheumatoid vasculitis 类风湿肺病变类风湿肺病变 Lung diseases 干燥综合征干燥综合征 Sjogrens syndrome 心包炎心包炎 Pericarditis 肾病变肾病变 Kidney diseasesA Pictur

9、e is Worth a Thousand Words实验室检查实验室检查 血液学异常血液学异常 血小板数增多血小板数增多 炎症指标炎症指标: 血沉增快血沉增快 C反应蛋白水平升高反应蛋白水平升高 类风湿因子类风湿因子 Rheumatoid factor（RF） 抗抗CCP抗体抗体RF = RA?CategoryDiseasesRheumatic diseasesRA, SLE, scleroderma, sjogrens syndromeViral infectionsAIDS, Hepatitis, influenza, after vaccinationChronic bacterial

10、 infectionsTuberculosis, leprosy, syphilis, subacute bacterial endocarditis,NeoplasmsAfter irradiation or chemotherapyOthersChronic liver or lung disease放射学检查放射学检查 确立诊断确立诊断 监测疾病发展监测疾病发展 监测药物治疗效果监测药物治疗效果鉴别诊断鉴别诊断 血清阴性脊柱关节病血清阴性脊柱关节病 骨关节炎骨关节炎 系统性红斑狼疮系统性红斑狼疮SLE 风湿热风湿热Rheumatic fever 7272岁女性，双膝关节痛岁女性，双膝关节

11、痛1010余年，双手指关节肿痛余年，双手指关节肿痛8 8个月。膝痛以上楼时为重，劳累可以诱发。近个月。膝痛以上楼时为重，劳累可以诱发。近8 8个月来双手近端指间关节、远端指间关节疼痛明个月来双手近端指间关节、远端指间关节疼痛明显，天气变化时加重。晨僵半小时。查血显，天气变化时加重。晨僵半小时。查血ESR ESR 24mm/h, RF24mm/h, RF（）。血常规正常。（）。血常规正常。处理处理 The ultimate goals are to:Prevent or control joint damagePrevent loss of function Decrease pain.治疗方法

12、治疗方法 非药物治疗非药物治疗 药物治疗药物治疗 外科治疗外科治疗治疗药物种类治疗药物种类 改变病情抗风湿药改变病情抗风湿药 Disease Modifying Anti-rheumatic Drugs (DMARDs) 糖皮质激素糖皮质激素Glucocorticoids 非甾体抗炎药非甾体抗炎药Nonsteroidal Anti- Inflammatory Drugs (NSAIDs) 生物制剂生物制剂Biologic agents 抗生素抗生素 Antibiotics？改变病情抗风湿药改变病情抗风湿药(DMARDs) 甲氨蝶呤甲氨蝶呤 Methotrexate （ MTX） 来氟米特来氟米

13、特 Leflunomide 柳氮磺吡啶柳氮磺吡啶 Sulfasalazine 金制剂金制剂 Gold, oral or intramuscular 硫唑嘌呤硫唑嘌呤 Azathioprine 青霉胺青霉胺 D-penicillamine 环孢素环孢素 Cyclosporine目前观点目前观点 所有所有RA患者均应采用患者均应采用DMARD治疗治疗 首选首选MTX. 严重严重RA患者可采用患者可采用DMARD联合治联合治疗，但方案中应包含疗，但方案中应包含MTX 症状缓解不等于治愈症状缓解不等于治愈Biologics in the treatment of RA小剂量糖皮质激素小剂量糖皮质激素 每天不超过每天不超过10mg的泼尼松的泼尼松:有效缓解症状有效缓解症状可能减慢关节侵蚀进展可能减慢关节侵蚀进展 应权衡得弊，综合考虑：应权衡得弊，综合考虑：骨质疏松骨质疏松 osteoporosis感染感染Infecti