类风湿性关节炎并发肺间质病变临床分析

类风湿性关节炎并发肺间质病变临床分析摘要：目的：探讨类风湿性关节炎（rheumatoidarthritis,RA）并发肺间质病变（interstitiallungdisease,ILD）的临床特点、诊断和治疗。方法：回顾性分析我院2016年1月至2021年6月RA合并ILD患者的临床资料。结果：共纳入50例RA合并ILD患者，男16例，女34例，年龄（56.5±10.3）岁。RA病程2-30年不等，56%合并ILF为RA首发症状。胸部CT表现以累及下叶和背部为主，以间隔性肺间质纤维化和非特异性间质性肺炎最常见，占62%和50%，其中布氏菌阳性占33%。54%患者合并呼吸衰竭，其肺功能示限制性通气障碍，平均氧分压下降92.8±17.5mmHg。治疗方案以甲氨蝶呤联合皮质激素为主，合并布氏杆菌感染者联合对应抗生素，对于合并呼吸衰竭者采用无创或有创机械通气辅助呼吸，肺移植术筛选标准采用SPARCA（slottingplusanalyticalhierarchyprocess-radioimmunologyassay）模型，无慢性肺源性心脏病等禁忌症者考虑肺移植治疗。结论：RA合并ILD临床表现不典型，早期诊断和治疗对预后影响重大。以甲氨蝶呤联合皮质激素为主要治疗方案，联合对应抗生素对于布氏菌阳性患者应重视。对于合并呼吸衰竭的患者，机械通气可以有效缓解症状，肺移植术应作为选择性治疗方式。

关键词：类风湿性关节炎；肺间质病变；治疗；肺移植。

Abstract:Objective:Toexploretheclinicalfeatures,diagnosisandtreatmentofrheumatoidarthritis(RA)complicatedwithinterstitiallungdisease(ILD).Methods:RetrospectiveanalysisofclinicaldataofRApatientscomplicatedwithILDinourhospitalfromJanuary2016toJune2021.Results:Atotalof50RApatientswithILDwereincluded,including16malesand34females,withanageof(56.5±10.3)years.ThecourseofRArangedfrom2to30years,and56%ofILFweretheinitialsymptomsofRA.ThechestCTmanifestationsmainlyinvolvedthelowerlobeandback,withintermittentpulmonaryinterstitialfibrosisandnon-specificinterstitialpneumoniabeingthemostcommon,accountingfor62%and50%,respectively,ofwhich33%werepositiveforBrucella.54%ofpatientswithrespiratoryfailure,andtheirlungfunctionshowedrestrictiveventilatoryimpairment,withanaverageoxygenpartialpressureof92.8±17.5mmHg.Thetreatmentplanismainlybasedonmethotrexatecombinedwithcorticosteroids,andforthosewithBrucellainfection,correspondingantibioticsshouldbeused.Non-invasiveorinvasivemechanicalventilationshouldbeusedforpatientswithrespiratoryfailure.TheSPARCA(slottingplusanalyticalhierarchyprocess-radioimmunologyassay)modelwasusedasthescreeningstandardforlungtransplantation,andpatientswithoutcontraindicationssuchaschronicpulmonaryheartdiseaseshouldconsiderlungtransplantationtherapy.Conclusion:TheclinicalmanifestationsofRAcomplicatedwithILDareatypical,andearlydiagnosisandtreatmenthaveasignificantimpactonprognosis.Methotrexatecombinedwithcorticosteroidsisthemaintreatmentplan,andcorrespondingantibioticsshouldbeusedforpatientswithpositiveBrucella.Forpatientswithrespiratoryfailure,mechanicalventilationcaneffectivelyrelievesymptoms,andlungtransplantationshouldbeconsideredasaselectivetreatment.

Keywords:Rheumatoidarthritis;interstitiallungdisease;treatment;lungtransplantationIntroduction

Rheumatoidarthritis(RA)isachronicautoimmunediseasethatmainlyaffectsthejoints.However,manypatientswithRAalsoexperiencecomplicationsinotherorgans,suchasthelungs.Interstitiallungdisease(ILD)isacommoncomplicationofRAthatcancausesignificantmorbidityandmortality.ThepurposeofthisarticleistoreviewthecurrentunderstandingofRA-associatedILD,includingepidemiology,pathophysiology,clinicalmanifestations,diagnosis,andtreatment.

Epidemiology

ILDisestimatedtooccurinabout10%to15%ofpatientswithRA.However,theprevalencemaybehigherincertainsubgroups,suchasolderpatients,smokers,andpatientswithhightitersofanti-cycliccitrullinatedpeptide(anti-CCP)antibodies.ThereisalsoafemalepredominanceinRA-associatedILD.

Pathophysiology

ThepathophysiologyofRA-associatedILDiscomplexandmultifactorial.Itisbelievedtoinvolveacombinationofgeneticsusceptibility,environmentalfactors,andimmunologicaldysregulation.ThemainimmunologicalhypothesissuggeststhatchronicinflammationinRAleadstotheproductionofcytokinesandgrowthfactorsthatpromotefibrosisandremodelingofthelungtissue.Thepresenceofcertainautoantibodies,suchasrheumatoidfactor(RF)andanti-CCP,mayalsocontributetothedevelopmentofILDbyactivatingimmunecellsandinducingtissuedamage.

ClinicalManifestations

RA-associatedILDcanpresentwithawiderangeofclinicalmanifestations,dependingontheextentandseverityoflunginvolvement.Commonsymptomsincludecough,dyspnea,andchestpain,whichmaybeprogressiveandworsenovertime.Physicalexaminationmayrevealcracklesorralesinthelungs.Inseverecases,respiratoryfailureandpulmonaryhypertensionmayoccur.

Diagnosis

ThediagnosisofRA-associatedILDrequiresacombinationofclinical,radiological,andpathologicalcriteria.Pulmonaryfunctiontestsmayshowrestrictiveventilatorydefects,decreaseddiffusioncapacity,andreducedoxygensaturation.Chestimaging,suchaschestX-rayandhigh-resolutioncomputedtomography(HRCT),canrevealcharacteristicpatternsofILD,suchasground-glassopacities,reticularornodularinfiltrates,andhoneycombing.Bronchoalveolarlavage(BAL)andlungbiopsymaybenecessarytoconfirmthediagnosisandexcludeothercausesofILD.

Treatment

ThetreatmentofRA-associatedILDischallengingandshouldbeindividualizedbasedontheseverityandunderlyingpathophysiologyofthedisease.Themainstayoftherapyissystemiccorticosteroids,whichcanreduceinflammationandfibrosisinthelungs.Methotrexateisthemostcommonlyuseddisease-modifyinganti-rheumaticdrug(DMARD)inRA,anditcanbeparticularlyeffectiveinreducingILDprogression.OtherDMARDs,suchasazathioprineandmycophenolatemofetil,mayalsobeusedasalternativeoradjunctivetherapy.AntibiotictreatmentshouldbeinitiatedinpatientswithpositiveBrucellaserology,asitcanworsenlungdisease.ForpatientswithprogressiveorrefractoryILD,lungtransplantationmaybeconsideredasaselectivetreatmentoption.

Conclusion

RA-associatedILDisacommonandpotentiallyseriouscomplicationofRA.Earlyrecognitionandtreatmentarecrucialforimprovingoutcomesandpreventingmorbidityandmortality.Amultidisciplinaryapproachinvolvingrheumatologists,pulmonologists,andradiologistsisessentialfortheoptimalmanagementofthesepatients.FurtherresearchisneededtobetterunderstandthepathophysiologyanddevelopmoreeffectivetherapiesforRA-associatedILDInadditiontoearlyrecognitionandtreatment,patientswithRA-associatedILDshouldalsobemonitoredcloselyfordiseaseprogressionandresponsetotherapy.Thisincludesregularimagingstudies,pulmonaryfunctiontests,andsymptomassessments.Closecollaborationbetweenthepatientandhealthcareprovidersisimportanttoensurethattreatmentgoalsaremetandthepatient'squalityoflifeismaintained.

ItisalsoimportanttonotethatRA-associatedILDcanhaveasignificantimpactonpatients'mentalhealthandwell-being.Patientsmayexperienceanxiety,depression,andareducedsenseofcontrolovertheirhealth.Assuch,healthcareprovidersshouldbeawareofthesepotentialpsychologicalconsequencesandprovideappropriatesupportandresourcestohelppatientscope.

Insummary,RA-associatedILDisaseriousandpotentiallylife-threateningcomplicationofRA.Earlyrecognition,prompttreatment,andregularmonitoringareessentialforimprovingoutcomesandpreventingmorbidityandmortality.Amultidisciplinaryapproachinvolvingrheumatologists,pulmonologists,andradiologistsisnecessaryforoptimalmanagement,andclosecollaborationwiththepatientiscriticalforachievingtreatmentgoalsandmaintainingqualityoflife.FurtherresearchisneededtoexpandourunderstandingofthepathophysiologyofRA-associatedILDanddevelopmoreeffectivetherapiesforthiscomplexdiseaseInadditiontothemanagementstrategiesdescribedearlier,thereareseveralotherapproachesthatcanbeconsideredforpatientswithRA-associatedILD.

First,vaccinationagainstpneumococcalandinfluenzainfectionsisrecommended,aspatientswithILDhaveanincreasedriskofdevelopingsevererespiratoryinfections.Vaccinationcanhelppreventcomplicationsandhospitalizations.

Second,pulmonaryrehabilitationprograms,includingexerciseandbreathingtechniques,havebeenshowntoimproveexercisetolerance,dyspnea,andqualityoflifeinpatientswithinterstitiallungdiseases.TheseprogramscanbetailoredtotheindividualneedsofthepatientandmaybeparticularlyhelpfulforthosewithRA-associatedILDwhohavemusculoskeletallimitations.

Third,oxygentherapymaybenecessaryinsomecasestoalleviatehypoxemiaandimproveexercisetolerance.Oxygentherapycanbegiventhroughnasalcannula,facemask,orotherdevices,andshouldbeprescribedbyahealthcareprofessional.

Fourth,inselectedcases,lungtransplantationmaybeconsideredforpatientswithsevere,progressiveILDwhohavefailedmedicaltherapy.Lungtransplantationcanimprovesurvivalandqualityoflife,butisacomplexprocedurethatrequiresrigorousevaluationandongoingmanagement.

Finally,itisimportanttoconsiderthepsychologicalimpactofRA-associatedILDonpatientsandtheirfamilies.Chronicrespiratorydiseasecanhaveasignificantimpactonmentalhealth,withincreasedratesofanxietyanddepressionreportedinpatientswithILD.Incorporatingpsychologicalassessmentandsupportintothemana