系统性红斑狼疮患者有症状关节病变的肌肉骨骼超声特点

doi:10.19723/j.issn.1671-167X.2020.01.026

摘要/Abstract

摘要：

目的:应用肌肉骨骼超声评价系统性红斑狼疮(systemic lupus erythematosus,SLE)患者有症状关节病变的种类及分布,以及不同关节病变与疾病活动度之间的关系,比较SLE与Rhupus综合征[类风湿关节炎(rheumatoid arthritis,RA)/SLE重叠]患者关节病变的异同。方法:自2014年5月至2017年8月共纳入114例有关节症状的SLE患者以及15例Rhupus综合征患者,应用肌肉骨骼超声评价各个有症状关节的病变,包括双侧手腕、肘、肩、膝、足踝、髋关节,病变类型主要包括滑膜增生、能量多普勒(power Doppler,PD)超声滑膜炎、腱鞘炎、关节腔积液、骨侵蚀、骨赘,同时收集SLE患者人口学及临床数据,包括性别、年龄、病程、疾病活动度指标及脏器受累情况等。分析不同病变类型出现的比例、不同关节部位的病变类型分布以及超声下炎症性病变与疾病活动度之间的关系,另外,比较Rhupus综合征与SLE患者双手腕关节超声下病变的差异。结果:应用肌肉骨骼超声共检查114例SLE患者1 866个关节,发现滑膜增生、PD滑膜炎、骨侵蚀、关节腔积液、腱鞘炎以及骨赘等病变均有出现。滑膜增生在腕(23/69, 33.3%)、膝(12/42, 28.6%)、踝(7/28, 25.0%)关节更常见,腱鞘炎(7/20, 35.0%)及骨侵蚀(13/22,65.0%)在肩关节更常见,骨赘在近端指间关节、肘关节及膝关节更常见。对69例SLE患者进行双手腕22关节超声检查,发现57例(82.6%)存在关节病变,36.2%的患者有滑膜增生,14.5%出现骨侵蚀。腕关节超声下的滑膜增生与腕关节体征(肿胀和/或压痛)的一致性不佳(κ=0.089, P=0.584),超声下有腕关节滑膜增生但无明显体征者占18.4%,腕关节有肿胀或压痛体征但超声下无滑膜增生者占15.8%。手指关节超声下滑膜增生与近端指间关节肿胀的一致性较好(κ=0.633, P<0.01)。超声下滑膜增生、PD滑膜炎、腱鞘炎、骨侵蚀与系统性红斑狼疮疾病活动度指数(SLE disease activity index, SLEDAI)评分之间均无相关性。15例Rhupus综合征患者与69例SLE患者相比,手腕关节超声下骨侵蚀病变更常见(66.7% vs. 14.5%, P=0.03),两组患者超声下滑膜增生出现的频率差异虽无统计学意义(73.3% vs. 36.2%, P=0.08),但前者比例较高,并且Rhupus综合征患者滑膜增生评分比SLE患者更高(7.4±6.4 vs. 1.6±4.1, P=0.04)。结论:SLE患者中,手腕、肘、肩、膝、足踝等全身多关节均可以受累,超声下可见多种病变,SLE超声下病变与临床表现之间没有相关性。与SLE患者相比,Rhupus综合征患者更容易出现手腕关节滑膜增生及骨侵蚀。

关键词: 系统性红斑狼疮, 关节疾病, 肌肉骨骼超声

Abstract:

Objective:To investigate the types and distribution of musculoskeletal ultrasonographic changes of the symptomatic joints, their correlations with clinical manifestations in systemic lupus erythematosus (SLE) patients, as well as the differences of ultrasonographic changes from Rhupus syndrome [SLE overlapping with rheumatoid arthritis (RA)] patients. Methods: In the study, 114 SLE patients who complained of arthralgia or arthritis from May 2014 to August 2017 and 15 Rhupus syndrome patients were recruited for ultrasound evaluation. Ultrasound scans of the symptomatic joint areas were completed. The correlation between ultrasonographic changes and clinical characteristics was analyzed. Additionally, ultrasound changes of bilateral wrists and hands of the SLE patients were compared with those of the Rhupus syndrome patients. Results: In a total of the 114 SLE patients with 1 866 joints scanned, synovial hyperplasia, tenosynovitis, erosion, and osteophytes were all observed. Synovial hyperplasia was more often observed in wrists in 33.3% (23/69) patients, knees in 28.6% (12/42) patients, and ankles in 25.0% (7/28) patients. Tenosynovitis and erosion were most commonly found in shoulders in 35.0% (7/20) and 65.0% (13/20) patients. Osteophytes were more common in proximal interphalangeal (PIP) joints, elbows and knees. Among 69 patients with 22 joints (bilateral wrists and hands) scanned, 57 (82.6%) of them had ultrasonographic changes. Synovial hyperplasia was observed in 36.2% of the patients and erosion in 14.5% of the patients. The agreement between synovial hyperplasia and swollen joints in PIP was fair (κ=0.633, P<0.01), however poor in wrists between synovial hyperplasia and swollen/tender joints (κ=0.089, P=0.584). 18.4% patients with synovial hyperplasia had no tenderness or swollen clinically, while 15.8% patients with tenderness or swollen had no synovial hyperplasia on ultrasound. No correlation was found between ultrasonographic changes with the SLE disease activity index. Both synovial hyperplasia and erosion were more common in the Rhupus syndrome patients (73.3% vs. 36.2%, P=0.08; 66.7% vs. 14.5%, P=0.03) with significantly higher grey scale scores (7.4±6.4 vs. 1.6±4.1, P=0.04) than in the SLE patients. Conclusion: Variety of changes could be observed by ultrasound in different joint areas of SLE patients. The ultrasonographic changes and clinical manifestations did not always correspond to each other. Synovial hyperplasia and erosion was more common in Rhupus syndrome patients.

Key words: Systemic lupus erythematosus, Joint diseases, Musculoskeletal ultrasound

中图分类号:

R593.2

耿研,李伯睿,张卓莉. 系统性红斑狼疮患者有症状关节病变的肌肉骨骼超声特点[J]. 北京大学学报（医学版）, 2020, 52(1): 163-168.

Yan GENG,Bo-rui LI,Zhuo-li ZHANG. Musculoskeletal ultrasound findings of symptomatic joints in patients with systemic lupus erythematosus[J]. Journal of Peking University(Health Sciences), 2020, 52(1): 163-168.

图/表 4

表1

有手腕关节症状的SLE患者人口学及临床特点(n=69)"

Demographic and clinical features	Data
Female, n (%)	62 (88.5)
Age/years, $x ?$ ±s	43.7±15.0
Disease duration/years, median (min, max)	6.0 (0.1, 40.0)
Joint involvement, n (%)	55 (79.7)
Skin involvement, n (%)	33 (47.8)
Raynaud’s phenomenon, n (%)	5 (7.2)
Lupus nephritis, n (%)	34 (49.2)
Neuropsychiatric lupus, n (%)	2 (2.9)
Hematologic involvement, n (%)	29 (42.0)
Hemolytic anemia, n (%)	5 (7.2)
Leukopenia, n (%)	24 (34.7)
Thrombocytopenia, n (%)	10 (14.5)
Interstitial lung disease, n (%)	5 (7.2)
Serositis, n (%)	3 (4.3)
ANA positive, n (%)	69 (100.0)
Anti-dsDNA positive, n (%)	46 (66.7)
Anti-Sm positive, n (%)	12 (17.3)
Anti-nRNP positive, n (%)	30 (43.4)
Anti-SSA positive, n (%)	35 (50.7)
Anti-SSB positive, n (%)	7 (10.1)
Anti-rRNP positive, n (%)	16 (23.2)
Complement 3/(g/L), $x ?$ ±s	0.64±0.29
Complement 4/(g/L), $x ?$ ±s	0.12±0.07
IgG/(g/L), $x ?$ ±s	18.7±7.7
Rheumatoid factor positive, n (%)	15 (21.7)
SLEDAI score, $x ?$ ±s	10.0±6.2

表1

表2

表3

表4

SLE与Rhupus综合征患者临床特点及双手腕超声下病变的比较"

Clinical and ultrasonographic features	SLE group (n=69)	Rhupus syndrome group (n=15)	P
Female, n (%)	62 (88.5)	14 (93.3)	0.576
Age/years, $x ?$ ±s	43.7±15.0	48.4±14.9	0.651
Disease duration/years, median (min, max)	6.0 (0.1, 40.0)	10.0 (1.0, 46.0)	0.061
Joint involvement, n (%)	55 (79.7)	15 (100.0)	0.064
Lupus nephritis, n (%)	34 (49.2)	8 (53.3)	0.776
Hematologic involvement, n (%)	29 (42.0)	12 (80.0)	<0.001
Serositis, n (%)	3 (4.3)	7 (46.7)	<0.001
ANA positive, n (%)	69 (100.0)	15 (100.0)
Anti-dsDNA positive, n (%)	46 (66.7)	12 (80.0)	0.311
Anti-Sm, n (%)	12 (17.3)	6 (40.0)	0.053
Anti-nRNP, n (%)	30 (43.4)	7 (46.6)	0.822
Anti-rRNP, n (%)	16 (23.2)	3 (20.0)	0.789
Anti-SSA, n (%)	35 (50.7)	7 (46.6)	0.776
SLEDAI, $x ?$ ±s	10.0±6.2	10.0±5.3	0.834
Complement 3/(g/L), $x ?$ ±s	0.64±0.29	0.56±0.35	0.476
IgG/(g/L), $x ?$ ±s	18.7±7.7	23.0±8.1	0.727
RF, n (%)	15 (21.7)	10 (66.7)	0.060
Synovial hyperplasia (GS>0), n (%)	25 (36.2)	11 (73.3)	0.083
Synovitis (PD>0), n (%)	11 (18.9)	5 (33.3)	0.121
GS score, $x ?$ ±s	1.6±4.1	7.4±6.4	0.040
PD score, $x ?$ ±s	0.4±1.4	1.1±1.8	0.613
Bone erosion, n (%)	10 (14.5)	10 (66.7)	<0.001

表4

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Ultrasonographic	Physical examination	P	κ
Synovial hyperplasia	Tender joint	0.419	0.130
Synovial hyperplasia	Swollen joint	0.746	-0.050
Synovial hyperplasia	Tender joint and/or swollen joint	0.584	0.089
Synovitis	Tender joint	0.133	0.224
Synovitis	Swollen joint	0.593	0.084
Synovitis	Tender joint and/or swollen joint	0.191	0.190

Ultrasonographic	Physical examination	P	κ
Synovial hyperplasia	Tender joint	0.019	0.327
Synovial hyperplasia	Swollen joint	<0.001	0.633
Synovial hyperplasia	Tender joint and/or swollen joint	0.069	0.229