目的:拟探索结合超声检查与单纯根据临床查体两种临床场景下银屑病关节炎(psoriatic arthritis,PsA)患者临床分型的差异。方法:入选2010年1月至2020年10月就诊北京大学第一医院风湿免疫科且临床和超声结果完整的PsA患者,根据患者的临床资料对其进行表型分类,再进一步结合能量多普勒与灰阶超声所发现的附着点炎及指(趾)炎对所有患者进行再次的表型分类,应用韦恩图表示纳入超声前后PsA各临床表型分组,临床表型构成比采用χ²检验或Fisher’s精确检验,纳入超声前后临床表型差异应用Wilcoxon符号秩检验。结果:共纳入227例PsA患者,分别存在一种或多种临床表现。临床查体发现:209(92.1%,209/227)例患者有银屑病皮损,98(43.2%, 98/227)例患者有指(趾)甲病变,219(96.5%,219/227)例患者有外周关节炎表现,25(11.0%,25/227)例患者脊柱受累,80(35.2%,80/227)例患者存在指(趾)炎,18(7.9%,18/227)例患者存在附着点炎。纳入超声评估后,发现另外18例患者超声下有指(趾)炎表现,另外80例患者超声下有急性附着点炎表现,其中异常回声减低55例,肌腱增厚62例,48例可见多普勒血流信号。与单纯根据临床查体分型相比,联合超声检查后对227例患者进行分型,发现最常见的单纯外周关节炎型患者明显减少(49.8% vs. 27.8%,P<0.001), 外周关节炎合并附着点炎患者比例明显增多(4.4% vs. 18.1%,P<0.001),外周关节炎合并附着点炎和指(趾)炎的患者也明显增多(1.8% vs. 17.6%,P<0.001)。结论:超声是发现附着点炎及指(趾)炎的有利工具,借助超声检查可以有效辅助风湿科医生更好地鉴别PsA的病变性质和类型,准确划分临床表型,并进一步指导治疗。

Objective: To explore the difference in phenotype recognition of PsA patients in two clinical scenarios, physical examination with and without ultrasound assessment. Methods: PsA patients who visited the rheumatology and clinical immunology department of Peking University First Hospital between January 2010 and October 2020, with complete data of clinical and ultrasound assessment were enrolled. The phenotypes were first identified based on physical examination only, and then combined with enthesitis and dactylitis shown on power doppler and gray-scale ultrasound. The phenotype groupings without and with ultrasound assessment were presented with Wayne diagram. The distributions of different clinical phenotypes were compared by using χ ² test or Fisher’s exact test. The differences of clinical phenotypes with and without ultrasound assessment were compared by using Wilcoxon signed rank test. Results: A total of 227 patients with PsA were enrolled with one or more clinical domains. Physical examination revealed that psoriasis was in 209 (92.1%, 209/227) patients, nail involvement in 98 (43.2%, 98/227) patients, peripheral arthritis in 219 (96.5%, 219/227) patients, axial involvement in 25 (11.0%, 25/227) patients,dactylitis in 80 (35.2%, 80/227) patients, and enthesitis in 18 (7.9%, 18/227) patients. Besides 18 patients with clinical enthesitis, ultrasound scan revealed acute enthesitis in 80 patients, with hypoechogenicity (55 cases), tendon thickening (62 cases), and presence of Doppler signals (48 cases). Similarly, dactylitis on ultrasound was found in 18 patients besides those patients with clinical dactylitis. Compared with the phenotypes recognized based on physical examination only, the additional ultrasound assessment revealed that the most common phenotypes, peripheral arthritis was significantly less frequently recognized (49.8% vs. 27.8%, P<0.001), however on the other hand, the proportion of the patients with peripheral arthritis and enthesitis was significantly increased (4.4% vs. 18.1%, P<0.001). The phenotype of peripheral arthritis combined with enthesitis, and dactylitis was also dramatically increased (1.8% vs. 17.6%, P<0.001). Conclusion: Ultrasound is a useful tool to identify enthesitis and dactylitis. With the aid of ultrasound assessment, rheumatologists can better identify the lesions of PsA, accurately identify the phenotypes, and further guide the subsequent treatment.