晚发型脊柱关节病的临床特征分析

目的 总结晚发型脊柱关节病(SpA)的临床特点,以期提高对本病的诊治水平.方法 分析56例晚发型SpA患者的临床、实验室及放射学资料,并与62例中青年发病的SpA患者进行比较.结果 晚发型SpA组,以外周关节起病者和起病时有下肢炎性凹陷性水肿患者显著多于中青年发病SpA组[86%(48/56)比47%(29/62)和43%(24/56)比8%(5/62),均P<0.01];而中青年发病SpA组在发病初即有腰背痛的患者显著多于晚发型SpA组[45%(28/62)比13%(7/56),P<0.01].随着病程的进展,晚发型SpA组出现外周关节炎的患者显著多于中青年发病SpA组[96%(54/56)比81%(50/62),P<0.01];而中青年发病SpA组出现腰背痛的患者显著多于晚发型SpA组患者[74%(46/62)比20%(11/56),P<0.01].晚发型spA组,关节外表现如发热显著多于中青年发病SpA组(P<0.01)、肌腱端炎及色素膜炎亦显著多于中青年发病SpA组(均P<0.05).晚发型SpA组和中青年发病的SpA组HLA-B27的阳性率分别为86%和82%,两组比较无显著性差异(P>0.05).血沉和C反应蛋白,晚发型SpA组均显著高于中青年发病SpA组(均P<0.01).中青年发病SpA组出现骶髂关节炎的患者显著多于晚发型SpA组患者[71%比21%,P<0.01].结论 晚发型SpA和中青年发病的SpA均以男性多发,HLA-B27阳性率相近;但晚发型SpA较中青年发病的SpA有更多的外周关节炎、更广泛的下肢炎性凹陷性水肿及更多关节外表现,而中青年发病SpA则有更多腰背痛和X线证实的骶髂关节炎表现.     

幼年发病型脊柱关节病的临床特征

目的　提高对幼年发病型脊柱关节病 (JSpA)的认识。方法　分析 190例JSpA患者的临床、实验室及放射学资料 ,并对幼年发病关节炎的诊断、分类和鉴别进行讨论。结果　 190例JS pA中 ,男性 16 3例 ,女性 2 7例 ,男女之比为 6∶1,发病年龄 3～ 16岁 ,平均 (12± 3)岁 ,8岁后发病 175例 ,占 92 1% ;15 7例 (82 6 % )患者首先出现的是外周关节炎 ,2 3例 (12 1% )以腰背痛为第一症状 ,病程中共有 187例 (98 4% )的患者出现了外周关节炎 ,12 3例 (6 4 7% )患者有或有过腰背疼痛史 ,外周关节炎与腰背疼痛出现的时间间隔 ,从同时发生到间隔 2 0年 ,平均 3 2年。 6 7例 (35 3% )有肌腱端炎的表现 ,2 0例 (10 5 % )腊肠指 (趾 ) ,9例虹膜炎。HLA B2 7的阳性率为 87 9% ,76 0 %有X线证实的骶髂关节炎。在 190例患者中 ,10 6例患者确诊幼年强直性脊柱炎 (JAS) ,此组患者平均病程 6 3年 ,明显长于JSpA组 (P <0 0 1)。 结论　JSpA的概念有助于提高对儿童关节炎的认识 ,半数以上JSpA患者约在发病 6 3年后发展为幼年强直性脊柱炎。     

HLA-B27与强直性脊柱炎的免疫生物学发病机制研究进展

脊柱关节炎（spondyloarhritis，SpA）是一组临床特征相似、均不同程度地与HLA—B27相关、发病机制互相关联的疾病，包括强直性脊柱炎（ankylosing spondylitis，AS）、反应性关节炎（reactive arthritis，ReA）、炎症性肠病相关关节炎、银屑病关节炎、幼年脊柱关节炎和未分化脊柱关节病（undifferentiated spondyloarthropathy，uSpA）。AS是SpA的原型，与HIA—B27关系最密切。1973年Schlosstein和Brewerton分别报道了HIA—B27与AS发病显著关联．[第一段]     

幼年脊柱关节病的早期特征

幼年脊柱关节病（ｊｕｖｅｎｉｌｅｏｎｓｅｔｓｐｏｎｄｙｌｏａｒｔｈｒｏｐａｔｈｉｅｓ,ＪＳｐＡ）系指１６岁以前发病的一组与ＨＬＡＢ２７相关的关节滑膜、肌腱端、腱鞘和滑囊的临床状况、综合征和疾病,肠道和泌尿道感染常为激发因子,脊柱炎和骶髂关节炎贯穿全病程,并可伴发关节外表现。由此可见,ＪＳｐＡ的疾病范围很广,它既包括一些具有明确临床、实验室和Ｘ线片特征,并符合有关诊断条件的脊柱关节病和综合征,如幼年强直性脊柱炎（ＪＡＳ）、幼年赖特综合征、幼年反应性关节炎和幼年银屑病关节炎及炎性肠病关节炎等（…     

127例未分化脊柱关节病五年随访

目的了解未分化脊柱关节病（undifferentiated spondyloarthropathies,uSpA）的临床特点及发展规律。方法分析127例uSpA患者临床特点及5年随访结果。结果127例uSpA患者：（1）男女比例为1．8：1,女性患者起病晚,病情轻,预后较好;（2）病程中腰背部疼痛（93．7％）和外周关节肿痛者（96．0％）最多见;（3）女性腰背部疼痛的首发率明显高于男性（P〈0．05）,男性髋关节、臀区或足跟及其他附着点部位疼痛起病的首发率均高于女性（P〈0．05）;（4）7例以手关节受累为首发症状者均为女性;（5）家族史阳性率42．5％,HLA．B27阳性率52．8％,两性间差异无统计学意义（P〉0．05）;（6）首诊影像学特点,CT对诊断uSpA较X线敏感,两者骶髂关节炎阳性率分别为75．0％（78／104）和60．0％（51／85）。两者诊断骶髂关节炎分级符合率45．6％（31／68）。男性骶髂关节破坏的阳性率高于女性（P〈0．05）;（7）5年随访,18例发展为强直性脊柱炎（ankylosing spondylitis,AS）,1例为炎性肠病关节炎,1例为银屑病关节炎（psoriatic arthritis,PsA）,20例仍为uSpA,16例症状消失。18例确诊AS的患者中男性13例,占72．2％。5年内骶髂关节CT示Ⅱ级以上骶髂关节破坏进展明显,初诊和5年后阳性率分别为3．6％和48．2％。结论uSpA是一组常见的临床症状多样的脊柱关节病,有遗传倾向;男性骶髂关节受累较女性严重;部分患者可进展为AS、PsA及炎性肠病关节炎等其他脊柱关节病。对uSpA患者应密切随访,定期行骶髂关节CT检查有助于早期诊断。     

幼年脊柱关节病的早期特征和治疗

复习近期有关幼年脊柱关节病(JSpA、早期特征和治疗的文献。肌腱端炎、关节炎、腊肠趾及血清阴性肌腱端病和关节病综合征是本病特征性表现。儿童通常出现某一临床表现，发展到某特定型脊柱关节病需要一段时间。JSpA的治疗主要为非甾体类抗炎药、甲氨蝶呤和柳氮磺吡啶。严重的肌腱端炎可用小剂量泼尼松。反应停、TNF拮抗剂和二膦酸盐对JSpA的疗效有待验证。     

脊柱关节病心血管损害的研究进展

血清阴性脊柱关节病(seronegative spondyloanthropathy,SpA)是一组相互关联的侵犯脊柱、外周关节和关节周围组织的多系统炎性疾病,包括强直性脊柱炎(AS)、反应性关节炎(ReA)与赖特综合征(RS)、银屑病关节炎(PsA)、炎性肠病关节炎、幼年发病的脊柱关节病以及未分化脊柱关节病(uSpA).其中,AS是SpA的原型,是一种最常见、最典型的脊柱关节病[1].     

伴前葡萄膜炎的脊柱关节病86例临床分析

目的 探讨脊柱关节病(SpA)合并前葡萄膜炎的临床特点及危险因素.方法 收集2005年3月至2008年12月在我科就诊的伴发前葡萄膜炎的86例SpA患者的临床和实验室资料,进行总结分析,对其进行随访,并与同期不伴前葡萄膜炎的93例SpA患者进行对比分析.正态分布资料用t检验,非正态资料用秩和检验;计量资料用x2检验;两变量间用线性相关分析,与眼炎发病风险相关的多种因素用Logistic回归分析.结果 眼炎组患者平均病程显著长于非眼炎组[分别为(11±8)年和(5±6)年,P＜0.01],阳性家族史比例显著升高(27.9%与9.7%,P＜0.01),患者出现夜间腰痛、晨僵、弯腰受限、脊柱畸形及骶髂关节X线严重病变的比例均高于非眼炎组(P均＜0.05),人类白细胞抗原(HLA)-B27阳性率也显著高于非眼炎组(92.2%与81.5%,P＜0.05).眼炎发作多有季节性和诱因;以前葡萄膜炎为首发症状患者的眼炎平均发作次数和出现眼睛永久性病变的比例显著升高(P均＜0.01).眼炎的发作次数与病程呈正相关(r=0.294,P=0.006).Logistic多因素回归分析显示,与眼炎发病风险相关的因素为病程[P=0.013,OR=1.099,95%可信区间(CI)1.030～1.183]和骶髂关节严重病变(P=0.012,OR=3.071,95%CI 1.286～7.314).结论 伴前葡萄膜炎的脊柱关节病有其自身特点,应重视前葡萄膜炎发病的危险因素,预防眼炎复发.     

老年发病的脊柱关节病的诊治特点

一、定义:广义的脊柱关节病(spondyloarthropathies,SpA)包括强直性脊柱炎(AS)、赖特综合征/反应性关节炎、银屑病关节炎、炎性肠病相关性关节炎、幼年发病的SpA以及尚不能满足现有的分类标准而称为分类未定的SpA(undifferentiatedspondy-loarthropathies,uSpA)等一组疾病。uSpA并不是一类疾病或单一的一种疾病,而是一个预测性的诊断。uSpA包括早期的SpA、尚未发展成为明确疾病的顿挫型SpA、具备二种疾病特征的重叠综合征,以及病因学尚不清楚、今后有可能发展成一种新的疾病的病人犤1～5犦。老年发病的SpA一般指50岁以后发病的SpA…     

脊柱关节病五例家系调查

脊柱关节病五例家系调查黄烽，赵华，施桂英脊柱关节病（ＳｐＡｓ）是青年男性常见多发的一组风湿性疾病，包括强直性脊柱炎（ＡＳ）与幼年强直性脊柱炎（ＪＡＳ），Ｒｅｉｔｅｒ综合征（ＲＳ）或反应性关节炎，银屑病脊柱关节病，炎性肠病脊柱关节病等，一些学者将白塞病...     

Prognosis of patients with juvenile chronic arthritis and juvenile spondyloarthropathy

OBJECTIVE: Evaluation of the course and the prognosis of juvenile chronic arthritis (JCA) and juvenile spondyloarthropathy (JSpA). METHODS: The entire medical histories of 171 patients with JCA or JSpA were reviewed. The study cohort comprised 102 patients with oligoarticular, 17 with systemic, and 24 with polyarticular onset of JCA; 28 patients had a SpA; 91 patients with JCA from a population based cohort were included in that study cohort. The mean period of followup was 7.4 years. The probability of remission was estimated by survival analysis methods (Kaplan-Meier method). RESULTS: After a disease duration of 10 years the highest probability of complete remission was estimated for patients with oligoarticular or systemic onset of JCA (54% and 38%, respectively). In the oligoarthritis group with late onset of JCA, a lower probability of remission was found for the HLA-B27+ patients compared with HLA-B27- patients. Patients with polyarticular onset of JCA had the poorest prognosis, with a significantly lower probability of complete remission (15%) within 10 years, more secondary injuries, and a lower functional capacity at followup. Patients with JSpA showed a 17% probability of remission after a disease duration of 5 years and ranged between the remission rates for oligoarticular and polyarticular JCA. The estimated remission rates for the patients with JCA in the population based cohort and in the whole cohort were quite similar. CONCLUSION: Our data suggest a favorable prognosis for JCA and JSpA in general, but with differences among the subtypes. It seems that more than 50% of the patients with JCA and JSpA reach adulthood with active arthritis and need further rheumatological care.     

How should we diagnose spondyloarthritis according to the ASAS classification criteria: a guide for practicing physicians

The Assessment of SpondyloArthritis International Society (ASAS) group has recently developed criteria to classify patients with axial SpA with or without radiographic sacroiliitis, and criteria to classify patients with peripheral SpA. The ASAS axial criteria consist of 2 arms and can be applied in patients with back pain (>3 months almost every day). In one arm, imaging (radiographs and magnetic resonance imaging [MRI]) has an important role, in the other arm--HLA-B27. MRI can detect active inflammation and structural damage associated with SpA. According to the ASAS axial SpA criteria, patients with chronic back pain aged less than 45 years at onset can be classified as having axial SpA if sacroiliitis on imaging (radiographs or MRI) plus 1 further SpA feature are present, or if HLA-B27 plus 2 further SpA features are present. The ASAS peripheral criteria can be applied in patients with peripheral arthritis (usually asymmetric arthritis predominantly involving the lower limbs), enthesitis, or dactylitis. Patients can be classified as having peripheral SpA if 1 of the following features is present: uveitis, HLA-B27, preceding genitourinary or gastrointestinal infection, psoriasis, inflammatory bowel disease, sacroiliitis on imaging (radiographs or MRI), or if 2 of the following features besides the entry feature are present: arthritis, enthesitis, dactylitis, inflammatory back pain, or a positive family history of SpA.     

Ankylosing spondylitis in North India: a clinical and immunogenetic study.

Fifty-one North Indian patients with ankylosing spondylitis (AS) are described with mean age of onset 21.2 years and male to female ratio of 16:1. AS began with peripheral arthritis in 47%, low back pain in 41%, acute anterior uveitis in 10%, and heel pain in 2% of the patients. 76% of 51 patients had one of the extra-axial features of AS: peripheral arthritis (61%), heel pain (24%), anterior uveitis (22%), urethritis (12%), kidney disease (10%), mucosal ulcerations (6%), aortic incompetence (4%), and apical pulmonary fibrosis (4%). A majority (71%) of the patients with peripheral arthritis had mono- or oligoarthritis affecting mainly the lower limb joints. Two patients had coexistent rheumatoid arthritis also. HLA-B27 antigen was detected in 48 (94%) of 51 patients compared with 7 (6%) of 118 controls (relative risk 254; Fisher's exact p = 3.49(-29]. On comparing patients with juvenile onset AS and patients with adult onset disease we found peripheral arthritis to be more frequent at the beginning and during the course of disease in the former.     

Ten-year follow-up study of patients with Yersinia arthritis

Eighty-five patients with acute Yersinia arthritis were seen in followup for a mean of 10 years. During that time, peripheral joint symptoms occurred frequently (51.8%), but these symptoms were mild (45.9%). Development of a new reactive arthritis (4.7%) or chronic arthritis (2.4%) was uncommon. One-third of the patients experienced low back pain, and one-third of the patients had radiologic evidence of sacroiliitis. The presence of sacroiliitis was more frequent in patients with low back pain (46.7%) than in those who did not have symptoms (21.2%). More patients with HLA-B27 had low back pain and sacroiliitis, but there was no association of this genetic factor with the residual symptoms in peripheral joints.     

Validation of screening criteria for spondyloarthritis in patients with inflammatory bowel disease in routine clinical practice

BackgroundSpondyloarthritis (SpA) is one of the most common extraintestinal manifestations of inflammatory bowel disease (IBD). Diagnostic delay must be avoided.AimsWe assessed the validity of SpA screening criteria (any of the following characteristics: chronic low back pain with onset before 45 years of age; inflammatory lower back pain or alternating buttock pain; arthritis; heel enthesitis; dacylitis; HLA-B27 positivity; sacroiliitis on imaging).MethodsThis was a multicenter cross-sectional observational study in IBD patients aged ≥18 years. After evaluating the SpA screening criteria, the gastroenterologists referred the participants to the rheumatologists, who determined whether the patient fulfilled the screening criteria and carried out the necessary tests for SpA diagnosis.Results35 (11.7%) out of 300 patients were diagnosed with SpA. The combination with the best balance between sensitivity and specificity (91.4% and 72.1%, respectively, when applied by the rheumatologists; 80% and 78.9%, when applied by the gastroenterologists) for SpA screening, was fulfillment of any of the following: chronic low back pain with onset before age 45 years, inflammatory low back pain or alternating buttock pain, arthritis, or dactylitis.ConclusionThis is one of the first studies to validate SpA screening criteria in IBD patients in routine clinical practice.     

Low grade radiographic sacroiliitis as prognostic factor in patients with undifferentiated spondyloarthritis fulfilling diagnostic criteria for ankylosing spondylitis throughout follow up

OBJECTIVE: To determine the rate and factors associated with ankylosing spondylitis in a cohort of patients with undifferentiated spondyloarthritides (SpA). METHODS: 62 consecutive patients with undifferentiated SpA seen between 1998 and 1999 underwent clinical and imaging evaluations throughout follow up. The main outcome measure was a diagnosis of ankylosing spondylitis. RESULTS: 50 patients with peripheral arthritis (n = 35) and inflammatory back pain (n = 24) (26 male; mean (SD) age at onset, 20.4 (8.8) years; disease duration 5.4 (5.7) years) were followed up for 3-5 years. At baseline, >90% of patients had axial and peripheral disease, while 38% had radiographic sacroiliitis below the cut off level for a diagnosis of ankylosing spondylitis (BASDAI 3.9, BASFI 2.9). At the most recent evaluation, 21 patients (42%) had ankylosing spondylitis. Two factors were associated with a diagnosis of ankylosing spondylitis in multivariate analysis: radiographic sacroiliitis grade <2 bilateral, or grade <3 unilateral (odds ratio (OR) = 11.18 (95% confidence interval, 2.59 to 48.16), p = 0.001), particularly grade 1 bilateral (OR = 12.58 (1.33 to 119.09), p = 0.027), and previous uveitis (OR = 19.25 (1.72 to 214.39), p = 0.001). Acute phase reactant levels, juvenile onset, and HLA-B27 showed a trend to linkage with ankylosing spondylitis (NS). CONCLUSIONS: Low grade radiographic sacroiliitis is a prognostic factor for ankylosing spondylitis in patients originally classified as having undifferentiated SpA. Low grade radiographic sacroiliitis should be regarded as indicative of early ankylosing spondylitis in patients with undifferentiated SpA.     

How to diagnose axial spondyloarthritis early

BACKGROUND: Chronic low back pain (LBP), the leading symptom of ankylosing spondylitis (AS) and undifferentiated axial spondyloarthritis (SpA), precedes the development of radiographic sacroiliitis, sometimes by many years. OBJECTIVE: To assign disease probabilities and to develop an algorithm to help in the early diagnosis of axial SpA. METHODS: Axial SpA comprises AS and undifferentiated SpA with predominant axial involvement. Clinical features include inflammatory back pain (IBP), alternating buttock pain, enthesitis, arthritis, dactylitis, acute anterior uveitis, a positive family history, psoriasis, inflammatory bowel disease, and good response to NSAIDs. Associated laboratory findings include raised acute phase reactions, HLA-B27 association, and abnormalities on skeletal imaging. Sensitivities, specificities, and likelihood ratios (LRs) of these parameters were determined from published studies. A 5% prevalence of axial SpA among patients with chronic LBP was used. The probability of the presence of axial SpA, depending on the presence or absence of the above clinical features of SpA, was determined. A probability of > or = 90% was used to make a diagnosis of axial SpA. RESULTS: The presence of inflammatory back pain features increased the probability of axial SpA from the background 5% prevalence to 14%. The presence of 2-3 SpA features was necessary to increase the probability of axial SpA to 90%. The highest LRs were obtained for HLA-B27 and MRI. Diagnostic algorithms to be used in daily practice were suggested. CONCLUSIONS: This approach can help clinicians to diagnose with a high degree of confidence axial SpA at an early stage in patients with IBP who lack radiographic sacroiliitis.     

Primary ankylosing spondylitis: patterns of disease in a Brazilian population of 147 patients

OBJECTIVE: To analyze patterns of disease in a population of Brazilian patients with primary ankylosing spondylitis (AS). METHODS: Retrospective study (1988-98) analyzing 147 patients with a diagnosis of primary AS according to the modified New York criteria. Selected patients had complete clinical (initial symptom, axial and peripheral involvement, heel enthesitis, extraarticular manifestations) and radiological (sacroiliac, lumbar, thoracic, and cervical spine) investigations, and these data were compared with sex, race, age at onset, and HLA-B27. RESULTS: There was a predominance of men (84.4%), Caucasian race (75.5%), adult onset (> 16 years, 85%), and positive HLA-B27 (78.2%). Family history of AS was noted in 14.3% of the patients. Pure axial AS was observed in 37 patients (25.2%). The predominant initial symptoms were inflammatory low back pain (61.9%) and peripheral arthritis (22.4%). Thoracic and cervical spine involvement was noted in 70.1% of the patients; radiological findings included syndesmophytes in 46.9% and "bamboo spine" in 20.4% of patients. The extraaxial joints most frequently involved were: ankles (39.5%), hips (36.1%), knees (29.3%), shoulders (19%), and sternoclaviculars (14.3%); heel enthesitis was present in 22.4%. Acute anterior uveitis was noted in 14.3% of patients. Male sex was associated with involvement of thoracic spine (p = 0.002), cervical spine (p = 0.002), and hips (p = 0.042), whereas female sex was associated with sternoclavicular (p = 0.024) involvement. Caucasian race presented higher frequency of positive family history (p = 0.023); there was no statistical significance of clinical and radiological variables compared with African-Brazilians. Juvenile onset AS presented higher frequency of ankle (p = 0.012) and knee (p = 0.001) involvement, heel enthesitis (p = 0.001), and total hip replacement (p = 0.038), whereas adult onset was associated with thoracic (p = 0.026) and cervical spine (p = 0.026) involvement and positive family history (p = 0.044). Positive HLA-B27 was associated with ankle involvement (p = 0.007) and heel enthesitis (p = 0.013). CONCLUSION: In this population women showed a milder axial involvement, Caucasian race presented axial and peripheral involvement similar to African-Brazilians, juvenile onset AS was associated with articular involvement of the lower limbs, and positive HLA-B27 was associated with ankle involvement.