The clinical features of rheumatoid arthritis
The clinical features of rheumatoid arthritis
复制标题
DOI：
10.1016/s0720-048x(98)00038-2
复制
发表时间：
1998-05-01
影响因子：
3.3
通讯作者：
Cervini, C
中科院分区：
文献类型：
--
作者：
Grassi, W;De Angelis, R;Cervini, C
类风湿关节炎(RA)是一种慢性炎症性疾病，以滑膜衬里关节进行性损害为特征，关节外表现多种多样。肌腱和法氏囊受累是常见的，在早期疾病中临床上常常占主导地位。RA可影响任何关节，但通常见于掌指关节、近侧指间关节和跖趾关节，以及手腕和膝盖。关节和关节周围的表现包括关节肿胀和触诊压痛，受累关节晨僵和严重的运动障碍。类风湿性关节炎的临床表现多种多样，但最常见的发现是隐匿性的疼痛发作，伴有小关节的对称性肿胀。在约25%的患者中，RA起病为急性或亚急性，但其表现形式也包括回文起病、单关节表现(包括慢型和急性型)、关节外滑膜炎(肌腱滑膜炎、滑囊炎)、多肌痛样起病以及全身症状(不适、疲劳、体重减轻、发热)。回文发作的特点是反复发作的少关节炎，没有残留的放射损伤，而多肌痛样发作在临床上可能无法与老年人的风湿性多肌痛区分开来。类风湿关节炎是一种典型的对称性腐蚀性疾病。虽然任何关节，包括环踝关节，都可能受累，但远端指间关节、骶骨关节和腰椎关节很少受累。滑膜炎的临床特征在早晨尤为明显。关节内和周围的晨僵，持续至少1小时，然后最大限度地改善是类风湿关节炎的典型症状。这是一种主观症状，需要仔细告知患者疼痛和僵硬之间的区别。晨僵持续时间与疾病活动性有关。手部受累是类风湿性关节炎的典型早期表现。滑膜炎累及掌指关节、近端指间关节和腕关节，触诊时会出现特征性的痛性肿胀，早期有严重的运动障碍，放射学上没有骨损伤的证据。乏力、发热、体重减轻和不适是常见的临床症状，可与关节外受累的各种表现有关，如类风湿结节、血管炎、血液系统异常、Felty综合征和内脏受累。虽然没有实验室测试来排除或证明类风湿性关节炎的诊断，但可以检测到一些实验室异常。全身性炎症检测异常是类风湿关节炎最典型的体液特征。这些指标包括：血沉、急性时相蛋白和血浆粘度。红细胞沉降率和C反应蛋白提供了有关急性期反应的最佳信息。C反应蛋白与临床评估和放射学改变密切相关。平片摄影是评估类风湿性关节炎患者解剖改变程度的标准检查。早期手部关节的X线表现为软组织肿胀和轻度关节旁骨质疏松。在过去的10年里，超声在研究类风湿关节炎的关节、肌腱和法氏囊受累方面得到了认可。它可能改善这些患者的早期临床评估和随访，显示诸如滑膜增厚等细节，即使在手指关节内也是如此。其他成像技术，如磁共振、计算机断层扫描和核素扫描，可能提供有关选定的类风湿性关节炎患者的解剖损害的特征和程度的有用信息。该病的自然病史并不明确，其临床病程起伏不定，预后难以预测。RA是一种流行病学相关的致残原因。对RA进行适当的早期治疗可能会改变疾病的进程。(C)1998爱思唯尔爱尔兰科学有限公司。保留所有权利。
Rheumatoid arthritis (RA) is a chronic inflammatory disease characterized by progressive damage of synovial-lined joints and variable extra-articular manifestations. Tendon and bursal involvement are frequent and often clinically dominant in early disease. RA can affect any joint, but it is usually found in metacarpophalangeal, proximal interphalangeal and metatarsophalangeal joints, as well as in the wrists and knee. Articular and periarticular manifestations include joint swelling and tenderness to palpation, with morning stiffness and severe motion impairment in the involved joints. The clinical presentation of RA varies, but an insidious onset of pain with symmetric swelling of small joints is the most frequent finding. RA onset is acute or subacute in about 25% of patients, but its patterns of presentation also include palindromic onset, monoarticular presentation (both slow and acute forms), extra-articular synovitis (tenosynovitis, bursitis), polymyalgic-like onset, and general symptoms (malaise, fatigue, weight loss, fever). The palindromic onset is characterized by recurrent episodes of oligoarthritis with no residual radiologic damage, while the polymyalgic-like onset may be clinically indistinguishable from polymyalgia rheumatica in elderly subjects. RA is characteristically a symmetric erosive disease. Although any joint, including the cricoarytenoid joint, can be affected, the distal interphalangeal, the sacroiliac, and the lumbar spine joints are rarely involved. The clinical features of synovitis are particularly apparent in the morning. Morning stiffness in and around the joints, lasting at least 1 h before maximal improvement is a typical sign of RA. It is a subjective sign and the patient needs to be carefully informed as to the difference between pain and stiffness. Morning stiffness duration is related to disease activity. Hand involvement is the typical early manifestation of rheumatoid arthritis. Synovitis involving the metacarpophalangeal, proximal interphalangeal and wrist joints causes a characteristic tender swelling on palpation with early severe motion impairment and no radiologic evidence of bone damage. Fatigue, feveret, weight loss, and malaise are frequent clinical signs which can be associated with variable manifestations of extra-articular involvement such as rheumatoid nodules, vasculitis, hematologic abnormalities, Felty's syndrome, and visceral involvement. Although there is no laboratory test to exclude or prove the diagnosis of rheumatoid arthritis, several laboratory abnormalities can be detected. Abnormal values of the tests for evaluation of systemic inflammation are the most typical humoral features of RA. These include: erythrocyte sedimentation rate, acute phase proteins and plasma viscosity. Erythrocyte sedimentation rate and C-reactive protein provide the best information about the acute phase response. The C-reactive protein is strictly correlated with clinical assessment and radiographic changes. Plain film radiography is the standard investigation to assess the extent of anatomic changes in rheumatoid arthritis patients. The radiographic features of the hand joints in early disease are characterized by soft tissue swelling and mild juxtaarticular osteoporosis. In the the past 10 years, ultrasonography has gained acceptance for studying joint, tendon and bursal involvement in RA. It may improve the early clinical assessment and the follow-up of these patients, showing such details as synovial thickening even within finger joints.Other imaging techniques, such as magnetic resonance, computed tomography and scintigraphy may provide useful information about both the features and the extent for anatomic damage in selected rheumatoid arthritis patients. The natural history of the disease is poorly defined; its clinical course is fluctuating and the prognosis unpredictable. RA is an epidemiologically relevant cause of disability. An adequate early treatment of RA may alter the disease course. (C) 1998 Elsevier Science Ireland Ltd. All rights reserved.