【作者】 宋丁；

【导师】 毕黎琦；

【作者基本信息】 吉林大学 ， 内科学， 2010， 硕士

【摘要】 目的:研究类风湿关节炎(rheumatoid arthritis,RA)关节受累的磁共振成像(megnetic resonance imaging,MRI)表现及临床对比的应用价值。方法:收集符合2009年ACR/EULAR诊断标准的RA患者25例,行双手MRI扫描。将X线片和MRI进行对比研究。同时收集患者的28个关节的疾病活动度评分(DAS28评分)、可视化量表(visual analog scale,VAS)评分、红细胞沉降率(ESR)、C反应蛋白(CRP)、类风湿因子分类(rheumatoid factor,RF分类)、抗环瓜氨酸肽抗体(anti-cyclic citrullinated peptide antibodies,anti-CCP antibodies,抗CCP抗体),与MRI表现进行对比分析。结果:25例患者中,MRI有滑膜炎19例(76.0%),其中有19个腕骨间+腕掌关节区;骨侵蚀17例(68.0%),其中腕骨36块;骨髓水肿22例(88.0%),其中腕骨65块;关节腔积液22例(88.0%),其中腕骨间78处。早期患者18例,滑膜炎13例(72.2%),有腕骨间+腕掌关节区出现滑膜炎12例;骨侵蚀12例(66.7%),其中腕骨31个;骨髓水肿16例(88.9%),其中有腕骨37块;关节腔积液16例(88.9%),腕骨间52处。在X线平片无表现的16例患者中,MRI有10例(62.5%)出现骨侵蚀,13例(81.25%)出现骨髓水肿,13例(81.25%)出现滑膜炎,13例(81.25%)出现关节腔积液。VAS评分与MRI骨侵蚀、关节腔积液及滑膜炎之间不具有相关性,与骨髓水肿呈正相关(r=0.562,p=0.003)。DAS28评分不同活动性与MRI各项改变均无统计学意义。ESR与MRI骨侵蚀、骨髓水肿、关节腔积液及滑膜炎不具有相关性。CRP与关节腔积液呈正相关(r=0.457,p=0.022)。X线SHARP评分(骨破坏)与相应部位MRI骨侵蚀评分不具有相关性。IgG-RF阳性组与阴性组之间MRI滑膜炎差异有统计学意义(P<0.05);IgA-RF阳性组血清IgA-RF浓度与骨髓水肿呈正相关(r=0.561,p=0.041)。无论患者病程小于1年还是超过1年,MRI骨侵蚀在抗CCP抗体阳性组与阴性组之间的差异有统计学意义(P<0.05)。在早期患者中,IgG-RF及IgM-RF阳性组与阴性组间MRI滑膜炎差异具有统计学意义(P<0.05)。结论:早期RA的MRI改变最常见于腕关节。患者的VAS评分与MRI骨髓水肿密切相关。无论是病程小于1年还是病程在1年以上,抗CCP抗体阳性提示MRI骨侵蚀。血清IgA-RF浓度可提示骨髓水肿程度。IgG-RF阳性可预示MRI的滑膜炎改变。在早期患者中,IgG-RF及IgM-RF阳性与MRI滑膜炎征象密切相关。CRP水平可反映关节腔积液的受累关节数目。更多还原

【Abstract】 Objective:In order to guide clinical work and provide the evidence of early diagnosis of RA,this study do further analysis of the MRI features,clinical symptoms and laboratory tests in different RA patient groups,and find the relationship between the hand-MRI and early joint destruction.Methods:This study included 25 cases of RA patients, and collected disease duration, swollen joint count(swollen joint count, SJC),tender joint counts(tender joint count, TJC),visual scale(visual analog scale, VAS) score, 28 joints disease activity score (DAS28 score), erythrocyte sedimentation rate(ESR), C-reactive protein(CRP), rheumatoid factor classification(RF classification), anti-cyclic citrullinated peptide antibodies(anti-cyclic citrullinated protein antibodies, anti-CCP antibodies, anti-CCP antibodies), X-ray of hands and wrist of the patients,then analyze the signs of MRI change and these indicators to further discuss the value of MRI in the diagnosis of RA. Meanwhile, to analyze the MRI signs differences between the two groups of positive or negative in IgG-RF, IgA-RF, IgM-RF and anti-CCP antibody.The results showed:1. Sensitivity of MRI bone erosion signs was 68.0% and the most bones to be involved was capitate bone, scaphoid bone, lunate bone. In 18 cases of early RA patients, capitate bone, triangular bone, scaphoid bone, lunate bone were affected more easier.2. The most bone marrow edema occurred in the capitate bone, triangular bone, lunate bone.3. Radiocarpal synovitis were present in patients of the course of disease more than a year, while in 18 cases of early RA patients, wrist synovitis can be found.4. The difference of arthroedema had statistically significant between the group of early RA and the group of course more than 1 year. The sensitivity of wrist arthroedema is 88.0%; in 18 cases of early RA patients, the sensitivity of wrist arthroedema was 87.1%.5. In the 16 patients of non-performance in X-ray, 10 cases (62.5%) had bone erosion, 13 cases (81.25%) had bone marrow edema, 13 cases (81.25%) had synovitis and 13 cases (81.25%) had joint arthroedema.6. No matter the duration of disease was less than 1 year or more than 1 year, the difference of bone erosion had statistically significant between the anti-CCP antibody-positive group and anti-CCP antibody negative group.7. No matter the duration of disease was less than 1 year or more than 1 year, the differences of synovitis had statistically significant between the IgG-RF positive group and IgG-RF negative group.8. The titer of IgA-RF was positively correlated with bone marrow edema.9. VAS had positive correlation with bone marrow edema.10. CRP had positive correlation with the number of arthroedema.Conclusion:1. Sensitivity of MRI bone erosion signs was 68.0% and the most bones to be involved is capitate bone, scaphoid bone, lunate bone. In 18 cases of early RA patients, capitate bone, triangular bone, scaphoid bone, lunate bone are affected more easier. Prompts that the wrist, especially in the capitate bone, triangular bone, scaphoid bone and lunate bone is the most frequent sites of bone erosion.2. Bone marrow edema of the carpal was significantly higher than metacarpal and phalanx. Prompt us that the carpal, especially capitate bone, scaphoid bone, lunate bone, is the most frequent sites of bone marrow edema.3. Synovitis of the wrist-metacarpus joints was significantly earlier than the antibrachio-carpal joints, prompts that we should focus the appearance of synovitis of the wrist-metacarpus joints in early RA patients.4. The sensitivity of carpal arthroedema was more higher in RA patients, especially in the course of disease less than 1 year.5. The importance of diagnosis of MRI was much larger than the X-ray examination in the paitents which the duration is less than 1 year, at the same time. Prompt that we should be pay close attention to the carpal joints in clinical work in patients which the course of RA is less than 1 year or the patients with non-performance of X-ray, because the carpal joints are more frequent sites of involvement than other joints.6. Anti-CCP antibody positive group had higher bone erosion than anti-CCP antibody-negative group, the titer was positively correlated with bone erosion.Prompt that anti-CCP antibodies appear more likely when the MRI bone erosion.7. This study also found that, the differences of synovitis had statistically significant between the IgG-RF positive group and IgG-RF negative group, and in patients which duration were less than 1 year, the differences of synovitis has statistically significant between the IgG-RF & IgM-RF positive group and negative group. Prompt IgG-RF could reflect the occurrence of MRI synovitis; IgG-RF and IgM-RF could reflect the occurrence of MRI synovitis in the patients which course of the disease less than 1 year.8. The titer of IgA-RF was positively correlated with bone marrow edema.9. MRI bone marrow edema was positively correlated with VAS score, indicating the degree of MRI bone marrow edema as a major factor of VAS scroe.10. The level of CRP can reflect the number of affected joints of MRI arthroedema.11. This study shows that, more longer course of disease of RA, means more involved bones and more serious of destruction. Therefore early diagnosis and treatment is more essential to alleviate pain and reduce disability in patients. In the early diagnosis, MRI has an absolute advantage; also has significant value to reduce the rate of mutilation and reduce the burden of treatment in the future.更多还原