类风湿性关节炎

nullRheumatoid Arthritis for Primary Care Physicians类风湿性关节炎Shenzhen China IPCEA Primary Care ProjectAugust 2013Rheumatoid Arthritis for Primary Care Physicians类风湿性关节炎Shenzhen China IPCEA Primary Care ProjectAugust 2013 William H. Stager, DO, MS, MPH, FAAFP, FAAMA, FAAO, FACOFP Clinical Professor, Dept. of Family Medicine, NSUCOM Clinical Associate Professor, Dept. of Family Medicine, LECOM 2013-2014 First Vice President, FOMA 2006-2010 President, Florida Academy of Osteopathy 2006-2013 President, FOMA District 9 2008-2009 President, FSACOFP Rheumatoid Arthritis: Introduction介绍Rheumatoid Arthritis: Introduction介绍Rheumatoid arthritis (RA) is a symmetric, inflammatory, peripheral polyarthritis of unknown etiology. It typically leads to deformity through the stretching of tendons and ligaments and destruction of joints through the erosion of cartilage and bone. If it is untreated or unresponsive to therapy, inflammation and joint destruction lead to loss of physical function, inability to carry out daily tasks of living, and maintenance of employment.类风湿性关节炎（RA）是对称的，炎症，病因不明的外周多发关节炎。它通常会通过拉伸肌腱、韧带导致畸形，侵蚀软骨和骨质来破坏关节。如果是未经处理的或无效的治疗，炎症和关节的破坏会导致生理功能丧失，不能正常进行日常生活和就业。 Early recognition and treatment with disease-modifying antirheumatic drugs is important in achieving control of disease and prevention of joint injury and disability. However, in patients with early disease, the joint manifestations are often difficult to distinguish from other forms of inflammatory polyarthritis. The more distinctive signs of RA, such as joint erosions, rheumatoid nodules, and other extraarticular manifestations, are seen primarily in patients with longstanding, poorly-controlled disease but are frequently absent on initial presentation.(1,2,3)早期识别和使用抗风湿药物治疗，是控制病情和防止关节损伤和残疾的要点。然而，在疾病早期的患者，关节的现往往难以区分于其他形式的炎症性的多发关节炎。RA的更鲜明的标志，首先要看比如关节侵蚀，类风湿结节，和其他关节外的表现。 Rheumatoid Arthritis: Diagnosis诊断Rheumatoid Arthritis: Diagnosis诊断Perform a thorough medical history, with particular attention to joint pain, reported swelling, and the presence, location (peripheral joints rather than low back), and duration (at least 30 minutes) of morning stiffness. The absence of other conditions or symptoms suggesting an alternative diagnosis, such as psoriasis, inflammatory bowel disease, or a systemic rheumatic disease such as systemic lupus erythematosus (SLE), helps to exclude other disorders.需要详细的病史，特别要注意关节疼痛，和肿胀，以及其他表现，存在的部位（外周关节，而不是腰部），和持续时间（至少30分钟）晨僵。缺乏其他条件或症状提示是另一种诊断，有助于排除其他疾病，如银屑病，炎症性肠病，或全身性类风湿性疾病如系统性红斑狼疮（SLE）。A complete physical examination is indicated to assess for synovitis, including the presence and distribution of swollen or tender joints and limited joint motion; extraarticular disease manifestations, such as rheumatoid nodules; and signs of diseases, such as systemic lupus erythematosus or psoriasis, included in the differential diagnosis.(1,2,3)评估滑膜炎需要一套完整的体检，包括关节肿胀和压痛的存在和分布以及关节运动的限制；关节外疾病的表现，如类风湿结节；以及疾病的体征，包括鉴别诊断，如系统性红斑狼疮、银屑病。Rheumatoid Arthritis: DiagnosisRheumatoid Arthritis: DiagnosisLaboratory tests which support the diagnosis if positive and/or elevated:类风湿关节炎：诊断性的实验室检查，阳性和/或升高时支持诊断： Rheumatoid factor (RF) and anti-cyclic citrullinated peptide (CCP) antibodies — Perform both RF and anti-CCP antibody testing when initially evaluating a patient with suspected RA.类风湿因子（RF）、抗环瓜氨酸肽（CCP）抗体 ：在评估疑似RA病人，进行RF和抗CCP抗体检测是必要的。The results of both tests are informative, since a positive result for either test increases overall diagnostic sensitivity, while the specificity is increased when both tests are positive.两个测试结果都是有用的，因为一个阳性的结果对整体诊断的的敏感度没有增加，当两个结果都是阳性时，特异性增加。 Despite this, both tests are negative on presentation in up to 50 percent of patients and remain negative during follow-up in 20 percent of patients with RA.尽管如此，多达50%的RA患者，两个检查均阴性，随访期间20%的RA患者是都是阴性的。 Erythrocyte sedimentation rate (ESR) and serum C-reactive protein (CRP) levels —Both the ESR and CRP are typically elevated in RA. ESR和CRP的水平，类风湿性关节炎通常会升高。 Antinuclear antibody (ANA) testing — A negative ANA helps exclude SLE and other systemic rheumatic diseases; the ANA may be positive in up to one-third of patients with RA. In patients with a positive ANA, anti-double stranded DNA and anti-Smith antibody testing should also be performed; these antibodies have high specificity for SLE.(1,2,3)抗核抗体（ANA）测试- ANA阴性帮助排除SLE和其他全身性风湿性疾病；约1/3的RA患者ANA是阳性。在ANA阳性的患者中，也应该进行抗双链DNA和抗Sm抗体测试；这些抗体对SLE有较高的特异性。 Rheumatoid Arthritis: DiagnosisRheumatoid Arthritis: DiagnosisComplete blood count (CBC) with differential and platelet count, tests of liver and kidney function, serum uric acid, and a urinalysis — The CBC is often abnormal in RA, with anemia and thrombocytosis consistent with chronic inflammation. Liver and kidney testing abnormalities indicate a disorder other than RA; if caused by comorbid conditions, they may affect therapeutic choices or drug dosing. Hyperuricemia may prompt additional efforts, including arthrocentesis and crystal search, to exclude gout; polyarticular gout can infrequently be mistaken for RA.全血细胞计数（CBC）和血小板计数，肝、肾功能试验，血清尿酸，尿--CBC在RA经常是不正常的，伴有贫血和血小板增多症，需考虑为慢性炎症。肝肾功能异常表示RA以外的疾病；如果是并存的条件造成的，他们可能会影响治疗的选择或药物剂量。高尿酸血症可能需要更多的工作，包括关节穿刺、查找晶体，来排除痛风；多关节型痛风可以经常被误诊为类风湿性关节炎。Radiographs of the hands, wrists, and feet — We obtain radiographs during the initial evaluation primarily as a baseline for monitoring disease progression. However, characteristic joint erosions may be observed in patients presenting with symptoms for the first time and, hence, aid in diagnosis. Additionally, in patients with other disorders, such as psoriatic arthritis, spondyloarthropathy, gout, or chondrocalcinosis, radiographic changes more characteristic of these conditions may point to an alternative diagnosis.(1,2,3)手，手腕和脚的X光片，我们在初步评估时得到的x光片，是监测疾病进展情况的一个基础手段。然而，特征性的关节侵蚀可能在首次症状的患者上观察到，因此，有助于诊断。此外，在其他疾病的患者，如脊柱关节病，银屑病关节炎，痛风，或软骨钙化，X光片的改变具有更多这些疾病的特征则提示其他的诊断。Rheumatoid Arthritis: DiagnosisRheumatoid Arthritis: DiagnosisSerologic studies for infection — In patients with a very short history (for example, less than six weeks) particularly those who are seronegative for anti-CCP and rheumatoid factor, we perform serologic testing for human parvovirus B19, hepatitis B virus (HBV), and hepatitis C virus (HCV). In areas endemic for Lyme disease, we perform serologic studies for Borrelia as well. •血清学的感染的研究----很短的病史的患者（例如，小于六周），尤其是那些血清抗CCP抗体和类风湿因子均阴性的患者，我们进行人类细小病毒B19，乙型肝炎病毒，丙型肝炎病毒的检测。在流行莱姆病的区域，我们进行包柔代螺旋体的血清学检查。 Synovial fluid analysis — We perform arthrocentesis and synovial fluid analysis for the diagnosis or exclusion of gout, pseudogout, or an infectious arthritis if a joint effusion is present and if there is uncertainty regarding the diagnosis, particularly in the setting a monoarthritis, oligoarthritis, or asymmetric joint inflammation. Synovial fluid testing should include a cell count and differential, crystal search, as well as Gram stain and culture. Synovial fluid analysis should also be obtained to exclude infection or crystalline arthropathy in patients who undergo glucocorticoid injections for symptomatic relief. •滑液分析---来分析诊断或排除痛风、假性痛风，或感染性关节炎，和如果关节积液存在，如果有诊断的不确定性，特别是在关节炎?，小关节炎，或不对称的关节炎症，我们进行关节腔穿刺和关节滑液分析。滑膜液测试应包括细胞计数和分类，晶体的搜索，以及革兰氏染色和培养。滑液分析也应得到排除感染或接受糖皮质激素治疗症状缓解的结晶性关节病的患者。 MRI and ultrasound are more sensitive than radiography at detecting changes resulting from synovitis and may be helpful in establishing the presence of synovitis in patients with normal radiographs and uncertainty regarding the diagnosis. (1,2,3) •MRI和超声监测滑膜炎引起的变化比X线更敏感，可能对X线正常的和不能确诊的滑膜炎的患者的诊断有帮助Rheumatoid Arthritis: DiagnosisRheumatoid Arthritis: Diagnosis2010 American College of Rheumatology (ACR) and European League Against Rheumatism (EULAR) classification criteria. 2010美国风湿病学会（ACR）和欧洲抗风湿联盟（EULAR）的分类标准。 Classification as definite RA is based upon:分类明确的RA是基于 the presence of synovitis in at least one joint,滑膜炎至少存在于一个关节以上 the absence of an alternative diagnosis that better explains the synovitis,没有别的更好的诊断可以解释滑膜炎的出现， and the achievement of a total score of at least 6 (of a possible 10) from the individual scores in four domains.四个领域的个体得分，达到6分及以上（满分10）。 The highest score achieved in a given domain is used for this calculation. These domains and their values are:在一个指定领域所达到的最高分会被用于此计算。这些领域和它们的数值为：Rheumatoid Arthritis: DiagnosisRheumatoid Arthritis: Diagnosis1. Number and site of involved joints 2 to 10 large joints (from among shoulders, elbows, hips, knees, and ankles) = 1 point： 2至10个大关节（从肩，肘，髋，膝，踝关节）= 1分； 1 to 3 small joints (from among the metacarpophalangeal joints, proximal interphalangeal joints, second through fifth metatarsophalangeal joints, thumb interphalangeal joints, and wrists) = 2 points 1至3个小关节（从掌指关节，近端指间关节之间，第二至第五跖趾关节，拇指指间关节，和手腕）= 2分 4 to 10 small joints = 3 points 4至10个小关节= 3分 .Greater than 10 joints (including at least 1 small joint) = 5 points大于10关节（包括至少1个小关节）= 5分 2. Serological abnormality (rheumatoid factor or anti-citrullinated peptide/protein antibody)(RF and CCP)血清学异常（RF、CCP） Low positive (above the upper limit of normal, ULN) = 2 points High positive (greater than three times the ULN) = 3 points 弱阳性（高于正常上限，ULN）= 2分 强阳性（大于三倍正常上限）= 3分 3. Elevated acute phase response (erythrocyte sedimentation rate or C-reactive protein) above the ULN = 1 point急性期反应升高的有：血沉、CRP=1分 Symptom duration at least six weeks = 1 point (1,2,3) Total Score > 6 = RA 症状持续至少六周＝1点（1,2,3）总分＞6＝RA Rheumatoid Arthritis: DiagnosisRheumatoid Arthritis: DiagnosisRheumatoid Factor (RF): Positive test in approximately 75%of patients with RA Occasionally occurs in other inflammatory diseases Not an accurate measure of disease progression. RA患者75%的呈阳性的试验偶尔出现在其他炎性疾病中。 疾病进展的没有一个精确的测量。 Anti-CCP antibodies:抗CCP抗体： 90% sensitivity and 98% specificity for RA ；RA 90%敏感性和98%特异性， Correlates well with disease progression与疾病进展的相关度较好 Anti-CCP antibody is present in approximately 30% of RF-negative RA (seronegative RA) RF阴性的RA患者中，抗CCP抗体可有30%阳性（阴性的RA） Erythrocyte sedimentation rate (ESR): Elevated in RA, useful to monitor course of disease. RA的患者升高，对监测病程有用。 C-reactive protein: Releases rapidly after tissue injury, useful to monitor course of disease. (1,2,3) 组织损伤后迅速释放，对监测病程有用。 Rheumatoid Arthritis: DiagnosisRheumatoid Arthritis: DiagnosisSigns and symptoms:体征和症状： Articular: 2-3 swollen hand/foot joints; MCP and/or MTP involvement (positive squeeze test); morning stiffness > 30 minutes; polyarticular, often symmetrical; joint tenderness and swelling; limited range-of-motion; malalignment of joints; pain, often at rest. •关节：2-3个手或脚关节肿胀；MCP和/或MTP受累（正挤压试验）；晨僵＞30分钟；多关节，常为对称的；关节压痛和肿胀； 有限的运动范围；关节不良；通常在休息时疼痛。 Systemic: fever, weight loss, anemia, fatigue, poor sleep.全身症状：发烧，体重减轻，贫血，疲劳，睡眠不好。 Co-morbidities: inflammation itself is a marker for co-morbidities; vasculitis; rheumatoid nodules; pulmonary fibrosis; ocular manifestations(sicca, episcleritis, scleromalacia); carditis; pericarditits; increased rates of infections, diabetes, and malignancies.(1,2,3)并发症：炎症本身是并发症的标志；血管炎；类风湿结节；肺纤维化；眼部表现（干燥性角结膜炎，巩膜炎，变形性骨炎）；心肌炎；心包炎；感染率增加，糖尿病，和恶性肿瘤。Rheumatoid Arthritis: DiagnosisRheumatoid Arthritis: DiagnosisDifferential diagnoses: Infections: viral (rubella, parvovirus B19, Hepatitis B and C, alphaviruses that are globally distributed mosquito-borne RNA viruses that cause epidemics of polyarthritis/arthralgia such as Chikungunya, human T lymphotropic virus type 1 (HTLV-I), Lyme arthritis, reactive arthritis (Reiter syndrome, antecedent GI or GU infections, HLA B27), MRSA, streptococcus, gonococcal, HIV, candidiasis, coccidioidomycosis, histoplasmosis, mycobacterium tuberculosis, immunodeificiencies.(1,2,3) 感染（风疹病毒，细小病毒B19，乙型和丙型肝炎，甲病毒属，是分布在全球各地的由蚊子传播的RNA病毒，会引起的关节炎或关节痛等病，比如人类T淋巴细胞白血病病毒1型（HTLV-I），莱姆关节炎，反应性关节炎（Reiter综合征，先行GI或GU感染，HLA B27），MRSA，链球菌，淋球菌，感染，念珠菌，球孢子菌病，组织胞浆菌病，结核分枝杆菌，免疫功能低下。Rheumatoid Arthritis: DiagnosisRheumatoid Arthritis: DiagnosisDifferential diagnoses: Degenerative Joint Disease – Osteoarthritis (DIP, PIP, not MCP) 退行性关节病–骨性关节炎（DIP，PIP，不是MCP） Systemic Lupus Erythematosus (SLE)系统性红斑狼疮 Gout 痛风 Chondrocalcinosis and Pseudogout软骨钙化、假性痛风 Fibromyalgia纤维肌痛 Trauma创伤 Carpal Tunnel Syndrome腕管综合征 Complex Regional Pain Syndrome/Reflex Sympathetic Dystrophy 复杂区域疼痛综合征/反射交感神经营养不良 Sarcoid arthropathy肉样瘤性关节病 Rheumatoid Arthritis: DiagnosisRheumatoid Arthritis: DiagnosisDifferential Diagnoses: Bursitis滑囊炎 Plantar Fasciitis足底筋膜炎 Polymyositis多发性肌炎 Dermatosmyositis皮肌炎 Sjogren Syndrome舍格伦综合征 Polymyalgia Rheumatica and Giant Cell Arteritis风湿性多肌痛和巨细胞动脉炎 Ankylosing Spondylitis强直性脊柱炎 Psoriatic Arthritis (Psoriasis usually precedes arthritis)银屑病关节炎 Paraneoplastic diseases: Myelodysplasia, hypertrophic pulmonary osteoarthropathy副肿瘤性疾病：脊髓发育不良，肺性肥大性骨关节病 Osteonecrosis. 骨坏死 Rheumatoid Arthritis: DiagnosisRheumatoid Arthritis: DiagnosisSummary and Recommendations: The following components of the medical evaluation are helpful in making a clinical diagnosis of RA, both for the identification of characteristic findings and for the exclusion of other diagnoses:以下的医疗评估有助于RA的临床诊断，既为辨别特征的表现和排除其他诊断， A thorough medical history, with particular attention to joint pain, stiffness, and associated functional difficulties详细病史，特别要注意关节疼痛，僵硬，和相关的功能的障碍。 A complete physical examination to assess for synovitis, limited joint motion, extraarticular disease manifestations, and signs of diseases included in differential diagnosis全面检查评估滑膜炎，有限的关节运动，关节外疾病的表现，以及需鉴别诊断的疾病的临床症状。 Basic and selected laboratory testing, including assays for acute phase reactants (erythrocyte sedimentation rate and C-reactive protein), rheumatoid factor, anti-cyclic citrullinated peptide (CCP) antibodies, and antinuclear antibodies基本的检查和选择的实验室测试，包括急性期反应试验（血沉和CRP），RF，CCP，抗核抗体 Selected imaging studies, including bilateral radiographs of the hands, wrists, and feet选择影像学检查，包括双侧的手、腕部和足部的X光片 Arthrocentesis, if there is diagnostic uncertainty.(1,2,3) •关节穿刺，如果诊断不确切。 Rheumatoid Arthritis: DiagnosisRheumatoid Arthritis: DiagnosisThe diagnosis of RA can be made in a patient with inflammatory arthritis involving three or more joints, positive rheumatoid factor and/or anti-citrullinated peptide/protein antibody, disease duration of more than six weeks, and elevated CRP or ESR, but without evidence of diseases with similar clinical features.在涉及三个或更多的关节的炎性关节炎患者中，如有RF和/或抗瓜氨酸的肽/蛋白质的抗体阳性，疾病持续时间大于六周，以及升高的CRP和ESR，但无临床表现相似的疾病的证据，可做RA的诊断。 RA may also be diagnosed in patients without all of the classic findings of disease. This includes patients with seronegative RA, those with clinically quiescent disease, and those with recent onset RA.？？？ Such patients have findings/clinical features that are generally consistent with those described as meeting the ACR/EULAR classification criteria for RA. RA也可以在没有所有疾病的典型表现的患者中诊断。这些病人的有表现或临床特征，通常与ACR /EULAR RA分类标准描述的一致。 Rheumatoid Arthritis: DiagnosisRheumatoid Arthritis: DiagnosisThe differential diagnosis of RA includes multiple disorders that can generally be distinguished clinically or by limited laboratory testing, based upon a combination of the following features (Limited duration (such as in viral arthropathy):类风湿性关节炎的鉴别诊断包括多种疾病，一般可以通过临床表现或有限的实验室检查来区分， The presence of other diseases (such as in psoriatic arthritis or arthritis of inflammatory bowel disease)，根据下列的组合特征（有限的病程（例如病毒性关节病）：其他疾病的表现（比如脊柱性关节炎或者炎症性肠病的关节炎） The pattern of joint involvement and other symptoms (such as in psoriatic arthritis, spondyloarthropathy, or polymyalgia rheumatica) The presence of systemic features (such as in systemic lupus or dermatomyositis)关节受累的模式和其他症状（如脊柱关节病，银屑病关节炎，风湿性多肌痛），表现为全身的症状（如系统性红斑狼疮、皮肌炎） Diagnostic laboratory tests associated with other conditions (such as specific autoantibodies in SLE, synovial fluid crystals in gout or calcium pyrophosphate disease) Relatively high specificity of anti-CCP antibodies for RA.(1,2,3)其他情况下的诊断性试验（如系统性红斑狼疮，有特异性抗体；焦磷酸钙晶体痛风病，关节液有结晶）抗CCP抗体对RA有相对高的特异性。 Rheumatoid Arthritis: Treatment治疗Rheumatoid Arthritis: Treatment治疗NSAIDs: reduce pain and inflammation, GI adverse effects 减少疼痛和炎症，有胃肠道的不良影响 Oral and injectable steroids: reduce pain and inflammation, slow disease progression, work quickly, adverse effects (osteoporosis, increased blood glucose/cholesterol/pressure, etc.)口服和注射类固醇：减少疼痛和炎症，延缓疾病进展，起效快，不良反应有（骨质疏松症，升高血糖/胆固醇/血压等） DMARDS (Disease Modifying Antirheumatic Drugs): work slowly, slow disease progression, methotrexate, sulfasalazine, leflunomide, hydroxychloroquine sulfate, minocycline; Tumor necrosis factor inhibitors (TNF-alpha inhibitors, targeting inflammation via immunology) etanercept, infliximab, adalimumab, certolizimab, golimumab; non TNF inhibitors abatacept, rituximab, tocilizumab. Prior to starting these: ppd testing, may use live vaccines, only killed vaccines used after. (1,2,3)起效缓慢，减缓病情进展，甲氨蝶呤，柳氮磺胺吡啶，来氟米特，硫酸羟氯喹，米诺环素； 肿瘤坏死因子（TNF-α抑制剂，通过免疫的以炎症为靶向的）依那西普、英夫利昔单抗，阿达木单抗，，certolizimab（专利药，无翻译），戈利木单抗；非TNF抑制剂、阿贝西普、利妥昔单抗、托珠单抗。首先进行这些试验：PPD试验，可以使用活疫苗，其后只能使用灭活的疫苗 Rheumatoid Arthritis: TreatmentRheumatoid Arthritis: TreatmentSurgical approaches 手术 Exercise programs 锻炼 Weight loss 减重 Patient education 患者教育 Osteopathic Manipulative Treatment (and other manual methods)整骨手法治疗（和其他手工方法）？？ Acupuncture (and other complementary/alternative methods) 针灸及其他替代疗法 Physical Therapy理疗 Dietary supplements (e.g., anti-inflammatories, curcuminoids, etc.).(1,2,3)膳食补充剂（例如，消炎药，姜黄素等）Clinical CaseClinical CaseA 45-year-old woman comes to your office with a 6-month history of vague malaise, fatigue, paresthesias in both hands, and vague pain in both hands and wrists and knees. She states that the pains in her joints are much worse in the morning, lasting more than 30 minutes. The patient has a normal family history, with no significant diseases noted. She is taking no drugs and has no allergies. On examination, vital signs are normal. The physician palpates slight swelling in both wrists and multiple metacarpophalangeal joints and both knees. There are no other joint abnormalities, and the rest of the physical examination is normal.(4)一位45岁的女性到你的诊所，她有6个月的乏力、疲劳、双手麻木，以及双手、手腕及膝部慢性疼痛的病史。她描述关节的疼痛早晨的时候更严重，持续超过30分钟。病人有正常的家族史，没有重大疾病史。她没有用药，没有过敏史。查体，生命体征正常。医生可触及双侧手腕、多个掌指关节和双侧膝关节有轻微的肿胀。没有其他的关节异常，其他查体无异常。   Clinical CaseClinical CaseWhat is the most likely diagnosis in this patient? Osteoarthritis骨关节炎 Gonococcal arthritis淋菌性关节炎 Gout痛风 Carpal Tunnel Syndrome腕管综合征 Rheumatoid arthritis. Clinical CaseClinical CaseThe pathophysiologic process of this disease based on:这个疾病的病理生理的过程是基于： bone destruction骨破坏 bone spur formation骨刺的形成 symmetric joint involvement对称关节受累 Trauma创伤 synovial inflammation.滑膜炎症 The pathophysiologic process of RA begins with synovial membrane swelling and proliferation. The synovium, which is normally only two cell layers thick, proliferates and erodes adjacent cartilage and bone. Macrophages secrete cytokines (protein messengers between cells), particularly interleukin-1 and tumor necrosis factor-α, which induce chondrocyte and osteoclast stimulation, prostaglandin secretion, and endothelial activation. CD4+ T lymphocytes promote the inflammation early in the disease and are abundant in the synovium and the synovial fluid. The complex network of the macrophage/cytokine system also causes characteristic systemic effects, such as fever and anemia. (4) RA的病理生理进程的开始是有滑膜的水肿和增殖。 滑膜，正常的只有2个细胞层那么厚，增殖和侵蚀临近的关节软骨和骨质。巨噬细胞分泌细胞因子（细胞间的蛋白信使），特别是肿瘤坏死因子和白介素1α，这导致软骨细胞和破骨细胞的刺激。前列腺素分泌和内皮的活化，CD4+T淋巴细胞均促进炎症 Clinical CaseClinical CaseRA tends to affect which particular part of the spine? RA往往会影响脊柱的哪部分？ 1.C 1-2 C 6-7 T 11-12 L 1-2 L 4-5 Instability of the cervical spine at C1-2 can be a life-threatening complication of RA, resulting from a cervical ligament synovitis in the region of C 1-2. This complication occurs in 30% to 40% of patients who develop RA, with 5% eventually developing a myelopathy or cord injury as a result of this instability.(4)颈椎C1-2的不稳定是RA危险生命的并发症，是C1-2区域的颈椎韧带滑膜炎导致的结果。这种并发症发生在RA30%-40%的患者中，这种脊椎的不稳定有5%最终发展为脊髓病或脊髓损伤。   Clinical CaseClinical CaseWhich of the following are systemic complications of RA?下列哪些是类风湿性关节炎的全身并发症？ Vasculitis 血管炎 Pericarditis 心包炎 Pleural effusion 胸腔积液 Diffuse interstitial fibrosis of the lung弥漫性肺间质纤维化 Rheumatic nodules