结缔组织疾病所致间质性肺疾病（附597例临床研究）
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摘要
目的:探讨各种结缔组织病(CTD)与间质性肺疾病(ILD)的相互关系,以提高对免疫结缔组织病所致肺间质损害(CTD-ILD)的认识,尽量做到早期就诊,早期发现,早期干预治疗,改善预后。方法:回顾性分析2008年1月1日到2009年12月31日期间我院明确诊断为CTD的597例住院患者的临床资料,分析CTD-ILD的发生情况,特点。结果:1.在597例住院患者中患有ILD的有87例,总发病率为14.6 %,其中各类CTD的ILD发生率为:系统性红斑狼疮(SLE) 8 %,类风湿关节炎(RA) 13.3 %,系统性硬化(SSC)37.5 %,皮肌炎/多发性肌炎(PM/DM)29.6 %,原发性干燥综合症(pSS )13.8 %。2.结缔组织病所致肺间质损害时,呼吸系统主要表现以咳嗽,气短为主;全身表现为关节痛,发热。高分辨CT表现为网格样,毛玻璃样及胸膜肥厚为主,血气表现为低氧血症,1型呼吸衰竭;呼吸功能表现为限制性通气功能障碍和弥散功能障碍为主。3.RA患者类风湿因子阳性,IgA在有无合并间质性肺疾病时有显著差异性具有统计学意义;SLE患者中LDH和IgG在有无间质性肺疾病时差异有显著性具有统计学意义;PM/DM患者表现为肌痛,发热,抗Jo-1阳性在有无间质性肺疾病时有显著差异具有统计学意义;pSS患者在表现为发热时对有无间型肺疾病时差异有显著性具有统计学意义。4.糖皮质激素联合大剂量的N-乙酰半胱氨酸与单用糖皮质激素治疗效果相比差异具有统计学意义。并且病程短的CTD-ILD患者对糖皮质激素治疗效果较好。结论:1.在所有的免疫系统疾病中,SSC最易导致间质性肺疾病,并且CTD-ILD发病时以咳嗽,气短为主要呼吸道症状,全身表现为关节痛和发热。高分辨CT主要表现为网格样,毛玻璃样改变及胸膜肥厚为主,血气分析主要是低氧血症,呼吸功能主要表现为限制性通气功能障碍,其次为弥散功能障碍及小气道功能受损。2.在RF阳性,IgA较高的类风湿关节炎患者更易患间质性肺疾病;系统性红斑狼疮患者中的LDH和IgG高的更易患间质性肺疾病;PM/DM患者中合并肌痛,发热,抗Jo-1阳性更易间质性肺疾病;pSS患者合并发热时更易患间质性肺疾病。3.治疗时应该尽早应用糖皮质激素,尽可能的联用大剂量N-乙酰半胱氨酸。晚期由于糖皮质激素治疗效果不佳,易合并不良反应,应用时应注意。
Objectives
Interstitial Lung disease complicated by Connective Tissue Disease (CTD-ILD)has high incidence and fatality. It is the main reason of the poor prognosis. But because it has not special symptom sand signs when one person got the disease and has not enough knowledge about it ,many CTD-ILD patients were missed diagnosed, He has stayed the sever stage of the disease when one person has typical symptoms and signs. The purpose of this study is to recognize the Interstitial Lung disease complicated by Connective Tissue Disease (CTD-ILD),with the aim of improving the understanding ,It is will be helpful for the early detection ,early diagnosis ,early treatment .Furthermore, it will be improve the prognosis and extend the survival time.
Methods
597 cases of hospitalized patients who has a clear diagnosis of connective tissue disease [including systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), systemic sclerosis(SSc), Polymyositis/ dermatomyositis (PM/DM), primary Sjogren's syndrome (pSS)]in China-Japan Friendship Hospital, Jilin University from January 1, 2008 to December 31,2009 carried out a retrospective clinical analysis with software application SPSS17.0,T test with measurement data, count data using X2 test, when P <0.05,It has statistically significant.
Results
In the 597 cases of hospitalized patients suffering from interstitial lung disease (ILD) of 87 patients, the total incidence rate was 14.6%, of which the incidence of various types of CTD for: SLE8%, RA 13.3%, SSC 37.5%, PM / DM29.6%, pSS13.8%.
Clinical manifestations: In all connective tissue disease due to interstitial lung damage, respiratory system mainly as cough (36.7%), shortness of breath (32.2%); general expression for the joint pain (50%), fever (47.1%). In all of the CTD-ILD, the high-resolution CT mainly for the grid-like (34.5%), ground glass (32.2%) and pleural thickening (25.3%); blood gas manifestations were hypoxemia (20.6 %), and 1 respiratory failure (19.5%); respiratory manifestations were restrictive ventilatory dysfunction (27.6%), diffuse dysfunction (11.5%) and small airway impairment (12.6%).
Clinical manifestations and laboratory comparison whether the various types of immune system diseases with interstitial lung disease : RA-ILD patients with and without rheumatoid factor positive RA patients with interstitial lung disease Compared, P <0.05, both with statistical significance. And RA-ILD patients with IgA (mean 3.59±1.31IU/ml) with and without interstitial lung disease in RA patients with IgA (mean 2.53±0.86 IU / ml) compared, P <0.05, difference statistically significance, significantly higher than RA patients with interstitial lung disease group. SLE-ILD patients with LDH (mean 431.11±332.3U / L) and IgG (mean 19.86±5.18IU/ml) with and without interstitial lung disease in SLE patients with LDH (mean 292.29±209.65U / L) and IgG (mean 15.75±7.49 IU / ml) compared, P <0.05, significant difference was statistically significant, SLE-ILD patients with LDH and IgG than those without interstitial lung disease in SLE patients with LDH and IgG; PM / DM-ILD patients showed myalgia, CK (average 1578.53±2143.64 U / L) and erythrocyte sedimentation rate increased with high interstitial lung disease in non-PM / DM patients compared, P <0.05, difference statistically significant, PM / DM-ILD manifested as muscle pain and in patients with elevated ESR were higher than those without interstitial lung disease in PM / DM patients; pSS merger between lung disease presents with fever and without interstitial lung disease in pSS comparison, P <0.05, significant difference was statistically significant, pSS merger between lung disease than those without fever pSS patients with interstitial lung disease.
Treatment: corticosteroids combined with high doses of N-acetyl cysteine and the single treatment with corticosteroids compared with statistical significance. Short course of corticosteroids for the CTD-ILD patients is better. Discussions
The experiments show that in all immune system diseases, SSC (incidence rate 37.5%) most likely to cause interstitial lung disease, followed by the PM / DM (incidence rate 29.6%), CTD-ILD onset in order to cough , shortness of breath as the main respiratory symptoms, systemic manifestations as joint pain and fever. High-resolution CT mainly for the grid-like, ground glass changes and pleural thickening; blood gas analysis showed hypoxemia and a major respiratory failure; respiratory function mainly as restrictive ventilatory dysfunction, followed by the diffusing capacity reduction and stingy Road impaired. Therefore, the disease has been diagnosed with the immune system of patients whether patients should pay attention to the occurrence of interstitial lung disease, early advocate for breast-related inspections .
In the RA-ILD patients and IgA rheumatoid factor positive and non-RA pat -ients with interstitial lung diseases was statistically significant compared to two, significantly higher than RA patients with interstitial lung diseases group. In RA patients, and IgA rheumatoid factor positive reflect the severity of the situation, can be seen, the RA patients with more severe disease in patients with higher risk of interstitial lung disease, while in the process of diagnosis of RA found inrheum -atoid factor titers, if more high, IgA higher the RA should be alert to the existen- ce of concomitant ILD; SLE-ILD patients with and without LDH and IgG in SLE patients with interstitial lung disease, the LDH and IgG, the difference was signif -ycant statistically significant, SLE- ILD in patients with LDH and IgG than thos- e without interstitial lung disease in patients with SLE LDH and IgG, in patients with SLE complicated with ILD, because of inflammation and release more LDH into the serum IgG and IgG so that LDH increased already diagnosis of SLE is not lear whether patients with interstitial lung disease, not with the line of high -resolution CT, LDH and IgG blood tests can aid diagnosis. PM / DM-ILD pati ents showed muscle pain, fever and ante-Jo-1 positive interstitial lung disease wit -h no PM / DM patients compared the difference was significant, and PM/DM-IL D patients showed muscle pain, fever and anti-Jo-1 positive than those without in -terstitial lung disease, PM / DM patients, accompanied by myalgia, fever and ant i-Jo-1 positive PM / DM patients with a high degree of vigilance should be possi -ble with interstitial lung disease; pSS merger between the type lung disease are fever and non-interstitial lung disease compared with pSS was significant differ- enttce statistically significant, pSS merger between lung disease than those witho -ut fever pSS patients with interstitial lung disease, research shows that, SSA-pos itive pSS patients with fever, rash, high incidence of ILD. PSS patients in this stu -dy, fever in the ILD group and the non-ILD group differences, there is some stat -istical significance, and literature are similar. But the rash and the SSA-positive patients without ILD and ILD group had no difference, no statistical significance, with the reported discrepancies may be related to the previous corticosteroids,im munosuppressive agents, samples and test a small amount related to the different.
In the treatment, glutathione is involved in cellular oxidation - reduction reaction of the important material, N-acetyl cysteine (NAC) as a precursor of glutathione, to increase the level of ILD in patients with lung glutathione and play a role in anti-oxidation. By the study implies that large doses of N-acetyl cysteine may retard the progress of interstitial lung disease and improve clinical symptoms in order to improve conditions, and treatment of glucocorticoid response depends on the progress of maturity of fibrosis, used alveolar or interstitial lung in inflammatory exudative, proliferative changes in the ILD and so on, has been formed on the lung fibrosis or other non-exudative changes associated with inflammatory diseases, the effect little performance as possible side effects to hormone-based clinical course. Experimental results were obtained by the application of a short course of hormone can improve the ILD patients, patients on the longer course of little value, but also can cause adverse reactions, such as disseminated tuberculosis, liver dysfunction, infections, when applied It should be noted.
In summary, the various types of immune system diseases with the above symptoms occur, and laboratory tests to a high degree of vigilance against the possible emergence of interstitial lung disease, so that early diagnosis, early treatment and reduce mortality and prolong survival time.
Objectives
Interstitial Lung disease complicated by Connective Tissue Disease (CTD-ILD)has high incidence and fatality. It is the main reason of the poor prognosis. But because it has not special symptom sand signs when one person got the disease and has not enough knowledge about it ,many CTD-ILD patients were missed diagnosed, He has stayed the sever stage of the disease when one person has typical symptoms and signs. The purpose of this study is to recognize the Interstitial Lung disease complicated by Connective Tissue Disease (CTD-ILD),with the aim of improving the understanding ,It is will be helpful for the early detection ,early diagnosis ,early treatment .Furthermore, it will be improve the prognosis and extend the survival time.
Methods
597 cases of hospitalized patients who has a clear diagnosis of connective tissue disease [including systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), systemic sclerosis(SSc), Polymyositis/ dermatomyositis (PM/DM), primary Sjogren's syndrome (pSS)]in China-Japan Friendship Hospital, Jilin University from January 1, 2008 to December 31,2009 carried out a retrospective clinical analysis with software application SPSS17.0,T test with measurement data, count data using X2 test, when P <0.05,It has statistically significant.
Results
In the 597 cases of hospitalized patients suffering from interstitial lung disease (ILD) of 87 patients, the total incidence rate was 14.6%, of which the incidence of various types of CTD for: SLE8%, RA 13.3%, SSC 37.5%, PM / DM29.6%, pSS13.8%.
Clinical manifestations: In all connective tissue disease due to interstitial lung damage, respiratory system mainly as cough (36.7%), shortness of breath (32.2%); general expression for the joint pain (50%), fever (47.1%). In all of the CTD-ILD, the high-resolution CT mainly for the grid-like (34.5%), ground glass (32.2%) and pleural thickening (25.3%); blood gas manifestations were hypoxemia (20.6 %), and 1 respiratory failure (19.5%); respiratory manifestations were restrictive ventilatory dysfunction (27.6%), diffuse dysfunction (11.5%) and small airway impairment (12.6%).
Clinical manifestations and laboratory comparison whether the various types of immune system diseases with interstitial lung disease : RA-ILD patients with and without rheumatoid factor positive RA patients with interstitial lung disease Compared, P <0.05, both with statistical significance. And RA-ILD patients with IgA (mean 3.59±1.31IU/ml) with and without interstitial lung disease in RA patients with IgA (mean 2.53±0.86 IU / ml) compared, P <0.05, difference statistically significance, significantly higher than RA patients with interstitial lung disease group. SLE-ILD patients with LDH (mean 431.11±332.3U / L) and IgG (mean 19.86±5.18IU/ml) with and without interstitial lung disease in SLE patients with LDH (mean 292.29±209.65U / L) and IgG (mean 15.75±7.49 IU / ml) compared, P <0.05, significant difference was statistically significant, SLE-ILD patients with LDH and IgG than those without interstitial lung disease in SLE patients with LDH and IgG; PM / DM-ILD patients showed myalgia, CK (average 1578.53±2143.64 U / L) and erythrocyte sedimentation rate increased with high interstitial lung disease in non-PM / DM patients compared, P <0.05, difference statistically significant, PM / DM-ILD manifested as muscle pain and in patients with elevated ESR were higher than those without interstitial lung disease in PM / DM patients; pSS merger between lung disease presents with fever and without interstitial lung disease in pSS comparison, P <0.05, significant difference was statistically significant, pSS merger between lung disease than those without fever pSS patients with interstitial lung disease.
Treatment: corticosteroids combined with high doses of N-acetyl cysteine and the single treatment with corticosteroids compared with statistical significance. Short course of corticosteroids for the CTD-ILD patients is better. Discussions
The experiments show that in all immune system diseases, SSC (incidence rate 37.5%) most likely to cause interstitial lung disease, followed by the PM / DM (incidence rate 29.6%), CTD-ILD onset in order to cough , shortness of breath as the main respiratory symptoms, systemic manifestations as joint pain and fever. High-resolution CT mainly for the grid-like, ground glass changes and pleural thickening; blood gas analysis showed hypoxemia and a major respiratory failure; respiratory function mainly as restrictive ventilatory dysfunction, followed by the diffusing capacity reduction and stingy Road impaired. Therefore, the disease has been diagnosed with the immune system of patients whether patients should pay attention to the occurrence of interstitial lung disease, early advocate for breast-related inspections .
In the RA-ILD patients and IgA rheumatoid factor positive and non-RA pat -ients with interstitial lung diseases was statistically significant compared to two, significantly higher than RA patients with interstitial lung diseases group. In RA patients, and IgA rheumatoid factor positive reflect the severity of the situation, can be seen, the RA patients with more severe disease in patients with higher risk of interstitial lung disease, while in the process of diagnosis of RA found inrheum -atoid factor titers, if more high, IgA higher the RA should be alert to the existen- ce of concomitant ILD; SLE-ILD patients with and without LDH and IgG in SLE patients with interstitial lung disease, the LDH and IgG, the difference was signif -ycant statistically significant, SLE- ILD in patients with LDH and IgG than thos- e without interstitial lung disease in patients with SLE LDH and IgG, in patients with SLE complicated with ILD, because of inflammation and release more LDH into the serum IgG and IgG so that LDH increased already diagnosis of SLE is not lear whether patients with interstitial lung disease, not with the line of high -resolution CT, LDH and IgG blood tests can aid diagnosis. PM / DM-ILD pati ents showed muscle pain, fever and ante-Jo-1 positive interstitial lung disease wit -h no PM / DM patients compared the difference was significant, and PM/DM-IL D patients showed muscle pain, fever and anti-Jo-1 positive than those without in -terstitial lung disease, PM / DM patients, accompanied by myalgia, fever and ant i-Jo-1 positive PM / DM patients with a high degree of vigilance should be possi -ble with interstitial lung disease; pSS merger between the type lung disease are fever and non-interstitial lung disease compared with pSS was significant differ- enttce statistically significant, pSS merger between lung disease than those witho -ut fever pSS patients with interstitial lung disease, research shows that, SSA-pos itive pSS patients with fever, rash, high incidence of ILD. PSS patients in this stu -dy, fever in the ILD group and the non-ILD group differences, there is some stat -istical significance, and literature are similar. But the rash and the SSA-positive patients without ILD and ILD group had no difference, no statistical significance, with the reported discrepancies may be related to the previous corticosteroids,im munosuppressive agents, samples and test a small amount related to the different.
In the treatment, glutathione is involved in cellular oxidation - reduction reaction of the important material, N-acetyl cysteine (NAC) as a precursor of glutathione, to increase the level of ILD in patients with lung glutathione and play a role in anti-oxidation. By the study implies that large doses of N-acetyl cysteine may retard the progress of interstitial lung disease and improve clinical symptoms in order to improve conditions, and treatment of glucocorticoid response depends on the progress of maturity of fibrosis, used alveolar or interstitial lung in inflammatory exudative, proliferative changes in the ILD and so on, has been formed on the lung fibrosis or other non-exudative changes associated with inflammatory diseases, the effect little performance as possible side effects to hormone-based clinical course. Experimental results were obtained by the application of a short course of hormone can improve the ILD patients, patients on the longer course of little value, but also can cause adverse reactions, such as disseminated tuberculosis, liver dysfunction, infections, when applied It should be noted.
In summary, the various types of immune system diseases with the above symptoms occur, and laboratory tests to a high degree of vigilance against the possible emergence of interstitial lung disease, so that early diagnosis, early treatment and reduce mortality and prolong survival time.
引文
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[3]Chen X, Cyclin G. a regulator of the p53-Mdm2 network [J]. Dev Cell.2002, 2(5): 518.
[4]Veeraraghavan S, Nicholson AG, Well Au,et al.Lung fibrosis:new classfications and therapy.Curr Opin Rheumatol,2001,13:500-504.
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[6]Katzenstein ALA,Myers JL.Idiopathic pulmonary fibrosis:clinical relevance of patholigic classification.Am J Respir Crit Care Med,1998,157:1301 -1315.
[7]Philip G,Chris W,Ann A,et aL Pleuropulmonary abnormalities in primary SjSgren 7S syndrome.J Rheumatol,1993,20:831-837.
[8]Yamado ri I,Fujita J,Bandoh S,et a1.Nonspecific interstitial pneumonia as pulmonary involvement of primary Sjogren’s syndrome.Rheumatol Int,2002, 22:89—92.
[9]Lee HK,Kim DS,Yoo B,et a1.Histopathologic pattern and clinical features of rheumatoid arthritis—associated interstitial 1ung disease.Chest,Z005, 127:2019-2027.
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[21]Pakas I,Ioannidis JA,Malagari K,et a1.Cyclophosphamide withlow or high dose prednisolone for systemic sclerosis lungdisease.J Rheumatol,2002,29:298-304.
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[23]Tansey D, Wells A U, Colby T V, et al. Variations in histologoical patterns of interstitial pneumonia between connective tissue disordes and their relationship to prognosis [J].Histopathology, 2004, 44: 585
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[2]刘涛,宋良文.肺纤维化发生的分子机制和早期防治研究进展.军事医学科学院院刊,2003,27;312—316.
[3]Chen X, Cyclin G. a regulator of the p53-Mdm2 network [J]. Dev Cell.2002, 2(5): 518.
[4]Veeraraghavan S, Nicholson AG, Well Au,et al.Lung fibrosis:new classfications and therapy.Curr Opin Rheumatol,2001,13:500-504.
[5]Vassallo R,Thomas CF.Advances in treatment of rheumatic interstititial lung disease. Curr Opin Rheumatol,2004,16:186-191.
[6]Katzenstein ALA,Myers JL.Idiopathic pulmonary fibrosis:clinical relevance of patholigic classification.Am J Respir Crit Care Med,1998,157:1301 -1315.
[7]Philip G,Chris W,Ann A,et aL Pleuropulmonary abnormalities in primary SjSgren 7S syndrome.J Rheumatol,1993,20:831-837.
[8]Yamado ri I,Fujita J,Bandoh S,et a1.Nonspecific interstitial pneumonia as pulmonary involvement of primary Sjogren’s syndrome.Rheumatol Int,2002, 22:89—92.
[9]Lee HK,Kim DS,Yoo B,et a1.Histopathologic pattern and clinical features of rheumatoid arthritis—associated interstitial 1ung disease.Chest,Z005, 127:2019-2027.
[10]Cortet B,Flipo RM,Remy_Jardin M,et a1.Use of high reso1ution computed tomog- raphy of the lung in patients with rheumatoid arthritis.Ann Rheum Dis,1995,54:815-819.
[11]Raghu G,Mageto YN,Lockhart D,et a1.The accuracy of the clinicaldiagnosis of new-onset idiopathic pulmonary fibrosis and other interstitial 1ung disease:a prospective study.Chest,999,116:1168-1174.
[12]Mori T, Matsui K. Cyclin K as a direct transcriptional targetof the p53 tumor suppressor[J]. Neoplasia, 2002, 4(3):268.
[13]Zhao L, Samuels T, Winckler S, et al. Cyclin G1 hasgrowth inhibitory activity linked to the ARF-Mdm2-p53 andpRb tumor suppressor pathways[J]. Mol Cancer Res, 2003,1(3): 195.
[14]Mac Donald SLS,Rubens MB,Hansell DM,et al.Nonsepecific interstitial pnermonia and usual interstitial pne.umonia:comparative appearances and diagnostic accuracy of high-resolution computed tomography.Radiology.2001,22 1:600-605.
[15]Cheema GS,Quismorio FP Jr.Interstitial lung disease in systemic sclerosis.Curr Opin Pulm Med,2001,7:283-290.
[16]Steen VD,Conte C,Owens GR,et al .Severe restrictive lung disease in systemic sclerosis.Arthritis Rheum,1994,37:1283-1289.
[17]李海云,郑毅.结缔组织病合并间质性肺疾病的的研究进展[J].中华湿病学杂志,2005,9:438-441.
[18]Latsi PI,Wells AU.Evaluation and management of alveolitis and interstitial lung disease in scleroderma. Curr Opin Rheumatol,2003,15:748-755.
[19]Lamblin C,Bergoin C,Saelens T,et a1 . Interstitiallung diseasesin collagen vascular diseases.Eur Respir J Suppl,200l,32:69s-803.
[20]Selman M,ThannichalⅥ,Pardo A,et a1.1diopathic pulmonar- yfibro- sis.Drugs,2004, 64:405-430.
[21]Pakas I,Ioannidis JA,Malagari K,et a1.Cyclophosphamide withlow or high dose prednisolone for systemic sclerosis lungdisease.J Rheumatol,2002,29:298-304.
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