類風(fēng)濕關(guān)節(jié)炎RheumatoidArthritis(RA)課件

類風(fēng)濕關(guān)節(jié)炎RheumatoidArthritis(RA)ByRaoulDufy(1877-1953)類風(fēng)濕關(guān)節(jié)炎RheumatoidArthritis(ROutlineDefinitionandhistoryPrevalanceEtiology,pathogenesisandpathologyClinicalfeaturesLaboratoryfindingsImagingDiagnosisanddifferentialdiagnosisManagementOutlineDefinitionandhistoryRA定義Anautoimmunedisorderofunknownetiologycharacterizedbysymmetric,erosivesynovitisand,insomecases,extraarticularinvolvement.Mostpatientsexperienceachronic

fluctuatingcourseofdiseasethat,despitetherapy,mayresultinprogressivejointdestruction,deformity,disability,andevenprematuredeath-----2003,AmericancollegeofRheumatologyRA定義AnautoimmunedisorderofMedicineasanartTheholyfamilywithSt.Anne(C1633—C1635)byPeterPaulRubens歷史MedicineasanartTheholyfamHistory:

Pierre-Auguste

Renoir

(1841-1919)OntheTerrace(1878)ByPierre-Auguste

RenoirHistory:

Pierre-AugusteRenoi歷史：

ErikWaalerErikWaalerTheoccurrenceofafactorinhumanserumactivatingthespecificagglutinationofsheepcorpuscles.ActaPatholMicroboilScand1940;1:172-88.歷史：

ErikWaalerErikWaalerTheGeneticFactorsinRADRB1GeneticFactorsinRADRB1Virus-infectionHypothesisVirus-infectionHypothesisSexHormoneonRASexHormoneonRARheumatoidPannus（血管翳）RheumatoidPannus（血管翳）Pannus（血管翳）Pannus（血管翳）RheumatoidArthritis:Hand,FusiformSwelling（梭形）RheumatoidArthritis:Hand,FuUlnar（尺側(cè)）DeviationandMuscleAtrophyUlnar（尺側(cè)）DeviationandMuscleSwanNeckDeformityandBoutonnièreDeformity鈕扣花SwanNeckDeformityandBoutonTelescopingSignTelescopingSignArthritisMutilans殘毀ArthritisMutilans殘毀ArthritisMutilansArthritisMutilansHypermobilityHypermobilityArthritisMutilansArthritisMutilansSubcutaneousNodule,Olecranon鷹嘴SubcutaneousNodule,OlecranonRheumatoidNodulesRheumatoidNodulesRheumatoidNodulesintheLungRheumatoidNodulesintheLungRheumatoidNodule:PathologyRheumatoidNodule:PathologyScleromalaciaPerforans

（穿孔性鞏膜軟化）ScleromalaciaPerforans

（穿孔性鞏膜VasculitisandGangrene（壞疽）VasculitisandGangrene（壞疽）ExtensorTendonRuptureExtensorTendonRupturePoplitealCyst

（腘窩囊腫）PoplitealCyst

（腘窩囊腫）ProgressiveRightPIP3Erosionsina60-yearOldLadySufferingFromRA3/19893/198911/19903/199211/19931/19956/1996ProgressiveRightPIP3ErosionRightWristintheSamePatient3/198911/19903/199211/19931/19956/19963/198911/19903/199211/19931/19956/1996RightWristintheSamePatienRheumatoidArthritis:KneesRheumatoidArthritis:KneesHip,LateErosionsHip,LateErosionsProtrusioAcetabuli髖臼突出ProtrusioAcetabuli髖臼突出患病率患病率病因遺傳因素感染因素內(nèi)分泌因素病因遺傳因素發(fā)病機(jī)理發(fā)病機(jī)理病理Synovitis(滑膜炎）VasculitisRheumatoidnodules病理Synovitis(滑膜炎）臨床表現(xiàn)關(guān)節(jié)表現(xiàn)晨僵Morningstiffness關(guān)節(jié)痛Arthralgia

和關(guān)節(jié)壓痛tenderness關(guān)節(jié)腫Jointswelling關(guān)節(jié)變形Jointdeformity關(guān)節(jié)外表現(xiàn)APictureisWorthaThousandWords臨床表現(xiàn)關(guān)節(jié)表現(xiàn)APictureisWorth關(guān)節(jié)外表現(xiàn)類風(fēng)濕結(jié)節(jié)Rheumatoidnodule類風(fēng)濕血管炎Rheumatoidvasculitis類風(fēng)濕肺病變Lungdiseases干燥綜合征Sjogren’ssyndrome心包炎Pericarditis腎病變KidneydiseasesAPictureisWorthaThousandWords關(guān)節(jié)外表現(xiàn)類風(fēng)濕結(jié)節(jié)RheumatoidnoduleA實驗室檢查血液學(xué)異常血小板數(shù)增多炎癥指標(biāo):血沉增快C反應(yīng)蛋白水平升高類風(fēng)濕因子Rheumatoidfactor（RF）抗CCP抗體實驗室檢查血液學(xué)異常RF=RA?CategoryDiseasesRheumaticdiseasesRA,SLE,scleroderma,sjogren’ssyndromeViralinfectionsAIDS,Hepatitis,influenza,aftervaccinationChronicbacterialinfectionsTuberculosis,leprosy,syphilis,subacutebacterialendocarditis,NeoplasmsAfterirradiationorchemotherapyOthersChronicliverorlungdiseaseRF=RA?CategoryDiseasesRheuma放射學(xué)檢查確立診斷監(jiān)測疾病發(fā)展監(jiān)測藥物治療效果放射學(xué)檢查確立診斷類風(fēng)濕關(guān)節(jié)炎RheumatoidArthritis(RA)課件鑒別診斷血清陰性脊柱關(guān)節(jié)病骨關(guān)節(jié)炎系統(tǒng)性紅斑狼瘡SLE風(fēng)濕熱Rheumaticfever鑒別診斷血清陰性脊柱關(guān)節(jié)病72歲女性，雙膝關(guān)節(jié)痛10余年，雙手指關(guān)節(jié)腫痛8個月。膝痛以上樓時為重，勞累可以誘發(fā)。近8個月來雙手近端指間關(guān)節(jié)、遠(yuǎn)端指間關(guān)節(jié)疼痛明顯，天氣變化時加重。晨僵半小時。查血ESR24mm/h,RF（＋）。血常規(guī)正常。72歲女性，雙膝關(guān)節(jié)痛10余年，雙手指關(guān)節(jié)腫痛8個月。膝痛以處理Theultimategoalsareto:PreventorcontroljointdamagePreventlossoffunctionDecreasepain.處理Theultimategoalsareto:類風(fēng)濕關(guān)節(jié)炎RheumatoidArthritis(RA)課件治療方法非藥物治療藥物治療外科治療治療方法非藥物治療治療藥物種類改變病情抗風(fēng)濕藥DiseaseModifyingAnti-rheumaticDrugs(DMARDs)糖皮質(zhì)激素Glucocorticoids非甾體抗炎藥NonsteroidalAnti-InflammatoryDrugs(NSAIDs)生物制劑Biologicagents抗生素Antibiotics？治療藥物種類改變病情抗風(fēng)濕藥DiseaseModify改變病情抗風(fēng)濕藥(DMARDs)甲氨蝶呤Methotrexate（MTX）來氟米特Leflunomide柳氮磺吡啶Sulfasalazine金制劑Gold,oralorintramuscular硫唑嘌呤Azathioprine青霉胺D-penicillamine環(huán)孢素Cyclosporine改變病情抗風(fēng)濕藥(DMARDs)甲氨蝶呤Methotrex目前觀點所有RA患者均應(yīng)采用DMARD治療首選MTX.嚴(yán)重RA患者可采用DMARD聯(lián)合治療，但方案中應(yīng)包含MTX癥狀緩解不等于治愈目前觀點所有RA患者均應(yīng)采用DMARD治療BiologicsinthetreatmentofRABiologicsinthetreatmentof小劑量糖皮質(zhì)激素每天不超過10mg的潑尼松:有效緩解癥狀可能減慢關(guān)節(jié)侵蝕進(jìn)展應(yīng)權(quán)衡得弊，綜合考慮：骨質(zhì)疏松osteoporosis感染Infection小劑量糖皮質(zhì)激素每天不超過10mg的潑尼松:非甾體抗炎藥NSAIDs不應(yīng)做為RA的單一治療具抗炎、鎮(zhèn)痛作用不改變RA病程、減慢關(guān)節(jié)破壞發(fā)展選擇應(yīng)基于療效、安全、方便性及費用布洛芬萘普生雙氯芬酸非甾體抗炎藥NSAIDs不應(yīng)做為RA的單一治療總結(jié)定義病理臨床表現(xiàn)診斷治療RaoulDufy,LeBouquetd'Arums,1939

總結(jié)定義RaoulDufy,LeBouquetd'1、有時候讀書是一種巧妙地避開思考的方法。12月-2212月-22Wednesday,December14,20222、閱讀一切好書如同和過去最杰出的人談話。01:35:3301:35:3301:3512/14/20221:35:33AM3、越是沒有本領(lǐng)的就越加自命不凡。12月-2201:35:3301:35Dec-2214-Dec-224、越是無能的人，越喜歡挑剔別人的錯兒。01:35:3301:35:3301:35Wednesday,December14,20225、知人者智，自知者明。勝人者有力，自勝者強(qiáng)。12月-2212月-2201:35:3301:35:33December14,20226、意志堅強(qiáng)的人能把世界放在手中像泥塊一樣任意揉捏。14十二月20221:35:33上午01:35:3312月-227、最具挑戰(zhàn)性的挑戰(zhàn)莫過于提升自我。。十二月221:35上午12月-2201:35December14,20228、業(yè)余生活要有意義，不要越軌。2022/12/141:35:3301:35:3314December20229、一個人即使已登上頂峰，也仍要自強(qiáng)不息。1:35:33上午1:35上午01:35:3312月-2210、你要做多大的事情，就該承受多大的壓力。12/14/20221:35:33AM01:35:3314-12月-2211、自己要先看得起自己，別人才會看得起你。12/14/20221:35AM12/14/20221:35AM12月-2212月-2212、這一秒不放棄，下一秒就會有希望。14-Dec-2214December202212月-2213、無論才能知識多么卓著，如果缺乏熱情，則無異紙上畫餅充饑，無補(bǔ)于事。Wednesday,December14,202214-Dec-2212月-2214、我只是自己不放過自己而已，現(xiàn)在我不會再逼自己眷戀了。12月-2201:35:3314December202201:35謝謝大家1、有時候讀書是一種巧妙地避開思考的方法。12月-2212月551、有時候讀書是一種巧妙地避開思考的方法。12月-2212月-22Wednesday,December14,20222、閱讀一切好書如同和過去最杰出的人談話。01:35:3301:35:3301:3512/14/20221:35:33AM3、越是沒有本領(lǐng)的就越加自命不凡。12月-2201:35:3301:35Dec-2214-Dec-224、越是無能的人，越喜歡挑剔別人的錯兒。01:35:3301:35:3301:35Wednesday,December14,20225、知人者智，自知者明。勝人者有力，自勝者強(qiáng)。12月-2212月-2201:35:3301:35:33December14,20226、意志堅強(qiáng)的人能把世界放在手中像泥塊一樣任意揉捏。14十二月20221:35:33上午01:35:3312月-227、最具挑戰(zhàn)性的挑戰(zhàn)莫過于提升自我。。十二月221:35上午12月-2201:35December14,20228、業(yè)余生活要有意義，不要越軌。2022/12/141:35:3301:35:3314December20229、一個人即使已登上頂峰，也仍要自強(qiáng)不息。1:35:33上午1:35上午01:35:3312月-2210、你要做多大的事情，就該承受多大的壓力。12/14/20221:35:33AM01:35:3314-12月-2211、自己要先看得起自己，別人才會看得起你。12/14/20221:35AM12/14/20221:35AM12月-2212月-2212、這一秒不放棄，下一秒就會有希望。14-Dec-2214December202212月-2213、無論才能知識多么卓著，如果缺乏熱情，則無異紙上畫餅充饑，無補(bǔ)于事。Wednesday,December14,202214-Dec-2212月-2214、我只是自己不放過自己而已，現(xiàn)在我不會再逼自己眷戀了。12月-2201:35:3314December202201:35謝謝大家1、有時候讀書是一種巧妙地避開思考的方法。12月-2212月56

類風(fēng)濕關(guān)節(jié)炎RheumatoidArthritis(RA)ByRaoulDufy(1877-1953)類風(fēng)濕關(guān)節(jié)炎RheumatoidArthritis(ROutlineDefinitionandhistoryPrevalanceEtiology,pathogenesisandpathologyClinicalfeaturesLaboratoryfindingsImagingDiagnosisanddifferentialdiagnosisManagementOutlineDefinitionandhistoryRA定義Anautoimmunedisorderofunknownetiologycharacterizedbysymmetric,erosivesynovitisand,insomecases,extraarticularinvolvement.Mostpatientsexperienceachronic

fluctuatingcourseofdiseasethat,despitetherapy,mayresultinprogressivejointdestruction,deformity,disability,andevenprematuredeath-----2003,AmericancollegeofRheumatologyRA定義AnautoimmunedisorderofMedicineasanartTheholyfamilywithSt.Anne(C1633—C1635)byPeterPaulRubens歷史MedicineasanartTheholyfamHistory:

Pierre-Auguste

Renoir

(1841-1919)OntheTerrace(1878)ByPierre-Auguste

RenoirHistory:

Pierre-AugusteRenoi歷史：

ErikWaalerErikWaalerTheoccurrenceofafactorinhumanserumactivatingthespecificagglutinationofsheepcorpuscles.ActaPatholMicroboilScand1940;1:172-88.歷史：

ErikWaalerErikWaalerTheGeneticFactorsinRADRB1GeneticFactorsinRADRB1Virus-infectionHypothesisVirus-infectionHypothesisSexHormoneonRASexHormoneonRARheumatoidPannus（血管翳）RheumatoidPannus（血管翳）Pannus（血管翳）Pannus（血管翳）RheumatoidArthritis:Hand,FusiformSwelling（梭形）RheumatoidArthritis:Hand,FuUlnar（尺側(cè)）DeviationandMuscleAtrophyUlnar（尺側(cè)）DeviationandMuscleSwanNeckDeformityandBoutonnièreDeformity鈕扣花SwanNeckDeformityandBoutonTelescopingSignTelescopingSignArthritisMutilans殘毀ArthritisMutilans殘毀ArthritisMutilansArthritisMutilansHypermobilityHypermobilityArthritisMutilansArthritisMutilansSubcutaneousNodule,Olecranon鷹嘴SubcutaneousNodule,OlecranonRheumatoidNodulesRheumatoidNodulesRheumatoidNodulesintheLungRheumatoidNodulesintheLungRheumatoidNodule:PathologyRheumatoidNodule:PathologyScleromalaciaPerforans

（穿孔性鞏膜軟化）ScleromalaciaPerforans

（穿孔性鞏膜VasculitisandGangrene（壞疽）VasculitisandGangrene（壞疽）ExtensorTendonRuptureExtensorTendonRupturePoplitealCyst

（腘窩囊腫）PoplitealCyst

（腘窩囊腫）ProgressiveRightPIP3Erosionsina60-yearOldLadySufferingFromRA3/19893/198911/19903/199211/19931/19956/1996ProgressiveRightPIP3ErosionRightWristintheSamePatient3/198911/19903/199211/19931/19956/19963/198911/19903/199211/19931/19956/1996RightWristintheSamePatienRheumatoidArthritis:KneesRheumatoidArthritis:KneesHip,LateErosionsHip,LateErosionsProtrusioAcetabuli髖臼突出ProtrusioAcetabuli髖臼突出患病率患病率病因遺傳因素感染因素內(nèi)分泌因素病因遺傳因素發(fā)病機(jī)理發(fā)病機(jī)理病理Synovitis(滑膜炎）VasculitisRheumatoidnodules病理Synovitis(滑膜炎）臨床表現(xiàn)關(guān)節(jié)表現(xiàn)晨僵Morningstiffness關(guān)節(jié)痛Arthralgia

和關(guān)節(jié)壓痛tenderness關(guān)節(jié)腫Jointswelling關(guān)節(jié)變形Jointdeformity關(guān)節(jié)外表現(xiàn)APictureisWorthaThousandWords臨床表現(xiàn)關(guān)節(jié)表現(xiàn)APictureisWorth關(guān)節(jié)外表現(xiàn)類風(fēng)濕結(jié)節(jié)Rheumatoidnodule類風(fēng)濕血管炎Rheumatoidvasculitis類風(fēng)濕肺病變Lungdiseases干燥綜合征Sjogren’ssyndrome心包炎Pericarditis腎病變KidneydiseasesAPictureisWorthaThousandWords關(guān)節(jié)外表現(xiàn)類風(fēng)濕結(jié)節(jié)RheumatoidnoduleA實驗室檢查血液學(xué)異常血小板數(shù)增多炎癥指標(biāo):血沉增快C反應(yīng)蛋白水平升高類風(fēng)濕因子Rheumatoidfactor（RF）抗CCP抗體實驗室檢查血液學(xué)異常RF=RA?CategoryDiseasesRheumaticdiseasesRA,SLE,scleroderma,sjogren’ssyndromeViralinfectionsAIDS,Hepatitis,influenza,aftervaccinationChronicbacterialinfectionsTuberculosis,leprosy,syphilis,subacutebacterialendocarditis,NeoplasmsAfterirradiationorchemotherapyOthersChronicliverorlungdiseaseRF=RA?CategoryDiseasesRheuma放射學(xué)檢查確立診斷監(jiān)測疾病發(fā)展監(jiān)測藥物治療效果放射學(xué)檢查確立診斷類風(fēng)濕關(guān)節(jié)炎RheumatoidArthritis(RA)課件鑒別診斷血清陰性脊柱關(guān)節(jié)病骨關(guān)節(jié)炎系統(tǒng)性紅斑狼瘡SLE風(fēng)濕熱Rheumaticfever鑒別診斷血清陰性脊柱關(guān)節(jié)病72歲女性，雙膝關(guān)節(jié)痛10余年，雙手指關(guān)節(jié)腫痛8個月。膝痛以上樓時為重，勞累可以誘發(fā)。近8個月來雙手近端指間關(guān)節(jié)、遠(yuǎn)端指間關(guān)節(jié)疼痛明顯，天氣變化時加重。晨僵半小時。查血ESR24mm/h,RF（＋）。血常規(guī)正常。72歲女性，雙膝關(guān)節(jié)痛10余年，雙手指關(guān)節(jié)腫痛8個月。膝痛以處理Theultimategoalsareto:PreventorcontroljointdamagePreventlossoffunctionDecreasepain.處理Theultimategoalsareto:類風(fēng)濕關(guān)節(jié)炎RheumatoidArthritis(RA)課件治療方法非藥物治療藥物治療外科治療治療方法非藥物治療治療藥物種類改變病情抗風(fēng)濕藥DiseaseModifyingAnti-rheumaticDrugs(DMARDs)糖皮質(zhì)激素Glucocorticoids非甾體抗炎藥NonsteroidalAnti-InflammatoryDrugs(NSAIDs)生物制劑Biologicagents抗生素Antibiotics？治療藥物種類改變病情抗風(fēng)濕藥DiseaseModify改變病情抗風(fēng)濕藥(DMARDs)甲氨蝶呤Methotrexate（MTX）來氟米特Leflunomide柳氮磺吡啶Sulfasalazine金制劑Gold,oralorintramuscular硫唑嘌呤Azathioprine青霉胺D-penicillamine環(huán)孢素Cyclosporine改變病情抗風(fēng)濕藥(DMARDs)甲氨蝶呤Methotrex目前觀點所有RA患者均應(yīng)采用DMARD治療首選MTX.嚴(yán)重RA患者可采用DMARD聯(lián)合治療，但方案中應(yīng)包含MTX癥狀緩解不等于治愈目前觀點所有RA患者均應(yīng)采用DMARD治療BiologicsinthetreatmentofRABiologicsinthetreatmentof小劑量糖皮質(zhì)激素每天不超過10mg的潑尼松:有效緩解癥狀可能減慢關(guān)節(jié)侵蝕進(jìn)展應(yīng)權(quán)衡得弊，綜合考慮：骨質(zhì)疏松osteoporosis感染Infection小劑量糖皮質(zhì)激素每天不超過10mg的潑尼松:非甾體抗炎藥NSAIDs不應(yīng)做為RA的單一治療具抗炎、鎮(zhèn)痛作用不改變RA病程、減慢關(guān)節(jié)破壞發(fā)展選擇應(yīng)基于療效、安全、方便性及費用布洛芬萘普生雙氯芬酸非甾體抗炎藥NSAIDs不應(yīng)做為RA的單一治療總結(jié)定義病理臨床表現(xiàn)診斷治療RaoulDufy,LeBouquetd'Arums,1939

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