免疫风湿科相关常用检查课件.ppt

1、2022/7/51免疫風濕科相關常用檢查台中榮民總醫院 過敏免疫風濕科2022/7/52一般檢查: CBCpWBCn下降: SLE, drug adverse effectn上昇:發炎性關節炎:RA & Spondyloarthropathy, Steroid usen大幅上昇: Adult onset Stills disease (AOSD), 感染p Plateletn下降: SLE, Antiphopholipid Ab syndrome, Vasculitis (含Cryoglobulinemia)n上昇 (400K): 發炎性關節炎:RA & Spondyloarthropathy

2、2022/7/53一般檢查: CBCHemoglobin (Hgb)p急性期 10mg/dL, 慢性期 100nHemolytic anemia Reticulocyte,MCV/LDH上昇, Coombs test(+) Haptoglobulin 下降 SLE, Antiphopholipid Ab syndrome最常見nMTX-induced anemia MTX(Methotrexate) 為葉酸(folic acid)之拮抗劑 葉酸為合成DNA之必要物質, 故MTX可抑制DNA合成, 對快速分裂繁殖細胞均有毒性:白血球,骨髓,胃腸道黏膜 可以folic acid (每日5-10mg

3、)補充來預防 2022/7/55一般檢查: CBCNormocytic & Microcytic anemiandisease本身(chronic illness)npeptic ulcer with bleeding & IDAnDrug adverse reaction:輕度骨髓抑制nThalassemia (地中海型貧血) 2022/7/56一般檢查: 生化pAlbumin: nLupus nephritis (狼瘡腎炎) 造成蛋白尿流失n慢性發炎性關節炎造成catabolism增加而消耗nSLE本身疾病活動性也可以使albumin下降pLDH上昇: hemolytic anemia,

4、myopathypCK上昇: myopathypTG/Cholesterol上昇nactive lupus nephritis in nephrotic range 2022/7/57一般檢查: 生化pGOT/GPT(AST/ALT)n除一般急性肝炎外, 肌肉病變/溶血亦可使GOT/GPT上昇nGOTGPT Alcohol/herb drug induced hepatitis Myopathy Hemolysis pAlk-P(Alkaline Phosphatase)/rGT明顯上昇n合併自體免疫肝炎或原發性膽汁性肝硬化症(PBC)n藥物(尤其是中草藥/健康食品)2022/7/58一般檢查

5、: Urine RoutinepUrine proteinnSpot Urine protein: 最sensitive 的篩檢性檢查 n24 hours urine protein: 狼瘡腎炎活性最佳及最主要單一指標p蛋白尿之臨床意義nSLE: Lupus nephritisnSjogren syndrome: kidney involvementnScleroderma(硬皮症): scleroderma kidneyn中草藥/健康食品腎病變2022/7/59一般檢查: Urine RoutinepCell:WBC/RBC nInfection/Lupus Cystitis 狼瘡膀胱炎 均

6、有夜尿, 排尿急迫感, 頻尿, 血尿 Concentrated urine 的 Gram Stain為最重要鑑別診斷p需取中段尿液於30分鐘內離心後取沈澱物做pphagocytosis 為最重要之發現p出現2種菌種則以被吞噬者為抗生素用藥選擇2022/7/510一般檢查: Urine RoutinepCastnWBC/RBC cast 最有意義,代表活動性腎炎, nGranular cast:代表確有蛋白尿 2022/7/511一般檢查: Urine RoutinepWBC Cast2022/7/512一般檢查: Urine RoutinepWBC Cast2022/7/513一般檢查: Ur

7、ine RoutinepWBC Cast2022/7/514一般檢查: Urine RoutinepRBC Cast2022/7/515一般檢查: Urine RoutinepRBC Cast2022/7/516一般檢查: Urine RoutinepGranular cast2022/7/517一般檢查: 篩檢性檢查pESR (紅血球沈降率)n用以作為screening testpCRP (C-reactive protein)n與infection,發炎性關節炎,vasculitis活性相關n大幅上昇(10)一定要考慮細菌性感染的可能nAOSD, very active RA也可有高效價C

8、RP pRPRn陽性時高度考慮有抗磷脂質抗體症候群2022/7/518抗核抗體ANAp從正常人到任何非自體免疫病或自體免疫病均可產生p需配合臨床症狀, 其他檢查, 以及特異性抗體結果決定意義2022/7/519抗核抗體ANAp效價: 以螢光指數表示n 不論型態時:1:160 以上較有意義n 高效價: 紅斑性狼瘡 SLE 混合性結締組織病變: MCTDn 低效價 老年人 Autoimmune disease: S.S., RA, SAE Infection, 尤其是慢性感染 (如TB等) Malignancy Drug-induced: 高血壓藥, 抗結核藥2022/7/520ANA 基本型態p

9、DiffusedpPeripheral pSpecklednCoarse specklednFine specklednDiscrete speckled pNucleolar 2022/7/521Diffused pattern與Chromatin(染色質)有關的抗體pAnti-dsDNA AbnSpecific for SLEpAnti-Histone AbnDrug induced lupus有關的抗體2022/7/522Peripheral pattern與Chromatin(染色質)有關的抗體p尤其是Anti-dsDNA AbnPattern specific for SLE2022

10、/7/523Coarse speckled patternRNP Abn 與MCTD, SLE, PSS, 雷諾氏現象有關Smith Abn Specific for SLE2022/7/524Fine speckled patternp較無專一性, 也可說是最常見的型態SSA (anti-Ro) SSB (anti-La) 2022/7/525Discrete Speckled PatternpCentromere Ab (著絲點抗體)nLimited type PSS, CREST syndromenSjogren syndromenPrimary biliary cirrhosisnPu

11、lmonary hypertension2022/7/526Nucleolar patternp染在核仁上p有許多種特有抗體p本例為anti-Scl-70 Ab (DNA topoisomerase Ab) 與廣泛性硬皮症 (dffused type PSS) 相關Anti-Scl70 Ab2022/7/527Cytoplasmic patternpRibosomal-P Abn Neuropsychiatric lupuspJo-1 Abn DMitis/anti-synthetase syndromepAnti-Mitochondrial Abn PBC2022/7/528Anti-tRN

12、A SynthetaseAnti-SRP Anti-Mi-2Onset Acute, SpringVery acute, WinterAcuteClinical Signs PMitisInterstitial Lung Dis.ArthritisMechanics hand Raynauds phenomenonSevere PMitisCardiac involvementClassic DMitisV-sign & Shawl-sign Periungual erythemaCuticular overgrowthSteroid ResponseModeratePoorGood 5ys-

13、survival 65% 30% 90%目前最新趨勢以自體抗體的不同進行分類2022/7/529類風濕因子Rhematoid FactorpAnti-human IgG Ab p一般是指 anti-IgG IgM (RF-IgM)p許多狀況均可呈陽性, 不是類風濕因子陽性加關節炎就是類風濕關節炎nAutoimmune disease: RA, S.S.,SLEnInfection:Bacterial:SBE, HCV-infection, TB/Fungal infectionnMalignancy 2022/7/530補體 ComplementpC3, C4n下降: SLE, Vasculi

14、tis, 先天性補體缺乏, 肝功能障礙n上昇:懷孕, 發炎性關節炎, 感染pCH50n代表真正整體補體系統活性n太低要考慮先天性補體缺乏 (3+(300), 24hours Urine protein0.5gm nCast: WBC cast, RBC cast, Granular cast pRPR 偽陽性n多半代表合併抗磷脂質抗體症候群(APS)pANA: 通常為 中至高效價昇高 2022/7/540類風濕關節炎(RA)CBCp血小板: active arthritis 時昇高n血小板明顯下降者要考慮: Felty syndromep白血球正常或小幅昇高n白血球下降多由藥物副作用引起 Im

15、uran, Methotrexate(MTX)等ESR/CRP: active arthritis時昇高p關節之X-ray檢查對疾病診斷及追蹤同等重要2022/7/541脊柱關節病變SpondyloarthropathypCBC: 血小板昇高,白血球正常或小幅昇高n白血球下降多由藥物副作用引起 Salazopyrin, Methotrexate(MTX)等pESR/CRP 昇高p類風濕因子(Rhematoid Factor)n應為陰性或非常低效價陽性pX-ray檢查對疾病診斷追蹤同等重要2022/7/542Normal Pattern Normal hairpin-shaped capilla

16、ries2022/7/543Morphological abnormalitypTerminology: SD/D patternnMeandering, Loop dilatation, Giant loop, nHemorrhagic spot, nAavascular zone, nBush formpDocumented to be a good way to evaluate the evolving of Raynauds phenomenon, or MCTD or severity of PSS2022/7/544Morphological abnormalitypMeande

17、ring loopnElongatednVisible subcapillary plexus 2022/7/545Morphological abnormalitypLoop dilatationnNormal vascular loop width ( 10 x normal 2022/7/547Morphological abnormalitypHemorrhagic spotnDroplet patternnBand patternnMixed pattern2022/7/548Morphological abnormalitypAvascular zone2022/7/549Morp

18、hological abnormalitypBush form2022/7/550Any Question?2022/7/551硬皮症硬皮症 自體抗體與臨床表現分類之關係自體抗體與臨床表現分類之關係pDiffuse 廣泛型 Scl-70 RNA Polymerase III Fibrillarin (U3-RNP)pLimited 局限型 Centromere (CENP) Anti-Th PM-SclpOverlaping 重疊型 U1-RNP PM-SclSystemicSystemicSclerosisSclerosisCentromereAnti-ThScl-70RNA polymer

19、ase IIIFibrillarinU1RNPPM-SclDiffuseDiffuseLimitedLimitedOverlapingOverlapingDiffuseDiffuse2022/7/552自體抗體與臨床表現之關係自體抗體與臨床表現之關係依Autoantibodies分類pCentromere Ab nLimited type PSSnCREST SyndromepScl-70 Ab (Anti-topoisomerase Ab)nDiffuse typen肺部: Fibrosing alveolitispRNA-polymerase III Ab nDiffuse typen 腎

20、臟, GI侵犯最多Centromere AbScl-70Disease severity as a predictor of outcome in scleroderma. Gelber AC, Wigley FM (Johns Hopkins University) Lancet 2002; 359:277-9. RNA Polymerase III fine speckled pattern2022/7/553自體抗體與臨床表現之關係自體抗體與臨床表現之關係pAnti-B23 (nucleolar phosphoprotein)n Scleroderma and pulmonary hyp

21、ertensionpAnti-Fibrillarin (U3RNP)n Severe scleroderman muscle and cardiopulmonary diseasepAnti-U1snRNP (nuclear RNA-splicing particle)n Mixed connective tissue disease (MCTD)pAnti-PM-Scl (nucleolar protein complex)n Scleroderma and inflammatory muscle diseaseanti-PM-Scl: Homogenous nucleolar pattern Disease severity as a predictor of outcome in scleroderma. Gelber AC, Wigley FM (Johns Hopkins University) Lancet 2002; 359:277-9. U3 RNP: Clumpy nucleolar pattern U1 RNP Coarse speckled pattern. Nucleoli and mitotic cells are negative.