Introduction

Introduction to adult rheumatoid arthritis scleritis

Rheumatoid arthritis (RA) is a common autoimmune disease characterized by multi-system inflammation characterized by chronic inflammatory lesions of joint tissues. It can also damage extra-articular tissues such as the eyes, skin, lungs, heart and peripheral nerves.

basic knowledge

Sickness ratio: 0.5%

Susceptible people: adults

Mode of infection: non-infectious

Complications: glaucoma, cataract, retinopathy

Pathogen

Causes of adult rheumatoid arthritis scleritis

Microbial infection (20%):

Triggered or sustained microbial infections, such as dampness, cold, fatigue, malnutrition, trauma, mental factors, etc., especially wet and cold are the main predisposing factors for this disease.

Host genetic factors (15%):

Gene chain inheritance is a phenomenon similar between biological parents and offspring, and between offspring individuals. Genetics generally refers to the phenomenon that the traits of the parent are expressed in the next generation, but genetically refers to the phenomenon that the genetic material is passed from the upper generation to the offspring.

Decreased autoimmunity (10%):

Refers to the human body to identify and destroy any foreign bodies (viruses, bacteria, etc.) that invade, to treat aging, injury, death, degeneration of self-cells, and to identify and treat mutant cells and virus-infected cells in vivo below normal levels.

Pathogenesis:

It is not yet clear that the most basic lesion of RA is synovitis, which is the result of the body's immune response to antigen stimulation, including both humoral and cellular immune responses.

Under the influence of environmental pathogenic factors, the synovial cells of the joint transform and release a large number of cytokines to promote the proliferation of synovial fibroblasts. Macrophage colony-stimulating factor activates macrophages and interacts with activated T lymphocytes to release IL. -1, prostaglandin E2 (PGE2) and IL-6, the most important cytokine is IL-6, which stimulates the activation of polyclonal B lymphocytes, promotes the degradation of proteoglycans by chondrocytes and inhibits their synthesis, leading to classes The production of rheumatoid factor (RF) becomes an antibody that binds to the IgG·Fc segment and is directly involved in the formation of synovial inflammation in rheumatoid arthritis. Most B lymphocytes are produced in the synovial membrane of RA. IgG·RF forms an immune complex with self-denatured IgG. This IgG·RF-self-denatured IgG complex is phagocytized by neutrophils and synovial cells, releasing inflammatory mediators and causing arthritis. Immune complexes activate complement, stimulate synovial cell proliferation and production of proteases and prostaglandins, attract white blood cells and platelets, causing occlusive vasculitis, forming rheumatoid nodules, In the same mechanisms that cause eye scleritis and uveitis.

Prevention

Adult rheumatoid arthritis scleritis prevention

Patients with RA have necrotizing anterior scleritis, which usually indicates a potentially fatal systemic vasculitis, and should be highly vigilant when this occurs.

Complication

Adult rheumatoid arthritis scleritis complications Complications glaucoma cataract retinopathy

Rheumatoid scleritis can spread to adjacent tissues, causing other pathological changes in the eye, such as keratitis, anterior uveitis, glaucoma, cataract, chorioretinopathy, optic neuropathy, and ocular dyskinesia. Some of these complications can cause vision. Decreased, caused by rheumatoid vasculitis can cause intestinal infarction, bleeding and perforation, can also involve the pancreas and peritoneal blood vessels.

Symptom

Adult rheumatoid arthritis, scleritis symptoms, common symptoms, ptosis, eye pain, tears, photophobia, scleral edema

1. Ocular manifestations The eye is the most susceptible organ for extra-articular lesions of the RA. Dry keratoconjunctivitis is the most common ocular lesion in RA. Scleritis and keratitis are the most serious eye injuries. Other eyes There are also scleritis and scleral inflammation and eye movement disorders.

(1) Scleritis: Systemic diseases causing scleritis are most common in RA. The incidence of RA in patients with scleritis is 10% to 33%, and the incidence of scleritis in patients with RA is 0.15% to 6.3%. RA scleritis More common on both sides, more common in patients over 60 years old, more women than men, the most common type of RA scleritis is diffuse anterior scleritis, patients with red eyes, eye pain, photophobia, tearing, conjunctival sac secretions and Symptoms such as decreased vision, the main features are diffuse anterior scleral inflammatory infiltration, less comorbidities, relatively better prognosis than other types of scleritis, diffuse congestive swelling of the sclera in the lesion, conjunctival edema, severe need to drop adrenaline Clear sclera, perforated scleral softening is almost entirely caused by RA, perforated scleral softening, also known as non-inflammatory necrotic scleritis, rare, mostly women over the age of 50, patients with hidden disease, rarely accompanied by inflammation And pain response, occurs in the anterior equator sclera, protein-like necrosis of scleral collagen fibers in the lesion, gray-yellow plaque, more than half of patients have more than one necrotic plaque, severe cases of carrion-like necrosis Necrotic tissue shedding, causing scleral defects, perforation and uveal prolapse, diffuse anterior scleritis is not treated in time or RA disease progression, progression, necrotizing anterior scleritis, characterized by localized necrosis of the anterior sclera Caused by vascular inflammation caused by immune complexes, extremely destructive, often other ocular complications and decreased vision, the course of disease is slowly delayed.

Scleritis can be the first manifestation of RA disease, but usually occurs after 13 to 14 years of long-term RA disease. Patients with RA scleritis have more advanced arthritis and extra-articular clinical conditions than patients with RA disease without scleritis. Performance, most of the extra-articular manifestations are the result of potential RA vasculitis, the typical incidence of RA subcutaneous nodules is 20% to 30%, the incidence of subcutaneous nodules of RA scleritis can reach 50%, RA sclera Other extra-articular lesions such as respiratory diseases, cardiac abnormalities, peripheral neuropathy, skin ulcers and amyloidosis are more common than those without scleritis. When the rheumatic activity of RA is severe, the condition of scleritis is worsened, and diffuse or nodular anterior scleritis can progress to necrotizing anterior scleritis, suggesting that other parts of the body have RA vasculitis, most RA scleritis, especially Necrotizing anterior scleritis has clear RA joints and extra-articular manifestations. The most common extra-articular manifestations are subcutaneous nodules and cutaneous vascular lesions. Other RA out-of-joint manifestations include:

1 abnormal respiratory system, such as pleural effusion, pneumonia and pulmonary rheumatoid nodules.

2 abnormalities in the heart, such as conduction disorders, valvular disease, myocardial infarction and pericarditis.

3 neurological diseases such as carpal tunnel syndrome, sensory neuropathy and sensory-motor neuropathy.

4 lymphadenopathy and non-Hodgkin's lymphoma.

5 amyloidosis.

6 liver function is mildly abnormal.

7 Gastroduodenal ulcers caused by gastrointestinal diseases such as long-term glucocorticoids and NSAID treatment.

Secondary nephropathy caused by treatment with 8 gold preparations.

9 abnormal bone tissue, such as osteoporosis caused by long-term glucocorticoid treatment.

(2) Scleral epithelial inflammation: To date, there is no clear evidence of a correlation between scleral epithelial inflammation and RA, and the incidence of RA in the scleral epithelial inflammation is reported to be 3.2% to 5.7% (Table 3). The incidence of scleral epithelial inflammation in RA is only 0.17%. Women with RA scleritis are more common than men, and there are many elderly patients in the 60-year-old. One or two sides, the type is simple or nodular, simple Sclera of the sclera is acute, with a short course of disease and periodic recurrence. In the acute phase, the eye is photophobic, tearing, burning pain and other discomfort. The superficial sclera of the lesion is localized with congestion and edema. The conjunctiva can move and the nodular sclera The outer layer of inflammation is mostly acute, with a short course of disease. It is characterized by localized nodular ridges on the surface of the sclera. The nodules are more single and dark red, with a diameter of 2 to 3 mm. The nodules and surrounding conjunctiva are congested and edema. 2 / 3 patients can relapse multiple times in different parts, the condition can be gradually relieved and completely resolved, generally does not affect vision, individual patients can develop scleritis. The bilateral scleral nodules of the RA sclera can occur simultaneously with active arthritis of RA (rheumatoid nodules); also in the inactive phase of RA (rheumatoid nodulosis) ); or patients with no underlying systemic disease (pseudo-rheumatic nodules, pseudodorumatoid nodules). Keratitis, including thinning of the cornea margin, acute stromal keratitis and sclerosing keratitis, is more common in patients with RA sclera than non-RA scleritis, but less severe, RA scleritis There are a few pre-meningal uveitis and cataracts.

(3) Other ocular lesions: keratoconjunctivitis sicca (KCS) or dry eye syndrome is caused by abnormal tear secretion in the lacrimal gland and accessory lacrimal gland, leading to tear film instability and ocular surface tissue lesions. There are symptoms of eye discomfort, the incidence rate in RA patients is 11% to 35%, female: male is 9:1, bilateral good-haired age is 40 to 50 years old, a few patients are asymptomatic, most patients have itching, burning Feelings, photophobia, foreign body sensation, dry eyes, little tears or tears, visual fatigue or fluctuations, or excessive tearing due to dry stimuli, early characteristic manifestations of mild conjunctival hyperemia, conjunctival sac mucus secretion, nipple Conjunctivitis, tear film rupture time (BUT) shortened, corneal sensation decline, superficial punctate keratitis and filamentous keratitis, chronic long-term dry stimulation caused by blepharitis, conjunctivitis and corneal ulcer, severity of KCS symptoms It is associated with the age of the patient or the course of RA, but not with the severity of arthritis. KCS with xerostomia and connective tissue disease (most commonly seen in RA) is a multisystem autoimmune disease, also known as Sjögren syndrome. , Sjogren's disease or KCS plus connective tissue disease can also be diagnosed as Sjögren syndrome. Sjögren syndrome is more common in patients with RA scleritis than in patients with general RA without scleritis. 32 cases of RA observed in Foster et al. In scleritis, 4 cases of KCS (12.5%) occurred, 2 of which developed aseptic corneal ulcers (3 eyes). Interestingly, 2 of 4 cases (1 case of corneal ulcers) had non-Hodge In gold lymphoma, this tumor occurs mostly in RA and Sjögren syndrome.

RA corneal scleritis complicated by corneal lesions according to whether there is corneal thinning, infiltration or ulceration, can be divided into marginal corneal thinning, acute or sclerosing stromal keratitis and peripheral ulcerative keratitis (PUK) The incidence of RA scleritis with keratopathy is reported to be 36% to 43.5%. Of the 32 RA cases of F-scleveitis reported by Foster et al, 16 (27 eyes) have keratitis (50%), 2 For example, corneal thinning, 1 case of acute stromal keratitis, 3 cases of stromal sclerosing keratitis, 10 cases of PUK (Table 3), corneal lesions, especially PUK is most common in patients with necrotizing scleritis, RA Independent corneal lesions can also occur. Anterior uveitis: The anterior uveitis of RA is almost caused by the spread of RA scleritis. The incidence of anterior uveitis in adult RA without scleritis is not higher than that in the normal population. Foster et al reported 32 cases of RA. 14 cases (44%) of scleritis had at least 1 anterior uveitis episode, 7 (50%) had necrotizing anterior scleritis, 5 had diffuse anterior scleritis, and 2 had nodular Scleritis, 1 case of patients with anterior uveitis nodular anterior scleritis also associated with posterior uveitis and posterior scleritis. Glaucoma: RA scleritis can cause elevated intraocular pressure, the incidence of glaucoma in RA scleritis is about 19%, but the removal of eyeball histology found that the incidence is as high as 45%, RA scleritis with glaucoma and non-RA The pathogenesis of glaucoma in scleritis is similar.

Cataract: Long-term systemic glucocorticoid therapy with RA can cause posterior subcapsular cataracts. Retinal, choroidal and optic nerve changes: mainly manifested as fundus changes in RA posterior scleritis, including choroidal folds, retinal streaks, subretinal masses, annular choroidal ciliary detachment, serous retinal detachment, optic disc edema, and cystoid macular Edema, etc., in patients with RA without scleritis, the fundus changes are rare, and the retinal cotton-like oozing changes can occur when the disease progresses and deteriorates. Ischemic optic neuropathy and short ciliary arteritis can also occur in patients with RA scleritis. Eye movement disorder: The incidence of ocular dyskinesia in RA scleritis is 12.9%, which is not significantly different from the incidence of scleritis in patients with non-RA arthritis. The ocular dyskinesia of RA scleritis is due to the spread of scleral inflammation. It is caused by posterior scleritis invading the extraocular muscles. Symptoms and signs of posterior scleritis with extraocular myositis are pain, diplopia, decreased vision, conjunctival edema, orbital edema and eye movement disorders. Brown syndrome can occur when there is scleritis and the formation of rheumatoid nodules in the posterior oblique muscle. It is manifested as an adduction disorder when the eye moves above the midline level. When the eye is in the adductive state, the upward movement is mild. Obstruction, when the eye is often in a mild adduction state, double vision occurs when looking upwards, the upper oblique tendon feels snoring through the ankle ring, and vasculitis of RA with or without scleritis can invade the nervous system, causing Abnormal pupils and motor muscle paralysis of the eye.

2. Non-ocular manifestations of RA in the onset of individual differences, initial onset is slow, first fatigue, fatigue, loss of appetite, weight loss, low fever and numbness of hands and feet, RA is a systemic disease, although each The motor joint is the most important site of involvement, but it also invades many organs throughout the body, as shown by clinical manifestations outside the RA eye. The characteristics of RA extraocular tissues and organs are as follows:

(1) Arthritis: 1 to 2 joint pains or joint stiffness that appear progressively and last for weeks to months, showing migratory, later developed into symmetrical polyarthritis, joint involvement often from the distal extremities of the extremities At the beginning, the other joints are gradually involved, and the proximal interphalangeal joints are most common, with a fusiform enlargement, followed by the metacarpophalangeal, toe, wrist, knee, elbow, ankle, shoulder joint, etc. Morning joint stiffness is an almost The invariable performance, its intensity and duration can be used as an assessment of the activity of the lesion. If the lesion continues to progress, the lesion is more painful and stiffer, the joint function is affected, the skeletal muscle around the joint is atrophy, and joint deformity often occurs. There are "goose neck deformity", "Z-shaped deformity", "carpal tube syndrome", "neck toe valgus" or "sacral subluxation", etc., patients' simple activities in daily life are limited, unable to work, RA does not Causes ankle arthritis or clinically significant chest, lumbar region lesions.

(2) subcutaneous nodules: the appearance of subcutaneous nodules is always associated with serum RF-positive and heavier joint lesions and extra-articular clinical manifestations, especially rheumatoid vasculitis, subcutaneous nodules appear around the joints and under pressure The site, ranging from a few millimeters to several centimeters in diameter, sometimes only one, the nodules can exist for months or years, and the nodules appear in patients with high RF-positive titers, reflecting the activity of the lesions, with subcutaneous nodules. RA has a poor prognosis.

(3) rheumatoid vasculitis: including inflammation and embolism of small and medium blood vessels, mostly in patients with severe disease, obvious joint disease, high RF positive titer, poor prognosis, microvascular vasculitis can affect internal organs, such as intestinal perforation, brain Vascular accidents, etc. (4) Heart disease: The most common heart disease is pericardial lesion. The pericardial effusion is characterized by low glucose concentration, elevated lactate dehydrogenase (LDH) and immunoglobulin levels, and decreased complement activity, myocardial, conduction system, Endocardium can also be affected, coronary artery disease and embolism can cause myocardial infarction.

(5) Pulmonary lesions: pleurisy and pleural effusion are the most common, pleural effusion glucose and complement content is low, LDH is elevated and RF is positive, effusion is mainly lymphocytes, no more than 5000 / ml, of which low concentration Glucose has the most diagnostic value, pulmonary rheumatoid nodules are multiple, more asymptomatic, and diffuse interstitial pneumonia and pulmonary fibrosis occur in advanced cases.

(6) Nervous system lesions: peripheral nerve damage is more common, after many years (average 10 years), RA patients often have peripheral sensory-motor nerve disorders, accompanied by lesions of skin vessels such as fingertips, distal toe infarction, gangrene and legs Ulcers, vasculitis even extend to the mesentery, coronary arteries and cerebral arteries, poor prognosis, although there are descriptions of intracranial vasculitis and intramedullary rheumatoid nodules, but the central nervous system is generally less affected.

(7) Lymph node lesions: RA patients often present in Sjögren syndrome, the treatment of RA proliferative synovitis can effectively control lymph node lesions.

(8) Laryngeal lesions: 25% of RA patients have ankle involvement or vocal cord paralysis and vocal cord nodules.

(9) Felty syndrome: a severe type of RA, rare, only occurs in less than 1% of RA patients, RA patients with splenomegaly and leukopenia, extra-articular manifestations, immune function is abnormal, patients of general age Large, long-term arthritis, sometimes anemia and thrombocytopenia, effective control of RA and spleen resection can effectively treat Felty syndrome.

(10) amyloidosis: due to starch deposition in the glomerulus, progressive proteinuria is the main clinical indicator of amyloidosis, more common in amyloidosis of the kidney, other organs that are rarely involved, heart, liver, spleen, intestinal wall And skin, Congo red staining the corresponding tissues (such as skin, rectum and gums) can be diagnosed, and effective control of RA is its treatment option.

(11) Other lesions: Early specific liver injury in RA is rare, but nearly half of patients have mild liver dysfunction, which is characterized by serum alkaline phosphatase (AKP), 5'-nucleotidase ( 5'-nucleotidase, 5'-NT), -glutamyl transpeptidase (-GT) is elevated, and 10% to 20% of patients have specific liver damage. There is still no specific diagnostic test, mainly based on the clinical manifestations of RA's scleritis, RF-positive, ESR-increasing and CRP-increasing, joint synovitis, characteristic histological changes of joint synovial and subcutaneous nodules, and joints X-ray findings of peripheral osteoporosis and joint erosion changes are helpful for diagnosis. In order to ensure the uniformity of investigation and epidemiological investigation, the American College of Rheumatology recently revised the diagnostic criteria of the original RA and reduced the original 11 items. For 7 items, 1 to 4 items must be seen by doctors for 6 weeks or more. Four items with 7 criteria can be used to diagnose RA. The diagnostic criteria for RA are shown in Table 5. The initial test in this standard is sensitive. 91% sex and 88% specificity.

Examine

Adult rheumatoid arthritis scleritis examination

Although no single test is specific for RA diagnosis, the following tests are helpful for the diagnosis and treatment of RA.

1. rheumatoid factor (RF) RF is an autoantibody that acts on certain determinants of IgG·Fc, usually including type 3: ie, IgM type, IgG type and IgA type, usually by coating IgG with latex The particles were tested for agglutination test. The relationship between RF and RA was first described by Waaler et al. in 1940. RA patients were 70% to 90% RF positive. RF positive was also seen in healthy individuals with secondary immune response. RF often occurred before RA attack. Continuous positive, RF titers are often associated with the severity of RA lesions.

Patients with RA who are RF-positive, especially those with higher titers, have more severe joint lesions, including X-ray abnormalities and dysfunction, and extra-articular manifestations (such as subcutaneous nodules, vasculitis, and nerve damage) are also more common than RF-negative patients. See, RA scleritis is usually RF positive, and some patients have higher titers.

2. Blood cell counts generally have normal cell dysplasia, occasionally eosinophils and thrombocytosis, treatment of proliferative synovitis can alleviate or eliminate abnormalities in the blood system, normal cells are anorectal anemia, often in RA Increased erythrocyte sedimentation rate, elevated C-reactive protein levels and post-surgical period of synovitis may be associated with erythropoiesis, mild thrombocytopenia is often associated with erythrocyte sedimentation rate, C-reactive protein, active synovitis and extra-articular clinical In the current relationship, the mechanism is unclear, and eosinophilia (accounting for more than 5% of total leukocytes) is usually present in patients with severe arthritis, pleural nodules, decreased complement levels, and vasculitis.

3. Acute phase of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) increased in almost all patients. Both of them were positively correlated with RA pathological activity. Patients with RA scleritis had no Patients with scleritis have higher ESR values. After treatment, the decrease in ESR and CRP indicates that the condition is improved and the rate of joint destruction is slowed or reversed. ESR is the most important laboratory indicator for the American Rheumatology Association to determine whether RA is improving. However, many serum proteins (fibrinogen, globin, immunoglobulin, etc.) can affect ESR changes. Therefore, ESR changes often do not reflect the improvement or deterioration of clinical conditions, and CRP synthesis and degradation are rapid, so it is Sensitive indicators that reflect efficacy.

Diagnosis

Diagnosis and diagnosis of adult rheumatoid arthritis scleritis

RA needs to be differentiated from heel pain, conjunctivitis gout, urethritis of Reiter syndrome, ankylosing spondylitis and butterfly erythema of systemic lupus erythematosus.