If a patient with hepatitis B encounters arthritis, the diagnosis can be confirmed by observing this symptom!

*Only for medical professionals' reference.
If you have any doubts about this issue, come here~ September 18, 2021, at the 13th Rheumatoid Arthritis International Forum, Dai Yu, Director of the Department of Rheumatology and Immunology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University The professor introduced the association between rheumatoid arthritis (RA) and liver disease
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Starting from the possible liver diseases of RA patients, Professor Dai Xun focused on the interaction between RA and viral hepatitis, and summarized the diagnosis and treatment characteristics of RA combined with liver disease
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Liver disease is the most common gastrointestinal disease associated with RA.
RA is a systemic autoimmune disease characterized by chronic and symmetrical polyarthritis.
In addition to invading joints, it can also invade the lungs, serous membranes, heart, etc.
Blood, blood vessels, nerves and other tissues and organs (Figure 1) cause a variety of extra-articular manifestations and concomitant diseases
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Figure 1 Extra-articular manifestations of RA Liver disease is the most common gastrointestinal disease associated with RA, accounting for 18% to 50%
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Liver diseases that may be associated with RA patients are divided into primary liver disease and drug-induced liver injury.
Primary liver diseases include viral hepatitis, non-alcoholic fatty liver (NAFLD), autoimmune liver disease, and liver amyloidosis.
Drug-induced liver injury is often caused by non-steroidal anti-inflammatory drugs (NSAIDs) and disease-improving anti-rheumatic drugs (DMARDs)
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HBV-associated arthritis vs RA combined with HBV infection: joint symptoms are the key As of 2019, there are 296 million patients with hepatitis B virus (HBV) infection worldwide, of which 1.
5 million are newly infected, and 820,000 have died from HBV infection.
Reason
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More than 95% of acute HBV infections occur in infants and young children, and only 5% occur in adults
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If it is not treated in time, it will develop into chronic hepatitis B.
8-20% of chronic hepatitis B patients will develop cirrhosis after 5 years, and a small number of patients will eventually develop hepatocellular carcinoma
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In addition to the liver, HBV can also invade many organs and tissues, such as the spleen, lymph nodes, kidneys, adrenal glands, stomach, colon and so on
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When a patient with hepatitis B has symptoms of arthritis, should it be diagnosed as HBV-related arthritis or RA combined with HBV infection? Professor Dai Xun used a case to illustrate the main points of the differential diagnosis
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▌ HBV-related arthritis: joint symptoms can be better by yourself.
Female, 28 years old; joint pain for 4 years: third interphalangeal joint (PIP 3), third metacarpophalangeal joint (MCP 3), wrist and knee joints at the proximal left side Repeated swelling, relieved by itself within half a day; CRP and ESR are normal; RF, CCP-Ab, ANA, ANCA are all negative; HBsAg (+), HBeAb (+), HBcAb (+), HBsAg (-), HBeAg (-); HBV-DNA 7.
07X 103 IU/ml; X-ray examination and MRI imaging examination are shown in Figure 2: Figure 2 Case 1 imaging examination results In HBV-associated arthritis, the incidence of joint disease in women is higher than that in men.
And knees are most commonly affected
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This type of joint disease is self-limiting, and there are currently no reports of chronic arthritis or joint damage
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Based on this feature, the case should be diagnosed as HBV-related arthritis
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Anti-hepatitis B treatment can make joint symptoms disappear in patients with HBV-related arthritis
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▌ RA combined with HBV infection: When joint symptoms persist and arthritis symptoms are persistent, regardless of whether RF is positive, it should be diagnosed as RA combined with HBV infection (Figure 3)
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Figure 3 2010 ACR/EULAR RA Differential Diagnosis Criteria ①There is HBV in the synovial fluid, be sure to "kill all".
Some readers will ask, when RA is combined with HBV infection, can evidence of the presence of HBV be found in the synovium or synovial fluid of the affected joints? In 1974, Schumacher et al.
used immunofluorescence technology to detect the presence of HBV in the serum of 2 patients with arthritis.
They also found that HBV virus particles mainly exist in synovial cells and vascular endothelial cells
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In 2006, Moohara et al.
reported a case of knee arthritis patient with positive serum HBsAg and HBeAg.
Immunohistochemical staining showed diffuse HBsAg expression in the synovium of the patient
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The current technology has further confirmed that the HBsAg(+), anti-HBe(+), anti-HBc(+), HBV-DNA 2.
37X 103copies/ml in the synovial fluid of the affected joints of RA patients with HBV infection
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Therefore, the answer to the above question is yes.
While treating RA, it is necessary to "kill all the HBV in the joints"
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②The key to treatment is to prevent HBV from reactivating.
The 2021 American Academy of Rheumatology Guidelines for the Treatment of Rheumatoid Arthritis strongly recommends that patients with RA combined with HBV infection should be combined with antiviral therapy in addition to immunosuppressive therapy
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This method is especially suitable for HBcAg-positive patients (regardless of the status of hepatitis B surface antigen), and HBcAg and HBeAg-positive patients who are being treated with bDMARD or tsDMARD
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Combined antiviral therapy can prevent HBV reactivation
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HBV reactivation is defined as a 10-fold increase in serum HBV-DNA from undetectable and detectable to greater than baseline, HBeAg and HBsAg changing from negative to positive, which can lead to persistently high HBV-DNA levels, cirrhosis and even the need for liver transplantation
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The main risk factors for HBV reactivation include host factors, viral factors and immunotherapy factors
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Older male patients with cirrhosis are more likely to reactivate HBV
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Positive HBsAg, high baseline HBV-DNA, and mixed hepatitis virus infection can also increase the risk of HBV reactivation
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The "APASL Clinical Practice Guidelines for the Application of HBV Reactivation and Immunosuppressive Therapy" points out that patients with RA combined with HBV infection should follow the following steps when undergoing immunosuppressive treatment: 1.
According to the degree of HBV reactivation, they are divided into different risk levels
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Figure 4 Risk stratification of RA combined with HBV infection 2.
After stratification, all patients who plan to receive immunosuppressive therapy should undergo pre-treatment screening, including screening for HBsAg, anti-HBs and anti-HBc positive patients.
The project can choose to quantify HBV-DNA and HBsAg.
All HBsAg-positive and HBsAg-negative, but anti-HBc-positive patients should be checked for liver fibrosis
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3.
The following indicators should be monitored at the same time during immunosuppressive therapy: Liver function testing should be performed every 1-2 weeks, including ALT, AST, bilirubin, albumin, globulin, etc.
; if ALT is greater than 2 times the baseline, Check HBsAg and HBV-DNA.
For patients with hepatitis and acute or chronic liver failure due to HBV reactivation, nucleoside analog therapy is recommended
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Medication skills for RA complicated with fatty liver The "2021 American Academy of Rheumatology Guidelines for the Treatment of Rheumatoid Arthritis" recommends that NAFLD patients who have not received DMARD, or liver enzymes and liver function tests are normal and there is no evidence of advanced liver fibrosis and have moderate to moderate to For patients with high disease activity, it is recommended to replace DMARDs with methotrexate (MTX)
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But pay attention to the risk of liver toxicity associated with MTX, and try to use non-invasive tests to diagnose liver fibrosis and staging
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It is necessary to consult a gastroenterologist or hepatobiliary doctor, and at the same time, liver function and other indicators should be monitored more frequently
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Summary: HBV-related arthritis should be differentiated from RA combined with HBV infection
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RA patients should be screened for HBV infection before immunosuppressive therapy, and the risk of HBV reactivation should be assessed at the same time, and relevant indicators should be monitored
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For patients at high risk of HBV reactivation, antiviral therapy should be strengthened
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References: [1]Autoimmune Rev.
2021 20(4):102776[2]Kheumatol Int.
2018;38(5);715-724[3]Cur Opin Rheumatol.
2010;22:91-6[4]Dig Dis Sci.
1992;37:1757-60[5]Arthritis Rheun.
2000;43:232-3[6]Schumacher HR et al.
The American Jounal of Medicine.
1974:655-64[7]Clin Exp Rheumaton,2006 ;24:111-2[8]Ann Rheum Dis 2021;0:1-7[9]Hepatol Int.
2021:1-18 Source of this article: Medical Rheumatism Channel Author of this article: Xiaomaida Review of this article: Deputy Director Chen Xinpeng Physician Responsible Editor: The original content of the cassette is affirmed by this article.
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