Rheumatism symptoms are too complex?

*For medical professionals to read and refer to Suspect Tracking, Rheumatology and Immunology, a compulsory course for rheumatologists, is often referred to as the hospital's "big miscellaneous hospital" -- Rheumatology and Immunology are inseparable from diseases of various systems in the bo.
Clinically, most diseases tend to be "sick according to the book", while rheumatology and immunology diseases are n.
As a rheumatologist, for these patients with mixed conditions and various symptoms, they often need a pair of sharp eyes to identify th.
Today, let's let Professor Liu Xu from Peking University People's Hospital peel for us and give a detailed explanation of three difficult cases of rheumatolo.
Case 1 What was the final diagnosis of this cardiac neoplasm? ■ The fog is heavy - case information Female, 44 years old, was admitted to the hospital because of "discovery of thrombocytopenia, splenomegaly for more than 20 years, and fatigue for 6 month.
The patient developed low-grade fever and thrombocytopenia for unknown reasons 20 years ago, about 40-50×109.
The physical examination revealed splenomegaly, and no further diagnosis and treatment were perform.
Eight years ago, the patient suddenly developed slurred speech and disturbance of consciousness for unknown reasons, accompanied by twitching of the limbs and staring of both ey.
Head CT showed cerebral hemorrha.
He was diagnosed as epilepsy after cerebral hemorrhage, which was relieved after treatme.
Seven months ago, the patient reappeared with convulsions, loss of consciousness, and transient asphyx.
Six months ago, the patient developed general malaise, hair loss, dry eyes and dry mouth for unknown reasons, accompanied by scattered livedo reticularis on both upper limbs, and shortness of breath after exerci.
Echocardiography: mitral valve prolapse and regurgitation, except for rupture of the anterior mitral leaflet chordae tendineae and vegetatio.
Since the onset of the disease, in the past 7 months, she has had dry eyes, dry mouth, hair loss, and her hands turned red and purple when exposed to co.
Physical examination on admission: BP120/70mmHg, general condition and spirit are poor, scattered livedo reticularis on both upper and lower extremities
Breath sounds were clear in both lun.
A systolic murmur of grade 2/6 could be heard in the auscultation area of ​​the mitral valve, with limited conduction, and no murmur was heard in the auscultation area of ​​the remaining val.

The liver is less than the rib, and the left side of the spleen is about 5cm below the r.

 ■ In one word - case characteristics The case has significant characteristics, a 44-year-old female with multiple organ system damage, a medical history of 22 yea.

The blood system (thrombocytopenia); the nervous system (convulsions, epileptic seizures);Obvious systemic symptoms, such as malaise, livedo reticularis, dry mouth, dry eyes, Raynaud's phenomenon,e.

Professor Liu Xu pointed out that women of childbearing age have multiple systemic damage manifestations, and the first disease to be considered is systemic lupus erythematos.

■ Multi-party tracking - differential diagnosis of verrucous endocarditis (Libman-Sackso), also known as lupus endocarditis, autopsy results show that 1/10 of lupus patients occur, so it is not uncomm.

For verrucous endocarditis, the valvular vegetations are essentially fibrin and platelet emboli, which mainly occur in the mitral valve > aortic valve > tricuspid valve, and the nature of the disease: regurgitation > stenos.

Long history of lupus, high activity and antiphospholipid antibody levels are associated with the occurrence of verrucous endocarditis (about 1/3 with antiphospholipid syndrom.

Vegetation in verrucous endocarditis can slough off, complicating cerebral embolism leading to stroke or TIA, or secondary bacterial endocardit.
 For this case, the supporting evidence for verrucous endocarditis is: the patient has no history of fever; the blood picture and classification are not high, no toxic particles are found in the bone marrow, and the blood culture is negative; there is no fresh microembolism, and the infective endocardium is not support.

Diagnosis of inflammation; lupus-related autoantibodies are positive, which is first considered to be caused by systemic lupus erythematos.

■ Treatment and prognosis verrucous endocarditis mostly has no or slight hemodynamic changes, most do not require surgical intervention (vegetation shedding, severe mitral insufficiency), and the prognosis is relatively go.

For the treatment of this patient, the regimen of hormone + immunosuppressant was adopted, and the curative effect was go.

The blood system completely recovered, the nervous system epilepsy did not recur, and the vegetations in the cardiovascular system disappear.

Case 2 was caused by the glass door ■ Fog Theater - Case Information The patient, male, 55 years old, was admitted to the hospital because of "unsteady walking, visual impairment for 4 months, and unresponsiveness for 2 month.

▎Clinical symptoms: 4 months ago, the patient had unsteady walking, visual disturbance and dizziness 10 days after the brain collided with the glass do.

Brain CT examination in our hospital showed right occipital cerebral hemorrha.

He was hospitalized in our neurosurgery department and given symptomatic treatme.

, without surge.

2 months ago, there was no incentive for chest tightne.

According to the changes of electrocardiogram and myocardial enzymes, the patient was diagnosed with non-ST-segment elevation myocardial infarcti.

After treatment, the patient improved and was discharged from the hospital in stable conditi.

One month ago, he developed general malaise, anorexia, and sometimes dizzine.

The family members complained that the patient was unresponsive, mentally poor, and unable to concentra.

Recently, the feeling of fatigue has worsened, and it is intolerable to climb 2 floors of stai.

Since the onset of the disease, he has lost about 15kg in weight in two months, no fever, no joint swelling and pain, no rash, no slurred speech, no nausea and vomiting, no amaurosis syncope, unconsciousness, low food intake, and normal bowel movemen.

▎Physical examination No dry or wet rales were heard on lung auscultation, heart rate was 84 beats/min, irregular rhythm, and no murmurs were heard in the auscultation areas of each val.
Nervous system examination: the muscle tone of the limbs was normal, the muscle strength of both upper limbs was V grade, and the muscle strength of both lower limbs was grade I.

▎Laboratory blood routine examination: white blood cells 186×109/L, neutrophil percentage 743%, red blood cell count 144×1012/L, hemoglobin content 90g.

Biochemical: alkaline phosphatase 543U/L, transpeptidase 332U.

24-hour protein 70g/d, urine routine: urine protein (-) urine occult blood (.

ESR80mm/H, CRP125mg.

Specific immune indicators: Lupus five items, anti-ds-DNA antibody, Acl and β2-glycoprotein I (-); determination of anti-glomerular basement membrane antibody (-); ANCA-mp.

Two blood cultures: G (+) coccus growth, other virus antibodies and infection routine negati.

▎Imaging brain CT: multiple lacunar foci in bilateral basal ganglia and center of semiovale, right occipital lobe softening foci; abdominal ultrasound showed: hepatic hemangioma, splenomegaly, splenic cystic fluid lesions, images consistent with spleen rupture, Intrasplenic hematoma formation; vascular color Doppler ultrasound: bilateral femoral arterial intima-media thickening; upper extremity arterial arterial wall thickening at the left elbow and thrombos.

■ Gangju Muzhang - Case characteristics A 55-year-old male patient had obvious vascular damage and increased inflammatory index.

Vascular hemorrhage (cerebral hemorrhage, spleen rupture); vascular embolism (myocardial infarction, arterial thrombosis); markedly elevated inflammatory indexes, fever, and progressive weight loss; in addition, autoantibody ANCA was positive, suggesting the possibility of vasculit.

A positive blood culture suggests the possibility of infective endocardit.
■ Multi-party tracking - differential diagnosis The differential diagnosis of this patient is mainly for vasculitis (positive ANCA support), infective endocarditis (positive blood culture suppor.

After consultation and discussion between the rheumatologist and the cardiologist, the case did not meet the core features of a detailed vasculitis, but it did meet the features of infective endocarditis, and echocardiography was required to confirm the diagnos.

vascular bleeding, possibly due to post-infarct hemorrha.

Arterial thickening is associated with smoking in middle-aged m.

Repeat echocardiogram showing mitral valve vegetations (posterior leaflet), mitral regurgitation (mild), decreased LV diastolic function, and after diagnosis of infective endocarditis was established, the patient underwent cardiac surgery treated and recovered we.

 Case three rheumatoid arthritis can also be combined with this disease? ■ Mist Theater - Case Information Male, 57 years old, was admitted to hospital mainly because of "polyarticular swelling and pain for 12 years, intermittent fever with pancytopenia for more than 1 yea.

The patient developed polyarticular swelling and pain after catching cold 12 years ago, accompanied by morning stiffness for >1 hour, and the local hospital checked positive for rheumatoid fact.

Six years ago, swan neck deformity of both hands gradually appeared, and X-ray found "aseptic necrosis of left femoral hea.

One year ago, the patient developed irregular fever with no incentive, accompanied by chills, the highest body temperature was 39°C, and there was no night swea.

Check blood routine white blood cells 30x109/L, neutrophil percentage 81, hemoglobin 94g/L, platelets 57x109.

A number of etiological screenings showed no positive findin.

Abdominal B-mode ultrasound showed splenomegaly, and chest CT and bone marrow biopsy showed no abnormali.

Local abdominal MRI showed diffuse liver damage, consider "rheumatoid arthritis, Felty syndrome, drug-induced hepatiti.
■ Peeling and pulling cocoons - case characteristics of a 57-year-old male patie.

The symptoms of this patient are mainly divided into two stag.

The first stage: diagnosed with rheumatoid arthritis, according to polyarticular swelling and pain, rheumatoid factor positive, swan neck deformity may be Diagnosed; second stage: fever and pancytopen.

The patient's fever and pancytopenia had obvious characteristics: ① aetiology was negative; ② splenomegaly; ③ hormone and cyclosporine treatment was effecti.

■ Multi-party tracking - differential diagnosis, but the reasons for the reduction of three lines in rheumatoid arthritis patients are not only Felty syndrome, but also hypersplenism and hematopoietic system diseases caused by combined liver cirrhosis (PBC/AIH/medicated live.

Therefore, these diseases need to be identified one by o.

In order to identify liver cirrhosis, a liver biopsy was performed, and the results showed no liver fibrosis, so autoimmune liver disease and liver cirrhosis were not support.

In order to identify the hematopoietic system diseases, bone marrow aspiration and biopsy were perform.

The pathological diagnosis does not rule out Hodgkin lymphoma involving the bone marrow, and it is recommended to exclude systemic tumors by systemic examinati.

In order to find evidence of Hodgkin's lymphoma, PET-CT examination was performed, and the results showed that the spleen, the deep left supraclavicular muscle group, the abdominal lymph nodes, and multiple metabolic enhancement foci were consider.

The possibility of lymphoma with bone marrow infiltration was consider.

Biopsy of metabolically enhanced lymph node on the left supraclavicular was taken, and the pathological result was classical Hodgkin lymphoma (mixed cell typ.

The patient's pathological result map The patient was finally diagnosed as: rheumatoid arthritis, Hodgkin's lymphoma stage .

Summary "If you have been around in other departments and are not optimistic, maybe it is time to go to the rheumatology departme.

" Many people jokingly call the rheumatology and immunology department, because it is always associated with intractable diseas.
The three cases introduced to us by Professor Liu Xu were eye-opening for .

For intractable diseases, Professor Liu Xu emphasized that diagnosis is a prerequisite for treatme.

Differentiation is the only rule for making a definite diagnos.

It is a compulsory course for every rheumatologist to master the diagnosis and grasp the doub.

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It is full of dry goods, not to be missed!