儿童关节结核误诊为幼年特发性关节炎五例临床分析

doi:10.19983/j.issn.2096-8493.20220099

摘要/Abstract

摘要：

目的: 分析儿童关节结核误诊为幼年特发性关节炎患者临床资料,以探寻误诊原因及减少误诊的方法。方法: 回顾性分析2021年4月1日至2022年4月1日首都医科大学附属北京儿童医院免疫科收治的误诊为幼年特发性关节炎的5例儿童关节结核患者临床特点及诊疗过程。结果: 5例患者中,误诊为与附着点炎症相关的关节炎2例,误诊为幼年特发性关节炎少关节型3例。均为下肢大关节非对称性受累,均表现为关节疼痛、活动受限。其中,多关节损害者4例,膝关节受累者4例;C反应蛋白(CRP)升高及血红细胞沉降率(ESR)增快者4例,误诊时PPD试验及T-SPOT.TB均为阳性者4例。3例患者确诊关节结核前均给予免疫抑制剂及生物制剂联合治疗,关节症状均有所加重,影像学结核病灶有进展。5例患者均于确诊关节结核时行肺部高分辨CT扫描,3例发现结核改变,关节影像学检查均可见多发骨质破坏;2例患者因关节肿胀明显行关节腔穿刺,抗酸杆菌染色均为阳性。最终5例患者均给予抗结核药物治疗,症状、炎性指标及影像学均有好转,但3例患儿遗留关节挛缩和肌肉萎缩后遗症。结论: 儿童关节结核与幼年特发性关节炎临床症状、实验室检查及影像学改变相似,缺乏病灶处病原学检查为主要误诊原因。完善受累关节处的结核分枝杆菌检测可有效降低误诊率。

关键词: 结核,关节, 幼年特发性关节炎, 儿童, 误诊

Abstract:

Objective: To analyze the clinical characteristics of children with joint tuberculosis misdiagnosed juvenile idiopathic arthritis (JIA), and to explore the methods of reducing the rate of misdiagnosis. Methods: We retrospectively analyzed the characteristics, diagnosis and treatment process of 5 children with joint tuberculosis who were misdiagnosed as JIA in Department of Immunology, Beijing Children’s Hospital, Capital Medical University from April 1, 2021 to April 1, 2022. Results: Of the five patients, two patients were misdiagnosed as enthesitis related arthritis, and three patients were misdiagnosed as oligoarticular JIA. All the five patients above had asymmetric arthritis in the large joints of the lower limbs, and presented with joint pain and limited movement. More than one joint with damage in four patients, and the knee was the most commonly affected (4/5). CRP and ESR increased in four patients, and PPD and T-SPOT.TB positive in four patients who were misdiagnosed. Three patients were given immunosuppressants and biological agents, with joint symptoms aggravating and imaging progressing before the diagnosis of joint tuberculosis. High resolution CT scanning was performed in five patients with joint tuberculosis. Tuberculosis was found in three patients, and multiple bone destruction was seen in joint imaging. Two patients underwent joint cavity puncture due to joint swelling, and acid fast bacillus staining was positive. Finally, all five patients were treated with anti tuberculosis drugs, and the symptoms, inflammatory indexes and imaging were improved. However, three patients had sequelae of joint contracture and muscle atrophy. Conclusion: The clinical symptoms, laboratory examination and imaging changes of children’s joint tuberculosis and juvenile idiopathic arthritis were similar. The main cause of misdiagnosis was lack of etiological examination at the lesion. Improving the detection of Mycobacterium tuberculosis in the affected joints can effectively reduce the misdiagnosis rate.

Key words: Joint tuberculosis, Juvenile idiopathic arthritis, Child, Misdiagnosis

中图分类号:

R529.9

李妍, 韩彤昕, 朴玉蓉, 毛华伟. 儿童关节结核误诊为幼年特发性关节炎五例临床分析[J]. 结核与肺部疾病杂志, 2022, 3(5): 364-370. doi: 10.19983/j.issn.2096-8493.20220099

Li Yan, Han Tongxin, Piao Yurong, Mao Huawei. Clinical analysis of five children with joint tuberculosis misdiagnosed juvenile idiopathic arthritis[J]. Journal of Tuberculosis and Lung Disease, 2022, 3(5): 364-370. doi: 10.19983/j.issn.2096-8493.20220099

图/表 4

图1~3

图4~5

图6~11

表1

误诊为幼年特发性关节炎的五例儿童关节结核患者临床资料

资料内容	病例1	病例2	病例3	病例4	病例5
性别	男	男	女	女	男
起病年龄	14岁11个月	8个月	11岁3个月	12岁11个月	2岁4个月
延误诊断时间(月)	1	16	2	12	1
结核病密切接触史	有	无	无	无	有
卡介苗接种史/卡疤	有/阳性	有/阳性	有/阳性	有/阳性	有/阳性
既往结核病病史	无	无	无	无	无
家族史	无	无	无	无	无
首发表现	关节疼痛	关节疼痛	发热	关节疼痛	发热
患病期间发热	有	无	有	无	有
受累关节	右膝关节、双侧骶髂关节、双髋关节	左膝关节	左侧骶髂关节、左髋关节	左膝关节、左踝关节	双膝关节、双踝关节
关节症状及查体	疼痛,僵直,双侧4字征阳性	疼痛,肿胀,活动受限,皮温升高	疼痛,活动受限,晨僵,左侧4字征阳性	疼痛,肿胀,活动受限,皮温升高	疼痛,肿胀,活动受限,皮温升高,局部发红
其他表现	咳嗽、胸闷、气短、乏力,体质量明显下降	消瘦	乏力	盗汗	盗汗,多发淋巴结肿大
白细胞计数(×10⁹/L)	6.6	8.6	7.8	6.5	9.2
中性粒细胞百分比(%)	70.2	40.0	67.6	58.4	57.9
淋巴细胞百分比(%)	21.7	45.9	24.6	33.7	27.8
C反应蛋白(mg/L)	46.1	25.4	26.0	<3.6	24.0
血红细胞沉降率(mm/1h)	29.0	36.0	75.0	15.0	53.0
PPD试验	+++	++	阴性	++	++
T-SPOT.TB	阳性	阳性	阴性→阳性	阳性	阳性
其他病原学检查	未做	左膝关节滑膜抗酸染色(+)	未做	左膝关节积液抗酸染色(+)	未做
肺部高分辨CT	结核性胸膜炎	原发性肺结核(钙化期)	未见异常	未见异常	血行播散性肺结核
关节影像	CT:骶髂和髋关节炎	CT:左膝关节炎	MRI:骶髂关节炎	CT:左膝关节炎	X线:关节炎
误诊疾病	ERA	OJIA	ERA	OJIA	OJIA
治疗方案及转归	H-R-E-Z方案→好转	抗风湿治疗→加重→停用原药物,予H-R-E-Z方案→好转,遗留后遗症	抗风湿治疗→加重→停用原药物;H-R方案→好转	抗风湿治疗→加重→停用原药物,予H-R-E-Z方案→好转,遗留后遗症	H-R-E-Z方案→好转,遗留后遗症

表1

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