abordarea pacientului cu suferinta · pdf fileevaluarea pacientilor cu afectiuni reumatologice...
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ABORDAREA PACIENTULUI
CU SUFERINTA
REUMATOLOGICA
C Baicus
www.baicus.ro
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• 33% din populatie este afectata de o
suferinta reumatologica - 20% dintre ei vin
la medic
• majoritatea nu necesita metode diagnostice
sau tratamente deosebite
• afectare importanta - dg
• diagnostic urgent (artrita septica, artrita
acuta cu microcristale, fractura) - debut
acut, monoarticular
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Evaluarea pacientilor cu afectiuni reumatologice
Scopuri:
• diagnostic exact
• tratament precoce
• evitarea investigatiilor superflue
Abordarea:
• localizare anatomica (articulara/nearticulara)
• natura procesului patologic (inflamator/neinflamator)
• extinderea afectarii
(mono/poliarticular/focal/generalizat)
• cronologie (acut/cronic)
• dg
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• Ex. clinic (anamneza) este cel mai
important pentru diagnostic !
• Nu cereti un test de laborator inainte de a
sti bine de ce il cereti si ce veti face daca
iese anormal.
• Nu toti pacientii pozitivi pentru FR sau
ANA au AR sau LES.
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• Varsta:
– copii: artrita juvenila
3ani-adolescenta: RAA
< 40 ani: LES, spondilita
> 40 ani: artroza
> 55 ani: ACG, polimialgia reumatica
• Sexul:
– femei: boli autoimune, osteoporoza
– femei inainte de menopauza: niciodata guta
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articulara/nearticulara
• originea anatomica a suferintei
• articulara: durere profunda, accentuata de
miscarile active si pasive; tumefactie
(proliferare sinoviala, lichid articular);
durere pe linia articulara;
• nearticulara: durere la miscari active (nu
pasive), durere punctuala la nivelul
insertiilor capsulare, ligamentare,
tendinoase
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inflamatorie/neinflamatorie
• Inflamatorie:
– septica (infectie)
– cu microcristale
– mecanism imun (AR, LES, reactiva)
– idiopatica
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• Inflamatie
– semne locale
– semne & simptome generale
– sdr. inflamator
inflamatorie/neinflamatorie
(febra, scadere ponderala, astenie, redoare matinala prelungita)
(VSH, CRP, FG, trombocitoza, anemie normocroma)
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Criteriul Inflamator Neinflamator
Redoare
matinala
> 1h < 1h
Oboseala intensa minima
Activitate fiz. amelioreaza agraveaza
Repaus agraveaza amelioreaza
Afect.
sistemica
DA NU
Rasp. CS DA NU
inflamatorie/neinflamatorie
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acuta/cronica, mono-/poliarticulara
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• Inflamatie:
– septica (Staph aur, gonococ, endocardita,
parvovirus B19)
– cu microcristale (guta, pseudoguta)
– reactiva (sdr. Reiter)
– mai rar: alte spondilartropatii sero-, colagenoze
• neinflamatorii:
– traumatice
– coagulopatie (sangerare netraumatica)
– lumbago
acuta, monoarticulara
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• reactiva (Reiter)
• microcristale
• septica (gonococ, endocardita, hep.B,
parvovirus B19, rubeola, post vacc. rubeola)
• colagenoza (AR, LES, sclerodermie, b. Still
a adultului)
acuta, poliarticulara
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• Inflamatorie
– colagenoze (AR, LES, scleodermie, b. Still a
adultului, Sjogren)
– spondilartrite seronegative (reactive, psoriatica,
ankilozanta, colopatii inflamatorii)
– artroza “incalzita”
– b. Lyme
– sdr. paraneoplazic (osteoartropatie hipertr. pulm)
– sarcoidoza
• Neinflamatorii
– artroza
cronica, poliarticulara
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• Neinflamatorie
– artroza
– hemartroza
– sicklemie
– traumatism repetat
– tumora
• Inflamatorie
– infectie oportunista (TBC, fungi)
cronica, monoarticulara
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Evolutia manifestarilor • remisiva
– artrite virale
• intermitenta
– perioade libere intre exacerbari: guta, hidrartroza
– fenomene reziduale intre acutizari: reumatismele
inflamatorii cronice
• migratoare
– artrite reactive, RAA
• progresiva
– lent: AR, artrozele
– rapid: psoriazica “mutilanta”
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Leziuni cutanate
Psoriazis
Exantem
Artrita psoriazica
Boala Still
Papule Gottron DMZ
Rash fotosensibil LES
Alopecie LES
Purpura palpabila Vasculite (HS, crio)
Telangiectazii
Ulceratii mucoase
Sclerodermie
Reiter, LES, Behçet
Cicatrici pulpa degete
Hemor. unghiale “aschie”
Raynaud
Vasculite
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Afectari de organ: rinichi
• LES: glomerulara, tubulo-interstitiala
• Vasculite ANCA+: glomerulara (rapid
progresiva), tubulo-interstitiala
• PAN: microanevrisme, sediment normal
• Sclerodermie: criza renala
• Sjogren: tubulo-interstitiala (acidoza tubulara
distala)
• SAFL: microtromboze
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Afectari de organ: plaman
• Pleurezie: LES, PR
• Hemoragie intraalveolara: vasculite, LES
• Noduli: Wegener (poliangeita cu granulomatoza)
• Astm: Churg-Strauss (vasculita granulomatoasa
eozinofilica)
• Interstitiala: scleroza sistemica, PMZ, BMTC
– rar LES, Wegener, Spondilita ankilozanta, Sjogren
• HTP: scleroza sistemica, BMTC, rar LES
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Afectari de organ: sinusuri
• Wegener (poliangeita cu granulomatoza)
distrugeri osoase
• Churg-Strauss (vasculita granulomatoasa
eozinofilica)
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Afectari de organ: cord
• Pericardita: LES, scleroza sistemica
• Miocardita: LES, vasculite, PMZ, scleroza
sistemica (cmp restrictiva)
• Endocardita (Liebman-Sachs): SAFL (LES)
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Afectari de organ: sistem nervos
• Polineuropatie: LES, vasculita (mononeuritis
multiplex), BMTC, Sjogren, SAFL
• SNC: LES, vasculite
• Maduva spinarii: LES, SAFL
• Meningita aseptica: LES, Behçet
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Investigatii de laborator
• hemoleucograma
• teste de inflamatie
• FR, ANA, C, ANCA, ASLO, ac. antiBorrelia -
VPP scazuta
• NU screening (baterie de teste)
• lichid sinovial (monoartrite, infect., guta)
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Imagistica
• Rx
• CT
• RMN (Sn+, Sp-)
• echo
• scinti
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• eco
• scinti
• CT
• RMN
• Chist sinovial, ruptura tendon,
lichid sinovial, sinovita, eroziuni
• metastaze, b.Paget, infectie acuta,
osteomielita
• hernie disc, sacroileita, stenoza
canal vertebral, tumori,
traumatisme
• necroza aseptica, osteomielita,
hernie disc, modificari vertebrale,
articulare si de tesuturi moi,
eroziuni
Imagistica
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artrita
anamneza+ex clinic
traumatism? investigheaza si trateaza DA
suspiciune septica/cristalina? DA
artrocenteza
alte elemente prezente
(clinice, laborator, imagistica)?
NU
artrita nediferentiata
(UPIA) Exista un dg specific?
Grupeaza dg in functie
de nr de articulatii
NU
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artrita nediferentiata
(UPIA)
Exista un dg specific?
Grupeaza dg in functie
de nr de articulatii
MONOARTRITA
•SpA axiala/periferica
•Artroza
•Artrita cristalina
•Artrita septica
•Artrita reumatoida
•Necroza avasculara
•BTC
•Sarcoidoza
•Neoplazie
•Virala
•Lyme
•Endocrinologica
•PMR
•Still adult
•Vasculita
POLIARTRITA
•Artrita reumatoida
•BTC
•SpA axiala/periferica
•Artrita cristalina
•Artroza
•Necroza avasculara
•Sarcoidoza
•Neoplazie
•Artrita septica
•Virala
•Lyme
•PMR
•Still adult
•Vasculita
NU
Reevaluare dg:
•periodic
•apar elemente noi
•agravare
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artrita
<6 sapt (acuta)
Traumatism
Osteonecroza
Rreactiva
Cristalina
Hemartroza
Early cronica
Septica
>6 sapt (cronica)
Inflamatia + Inflamatia -
artroza mono / pauci (2-5) poli (<6)
Infectie indolenta, TBC
Early poli
Spodilartropatie
(psoriasis,
spondilita,
boala inflamatorie
intestinala,
reactiva
Autoimuna
AR, LES, sclerodermie,
BMTC, Sjogren, PMZ/DMZ
Spodilartropatie
(psoriasis,
spondilita,
boala inflamatorie intestinala,
reactiva)
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artrita inflamatorie
FR IgM
antiCitrulina
AR
Sn70%
Sp98%
ANA
antiADNdc Anticentromer
Scl70
LES SS
U1RNP
B mixta TC
antiSm
antiRo
antiLa
Sjogren
ANCAc
ANCAp
PAN
+
-
+
-
+ +
+
+ +
Wegener
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ANA
BOALA ANA cu SnNout ANA SpPin
LES ANA Anti ADNdc
Anti Sm
LES medicamentos ANA
Anti-histone
-
BMTC ANA
Anti RNP
-
S Sjogren - Anti Ro/SSA
Anti La/SSB
Sclerodermie (limitata) ANA Anti centromer
Sclerodermie (difuza) ANA Anti Scl70
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ANA si afectarea de organ
• Anti ADNdc: nefrita lupica
• Anti Scl70: afectare cutanata difuza, boala
interstitiala pulmonara
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Artrocenteza
Caracteristica Normal OA, PR Cristalina Septica
Culoare si
transparenta
Galben,
transparent
Galben,
transparent
Galben-verzui,
opac
Galben-verzui,
opac
NL/mm3 <500 <2000 2000-50000 >50000
PMN% <25 <50 >50 >70 (>90)
Frotiu Gram
sau cultura
- - - + (de obicei)
Cristale - - + -
Nr leucocite > 50.000/mm3: LR=7,7 pt artrita septica
Nr leucocite >100.000/mm3: LR=28,0 pt artrita septica
PMN 90%: LR=3,4 pt artrita septica
PMN < 90%: LR=0,34 pt artrita septica
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