This 45-year-old woman was diagnosed as asthma when she was
a child. There was no more attack for many years until 1997.
She suffered from sudden onset of dyspnea and then was sent to
emergency room. Asthma attack was impressed at that time.
After that she received regular medication, including inhaled
steroid.
She was a patient of Sjogren’s syndrome, which was
diagnosed in 1989 with presentation of dry eye and dry mouth.
Persisted keratoconjunctivitis troubled her and artificial
tear was used since then. She also had morning stiffness and
painful swelling over bilateral multiple hand joints. She
received regularly follow-up since then. She came to our
rheumatology out-patient department since March 2001.
Rheumatoid factor(+) (1:1280) and ANA(+) were noted at that
time. Anti-HCV antibody was negative. Polyarthritis involving
wrist and PIP joints was noted and rheumatoid arthritis was
diagnosed. Prednisolone and NSAIDs (non-steroid
anti-inflammatory drugs) were prescribed at out-patient
department. She received rehabilitation at our hospital.
Sudden onset of dyspnea occurred in the morning of Nov 19,
2001. She was admitted on Nov 20.
After admission, physical examination showed normal blood
pressure 110/70 mmHg, body temperature 37.2℃, heart rate
84/min, and respiratory rate 22/min. Ausculation didn’t show
obvious wheezing. Chest x-ray showed only mild inferior lung
field infiltration. Blood gas showed pH 7.42, pCO2 32.2, pO2
199.2, HCO3 20.6, and BE -2.8. Pulmonary function test was
normal except mild impairment of DLco. Dyspnea improved
partially under inhaled bronchodialator therapy. Due to
multiple joint pain, NSAIDs, methotrexate and prednisolone
were given. Nasal discharge was noted and acute paranasal
sinusitis was impressed. Empirical antibiotics were prescribed
and kept for one week. Gr I/VI systolic heart murmur over apex
was noted and cardiac echo was arranged. However, the cardiac
echo didn’t show abnormality. Under medical treatment, her
symptom improved. She was discharged under stabled
condition.
<請參考圖一>
案例分析 在風濕免疫科的病人,如果有喘的表現,必須考慮多方面的原因。以本病人為例,類風濕性關節炎和謝格連氏症(Sjogren’s
syndrome),都可能有間質性肺病的表現,在肺功能測試中應包括DLco的項目。呼吸道的症狀,可能因感染或肋膜積液而加重。且除了呼吸道本身的問題,心包積液,腎小管酸血症也是可能的考慮。在這個病人,謝格連氏症可能次發於類風濕性關節炎,疾病的控制如果對類固醇反應不佳,應及早使用DMARDs(Disease
modifying anti-rheumatic
drugs)。
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