过敏性紫癜245例的临床分析
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摘要
【目的】探讨过敏性紫癜(Henoeh一Schonlein purpura,HSP)的临床特征和诊治情况,分析临床特征和治疗及预后之间的关系,为过敏性紫癜的诊断和治疗提供参考。
【方法】回顾性分析我院皮肤科2001年1月~2009年6月收治的245例过敏性紫癜病例。对患者的性别、年龄、发病季节、诱发因素、症状体征、实验室检查、治疗等住院资料进行收集整理,并依据1990年美国风湿病协会的标准[1]将患者按年龄分为两组,青少年组(≤18岁)和成年组(>18岁),将其临床资料进行比较分析,数据采用卡方检验的统计方法进行处理。
【结果】1)一般资料245例HSP患者中发病年龄在4～86岁,其中≤18岁的有151例,占61.6%,>18y的有94例,占38.4%。男∶女=1.15∶1。202例(82.8%)在冬春季节发病。2)可能的发病诱因发病前1～2周有明显上呼吸道感染者131例(53.5%);可能与食物有关者24例(9.8%);可能与药物有关者12例(4.9%);78例(31.8%)诱因不明。3)临床表现245例(100%)均出现皮肤紫癜,皮疹累及双下肢者245例,双上肢27例,臀部55例。245例患者中单纯皮疹型51例(20.8% ),关节型47例(19.2% ) ,其中踝关节受累31例,膝关节16例;腹型57例(23.3% ) ,轻症者表现恶心、呕吐、腹胀、腹泻,重症者表现有消化道出血征象。肾型90例(36.7% ) ,表现为血尿或/和蛋白尿,且成人组较青少年组肾损害发生率更高。4)实验室和辅助检查三大常规检查:本组245例行血常规检查:结果WBC增高和/或中性粒细胞比例增高109例(44.6%),轻、中度贫血63例(25.6%)。尿常规异常(表现为血尿、蛋白尿)90例(36.7%),大便潜血试验(OBT)阳性25例(10.2%)。血生化及凝血功能检查: ALT升高37例(15.4%),AST升高37例(15.4%),白蛋白(ALB)降低者67例(27.3%),肾功能尿肌酐Cr、尿素氮Bun升高者6例(2.5%),APTT轻度延长13例(5.2%)。体内、外过敏原检测:36例(14.7%)检出多种过敏原阳性。免疫学检查:75例查IgA及补体C3、C4,结果IgA升高33例(13.5%),C3、C4降低28例(11.4%)。其它检查: ESR升高45例(18.4%) ,ASO升高55例(22.4%)。HBV感染3例,EBV感染2例和CMV感染1例。胃镜检查示胃/十二指肠胃溃疡,C14呼气试验查HP阳性共15例(6.1%)。腹部B超检查腹腔积液3例(1.2%)。
【结论】HSP可在任何年龄发病,但青少年较成人更为多见。本病有一定的好发季节,即主要发生于冬春季。诱因中上呼吸道感染占第一位、食物及药物过敏等因素亦占一定比例。过敏性紫癜首发症状主要为皮疹,但有少数为腹痛、关节痛等,以消化道症状为首症者极易误诊。临床上要重视过敏性紫癜患者的多系统损害,特别是肾损害,成人过敏性紫癜患者的肾脏损害较青少年患者的肾损害更多且更常见,临床上应予以高度重视。对于早期皮疹不典型者,也应该注意监测其尿常规及肾功能。
Objective: In order to probe the clinical significance of etiological diagnosis, the clinical symptom feature and intercommunication of Henoch-Schonlein purpura (HSP) .And to analyze the relationship of the clinical symptom, therapy and prognosis .It can provide reference for the clinical diagnosis and therapy of HSP.
Methods : Retrospective study of cases discharged with a diagnosis of HSP from the Department of Dermatology Tongji Hospital of Huazhong University of Science and Technology between January 2001 and June 2009.245 patients with HSP were analyzed retrospectively and statistically .These data include common information, past and present illness history, medical treatment, laboratory and auxiliary examination, diagnosis and misdiagnosis, treatment and prognosis. All patients were divided into two sets according to American Rheumatism Association (ARA) in 1990. Teenagers group≤18years and adults group >18years.
Results: 1) The study group consisted of 245 cases,131 male(53.46%) and female (46.53%),and the ratio of male to female was 1.15. The disease was often occurred from December to April .The age of onset was 4~86y. There were 151 cases under 18 years old. 2) Of the 131 cases had a history of upper respiratory tract infection in the early stage. 24 cases (6.12%) were concerned with food; 12 cases (3.67%) were related with medicine. 78 cases (31.8%) didn’t reveal evident predisposing factors. 3) 245 cases (100%) all had typical purpura .The distribution of rash in the lower extremities and haunch. 57 cases had digestive tract symptom and 47 cases whose joints were involved in. 90 cases who complained albuminuria and /or hematuria. 221 cases (90.2%)whose initial symptom were purpura;stomachache and joint pain could appear before purpura several days , or accompaniment other symptom ; but no one whose initial symptom was kidney damage. The teenagers were more easy than the adult to have simple skin rash 4) Three routine examination、APTT、blood-biochemistry : There were 109 cases (44.6%) whose WBC or ratio of Neu raised up. There were 63 cases (25.6%) had anaemia . There were 90 cases (36.7%) which had urine abnormality. There were 67cases (27.3%) whose ALB raised and 37 cases (15.4%) whose ALT and AST raised up. There were 13 cases (5.2%) who showed a little higher of APTT. The incidence and the severity of kidney in adult group were higher than that of the teenager group(P<0.0 5).Of 51 cases were simple type , 57 cases abdomen, 47 cases joint type , 90 cases kidney type respectively .Some cases were misdiagnosed as the disease of digestive system , for example, 2 cases were misdiagnosed as the appendicitis 5) 226 cases were recovery or the symptom had disappeared . Conclusion : HSP can happens in any age ,but the teenager is easier to be seen than adult ,most of those in winter or spring .Male patients are more than female . Children are easy to happen purpura, stomachache and arthralgia. But the adult have more nephritis than the teenager, and the symptom were serious. Sometimes misdiagnosis should be warned when stomachache is the first symptom in clinical. Because there are short of specific laboratory examinations, so physical examinations must been done carefully early days. Those who Urine-Rt is negative should check again. The Cause of HSP should be finding finally and we should care for acute tonsillitis .The stomachache patients should use the hormone therapy at the early days of the disease. The patients of hemorrhage of digestive tract should use anti-Hp and corticosteroids treatment, or maybe two treatments together sometimes. Therapy and follow-up are both important to those patients. It’s important to monitor the urine-routine and renal function for the patients whose rash is inconspicuous early days.
【方法】回顾性分析我院皮肤科2001年1月~2009年6月收治的245例过敏性紫癜病例。对患者的性别、年龄、发病季节、诱发因素、症状体征、实验室检查、治疗等住院资料进行收集整理,并依据1990年美国风湿病协会的标准[1]将患者按年龄分为两组,青少年组(≤18岁)和成年组(>18岁),将其临床资料进行比较分析,数据采用卡方检验的统计方法进行处理。
【结果】1)一般资料245例HSP患者中发病年龄在4～86岁,其中≤18岁的有151例,占61.6%,>18y的有94例,占38.4%。男∶女=1.15∶1。202例(82.8%)在冬春季节发病。2)可能的发病诱因发病前1～2周有明显上呼吸道感染者131例(53.5%);可能与食物有关者24例(9.8%);可能与药物有关者12例(4.9%);78例(31.8%)诱因不明。3)临床表现245例(100%)均出现皮肤紫癜,皮疹累及双下肢者245例,双上肢27例,臀部55例。245例患者中单纯皮疹型51例(20.8% ),关节型47例(19.2% ) ,其中踝关节受累31例,膝关节16例;腹型57例(23.3% ) ,轻症者表现恶心、呕吐、腹胀、腹泻,重症者表现有消化道出血征象。肾型90例(36.7% ) ,表现为血尿或/和蛋白尿,且成人组较青少年组肾损害发生率更高。4)实验室和辅助检查三大常规检查:本组245例行血常规检查:结果WBC增高和/或中性粒细胞比例增高109例(44.6%),轻、中度贫血63例(25.6%)。尿常规异常(表现为血尿、蛋白尿)90例(36.7%),大便潜血试验(OBT)阳性25例(10.2%)。血生化及凝血功能检查: ALT升高37例(15.4%),AST升高37例(15.4%),白蛋白(ALB)降低者67例(27.3%),肾功能尿肌酐Cr、尿素氮Bun升高者6例(2.5%),APTT轻度延长13例(5.2%)。体内、外过敏原检测:36例(14.7%)检出多种过敏原阳性。免疫学检查:75例查IgA及补体C3、C4,结果IgA升高33例(13.5%),C3、C4降低28例(11.4%)。其它检查: ESR升高45例(18.4%) ,ASO升高55例(22.4%)。HBV感染3例,EBV感染2例和CMV感染1例。胃镜检查示胃/十二指肠胃溃疡,C14呼气试验查HP阳性共15例(6.1%)。腹部B超检查腹腔积液3例(1.2%)。
【结论】HSP可在任何年龄发病,但青少年较成人更为多见。本病有一定的好发季节,即主要发生于冬春季。诱因中上呼吸道感染占第一位、食物及药物过敏等因素亦占一定比例。过敏性紫癜首发症状主要为皮疹,但有少数为腹痛、关节痛等,以消化道症状为首症者极易误诊。临床上要重视过敏性紫癜患者的多系统损害,特别是肾损害,成人过敏性紫癜患者的肾脏损害较青少年患者的肾损害更多且更常见,临床上应予以高度重视。对于早期皮疹不典型者,也应该注意监测其尿常规及肾功能。
Objective: In order to probe the clinical significance of etiological diagnosis, the clinical symptom feature and intercommunication of Henoch-Schonlein purpura (HSP) .And to analyze the relationship of the clinical symptom, therapy and prognosis .It can provide reference for the clinical diagnosis and therapy of HSP.
Methods : Retrospective study of cases discharged with a diagnosis of HSP from the Department of Dermatology Tongji Hospital of Huazhong University of Science and Technology between January 2001 and June 2009.245 patients with HSP were analyzed retrospectively and statistically .These data include common information, past and present illness history, medical treatment, laboratory and auxiliary examination, diagnosis and misdiagnosis, treatment and prognosis. All patients were divided into two sets according to American Rheumatism Association (ARA) in 1990. Teenagers group≤18years and adults group >18years.
Results: 1) The study group consisted of 245 cases,131 male(53.46%) and female (46.53%),and the ratio of male to female was 1.15. The disease was often occurred from December to April .The age of onset was 4~86y. There were 151 cases under 18 years old. 2) Of the 131 cases had a history of upper respiratory tract infection in the early stage. 24 cases (6.12%) were concerned with food; 12 cases (3.67%) were related with medicine. 78 cases (31.8%) didn’t reveal evident predisposing factors. 3) 245 cases (100%) all had typical purpura .The distribution of rash in the lower extremities and haunch. 57 cases had digestive tract symptom and 47 cases whose joints were involved in. 90 cases who complained albuminuria and /or hematuria. 221 cases (90.2%)whose initial symptom were purpura;stomachache and joint pain could appear before purpura several days , or accompaniment other symptom ; but no one whose initial symptom was kidney damage. The teenagers were more easy than the adult to have simple skin rash 4) Three routine examination、APTT、blood-biochemistry : There were 109 cases (44.6%) whose WBC or ratio of Neu raised up. There were 63 cases (25.6%) had anaemia . There were 90 cases (36.7%) which had urine abnormality. There were 67cases (27.3%) whose ALB raised and 37 cases (15.4%) whose ALT and AST raised up. There were 13 cases (5.2%) who showed a little higher of APTT. The incidence and the severity of kidney in adult group were higher than that of the teenager group(P<0.0 5).Of 51 cases were simple type , 57 cases abdomen, 47 cases joint type , 90 cases kidney type respectively .Some cases were misdiagnosed as the disease of digestive system , for example, 2 cases were misdiagnosed as the appendicitis 5) 226 cases were recovery or the symptom had disappeared . Conclusion : HSP can happens in any age ,but the teenager is easier to be seen than adult ,most of those in winter or spring .Male patients are more than female . Children are easy to happen purpura, stomachache and arthralgia. But the adult have more nephritis than the teenager, and the symptom were serious. Sometimes misdiagnosis should be warned when stomachache is the first symptom in clinical. Because there are short of specific laboratory examinations, so physical examinations must been done carefully early days. Those who Urine-Rt is negative should check again. The Cause of HSP should be finding finally and we should care for acute tonsillitis .The stomachache patients should use the hormone therapy at the early days of the disease. The patients of hemorrhage of digestive tract should use anti-Hp and corticosteroids treatment, or maybe two treatments together sometimes. Therapy and follow-up are both important to those patients. It’s important to monitor the urine-routine and renal function for the patients whose rash is inconspicuous early days.
引文
1. Mills JA,Michel BA, Bloch DA, et al. The American College of Rheumatology 1990 Criteria for the Classification of Henoch - schonlein Purpura [ J ]. Arthritis Rheum, 1990, 33(8) : 1114 - 1121.
2.杨国亮.现代皮肤病学.第1版.上海:上海医科大学出版社,2001 ,674.
3.张碧丽,王文红,范树颖.儿童过敏性紫癜575例.中华儿科杂志, 2006;12(1):20-22.
4.欧弼悠,吴秀英,陈肖肖等.小儿消化道出血病因的内镜诊断治疗[J].中华消化内镜杂志. 1997,14(5):315—316.
5. Aydin Ece,Selvi Kelekci,Askin Hekimoglu et al. Neutrophil activation,protein oxidation,and ceruloplasmin levels in children with Henoch—Schonlein purpura [J]. Pediatr Nephrol,2007,22 : 1151-1157.
6. Blanco R,Martinez-Taboada VM,Rodriguez—Valverde V,et al.Henoch—Schonlein purpurain adulthood and childhood : two different expressions of the same syndrome.Arthritis Rheum. 1 997, 40:859-864.
7. Roberts PF,Waller TA,Brinker TM,et al.Henoch-Schonlein purpura:a review article.South Med J.2007, 100:821—824.
8. Nong BR,Huang YF,Chuang CM,et al.Fifteen-year experience of children with Henoch-Schonlein purpura in southern Taiwan.1991·2005.J Microbiol Immunol Infect.2007, 40:371-376.
9.陈新谦,金有豫.新编药物学[M].第14版.北京:人民卫生出版社,1997. 538.
10. Narchi H.Risk of long term renal impairment and duration of follow-up recommended for Henoch-Schoenlein purura with normal or minimal urinary findings : a systematic review .Arch Dis Child,2005 Sep,90(9),916-20.
11. Coldstein AR,White RH,Akuse R,et al. Long-term follow-up of childhood Henoch-Schoenlein nephritis .Lancet,1992 Feb 339(8788),280-2.
12. Magro CM, Crowson AN .A clinical and histologic study of 37 cases of immunoglobulin A-associated vasculitis .Am J Dermatopathol , 1999,21(3), 234-240.
13. Kato S,Ozawa K,Ando N,et a1.Immunoglobulin A enteropathy:a possible variant of Henoch-Schonlein purpura [J].Dig Dis Sci , 2004,49(1l—12):1777—1781.
14.韩少良,周宏众,程骏,等.腹型过敏性紫癜的误诊原因与外科治疗[J].中国胃肠外科杂志,2006,9(4):357—358.
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20. SZETO CC, CHIO PC, TO KF, et al. grading of acute and chronic renal lesions Henoch-Schonlein purpura [J]. Mod Pachol, 2001, 14(7):635-640.
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2.杨国亮.现代皮肤病学.第1版.上海:上海医科大学出版社,2001 ,674.
3.张碧丽,王文红,范树颖.儿童过敏性紫癜575例.中华儿科杂志, 2006;12(1):20-22.
4.欧弼悠,吴秀英,陈肖肖等.小儿消化道出血病因的内镜诊断治疗[J].中华消化内镜杂志. 1997,14(5):315—316.
5. Aydin Ece,Selvi Kelekci,Askin Hekimoglu et al. Neutrophil activation,protein oxidation,and ceruloplasmin levels in children with Henoch—Schonlein purpura [J]. Pediatr Nephrol,2007,22 : 1151-1157.
6. Blanco R,Martinez-Taboada VM,Rodriguez—Valverde V,et al.Henoch—Schonlein purpurain adulthood and childhood : two different expressions of the same syndrome.Arthritis Rheum. 1 997, 40:859-864.
7. Roberts PF,Waller TA,Brinker TM,et al.Henoch-Schonlein purpura:a review article.South Med J.2007, 100:821—824.
8. Nong BR,Huang YF,Chuang CM,et al.Fifteen-year experience of children with Henoch-Schonlein purpura in southern Taiwan.1991·2005.J Microbiol Immunol Infect.2007, 40:371-376.
9.陈新谦,金有豫.新编药物学[M].第14版.北京:人民卫生出版社,1997. 538.
10. Narchi H.Risk of long term renal impairment and duration of follow-up recommended for Henoch-Schoenlein purura with normal or minimal urinary findings : a systematic review .Arch Dis Child,2005 Sep,90(9),916-20.
11. Coldstein AR,White RH,Akuse R,et al. Long-term follow-up of childhood Henoch-Schoenlein nephritis .Lancet,1992 Feb 339(8788),280-2.
12. Magro CM, Crowson AN .A clinical and histologic study of 37 cases of immunoglobulin A-associated vasculitis .Am J Dermatopathol , 1999,21(3), 234-240.
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