口 絵 · 2020. 9. 16. · Behçet 病,Whipple 病もSpA に分類されていた.しか...

154
本項は,本書本文中にモノクロ掲載した写真のうち,カラーで提示すべきものを,本文出 現順にならべたものである. ・各写真には当該写真の本文掲載ページを示している. ii 口 絵 口絵 1 強直性脊椎炎に合併した再発性の急性前部 ぶどう膜炎〔p.23 参照〕 口絵 2 強直性脊椎炎に合併した大動脈弁閉鎖不全 症〔p.25 参照〕 心尖部 5 腔断面図:拡張期の大動脈弁逆流ジェット 口絵 3 頭部乾癬〔p.64 参照〕

Transcript of 口 絵 · 2020. 9. 16. · Behçet 病,Whipple 病もSpA に分類されていた.しか...

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ACR American College of Rheumatology AS ankylosing spondylitis ASAS assessment of spondyloarthritis international society ASDAS ankylosing spondylitis disease activity score axSpA axial spondyloarthritis BASDAI Bath ankylosing spondylitis disease activity index BASFI Bath ankylosing spondylitis functional index BASMI Bath ankylosing spondylitis metrology index CASPAR classification criteria for psoriatic arthritis DISH diffuse idiopathic skeletal hyperostosis DMARDs disease–modifying anti-rheumatic drugs ESR erythrocyte sedimentation rate ESSG European Spondylarthropathy Study Group -
EULAR European League Against Rheumatism FM fibromyalgia IBD inflammatory bowel diseases ILAR International League of Associations for Rheumatology JAK janus kinase JIA juvenile idiopathic arthritis LEI Leeds enthesitis index MASES Maastricht ankylosing spondylitis enthesitis score MEI Mander/Newcastle enthesitis index mSASSS modified stoke ankylosing spondylitis score MTX methotrexate nr-axSpA non-radiographic axial spondyloarthritis X NSAIDs non-steroidal anti inflammatory drugs OA osteoarthritis PsA psoriatic arthritis pSpA peripheral spondyloarthritis RA rheumatoid arthritis r-axSpA radiographic axial spondyloarthritis X ReA reactive arthritis RF rheumatoid factor SASP salazosulfapyridine SNSA seronegative spondyloarthropathies SpA spondyloarthritis SPARCC Spondyloarthritis Research Consortium of Canada TNF tumor necrosis factor uSpA undifferentiated spondyloarthritis
xiv
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1 2 GalenRA AS 1691 Conner 1824Wenzel
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tionARA“ankylosing spondylitis” 1974Moll “spondyloarthritisSpA” SNSA Moll BehçetWhipple SpA HLAB27 1973 Schlosstein BrewertonHLA B27 BehçetWhipple SpA SpA HLAB27 HLAB27 8%AS HLAB27
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than diagnose patients with axial spondyloarthritis. Ann Rheum Dis 2016 791794.
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van der Heijde D,et al.2016 update of the ASASEULAR management recommendations for axial spondyloarthritis. Ann Rheum Dis
2017 978991.
ing/pamphlet.pdf
etyASAS AS 42010 update5 2016 axSpA
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van der Heijde D, et al.2016 update of the ASASEULAR management recommendations for axial spondyloarthritis. Ann Rheum Dis 2017 978991.
TNF NSAIDs AS 2 NSAIDs BASDAI 4 ASDAS 2.1 TNF 41 2020 3AS TNF TNF BASDAIASDASMRI 1718
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XCTMRI
on markers of inflammation and bone turn-
over and associations with bone mineral
density in patients with ankylosing spondy-
litis. Ann Rheum Dis 200968175182.
2Sidiropoulos PI, et al.Evidence-based
recommendations for the management of
ankylosing spondylitis: systematic literature
involving a broad panel of experts and prac-
tising rheumatologists. Rheumatology




















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/

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10 1672019
EULAR 17
1 EULAR 3
7
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4 PsA

i
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A PsA B PsA
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10 1 / 2 PsA NSAIDs 3 /CRP csDMARDs MTX
4 PsA
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6 1 csDMARDsTNFIL12/23
IL17 7 1 csDMARDsPDE4
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9 NSAIDs TNF
10 TNF

PsA

NSAIDs→csDMARDs→bDMARDs→JAK csDMARDsMTX 1 SASP LEF bDMARDs TNFIL17IL12/23
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TNF IL12/23
PDE4

TNF
IL17


85
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MTX 1 16 mgMTX 1 5 mgMTX
X
24 EULAR 2015 2 1
5
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4 1 csDMARD TNF /csDMARDTNF

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87
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mg ACR20 2462%58%30% 2 40 mg X TNF PsA 363 160 mg 2 4 80
mg24 ACR20
48%53%20%24 IL17 210 mg 012 2 PsA25 PsA 140 280 mg 01 2 2 12 280 mg 24 210 mg
2 12 ACR20140 mg 36.8280 mg 39.3 18.2 24 140 mg
51280 mg 64 44

3IL12/23 p40 IL12
IL23 p40 PsA 4 12 45 mg 90 mg PSUMMIT1 NSAIDs DMARDsTNF PsA 615090 45 mg 16 590 mg 45 mg26 52 ACR90 mg45 mg vs 50% 42%23% 3 PSUMMIT2 TNF 58%27 PSUMMIT1 PSUMMIT2 24 van der Hejide Sharp score0.4 vs 1.0 52 28
88
C

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/


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AhvonenReA 1 Reiter ReA LeroyFiessingerReiter 23Reiter ReA ReA poststreptcoccal reactive arthritisPSRA Lyme ReA ReA 1999 ReA ReA HLAB27 SpA infectionrelated arthritis 45

ReA 100,000 45 67 712% ReA 81112 2016 38% ReA13 123 10.8% ReA14 8,145 ReAReA 0%
15 ReA

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/
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AIDS

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// / /





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1
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Wolfe F, et al.The American College of Rheumatology 1990 crite- ria for the classification of fibromyalgiareport of the Multicenter Criteria Committee. Arthritis Rheum 199033160172.
2
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Wolfe F, Smythe HA, Yunus MB, et alThe American College of Rheumatology 1990 criteria for the classification of fibromyalgia report of the Multicenter Criteria Committee. Arthritis Rheum 1990 33160172.
1
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ASDAS Juvenile spondyloarthritis disease activity indices
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MRI
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/










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127

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2
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4
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130






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135




1 g 2 1 24 g 46 8 g 31 1.52 g 2 g
/1 6 mg1 1 2 3 2 121 2 63 5 1 1 16 mg
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3
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1616
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12 24 20 20 4
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1616
1 10 mg/kg 2 4 4 75 kg 100 kg 1 750 mg 100 kg 1 1 g


1 2 3 4 5 6
10 mg 10 mg 10 mg 10 mg 20 mg 20 mg 20 mg 20 mg 30 mg 30 mg 30 mg
136
Clinical criteria
1 Low back pain and stiffness for more than 3 months, not relieved by test
2 Pain and stiffness in the thoracic region
3 Limited motion in the lumber spine
4 Limited chest expansion
Radiologic criterion
exclude bilateral osteoarthritis of the sacroiliac joints Definite ankylosing spondylitis if
1 Grade 3 or 4 bilateral sacroiliitis with at least one clinical criterion
2 At least four clinical criteria
bNew York, 1966
Diagnosis
1 limitation of motion of the lumber spine in all three planes anterior flexion, lateral flexion, and extension
2 Pain at the dorsolumbar junction or in the lumber spine
3 Limitation of chest expansion to 2.5 cm or less measured at the level of the fourth inter costal space
Grading of radiographs
Normal. 0suspicious, 1minimal sacroiliitis, 2moderate sacroiliitis, 3ankylosing, 4
Definite ankylosing spondylitis if 1 Grade 3 or 4 bilateral sacroiliitis with at least one clinical criterion
2 Grade 3 or 4 unilateral or grade 2 bilateral sacroiliitis with clinical criterion 1 or with both clinical criteria
2 and 3
Probable ankylosing spondylitis
Grade 3 or 4 bilateral sacroiliitis with no clinical criteria
2 ASAS
IBP
IBP 5 4 140 2 3 4 5
NSAID NSAIDs2448





1 2 a b c d e
HLAB27


X New York 24 34
MRI /
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SpA /




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SpA /


1 2 a b c d e
HLAB27




0 30 1 1 2
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
10 BASDAI
10
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
142
D cm
E AB cm
B 10 cm 2 10 cm cmSchober
A 2 cm
0 1 2
B modiried Schoder
C 70° 20°70° 20° D
10 cm 510 cm 5 cm
E 100 cm 70100 cm 70 cm
02 5 10
143

1.
2.
3.
4.
5.
6.
7.
8.
















9.
14 psoriatic arthritis Ratingen score
40DIP8IP2PIP8MCP102 IP2MTP8 54 destruction score 0 11 mm 10% 2 1125% 3 2650% 4 5175% 5 75% proliferation score 0 1 12 mm 25%
223 mm 2550% 33 mm 50% 4


1
3

2
10
11
12
146


0 1 2
0 1 2 3
4 5 6