项羽评价【病例分析】AdultOntsStillsDia（AOSD）成人Still’s病
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【原文】Middle aged female prenting with shoulder pain. She had polyarticular synovitis involving left shoulder, right 3rd PIP, left 2nd and 3rd MCP and right knee. She was febrile and with a leukocytosis and had the skin findings. Initial concern was for strep bacteremia/endocarditis and antibiotics were started. Blood cultures remained negative and #Arthrocentesis of shoulder and knee neg for infection. What would you do next?
【译文】中年女性由于肩部疼痛前来就诊，患有包括左肩、右手第3近端指关节（PIP：proximal interphalangeal 近端指关节）、左手第2、3掌指关节和右侧膝关节多关节的滑膜炎，有发热症状伴白细胞计数的增高还有上图所示的皮肤表面的改变。最初我们怀疑是链球菌感染导致菌血症致感染性心内膜炎并开始使用抗菌素进行治疗，但是血培养结果是阴性、
对肩关节和膝关节行关节穿刺术结果也是非感染性的。如果是你，将如何进行下一步治疗？
[discussion]/【讨论】
top ddx is adult onts Still's dia as pt have fever, oligoarthritis, leukocytosis and bumpy rash. a dx of exclusion. check s- ferretin in adition to autoimmune tests.
第一诊断是成人Still’s病，主要临床症状包括病人的发热、少关节炎、白细胞增多症和皮疹，若想排除这个病的可能，还应该再做一个铁蛋白的自身免疫性试验。
Like your explanation, agree. What's the reason for ferritin?二与一为三
成语谜语和答案喜欢你的解释，我很赞同，请问一下，为什么要检测铁蛋白？
it is a good marker. if it comes normal we could exclude Still's dis.
铁蛋白是一种很好的标记物，如果结果正常，那么我们就会排除成人Still’s病
But it’s elevated in does that include #Still's-dia ?
但是铁蛋白在一些炎性疾病中也会有升高，那样也可以排除成人Still’s病吗?
yes correct. moderate elevation in other inflammatory conditions. very high in Stills dis.
嗯，是的，中等程度的升高时指向炎性疾病，但是非常高的话就是成人Still’s病的特征了
Still's Dia, or Systemic-Ont JUVENILE Idiopathic Arthritis (this woman is middle-aged), is rare in adults. Its diagnod by the characteristic clinical features of high intermittent fever, joint inflammation and pain, muscle pain - which this patient prents with; as well as salmon-colored skin rash, lymphadenitis & enlarged spleen & liver. I'd order CT to asss the organs also.
成人Still’s病，或者叫系统性幼年特发性关节炎（这个患者是中年发病），极少在成年人中出现，根据典型临床症状特征确诊：包括该患者表现出来的间歇高热、关节炎症和疼痛、肌肉疼，还有橙红色的皮疹、淋巴腺炎、增大的脾脏和肝脏。对于这个患者，我建议给他预约一个CT以评估这些器官的情况。
What was the leukocytes count in the synovial fluid ? Negative for infection- u mean nega
tive culture ? But was it inflammatory ? What's about liver function test ? ESR? And other inflammatory markers ? And yes I agree Autoimmune panel is well needed. And last question- was there a specific pattern for Fever evolvement?
关节滑液的白细胞计数是怎么样的？否定了感染，是因为血培养结果阴性？那么炎症呢？要不要测个肝功？测个血沉？或者其他的炎症的标记物？我很赞同那个自身免疫的测试。最后一个问题：患者的发热是否有特殊的演变过程模式？
It could be reactive arthritis, any history of dysuria or diarrhea in recent days?
有可能是活动性的关节炎，近几天有排尿困难或者腹泻吗？
Is she on NSAIDs or ASA or any other meds that can effect platelets and/or coagulation? Agree check autoimmune panel.
他有使用什么非甾体类抗炎药或者阿司匹林或者其他能影响血小板/凝血药物吗？同意做一个自身免疫测试。
新疆驴Could be autoimmune dia with vasculitic purpura/ ecchymos or erythema nodosum.
会不会是自身免疫性疾病合并血管性紫癜、瘀斑或结节性红斑？
Check liver and kidney function, heart, Hep B thinking this may be Polyarteritis Nodosa. This looks vasculitic (vs salmon rash of Still's)
检查肝肾功，心脏、乙肝病毒也可以考虑是结节性多动脉炎，这个看起来是血管性疾病（与成人Still’s病的橙红色皮疹鉴别）
Henoch Schonlein purpura? Unusual at her age though. Are the skin lesions on backs of legs or buttocks as well? Any recent infection or abdominal pain?
亨诺-许兰紫癜？不过通常不发生在她这个年纪。背部或臀部的皮肤也有损伤吗？最近有感染或腹痛吗？
Acute sarcoidosis?
一年级体育教学计划
急性肉状瘤病？
ESR and Ferritin levels for confirmation of stills dia will be ideal
防校园欺凌教案血沉和铁蛋白的检测对于成人Still’s病是理想的确诊标准
Still's Ds should probably be in the differential, but I'm going to disagree as the rash looks like purpura. My first thought would be a vasculitis so a rheumatologic workup is necessary. But we need to know FH for rheum ds, platelet count, differential and med list to get started. Would possibly look at coagulation workup pending other info needed.
我觉得成人Still’s病应该算是这个疾病的鉴别诊断，还有，我不太认同这个患者的皮疹看起来像紫癜，我第一感觉觉得应该是血管性的疾病，风湿性疾病的检查是有必要的。但是我们需要FH、血小板计数还有药物服用清单来鉴别风湿免疫疾病。可能还需要看一下凝血试验的结果等。
Next step : CXR ? TB or Sarcoidosis
下一步：胸部X线？结核或者肉状瘤病？
Rash looks like erythema nodosum so would biopsy to confirm, check for TB, Leprosy (if circumstances relevant), check history re Strep infection and check ASOT, anti-DNa B titres, and if all negative consider sarcoid - get CXR and check rum ACE, rum corrected calcium
那些皮疹看起来像是结节性皮疹，所以做个活检就可以确诊，还要检查是否患有结核、麻风病（如果周围有人患病），查看是否有链球菌感染病史并检测抗链球菌抗体滴度、抗-anti-DNa B 滴度，如果都是阴性，那就考虑肉状瘤病，拍个胸片，检测血清血管紧张素转换酶及血清内钙离子浓度。
Fever, multiple joint pain, rash and elevated white counts. Sepsis still on top list. Disminated gonorrhea?
一年级小故事100篇发热，多个关节疼痛、皮疹和升高的白细胞计数，败血症是最主要诊断，播散性淋病？
炖牛肉的做法大全Vasculitic lesions ?erythema nodosa indicates autoimmune phenomenon.Suggest starting oral steroids for acute relief of symptoms.
