过去的二十年为儿科风湿病实践带来了新的治疗选择和高质量的指南。然而,由于症状模糊和对现有治疗方式无反应,许多患者仍面临诊断和治疗挑战.
我们报告了一例16岁女孩患有多关节型幼年特发性关节炎的多种治疗方案难治。她在4岁时首次出现双膝肿胀和挛缩。她的症状最初对非甾体类抗炎药无反应,尽管接受了关节内和全身性糖皮质激素和甲氨蝶呤治疗,但仍有进展。多年来,她接受了几种生物制剂,并连续服用了非甾体抗炎药和疾病缓解抗风湿药,以及在疾病发作时的关节内和全身糖皮质激素。然而,这些选择都不能永久缓解,所以各种其他模式,以及其他可能的诊断不断被考虑。最终,她开始依赖每日剂量的全身性糖皮质激素。2018年,Janus激酶抑制剂托法替尼开始治疗,导致肌肉骨骼症状的逐渐改善,改善炎症标志物和整体健康状况,以及全身性糖皮质激素的断奶。随着手腕肿胀多年来第一次消退,马德隆的畸形被注意到了,首先在临床上,后来也是射线照相。遗传分析显示身材矮小的同源异型盒基因缺陷,并证实了LeriWeill综合征的诊断。
本病例报告强调报告难治性病例的必要性,来自日常临床实践的复杂病例,以积累整体知识和分享经验,这是对现有指南的补充。个别难以治疗的病例报告,特别是当涉及额外的诊断时,可以帮助医生治疗常见的风湿病患者,如幼年特发性关节炎。
The last two decades brought new treatment options and high quality
guidelines into the paediatric rheumatologic practice. Nevertheless, a number of patients still present a diagnostic and therapeutic challenge due to combination of vague symptoms and unresponsiveness to available treatment modalities.
We report a case of sixteen years old girl suffering from polyarticular type of juvenile idiopathic arthritis refractory to multiple treatment options. She first presented at the age of 4 with swelling and contractures of both knees. Her symptoms were initially unresponsive to nonsteroidal anti-inflammatory drugs and progressed despite treatment with intraarticular and systemic glucocorticoids and methotrexate. Throughout the years, she received several biologics together with continuous administration of nonsteroidal anti-inflammatory drugs and disease modifying anti-rheumatic drugs as well as intraarticular and systemic glucocorticoids in disease flares. However, none of this options provided a permanent remission, so various other modalities, as well as other possible diagnoses were constantly being considered. Eventually she became dependent on a daily dose of systemic glucocorticoids. In 2018, the treatment with Janus kinase inhibitor tofacitinib was initiated, which led to gradual amelioration of musculoskeletal symptoms, improvement of inflammatory markers and overall well-being, as well as to the weaning of systemic glucocorticoids. As the swelling of the wrists subsided for the first time in many years, Madelung\'s deformity was noticed, first clinically, and later radiographically as well. Genetic analysis revealed short-stature homeobox gene deficiency and confirmed the diagnosis of Leri Weill syndrome.
This case report emphasizes the need for reporting refractory, complicated cases from everyday clinical practice in order to build-up the overall knowledge and share experience which is complementary to available
guidelines. Individual reports of difficult to treat cases, especially when additional diagnoses are involved, can be helpful for physicians treating patients with common rheumatological diseases such as juvenile idiopathic arthritis.