目的:分析膝关节痛风性关节炎患者急性痛风发作与关节镜下术后感染的临床特征差异,为临床诊治提供指导意见。
方法:2017年1月至2022年12月,共收治痛风性膝骨关节炎患者235例,并接受关节镜清理联合滑膜切除术。其中,35例术后发热,体温高于38°C,发红时出现急性炎症,肿胀,手术关节的热和疼痛。有29名男性和6名女性,平均年龄(41.48±13.90)岁。其中23例患者被诊断为急性痛风发作,经给予秋水仙碱和泼尼松龙治疗后恢复良好;12例患者诊断为术后关节感染,经抗感染治疗和关节腔清洗冲洗后治愈。对比分析两组患者术前一般资料,手术条件,血液学,接头流体,肢体功能等临床特点。
结果:两组患者术前一般资料差异无统计学意义。术后急性痛风发作组发热多发生在48小时内,明显早于术后感染组(P=0.037)。急性痛风发作组视觉模拟评分(5.32±1.38)分明显高于术后感染组(2.45±0.68)分(P=0.000),14例急性痛风发作患者伴有其他关节剧烈疼痛。血液学,白细胞计数和比率等指标在两组中均显著较高.在炎症指标方面,IL-6,红细胞沉降率,降钙素原和其他炎症指标在两组中均显著升高,但两组间无统计学差异。术后感染组C反应蛋白水平(220.97±116.30)mg·L-1高于术后急性痛风发作组(120.67±82.45)mg·L-1(P=0.006)。术后急性痛风发作组血尿酸(316.55±112.84)μmol·L-1高于术后感染组(159.14±126.92)μmol·L-1(P=0.001)。在术后感染组的关节液检查中,糖代谢指标明显低于急性痛风发作组,其中五个细菌培养呈阳性。
结论:急性痛风发作的症状由于其相似性而可能被误认为是术后感染,因此需要仔细区分。鉴别诊断应基于临床体征的组合,血液学和关节液检查结果,应给予针对性治疗,避免严重并发症的发生。
OBJECTIVE: To analyze the differences of clinical features of acute gout flare and postoperative infection under arthroscopy of knee gouty arthritis patients to offer guiding opinions of clinical diagnosis and treatment.
METHODS: Between January 2017 and December 2022, 235 patients with gouty knee osteoarthritis were admitted, and underwent arthroscopic debridement combined with synovectomy. Among them, 35 cases had fever with a temperature higher than 38 °C postoperatively while acute inflammatory appears under redness, swelling, heat and pain of the operated joints. There were 29 males and 6 females, with an average age of (41.48±13.90) years old. Among them 23 patients were diagnosed with acute gout attack, and recovered well after being given colchicine and prednisolone;12 patients were diagnosed with postoperative joint infection, and were cured after being given anti-infective treatments and cleaning and rinsing of the joint cavity. The two groups of patients were compared and analyzed in terms of preoperative general data, surgical conditions, hematology, joint fluid, limb function and other clinical characteristics.
RESULTS: There were no significant difference in the preoperative general data between two groups. The onset of fever in the postoperative acute gout flare group occurred mostly within 48 hours, significantly earlier than that in the postoperative infection group(P=0.037). The visual analogue scale score was significantly higher in the acute gout flare group (5.32±1.38) score than in the postoperative infection group (2.45±0.68) score (P=0.000), while 14 patients with acute gout flare were accompanied by severe pain in other joints. Hematologically, indicators such as white blood cell counts and ratios were significantly higher in both groups. In terms of inflammatory indicators, IL-6, erythrocyte sedimentation rate, procalcitonin and other inflammatory indicators were significantly elevated in both groups, but there was no statistical difference between two groups. The C-reactive protein level in the postoperative infection group (220.97±116.30) mg·L-1 was higher than that in the postoperative acute gout attack group(120.67±82.45) mg·L-1(P=0.006). Blood uric acid (316.55±112.84) μmol·L-1 was higher in the acute postoperative gout flare group than in the postoperative infection group (159.14±126.92) μmol·L-1(P=0.001). In the joint fluid examination of the postoperative infection group, the glucose metabolism indicator was significantly lower than that of the acute gout flare group, and five of them had positive bacterial cultures.
CONCLUSIONS: The symptoms of acute gout flare could be mistaken as postoperative infection due to their similarity, therefore requires careful differentiation. Differential diagnosis should be based on a combination of clinical signs, hematology and joint fluid findings, and targeted treatment should be given to avoid serious complications.