【作者】 赵千子；

【导师】 王国春；

【作者基本信息】 北京协和医学院 ， 内科学， 2014， 博士

【摘要】 目的：成人多发性肌炎(polymyositis, PM)和皮肌炎(dermatomyositis,DM)属于特发性炎性肌病,是一组可损害骨骼肌、皮肤及多种脏器的全身性自身免疫性疾病。PM/DM伴器官损害是影响疾病预后的重要因素。本课题拟：1)组织我国最大规模的关于PM/DM的多中心回顾性研究,总结分析成人PM/DM临床表现及主要器官损害的发生率和特点,确定与其相关的特异性因素；2)探讨基质金属蛋白酶-9降解工Ⅲ型胶原蛋白的降解产物(C3M)与PM/DM患者合并间质性肺病(interstitial lung disease, ILD)及主要临床指标的相关性,评价其是否可以作为PM/DM患者合并ILD的血清学诊断指标。3)从固有免疫角度探讨炎症体在此类疾病发病机制中的作用。对象和方法：本研究分为三部分：第一部分使用统一的调查表,回顾性收集所有于2007-2012年间在全国22个三级甲等医院风湿免疫科住院的符合纳入排除标准的1387例成人PM/DM患者的病例资料,并进行多因素logistic回归分析；第二部分采用酶联免疫吸附法检测46例成人PM/DM(30例合并ILD,15例不合并ILD)和19例正常对照血清C3M浓度,用ROC曲线分析C3M的诊断价值,并统计分析C3M与主要临床表现及辅助检查结果之间的相关性；第三部分采用免疫组织化学的方法检测新发病并未经治疗的成年PM/DM患者肌肉标本10例(PM6例,DM4例)及5例健康对照肌肉组织NALP1、NALP3、ASC及caspase-1的表达情况。结果：第一部分：共收集1387例患者,其中PM者460(33.2%)例和DM者927(66.8%)例,女性980例,男性407例(女：男=2.4：1)。发病年龄为46.7±14.2(18-83)岁。74.3%(1031例)的患者出现至少1个器官损害,其中47.1%(486例)的患者出现2个及以上器官损害,11.9%(123例)的患者出现3个及以上器官损害,1.2%(12例)的患者出现4个器官损害。肺部损害(55.2%)发生率最高,其次是关节炎(32.3%)、心脏损害(27.5%)及消化道损害(21.9%)。多因素回归分析显示,肺部损害与年龄大于40岁正相关(OR3.135,95%CI2.145-4.582,P<0.01),与肌痛负相关(OR0.691,95%CI0.486-0.982,P<0.05)。与关节炎正相关的有发热(OR1.716,95%CI1.079-2.728,P<O.05)、体重下降(OR1.876,95%CI1.059-3.325,P<O.05)及雷诺现象(OR3.523,95%CI1.794-6.920,P<0.01)。关节炎与肌无力负相关(OR0.587,95%CI0.377-0.915,P<O.05)。与消化道损害正相关的有体重下降(OR1.916,95%CI1.019-3.600,P<O.05)、雷诺现象(OR3.331,95%CI1.509-7.356,P<O.01)和肌无力(OR2.056,95%CI1.029-4.108,P<0.05)。与心脏损害正相关的有体重下降(OR2.337,95%CI1.135-4.809,P<0.05)及四肢肿胀(0R2.633,95%CI1.214-5.711,P<0.05)。第二部分：在PM/DM合并ILD组、不合并ILD组及正常对照组中,血清C3M的浓度分别为7.16±3.77ng/ml,4.56±0.84ng/ml及4.63±0.85ng/ml。合并ILD组的C3M水平高于不合并ILD组和正常对照,结果均具有统计学差异(P均<0.01)。以5.42ng/ml为cut-off值,C3M阳性对PM/DM合并ILD诊断的敏感性为71.0%,特异性为86.7%,阳性预测值为91.7%,阴性预测值为59.1%。C3M阳性与PM/DM合并ILD显著相关(P<0.001)。C3M的浓度与血沉及C反应蛋白呈正相关,而与一氧化碳弥散量呈负相关。第三部分：4例DM患者肌肉组织中CD3+T细胞及CD20+B细胞均表达ASC及caspase-1,其中2例表达NALP3。6例PM患者中仅有1例肌肉组织中CD3+T细胞及CD20+B细胞表达NALP3、ASC及caspase-1。10例患者均不表达NALP1。5例正常对照肌肉组织均不表达NALP1、NALP3、ASC及caspase-1。DM组ASC及caspase-1的表达阳性率均(均为100%)高于PM组(均为16.7%)及正常对照组(均为0),差异均具有统计学意义(P<0.01和P<O.05)。NALP3的表达阳性率(50%)高于PM组(16.7%)及正常对照组(0),但差异无统计学意义(P>0.05和P>O.05)。结论：本研究是我国关于成人PM/DM最大规模的多中心回顾性研究,结果可以代表中国人群成人PM/DM的临床表现及器官损害的特点。成人PM/DM器官损害发生率高,年龄大于等于40岁,无肌痛的患者更易合并肺部损害；有雷诺现象和肌无力的患者更易合并消化道损害；有四肢肿胀的患者更易合并心脏损害；有体重下降的患者更可能有多个器官损害。C3M与PM/DM合并ILD存在显著相关性,是否可作为PM/DM合并ILD诊断的血清标志物仍需大样本随访研究进一步明确。在发病机制方面,固有免疫反应与调节在DM和PM中起不同的作用。炎症体可能参与DM的发病过程,部分由NALP3激活。而炎症体激活可能并不参与大部分PM的发病。更多还原

【Abstract】 Objectives Adult polymyositis (PM) and dermatomyositis (DM) belong to the category of idiopathic inflammatory myopathy, which is a group of systemic autoimmune diseases characterized by the damage of skeletal muscles, skin and multiple organs. Organ involvement of PM/DM is the major factor affecting the prognosis of the diseases. The aims of this dissertation are:1) to organize the largest multi-center retrospective study of PM/DM in China, summarize and analyze the prevalence and characteristics of clinical features and main organ involvement in adult patients with PM and DM, and determine their specific relative factors;2) to investigate whether matrix metalloproteinases-9-cleaved fragment of type III collagen (C3M) may be used as novel markers for interstitial lung disease (ILD) in PM and DM;3) to discuss the possible pathogenesis of inflammasome in the diseases from the perspective of innate immune.Methods This study is composed of three parts. In the first part of the study, we retrospectively collected the medical records of1387confirmed adult PM and DM patients accommodated from2007to2012in22rheumatology centers in China using unified questionnaire. Statistical analyses were done with chi-square or Fisher exact test and multivariate analyses with logistic regression method. In the second part, serum concentrations of C3M were determined by enzyme-linked immunosorbent assay in46adult PM/DM patients (31with ILD,15without ILD) and19healthy controls. The correlations between serum C3M levels and clinical features or laboratory examinations of PM/DM patients were investigated. In the third part, immunohistochemistry was performed to determine the expression of NALP (NACHT-LRR-PYD-containing protein), NALP3, ASC (apoptosis-associated speck-like protein containing a CARD) and caspase-1in muscle of10newly diagnosed and untreated adult DM/PM patients (6PM and4DM) and5healthy controls.Results In the first part of the study, a total of1387patients were collected with460(33.2%) PM and927(66.8%) DM. There were980females and407males (female:male ratio of2.4:1). The onset age was46.7±14.2(18-82) years. A total of 1031(74.3%) patients had organ involvement. Among them,47.1%(486) patients had more than one organ involvement, while11.9%(123) had more than two,1.2%(12) had more than three. The prevalence of pulmonary involvement, arthritis, gastrointestinal and cardiac involvement were55.2%,32.3%,27.5%and21.9%, respectively. The multivariate analysis indicated that older onset age (OR3.135,95%CI2.145-4.582, P<0.01) was positively associated with pulmonary involvement, while myalgia (OR0.691,95%CI0.486-0.982, P<0.05) was negatively associated. Fever (OR1.716,95%CI1.079-2.728, P<0.05), weight loss (OR1.876,95%CI1.059-3.325, P<0.05) and Raynaud’s phenomenon (OR3.523,95%CI1.794-6.920, P<0.01) were positively associated with arthritis, while muscle weakness (OR0.587,95%CI0.377-0.915, P<0.05) was negatively associated. Weight loss (OR1.916,95%CI1.019-3.600, P<0.05), Raynaud’s phenomenon (OR3.331,95%CI1.509-7.356, P<0.01) and muscle weakness (OR2.056,95%CI1.029-4.108, P<0.05) were positively associated with gastrointestinal involvement. Weight loss (OR2.337,95%CI1.135-4.809, P<0.05) and swollen limbs (OR2.633,95%CI1.214-5.711, P<0.05) were positively associated with cardiac involvement. In the second part, the serum levels of C3M were7.16±3.77ng/ml in PM/DM with ILD group,4.56±0.84ng/ml in PM/DM without ILD group, and4.63±0.85ng/ml, in healthy controls, respectively. Serum C3M level in ILD group was significantly higher than without ILD group and healthy controls (both P<0.01). With cut-off value at5.42ng/ml, the sensitivity and specificity of positive C3M for ILD in PM/DM were71.0%and86.7%, respectively. The positive predictive value and negative predictive value of C3M were91.7%and59.1%, respectively. C3M was significantly related to PM/DM associated ILD. The serum levels of C3M were positively correlated with ESR and CRP levels, and negatively correlated with%DLCO.In the third part, in muscle of4DM patients, ASC and caspase-1were expressed in the plasma of CD3+T and CD20+B cells, while in2of them NALP3was also expressed. Only1PM patient in6expressed NALP3, ASC and caspase-1in the plasma of CD3+T and CD20+B cells. NALP1was not expressed in all of the10patients. No NALP1, NALP3, ASC and caspase-1were expressed in the muscle of5healthy controls. The positive rate of ASC and caspase-1(both100%) in DM group was significantly higher than that in PM (both16.7%) and control group (both0)(P<0.01and P<0.05), while the positive rate of NALP3in DM group (50%) was higher than that in PM (16.7%) and control group (0), but with no statistical significance ((P>0.05and P>0.05). Conclusions This is the largest multi-center retrospective study about adult PM/DM in China. The results can represent the characteristic of clinical features and organ involvement of PM/DM patients in Chinese population. The prevalence of organ involvement is high in adult patients with PM/DM. Patients with older onset age and no myalgia are more likely to have pulmonary involvement. Patients with Raynaud’s phenomenon and muscle weakness are more likely to have gastrointestinal involvement. Patients with swollen limbs are more likely to have cardiac involvement. Patients with weight loss are more likely to have multiple organ involvement. C3M is significantly associated with ILD. Further study has to be done to confirm the diagnostic value for ILD in PM/DM patients. Innate immune plays different role in the pathogenesis of DM and PM. Inflammasome participates in the inflammation of DM but not in PM, and may be activated by NALP3.更多还原