Nakayamada Shingo, Saito Kazuyoshi, Nakatsuka Keisuke, Nakano Kazuhisa, Tokunaga Mikiko, Tsujimura Shizuyo, Ota Toshiyuki, Tanaka Yoshiya
First Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu-city.
Ryumachi. 2002 Jun;42(3):618-23.
We document a case of 61-year-old woman with a 24 year history of rheumatoid arthritis (RA), who developed severe polyarthralgia, dry cough, paresthesia in the legs, frequent micturition, and severe macrohematuria. We diagnosed as severe RA with extraarticular manifestations based on interstitial pneumonia, mononeuritis multiplex, subcutaneous nodules, and high titer of rheumatoid factor. Ultrasonography demonstrated an intravesical mass lesion. A histological examination of the urinary bladder by endoscopic biopsy revealed marked deposition of AA amyloid. The diagnosis of secondary amyloidosis and bacterial cystitis were made based on histological findings and urine culture. At first, we administered antibiotics by intravenous infusion, which resulted in cure of cystitis and partial improvement of macrohematuria. Then combination therapy of corticosteroids and cyclophosphamide successfully reduced the disease activity of RA. There have only been a few reports published so far on the vesical amyloidosis in patients with RA. However, 5 of 10 patients (50%) in vesical amyloidosis died because of continuous massive hematuria, which induced disseminated intravascular coagulation and multiple organ failure. In conclusion, secondary amyloidosis of the urinary bladder should be considered as a possible cause of hematuria in patients with long-term RA and as an important prognosis factor of RA.
我们记录了一例61岁女性患者，她有24年类风湿关节炎（RA）病史，出现了严重的多关节痛、干咳、腿部感觉异常、尿频和严重肉眼血尿。基于间质性肺炎、多发性单神经炎、皮下结节和高滴度类风湿因子，我们诊断为伴有关节外表现的重度RA。超声检查显示膀胱内有占位性病变。经内镜活检对膀胱进行组织学检查，发现有大量AA淀粉样蛋白沉积。根据组织学检查结果和尿液培养，诊断为继发性淀粉样变性和细菌性膀胱炎。起初，我们通过静脉输注给予抗生素，膀胱炎得以治愈，肉眼血尿部分改善。然后，皮质类固醇和环磷酰胺联合治疗成功降低了RA的疾病活动度。迄今为止，关于RA患者膀胱淀粉样变性的报道仅有少数几例。然而，膀胱淀粉样变性患者中有5例（50%）因持续大量血尿死亡，这导致了弥散性血管内凝血和多器官功能衰竭。总之，膀胱继发性淀粉样变性应被视为长期RA患者血尿的可能原因以及RA的重要预后因素。
