Смежные болезни: дерматомиозит, склеродермия системная
Врачи в каталоге: иммунолог, дерматолог
Пораженный орган: иммунная система организма
Факторы риска
- Конституциональная предрасположенность;
- Многие лекарственные препараты;
- Генетическая предрасположенность;
- Профилактические прививки, вакцины и сыворотки.
Описание
Системная красная волчанка (син. СКВ, болезнь Либмана-Сакса, от лат. lupus erythematodes, англ. systemic lupus erythematosus) — системное аутоиммунное заболевание, характеризующееся системным иммунокомплексным поражением соединительной ткани и её производных, с поражением сосудов микроциркуляторного русла.
Системное аутоиммунное заболевание, при котором вырабатываемые иммунной системой человека антитела повреждают ДНК здоровых клеток, преимущественно повреждается соединительная ткань с обязательным наличием сосудистого компонента. Название болезнь получила из-за своего характерного признака — сыпи на переносице и щеках (поражённый участок по форме напоминает бабочку), которая, как считали в Средневековье, напоминает места волчьих укусов.
Распространенность
Системная красная волчанка (СКВ) встречается во всех климатогеографических зонах и на всех континентах. Эпидемиологические исследования последних лет показали, что системная красная волчанка встречается чаще, чем предполагалось ранее, заболевает в разных регионах ежегодно 1 человек из 400-2000.
Отмечаются возрастные и расовые различия в частоте заболевания. Так, более 70% заболевают в возрасте 14-40 лет, а «пик» заболеваемости приходится на 14-25 лет.
Соотношение мужчин и женщин, заболевших системной красной волчанки, составляет, по данным разных исследовании, от 1:8 до 1:10, однако среди детей соотношение мальчиков и девочек составляет 1:3. В период между 13 и 30 годами почти 90% заболевших женского пола.
Причины
Конкретная причина системной красной волчанки не установлена, однако ряд клинических проявлений и определенные закономерности течения болезни сближают системную красную волчанку с многими заболеваниями, обусловленными вирусной природой.
В основе патогенеза системной красной волчанки лежит нарушение иммунорегуляции, когда в качестве аутоантигенов выступают белковые компоненты клетки, прежде всего ДНК и в результате адгезии мишенью становятся даже те клетки, которые изначально были свободны от иммунных комплексов.
Присутствует повышение титров к ряду РНК-содержащих вирусов — кори, краснухи, гриппа А и В, парагриппа, паротита и других, а также ДНК-содержащих герпетических вирусов — Энштейна-Барра, цитомегаловируса, вируса простого герпеса). Вместе с тем имеются некоторые эпидемиологические данные о роли хронической вирусной инфекции, обусловленной латентными или медленными вирусами (ретровирусами). Так, у больных системной красной волчанки и у окружающих их близких людей обнаруживаются такие маркеры хронической вирусной инфекции, как лимфоцитотоксические антитела, а у больных, родственников и медицинского персонала, работающего с больными, антитела к вирусной двуспиральной РНК. Вновь повысился интерес к вирусной инфекции в связи с обнаруженным сходством иммунных нарушений при системной красной волчанке и СПИД.
Согласно сформулированной ранее вирусногенетической концепции системной красной волчанки, хронизация вирусной инфекции связана с определенными генетическими особенностями организма. Применительно к системной красной волчанке установлено, что семейная распространенность во много раз выше популяционной.
Симптомы
При красной волчанке поражается соединительная ткань, кожа и эпителий. Важным диагностическим признаком является симметричное поражение крупных суставов, и, если возникает деформация суставов, то за счет вовлечения связок и сухожилий, а не вследствие поражений эрозивного характера. Наблюдаются миалгии, плевриты, пневмониты.
Но наиболее яркие симптомы красной волчанки отмечаются на коже и именно по этим проявлениям в первую очередь и ставят диагноз.
На начальных стадиях заболевания красная волчанка характеризуется непрерывным течением с периодическими ремиссиями, но почти всегда переходит в системную форму. Чаще отмечается эритематозный дерматит на лице по типу бабочки — эритема на щеках, скулах и обязательно на спинке носа. Появляется гиперчувствительность к солнечному излучению — фотодерматозы обычно округлой формы, носят множественный характер. При красной волчанке особенностью фотодерматозов является наличие гиперемированного венчика, участка атрофии в центре и депигментации пораженной области. Отрубевидные чешуйки, которыми покрывается поверхность эритемы, плотно спаяны с кожей и попытки их отделить, очень болезненны. На стадии атрофии пораженных кожных покровов наблюдается формирование гладкой нежной алебастрово-белой поверхности, которая постепенно замещает эритематозные участки, начиная с середины и двигаясь к периферии.
У некоторых пациентов с красной волчанкой поражения распространяются на волосистую часть головы, вызывая полную или частичную алопецию. Если поражения затрагивают красную кайму губ и слизистую оболочку рта, то очаги поражения представляют собой синюшно-красные плотные бляшки, иногда с отрубевидными чешуйками сверху, их контуры имеют четкие границы, бляшки склонны к изъязвлениям и причиняют боль во время еды.
Красная волчанка имеет сезонное течение, и в осенне-летние периоды состояние кожи резко ухудшается из-за более интенсивного воздействия солнечного излучения.
При подостром течении красной волчанки наблюдаются псориазоподобные очаги по всему телу, ярко выражены телеангиэктазии, на коже нижних конечностей появляется сетчатое ливедио (древоподобный рисунок). Генерализованная или очаговая алопеция, крапивница и кожный зуд наблюдаются у всех пациентов с системной красной волчанкой.
Во всех органах, где имеется соединительная ткань, со временем начинаются патологические изменения. При красной волчанке поражаются все оболочки сердца, лоханки почек, желудочно-кишечный тракт и центральная нервная система.
Если помимо кожных проявлений пациентов мучают периодические головные боли, суставные боли без связи с травмами и погодными условиями, наблюдаются нарушения со стороны работы сердца и почек, то уже на основании опроса можно предположить о более глубоких и системных нарушениях и обследовать пациента на наличие красной волчанки. Резкая смена настроения от эйфоричного состояния до состояния агрессии тоже является характерным проявлением красной волчанки.
У больных красной волчанкой пожилого возраста кожные проявления, почечный и артралгический синдромы менее выражены, но чаще наблюдается синдром Шегрена — это аутоиммунное поражение соединительной ткани, проявляющееся гипосекрецией слюнных желез, сухостью и резью в глазах, светобоязнью.
Дети, с неонатальной формой красной волчанки, родившиеся от больных матерей, уже в младенческом периоде имеют эритематозную сыпь и анемию, поэтому следует проводить дифференциальный диагноз с атопическим дерматитом.
Диагностика
При подозрении на системную красную волчанку пациента направляют на консультацию иммунолога и дерматолога. Диагностируют красную волчанку по наличию проявлений в каждой симптоматической группе.
Критерии для диагностики:
- со стороны кожных покровов: эритема в форме бабочки, фотодерматит, дискоидная сыпь;
- со стороны суставов: симметричное поражение суставов, артралгии, синдром «жемчужных браслетов» на запястьях из-за деформации связочного аппарата;
- со стороны внутренних органов: различной локализации серозиты, в анализе мочи персистирующая протеинурия и цилиндрурия;
- со стороны центральной нервной системы: судороги, хорея, психозы и перемена настроения;
- со стороны функции кроветворения красная волчанка проявляется лейкопенией, тромбоцитопенией, лимфопенией.
Верификация диагноза системной красной волчанки требует тщательного клинического анализа и целенаправленного лабораторного обследования.
Методы исследования. Рутинные методы исследования периферической кропи, иммунологические исследования крови с акцентом на вы явление антинуклеарных AT, определение концентрации и величины ЦИК, определение состава и функциональной активности клеточных популяций иммунной системы; исследование мочевого осадка. Реакция Вассермана может быть ложноположительной, как и другие серологические исследования, что порой приводит к назначению неадекватного лечения. Пункционная биопсия почек, биопсия кожи для определения депозитов фиксированных на тканевых структурах иммунных комплексов.
При развитии пневмонии проводят рентгенографию легких, при подозрении на плеврит проводят плевральную пункцию. Для диагностики состояния сердца назначают ЭКГ и эхокардиографию.
Формулировка диагноза в соответствии с принятой классификацией должна отражать нозологическую форму, активность патологического процесса, вовлечение органов и систем, степень функциональных нарушений. Например, системная красная волчанка подострого течения, умеренной степени активности с генерализованной лимфаденопатией, поражением кожи (симптом "бабочки"), сосудов (капилляриты концевых фаланг), артриты коленных суставов без деформации и с умеренным снижением функции, миокардит, недостаточность кровообращения I степени (преимущественно по малому кругу), гломерулонефрит латентного течения с сохранной функцией почек.
Дифференциальная диагностика
В основу диагностики красной волчанки необходимо положить системность поражения. Отдельные симптомы красной волчанки стречаются при многих заболеваниях, особенно ревматических. Системную красную волчанку трудно отличить от других аутоиммунных заболеваний — дерматомиозита, склеродермии, при которых отмечается синтез AT к компонентам клеток, но преобладание AT к нДНК выражено преимущественно при СКВ. При так называемых смешанных заболеваниях соединительной ткани (синдром Шарпа) редко встречаются нефрит и поражение ЦНС. Лекарственная волчанка определяется при установлении моно- или поливалентной лекарственной непереносимости.
Лечение
Как правило, первоначальное лечение красной волчанки бывает неадекватным, так как ставятся ошибочные диагнозы фотодерматозов, экземы, себореи и сифилиса. И только при отсутствии эффективности назначенной терапии проводятся дополнительные обследования, в ходе которых и диагностируется красная волчанка. Полного излечения от этого заболевания добиться невозможно, но своевременная и корректно подобранная терапия позволяет добиться улучшения качества жизни пациента и избежать инвалидизации. Лечение направлено на подавление иммунокомплексной патологии.
Пациентам с красной волчанкой нужно избегать прямых солнечных лучей, носить одежду, прикрывающую все тело, а на отрытые участки наносить крема с высоким защитным фильтром от ультрафиолета. На пораженные участки кожи наносят кортикостероидные мази, так как использование негормональных препаратов не приносит эффекта. Лечение необходимо проводить с перерывами, чтобы не развился гормонообусловленный дерматит.
В при неосложненных формах красной волчанки для устранения болевых ощущений в мышцах и суставах назначаются нестероидные противовоспалительные препараты, но с осторожностью следует принимать аспирин, так как он замедляет процесс свертывания крови. Обязателен прием глюкокортикостероидов, при этом дозы препаратов подбираются таким образом, чтобы при минимизации побочных эффектов защитить внутренние органы от поражений.
Метод, когда у пациента делают забор стволовых клеток, а потом проводят иммунодепрессивную терапию, после чего для восстановления иммунной системы вновь вводят стволовые клетки, эффективен даже в тяжелых и безнадежных формах красной волчанки. При такой терапии аутоиммунная агрессия в большинстве случаев прекращается, и состояние пациента с красной волчанкой улучшается.
Здоровый образ жизни, отказ от алкоголя и курения, адекватная физическая нагрузка, сбалансированное питание и психологический комфорт позволяют пациентам с красной волчанкой контролировать свое состояние и не допустить инвалидизации.
Советы по изменению образа жизни
Убедить в необходимости длительного непрерывного лечения и строгого выполнения рекомендаций врача. При самых незначительных изменениях самочувствия следует обращаться к специалисту. Исключить неконтролируемый прием лекарств (в том числе и фитопрепаратов). Гормональные препараты принимать в строго назначенной дозе и снижать ее по схеме, предписанной врачом. Не прекращать прием лекарств без рекомендации врача. Соблюдать режим труда и отдыха. Придерживаться диеты с ограничением поваренной соли и углеводов, богатой белками и витаминами. Избегать инсоляции, переохлаждения, осторожно проводить легкие закаливающие процедуры. При обострении очаговой или интеркуррентной инфекции обращаться к врачу для назначения антибиотиков.
Профилактика
Для первичной профилактики заболевания следует выделить семьи, в которых имеются больные с системными заболеваниями соединительной ткани. Такие семьи должны быть тщательно обследованы, и при выявлении даже одного из симптомов (антитела к ДНК, гипергаммаглобулинемия, стойкая тромбоцитопения, лейкопения, повышенная СОЭ) рекомендовать строго контролируемое употребление лекарств и исключение инсоляции.
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