劉　穎，梅煥平，吳云娟，張繆佳

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·論著·

抗內(nèi)皮細(xì)胞抗體在多發(fā)性肌炎/皮肌炎合并間質(zhì)性肺疾病中的應(yīng)用

劉穎，梅煥平，吳云娟，張繆佳

目的研究抗內(nèi)皮細(xì)胞抗體(anti-endothelial cell antibody, AECA)對多發(fā)性肌炎/皮肌炎(polymyositis/dermatomyositis, PM/DM)合并間質(zhì)性肺疾病(interstitial lung disease, ILD)的診斷價(jià)值及其與ILD病情活動(dòng)度的關(guān)系。方法PM/DM患者106例分為合并ILD(PM/DM-ILD)組58例和未合并ILD(PM/DM-NILD)組48例，42例健康體檢者為對照組。采用間接免疫熒光法(IIF)檢測患者血清中AECA，記錄患者年齡、病程、白細(xì)胞計(jì)數(shù)(WBC)、中性粒細(xì)胞比值[N(%)]、丙氨酸氨基轉(zhuǎn)移酶(ALT)、天冬氨酸氨基轉(zhuǎn)移酶(AST)、乳酸脫氫酶(LDH)、肌酸激酶(CK)、C反應(yīng)蛋白(CRP)、血沉(ESR)、免疫球蛋白G(IgG)及其他臨床資料。結(jié)果① PM/DM-ILD組、PM/DM-NILD組、對照組AECA陽性率分別為62.07%、33.33%、9.52%；前兩組與對照組相比，陽性率差異有統(tǒng)計(jì)學(xué)意義，PM/DM-ILD組與PM/DM-NILD組相比，差異亦有統(tǒng)計(jì)學(xué)意義。② 比較PM/DM-ILD組和PM/DM-NILD組的其他各項(xiàng)指標(biāo)，差異無統(tǒng)計(jì)學(xué)意義，僅中性粒細(xì)胞比值差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。③ 根據(jù)胸部高分辨CT及臨床表現(xiàn)將58例PM/DM-ILD患者分為活動(dòng)期組(40例)和穩(wěn)定期組(18例)，兩組AECA陽性率分別為80.00%、22.22%，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。④ AECA用于PM/DM診斷的敏感性為49.06%，特異性為90.48%，陽性預(yù)測值為92.86%，陰性預(yù)測值為41.30%。用于PM/DM-ILD診斷敏感性為62.07%，特異性為77.78%，陽性預(yù)測值為64.29%，陰性預(yù)測值為76.09%。結(jié)論在PM/DM患者血清中檢測出AECA反映ILD炎性活動(dòng)，有助于PM/DM-ILD的診斷和鑒別診斷。

抗內(nèi)皮細(xì)胞抗體；多發(fā)性肌炎/皮肌炎；間質(zhì)性肺疾病

抗內(nèi)皮細(xì)胞抗體(anti-endothelial cell antibody，AECA)是以血管內(nèi)皮細(xì)胞為靶抗原的自身抗體，多種自身免疫性疾病如韋格納肉芽腫(Wegener`s granulomatosis, WG)、系統(tǒng)性紅斑狼瘡(systemic lupus erythematosus, SLE)、系統(tǒng)性硬化癥(systemic sclerosis, SC)、多發(fā)性肌炎/皮肌炎(polymyositis/dermatomyositis, PM/DM)均可檢出。PM/DM有不同程度橫紋肌受累、慢性非化膿性炎癥病變，具有較高的致殘率和致死率。間質(zhì)性肺疾病(interstitial lung disease，ILD)是PM/DM最常見的肺部并發(fā)癥，常出現(xiàn)于PM/DM急性加重期，并可出現(xiàn)于病程的任何時(shí)期。ILD可累及內(nèi)皮及上皮細(xì)胞基底膜空隙，在炎癥進(jìn)行及修復(fù)過程中導(dǎo)致肺組織可逆或不可逆性損傷。ILD治療較為困難，是影響預(yù)后的重要因素。既往關(guān)于AECA在多發(fā)性肌炎/皮肌炎合并間質(zhì)性肺病的研究報(bào)道較少。本文探討AECA在PM/DM-ILD中臨床意義。

1　對象與方法

1.1標(biāo)本來源選擇2013年2月-2015年12月本院PM/DM患者106例，男32例，女74例，年齡19.0～72.0(49.0±13.3)歲，病程1.0～120.0(19.9±33.6)月。臨床診斷均符合Bohan/Peter標(biāo)準(zhǔn)，均未合并其他類型自身免疫病，胸部高分辨CT提示106例PM/DM患者中有48例未伴發(fā)ILD(PM/DM-NILD組)，58例伴發(fā)間質(zhì)性肺疾病(PM/DM-ILD組)，表現(xiàn)為肺部網(wǎng)狀結(jié)節(jié)影、磨玻璃影、蜂窩狀影、條索樣影，并有程度不同的咳嗽、胸悶、氣促等臨床癥狀，其中炎癥活動(dòng)期40例，穩(wěn)定期(非活動(dòng)期)18例。健康體檢者42例為對照組，來自我院體檢中心，男14例，女28例，年齡29.0～77.0(42.3±11.7)歲。血常規(guī)、肝腎生化和尿常規(guī)檢查結(jié)果均在參考值范圍內(nèi)。

1.2方法取待檢者靜脈血3 mL于促凝管中自然靜置2 h，離心后取血清于EP管中，保存在-70℃的冰箱中備用。用間接熒光免疫法檢測抗內(nèi)皮細(xì)胞抗體，試劑盒購自德國歐蒙公司(抗內(nèi)皮細(xì)胞抗體IgG檢測試劑盒，間接免疫熒光法，批號FA1960-1005)，按照試劑盒說明書操作，初始稀釋度為1∶10，如遇陽性樣本，則按1∶32、1∶64、1∶100、1∶320的順序依次增加稀釋度，直至基質(zhì)片AECA為陰性。AECA陽性表現(xiàn)為基質(zhì)片核周及胞質(zhì)中出現(xiàn)粗大綠色熒光顆粒。由2名閱片經(jīng)驗(yàn)3年以上技師同時(shí)進(jìn)行閱片，同一樣本閱片結(jié)果相差2個(gè)稀釋度以上者剔除。記錄PM/DM患者年齡、病程，同日檢測白細(xì)胞計(jì)數(shù)(WBC)、中性粒細(xì)胞比值[N(%)]、丙氨酸氨基轉(zhuǎn)移酶(ALT)、天冬氨酸氨基轉(zhuǎn)移酶(AST)、乳酸脫氫酶(LDH)、肌酸激酶(CK)、C反應(yīng)蛋白(CRP)、血沉(ESR)、免疫球蛋白G(IgG)。

2　結(jié)　果

2.1AECA陽性率PM/DM患者陽性率為49.06%(52/106)，其中PM/DM-ILD組為62.07%(36/58)，PM/DM-NILD組為33.33%(16/48)，對照者陽性率為9.52%(4/42)。與對照組比較，PM/DM-ILD組和PM/DM-NILD組AECA陽性率差異均有統(tǒng)計(jì)學(xué)意義(PM/DM-ILD組χ2=28.02，P=0.000；PM/DM-NILD組：χ2=7.35，P=0.007)。PM/DM-ILD組與PM/DM-NILD組比較，AECA陽性率差異亦有統(tǒng)計(jì)學(xué)意義(χ2=8.68，P=0.003)。

2.2WBC、ALT、AST等其他實(shí)驗(yàn)室指標(biāo)PM/DM-ILD組和PM/DM-NILD組患者的年齡、病程WBC、N(%)、ALT、AST、LDH、CK、CRP、ESR、IgG水平差異均無統(tǒng)計(jì)學(xué)意義，僅N(%)差異有統(tǒng)計(jì)學(xué)意義(P<0.05),見表1。

表1　PM/DM-ILD組和PM/DM-NILD組各項(xiàng)指標(biāo)比較

2.3間質(zhì)性肺疾病炎癥活動(dòng)期與穩(wěn)定期AECA陽性率比較根據(jù)胸部高分辨CT將58例PM/DM-ILD患者，分為炎癥活動(dòng)期40例，穩(wěn)定期18例。活動(dòng)期AECA陽性率為80.00%(32/40)，高分辨CT表現(xiàn)為磨玻璃樣及斑片狀改變。穩(wěn)定期AECA陽性率為22.22%(4/18)，高分辨CT表現(xiàn)為網(wǎng)格、條索樣、蜂窩樣改變。兩組AECA陽性率差異有統(tǒng)計(jì)學(xué)意義(χ2=17.60，P<0.05)。

2.4AECA對PM/DM和PM/DM-ILD的診斷價(jià)值A(chǔ)ECA用于PM/DM診斷的敏感性為49.06%，特異性為90.48%，Youden指數(shù)為0.40，陽性預(yù)測值為92.86%，陰性預(yù)測值為41.30%，ROC曲線下面積為0.68。用于PM/DM-ILD診斷的敏感性為62.07%，特異性為77.78%，Youden指數(shù)為0.40，陽性預(yù)測值為64.29%，陰性預(yù)測值為76.09%，ROC曲線下面積0.61。

3　討　論

AECA是以血管內(nèi)皮細(xì)胞膜蛋白或吸附于其細(xì)胞膜的異質(zhì)性蛋白為靶抗原的自身抗體。AECA介導(dǎo)多種自身免疫性血管炎病變，并隨病情好轉(zhuǎn)而減少或消失。AECA在結(jié)締組織病(connective tissue disease, CTD)合并的ILD中參與組織損傷和纖維化修復(fù)過程。Damianovich等報(bào)道AECA可與內(nèi)皮細(xì)胞表面抗原結(jié)合，破壞內(nèi)皮細(xì)胞的結(jié)構(gòu)與功能，輔助自然殺傷細(xì)胞產(chǎn)生細(xì)胞毒性作用。Matsui等[10]研究發(fā)現(xiàn)，有肺損傷的自身免疫病患者血清AECA水平高于沒有肺損傷的自身免疫病患者。與在原發(fā)性ILD中，AECA與非特異性間質(zhì)性肺炎(nonspecific interstitial pneumonia, NSIP)高度相關(guān)。AECA僅存在于NSIP中，而普通型間質(zhì)性肺炎/特發(fā)性肺纖維化(usual interstitial pneumonia/idiopathic pulmonary fibrosis, UIP/IPF)患者均未檢出AECA。膠原血管病相關(guān)性間質(zhì)性肺病(collagen vascular disease-associated ILD, CVD-ILD)患者的AECA陽性率與NSIP的陽性率相似，因此認(rèn)為AECA與自身免疫病合并間質(zhì)性肺疾病密切相關(guān)，參與了某些特殊類型間質(zhì)性肺疾病的發(fā)生與發(fā)展。

本研究證實(shí)，PM/DM患者血清AECA陽性率顯著高于健康體檢者，與文獻(xiàn)報(bào)道相符[11]。而PM/DM-ILD患者血清中AECA陽性率顯著高于PM/DM-NILD患者，這說明AECA與PM/DM-ILD患者間質(zhì)性肺疾病發(fā)生相關(guān)。其機(jī)制可能是在AECA的作用下肺間質(zhì)形成免疫復(fù)合物，提高肺巨噬細(xì)胞活性，促進(jìn)趨化因子的生成與釋放，使大量中性粒細(xì)胞、淋巴細(xì)胞在肺間質(zhì)聚集并產(chǎn)生氧自由基、蛋白酶類物質(zhì)，引起肺間質(zhì)結(jié)構(gòu)破壞和損傷。病情進(jìn)展過程中成纖維細(xì)胞活性異常增殖，破壞彈性蛋白、膠原蛋白代謝平衡，進(jìn)而發(fā)生彌漫性肺纖維化。比較PM/DM-ILD組和PM/DM-NILD組患者年齡、病程、WBC、N%、ALT、AST、LDH、CK、CRP、ESR、IgG，發(fā)現(xiàn)兩組間只有中性粒細(xì)胞比值差異有統(tǒng)計(jì)學(xué)意義(P<0.05)，提示AECA和中性粒細(xì)胞共同參與PM/DM患者ILD的形成。根據(jù)胸部高分辨CT表現(xiàn)將PM/DM-ILD組患者再分為活動(dòng)期組和靜止期組，活動(dòng)期組AECA陽性率明顯高于靜止期組，差異有顯著性統(tǒng)計(jì)學(xué)意義，表明AECA可作為評價(jià)PM/DM-ILD患者間質(zhì)性肺疾病活動(dòng)性指標(biāo)。

目前用于診斷和監(jiān)測PM/DM的實(shí)驗(yàn)室指標(biāo)仍較為局限。WBC、中性粒細(xì)胞比值、CRP、ESR、IgG為常用炎癥指標(biāo)，但受感染、情緒、運(yùn)動(dòng)等多種因素影響。據(jù)蘇江等[12]報(bào)道CRP、ESR均與肌無力、肌痛嚴(yán)重程度無相關(guān)性，不能作為評價(jià)疾病活動(dòng)度的指標(biāo)?？拱被RNA合成酶 (aminoacyl-transfer RNA synthetase，ARS)抗體是PM/DM患者中最常見的一類特異性抗體[13]。迄今為止共發(fā)現(xiàn)8種抗ARS抗體，分別針對組氨酸(Jo-1)、蘇氨酸(PL-7)、丙氨酸(PL-12)、甘氨酸(EJ)、異亮氨酸(OJ)、門冬氨酸(KS)、酪氨酸(Ha)和苯丙氨酸(Zo)的氨?；D(zhuǎn)移酶[14]，其中抗Jo-1抗體最為常見，而抗Ha及抗Zo抗體最為罕見。在PM/DM患者中，抗ARS抗體總陽性率為27.6%，其中抗Jo-1抗體最高，總陽性率為16.6%[14]。本研究發(fā)現(xiàn)AECA診斷PM/DM的敏感性為49.06%，遠(yuǎn)超過抗Jo-1抗體，而其特異性、陽性預(yù)測值均較高，分別為90.48%和92.86%，故其對PM/DM的診斷意義應(yīng)優(yōu)于抗Jo-1抗體。

總之，AECA在PM/DM-ILD患者中有較高的檢出率，且與疾病活動(dòng)性高度相關(guān)，對PM/DM-ILD的診斷和活動(dòng)性監(jiān)測具有一定價(jià)值。

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(本文編輯：齊名；英文編輯：王建東)

Diagnostic and monitoring significance of Anti-endothelial cell antibody in patients with polymyositis/dermatomyositisaccompanied by interstitial lung diseases

LIU Ying, MEI Huan-ping, WU Yun-juan,ZHANGMiu-jia.

DepartmentofRheumatology,theFirstAffiliatedHospitalofNanjingMedicalUniversity,Nanjing,Jiangsu210029,China

ObjectiveTo identify the diagnostic value of Anti-endothelial cell antibody(AECA) andthe association with disease activity. MethodsOne hundred and six patients with PM/DM were assigned into two groups of PM/DM-ILD (with ILD,58 cases) and PM/DM-NILD (without ILD,48 cases). Another 42 healthy people were taken as the control (HC). Serum AECA collected from these patients were tested by indirect immunofluorescence (IIF). We reviewed patient clinical details such as age, and duration as well as laboratory data of WBC, N (%), ALT, AST, LDH, CK, CRP and ESR. Results① The positive rate of AECA in PM/DM-ILD, PM/DM-NILD and HC was 62.07%, 33.33% and 9.52% respectively. The former two groups showed significant difference compared with HC (PM/DM-ILD:χ2=28.02,P=0.000; PM/DM-NILD;χ2=7.35,P=0.007). Furthermore, the group of PM/DM-ILD got a significant higher positive rate than the PM/DM-NILD group (χ2=8.68,P=0.003). ② There was a higher level of N% in PM/DM-ILD group compared with the PM/DM-NILD group. All other clinical features were similar. ③ 58 patients were then divided into active group (40 cases) and stable group (18 cases) according to HRCT and clinical manifestation. The active group took a significant higher prevalence of AECA than the stable one (80.00% versus 22.22%,χ2=17.60,P<0.05). ④ The sensitivity, specificity, positive predictive value and negative predictive value for AECA to diagnose PM/DM were 49.06%, 90.48%, 92.86% and 41.30%. In aspect of PM/DM-ILD, the four diagnostic value were 62.07%, 77.78%, 64.29% and 76.09%, respectively.

ConclusionThe identification of serum AECA in PM/DM patients reflected the activity of ILD to some extent and plays a useful part in diagnosing and differential diagnosing of PM/DM-ILD.

anti-endothelial cell antibody(AECA); PM/DM; ILD

重點(diǎn)病種規(guī)范化診療研究(BL20130134)

210029江蘇南京，南京醫(yī)科大學(xué)第一附屬醫(yī)院風(fēng)濕免疫科

張繆佳，E-mail：miaojiazhang01@gmail.com

R563.1+3

A

10.3969/j.issn.1672-271X.2016.03.017

2016-03-04；

2016-03-12)

引用格式：劉穎，梅煥平，吳云娟,等.抗內(nèi)皮細(xì)胞抗體在多發(fā)性肌炎/皮肌炎合并間質(zhì)性肺疾病中的應(yīng)用.東南國防醫(yī)藥，2016,18(3):278-280,286.