This 45-year-old woman was diagnosed as asthma when she was a child. There was no more attack for many years until 1997. She suffered from sudden onset of dyspnea and then was sent to emergency room. Asthma attack was impressed at that time. After that she received regular medication, including inhaled steroid.

She was a patient of Sjogren’s syndrome, which was diagnosed in 1989 with presentation of dry eye and dry mouth. Persisted keratoconjunctivitis troubled her and artificial tear was used since then. She also had morning stiffness and painful swelling over bilateral multiple hand joints. She received regularly follow-up since then. She came to our rheumatology out-patient department since March 2001. Rheumatoid factor(+) (1:1280) and ANA(+) were noted at that time. Anti-HCV antibody was negative. Polyarthritis involving wrist and PIP joints was noted and rheumatoid arthritis was diagnosed. Prednisolone and NSAIDs (non-steroid anti-inflammatory drugs) were prescribed at out-patient department. She received rehabilitation at our hospital. Sudden onset of dyspnea occurred in the morning of Nov 19, 2001. She was admitted on Nov 20.

After admission, physical examination showed normal blood pressure 110/70 mmHg, body temperature 37.2℃, heart rate 84/min, and respiratory rate 22/min. Ausculation didn’t show obvious wheezing. Chest x-ray showed only mild inferior lung field infiltration. Blood gas showed pH 7.42, pCO₂ 32.2, pO₂ 199.2, HCO₃ 20.6, and BE -2.8. Pulmonary function test was normal except mild impairment of DLco. Dyspnea improved partially under inhaled bronchodialator therapy. Due to multiple joint pain, NSAIDs, methotrexate and prednisolone were given. Nasal discharge was noted and acute paranasal sinusitis was impressed. Empirical antibiotics were prescribed and kept for one week. Gr I/VI systolic heart murmur over apex was noted and cardiac echo was arranged. However, the cardiac echo didn’t show abnormality. Under medical treatment, her symptom improved. She was discharged under stabled condition.

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案例分析
在風濕免疫科的病人，如果有喘的表現，必須考慮多方面的原因。以本病人為例，類風濕性關節炎和謝格連氏症（Sjogren’s syndrome），都可能有間質性肺病的表現，在肺功能測試中應包括DLco的項目。呼吸道的症狀，可能因感染或肋膜積液而加重。且除了呼吸道本身的問題，心包積液，腎小管酸血症也是可能的考慮。在這個病人，謝格連氏症可能次發於類風濕性關節炎，疾病的控制如果對類固醇反應不佳，應及早使用DMARDs（Disease modifying anti-rheumatic drugs）。

1. (A) Rheumatoid arthritis
2. (D) 乾眼是中老年人常見的主訴，對於乾眼症的病人，應考慮藥物，病毒之感染如C型肝炎，HIV等等，除此外有一部份fibromyalgia 的病人，也因自律神經系統的異常而有淚液或口水分泌減少的現象。此時除一般生化檢查外，可安排Schirmer’s test 或唾腺生檢做進一步的確認。Harrison’s Principle of Internal medicine ed.15 p.1949
3. (C) Osteoarthritis 不會伴隨 rheumatoid factor 的升高
4. (C) Harrison’s Principle of Internal medicine ed.15 p.1949
5. (B) Harrison’s Principle of Internal medicine ed.15 p.1949
6. (B) Harrison’s Principle of Internal medicine ed.15 p.1948
7. (D) Harrison’s Principle of Internal medicine ed.15 p.1932
8. (D) Harrison’s Principle of Internal medicine ed.15 p.1948 D.以上皆有可能。在Sjogren syndrome的病人，也要考慮腎小管酸血症以喘為初始表現。
9. (A) 因為Methotrexate相對毒性較小，作用起始較快，在無禁忌症的情況下通常作為第一選擇。Anit-TNF-alpha (如imfliximab) 製劑雖然某些副作用較其他DMARDs低，因為價格的問題，仍非第一線用藥。Harrison’s Principle of Internal medicine ed.15 p.1935
10. (D) 低劑量的類固醇是有用的輔助療法，且有證據顯示低劑量的類固醇可以減緩骨侵蝕的進行。Harrison’s Principle of Internal medicine ed.15 p.1935