Leitsymptom Dyspnoe bei entzündlichrheumatischen Erkrankungen

Zusammenfassung

Dyspnoe bei „Rheumapatienten” sollte als Warnsignal ernst genommen werden und auch immer wieder gezielt anamnestiziertwerden.Neben den allgemeinen Differenzialdiagnosen des Symptoms müssen bei Patienten mit entzündlich-rheumatischen Erkrankungen spezifische Proble-me berücksichtigt werden. Dyspnoe kann Symptom einer koronaren Herzerkrankung sein. Aufgrund des erhöhten kardiovaskulären Risikos ist eine entsprechende Diagnostik erforderlich. Andere kardiovaskuläre Risikofaktoren sollten evaluiert und gegebenenfalls therapiert werden. Bei Pa-tienten mit Kollagenosen ist in besonderem Maße die Differenzialdiagnose der Lungenbeteiligung und der pulmonalarteriellen Hypertonie (PAH) zu berücksichtigen. Zum Screening eignen sich die Lungenfunktion mit Diffusions-kapazität und die Echokardiografie. Aufgrund der immunsuppressiven Medikation kommen bei einer Infektion auch atypische Krankheitserreger sowie ein atypischer Verlauf in Frage. Spezielle Krankheitsbilder im Rahmen der rheumatologischen Medikation sind z.B. Methotrexat-Pneumonitis oder Aggravierung einer Herzinsuffizienz durch nichtsteroi-dale Antirheumatika (NSAR).

Summary

Dyspnea in patients with inflammatory rheumatic diseases needs special attention. Specific characteristics of the diseases must be taken into consideration besides the usual differential diagnoses. Dyspnea may be a symptom of coronary artery disease. Due to the increased cardiovascular risk of chronic inflammatory diseases other cardivascular risk factors should be evaluated and treated. In vasculitis and connective tissue diseases pulmonary involvement and pulmonary arterial hypertension (PAH) must be excluded. Doppler echocardiography and pulmonary function tests including diffusing capacity are appropriate screening tools for PAH. Atypical infections under immunosuppressive therapy have to be considered. Metotrexate pneumonitis, and worsening of chronic heart failure due to non-steroidal antiinflammatory drugs are examples of adverse events of medication.

Schlüsselwörter

Dyspnoe - pulmonale Manifestationen von Kollagenosen und Vaskulitiden - pulmonal-arterielle Hypertonie - Methotrexat-Pneumonitis

Keywords

Dyspnea - pulmonary involvement in connective tissue disease - pulmonary arterial hypertension - Methotrexate pneumonitis

• Literatur

• 1 Recommendations on the management of pulmonary hypertension in clinical practice. Heart 2001; 86 (Suppl. 01) Suppl I1-13.
• 2 Asherson RA., Cervera R.. Review: antiphospholipid antibodies and the lung. J Rheumatol 1995; 22 (01) 62-66.
• 3 Brown KK.. Rheumatoid lung disease. Proc Am Thorac Soc 2007; 4 (05) 443-448.
• 4 Collard HR., King Jr TE., Bartelson BB.. et al. Changes in clinical and physiologic variables predict survival in idiopathic pulmonary fibrosis. Am J Respir Crit Care Med 2003; 168 (05) 538-542.
• 5 Cook DG., Shaper AG.. Breathlessness, angina pectoris and coronary artery disease. Am J Cardiol 1989; 63 (13) 921-924.
• 6 Dawson JK., Graham DR., Desmond J.. et al. Investigation of the chronic pulmonary effects of low-dose oral methotrexate in patients with rheumatoid arthritis: a prospective study incorporating HRCT scanning and pulmonary function tests. Rheumatology (Oxford) 2002; 41 (03) 262-267.
• 7 Doran MF., Crowson CS., Pond GR.. et al. Predictors of infection in rheumatoid arthritis. Arthritis Rheum 2002; 46 (09) 2294-2300.
• 8 Feenstra J., Heerdink ER., Grobbee DE.. et al. Association of nonsteroidal anti-inflammatory drugs with first occurrence of heart failure and with relapsing heart failure: the Rotterdam Study. Arch Intern Med 2002; 162 (03) 265-270.
• 9 Freemer MM., King TEJ.. Connective tissue disease. In King TEJ., Schwarz MI.. editors Interstitial Lung Disease. 4th edition. Hamilton, ON, Canada: B. C. Decker Publisher; 2003: 536.
• 10 Fuhrman C., Parrot A., Wislez M.. et al. Spectrum of CD4 to CD8T-cell ratios in lymphocytic alveolitis associated with methotrexate-induced pneumonitis. Am J Respir Crit Care Med 2001; 164 (07) 1186-1191.
• 11 Fujisawa T., Suda T., Nakamura Y.. et al. Differences in clinical features and prognosis of interstitial lung diseases between polymyositis and dermatomyositis. J Rheumatol 2005; 32 (01) 58-64.
• 12 Gabbay E., Tarala R., Will R.. et al. Interstitial lung disease in recent onset rheumatoid arthritis. Am J Respir Crit Care Med 1997; 156 (2 Pt 1) 528-535.
• 13 Hachulla E., Gressin V., Guillevin L.. et al. Early detection of pulmonary arterial hypertension in systemic sclerosis: a French nationwide prospective multicenter study. Arthritis Rheum 2005; 52 (12) 3792-3800.
• 14 Hedgpeth MT., Boulware DW.. Interstitial pneumonitis in antinuclear antibody-negative systemic lupus erythematosus: a new clinical manifestation and possible association with anti-Ro (SS-A) antibodies. Arthritis Rheum 1988; 31 (04) 545-548.
• 15 Hunzelmann N., Riemekasten G.. Pulmonary arterial hypertension in collagen disease: experiences of the German Network for Systemic Scleroderma. Dtsch Med Wochenschr 2006; 131 (Suppl. 09) 49 Suppl S325-327.
• 16 Memet B., Ginzler EM.. Pulmonary manifestations of systemic lupus erythematosus. Semin Respir Crit Care Med 2007; 28 (04) 441-450.
• 17 Mukerjee D., St George D., Knight C.. et al. Echocardiography and pulmonary function as screening tests for pulmonary arterial hypertension in systemic sclerosis. Rheumatology (Oxford) 2004; 43 (04) 461-446.
• 18 Nawata Y., Kurasawa K., Takabayashi K.. et al. Corticosteroid resistant interstitial pneumonitis in dermatomyositis/polymyositis: prediction and treatment with cyclosporine. J Rheumatol 1999; 26 (07) 1527-1533.
• 19 Nicola PJ., Crowson CS., Maradit-Kremers H.. et al. Contribution of congestive heart failure and ischemic heart disease to excess mortality in rheumatoid arthritis. Arthritis Rheum 2006; 54 (01) 60-67.
• 20 Park JH., Kim DS., Park IN.. et al. Prognosis of Fibrotic Interstitial Pneumonia: Idiopathic versus Collagen Vascular Disease-related Subtypes. Am J Respir Crit Care Med 2007; 175 (07) 705-711.
• 21 Pines A., Kaplinsky N., Olchovsky D.. et al. Pleuropulmonary manifestations of systemic lupus erythematosus: clinical features of its subgroups. Prognostic and therapeutic implications. Chest 1985; 88 (01) 129-135.
• 22 Roman MJ., Shanker BA., Davis A.. et al. Prevalence and correlates of accelerated atherosclerosis in systemic lupus erythematosus. N Engl J Med 2003; 349 (25) 2399-2406.
• 23 Saag KG., Kolluri S., Koehnke RK.. et al. Rheumatoid arthritis lung disease. Determinants of radiographic and physiologic abnormalities. Arthritis Rheum 1996; 39 (10) 1711-1719.
• 24 Schnabel A., Richter C., Bauerfeind S.. et al. Bronchoalveolar lavage cell profile in methotrexate induced pneumonitis. Thorax 1997; 52 (04) 377-379.
• 25 Singh G., Wu O., Langhorne P.. et al. Risk of acute myocardial infarction with nonselective non-steroidal anti-inflammatory drugs: a meta-analysis. Arthritis Res Ther 2006; 8 (05) R153.
• 26 Wiedemann HP., Matthay RA.. Pulmonary manifestations of systemic lupus erythematosus. J Thorac Imaging 1992; 7 (02) 1-18.
• 27 Winslow TM., Ossipov MA., Fazio GP.. et al. Five-year follow-up study of the prevalence and progression of pulmonary hypertension in systemic lupus erythematosus. Am Heart J 1995; 129 (03) 510-515.
• 28 Wolfe F., Caplan L., Michaud K.. Treatment for rheumatoid arthritis and the risk of hospitalization for pneumonia: associations with prednisone, disease-modifying antirheumatic drugs, and anti-tumor necrosis factor therapy. Arthritis Rheum 2006; 54 (02) 628-634.
• 29 Zamora MR., Warner ML., Tuder R.. et al. Diffuse alveolar hemorrhage and systemic lupus erythematosus. Clinical presentation, histology, survival, and outcome. Medicine (Baltimore) 1997; 76 (03) 192-202.